DOI: 10.1111/1471-0528.

12780 Abstracts
[Link]

E-Posters

General Gynaecology

EP4.01 significance 1.33 (0.99–1.81, P = 0.061); oral medication and

The National Heavy Menstrual Bleeding Audit: the other treatments showed no significant associations with ethnicity.
association between ethnicity and treatment Conclusion This national study demonstrates that hospital
received in hospital treatment for HMB varies by patient’s ethnicity. After accounting
for potentially confounding factors, the effect is still observed.
Kiran, A1; Gurol-Urganci, I1; Tsang, C1; Knight,
Women of white (versus non-white) ethnicity were more likely to
H1; Cromwell, D1; Mahmood, T2; van der receive treatment by IUS and endometrial ablation, but were less
Meulen, J1 likely to receive myomectomy and UAE. Further research into the
1
London School of Hygiene & Tropical Medicine, London, UK; 2Royal pathology of HMB and its management by ethnicity is needed.
College Of Obstetricians and Gynaecologists, London, UK

Introduction Heavy menstrual bleeding (HMB) is prevalent in the

UK, affecting a quarter of women of reproductive age. The UK’s EP4.02
ethnic minority population has more than doubled since 1991, yet Will 3D USG substitute the gold standard
there is limited information on the relationship between ethnicity diagnostic tests of uterine anomalies?
and HMB. This study examines the association between ethnicity Nanjundan, P1; Pandian, R2; Rajesh, H1;
and the treatment for HMB in hospitals across England and Govindarajan, M1
Wales. 1
Women’s Center, Coimbatore, Tamil Nadu, India; 2Department of
Methods The National HMB Audit surveyed women attending
Community medicine, PSG Medical College, Coimbatore, India
their first outpatient gynaecological clinic for HMB in England
and Wales (February 2011–January 2012). Women completed a Introduction Exact prevalence of congenital uterine anomalies is
postal follow-up questionnaire 1 year later (February 2012– often underestimated due to lack of universal accepted diagnostic
January 2013) and reported the treatment received in hospital (no criteria and invasive nature of diagnostic techniques. 3D USG is a
treatment, oral medication, intrauterine system (IUS), endometrial non-invasive method for diagnosing congenital uterine anomalies
ablation, hysterectomy, myomectomy, uterine artery embolisation with high accuracy and high reproducibility. This study aims to
(UAE) and other treatment). compare the accuracy of 3D USG in diagnosing congenital uterine
The association between non-white/white ethnicity (predictor) anomalies.
and the last likely treatment received for HMB using clinical Methods The study included hospital based secondary data
protocol (outcome), was assessed using multinomial logistic among women who attended a tertiary care centre for
regression. The model adjusted for baseline factors of age, overall reproductive medicine and high risk pregnancies at the Women’s
health, parity, previous treatment for HMB, prior HMB related Center, Coimbatore from January 2010 to August 2013.
conditions and comorbidities. Retrospective analysis was done based on their 2D and 3D USG
Results 8517/15,325 (55.6%) women completed questionnaires at diagnosis and compared with hysterolaparoscopy.
baseline and follow-up. 7305 women had complete data for this Results In our study, 112 women had been documented with
analysis. Women included in this study (n = 7305), compared to congenital uterine anomalies. The majority of them are infertile
women not included (n = 8020), were more likely to be of white women (59.82%) and women who have had recurrent pregnancy
ethnicity (91.7% versus 84.8%), older [median (IQR) 45 years loss (14.28%). 2D USG was done as a routine investigation in all
(40–48) versus 43 years (39–47)], in excellent/very good overall women. 3D was done in 69.6% when 2D diagnosis was
health (42.3% versus 33.1%), have 2 or more previous treatments inconclusive. A correlation between 2D and 3D USG for identical
for HMB (25.6% versus 23.1%) and have HMB related conditions diagnosis was seen in 44.7% of women; arcuate uterus being the
(56.5% versus 49.9%). Differences in parity and co-morbidities most common congenital anomaly. The most commonly reported
were not statistically significant. anomalies with 3D was arcuate (44.87%) followed by septate
The reference treatment group used in adjusted multinomial (34.61%) and then bicornuate uterus (14.5%), whereas in 2D the
logistic regression analysis was no treatment. Women of white most common anomaly was subseptate uterus (35.7%), the
ethnicity were more likely to be treatment by IUS, relative risk majority of them being classified as arcuate with 3D scan thus
ratio (95% CI) of 1.59 (1.21–2.09, P = 0.001) and endometrial avoiding hysterolaparoscopy in them. Hysterolaparoscopy was
ablation, 2.99 (2.11–4.23, P < 0.001). They were less likely to carried out in 38.3% women only and mostly done for septal
have myomectomy 0.45 (0.31–0.64, P < 0.001) and UAE 0.41 resection (65.1%) and for diagnostic purposes (34.9%) when 3D
(0.23–0.76, P = 0.004). Hysterectomy showed borderline diagnosis was inconclusive. A correlation between 3D and

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 45
E-Posters: General Gynaecology

hysterolaparoscopy was seen in 51.16%. 3D USG was performed thrombophilia. The presence of multiple thrombophilias was
in 89.7% cases by a radiologist, whereas 2D was done by a common.
reproductive medicine specialist and a radiologist in 48.7% There was no significant difference in age between women with
and 51.3% women, respectively. Difference of opinion in unexplained SRM and those with an identified cause (35.5 years
documenting 2D and 3D diagnosis among different specialists versus 35.6 years, P = 0.93).
was seen in 41% cases. Pregnancy outcomes: regardless of aetiology, overall the prognosis
Conclusion Our study highlights a higher prevalence of in SRM was good with successful pregnancy rates of 53–75%
congenital uterine anomalies among infertile women. 2D USG across all categories for the subsequent pregnancy. We looked at
can be considered as an initial screening tool. 3D USG can the impact of various risk factors on prognosis and found that
serve as a cost-effective tool for making definitive diagnosis maternal age and history of first-born male, but not mode of
with good accuracy,and thereby obviating the need for more delivery, influence the chance of successful pregnancy outcome.
invasive procedures like hysterolaparoscopy and MRI for Conclusion RM is a heterogenous condition with many potential
diagnosis. Hysterolaparoscopy can be reserved for corrective aetiologies. Despite having had a prior successful pregnancy
surgery and other associated infertility factors in warranted outcome, underlying risk factors may be identified in 58% of
cases. Only 55% of women who had 3D USG required patients with SRM and so careful investigation is warranted. It
hysterolaparoscopy. The accuracy of 3D diagnosis is improved seems likely that immunological, haemostatic and endocrine
by efficient training, being performed by a radiologist or factors all play finely balanced role to allow the successful
reproductive medicine specialist. implantation and development of the fetus and, as a significant
proportion of RM remains unexplained, there is undoubtedly
much still to be learnt.

EP4.03
Aetiology and pregnancy outcomes in secondary
recurrent miscarriage EP4.04
Das, S; Maclaran K; Aziz M; Katsaforou P; Rai R; Transvenous occlusion of incompetent pelvic veins
Regan, L for chronic pelvic pain in women: a systematic
review
St. Mary’s Hospital, London, UK
Hansrani, V1; Abbas, A1; Bhandari, S1;
Introduction Recurrent miscarriage (RM) is usually defined as the Caress, A-L2; Seif, M3; McCollum, C1
loss of three or more consecutive pregnancies (ESHRE 2006, 1
Manchester Academic Health Science Centre, ERC University
RCOG 2011). When this occurs in women who have previously Hospital of South Manchester, University Of Manchester, Manchester,
delivered a viable infant it can be termed secondary RM (SRM), UK; 2The School of Nursing, Midwifery and Social Work, University
which is thought to affect around 40–45% of RM patients (Jivrai of Manchester, Manchester, UK; 3Institute of Cancer Sciences, St.
2001, Clifford 1994). Although in both the literature and clinical Mary’s Hospital, University of Manchester, Manchester, UK
practice a distinction is rarely made between primary and
secondary RM, there are increasing data to suggest different Introduction Chronic pelvic pain (CPP) affects 24% of women
underlying pathological mechanisms. Furthermore, few worldwide; the cause cannot be identified in 40% despite invasive
epidemiological studies have described the aetiology of SRM and investigations. Dilated, refluxing pelvic veins may be a cause of
investigated whether this differs from primary RM. CPP and treatment by transvenous occlusion is increasingly
This study aims to describe the aetiology and pregnancy outcomes performed when gynaecological causes are excluded, but is it
in, to our knowledge, the largest cohort of SRM patients effective?
published to date. Methods A systematic review of the literature published between
Methods From 2003 to 2012, women with SRM were identified 1966 and July 2013 was conducted. MEDLINE, EMBASE,
from patients attending the RM clinic (RMC) at St Mary’s PsychINFO, the Cochrane Library, CINAHL, MEDION, SIGLE,
Hospital, London, UK. Ethics Committee approval was obtained. LILACS, Index of scientific proceedings, DARE and the British
All patients attending the RMC undergo standardised Nursing Index were searched to identify 29 potentially eligible
investigations to identify potential aetiological factors. In addition papers. Hand searching, internet searches and attention to the
to screening for antiphospholipid syndrome (APS), factor V ‘grey literature’ were also used. Two authors independently
Leiden deficiency and prothrombin gene mutation, a reviewed potential studies according to a set of eligibility criteria,
thromboelastogram (TEG) test was done to provide a global with a third assessor available as an arbiter. The same two authors
assessment of thrombotic tendency. Data were collected independently extracted data from the potentially eligible primary
retrospectively from the RMC database, medical records and studies and crosschecked their results.
patient contact by telephone. Results Thirteen studies including 866 women evaluating
Results A total of 868 patients with SRM were identified out of transvenous occlusion of pelvic veins for CPP were identified
which 755 patients were analysed. Aetiology 42.2% of the study (Level of evidence: 1 study grade 1b, 12 studies graded 4).
population was classified as unexplained SRM. 418 (55.4%) Technical success was found to be 98–100% with low
patients had evidence of either an acquired or inherited complication rates: coil migration (1.6%), abdominal pain (1.2%)

