Embryonic Development of Human Haematopoietic Stem …



Proceedings of The Annual Meeting Of Northern Obstetrical And Gynaecological Society Of Scotland

Held At Queen Margaret Hospital, Dunfermline, Scotland

On 6th June 2014

Chairman: Professor Siladitya Bhattacharya

Honorary Secretary: Dr Lucy Caird

Scientific Secretary: Dr Tahir Mahmood

(Correspondence to : Professor Bhattacharya)

Embryonic Development of Human Haematopoietic Stem Cells: Gynaecology Contributes to Stem Cell Biology

Andrejs Ivanovs,1,2 Stanislav Rybtsov,1 Richard A. Anderson,3 Marc L. Turner1,4 and Alexander Medvinsky1

1MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh

2Department of Obstetrics and Gynaecology, Victoria Hospital, Kirkcaldy

3MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh

4Scottish National Blood Transfusion Service, Edinburgh

Background: Haematopoietic stem cells (HSCs) emerge early during embryogenesis and maintain haematopoiesis throughout the entire lifespan of the organism. Due to a very limited access to early human embryonic tissues, the embryonic development of the human HSCs remains a largely unexplored area of research. A better understanding of this process is not only of academic interest but also of potential practical importance. Although bone marrow and umbilical cord blood-derived HSC transplantation is performed for a number of therapeutic indications in the clinic, the availability of suitable donors is inadequate. Therefore, many research laboratories are investigating the possibility of generating HSCs from pluripotent stem cell under controlled conditions in the laboratory s. For many years, this remains a significant challenge. We believe that a better understanding of the embryonic development of human HSCs may be instrumental in developing novel protocols for their production in vitro.

Materials and methods: Human embryos (n=112) were obtained immediately after elective medical termination of pregnancy. The study was approved by the Lothian Research Ethics Committee. Before tissue specimens were obtained and anonymised, each patient gave informed consent in writing for the use of human embryonic tissues in research. Sublethally irradiated immunodeficient NOD.Cg-PrkdcscidIl2rgtm1Wjl/Sz mice were used as recipients for human embryonic HSCs.

Results: Employing the xenotransplantation assay, we have performed the spatio-temporal mapping of HSC activity in the human embryo and have shown that human HSCs emerge first in the aorta-gonad-mesonephros (AGM) region, specifically in the ventral wall of the dorsal aorta. Human AGM region HSCs transplanted into immunodeficient mice provide long-term high-level multilineage haematopoietic repopulation. These cells, although present in the AGM region in low numbers, exhibit a very high self-renewal potential. A single HSC derived from the AGM region generates around 600 daughter HSCs in primary recipient mice, which disseminate throughout the entire recipient bone marrow and are retransplantable. We also established the immunophenotype of the earliest human HSCs, which is CD34+VE-cadherin+CD45+c-Kit+Thy-1+Endoglin+Runx1+CD38-CD45RA-.

Conclusions: We provide a systematic spatio-temporal analysis of HSC emergence in the early human embryo and identify the AGM region as the primary source of HSCs with enormous self-renewal capacity, which supersedes that of bone marrow and umbilical cord blood-derived HSCs currently used in the clinic. This high potency of the earliest HSCs sets a new standard for in vitro generation of HSCs from pluripotent stem cells for the purpose of regenerative medicine.

Where is the Ectopic? A Clinical Dilemma

Alexandra Ricea, Maria-Lena Gregoraidesb, Tahir Mahmooda

a. Department of Obstetrics and Gynaecology, Victoria Hospital, Kirkcaldy, Fife

b. Department of Radiology, Victoria Hospital, Kirkcaldy, Fife

Introduction:

Diagnosis of ectopic pregnancy remains a challenge, this is further compounded in cases of abdominal pregnancy where delayed diagnosis can be potentially life threatening. 95.5% of ectopic pregnancies are fallopian in origin. Of the rest 1.3% are abdominal; omental, splenic, hepatic and intestinal. Despite their relative rarity the mortality associated with abdominal pregnancy is 5.1 per 1000 cases, 7 times higher than other ectopics. The spleen is one of the rarest intra-abdominal sites for a pregnancy to implant. There have been 16 reported cases of splenic ectopic pregnancy in English literature – we believe this, the 17th case and the first to have been successfully treated with systemic methotrexate.

Case:

A 35 year old woman presented with shoulder tip and abdominal pain of 24hours duration with a positive urinary hCG. Abdominal ultrasound scan revealed large volume intra-abdominal haemorrhage and an empty uterine cavity. Initial serum hCG was over 11000. Emergency laparotomy was undertaken confirming large volume intra-abdominal haemorrhage. Pelvic and abdominal organs were inspected. Uterus, ovaries and fallopian tubes were normal, upper abdomen and omentum were inspected and no source of bleeding was seen. Given that there was no active bleeding a provisional diagnosis of tubal abortion was made. A wide bore drain was left in situ. In the following 24hours and she underwent a CT angiogram. This showed a ‘splenic haemangioma’ and a small amount of blood in the peritoneal cavity. Repeat serum hCG at 48hours showed a rise to over 12000. An ultrasound scan showed a ‘likely’ gestational sac in the hilum of the spleen. The patient then received methotrexate (100mg). Her hCG fell gradually and when it was no longer recordable a CT angiogram was undertaken and showed a residual splenic seroma proving successful treatment of the ectopic.

