Peritoneal tuberculosis mimicking advanced ovarian carcinoma: an important differential diagnosis to consider.

BACKGROUND: Female patients who present with ascites, adnexal masses and elevated CA125 levels are typically presumed to have advanced ovarian carcinoma. This can lead to radical surgery with its associated morbidity. An important differential diagnosis to consider is tuberculous peritonitis which can present in a similar manner and responds well to medical treatment. CASE PRESENTATION: A 44 year old female presented with abdominal distension, weight loss and low grade fever. Her CA125 level was 909 U/ml. Imaging studies revealed an adnexal lesion and ascites. The lungs appeared normal and a Mantoux test was negative. Ovarian malignancy was highly suspected. Cytology of ascites was negative for malignant cells. The patient subsequently developed a large pleural effusion which was drained and negative for malignant cells and acid fast bacilli. Repeat imaging revealed a 'tree in bud' appearance of the lung parenchyma and dense ascites. Histology from diagnostic laparotomy revealed caseating granulomas with epithelioid cells and Langhan's type giant cells. The patient responded well to antituberculosis therapy with normalization of CA125 levels, confirming the diagnosis of peritoneal tuberculosis. CONCLUSION: CA125 levels lack specificity, with elevated levels encountered in many benign and malignant conditions, including tuberculosis. There are a few discriminating features that suggest a diagnosis of tuberculous peritonitis rather than ovarian carcinoma. Apart from chest findings which may not always be present, smooth peritoneal thickening and a dirty omentum on CT favours a diagnosis of peritoneal tuberculosis compared with nodular thickening of the peritoneum and omentum in peritoneal carcinomatosis. PCR and ADA testing of ascitic fluid can also be helpful. When these tests are negative or unavailable then diagnostic laparoscopy or laparotomy should be performed with the aid of frozen section to avoid unnecessary radical surgery in cases of peritoneal tuberculosis.

Is this the end of the line for the moderate dyskaryotic smear?

OBJECTIVE: The British Society for Clinical Cytology has recently proposed that the terminology for cervical smear reporting is to be changed from a 3-tier system (mild, moderate, severe dyskaryosis) to a 2-tier system of low-grade and high-grade dyskaryosis. This modification eliminates the central category of moderate dyskaryosis which would be incorporated into the high-grade group. The aim of this study was to investigate the role of the moderate dyskaryotic smear in clinical practice. MATERIALS AND METHODS: A retrospective review of all women who were referred for colposcopy because of a moderate dyskaryotic smear was carried out for a 6-month period. Data collected included colposcopic impression, procedure performed and final histopathology. Two cytologists who were unaware of the original smear report were asked to reclassify these smears using the new 2-tier system. Their findings were compared with the documented colposcopic and histopathology results. RESULTS: One hundred women with moderate dyskaryotic smears were referred for colposcopy during the study period. Most of these were reclassified as high-grade dyskaryosis using the new system. Fifty-six (72%) of the moderate dyskaryotic smears which were correctly regraded as high grade by cytologist 1 were found to have cervical intraepithelial neoplasia 2/3 on final histopathology, whereas for cytologist 2, 66 (68%) were found to have high-grade cervical intraepithelial neoplasia. CONCLUSION: There is no clinical benefit in retaining the term moderate dyskaryosis. This study emphasizes the need for a uniform 2-tier system.

Isolated clear cell adenocarcinoma in scar endometriosis mimicking an incisional hernia.

BACKGROUND: The development of a mass in association with a previous surgical scar can pose a diagnostic dilemma due to similarities in appearance to hernias, abscesses, hematomas, or desmoid tumors. Scar endometriosis is an uncommon cause of such a lump, but malignant change within this ectopic tissue is exceptionally rare. CASE: We present a case of a 55-year-old woman who was found to have an isolated clear cell adenocarcinoma in an area of scar endometriosis more than 30 years after an open tubal sterilization. This mass was initially thought to be an incisional hernia, but was later diagnosed intraoperatively by frozen section and then incompletely excised, highlighting the difficulties in preoperative diagnosis as well as surgical treatment. CONCLUSION: Malignant change within scar endometriosis is rare, but increased awareness of this phenomenon is required. Vigilance is paramount and a mass located in or close to a surgical scar should be treated with suspicion.

