Trends in compliance with the national colposcopy guidelines.

This study aims to assess trends in compliance with current colposcopy guidelines in 10 gynaecological units in four English counties since 1996; to identify constraints on compliance and suggest change in practice. All 10 gynaecology units in Oxfordshire, Buckinghamshire, Northamptonshire and Berkshire participated. Data were collected prospectively by colposcopists from 23,500 new referrals across a 55-month period from September 1996 to March 2001. The Oxford Cancer Intelligence Unit performed collation, quality assurance and retrieval of data for incomplete records. Audit results were disseminated annually to colposcopists via the Regional Colposcopy Group. Colposcopy waiting times exceeded the standards, but waiting times for high-grade referrals showed statistically significant improvement. Six standards were achieved; relating to accuracy, appropriateness of management and outcomes. The seven unmet standards relate to waiting times, colposcopist's caseload, follow-up policy and the proportion of cervical epithelial neoplasia (CIN) on histology. Changes in practice are suggested, constraints on compliance are identified and the appropriateness of some guidelines is questioned.

Dermatomyositis presenting in pregnancy.

We report the onset of dermatomyositis in a woman pregnant 38-weeks who subsequently delivered a healthy infant. The disease improved rapidly following delivery. The association of dermatomyositis with pregnancy is unusual, and fetal outcome may be adversely affected.

Mild cervical dyskaryosis: safety of cytological surveillance.

How best to manage women who are found on cervical screening to have mild dyskaryosis remains controversial. Cytological surveillance misses some lesions picked up by colposcopy, but colposcopy is emotionally traumatic for women, the majority of whom will have a normal result. To determine what proportion of lesions are missed by cytological surveillance, and whether any abnormalities persist after colposcopy, we studied, by means of colposcopy and biopsy, the prevalence of cervical intraepithelial neoplasia (CIN) and subclinical human papillomavirus infection (HPVI) in two groups of patients who had had a first smear showing mild dyskaryosis at least 24 months earlier. One group was recruited from a centre practising cytological surveillance, with colposcopy for patients showing persistent or progressive cytological abnormality. The other group all had early colposcopy and treatment. Of 214 patients recruited into the cytological surveillance group, 70 (33%) had been referred for colposcopy within 24 months. Colposcopy of the remaining 144 (after a mean interval of 27 months from presentation) revealed that 54 (38%) were disease free, 64 (44%) had HPVI/CIN1, 8 (6%) had CIN2, and 18 (12%) had CIN3. A smear at that time identified 12 of the 18 (67%) with CIN3 as needing close cytological follow-up (1 patient) or prompt referral for colposcopy (11 patients). 137 women in the early colposcopy group attended for the study colposcopy (after a mean interval of 32 months from presentation). 37% were found to have some abnormality persisting after an earlier colposcopy, but none had CIN3. Cytological surveillance of mild dyskaryosis resulted in a 12% risk of patients having a small CIN3 lesion after 2 years, but this risk was reduced to 4% by the addition of a third repeat smear 12 months after the second. With such a policy only about a third of women would require colposcopy, and the risk of missing serious underlying precancerous changes would be low.

Management of the pregnant woman with spinal cord injuries.

This paper forms part of an ongoing prospective study of pregnancy and labour in women with spinal cord injuries and combines a prospective and retrospective analysis of 17 pregnancies in 15 women with spinal injuries. The management and outcome in those 17 pregnancies is reviewed.

Controlled trial of a new cervical spatula.

A wooden spatula was designed to scrape the varied distribution of epithelial abnormalities of the cervix as seen at colposcopy. The efficiency of the spatula in obtaining dyskaryotic cells and improving the cellular quality of smears was compared with that of the Ayre spatula in a controlled trial. More than 17,000 smears were taken from women aged 14-86 years by more than 200 smear takers from 74 centres. Twenty two per cent more dyskaryotic smears were obtained with the trial spatula, and the cellular quality of the smears was improved in all age groups. Although it was associated with a slightly increased risk of bleeding, 83% of users preferred the trial spatula.

Abnormal cervical smears: are we in for an epidemic?

A retrospective study was conducted to examine the pattern of a disturbing increase in abnormal cervical smears in one health district. Past records over fifteen years (1965-79) were analysed to produce pick up rates according to age, screening state, severity of lesion, and area of residence. Main findings included an increased pick up rate in unscreened (5.8 to 12.9/1000 smears) and screened (0.9 to 3.6/1000 smears) women. The order of increase was proportionately much higher in women under 40 years. The only significant epidemiological variable in the catchment area was a substantial population increase, overweighted by the younger age groups. The principal conclusion of the study was that the increased pick up rates of abnormal cervical smears in the district reflected a true increase in the incidence of premalignant lesions of the cervix. Screening efforts aided by computerisation should be examined nationwide in order to reach high risk groups and thus try to prevent an increase in carcinoma of the cervix.

Female genital actinomycosis.

Four cases of female genital actinomycosis are added to the reported total of about 300. The relationship of the disease to the normal microbial flora, intrauterine contraceptive device usage and pelvic sepsis is explored. It is suggested that the disease may be more frequent than hitherto realized.