Discussion:

We present a review of the literature on splenic ectopic pregnancies. Of the now 17 cases, a primary diagnosis of splenic ectopic pregnancy was made in only 18% of cases. 70% of cases had an initial diagnosis of ‘ectopic pregnancy’. All but 2 of the cases required splenectomy for treatment; one case was managed with laparoscopic methotrexate injection and the case as above. We believe this to be the first successfully treated with systemic methotrexate. Although rare there must be reasonable clinical suspicious of abdominal ectopic pregnancy so as to allow for timely diagnosis and management.

Memorial Services Offered Following an Early Pregnancy Loss - What is Scotland Doing?

Dr. CH Irvine. Professor GP. Cumming – Dr Gray’s Hospital, Elgin, NHS Grampian

Introduction / Aims:

In the United Kingdom there is no legal requirement before the 24th week of gestation or having showed no signs of life to officially mark or recognize a pregnancy loss, but for some couples it is important to acknowledge the significance that this loss has had on their lives, regardless of gestation. Therefore, the aim was to review the services available to Scottish couples following a loss under 24 weeks gestation.

Methods:

With the use of a questionnaire, a phone call conversation was had with either the Sister-in-charge or Maternity Coordinator of twenty-two identified Early Pregnancy Units or Maternity Units in Scotland.

Results:

Twenty units were contacted. Thirteen of the twenty units responding offered a Memorial Service following an early pregnancy loss to all women after miscarriage, while the other seven units not routinely offering would only accommodate bereaving parents upon individualized request.

Of the thirteen units that do offer, eight hold annual services, two biannually and three units hold a service three times a year, quarterly or monthly respectively. Services were facilitated by hospital Chaplaincy in seven units, while three units held a midwife – led service and three units had a shared chaplaincy and midwifery input and one unit reported as being facilitated by a funeral director.

Twelve units advertised their memorial service through placing local newspaper bulletins, one unit included the use of local radio broadcast and two units used website advertisement. Eight units extended personal invitations. Eight units held their memorial services on site at the Hospital Chapel, with two satellite units referring families onto their main site. Four units held services at a crematorium and one unit held their service at a local church. Nineteen units offered mementoes, regardless of memorial services being offered or not.

 

Conclusion:

Memorial services held for couples following an early pregnancy loss vary across Scotland. These services are multidisciplinary and are held from monthly to annually. Advertisement of the services utilizes local media resources more than that of personal invitations, giving way to the possibility of ‘postcode lottery’ attendees. Those units who did not offer a routine memorial service were found to have not signposted to others that do. More work is required to ensure that the needs of couples are being addressed with respect to memorial services in Scotland.

Termination of Pregnancy service provision in Tayside-A step forward

Vidhya Balakumar, Speciality trainee year 3, Mythili Ramalingam, Academic Clinical Lecturer in Reproductive Medicine, Yeshwanthini Bhushan, Consultant Obstetrician & Gynaecologist – Ninewells Hospital and Medical School, NHS Tayside, Dundee.

Background: A total of 15/1000 women between the age group of 15 – 44 undergo termination of pregnancy (TOP) in Tayside according to the National Statistics Publication 2013. Termination services should aim to provide high-quality, efficient, effective and comprehensive care in order to improve outcome for women. NHS Tayside has the highest rate of termination throughout Scotland. There was a huge service provision change that happened in 2012 in our unit to provide best care for our patients attending this service.

Aims:

1.     To identify the number of women undergoing different types of TOP.

2.     To establish the compliance of seeing patients.

3.     To see the uptake of Longer acting reversible contraceptives (LARC).

4.     To compare the above characteristics before and after implementation of changes.

 

Methods: A retrospective review of data was performed.  All the patients who attended the TOP clinic over a 6 month period between 01/10/2013 – 31/03/2014 were included. A total number of 319 cases were identified. This population was then compared with the women who underwent TOP during the same time in 2009-10.

Results:

1. During 2013-14, 319 patients underwent termination of pregnancy compared to 491 in 2009-2010.In 2013-14, 79% had Medical TOP, 19% had Surgical TOP. There has also been a recent introduction of Manual Vaccum aspiration (MVA) which accounted for 2% of the cases. However in 2009-10, 85% had MTOP and 10% had STOP.

