A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage.

OBJECTIVE: To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding. DESIGN: A randomised controlled trial. SETTING: Two university teaching hospitals. PARTICIPANTS: Four hundred women with abnormal uterine bleeding (postmenopausal bleeding, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular periods) above the age of 35 years, between June 1993 and January 1995. MAIN OUTCOME MEASURES: 1. Incidence of detection of abnormal pathology by vaginal ultrasound, outpatient hysteroscopy and endometrial biopsy compared with inpatient hysteroscopy and curettage; 2. Number of 'lesions' (e.g. fibroids, polyps, endometrial hyperplasia or malignancy) found by hysteroscopy that would have been missed by the combination of endometrial sampling and ultrasound; 3. Comparison of the quality of tissue obtained for histology by outpatient endometrial sampling and inpatient curettage; and 4. An evaluation of patient acceptability of outpatient and inpatient procedures. RESULTS: 1. A combination of transvaginal sonography, Pipelle endometrial biopsy and outpatient hysteroscopy has similar efficacy to inpatient hysteroscopy and curettage for the investigation of abnormal uterine bleeding; 2. Hysteroscopy will detect some fibroids and polyps missed by a combination of transvaginal ultrasound and Pipelle endometrial sampling; 3. The quality of histological samples obtained by outpatient Pipelle were comparable to those obtained by formal inpatient curettage; and 4. Outpatient procedures were well tolerated, with good patient acceptability. CONCLUSION: Transvaginal sonography and endometrial biopsy can safely be used as the initial investigations in the management of abnormal uterine bleeding. Hysteroscopy can be used as a second line investigation. Outpatient hysteroscopy with local anaesthesia is well tolerated although general anesthesia may occasionally be necessary.

Detection of glove puncture and skin contamination during caesarean section.

Measures that can be taken to reduce exposure to potentially infected body fluids are of particular relevance in obstetric and gynaecological surgery due to high rates of glove puncture and relatively higher prevalence of human immunodeficiency virus seropositivity in the obstetric age group. We describe the use of a simple electronic device that alarms following puncture of surgical gloves or the creation of a fluid bridge between surgeon and patient. Further exposure to potentially infected body fluids is thus prevented. This present study was performed in the context of caesarean section, but the application of the technique to gynaecological procedures is appropriate.

Endometrial resection after radiotherapy for cervical carcinoma.

A patient with persistent chaotic menses during hormone replacement therapy after radiotherapy for cervical cancer was rendered amenorrheic by transcervical endometrial resection.

Ultrasound of the common bile duct in patients undergoing cholecystectomy.

One hundred patients undergoing cholecystectomy underwent ultrasonography of the biliary tree on the day prior to surgery. At operation a per-operative cholangiogram was performed unless stones were palpable in the duct. Pre-operative biliary ultrasonography accurately identified dilatation of the common bile duct (sensitivity 96%, specificity 95%) but was less accurate at detecting common duct stones (sensitivity 36%, specificity 98%). Thirty three percent of patients with dilated ducts on ultrasound did not have stones in the duct, while 20% of patients with common duct stones had normal sized ducts. We conclude that ultrasonography alone cannot reliably select patients who require exploration of the common bile duct, or select patients for operative cholangiography. Although pre-operative demonstration of common bile duct dilation is an absolute indication for operative cholangiography, by itself it does not indicate the need for exploration.

Recovery of the intrauterine contraceptive device from the sigmoid colon. Three case reports.

PIP: 3 cases of copper IUDs recovered during laparotomy from the sigmoid colon are presented. One woman was a 24-year old mother of 5 who had had 2 cesarean sections since the disappearance of her Cu-7 IUD in 1980. She had right upper quadrant abdominal pain for 1 year with gall bladder stones. The IUD was found lying 80% in the gut lumen. After colotomy she recovered. The 2nd woman was 31 years old, pregnant for the 4th time after failure of her IUD. She was experiencing a constant left iliac fossa ache. The IUD was shown to be extrauterine by ultrasound, could not be seen at laparoscopy, and was removed by colotomy. The 3rd woman was a 37-year old mother of 5, 19 weeks' pregnant, having a septic miscarriage on admission. She had labor induced, but the IUD was not expelled. Her pain worsened, and fever and tachycardia persisted. Emergency laparotomy revealed a perforated posterior uterine wall with the Cu-7 eroding the serosa of the sigmoid colon. It was removed but the defect was not repaired. She required a subtotal hysterectomy, and a second laparotomy with a temporary colostomy, and her recovery was complicated by pulmonary embolism and cardiac failure. These cases draw attention to the importance of proper management of patients with no visible IUD thread. Ultrasound, and if necessary x-rays and laparoscopy should precede laparotomy. Expulsion of an IUD is rarely unnoticed, nor should pregnancy with an IUD be assumed to be due to an expelled device.^ieng