The place of laparoscopic sterilization following previous abdomino-pelvic surgery - abstract

From 1991, women with previous pelvic surgery and who requested laparoscopic sterilization were evaluated clinically to determine their suitability for safe laparoscopic sterilization. Women who gave a history of postoperative sepsis or who had evidence of puckering of the surgical scar, immobility of the uterus and adnexae as well as the presence of a midline incision extending through the umbilicus were excluded. Forty women were evaluated, seven were found to be unsuitable by the above criteria. The other thirty-three had safe laparoscopic sterilization with no failures. The study also related the presence of intra abdominal adhesions with respect to the type of incision at Caesarean Section and other non-obstetric surgery. Adhesions were found in 9 of the 22 (41 percent) women who underwent caesarean section. Two of the other nine women were free of adhesion. In contrast, 7 of the 11 (64 percent) women with pfannestiel incisions had adhesions. There were adhesions in 4 of 11 women with non-obstetric surgery. In this group, 3 of the 4 women with midline scars and 1 of the 2 women with appendectomy scars had adhesions. The absence of injury to omentum and bowel in this study compares favourably to the 6 percent incidence noted in a similar but larger study published in early 1995. The low incidence of adhesions after midline scars at caesarean section is worth noting, especially since in our setting, women with this type of incision have traditionally been denied laparoscopic sterilization. It may be that the large postpartum uterus confers some degree of protection between the inferior surface of the midline abdominal incision and the bowel and omentum. It is felt that women with previous abdomino-pelvic surgery who request sterilization can benefit from safe laparoscopic sterilization using the above clinical screening criteria (AU)

Born before arrival (BBA) in Trinidad and Tobago: a 7-year case controlled study - abstract

328 babies were born before arrival (BBA) at Hospital over a 7-year period during which time the total number of births was 40,188. These were compared with two separated hospital delivered control groups (Control I: 302 patients of similar age and parity); (Control II: 262 patients of similar gestational age and foetal birth weight). It was found that BBA was more common in multiparous women (92.9 percent vs 75.5 percent) who had lack of antenatal care (20.1 precent vs 3.0 percent vs 3.4 percent, P<0.001) and who had a similar previous event(p<0.001). The condition was associated with a significant higher incidence of genital tract trauma (p<0.05) than in controls. Perinatal mortality was more common than in control group I but was similar to control group II, the latter because of the high risk obstetrical cases in this group. Unlike other studies, young maternal age, unmarried and distance from hospital were not significant contributing factors. Provision and uptake of antenatal care must be considered the cornerstone in the prevention of BBA and its serious consequences (AU)

The value of a prospective report on maternal deaths: a Trinidad experience letter

Most official measures of maternal mortality are underestimates and in 1984 it was noted that there was routine reporting of maternal deaths in only 35 percent of the world's population. Under-reporting in the USA ranges from 25-70 percent and a recent enquiry in France has estimated a 56 percent under-reporting. The problem is likely to be even worse in developing countries. Reporting of maternal deaths has been largely retrospective and Royston and Abou Zahr have identified poor record keeping, tampering and misplacement of patients' notes as factors which adversely affect the proper audit of amaternal deaths. In addition, in certain instances, deaths on the gynaecological wards, e.g. associated with ectopic pregnancy and septic abortion may not be recorded as maternal deaths, and the same can be said for maternal deaths on general medical wards. Over the 18 month period 7 May 1991 to 31 October 1992, we concluded a 'prospective' audit of maternal deaths at the San Fernando General Hospital, Trinidad. The mechanism of this audit was that the entire hospital staff was alerted and a specially designed form circulated so that complete data were entered as soon as a death occurred. There were 14 deaths giving a maternal mortality rate of 157/100 000 births. Six women died from haemorrhage (42.9 percent), with criminal abortion and hypertensive disorders of pregnancy accounting for three each. One died from puerperal sepsis and no definite cause was found at postmortem for one who died 24 h following elective Caesarean section. Our maternal mortality rate was found to be 20.7 times greater than that recorded in England and Wales in the triennium 1985-1987. This disparity also extended to the causes of deaths since deaths in Trinidad now follow a pattern that was present in the UK in the early part of this century. This rate of 157/100 000 birth represents as closely as possible the precise rate of maternal deaths in southern Trinidad. In contrast, a recent report has indicated the maternal mortality rate in Trinidad to be 30/100 000 births, a figure which compares favourably with those of other developing countries. However, this report emanated from another institution in Trinidad where deaths occurring over a 10-year period were analysed retrospectively, a method which lends itself to under reporting. Maternal deaths occurring in the community are received by the District Medical Officer who issues the death certificate. These are recorded at the Central Statistical office and only the principal cause of death, e.g. cerebrovascular accident is noted. These deaths are not recorded as maternal mortalities. Our finding in contrast indicates that using maternal mortality as an indicator, maternal care in Trinidad is several decades behind that of the developed world and, therefore, demonstrates the value of prospective data collection on maternal deaths (AU)