2. The compliance of seeing the patients within 7 days improved drastically from 31%to 85%. Ninety five percentage of the women were given treatment within 9 weeks gestation compared to seventy five percentage in 2009-10.About 95% and 97% of patients received treatment within 2 and 3 weeks respectively. This has also significantly improved from 46% and 81% respectively.

3. LARC contributed to 50% of all post termination contraception like before, of which nexplanon (31%) was the most desired method. There was an increase in the uptake of combined contraceptive pills (COCP) – (38% vs. 18%) There was also a decrease in use of condoms (9% vs. 14%).About 3% of the population went home without contraception.

Conclusion: The compliance rate of seeing and treating the patients have improved remarkably, after implementation of the recent changes in the unit. Majority of the patients choose LARC as the preferred method, although there is a rise in the patients choosing COCP recently. Medical TOP remains the common method of termination with a significant proportion undergoing the procedure prior to 9 week gestation.

An Audit on referral of Poly Cystic Ovarian Syndrome (PCOs) cases from primary to secondary care.

A. Kamran, M. Joy, P. Ashok – Aberdeen Royal Infirmary, Aberdeen.

Aims: To investigate the appropriateness of referrals made from primary to secondary care for the diagnosis and management of polycystic ovary syndrome. To check if appropriate and complete investigations were done and symptomatic treatment was started prior to referral.

Methods: Electronic referral letters from primary care and specialist consultation documents of all patients seen in Gynaecology OPD in 6 months were retrospectively reviewed to identify referrals made to secondary care for PCOS diagnosis and management.

Results: 19 cases were identified. 53% referrals were inappropriate. Only 20.5% cases were referred after complete biochemical profile. 53% had incomplete profile and 26.5% had no profile done. No pelvic USS was requested in 47% cases which subsequently had to be arranged in secondary care. Basic symptomatic treatment was initiated on only 5% cases prior to referral. Average waiting time for specialist appointment was 3 months, after which 26% patients were discharged back to primary care with standard lifestyle modification advice.69% cases were initiated with basic symptomatic treatment with no specialist follow up needed. 15 % patients were followed up, most cases for reviewing initial incomplete biochemical profile , updated in secondary care.

Conclusions: Lack of consensus exists on threshold of referrals to specialist care. Referral without complete investigations or trial of symptomatic treatment have resource and cost implications. A re audit be done after dissemination and implementation of a referral pathway with clear algorithm for diagnosis and management for cases in primary care and referrals to specialist care be made after fulfilling set criteria to possibly reduce unnecessary workload and cost implications.

Ovarian cysts in Pre-menopausal women as emergency Gynaecology admission: An Audit

Fatima F, Haque L, Ashok P – Aberdeen Royal Infirmary, Aberdeen

Objective: Ovarian cysts are common and up to 10% of women will undergo some form of surgery during their lifetime for the presence of an ovarian mass. These are usually benign in almost all premenopausal women. The aim of clinical management is to identify those women who will require more than only conservative management, given that most ovarian cysts in this population will resolve spontaneously.

Method: Retrospective case note analysis. Total 36 patients identified as acute admissions between May to August 2012

Results: Twenty four women were managed conservatively and 11 underwent laparoscopy (Diagnostic +\- proceed), due to symptoms or the size of cysts on ultrasound. Among these, 2 patients had negative findings in theatre. One patient required referral to oncology services and had a laparotomy. One patient underwent aspiration under ultrasound guidance, due to very high BMI being a contra-indication to definitive surgical management. Imaging heavily influenced management in all cases. TransVaginal (TVUSS) ultrasound is favoured over TransAbdominal (TAUSS) and is also recommended. In this population 31 underwent TVUSS. Two had only TAUSS. Three patients underwent Computed Tomography (CT) without any other imaging and they were initially under the care of the general surgeons, referred to gynaecology after CT. Four cases were identified in which complex cysts may have necessitated further imaging by either CT or MRI. CA125 is a useful tumour marker in those with non-simple cysts. Seventeen women had this measured. However seven of these women had only simple cysts. There were eleven cases identified whose imaging should have prompted measurement of CA125, but did not, three of these were initially under the care of the general surgeons. Other tumour markers, such as LDH and AFP were ordered inappropriately in three cases,CEA,HCG inappropriately in seven cases and should have been requested in one other case. None of the 36 patients identified had had a Risk of Malignancy Index(RMI) documented. Twenty seven patients were appropriately followed up.The remaining patients were seen in clinic or re-scanned inspite of no indications.

Conclusion: Clinical judgement clearly plays a key role in the management of premenopausal women with ovarian cysts. There may be a greater role for the use of definitive guidelines. A better working knowledge of these as well as expert consensus on management may improve patient outcomes and reduce costs.

Reference:

1. RCOG, Management of Suspected Ovarian Masses in Premenopausal Women (Green-top 62)

An audit of pre-referral ultrasound scanning and calculation of risk of malignancy index (RMI) in women referred to the gynaecology oncology service with suspected ovarian cancer.