46 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

and visceral injury (0.5%). All studies reported a subjective 3 months, but no relationship between superfertility and
improvement in pain symptoms after transvenous occlusion. pregnancy outcome could be established (P = 0.380).
Mean pain levels in 108 patients who had undergone coil Conclusion This study aims to shed light on an aspect of RM
embolisation had significantly improved from 7.6  1.8 before where evidence is currently lacking, and shows that women
embolisation, to 2.9  2.8 after treatment (P < 0.0001). with unexplained RM do appear to be at greater risk of
Statistically significant improvements were seen in pelvic pain, complications during pregnancy, although further work is
dysmenorrhoea and dyspareunia at 1, 3, 6 and 12 months using a needed in this aspect. These women must be monitored closely
symptom severity score after foam sclerotherapy. Recurrence of when pregnant. The high proportion of these women that
varicose veins in the legs was seen in 13% of 179 women 5-years achieve a successful pregnancy outcome with supportive care
following coil embolisation. Mean left ovarian vein diameter was alone should serve as an important reminder that while the
reduced from 4.5 to 3.19 mm 6 months after transvenous demand for research still exists, there is no need to subject this
occlusion in 33 patients. The occlusion material used had no population to unnecessary interventions that could cause more
influence on success clinically. Only five studies commented on harm than good. Superfertility may provide a promising
symptom recurrence, which ranged from 4–17%. None of these explanation as to why recurrent miscarriage occurs. A detailed
studies reported on acceptability of transvenous occlusion or its literature review has been undertaken and is presented
impact on quality of life. along with.
Conclusion The proven effect of transvenous occlusion of pelvic
veins for CPP remains unclear and recommendations are based
largely on single studies. Further research is needed, in particular,
pragmatic, multi-centre RCTs in well-defined populations. EP4.06
Informing others of a termination of pregnancy –
whom do women tell?
Ingham, A1; Whiteway, S1; Crawford, J2;
EP4.05
Thomson, A2
Late pregnancy complications in women with 1
University of Glasgow, Glasgow, UK; 2NHS Greater Glasgow and
unexplained recurrent miscarriage
Clyde, Glasgow, UK
Kumar, M; Das S; Aziz M; Rai R; Regan, L
St. Mary’s Hospital, London, UK Introduction Approximately 12 500 induced terminations of
pregnancy (TOPs) were undertaken in Scotland in 2012,
Introduction Miscarriage is the most common complication of representing one of the most commonly performed gynaecological
pregnancy, with 1 in 4 pregnancies affected. Recurrent miscarriage procedures. We advise women undergoing TOP to inform others
(RM), defined as 3 or more consecutive losses, affects 1% of about the procedure, to provide support and in the event of a
couples trying to conceive, and over 50% of cases occur for complication. We aimed to determine whom women inform
unknown reasons. An emergent theory suggests these women may about their decision and to investigate whether informing others
be ‘superfertile’ and are able to conceive quickly but unable to is dependant on the woman’s age.
effectively select and invest in promising embryos, and therefore Methods We undertook a prospective observational study of
miscarry frequently. Reassuringly, up to 75% of the unexplained women undergoing a TOP in our unit from 2001–2013. Women
RM population spontaneously achieve a live birth. were asked whom they had informed about their decision (general
The primary aim of this study is to see whether women with a practitioner [GP], partner, parents, friends and siblings), and
history of unexplained RM suffer significantly more late these data, together with their ages, were logged on to a
complications in pregnancy. A secondary aim is to look at the computerised database.
time taken to conceive between pregnancies and establish whether Results During the study period 4746 women attended our TOP
the concept of ‘superfertility’ does exist, and to see whether this clinic, (144 were <16 years old, 1466 were aged 16–20, 2106 were
affects the reproductive outcome of these unfortunate women. aged 21–30, 935 were 31–40 years, and 95 were >40 years old).
Methods This is a retrospective study involving patients who There were variations amongst the age groups regarding whom
attended the RM clinic (RMC) at St Mary’s Hospital, London, women informed of the TOP. Significantly fewer under-16s (64%)
UK. 726 women with unexplained recurrent pregnancy losses were informed their GP about the TOP (P < 0.0001), (16–
identified using a database containing information on all patients 20 years = 83%, 21–30 years = 88%, 31–40 years = 87% and
who had ever attended this clinic. Detailed information on the >40 years = 87%). Significantly fewer under-16s (51%) informed
previous pregnancies of 97 women was collected along with the their partner about the TOP (P < 0.0001), (16–20 years = 69%,
time it had taken for 74 women to conceive their pregnancies. 21–30 years = 66%, 31–40 years = 67% and >40 years = 72%).
Results 65.3% of these 726 patients achieved a live birth after With increasing age fewer women informed their parents,
attending clinic. 26.7% of 97 women had suffered from (under-16s = 63%, 16–20 years = 38%, 21–30 years = 26%, 31–
complications such as haemorrhages and preterm labour, while 40 years = 14% and >40 years = 14%). 83 women (1.75%)
15.2% had suffered from hypertensive disorders and informed no-one about their decision; women over the age of 40
pre-eclampsia. 14.3% had experienced a stillbirth or neonatal were significantly less likely to confide in others (5.3%),
death. 47.3% of the 74 women studied conceived within (P = 0.009).

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 47
E-Posters: General Gynaecology

Conclusion Many women undergoing a TOP are unable or risk, to decide the route, and to improve surgical plan and
unwilling to tell others about their decision. Furthermore there outcome. ‘SLOPE’ can be an important tool in training
are age differences in whom they confide. It remains concerning programmes.
that a proportion of women, though small, is unable to inform
anyone about their decision; these women may be more
vulnerable if a complication were to arise.
EP4.08
Effect of levonorgestrel-releasing intrauterine
device on menorrhagia and dysmenorrhoea and
EP4.07 uterine volume in adenomyosis: a pilot study
‘SLOPE’ score in hysterectomies for fibroid uterus Choudhary, D; Vaid N; Guleria, K
Kakatkar, S
University College Of Medical Sciences and Guru Teg Bahadur
MJM Hospital and Poona Hospital and Research Centre, India Hospital, India

Introduction Uterine volume, subpubic angle, vaginal capacity, Introduction Adenomyosis is a common gynaecological disorder
high placed immobile cervix, and lateral angle between the cervix and is an important cause of menorrhagia and dysmenorrhoea
and the corpus are the factors influencing intraoperative which significantly affects the quality of life by disrupting
difficulties in non-descent vaginal hysterectomy (NDVH). In fact, social, domestic and professional lives of affected women.
difficulty level in NDVH is the result of the combined interplay of Historically, definitive treatment for adenomyosis has been
such factors, for example, large fundal fibroid may be easier to hysterectomy. Levonorgestrel-releasing intrauterine device
operate than moderate cervical fibroid, large uterine size and (LNG-IUD), originally developed for contraception, is emerging
adhesions affect cervical position and mobility, type and number as a promising minimally invasive therapy. The present study
of deliveries may influence sub-pubic angle and vaginal capacity, was designed to evaluate the effectiveness of LNG-IUD on
fibroid-induced disturbed uterine position leads to acute lateral menorrhagia, dysmenorrhoea and uterine volume in
angle, etc. Preoperative study and anticipation of these factors adenomyosis using pictorial blood loss assessment chart
improves surgical planning and outcome. (PBAC), visual analogue score (VAS) and transvaginal
Method This study aims to provide a scientific basis to choose ultrasonography (TVS).
between NDVH and laparoscopic hysterectomy (LH) by Methods A pilot study was conducted on 37 women aged
quantifying the intraoperative difficulties in NDVH. It also tries 20–50 years attending gynecology clinic of a tertiary teaching
to develop guidelines for, and to customise procedure of, hospital in North India. The patients were diagnosed with
NDVH for fibroid uterus. This is a study of 200 patients of adenomyosis on the basis of clinical symptoms and transvaginal
fibroid uterus undergoing hysterectomy. Internal examination ultrasound examination. PBAC, VAS and TVS were done before
was done in dorsal position without sedation or anesthesia, the insertion of LNG-IUD and were followed up at 3 and
after emptying bladder. Subpubic angle, vaginal capacity, 6 months.
cervical position and mobility, uterine position, size and Results The study included 37 patients who underwent LNG-IUD
regularity were noted and correlated with obstetric history and insertion. The mean age of the patients was 40  3.76 years, and
sonographic findings. Fibroid size and location, obliteration of all the patients were multiparous (parity 2–5). Thirty two patients
fornices, parity, and cervical evaluation were individually scored completed 3 and 6 months follow-up as one patient had
with 0 to 3 points, which were aggregated. Total score was spontaneous expulsion of LNG-IUD while two patients requested
categorised in three groups in ascending order of difficulty and removal of LNG-IUD due to severe pain and irregular bleeding.
subjected to surgery as follows: Two patients had hysterectomy due to continued excessive
1 Group 1, score 0 to 4: low risk, safe for NDVH with standard bleeding. The most common menstrual pattern observed at
protocol. 3 months was spotting; the majority of patients had decreased
2 Group 2, Score 5 to 10: moderate risk, NDVH may need morcella- menstrual blood flow and oligomenorrhoea cycles at 6 months.
tion and myomectomy, preferably through bisected uterus. There was significant decrease in the median uterine volume
3 Group-3, score of 11+: high risk, trial NDVH or direct AH or LH (146.0–132.5 mL), median PBAC score (269–10,) and median
Surgical duration and blood loss were noted in all the cases. VAS score (7–0) at 6 months compared to baseline values.
Results Out of 200 patients considered for ‘SLOPE’ study, 197 Backache and lower abdominal pain were the most common side
could undergo successful NDVH. Of the remaining three patients effects observed.
two had failed trial NDVH followed by abdominal conversion, Conclusion LNG-IUD seems a good minimally invasive alternative
whereas one was directly posted for abdominal hysterectomy. to hysterectomy; however further studies are needed to validate
Blood loss was between 50 and 200 mL, and surgical duration was the results.
between 30 and 120 minutes.
Conclusion ‘SLOPE’ score covers all factors, individually and
collectively, influencing the level of difficulty in VH of a fibroid
uterus. It is a plain, simple, pre-operative measure to evaluate the

