Developing a robust and efficient pathway for the referral and investigation of women with post-menopausal bleeding using a cut-off of < or =4 mm for normal thickness.

The majority of women with post-menopausal bleeding (PMB) do not have endometrial cancer, and transvaginal ultrasound (TVUS) is accepted as the screening tool of choice to identify those at highest risk of malignancy. A new referral pathway was instigated in 2000, with patients only being referred to a gynaecologist following an abnormal TVUS result. An initial audit revealed a low positive predictive value for TVUS and a low incidence of detected malignancy. The cut-off value for a normal endometrium was increased from 3 mm to 4 mm in line with published data. This re7hyphen;audit evaluated the effectiveness of implemented changes and identified other areas for improvement. Of the 277 women referred during the study period, 193 had an abnormal or unseen endometrium and were subsequently seen by a gynaecologist. For patients without a histological diagnosis, clinical notes were reviewed and the hospital cancer database scrutinized for all endometrial cancers. Despite a 15.4% increase in referrals, only an additional 2.9% were assessed by gynaecologists. 14 cases of malignancy were identified with a mean endometrial thickness (ET) of 15.7 mm. Failed endometrial sampling was more prevalent with a minimally thickened endometrium. 80 patients with abnormal TVUS had no recorded histological diagnosis. Increasing the ET cut-off value has reduced unnecessary investigations in women at low risk of malignancy. No woman discharged back to her GP has been diagnosed with an endometrial malignancy within 1 year of initial referral. An algorithm has been proposed to further improve the investigation of women with PMB following an abnormal TVUS.

Annual surveillance by CA125 and transvaginal ultrasound for ovarian cancer in both high-risk and population risk women is ineffective.

OBJECTIVE: To assess the efficacy of annual CA125 and transvaginal ultrasound (TVU) scan as surveillance for ovarian cancer. DESIGN: Retrospective audit. SETTING: NHS Trust. POPULATION: Three hundred and forty-one asymptomatic women enrolled for ovarian cancer screening: 179 were in a high-risk group (>10% lifetime risk of developing ovarian cancer), 77 in a moderate risk group (4-10% lifetime risk of developing ovarian cancer) and 71 in a near population risk group (<4% lifetime risk). METHODS: Retrospective audit of case records, laboratory CA125 results, radiology reports, histology records and local cancer registry data. MAIN OUTCOME MEASURES: Ovarian cancers occurring in study population. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TVU, and CA125 as a screening tool for ovarian cancer. RESULTS: Four ovarian cancers and one endometrial cancer occurred. One ovarian cancer was detected at surveillance, three occurred in women who presented symptomatically between screenings. Thirty women underwent exploratory surgery because of abnormal findings at surveillance. Two women had cancer (PPV = 6.7%); one had ovarian cancer and the other endometrial cancer. Twenty-eight women (93.3%) had no malignancy. Sensitivity, specificity, PPV and NPV for TVU in the whole cohort were 33.3, 85.8, 0.6 and 99.8%, respectively. For high-risk individuals, the figures for TVU were 33.3, 84.5, 1.1 and 99.6, respectively. Combining both modalities for the whole cohort, the sensitivity, specificity, PPV and NPV were 66.7, 82.9, 1.5 and 99.8% and 50.0, 82.8, 1.3 and 99.7%, respectively, for the high-risk group alone. CONCLUSIONS: Ovarian screening by annual TVU and CA125 is inefficient at detecting early-stage ovarian cancers.

Accuracy of transvaginal ultrasound in diagnosing endometrial pathology in women with post-menopausal bleeding on tamoxifen.

The incidence of endometrial pathology is increased in women with tamoxifen-induced post-menopausal bleeding (PMB). The aim of this study was to determine the accuracy of transvaginal ultrasound (TVS) in diagnosing endometrial pathology in symptomatic women taking tamoxifen, using endometrial thickness measurements (5 mm and 10 mm cut-offs) and morphological changes within the uterine cavity to define abnormality. The sensitivity of TVS was 97% (95% confidence interval (CI) 83% to 100%) and the specificity 35% (95% CI 17% to 56%) at a 5 mm threshold. The corresponding likelihood ratios for a positive test were 1.47 (95% CI 1.16-2.10) and a negative test were 0.09 (95% CI 0.02-0.53). The use of a higher 10 mm threshold, characterization of endometrial morphology or combining endometrial thickness and morphology did not improve overall accuracy. TVS measurement of endometrial thickness using a 5 mm cut-off is highly accurate in excluding endometrial disease in symptomatic women taking tamoxifen and may negate the need for further diagnostic testing in women unless symptoms recur. A positive TVS result is of little value, so further testing is mandatory in order to detect benign and malignant endometrial disease associated with tamoxifen and PMB.

Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary.

BACKGROUND: Absence of the adnexa may be congenital or acquired. However, the etiology is often uncertain. CASE: A 27-year-old woman presented with a 3-year history of subfertility. Her irregular menstruation was associated with acne vulgaris, alopecia, and elevated body mass index. Transvaginal ultrasonography of the pelvis showed a normal uterus, a normal right ovary, but a polycystic-appearing left ovary. A hysterosalpingogram demonstrated a normal uterine cavity, prompt filling and spilling of contrast material from the left fallopian tube, but no filling on the right. Subsequent laparoscopy showed an unexpected absence of right adnexa and presence of a solitary rounded free-floating mass enshrouded in the omentum. She did not have a history of abdominal pain or surgery. CONCLUSION: The evidence suggests that the patient might have had an asymptomatic infarction of the right adnexa.

Long term safety of fluoroscopically guided selective salpingography and tubal catheterization.

BACKGROUND: The irradiation of the ovaries of reproductive age women during fluoroscopically guided selective salpingography and tubal catheterization has raised concern about the safety of the procedure. In addition to the risk of cancer induction, which exists with the irradiation of all tissues, with the gonads, the induction of hereditary disorders is possible. The objective of this study was to estimate these risks and present them in a clinically meaningful way. METHODS: Retrospective analysis was undertaken of 366 consecutive cases of selective salpingography and tubal catheterization performed at the Birmingham Women's Hospital, UK. The radiation doses of different types of procedure were compared with the background annual radiation dose. The risks of cancer and genetic disorders induction were calculated using conversion coefficients published by the International Commission on Radiological Protection. RESULTS: The radiation dose women were exposed to during selective salpingography and tubal catheterization under fluoroscopic guidance was a fraction of the background annual radiation dose. The excess lifetime risks of cancer and hereditary disorders were in the order of four to 13 and two to six per million procedures respectively. CONCLUSIONS: The long term risks of selective salpingography and tubal catheterization under fluoroscopic guidance are low.

Obstetric ultrasound: What the radiologist needs to know.

Obstetric ultrasound forms an integral part of modern obstetric care. This includes the use of ultrasound for screening as well as in diagnostic and therapeutic roles. Radiologists involved in this field must have the appropriate training and expertise to match the type of investigation or screening procedure to be undertaken. There should be an explicit understanding of this training and expertise both for the referring obstetrician and expectant mother. All radiologists involved in the care of women should have a thorough understanding of the normal and abnormal appearances of the first trimester as early pregnancy disorders present to the generalist; however, a smaller number of radiologists are involved in anomaly screening and management of growth disorders and still fewer in tertiary referral work. Obstetric medical practice is increasingly litigious and the aims of screening ultrasound and the limitations (false-negative and false-positive rates) should be explicit not only to the referring clinician but also to the expectant parents prior to screening. The diagnostic accuracy of ultrasound should be known in order that the expectant mother can give informed consent.

Patient dosimetry in hysterosalpingography: a comparative study.

Ovarian doses for 45 women undergoing hysterosalpingography (HSG) at our institution were calculated. Lithium borate thermoluminescent dosemeters were used to measure entrance surface doses in standard positions. The study compares the estimated dose received by 21 patients undergoing the procedure using an analogue fluoroscopic unit and standard film-screen radiography with that received by 24 patients who were imaged using a digital screening system with a C-arm. Our results show significant dose reduction is obtainable for patients undergoing HSG when a digital system is employed.

Bladder visualisation as a prognostic sign in oligohydramnios-polyhydramnios sequence in twin pregnancies treated using therapeutic amniocentesis.

Oligohydramnios-polyhydramnios sequence in twin pregnancies may be managed by aggressive amniocentesis and is described in nine consecutive cases. In four of the nine pregnancies both twins survived, one pair died in the neonatal period, and the other four pairs all suffered intrauterine death. The median number of amnioreductions performed was five (range 2-7). In this series the reaccumulation of urine in the bladder of the 'stuck twin' was a predictive prognostic marker of survival in both twins, with a sensitivity and specificity of 100%.

Fetal echogenic gut: a marker of intrauterine gut ischaemia?