Basic practical gynaecology

The aim of this manual is to provide medical students and junior doctors with a means by which they can confidently approach the management of commonly encountered clinical problems in gynaecology. The format is intended to allow rapid and easy access to information because of the alphabetical listing; the wide margins are meant to highlight important differential diagnosis, to suggest helpful hints as well as to provide prescription information. Ample space has been left for personalised notes. As teachers at the University of the West Indies, we have been able to identify that these are the aspects of knowledge which trainees and students seek in order to complement information obtained from the traditional textbooks. It is our hope that readers find that their reference to these pages provides them with information which will impact favourably upon the efficient management of their patients

Basic practical gynaecology

The aim of this manual is to provide medical students and junior doctors with a means by which they can confidently approach the management of commonly encountered clinical problems in gynaecology. The format is intended to allow rapid and easy access to information because of the alphabetical listing; the wide margins are meant to highlight important differential diagnosis, to suggest helpful hints as well as to provide prescription information. Ample space has been left for personalised notes. As teachers at the University of the West Indies, we have been able to identify that these are the aspects of knowledge which trainees and students seek in order to complement information obtained from the traditional textbooks. It is our hope that readers find that their reference to these pages provides them with information which will impact favourably upon the efficient management of their patients (AU)

The relationship of a prenatal one-hour plasma glucose screening and risk factors in a mixed population - abstract

A 50 gm prenatal one-hour plasma glucose challenge test was done on 158 mothers between 24 and 28 weeks' gestation to evaluate the relationship of this test with recognized risk factors and ethnicity. A value of 140 mg/dl or more was considered abnormal. Twenty-one (13.9 percent) had an abnormal result. When compared to those with normal values we found that a positive result was noted in 36.8 percent of mothers over 30 years old compared to 6.6 percent of mothers less than 30 years old (p<0.001). There was no significant difference between both groups with respect to parity and a family history of diabetes mellitus or hypertension. More women of East Indian descent (20.9 percent) had an abnormal result compared to those of African and Mixed descent (11.3 percent); but the difference was not significant (p<0.1). Fifty percent of the women who were over 30 years of age and of East Indian descent had a positive screen. The sensitivity and specificity of the risk factors - age over 30 years and being of East Indian descent - were 63.6 percent and 40.9 percent for sensitivity with the specificity being 82.4 percent and 75.0 percent, respectively. The 13.9 percent positive screening value is high in comparison to international figures. This screening test has a role in primary care obstetrics, but because of the potential cost limitations to testing all antenatal patients, we recommend that there is merit in initially confining screening to the above two risk groups in our population (AU)

A comparison of the adhesion-barrier interceed (free), interceed (fixed) and Ringer's lactate in the prevention of post-operative adhesion formation - abstract

Forty white rats were randomly assigned into four groups in which a standardized adhesion-forming lesion was created at laparotomy. Attempts to prevent adhesion formation were made in the presence of an artificial adhesion barrier, Interceed (free or fixed with 6/0 vicryl sutures) and Ringer's lactate versus a control group. Interceed freely placed on the site resulted in either very low or very high adhesion scores. This suggests that Interceed is an effective adhesion barrier but that a method which does not itself create tissue reaction must be devised to keep the barrier in place. Further research into an appropriate "tissue glue" is required (AU)

Induced abortion: the unrecognized epidemic - abstract

A survey was conducted on 526 pregnant women attending 2 major general hospitals in Trinidad during late 1992 to early 1993 to determine the incidence of attempted termination of pregnancy, the popularity of the methods, the sources and agents as well as the immediate outcome following the attempt. Five hundred and six (96.0 percent) had unplanned pregnancies, and 168 (31.9 percent) had made an attempt to terminate the pregnancy. Chemical methods were twice as popular but physical methods were more successful (41.0 percent vs 34.8 percent); 25/56 physical attempts were done as backyard abortions with a failure rate of 88.0 percent. Medical practitioners were more likely to be successful (66.0 percent). Four women (7.1 percent) used self-administered physical methods. The pharmacist was the most popular source to offer chemical agents (32.1 percent) followed by the patient acting on her own (22.3 percent), a friend (19.6 percent) and the doctor (18.7 percent). The main agents offered were unknown while tablets (35.7 percent), herbs and bush (23.2 percent), misoprostol (22.3 percent), hormones (25.8 percent) and aloes (5.3 percent) were identified. Misoprostol and hormones were offered mainly by the pharmacist and had a success rate of 56.0 percent and 44.8 percent, respectively. Herbs and bushes offered by lay persons were generally unsuccessful. The high level of unplanned pregnancies and attempted terminations is a major public health issue. It reflects the deficiency in effective contraceptive practices and the preference of women to use "hind sight" birth control. The easy availability of potentially harmful drugs, in particular misoprostol, over the counter demonstrates the poor control of drug marketing and irresponsible behaviour. Unless the relevant authorities are sensitized to the magnitude of the problem induced abortion will remain the unrecognized epidemic (AU)