48 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

EP4.09 presentation for evaluation and care. Gynaecologic problems

Assessment of adnexal masses by color Doppler include menstrual disorders, vaginal infections, PID, STD and
study and serum CA125 assay cervical dysplasias.
Methods The present study was conducted in the Department of
Goyal, S
Obstetrics and Gynaecology, Pt. B.D. Sharma PGIMS, Rohtak in
Christian Medical College and Hospital, Ludhiana 200 HIV seropositive females in the age group 18–50 years
attending the ART clinic. Serologic reactivity to HIV-1 and 2 was
Introduction Adnexal mass is a common presentation in office
determined by ELISA, staging done by WHO staging, menstrual,
visit to a general gynaecologist. An adnexal mass may be benign
medical and treatment history taken and physical examination
or malignant; it is the risk of malignancy that propels us for early,
performed. Blood samples taken to determine the CD4
accurate and prompt diagnosis to lessen the morbidity and
lymphocytes count.
mortality. With the development of sonography including color
Results Nearly 53% of the women in the study belonged to stage
Doppler study we are able to make early and more specific
I. Only 1% had stage IV disease while 58% and 34% had stage II
diagnosis of adnexal mass and develop individual strategies to
and III respectively. Thirty five percent patients were not on ART,
avoid unnecessary interventions.
23.5% were taking ART for <1 year while only 1% were taking
Methods The hospital records of patients who underwent
ART for more than 5 years. Sixty six percent HIV positive women
laparotomy for adnexal masses in the obstetrics and gynaecology
had their CD4 counts more than 200 cells/lL while 34% were
department of the Christian Medical College and Hospital,
more immunocompromised with CD4 count of <200 cells/lL.
Ludhiana from January 2011 to December 2012 were
In the study 23.5% patients had menstrual disorders while 76.5%
retrospectively evaluated. Medical, reproductive history and
patients had regular menstrual cycles. Out of 47 patients with
demographic features were recorded. Preoperative findings of
menstrual disorders, 17.5% had oligomenorrhoea, 3.5% had
physical and pelvic examination, transvaginal sonography
amenorrhoea, 2% had menorrhagia and 0.5% had
including color Doppler studies and CA125 level were noted.
polymenorrhoea. Incidence of menstrual disorders increased with
Color Doppler evaluation findings noted presence of abnormal
falling CD4 counts. No effect of ART on menstrual cycle was
vascularity, RI (Resistance index), PI (Pulsality index). Diagnosis
observed. Candidiasis and bacterial vaginosis infections were
by sonographic findings was compared with the histopathologic
found in 43.2% and 47.7% respectively, while trichomoniasis
diagnosis.
accounted for 3% of vaginal infections. CD4 count <200/lL was
Results Among the 68 patients, histopathological examination
significantly associated with vaginal infection. No beneficial effect
showed 28 (41.17%) as malignant and 40 (58.82%) benign
of ART on prevention of vaginal infections was observed.
ovarian tumors. Sensitivity, specificity, positive and negative
Conclusion This study demonstrates that HIV seropositive women
predictive value of the diagnosis made by color Doppler and
had a higher incidence of menstrual disorders and vaginal
CA125 in discrimination of benign and malignant ovarian tumor
infections which worsened with increasing immunosuppression
was calculated. With cut-off of 0.5, RI had sensitivity of 92.85%
and underscores the need for regular gynaecological assessment
and specificity of 90%. Predictive values for positive (86.66%) and
and treatment as infections may increase the HIV levels in the
negative (94.73%) were also quite high. PI was found to be
genital tract and facilitate transmission to sexual partners and
moderately sensitive with sensitivity of 71.42% with cut-off of <1
infants and treatment of menstrual abnormalities and infections
for malignancy. CA125 with a cut-off of >35 was found to detect
improves the quality of life.
benign cases in 90% of patients. RI was found to be more
sensitive in detection of malignant cases and CA125 was more
accurate for detection of benign cases.
Conclusion Concurrent use of color Doppler sonography and EP4.11
CA125 can help in preoperative diagnosis of adnexal masses. Performance of IOTA simple rules and RMI in
preoperative classification of adnexal lesions in
DGH setting
EP4.10 Murala, KS1; Ma, K2; Henry, RJW1; Snape, S2;
Gynaecological complaints in HIV seropositive Dwivedi, R2
women of reproductive age 1
Poole Hospital Foundation NHS Trust, UK; 2Royal Bounemouth and
Lallar, M Christchurch Hospitals Foundation NHS Trust, UK
SHKM Medical College, Nlahar, Mewat, Haryana, India
Introduction Preoperative differentiation between benign and
Introduction Ninty eight percent of HIV seropositive women
malignant adnexal masses is crucial in planning management. This
live in developing countries. As HIV transmission here is largely allows appropriate selection between conservative or surgical
through heterosexual contact, the infection rate for women is management, whether the care is delivered by a general
increasing, and the low economic and social status of women gynaecologist or oncology subspecialist team. Hence there are
continues to be a barrier to preventing new infections. important cost benefits for healthcare providers to improve the
Gynaecologic problems are common among HIV-positive diagnostic accuracy of tests used. With a proposal for our unit to
women and are frequently present at the time of initial introduce the international ovarian tumour analysis (IOTA)

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 49
E-Posters: General Gynaecology

simple rules in conjunction with the Risk of Malignancy index the form of NDVH has proven to be a boon for the masses. The
(RMI) to aid differentiation of benign and malignant adnexal given study proposes to evaluate the intraoperative and
masses, we felt it was important to assess its diagnostic accuracy postoperative morbidity associated with debulking procedures
and predictive value in this setting, and the current study sought used for difficult cases of NDVH.
to address this. Methods In this prospective study, 200 women requiring
Methods Retrospective study of all women who were referred to hysterectomy for benign gynecological disorders without uterine
Poole District General Hospital (DGH) and Royal Bournemouth descent were included. Debulking techniques were employed for
DGH with suspected adnexal pathology between September 2012 difficult cases such as enlarged uterus, fibroids, previous surgery
and September 2013. The ultrasound scan images were analysed by (caesarean, myomectomy), high anterior pouch, hypertrophic
non expert gynaecology trainees using IOTA simple rules and the cervix and benign adnexal masses / cysts.
adnexal masses were classified into benign, malignant and Results The most common indication of hysterectomy was
inconclusive masses. RMI was calculated using menopausal status, fibroids (37%). Most women had a uterine volume of 250–350 cc
ultrasound findings and serum concentrations of CA125. As per for which we used debulking techniques. A combination of
RCOG guidance RMI of more than 250 was classified as a malignant bisection, myomectomy, morcellation, cervical amputation and
mass. The histological diagnosis provided final standard. The wedge de-bulking was used in majority of women. Most of the
diagnostic performance of each method was compared by women could be operated successfully vaginally with an average
calculating sensitivity, specificity, positive predictive values and time of 36.6 min and an acceptable blood loss of a moderately
negative predictive values with 95% confidence intervals. soaked sponge. No significant intraoperative surgical complication
Results 51 women were eligible for the study. There were 13 was observed. Blood transfusion was required in two percent
(25%) benign tumours, 21(41%) malignant tumours and 3(6%) women. Three cases had to be converted to abdominal
borderline tumours. The IOTA simple rules yielded a conclusive hysterectomy after a trial of vaginal route. They were previous two
result in 31 cases (65%), which resulted in a sensitivity of 94% caesarean with uterus badly adhered to anterior abdominal wall,
(95% confidence interval of  10%), a of specificity of 80% previous two caesarean with dense adhesions and endometriosis
( 20%), a positive predictive value(PPV) of 85% ( 16%), a with dense adhesions. Postoperatively the women were
negative predictive value(NPV) of 92%( 14%). The comfortable and were mobilised early. No significant
corresponding sensitivity, specificity, positive and negative postoperative complications were seen. Minor complaints like
predictive value of using RMI >250 as a cut off for malignancy is fever, discharge per vaginum, urine infection, backache and
72%( 18%), 80%( 18%) 82%( 16%), 70%( 19%) bleeding per vaginum were present which were managed
respectively. Combining the simple rules and RMI resulted in conservatively.
sensitivity, specificity, PPV and NPV of 93%, 83%. 87% and 92% Conclusions In today’s era of minimal invasive surgery, debulking
respectively. procedures in NDVH have been put to use with appreciable
Conclusion IOTA simple rules have good prediction value as a success, offering a cost-effective surgical method for developing
triage tool to discriminate between benign and malignant adnexal countries. By virtue of conserving operative time and avoiding
masses in non-expert hands. Inconclusive cases may then be undue pull on the suspensory ligaments, a quicker postoperative
referred for further imaging by an expert ultrasound examiner. recovery with lesser morbidity and better overall acceptance of
Hence we propose to prospectively study the performance of NDVH is achieved.
IOTA simple rules as a triage test in our DGH unit. We aim to
standardise and implement a reporting system for adnexal masses
to facilitate accurate preoperative classification and appropriate
management. EP4.13
Magnetic resonance guided high intensity focused
ultrasound (MRgHIFU): a non invasive modality in
the treatment of uterine fibroids
EP4.12 Bedi, M; Khanna, SB; Rastogi, H
Role of debulking procedures in non-descent
Indraprastha Apollo Hospitals, New Delhi, India
vaginal hysterectomy
Singh, N; Singh S; Jain, M Introduction Fibroids are the most common benign uterine
Sarojini Naidu Medical College, Agra, India tumors in women of child bearing age with 30% incidence.
Though the mainstay of treatment is surgical either myomectomy
Introduction The initial attempts at performing non-descent or hysterectomy but non invasive methods like Magnetic
vaginal hysterectomy (NDVH) were limited to multiparous uteri resonance guided high intensity focused ultrasound (MRgHIFU)
of normal size with good mobility. However, as the surgeons are being investigated to reduce the morbidity. MRgHIFU is a
gained experience, the list of contraindications gradually shrunk. novel modality for the treatment of uterine leiomyoma, gaining
Although newer and more sophisticated techniques like total popularity as an alternative to medical and surgical interventions
laparoscopic hysterectomy (TLH) have come now, in a developing being leiomyoma specific therapy. There are a few clinical studies
country with low resource settings, there is little place for such an that demonstrate MRgHIFU is a safe and well-tolerated procedure
extensive set-up and an equally effective yet cheaper alternative in which has shown a sustained relief of leiomyoma symptoms