The pathophysiological significance of fetal echogenic gut (FEG) is unknown. Our aim was prospectively to evaluate FEG in infants with intrauterine growth retardation (IUGR) and absent umbilical artery end diastolic flow velocities. Over a 15 month period, nine infants with FEG met these criteria. Nine infants who, on antenatal assessment, had demonstrated IURG and absent umbilical artery end diastolic flow velocities, but no evidence of FEG, were selected as case-controls. Gastrointestinal function was then prospectively evaluated in both groups after delivery. All liveborn infants received nasogastric feeds of breast milk by 8 days of age. All in the FEG group developed marked abdominal distension, large, bile stained, nasogastric aspirates, and constipation requiring rectal washouts. This led to a discontinuation of enteral feeds on one or more occasions. Two patients in the FEG group required water soluble contrast enemas in order to relieve intestinal obstruction. In the control group, 3/9 patients had abdominal distension, but no rectal washouts were given and enteral feeds were not interrupted. The median (range) time to tolerate full enteral feeds was 15 (7-32) days in the FEG group, compared with 4 (1-8) days in the control group. In the FEG group 5/6 patients required parenteral nutrition for 5-27 days. In the control group one patient required parenteral nutrition over a period of four days only. No child had necrotising enterocolitis or cystic fibrosis. When FEG is observed in the fetus with IUGR, problems with enteral feeding should be anticipated.

Patients' perception of the hysterosalpingogram: the initial stages of the audit cycle.

A prospective study of 98 consecutive hysterosalpingogram examinations was undertaken to evaluate patients' understanding of the examination, to assess their anxiety levels and to identify any factors where improvements might alleviate this anxiety. This was achieved by employing three simple questionnaires, two being completed by the patient (before and after the examination), the third being completed by the radiologist who recorded clinical and technical details. In this study the majority of patients knew why the examination was being performed, although only 50% had received an explanation of the technique prior to their arrival in the department. Anxiety levels associated with the examination were high. The importance of a sympathetic approach by the radiologist prior to the examination was highlighted, and it was found that time delays contributed to the anxiety level.

The role of hysterosalpingography in modern gynaecological practice.

A retrospective review of hysterosalpingography (HSG) in a major gynaecological centre was carried out. 324 patients attended (95%) for HSG out of 341 patients referred for this investigation. 189 examinations (58.3%) were abnormal. The requests and radiological findings were reviewed and the results compared with laparoscopy. HSG remains an integral part of gynaecological investigation and its value has not diminished in modern practice.

Duplex ultrasound of the common femoral vein in pregnancy and puerperium.

The common femoral veins of 34 apparently normal women were examined by ultrasound during or just after pregnancy. The cross sectional areas of these veins were measured at rest in the supine position and during a Valsalva manoeuvre. The veins were also assessed by pulsed Doppler ultrasound. We believe that Doppler examination is superior to calibre response assessment during the Valsalva manoeuvre in excluding an isolated iliac occlusion in women in late pregnancy and in early puerperium.

Prenatal diagnosis of nuchal cystic hygroma.

Twenty-seven cases of nuchal cystic hygroma were diagnosed prenatally over a 5-year period at the Birmingham Maternity Hospital. Karyotypes were obtained in 20 cases, of which 14 (70%) were abnormal. Two-thirds of these represented various trisomy syndromes in contrast to other series where cases of Turner's syndrome have predominated. Twenty pregnancies were terminated. There was one intra-uterine death and two neonatal deaths. Hydrops was present in 15 cases, none of which survived to term. Associated structural abnormalities, mainly skeletal, renal and cardiac, were present in 18 cases. There were four long-term survivors with good quality of life, including both normal and abnormal karyotypes. In utero regression of the hygroma was documented in five cases, total in three and subtotal in two cases born with residual neck webbing.

The prevalence of pleural effusions in pre-eclampsia: an ultrasound study.

A prospective ultrasound study was undertaken to investigate the prevalence of pleural effusion in patients with moderate or severe pre-eclampsia. The costophrenic angles of 34 consecutive patients were scanned postpartum with a real-time sector scanner. Six patients had pleural effusions. These patients did not have a greater degree of hypertension or proteinuria than the group without pleural effusion but had early severe disease requiring early delivery. The prematurity of these infants resulted in tenfold increase in perinatal death.

Postpartum pleural effusion.

A prospective ultrasound study investigated the reportedly high frequency of asymptomatic pleural effusions in the early postpartum period. The pleural space of 50 women within 1-45 h of delivery was scanned with a real-time sector scanner. Only one woman had a pleural effusion. This patient had severe pre-eclampsia with clinically apparent pulmonary oedema. Our findings do not substantiate the previously reported high frequency of pleural fluid in healthy women immediately after delivery.

Ultrasound findings in children with cystic fibrosis.

The results of a prospective study using ultrasound to assess abdominal complications in 76 children with proven cystic fibrosis are reported. Fifty-six patients (74%) had normal liver ultrasound scans. The most striking abnormality was an irregular, inferior edge to the liver occurring in 85% of abnormal liver scans and in 70% there was corresponding clinical and biochemical evidence of abnormal liver function. This finding has been only briefly mentioned before. Increased reflectivity in abnormalities of the pancreas and gallbladder is also described.