PIP: Actinomycosis of the female genital tract is the subject of this brief review article, which adds 4 new cases to 300 previously reported. The problem of delayed diagnosis because of the nonspecific nature of the symptoms is emphasized, and at present no definitive tests for the disease exist, furthering the likelihood of serious complications. Clinical grounds are the only means of diagnosis, and if actinomycosis is suspected clinically, a careful examination of a cervical smear or endometrial biopsy may let the physician prescribe antibiotics before laparotomy (or removal of an IUD, if present). Penicillin in large doses is recommended, but the organism is sensitive to many antibiotics. Recently, lincomycin and clindamycin have been used because of their better penetration into the circumscribed fibrotic abscess cavities which develop during actinomycosis, in addition to being effective against the secondary organims present. Abscess drainage and pelvic toilet at laparotomy are therapeutic, and at least 3 months of effective antibiotic treatment are required. The frequency of this pelvic infection is rising at an alarming rate, since doctors are now more likely to diagnose the condition.

Fetal wastage as a result of an alpha-fetoprotein screening programme.

Amniocentesis was performed in 102 pregnancies in which maternal serum-alpha-fetoprotein (A.F.P.) concentrations were raised. 18 pregnancies were terminated. There were 15 neural-tube defects, 2 gastrointestinal abnormalities (1 of which could have been corrected by surgery), and 1 case of hydrocephaly. There was an association between raised maternal serum-A.F.P. and complications of late pregnancy including premature labour, perinatal death, and severe pre-eclampsia. After amniocentesis there was spontaneous abortion of 3 normal fetuses and 1 abnormal fetus.

Controlled clinical trial of arginine for infertile men with oligozoospermia.

64 infertile men with oligozoospermia took part in a double blind cross-over trial. Each patient received matching capsules of a placebo and arginine for periods of 12 weeks. There was no difference in the conception rates of the wives or changes in the quality of the semen during each period of treatment.

[Tumors of the hilar cells of the ovary. Apropos of 3 cases]. / Tumeurs des cellules hilaires de l'ovaire. A propos de trois cas.

Three new cases of ovarian hilar cell tumour are presented. The variable types of presentation are discussed as well as the methods of approach to confirmatory diagnosis. A full range of investigations is essential to diagnosis prior to operation.

Artificial insemination (A.I.H.) for sperm antibodies and oligozoospermia.

Artificial insemination using husband's semen (A.I.H.) was carried out in 74 couples in most of whom the men had low sperm densities and/or a reduced sperm motility. There were 19 pregnancies (24%). The problems encountered and the reasons for failure are discussed.

PIP: A method of artificial insemination with couples suffering a variety of infertile conditions (retrograde ejaculation, low sperm density, low sperm motility, sperm antibodies, and cervical ''hostility'') is presented. 19 pregnancies from 74 couples were achieved in 2 years. Where appropriate, ovulation was induced in women with clomiphene citrate. Men with low sperm densities were given clomiphene citrate 50 mg daily and/or fluoxymesterone 5 mg daily. After a good response to treatment was noted (a sperm count of more than 10 X 10(6)/ml, when motility was more than 30%, if antibodies were demonstrated in either partner, and if cervical ''hostility'' had been demonstrated), AIH was offered. Couples were asked to abstain from intercourse for 1 week before the husband produced a fresh specimen of semen on the day of insemination. Sperm samples were washed and centrifuged twice. The woman was positioned in a cystoscopic chair and the semen was injected slowly. The patient rested after insemination for about 15 minutes. 6 inseminations were performed in each case before the situation was reviewed. Failures were due to tubal obstruction which was undiagnosed, endocrine deficiencies, and cervical ''hostility.''

The use of a computer in an obstetric department.

Experience with a computer in an obstetric department is presented. A regular statistical analysis of the work of the department was readily available and computer printed summaries were produced for 86 per cent of the patients within one week of their discharge home. Solutions to problems encountered are discussed. It is concluded that a computer can be used economically and advantageously in this way even in hospitals without a computer on site. Future developments in the use of the computer are outlined.

Mangement of vaginal carcinoma after hysterectomy.

Vaginal carcinoma after hysterectomy occasionally has developed into an invasive lesion. Three cases, all treated differently, are described. The means of preventing further disease and for differently treating the vaginal lesion are discussed. Radiotherapy is recommended for invasive lesions and surgery or surveillance for noninvasive lesions.

Intrauterine death treated with intrauterine extra-amniotic prostaglandin E2.

PIP: This paper presents 2 cases of intrauterine death induced satisfactorily using intrauterine extraamniotic Prostin E2. The 1st case involved a 39-year old woman with severe hypertension and superimposed toxemia. She was admitted at 24 weeks with a blood pressure of 175/100 mm Hg, albuminuria, and edema. Ultrasonic biparietal measurement showed increasingly retarded fetal growth. Intrauterine death occured at 32 weeks. Labor was induced with intrauterine extraamniotic Prostin E2 introduced by a Foley catheter. This was the method of choice because of the patient's hypertension, albuminuria, and impaired renal function. The patient delivered uneventfully after 5 hours and 3 doses of 2 ml. There was no puerperal pyrexia. The 2nd case involved a 38-year old woman who suffered intrauterine death at 28 weeks due to severe Rhesus isoimmunization. Intravenous oxytocin and intravenous prostaglandin were initially used unsuccessfully to induce labor. Labor was induced rapidly using PGE2 via the intrauterine extraamniotic route. Full dilation was achieved with intravenous oxytocin. Induction delivery interval was 9 hours. There was no puerperal pyrexia. It is suggested that intrauterine but extraamniotic PGE2 is a reasonable method of induction in cases of intrauterine death because of the short induction delivery interval. Active management of intrauterine death is needed to avoid potentially serious complications, the most serious of which is the risk of coagulation disorder if the dead fetus is left in utero. Other important considerations are the patient's hospital beds. Intrauterine extraamniotic PGE2 may be safer and more effective than amniotomy and intravenous oxytocin and intraamniotic hypertonic saline because the membranes are left intact and because of the rapid induction time.^ieng