50 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

comparable with other more invasive treatment modalities. The one polyp). The area under the ROC curve (AUC) was 0.92 (95%
purpose of this study is to analyse the efficacy of MRgHIFU. CI, 0.85–0.98). The best negative likelihood ratio was obtained at
Methods The study has been carried out in the Department of an endometrial thickness of 11.5 mm with a negative predictive
Obstetrics and Gynecology and Radiology, Indraprastha Apollo value (NPV) of 96.7% and a positive predictive value of 42.1%.
Hospitals, New Delhi from November 2011 to December 2012. It The sensitivity and specificity of using a endometrial thickness cut
is a prospective observational study. A screening MRI was done off value of 11.5 mm was 80% and 84.3% respectively.
which, if found appropriate, patient was taken up for HIFU. Conclusion In premenopausal women presenting with AUB, TVS
MRgHIFU therapy was performed using Philips Sonalleve measurement of endometrial thickness is efficacious in ruling out
MR-HIFU Fibroid Therapy System integrated into 3-T MR endometrial pathology however the diagnostic accuracy is not
imager. Patients were then evaluated for symptomatic relief as well good. Endometrial thickness of 11.5 mm in premenopausal
as the size of the fibroid by repeat MRI at one and 6 months after women with AUB may serve as a cut off point for predicting
the procedure. pathology negative cases and diagnostic uterine curettage may be
Results 158 patients were screened for the procedure but only 44 avoided in these patients.
could be treated by MRgHIFU by applying the exclusion criteria.
An improvement of symptoms was found in 75% of the patients.
The mean volume of regression in the fibroids was 17.43% and
22.83% at the end of 1 and 6 months respectively. Few minor side EP4.15
effects like redness, pain, diarrhoea, haematuria, skin burns were Conservative surgery and outcome of ovarian
noted in 31.12% patients. torsion
Conclusion MRgHIFU provides a novel treatment option for Chinthakula, H; Padma
patients with symptomatic uterine fibroids. The total lack of Meenakshi Mission Hospital and Research Centre
invasiveness of this modality compared with all other fibroid
procedures and the fact that this is performed as an outpatient Introduction Adnexal torsion is a rare gynaecological event with
procedure makes it particularly attractive for patients who, for an incidence of 2.7%.The objective of our study is to determine
various reasons, want to defer a surgical procedure. However, this that detorsion of the twisted adnexa is better than traditional
is an evolving technique where experience of the centre does adnexectomy to conserve the adnexa and preserve its function.
matter. Once the learning curve is crossed, with the improvement Methods Our study is a retrospective analysis of case records of 10
in technology, efficacy can be improved. If the results become women with diagnosis of ovarian torsion who had been treated by
better, MRgHIFU would become the treatment option for a larger detorsion and plication over a period of 4 years (between January
number of patients. 2009 and October 2013). The information collected regarding all
the selected cases were recorded in a Master Chart. Data analysis
was done using STATA11.1 (College Station TX USA).
Results Women in our study are aged between 10 and 38 years of
EP4.14
which 50% were between 11 and 20 years. 70% of them presented
The role of transvaginal ultrasonography in initial to us with both abdominal pain and vomiting. Average cyst size
evaluation of abnormal uterine bleeding (AUB) in to undergo torsion was 6.7 9 5.5 cm. We could conserve the
premenopausal women adnexea in 100% of cases which had undergone detorsion and
Chandra, C1; Shekhar, S1; Vyas, J2 plication of which 60% regained normal regular mensytruation
1
Department of Obstetrics and Gynecology, AIIMS Jodhpur, India; and 67% coceived later. In one case we had recurrence (10%)of
2
Department of Obstetrics and Gynecology, S.P Medical College, India torsion.
Conclusion Timely diagnosis and intervention can make the
Introduction Aim of this study was to evaluate the diagnostic difference between ovarian loss and salvage- an outcome of great
accuracy of ultrasound parameters in assessing endometrial importance in population of reproductive age females.
pathology and to determine the most sensitive cut-off value of
endometrial thickness for the exclusion of endometrial lesions in
premenopausal women with abnormal uterine bleeding (AUB).
Methods This study was conducted in the department of
EP4.16
Obstetrics and Gynecology, P.B.M. Hospital and S.P. Medical Abdominal fat distribution, insulin resistance and
College, Bikaner from February 2012 to January 2013. During this cardiovascular risk profiles in women with
period 80 premenopausal women who presented with abnormal polycystic ovary syndrome
uterine bleeding were evaluated with transvaginal sonography Dalal, R; Pai H; Palshetkar, N
(TVS) and followed by endometrial biopsy within 48 hours. Lilavati Hospital and Research Center, Mumbai
Statistical evaluation was done using SPSS 17. Receiver operating
characteristics (ROC) curves for endometrial thickness and Introduction This study aims to determine potential associations
abnormal endometrial histopathology were analysed. of abdominal fat distribution with insulin resistance and
Result Abnormal endometrial pathology (hyperplasia and polyp) cardiovascular risk in women with polycystic ovary syndrome
was confirmed in 10 women (9 with endometrial hyperplasia and (PCOS).

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 51
E-Posters: General Gynaecology

Methods Cross-sectional study that included detailed clinical In most cases, ‘life saving procedures’ or ‘repair to damage’ was the
examination, body mass indices (BMI), waist–hip ratio, insulin only documented additional procedures and in some, no additional
resistance and cardiovascular risk scores for 350 women registered procedures were documented. For the hysterectomy group, no
between August 2008 and December 2009. Biochemical analysis patient was informed of the risks of premature failure of the ovaries,
included fasting blood glucose level, serum insulin level, wound complications or serious risks of return to theatre, failure to
triglycerides, total cholesterol and HDL cholesterol. Primary complete procedure, urinary dysfunction or death. Only 50% were
outcomes of interest included insulin resistance and cardiovascular consented for blood transfusion. In all cases, ‘damage to
risk score. surrounding structures’ or ‘organ damage’ was used to cover risks
Results The mean age of the subjects was 25.77 years. urinary, bowel and major blood vessels damage. All forms were
Oligoovulation was present in 99% of the women. Eighty-two handwritten and most signed by specialist registrars or SHOs. In
(23.43%; 95% confidence interval [CI]: 19.21%, 28.08%) women 65% of cases was the doctor taking consent at the operation.
were obese and 100 (28.57%; 95% CI: 24.02%, 33.47%) women Anaesthetic type was listed in 63%. One patient had a patient
had android obesity. Insulin resistance was present in 136 information leaflet prior to surgery. Risks were noted as discussed
(38.86%; 95% CI: 33.85%, 44.05%) women and 107 (30.57%; on the day of the procedure but rarely documented prior to
95% CI: 25.91%, 35.55%) women had a cardiovascular risk >1. admission.
Women with a waist–hip ratio >0.85 were more likely to have Conclusion The RCOG series clearly documents and quantifies
insulin resistance (OR 2.70; 95% CI: 1.68, 4.35, P < 0.001) and at procedure specific risks and states the patients should be fully
increased risk for cardiovascular events (OR: 1.82; 95% CI: 1.12, informed about their procedure. Although risk may be different
2.97, P = 0.02). Obese women were more likely to have insulin for each patient, a standardised consent form, modified as
resistance (OR 2.53; 95% CI: 1.53, 4.19, P < 0.001) and at necessary, would improve informed consent. Patient information
increased risk for cardiovascular events (OR: 2.17; 95% CI: 1.30, leaflets with adequate preoperative documentation would ensure
3.63, P = 0.003). no new information is given on the day of the procedure.
Conclusion Long-term health hazards of PCOS have to be
considered as these may be prevented to some extent by early
identification and interventions, such as changing the lifestyle of
the individual. EP4.18
The effectiveness of preoperative erythropoietin in
averting allogenic blood transfusion among
women with abnormal uterine bleeding and severe
EP4.17 anaemia
Consent: are we telling our patients enough?
Mohan, S1; Marwaha, A1; Gami, N2; Sandhu, N1;
Khoo, C; Davies R; Baines G; Gordon, A
Singh, S2
Heatherwood And Wexham NHS Trust, UK 1
Army College of Medical Sciences, New Delhi, India; 2University
College of Medical Sciences, New Delhi, India
Introduction The Royal College of Obstetricians and
Gynaecologists (RCOG) gives clear advice in the Consent Practice
Introduction The use of blood conservation techniques is
Series. This audit looks at gynaecological consent taken locally,
important in patients with abnormal uterine bleeding (AUB) as
and whether risks are quantified, specified and within guidelines.
peroperative blood loss is common and allogenic blood
Additionally it looks at who obtains consent, and whether
transfusion (BT) carries risk of transfusion reactions as well as
adequate ‘cooling off’ time has occurred.
infection transmission. Erythropoietin with or without
Methods The consent forms and documentation for the 3 most
intravenous iron supplementation is one of the methods to avoid
common procedures (laparoscopy, hysteroscopy/resection of
allogenic BT. The objective of this study was to assess the
fibroids and hysterectomy – laparoscopic or abdominal) were
effectiveness of erythropoietin in reducing risk of exposure to
retrospectively analysed using a pro forma based on RCOG
allogenic BT in women with severe anaemia and AUB.
guidelines over a 2 week period.
Methods A study was conducted in the Army College of Medical
Results For hysteroscopy, 3 women had resectoscope use, though
Sciences and Base Hospital Delhi cant between March 2010 and
only 1 had consented. ‘Perforation’ was always documented
August 2010 where in 15 women with AUB and severe anaemia
although the organ was not specified. Infertility or Asherman’s
were included in to the ongoing study after applying the necessary
syndrome was never documented where applicable (60%).
inclusion and exclusion criteria. The dosing regimen involved
Additional procedures of laparoscopy or laparotomy was consented
administration of iron sucrose (200 mg) and erythropoietin
for in most cases, sometimes added by the consultant. For
(200 IU) on alternate days and repeating the haemogram on day
laparoscopy, in 2 cases the proposed procedure was not the
7 to study the rise in haemoglobin (Hb).
procedure performed, or additional non life saving procedures were
Results An average rise in Hb of 1.2 g/week from the first week
performed without consent. In none of the cases were named organs
of therapy was seen in the women taken up in this study
specified as at risk, nor was undiagnosed injury or return to theatre
following the above therapy. This rapid rise in Hb has made it
documented. In no cases were serious or frequent risks such as
possible to avoid the need of blood transfusion both
hernia, shoulder tip pain, bruising or wound problems documented.
intraoperatively and postoperatively.