Ruth Hadebe, Daniel Chew, Zaid Hasafa, Jon Clarke – Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen.

Aims: The aim of this audit was to see if women referred with suspected ovarian cancer had undergone appropriate ultrasound scanning and calculation of RMI prior to referral in line with current guidelines.

Methodology: A prospective study over ten weeks identifying women referred with possible adnexal pathology. A proforma was produced to record patient age, source of referral (General Practice, inter- or intradepartmental referrals), whether an appropriate ultrasound scan had been performed to allow calculation of RMI and any other imaging performed. In addition the types of tumour marker requested was recorded and the final diagnosis was correlated with the calculated RMI.

Results: there are almost 800 women per year referred to the gynaecology oncology department each year with approximately 20% of these referred with adnexal masses. In the timeframe of this audit there were 24 patients included. Half of these women had not had an Ultrasound scan of pelvis performed making it impossible to calculate the RMI. In these patients, the pathology correlated appropriately with the RMI in almost every case. Several patients had inappropriate multiple tumour marker testing carried out.

Conclusions: Patients referred to gynaecology oncology should have an RMI calculated to allow appropriate triage. This should be done prior to referral to the gynaecology oncology team.

Twin pregnancy: Timing of planned delivery in a district hospital in Scotland

Ezzat A,Elkattan E, Marnoch K, Caird L, Kosseim M – Obstetrics and Gynaecology Unit, Raigmore Hospital, Inverness

Background: Multiple pregnancies are associated with higher complication rates than singletons. Over the last four decades multiple maternity rates have nearly doubled to 15.9 per 1000 births.

Aim: We aimed to audit the planned timing of uncomplicated twin pregnancy against the guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG) Consensus views arising from the 50th Study Group: Multiple Pregnancy.

Material and Methods: The RCOG guidelines on multiple pregnancies were used as audit standards. The retrospective audit assessed the timing of planned delivery in uncomplicated twins during the period from April 2011 to the end of December 2013. In total, 87 twin deliveries were audited (Monochorionic twins (MC)=15, Dichorionic twins (DC)=72).Eight deliveries were excluded (one triplet delivery and seven transferred deliveries). Variables assessed included chorionicity (MC and DC), gestational age at delivery, mode of delivery and obstetric complications, in addition to fetal and neonatal mortality.

Results: The mean gestational age of delivery for MC and DC twins was 251.4 days (95%CI -4.17, 2,97, SD=6.5, range=23) and 253.8 days (95%CI -9.12, -1.38, SD=16.5, range=112), respectively. There was no statistical significance between MC and RCOG guidelines of 252 days (p=0.724), with significance between DC and RCOG guidelines of 259 days (p=0.009). Total complication rate (obstetric complications and fetal mortality) for MC was 40% vs 42% in DC pregnancies. Malpresentations were reported as 13% breech in MC vs 18% breech and 1% hand in DC. Four fetal deaths and one neonatal death were reported in DC pregnancies with none reported in MC group. Overall, there were 47% vaginal and 53% caesarean section deliveries in MC compared to 39% and 61%, respectively, in DC pregnancies.

Conclusions: The timing of planned delivery in MC twin pregnancies was in accordance with the RCOG guidelines but not that of DC pregnancies which was significantly earlier. In this cohort, total complication rate for MC and DC pregnancies was surprisingly similar at 40%, which is inconsistent with existing literature that associates MC pregnancies with higher complications than DC. Additionally, at Raigmore District Hospital, DC pregnancies have a 1 in 6 chance of complicated breech malpresentation, higher than MC with a 1 in 8 chance. DC deliveries are also more likely at Raigmore District Hospital to be by caesarean section, whilst MC deliveries have a 50% chance.

Provision of information about delayed childbearing – Does it make a difference?

Michaela Watt (medical student), Prof Jennifer Cleland, Dr Abha Maheshwari – University of Aberdeen, Aberdeen

Background:

Throughout the world a greater proportion of women are postponing pregnancy. Numerous studies have repeatedly suggested that women are unaware of the implications of this decision and furthermore, have an overreliance on fertility treatments. Studies have suggested the need to provide information concerning this early in life, hence empowering women to make more informed choices. However, it is not currently known how best to frame such information, when to provide it and whether reproductive intentions can be modified by providing this.

Aim:

To identify if providing information about delayed childbearing alters the intended age of first childbirth of young professional women.

Methods:

This was a cross-sectional e-questionnaire study of female medical students at the University of Aberdeen. The study questionnaire was designed by drawing on the wider literature and Prospect Theory, allowing identification of what questions to ask and how to frame them positively and negatively.