Is vaginal breech delivery at term a safe choice? a five-year experience at Mount Hope Women's Hospital, Trinidad - abstract

Of 29,785 deliveries during the 5-year period, 1986-1990, 675 (2.3 percent) were breech presentations at term. There were 279 primiparae (41.3 percent) and 396 multiparae. Total primary obstetrical care was provided at the local health centres for 274 patients (40.5 percent), by general practitioners in 79 and at the hospital clinics in 297 (44 percent). Foetal outcome was best in the latter group. Vaginal delivery was accomplished in 387 (57.3 percent) women and of the 288 caesarean sections, 138 were in primigravidae and 150 in multiparae. Foetal outcome as measured by the occurrence of birth asphyxia, fresh still births and early neonatal deaths was significantly worse for vaginally delivered breech babies. Improved outcomes would be expected if parturients with breech presentation are referred to the hospital specialist clinics and fewer vaginal births permitted. The alternatives of increased caesarean section rates or external cephalic version at term must be evaluated (AU)

The safety of short hospital stay for abdominal hysterectomy - abstract

During the period January, 1990 to April, 1992, a total of 138 abdominal hysterectomies were performed. Of these, 73 patients were permitted traditional full-length hospital stay (mean 6.0 days) and 65 were scheduled to stay for a short post-operative recovery (mean 3.6 days). Indications for surgery and patient characteristics were similar in the two groups. Only two of the short-stay patients had to kept longer than planned. Post-operative complications were fewer in the short-stay group. It is concluded that significant economic benefits and improved bed-space availability can be achieved safely by the curtailment of the length of hospital stay in patients for routine hysterectomy (AU)

The role of colposcopy in the evaluation of the clinically suspicious cervix - abstract

Women with any of the following symptoms of postcoital or intermenstrual bleeding, heavy bloodstained vaginal discharge, contact bleeding on smear taking, or clinical suspicion of cervical cancer, were evaluated by colposcopy without a prior Papanicolaou smear. This was done in order to evaluate the role of colposcopy in the evaluation of the "Clinically suspicious cervix", as Papanicolaou smear-taking in the presence of these conditions is associated with contact bleeding or heavy inflammation, resulting in an unsatisfactory smear or unreliable reporting. The colposcopic directed biopsies in 73 affected women found one (1.4 percent) to be normal, 20 (27.4 percent) to have cervicitis, 36 (49.3 percent) to have evidence of koilocytosis or mild to moderate dysplasia and 16 (21.9 percent) to have carcinoma in situ, microinvasive carcinoma or invasive cancer. The finding of pre-neoplasia and/or koilocytosis and carcinoma in one-fifth of women with a clinically suspicious cervix reinforces the clinical significance of the symptoms of postcoital and intermenstrual bleeding, as well as the importance of inspection of the cervix in relation to the detection of cervical cancer. The benefit of direct referral for colposcopy in such patients prior to Papanicolaou smear-taking is underscored (AU)

Carcinoma of the vulva in Trinidad: its clinical presentation and outcome - abstract

Carcinoma of the vulva comprises less than 3 percent of all gynaecological cancers. A review of the status of this relatively rare carcinoma in 24 Trinidadian women found 75 percent to be menopausal and 96 percent to be symptomatic with a mean duration of symptoms of 18 months. An advanced stage of disease was found in 70.7 percent and this, together with co-existing medical problems, accounted for the low operability rate of 68.4 percent. All 14 surgical cases suffered varying degrees of morbidity and there were 2 deaths. The 6 women who were deemed unsuitable for surgery died within months of presentation. Four of the 5 women with carcinoma in-situ benefited from excision-biopsy and remain disease free. Late diagnosis mainly due to a delay in clinical presentation adversely affected management. Improved health education concerning vulval diseases as well as closer clinical scrutiny of the vulva in symptomatic menopausal women would allow for earlier diagnosis and so reduce the unfavourable sentiments which surround this carcinoma (AU)