52 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

Conclusion There was a rapid and significant rise in Hb in all the hysterectomy procedures, in group A (n = 1000) and
women included in study. Thus we conclude that in conventional method of abdominal hysterectomy in group B
haemodynamically stable patients with severe anaemia blood (n = 450) from January 2000 to December 2009.
transfusion can be averted by this therapy. Results In group A traumatic injury to (L) uterine vessel 4 (0.4%)
and (R) uterine vessel 3 (0.3%)cases were detected in absence of
injury to the ovarian vessels, ureter and bladder. Injury to (L)
uterine 11 (2.4%).ureter 1 (0.1%), bladder 6 (1.5%), haematoma
EP4.19
10 (2.2%) were found to be more in group B. Postoperative
Case study: cardiac arrest at myomectomy, complications were found to be uneventful in group A.
secondary to massive pulmonary embolism Conclusion Present studies conclude that ligation of uterine and
Chaggar, P; Sathiyathasan S; Lee, C ovarian arteries, prior to conventional abdominal hysterectomy
NHS, Ealing Hospital, Wallington, UK procedures, were found to be extremely safe procedure thereby
reducing the risk of intraoperative and postoperative
Backgound Although fibroids constitute the most commonly complications.
occurring tumour in women of reproductive age, they seldom
cause acute complications. We report a rare case of large uterine
fibroids, leading to cardiac arrest and subsequent death at
abdominal myomectomy.
EP4.21
Case A 38-year-old, nulliparous lady underwent a myomectomy A study of feasibility of postoperative follow-up in
for debilitating menorrhagia secondary to a grossly enlarged the community in general gynaecology
multifibroid uterus. The procedure was straightforward, until Eedarapalli, PK; Kar, A
commencement of abdominal closure, at which point the patient Royal Bournemouth and Christchurch Hospitals NHS Foundation
lost cardiac output, and arrested. Following several cycles of CPR, Trust, UK
thrombolysis was performed for a presumed diagnosis of massive
pulmonary embolism (PE). There was subsequently a return of Introduction With the current reduction in NHS budgets in the
spontaneous circulation. An echocardiogram confirmed gross UK, there is a trend to shift postoperative follow-up after routine
dilatation of the right cardiac chambers, in keeping with a PE. elective surgery from the hospital to the community. Utilising
She had a further cardiac arrest following closure of the abdomen, nurse, questionnaire or telephonic follow-up by the hospital
but return of spontaneous circulation was quickly achieved. She was versus follow-up with GP are the options currently being
subsequently transferred to ITU, where she had a third cardiac explored. A few studies, in mainly other surgical specialties,
arrest. Following 14 cycles of CPR, a decision was made to stop CPR. showed that such an approach is safe. The objectives of this study
A post mortem revealed compression of the pelvic veins by were to: (1) evaluate whether a questionnaire follow-up to screen
large fibroids, leading to the formation of a thrombus. This for the patients needing hospital appointment after routine major
dislodged at myomectomy, resulting in the fatal pulmonary and intermediate general gynaecological operations will (i)
embolus. improve service and cost savings (ii) reduce outpatient clinic
Conclusion A literature search has found only one other reported waiting times (iii) improve patient choice (iv) improve patient
fatality from a similar presentation. However, despite the rarity of satisfaction/experience; (2) carry out a questionnaire survey of (i)
such adverse outcomes, we would recommend a raised index of the local GP practices (ii) local consultant gynaecologists to
suspicion in women with very large uterine fibroids, undergoing ascertain their preferences for the place of follow-up; (3) carry out
myomectomy or hysterectomy. A simple, inexpensive investigation an audit of postoperative outcomes to identify what proportion
in asymptomatic women would be preoperative D-Dimer levels. were suitable for a community follow-up.
Abnormally high levels should prompt further investigation. Methods A retrospective analysis of case notes and electronic
records of all major and intermediate open and laparoscopic
procedures performed between January and April 2012 under one
consultant at Bournemouth Hospital. Analysis included only cases
EP4.20 with benign aetiology, uncomplicated history, surgery and
Abdominal hysterectomy: a new improving surgical immediate postoperative recovery. We excluded new and complex
technique procedures. Questionnaires were sent prospectively to the above
Dutta, DKR1; Dutta, I2 mentioned groups and a separate cohort of patients operated
1
GICE Hospital, India; 2IQ City Medical College,India between October 2012 and January 2013, 4 weeks later.
Results A total of 44 (endometrial ablation -10, hysterectomy-23,
Introduction This is a comparative study to analyse the impact of laparoscopic procedures-11) records were analysed for outcomes.
early ligation of uterine and ovarian arteries to prevent These included minor infection rates 10–30%; pelvic pain 8–18%;
intraoperative and postoperative complications during abdominal bladderand bowel symptoms 5–8%; sexual problems 8%. 75%
hysterectomy operation. were suitable for a community follow-up. 95% of 34 patients sent
Methods Ligation of uterine and ovarian arteries (in case of a questionnaire responded. In this cohort the self reported
salpingo-oopherectomy) was performed, prior to abdominal symptoms as above were in the range of 2–11%. Self reported

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 53
E-Posters: General Gynaecology

return to daily activity and response to treatment were 90% EP4.23

(versus 70–80% in the case note cohort). Two thirds of patients Cornual pregnancies at a tertiary care referral
preferred to have the choice of either filling out a questionnaire or centre in South India: a retrospective review
see GP. 50% of 20 practices responded. The Dorset CCG showed
Bharathi, BV; Rao, G Sirisha
interest in the concept. 70% of GPs agreed with questionnaire
mode. 33% suggested telephone follow-up as a better alternative. Fernandez Hospital, India
50% consultants prefer follow-up with GP.
Introduction Cornual ectopic pregnancy (CEP) refers to a
Conclusions The majority of GPs, patients and consultants prefer
gestation in the uterine part of fallopian tube or rudimentary
community follow-up. We aim to introduce nurse telephone
horn of a unicornuate uterus. CEP occurs in 2–4% of all ectopic
follow-up to assess recovery, questionnaire follow-up for select
pregnancies and accounts for <1% of all pregnancies. The
patient groups and provide a ‘hotline’ for patients. The savings for
diagnosis and treatment are challenging, and frequently constitute
CCG would be in the range of £ 25,000 per year.
a medical emergency.
Methods All CEPs between January 2002 and October 2013 at
Fernandez hospital, India were reviewed. Data pertaining to
EP4.22 clinical presentation, ultrasound findings, treatment modalities
Case study: histopathological correlation of the and surgical details were retrieved from the medical records.
transvaginal sonography and hysteroscopy in Details of succeeding pregnancies were retrieved from case records
postmenopausal women or enquired over telephone.
Results A total of 34 cases of CEP were identified; incidence was
Gupta, K; Dagar M; Srivastava M; Ganguli, I
1 in 1610 deliveries. The mean (SD) age was 28.2 (3.6) years and
Sir Ganga Ram Hospital, New Delhi, India 35.3% were primigravidae. Seven (20.6%) women had a prior
ipsilateral salpingectomy. The mean gestational age and serum
Introduction The aims of this study were to (1) study the etiology
b-hCG at diagnosis were 7.8 weeks and 18860.7 mIU/mL
of Postmenopausal Bleeding (PMB) and (2) correlate the respectively. Except for one ruptured CEP diagnosed at 18 weeks
diagnosis after transvaginal sonography (TVS), hysteroscopy and of gestation, all others were detected in the first trimester, one of
histopathological diagnosis. which was a heterotopic pregnancy. Sonographic diagnosis of CEP
Methods This was a prospective study done at Institute of
was made in 18 (52.9%) cases. The associated m€ ullerian anomalies
Obstetrics and Gynecology, Sir Ganga Ram Hospital, New Delhi, were septate uterus and unicornuate uterus with rudimentary
from July 2006 to November 2008. About 100 postmenopausal horn (n = 1 and 2 respectively). Primary medical treatment was
women with complaints of bleeding per vaginum were recruited offered to 14 (41.2%) women and 6 of them required surgery
in the study. They were evaluated clinically as well as by later: the reasons being rupture, high b-hCG, persistent cardiac
transvaginal sonography followed by diagnostic and/or therapeutic activity or persistent ectopic mass. Most (19/25, 64.3%) surgeries
hysteroscopy and guided biopsy. Results were analysed and for CEP were accomplished laparoscopically. Rupture was noted
compared with histopathology as gold standard. Transvaginal in 12 (35.3%) cases. The surgeries performed were cornual wedge
sonography was classified as normal if the double layer thickness resection (n = 8, 23.5%), cornuostomy (n = 4, 11.8%), excision of
of the endometrium on longitudinal section was <4 mm and with gravid rudimentary horn (n = 2, 5.9%) and haemostatic
no evidence of focal abnormality. On hysteroscopy the findings procedures (n = 9, 26.5%). Concurrent ipsilateral salpingectomy
were classified as normal (proliferative, atrophic) and abnormal was performed in 11 (32.4%) cases. Three (8.8%) women received
(benign/malignant). postoperative methotrexate. The future reproductive outcome was
Results Transvaginal sonography has overall sensitivity of 85.96%
unknown in 14 (41.2%) women who were lost to follow-up. One
and specificity of 34.88% in predicting abnormal histopathology. woman underwent concurrent tubectomy and another opted for
Overall sensitivity and specificity of hysteroscopy was 70% and gestational surrogacy. Six women had uneventful pregnancies and
72% respectively for diagnosing abnormal histopathology. On three were pregnant at the time of writing this report. Recurrence
combining transvaginal sonography with hysteroscopy the of CEP following cornuostomy was observed in one case (2.9%).
sensitivity and specificity was 83% and 100% for diagnosing Conclusion Salpingectomy does not preclude a future ipsilateral
endometrial carcinoma. CEP as is evident from our study and therefore vigilance is the
Conclusion In women with postmenopausal bleeding transvaginal
key to its diagnosis. Early diagnosis and availability of surgical
sonography can be used as screening modality with cut off expertise can facilitate medical/endoscopic management of CEP
endometrial thickness of 4 mm with good sensitivity in predicting and obviate the need for laparotomy. It is time to introspect
abnormal histopathology. However specificity is low, hence surgical techniques for salpingectomy in order to prevent
hysteroscopy followed by endometrial biopsy is recommended as subsequent CEP.
the diagnostic modality in evaluation of postmenopausal bleeding.