Results:

Almost half (249 / 588) of potential participants responded. Providing information about delayed childbearing in either a positively or negatively framed manner and in a non-threatening and objective manner as a part of the curriculum had no significant impact on reproductive intentions. The success of fertility treatments were overestimated, as was the age at which fertility declines. Most participants agreed that information about the implications of delayed childbearing should be provided to both boys and girls.

Conclusion:

Further research is required to identify innovative methods to deliver information about delayed childbearing, thus enabling women to make more informed decisions on this matter.

Review of the University of Dundee Cumulative Assessment Programme (CAP)

Miss Kirsten Murray, Dr Vanessa Kay - University of Dundee Medical School, Dundee

Background:

Formative assessment is an important part of both undergraduate and postgraduate medical education in Obstetrics and Gynaecology. The Cumulative Assessment Programme (CAP) is a new, compulsory online formative assessment at Dundee Medical School. It is completed within 1 week and, to maintain flexibility, is not invigilated; nonetheless, students are instructed to abide by closed-book conditions throughout. The CAP contains questions from systems relevant to the students’ year of study. The feedback provided to students can be used to focus revision and facilitate an improvement prior to the summative assessments.

Aim and Methods:

The aim of this project was to analyse students’ feedback of the 2nd year medical student 2013 CAP using thematic analysis, suggest improvements to the medical school then analyse students’ feedback of the 2nd year medical student 2014 CAP and discuss whether the changes made had been successful.

Results:

The results show that there were similar positive aspects of the 2013 and 2014 2nd year CAPs, according to students. These include the opportunity to practice exam-style questions prior to summative assessment, being able to focus study on poorly-performing areas and helpful IT support. In addition, there were similar negative aspects; these include inadequate formative assessment provision within the curriculum and the inclusion of questions not yet covered by teaching.

Furthermore, the results demonstrate improvements between the 2013 and 2014 2nd year CAPs, according to students. These include the feedback, topic coverage, flexibility, ease of use, accessibility, reduction in errors and the provision of sufficient, clear and fairly distributed information pre-CAP. Finally, the results illustrate that some negative aspects have not been resolved between the 2013 and 2014 2nd year CAPs, in the opinion of students. These include IT issues, poor or noisy computer facilities and question topic proportions not being representative of the curriculum.

Conclusion:

The results show that the improvements made to the CAP have partly succeeded, but that room for future improvement remains.

Audit of the Management of Obstetric Cholestasis in NHS Tayside

M Smith, A Nicoll - Ninewells Hospital, Dundee

Aims: To determine whether women with obstetric cholestasis were being managed according to the local department protocol.

Methods: Women attending the Day Care Assessment Unit (DCAU) with ‘itch’ or ‘cholestasis’ between 01/12/2011 and Dec 01/12/212. Twenty-one women were confirmed as having obstetric cholestasis during this period. Information on investigations and management were obtained from Protos, ICE and medical records and standards were based on the local protocol. Data was analysed using Excel.

Results: The age range of the woman was 18-38 years (median 29 years). Obstetric cholestasis was diagnosed at a median gestation of 33 weeks (range 27-37 weeks). 10 women were nulliparous and 11 were parous, with 20 singleton pregnancies and one twin pregnancy. A previous history of OC was documented in 5 of the 11 parous women. Fourteen women (67%) had a viral liver screen performed at diagnosis and 7 (33%) had a liver ultrasound scan. Weekly LFTs and CTGs were peformed in 18 women (90%). Ursodeoxycholic acid was prescribed for 12 women. Induction of labour was arranged for 94% (17/18) and 95% of women delivered in the consultant-led unit. The women were delivered at a mean gestation of 37 weeks (range 35-40). Eleven women (52%) had a SVD, 5 (24%) had an instrumental delivery, 3 (14%) women had an elective Caesarean section and 2 (10%) had an emergency Caesarean section. Active management of the third stage occurred in all cases and four women (19%) had a PPH ≥1000ml. Neonatal vitamin K was given in all cases.

47.6% had LFTs taken on day 10 post delivery and 23.8% were reviewed in DCAU between day 14-31 to confirm resolution of itch and LFTs. Of the women who were not followed up, 1 was subsequently diagnosed with autoimmune hepatitis and 2 had laparoscopic cholecystectomies.

Conclusions: Since obstetric cholestasis remains a diagnosis of exclusion the local protocol recommends a viral liver screen and liver ultrasound scan, however this was not achieved in all cases. Improvements should also be made in postnatal follow-up and it is thought that the implementation of a checklist may help achieve these standards.

Review of maternal and perinatal outcomes for women with polyhydramnios

A. Y. Goh, A. E. Nicoll – Ninewells Hospital, Dundee

Aims: The aim was to investigate maternal and perinatal outcomes for women with singleton pregnancies with polyhydramnios in Tayside.