The Clinical effect of maternal hypertension on pre-term pregnancy - abstract

Pre-term neonates of hypertensive mothers have been reported to have an accelerated lung maturity and so an improved perinatal outcome compared to their normotensive counterparts. In order to substantiate this, we examined the case notes of 418 consecutive pre-term pregnancies (< 34 weeks) delivered during a 36-month period. Forty-eight cases without any other obstetric complication were identified. They were compared with 141 normotensive pregnancies identified similarly. More hypertensive mothers were delivered by Caesarean Section (77.1 per cent vs 3.5 per cent). Significantly more hypertensive pre-term pregnancies were associated with foetal distress in labour (44.8 per cent vs 2.8 per cent; p < 0.001) and low birth weight (41.7 per cent vs 1.4 per cent; p < 0.001). There were no differences in low apgar scores, respiratory distress syndrome and neonatal deaths. The findings suggest that maternal hypertension in pre-term pregnancies is associated with an increased incidence of intrauterine growth retardation and foetal distress, and that the perinatal outcome is no better than their normotensive counterparts. The previously reported benefit of "intrauterine stress" in hypertensive pregnancies is not substantiated in this series (AU)

Perinatal and neonatal care at the Port-of-Spain General Hospital, Trinidad: an analysis of mortality - abstract

In this retrospective study the following information was recorded for all 1,296 infants born in 1990 and admitted to the neonatal ward, General Hospital, Port-of-Spain: date of birth, gestational age, birthweight, Apgar scores after one and five minutes, type of delivery, foetal presentation, mother's address and data concerning death. The annual perinatal mortality rate was 25.2 per 1,000 live births. The neonatal mortality rate (NMR) equaled 12.8 per 1,000 live births and the still birth rate was 15.0 per 1,000 births. The NMR for the month of August was remarkably high. During the past ten years, the NMR showed a sharp decline since 1982. From a regression analysis, birthweight (R2 = .27), Apgar score after five minutes (R2 = .26) and gestational age (R2 = .22) emerged as predictors of neonatal mortality. Birthweight-specific NMRs in infants born in a regional hospital were equal to or higher than our monthly, yearly and interhospital variations in mortality rates, although the effects of differences in the study populations cannot be completely excluded (AU)

The knowledge and awareness of cervical cancer and the pap smear among schoolgirls in North Trinidad - abstract

Six urban secondary schools in North Trinidad were randomly selected and 500 questionnaires containing 15 questions to assess knowledge about cervical cancer and the pap smear were issued to their Fourth Form students (n=500). Three hundred and sixty-eight (74 per cent) completed questionnaires were analysed; 175 girls (47.4 per cent) were unaware of cervical cancer or the pap smear. Of the other 193, 88.6 per cent and 62.7 per cent had heard of cervical cancer and the pap smear, respectively. On further questioning of these 193 girls, 57.0 per cent, 57.5 per cent and 50 per cent answered appropriately to the questions on risk factors, the procedure and the venue for taking a pap smear, respectively. Lower percentages (29.0 per cent and 23.0 per cent) were able to correctly locate the cervix and identify the symptoms of invasive cancer. Reading was the most popular source of information (39.4 per cent), followed by parents (21.8 per cent) and teachers (8.8 per cent). These results imply that there is a substantial deficit in the knowledge and awareness of cervical cancer and the pap smear among secondary schoolgirls. A call is made for the introduction of a female health education programme in secondary schools (AU)

Is teenage pregnancy high risk? - the experience in Trinidad - abstract

In this case-controlled study of teenage pregnancy, all mothers aged greater than 16 years who delivered between January 1, 1992 and March 31, 1992 together with consecutive control patients aged 20-25 years of the same parity were enrolled. There were 147 teenagers and 145 matched controls. Among the teenagers, 2 were 13 years, 14 per cent were 14 years and 26 per cent were 15 years of age. The antenatal care uptake was high (97 per cent) in both groups. The incidence of anaemia, pregnancy-induced hypertension, preterm labour and preterm rupture of the membranes was similar in teenagers and controls. Gestational age at delivery was the same in the 2 groups. Obstetrical performance as measured by antenatal and intrapartum complications was similar in the two groups and there was no significant difference in foetal outcome. These findings are unusual for a developing country and may be related to the report that Trinidad and Tobago has enjoyed the status of being one of the most advanced countries within Latin America and the Caribbean with a high education and literacy rate and a substantial per capita income. Our data suggest that it is not necessary for pregnant teenagers to be referred for routine hospital antenatal care, thus allowing high-risk parturients of any age to be more efficiently accommodated and managed (AU)