54 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

EP4.24 EP4.25
Case study: laparoscopic diagnosis of 20 weeks’ Study of cardiovascular risk factors in polycystic
caesarean scar pregnancy and subsequent ovary syndrome
management Hari, A; Murthy NLN; Mahesh, C
Bhattacharyya, P; DasMahapatra Ghosh P; Gandhi Medical College, Secunderabad, India
DasMahapatra, P
Introduction Polycystic ovary syndrome (PCOS) is a
Spectrum Clinic and Endoscopy Research Institute, Kolkata
heterogeneous multi system endocrine disorder of reproductive
Background Caesarean scar pregnancy (CSP) is increasingly age and is associated with many cardiac risk factors. This study
reported due to escalating rate of caesarean delivery and aims to evaluate the cardiovascular risk factors including vascular
widespread use of early pregnancy sonography. Though the endothelial dysfunction in women with PCOS and compare them
commonest presentation is abdominal pain with vaginal bleeding with healthy age and weight matched controls.
between 6 weeks and mid-pregnancy, up to 40% may remain Methods This study took place at the Department of Obstetrics &
asymptomatic. Transvaginal sonography (TVS) is highly sensitive Gynaecology & Imageology, Gandhi Medical College/Hospital,
for diagnosis; magnetic resonance imaging (MRI) is also emerging A.P. India. Fifty PCOS subjects and 50 age-and BMI-matched
as a promising adjunct. Here we present an atypical case of CSP, controls were included in the study. The study took place from
which could be confirmed only by laparoscopy at 20th week of May 2010 to May 2013. It is an observational, analytical and case–
gestation and was managed by laparotomy. control study. All subjects and controls were studied regarding
Case Mrs. SC, 30-years-old, conceived during lactational insulin resistance, serum testosterone, fasting serum lipid profile,
amenorrhoea after 5 months following lower segment caesarean intima media thickness of common carotid artery by carotid
delivery. The pregnancy remained undiagnosed until 16th week artery Doppler study and vascular endothelial dysfunction by
when she underwent a transabdominal sonography (TAS) for brachial artery flow mediated dilatation study. The dialatation was
episodes of spotting and pelvic pain. The first TAS and a repeat assessed 30 sec, 1, 2, 4 min after inducing ischemia by
one at 18 weeks suggested viable intrauterine pregnancy and she sphygmomanometer and later deflation.
was advised oral progesterone. While attended our clinic at 20th Results PCOS subjects exhibit high insulin resistance, high
week with persistent vaginal bleeding and intermittent abdominal testosterone levels where P value is < 0.001 compared to their
pain, she was pale yet with stable vitals. Examination revealed a controls. PCOS subjects had increased carotid intima media
16 weeks’ size irregular abdomino-pelvic lump and closed internal thickness (P < 0.001) and abnormal flow mediated dilatation of
os with mild bleeding. TAS and TVS showed a 20 weeks’ viable brachial artery (P < 0.001) 240 sec after ischemia.
intrauterine fetus with a suggested haemorrhagic ovarian cyst. Conclusion Abnormal vascular compliance and increased carotid
Amidst this diagnostic dilemma, we counselled the couple for a intima medial thickness are new findings in PCOS subjects which
diagnostic laparoscopy with consent for laparotomy if needed. On are cardiovascular risk factors due to insulin resistance. The
laparoscopy, the uterus was 16 weeks and one 20 9 20 cm mechanism of altered insulin regulation of endothelial nitric oxide
severely congested mass was seen protruding out of the lower in PCOS identifies a new therapeutic target that necessitates
uterine segment into the uterovesical pouch. The adnexae were further investigations. The present data suggest that there is a long
normal. We converted to laparotomy, carefully dissected and term cardio vascular risk in PCOS subjects which needs attention
excised the whole mass consisting of placenta and amniotic sac and counselling.
with a living fetus. The lower uterine segment was closed after
paring the margins. The baby weighed 380 g and expired soon.
Recovery was uneventful and she opted for oral contraception. EP4.26
Conclusion This is a rare condition where a CSP was missed after
Sertoli leydig cell tumor (SLCT) of ovary with
repeated clinical visits and sonography and it continued until
heterologous element and raised a-fetoprotein
20 weeks without frank rupture. Though MRI might have helped
in diagnosis, we went straightforward for surgical intervention as Kharka, L; Pai M; Nambiar, J
it was the only definite management. Once confirmed by Manipal University, India
laparoscopy, only a laparotomy was reasonable to deliver the fetus
intact for ethical reason and repair the uterine margins Background Sertoli leydig cell tumors (SLCT) of ovary are rare
meticulously. In the scenario of rising incidence of CSP, keeping tumours seen in young women characterised by androgen
it in mind while dealing with haemorrhage and pain in producing testicular structures resulting in virilisation, and variety
post-caesarean pregnancy may prevent maternal morbidity or of histological patterns of prognostic significance. Also, the
mortality. tumors contain heterologous elements such as endodermal and
mesenchymal, in approximately 20% of cases. A small group of
these SLCTs are found to produce a-fetoprotein (AFP) the
histogenesis of which is not yet clearly understood. We present a
rare case of ovarian SLCT in a 17-year-old girl with heterologous
mucinous glands and raised serum AFT.

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 55
E-Posters: General Gynaecology

Case A 17-years-old girl presented with a history of amenorrhea Results Out of 120 patients, 15 patients conceived, 23 had repeat
since 1 year and abdominal distension, excess hair growth, laparoscopy for ultrasound recurrence of endometriotic cyst and
reduction in breast size and hoarseness of voice for the last long standing infertility. Recurrence rate of pain during the first
4 months. Physical examination revealed hirsutism, breasts year was 12.5% and during the second year was 10.8%.
(Tanner stage II), cliteromegaly and an abdominal mass of Ultrasound recurrence of a cyst during the first year was 10.8%
22 9 15 cm which was cystic and non-tender. Ultrasound and CT and during the second year was 15.8%. Over all recurrence rate of
scan confirmed a large multilocular cystic lesion of endometriosis was 15.9%. Recurrence rate is higher in patients
15 9 9 9 23 cm in pelvis with solid components arising from with advanced endometriosis at surgery and in younger patients.
right adnexa. There was mild ascites and bilateral moderate Pregnancy after surgery decreases recurrence of endometriosis.
hydronephrosis. Laboratory tests showed increased serum levels of Patients who took postoperative medical treatment with femilon
total testosterone of 502.4 ng/dL, AFP of 290.7 IU/mL. Based on also had a decrease in recurrence of pain.
these findings a provisional diagnosis of androgen secreting tumor Conclusion In spite of increasing number of operative
was made and patient was posted for laparotomy. Peroperatively, laparoscopies performed for endometriosis, postoperative
there was minimal ascites, right ovary replaced by a 20 9 16 cm recurrences are very common. various risk factors influence
solid smooth surface tumour with intact capsule. Right salphingo recurrence rate. According to risk factors and follow-up period,
ovarectomy was [Link] histopathology report was recurrence rates and conception rates may also alter.
consistent with SLCT with heterologous elements–mucinous
component. The postoperative period was uneventful. After a
detailed discussion with the medical oncologists and patient,
chemotherapy was deferred and regular follow-up advocated. Two EP4.28
weeks following surgery CT scan showed no residual tumor, Arborisation of the pelvis by retroperitoneal
normal serum testosterone (0.1 ng/mL) and decreasing serum leiomyoma: an astonishment
AFP-74.8 (ng/mL). Maharajan, S; KS, Rajeshwari
Conclusion SLCT should always be considered in a young female Sri Ramachandra University, Chennai, India
patient who has symptoms of virilisation and an ovarian mass on
examination or investigation. Management issues mostly revolve Background Excluding pregnancy, leiomyoma is the most
around the histopathology of the tumor. The majority of these common of all pelvic tumours being present in aproximately 20%
tumors are unilaterally localised, and conservative surgery is over 20 years of age and in 40% of women over the age of 40 years.
sufficient. To date, no standard therapy exists. AFP secreting Retroperitoneal leiomyoma is an uncommon clinical entity. We
SLCTs are now identified as a distinct entity among the describe a case of a 33-year-old woman with retroperitoneal
uncommon group of sex cord tumors of ovary owing to rarity of leiomyoma of around 20 9 18 cm extending into right paravesical,
ovarian SLCTs, limited number of documented case reports/series vesico vaginal space, prerectal space, obturator fossa.
and lack of randomised clinical trials, effectiveness of Case A 33-year-old, para 3, live 3, was referred to our institution
postoperative chemotherapy remains questionable and requires from rural hospital. Laparotomy at rural hospital revealed a soft
further evaluation. compressible diffuse retroperitoneal mass. Abdomen was closed
and referred for further management. A firm mass palpable up to
20 weeks size was present. Preoperatively CT with contrast,
colonoscopy, tumour markers were performed. A
EP4.27
multidisciplinary approach involved a gynaecologist, a surgical
Reccurence rate of endometriosis after laparoscopic oncologist and a urologist. Laparotomy with DJ stenting, total
excision of ovarian endometrioma abdominal hysterectomy with bilateral salpingooopherectomy with
Kola, S; Gadige S; Gutti, S enbloc excision of retroperitoneal mass was carried out.
Lakshmi Clinic, India Peroperatively the tumour was occupying the right broad ligament
displacing the uterus laterally, the bladder anteriorly and rectum
Introduction Ovarian endometrioma is frequently diagnosed in posteriorly. The tumour was splaying the ureter extending into
women of reproductive age, laparoscopic excision of ovarian obturator fossa and pouch of Douglas. In view of the benign
endometrioma is performed for most cases. However nature on frozen section the ureter was not resected.
endometrioma frequently recurs after repeated surgical Histopathology and immunohistochemistry showed the origin
procedures. The aim of our study is to evaluate the recurrence from smooth muscle cells suggestive of leiomyoma. The patient
rate of endometriosis and associated risk factors for recurrence. was discharged on 14th postoperative day.
Methods This was a retrospective cohort study. We evaluated 120 Conclusion This patient had a smooth muscle cell tumour with
patients who had laparoscopic excision of endometrioma at the an invasive and unusual growth pattern. Leiomyoma can arise
Lakshmi clinic during period of 2008–2011. All patients had tissue from the uterus and from pelvic,abdominal and parietal
diagnosis of endometriosis and had adequate follow-up. During peritoneum. Retroperitoneal leiomyoma is a distinctive lesion that
follow-up clinical examination and transvaginal ultrasound were could arise from mesometrial smooth muscle. This case is
done at 6 months, 1 and 2 years after surgery. A cyst of >2 cm presented because of its mammoth size, unusual location and
was considered as recurrence on transvaginal ultrasound. enbloc excision without ureteric transection.