Methods: All women diagnosed with polyhydramnios (AFI≥25cm/deepest pool≥8cm) between 01/01/13-31/10/13 were included. All women had an ultrasound scan (USS) assessment of fetal anatomy and a random blood sugar assessment as part of routine ante-natal care. Data for obstetric outcomes were collected from the local maternity database (Torex Protos Evolution, v3.5.19).

Results: 59/3270(1.8%) were diagnosed with polyhydramnios. Median gestation at diagnosis was 34+2weeks (range=23+4-40+1weeks).

14/59(23.7%) were associated with diabetes; 5/59(8.5%) had pre-existing diabetes and 9/59(15.3%) had gestational diabetes.

5/59(7%) had perinatal aetiology; 1 case of rhesus isoimmunisation diagnosed at the ante-natal booking visit and 4 congenital abnormalities. 2 congenital abnormalities were diagnosed ante-natally (1 exomphalos, 1 oro-facial cleft). 1 tracheo-oesophageal fistula and 1 case of arthrogryposis multiplex congenita were diagnosed following delivery.

40/59(68%) had idiopathic polyhydramnios. 14/40(35%) resolved on USS. Median gestation at delivery was 39+1weeks (range=32+6-41+4weeks). Median birth weight was 3480g (range=1375-4400g). 3/40(7.5%) had pre-term birth. 18/40(45%) had induction of labour (IOL). The median gestation for IOL was 39+1weeks (range=37+1-40+3weeks). 20/40(50%) required caesarean section. 13/20 had planned CS and 7/20 had emergency CS. 4/40(10%) had major post-partum haemorrhage (PPH). 2/40(5%) neonates required NICU admission.

Conclusions: Idiopathic polyhydramnios is associated with a high rate of obstetric interventions. A diagnosis of polyhydramnios was associated with high rates for induction of labour, operative delivery and major PPH, and also adverse perinatal outcome. This information will be useful to counsel women with polyhydramnios and plan management.

The Role of Positron Emission Tomography - Computed Tomgraphy (PET-CT) In Cervical Cancer

A. Y. Goh – Ninewells Hospital, Dundee

Aims: The aim was to investigate the use of PET-CT in the detection of nodal metastases in cervical cancer before primary treatment. Lymph node involvement is an important predictor of long term survival in women with cervical cancer. The evaluation of nodal status using reliable imaging modalities is thus vital to improve treatment decisions. PET-CT is emerging as the best tool to detect nodal metastases.

Methods: A retrospective study was done on all women with cervical cancer in Tayside who underwent PET-CT before primary treatment. Nodal status reported on PET-CT was compared to histological findings after pelvic lymphadenectomy. In cases unsuitable for surgery, findings of PET-CT were compared to MRI to assess discordances.

Results: From September 2010 till January 2014, 26 patients underwent PET-CT at primary presentation of cervical cancer. 21(81%) who had stage IIA or lesser disease received surgery which included pelvic lympadenectomy. 2 out of these 21 women (9.5%) exhibited positive pelvic lymph nodes on PET-CT, but had negative nodes on histological examination. None of the 21 patients had positive nodes on histological examination.

5/26(19%) were unsuitable for surgery due to locally advanced disease and received chemo-radiotherapy. 4 had pelvic nodal involvement that was picked up on PET-CT and MRI. 2 had para-aortic nodal involvement on PET-CT, of which only 1 was detected on MRI.

8/26(31%) had incidental findings on PET-CT which necessitated involvement of non-gynaecological specialties. 3 underwent further investigations such as FNA of cervical adenopathy, repeat PET-CT and mammogram+breast core biopsy. None of these yielded abnormal results.

Conclusions: PET-CT is valuable in nodal detection for patients with locally advanced disease who have a high risk of nodal metastatic disease. However, false positive nodal uptake might occur. Women with operable disease should have nodal status confirmed by nodal sampling before a change in treatment plan is undertaken. PET-CT has the pitfall of false positive interpretations which can lead to unnecessary and potentially invasive investigations.

WHEN TO EMBOLIZE UTERINE FIBROIDS?

Does it have a place in the management of Intravenous Leomyomatosus?

Eman Elkattan*, James Mudzamiri* Natasha Inglis**

*Department of Obstetrics and Gynaecology, Raigmore Hospital, Inverness

**Department of Pathology, Raigmore Hospital, Inverness

Background: intravenous leiomyomatosis is an unusual presentation of uterine fibroids. They are intraluminal extensions of smooth muscle cells in either venous or lymphatic blood vessels. We present the case of a patient who requested embolisation for a fibroid uterus

Case report: 47 years old, para 4 patient who presented with heavy periods and pressure symptoms. Ultrasound scan was suggestive of multiple fibroid uterus with an intracavitary echogenic area which may represent submucous fibroid or endometrial polyp. MRI suggested an abnormality from the endometrial cavity passing through the entire uterine wall with partial enhancement and of unknown aetilology. The features were unusual and on that basis the request for endometrial ablation was denied. The patient underwent laparotomy and total abdominal hysterectomy and bilateral salpingoophrectomy was performed. A diagnosis of intravenous leiomyomatosis was confirmed at histopathology. We present a review of literature with a clearly described embolisation criteria for cases with suspected intravascular leiomyomatosis. We will also present this unusual case with MRI and pathology slides and propose options regarding management of this unusual pathology.