56 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

EP4.29 EP4.30
Establishing an outreach programme: lessons learnt Women’s perception and attitude about
Mahmud, G1; Fatima, S2; Javeed, K2; Sultana, M2 hysterectomy for abnormal uterine bleeding in
1
Qpgmc, Pims, Pakistan; 2MCH Centre, PIMS, Pakistan Puducherry
Manivasakan, J; Dongre, A; Kalaiselvan;
Introduction Pakistan is signatory to the safe motherhood Arunachalam, B
initiative which started in 1987 in Cairo, and calls for 50%
Sri Manakula Vinayagar Medical College And Hospital, Puducherry,
reduction in maternal morbidity and mortality. The Maternal and
India
Child Health (MCH) Centre, Pakistan Institute of Medical
Sciences (PIMS), in collaboration with JICA, UNICEF, WHO and Introduction Abnormal uterine bleeding is the most common
UNFPA-MOH, is the pioneer in launching the safe motherhood complaint in a gynecology clinic. Even though there are various
project in Pakistan. Some of the interventions include baseline modalities of management, hysterectomy is often suggested when
safe motherhood health surveys and establishment of an effective there is failure of medical management or if patient not willing to
referral system for Islamabad capital territory (ICT). The outreach come for regular follow-up. Many quantitative studies have been
programme aimed at developing an effective coordination between done in the field of abnormal uterine bleeding in India.
healthcare providers in ICT with the MCH centre, to expedite the Evaluation of diagnostic tools and various modes of management
referral of high risk patients to tertiary care centers and to develop were studied. But how far this has reached the general public and
linkage with the population in the rural areas. The objective of the what impact it has caused in terms of patients perception about
programme is to reduce maternal mortality rate by preventing the the disease and the choice of management is available or feasible
three delays and to establish an effective referral system through has not been extensively studied. The objective of this study was
linkages among healthcare providers. to explore what kind of information participants had accessed
Methods This is a prospective observational study at the MCH prior to their surgery, and how this may have affected their
centre, PIMS. Healthcare providers were given training by the decisions about treatment and understand variations in patients’
MCH centre staff followed by an outreach programme to facilitate preferences for information and involvement in decision making,
the establishment of referral model in the rural ICT area. Women and the factors that influence them.
health workers and visitors visited the households and referred Methods In-depth semi structured interviews were conducted
patients to primary care facilities i.e., BHU, RHC etc. They were among 20 women with self-reported heavy menstrual bleeding,
then referred to THQ/DHQ and ultimately to the tertiary care not currently pregnant, willing to discuss their bleeding freely and
facilities where they were booked and managed accordingly. The able to give informed consent and waiting for hysterectomy in the
main outcome measure was the reduction in maternal mortality age group of <40 years. The interviews were conducted in the
rate. Gynaecology Inpatient Department at the Sri Manakula Vinayagar
Results The total number of patients seen at ICT centers from Medical College and Hospital, Puducherry, South India. The
January 2001 to April 2010 was 10 517. Of these, 7768 were interview was aimed to elicit information regarding their
referred to MCH centre PIMS. 14 056 patients were seen in awareness about various modalities of management available for
referral room which makes up 93.6% of total referred patients. abnormal uterine bleeding and what has influenced their decision
79% were obstetric patients and 21% were gynecological patients. for hysterectomy and their role in it. The interviews were audio
There was an increase in the number of high risk patients being recorded and transcribed and translated into English. A coding
referred to MCH centre unit-I from 489 in 1999 to 14 056 in year frame was developed from relevant literature and themes arising
2009. Similarly the number of admissions also increased over the from the first three interviews jointly by the authors.
years. The number of high risk women requiring intensive Results Most women had delayed seeking medical help. The
monitoring during labour also increased. A profound difference in women reported that they accepted the decision taken by the
the maternal mortality rate (235/100 000 versus 126.1/1 000 000) gynaecologist since they have already attempted medical treatment
was found when data were compared between year 2001 and and it did not work and they don’t have to worry about the cycles
2009. anymore. Women were not aware of other modalities of
Conclusion The establishment of effective referral system enabled treatment. Advantages and disadvantages of hysterectomy were
the screening of high risk pregnancies with improved reproductive not discussed with them. Their main concern after surgery is if
health outcomes, resulting in reduced maternal mortality rate. and when they are able to do routine work.
Conclusion Most of the patients want their gynaecologists to
make the important decision. Policies should be made to promote
patients involvement in decision making and acceptable to people
with diverse preferences and abilities.

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 57
E-Posters: General Gynaecology

EP4.31 varying grades of severity. Diagnosis requires a high degree of

Case study: severe pre-eclampsia and suspicion and diagnostic ultrasound and Doppler. Early diagnosis
hyperthyroidism complicating a partial reduces patient morbidity like circulatory collapse, severe anaemia
hydatidiform molar pregnancy at 16 weeks of –requiring multiple transfusions and hysterectomy.
Case series In our institution, during the period 2008–2013, five
gestation
cases of symptomatic uterine AVMs have been reported. All of
Nimbe, O; Razley A; McKernan, M them were in the reproductive age group (22–36 years);
Letterkenny General Hospital, County Donegal, Ireland presenting with a history of miscarriage or termination of
pregnancy for which curettage was done. The presentation was
Background A partial hydatidiform mole commonly presents with with recurrent bouts of torrential bleeding, some triggered by a
vaginal bleeding in early pregnancy and the majority result in second curettage, and not controlled with regular measures. Severe
miscarriage. Other frequently reported features include excessive anaemia was the rule 4/5 presented with haemoglobin levels of
uterine size, hyperemesis gravidarum and, more rarely, theca lutein 4.6–8.4 (mean = 7.24 g%). Diagnosis was by ultrasound-gray
cysts, early onset pre-eclampsia, hyperthyroidism and trophoblastic scale, color Doppler and spectral Doppler, all confirmed by an
pulmonary emboli. We present a case of severe pre-eclampsia and operator of >15 years’ experience. The time interval between onset
hyperthyroidism complicating a 16+0 week partial hydatidiform of symptoms and the primary curettage was 8–89 days. All were
molar pregnancy with a coexisting viable fetus. offered selective arterial embolisation, performed by 2
Case A 33-year-old, para 1+0 presented with vaginal bleeding at cardiologists trained in interventional cardiology. Four patients
12 and 15 weeks of gestation. Ultrasonography demonstrated a underwent selective arterial embolisation (2 – unilateral uterine
viable singleton fetus on both occasions. The second scan showed artery; 1 – bilateral uterine artery + unilateral ovarian artery; 1 –
features consistent with partial molar pregnancy with a large bilateral uterine artery+ unilateral anterior division of internal
volume, oedematous placenta and reduced liquor volume. Initial iliac artery). Gel foam was the material used in most cases, one
management was expectant in view of the continuing pregnancy. required a coil placement due to the complex nature of AVM.
She returned 2 days after discharge from her second admission One patient opted for hysterectomy despite being counselled
feeling generally unwell with an associated pyrexia. A septic screen regarding arterial embolisation.
was found to be negative. During the course of admission she Conclusion Uterine AVM should be thought of as a differential
developed a headache, nausea and epigastric pain and at diagnosis in all cases presenting with bleeding after miscarriage
16+0 weeks she acutely deteriorated, complaining of a severe or curettage,since diagnosis is simple and treatment by selective
headache and of feeling ‘jittery’. Blood pressure was elevated up to arterial embolisation saves morbidity of surgery and anaesthesia
192/106 mmHg, there was 3+ proteinuria, hyperreflexia, and more importantly reduces hospital stay and absence
generalised oedema and epigastric tenderness. Ultrasound scan from work.
demonstrated a viable fetus and an enlarged hydropic placenta.
Blood investigations showed an elevated uric acid of 383 lmol/L,
b-hCG of 828 530 mIU/mL and an elevated T4 at 26.1 nmol/L
with a suppressed TSH at 0.03 mU/L. She was managed as severe EP4.33
pre-eclampsia with intravenous magnesium sulphate and labetalol Case study: twin pregnancy in uterus didelphys
infusion. Subsequently, medically managed termination of Raman Attuveppil, V; Narayan D; Khan, S
pregnancy was performed following advice from the molar
Ministry of Health, Oman
pregnancy registry in Ireland and United Kingdom. Additionally,
she was commenced on anti-thyroid medication for her Background Twin pregnancy in uterus didelphys is a rare
hyperthyroidism. Following delivery, the placenta weighed 649.5 g condition which occurs when implantation occurs in each horn
and histopathology confirmed a partial hydatidiform mole. separately. M€ ullerian duct anomalies occur in 1–10% of
Conclusion Clinical and biochemical features of pre-eclampsia unselected population. 15–25% of women with congenital uterine
and hyperthyroidism in early pregnancy should prompt a clinical anomalies have fertility and pregnancy related problems.
evaluation by a multidisciplinary team to exclude a hydatidiform Association of urinary anomalies with mullerian anomalies point
molar pregnancy. to the common origin of both systems. Renal agenesis most
commonly occurs in association with uterus didelphys than with
EP4.32 any other type of mullerian anomaly. Reported incidence of renal
Case study: uterine arteriovenous anomalies in this group is 20%.
malformations-case series and literature review Case A gravida 4, para 2, abortion 1 was seen in antenatal clinic
as a referred case from regional hospital as, twin pregnancy at
N, Lalitha; Panicker S; Shanmugasundaram;
33 weeks of gestation. She was a diagnosed case of uterus
G, Rajendran didelphys with vaginal septum and hypoplastic left kidney prior to
PSG Institute of Medical Sciences and Research, Peelamedu, her first pregnancy when she was investigated for primary
Coimbatore subfertility. This was a spontaneous conception with each fetus in
two different horns of the uterus. Her booking investigations and
Background Uterine arteriovenous malformation (AVM) is a rare anomaly scan were normal. She was monitored for discordant
cause of torrential post-abortal haemorrhage, which can present in