An unusual cause of chronic pelvic pain – case report and review of literature

Gopal G, McKinley C, Mahmood TA – Department of Obstetrics and Gynaecology, Victoria Hospital, Kirkcaldy KY2 5AH

Introduction: Permanent sterilization can be performed by removal of part of fallopian tube, by applying occlusive clips across the fallopian tube and more recently by introducing a coil hysteroscopically into the fallopian tubes to block the fallopian tube. Among these methods, Filshie clips are frequently used in the UK for female sterilisation.

Case report: A 45 yr old women, P1+1 with previous Spontaneous vaginal delivery and a termination of pregnancy 14 years ago, presented at the gynaecology outpatients with right iliac fossa pain for the past six years. The pain was described as “contractions in labour”, which had now become severe during the past three months. She had NOVASURE endometrial ablation and Laparoscopic sterilization in 2008. Up-to-date with cervical smears and pelvis was reported to be normal at previous laparoscopy. She had BMI 35, and abdominal examination revealed, tenderness in right adnexa, with no mass palpable. Pelvic ultrasound was reported normal. At laparoscopy we found dilated and fixed right fallopian tube adherent to anterior abdominal wall along with filshie clip attached under the visceral peritoneum. Uterus was fixed in acute ante version. There was no evidence of endometriosis or pelvic adhesions and abdomen and pelvis was otherwise normal.

The objective of this presentation is to understand and expand our knowledge and raise awareness about Filshie clip migration, as a cause of chronic pelvic pain. A literature review has been carried out, which raises a few ethical questions whose answers could be of value in our daily practice.

Methodology: A literature search was carried out in PubMed, MEDLINE with words ”Filshie clip migration”, “Filshie clip abdominal pain” on 23rd March 2014.

Results: This literature search has identified a total of 30 case reports and three reviews from 1991 to 2013. Most common symptoms were abdominal pain, dysuria, and recurrent abscess in ischiorectal, perianal, abdominal or pelvis. Spontaneous expulsion was also reported from Urinary tract or abdominal wall and through a fistulous tract. Investigations in these cases included abdominal x-ray, hysterosalpingomgram, hysteroscopy, laparoscopy, cystoscopy and fistulogram performed. Treatment involves antibiotics, surgery for repair of abdominal wall and bladder, recurrent abscess and fistulous tract. No death has been reported in any of these cases.

Discussion: ‘Not all cases of chronic pelvic pain are associated with Flishie clip migration’ but this literature search raises an important question. Should we include previous application of a Filshie clip in a list of differential diagnosis of chronic pelvic pain? The incidence of Filshie clip migration has been quoted as 1 to 6 in 1000 cases as against 2.5 to 7 in 1000 for failure of sterilization with filshie clip, from various parts of world. Should pre operative counseling also include the risk of Filshie clip migration or will we be overstating the risk? We are looking forward to a consensus view from the fellow colleagues.

An outlook of Outpatient Hysteroscopy services in NHS Fife

Siddiki S, Gopal G, Rob BA, Monaghan S – Department of Obstetrics and Gynaecology, Queen Margaret Hospital, Kirkcaldy, Fife

Aim:

RCOG recommends that all gynaecology units should provide a dedicated Outpatient Hysteroscopy service. There are clinical and economic benefits with this type of service. Our aim is to establish a patient-centred, cost effective and efficient outpatient hysteroscopy service at NHS Fife.

Methodology:

At Queen Margaret Hospital we run a weekly outpatient Hysteroscopy service with a consultant, two nurses and a healthcare assistant. The referrals are made after suitable patient selection. Patients receive an information leaflet and appropriate counselling prior to appointment. This prepares and sets patients expectations for a successful outpatient procedure. Each patient slot is 40mins including health check, vital signs, consent, procedure and recovery time. On average six patients are booked in one clinic session 0900-1230hrs.

Results:

We analysed our data from January 2012 to April 2014. A total of 160 cases were performed in the outpatient setting, including both diagnostic and operative Hysteroscopy. Endometrial biopsies, coil insertions/removals or vulval biopsies were excluded from selection criteria.

|Name of procedure |Number |

|Hysteroscopy +/- Endometrial biopsy |107 |

|Endometrial ablation (NOVASURE) |40 |

|Polyp removal (MYOSURE) |13 |

Safety: Of these 160 cases two were abandoned due to pain and vasovagal syncope and one for suspected perforation of uterus and procedure abandoned. The incidence of uterine perforation was very low in outpatient service compared to day case performed under general anaesthetic (GA).

Patient centred: The patient feedback survey for NOVASURE endometrial ablation revealed, 100% control of pain and bleeding, All patients expressed were glad that the procedure was carried out in outpatient setting and 95% said the pain was acceptable and would recommend to friend or family. There was no difference in uterine cavity dimensions and ablation time, when compared with NOVASURE performed as Day case under GA.

Cost-effective: In the absence of this clinic, these cases would have taken in-patient theatre slots. They would require a theatre team including anaesthetist, GA, hospital day surgery bed; potential need for 23hrs stay and 2-4 days leave from work.

Conclusion:

Outpatient Hysteroscopy is an essential part of ambulatory Gynaecology service. It is popular, acceptable, cheaper and successful service. We have demonstrated the successful extension to the procedures safely offered in this type of setting.

Audit on Outcomes of Laparoscopy Vs Open hysterectomy in benign Hysterectomy women in fife population – a preliminary report

Gopal G, Alsharaydeh I, Thanoon O, Lim C, Mahmood TA – Department of Obstetrics and Gynaecology, Victoria hospital, Kirkcaldy, Fife

Aim: To compare patient characteristics and clinical outcomes of women who underwent either Laparoscopic hysterectomies or Open abdominal hysterectomies for non-cancerous indications in Fife from August 2012 to October 2013. The audit has been set up to compare our unit’s performance against NICE guideline N1413, Laparoscopic techniques for hysterectomy Nov 2007. This audit has been set out to compare 100 cases in each group, and these are the preliminary results of first 54 cases.

Methodology: All benign total hysterectomies (Laparoscopic, Laparoscopic Assisted vaginal and Abdominal) with or without bilateral salpingo-oophorectomy performed at Victoria hospital, Kirkcaldy from August 2012 until October 2013 were included. All women, who had Subtotal hysterectomies or operated by the oncology team and had a suspicion of malignancy, were excluded. Audit project registered with the Quality improvement team for NHS Fife. Data were collected from OPERA and SCI store Software, which are used in Fife to capture theatre and labs activity respectively.

Results: We had 27 women in each group, with a total of 54 during this period. Age and BMI distribution were similar between two groups. There were six women with previous caesarean section in open group but none in the laparoscopic group. In the Laparoscopy group, five patients had Intra or post-op complications (3 were treated with antibiotics, 1- required a Laparotomy with an excessive blood loss and one patient had a blood transfusion). In open hysterectomy group, ten women had intra or post-operative complications (3 patients required antibiotics, one patient had an excessive blood loss >1000mls, two were reported to have pelvic collections, one patient suffered from pulmonary embolism, and two women were readmitted). All women with open procedure required opioid PCA (Patient controlled Analgesia) and whereas nine patient in the laparoscopy group needed opioid PCA for pain relief. Average Uterine weight of the of the Histopathology specimen in the laparoscopy group was 157 grams compared with 51 grams in the open group.

|Averages |Lap group |Open group |

|Operating time (mins) |80.2 |84.82 |

|Intra & post-op complications (patient) |5 |10 |

|Post-op Hb drop (g/dl) |2 |2.88 |

|Length of stay (days) |2.33 |3.4 |

Discussion: Current evidence on the safety and efficacy of laparoscopic techniques for hysterectomy appears adequate to support their use. Operating time and length of stay was marginally shorter in the laparoscopic group. Intra-op and Immediate post-op Complications were lower in the laparoscopic group when compared to NICE standards. In our hospital, patient outcomes following laparoscopic hysterectomy are similar to what had been reported in the literature (NICE guidance, N1413).

Audit of Work Based Assessment Activity leading to a Code of Practice

Rebecca Northridge, Katrine Orr, Clare McKenzie - Ninewells Hospital, Dundee

Aim: The GMC 2011 survey highlighted difficulties for trainees in obtaining work based assessment targets as set out as standard in the RCOG matrix. The aim of this audit was to investigative this survey’s finding. A secondary aim was to establish the contribution by individual consultants to this assessment process to enable individualised feedback.

Methodology: One year of data was collected from 9 trainee eportfolios and analysed between August 2011- August 2012.

Results:

7.5 CBD’s per trainee average (Range 5-9), 2/8 trainees failed to meet matrix standard and 5/8 just reached minimum requirement of the 6

• 6 CEX per trainee average (Range 6-10), 0/8 failed to meet matrix standard and 4/8 reached the minimum requirement of 6

• 26 OSATS per trainee average (Range 6-33), 6/8 failed to meet matrix standard, largely in laparoscopic and basic labour ward skills

• No scanning OSAT’s were assessed by the consultant body

Conclusions: There was a need for a Work Based Code of Practice to raise awareness of the training needs of trainees but also to provide further guidance for consultants who are required to provide these formative assessments throughout the year. A code of practice guideline was produced in conjunction with several trainees and consultants.

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