58 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

fetal growth from 33 weeks of gestation by weekly Dopplers, 13 years (range 11–17) and 14 women (19.7%) were nulliparous.
cardiotocography and biophysical profiles. Liquor and Dopplers of There were 11 women <50 years of age and 60 women more than
umbilical and middle cerebral arteries were normal. Elective 50 years of age in group A with confirmed PCOS. PCOS as
caesarean section was done at 37 weeks. At caesarean section two determined by the questionnaire was observed in 4 (36%) cases
separate horns were seen which were fused in the lower part. Both <50 years of age compared to 7 (11.6%) cases more than 50 years
fetuses were delivered through single lower segment transverse of age with a P < value of 0.018. A cohort of women with
incision. Twin A in the left horn was delivered as vertex followed endometrial cancer attending the unit revealed they had type 2
by the second one as breech from the right horn. Placentae were diabetes and hypertension at a prevalence rate of 26.8% and
delivered from each horn separately. Twin A weighed 2000 g and 29.65% respectively. Obesity was associated in 33 women (46.5%)
twin B 3100 g. Both babies were males with Apgar scores of 8 at 1 in group A compared to 21 women (14.6%) in group B.
and 9 at 5 min. Examination of the uterine cavity revealed a Conclusion The prevalence of PCOS in group A was 15.5%
septum extending from the fundus up to the vagina which was compared to 9.7% in group B which is statistically not significant
thick in the upper part and thin in the lower part. Patient made (P = 0.21). However PCOS was seen in a greater proportion of
an uneventful recovery and was discharged on the fourth endometrial cancer patients whose diagnosis of cancer had been
postoperative day. made at or below the age of 50 years. PCOS symptoms including
Conclusion Hypoplastic left kidney which our patient had is hirsutism and very irregular periods were not significantly
explainable by the developmemental association. Renal agenesis is associated with endometrial cancer risk in our study (P = 0.48).
thought to be due to developmental arrest in one wolffian duct We believe a population based study involving women below
which in turn affects the induction of nephrogenesis and 50 years of age may address this important question of the
positioning of the ipsilateral m€
ullerian duct. The malpositioned association of PCOS and endometrial cancer.
m€ullerian duct is incapable of successful fusion and thus two
hemiuteri develop. Optimal mode of delivery in uterus didelphys
with twin pregnancy remains controversial. Considering the risk
of dystocia and uterine rupture, elective caesarean section appears
EP4.35
to be the appropriate mode of delivery. Does the discovery of a twin pregnancy affect the
decision to proceed with termination of
pregnancy?
Whiteway, S1; Ingham, A1; Crawford, J2;
EP4.34
Thomson, A2
Polycystic ovarian syndrome: A risk factor for
1
endometrial carcinoma? A retrospective cross University of Glasgow, Glasgow, UK; 2NHS Greater Glasgow and
Clyde, Glasgow, UK
sectional case control study in a busy unit in
Srilanka Introduction Ultrasound is commonly used to assess pregnancies
Shah, A1; Wijeweera, R2; Krishna-moorthy, P1 in women requesting induced termination of pregnancy (TOP) to
1
Medway NHS Foundation Hospitals Trust, Kent, United Kingdom; determine gestation and viability, and to confirm the pregnancy is
2
Castle Street Hospital for Women, Colombo, Sri Lanka intrauterine. Occasionally the ultrasound scan may reveal that the
woman has a twin pregnancy. The purpose of this study was to
Introduction Although polycystic ovary syndrome (PCOS) is determine whether the discovery of a twin pregnancy affects the
commonly cited as a risk factor for endometrial cancer, woman’s decision to proceed with TOP.
supporting epidemiological evidence is currently very limited. Our Methods We undertook a prospective observational study of
aim was to assess the associations between PCOS, PCOS women referred for induced TOP and had an ultrasound scan
symptoms, and risk of endometrial cancer in a cohort of Sri performed in our unit from 2001 to 2013. Women who did not
Lankan women. have an ultrasound scan were excluded from the study. The
Methods A retrospective cross-sectional case–control study was pregnancy order was recorded (single or multiple pregnancy), in
performed in patients with confirmed histology diagnosis of addition to other variables including: decision to proceed to a TOP,
endometrial carcinoma who were being followed-up at a busy maternal age, scan gestational age, marital status and maternal
cancer unit. A total of 215 women were included in this study. parity. All women were informed if they had a multiple pregnancy.
Seventy-one women were included with endometrial cancer and Results 4706 women attending our TOP clinic had an ultrasound
PCOS (group A). The control group included 144 women who scan performed and the results and pregnancy order recorded. 156
had a diagnosis of PCOS confirmed and no evidence of women were excluded from further analysis because of: early fetal
endometrial cancer (group B). A four point validated demise (n = 123), ectopic pregnancy (n = 4) and non-pregnant
questionnaire was discussed with all the participants and analysed (n = 29). Of the remaining 4550 women, 40 had a twin pregnancy
in a spreadsheet. Statistical analysis was performed with P < 0.05 (0.9%) and 4510 a singleton (99.1%). Of the 40 twin pregnancies,
as significant result. Ethical approval was sought as per the 35 proceeded to termination (87.5%) and of the 4510 singleton
Declaration of Helsinki, World Health Organization. pregnancies, 4236 underwent termination (93.9%), (chi-square
Results The mean age of women with endometrial cancer at P = 0.0908). Amongst those proceeding with a TOP, there was so
diagnosis was 57.2  9.4 years; their average age at menarche was significant difference in gestational age (chi-square P = 0.2460),

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 59
E-Posters: General Gynaecology

marital status (chi-square P = 0.9952) or maternal parity EP4.37

(chi-square P = 0.1811) between the singleton and twin pregnancy Case series: arteriovenous malformations (AVM)
groups. However, those with a twin pregnancy were more likely to Bhalla, R; Adegoke, E; Tripathi, L; Foggin, R;
be aged 21 or over (86% versus 65.8%, chi-square P = 0.0130).
Edwards, L
Conclusion In our cohort of patients, women with a twin
pregnancy were less likely to proceed to a TOP (87.5%) compared North Manchester General Hospital, Manchester, UK
with women with a singleton pregnancy (93.9%). Whilst of
Background Uterine arteriovenous malformations (AVM) are
interest, this trend was not statistically significant owing to the
small sample group of twin pregnancies. Qualitative research to rare, but are associated with increased morbidity and mortality.
determine why women decide not to proceed with TOP, should AVMs usually occur in women of reproductive age and present as
specifically address multiple pregnancies. recurrent or intractable uterine bleeding and can be congenital or
acquired. They typically present as postpartum haemorrhage
(PPH), following uterine instrumentation or as symptom of
endometrial cancer or gestational trophoblastic disease. Pelvic
EP4.36 Doppler ultrasound and pelvic angiography are the mainstay of
Case study: multiple leiomyoma uteri, 112 fibroids investigations, with embolisation of the artery being the current
from single case gold standard treatment. We present two cases of AVMs.
Banu, LF Case 1 A 33-year-old woman, gravida 4 para 2 presented to the
emergency department 2 months following conservative
Fehmicare Hosptal, India
management of a miscarriage at 10 weeks of gestation. She
presented with persistent vaginal bleeding since the miscarriage
Case Miss RW, 24-year-old, unmarried woman, with complaints
which had become increasingly heavier with a foul smell. She was
of severe menorrhagia for 4 years and breathlessness for 6 months
tachycardic and had low blood pressure. Her haemoglobin
presented in the clinic. Clinically she was anaemic and had mass
dropped to 52 units. She had four units of blood. In view of the
per abdomen corresponding to 18 weeks of gestation. Her
clinical findings, she was treated with intravenous antibiotics and
haemoglobin was 6 g/dL and she had 3 units of packed RBC
had surgical evacuation of retained products of conception which
transfusion. A USG revealed multiple fibroids (18–20) including a
was later confirmed on histology. The vaginal bleeding settled
big sub mucus fibroid of 5 9 4 cm. Her elder sister had fibroid
following this and she was discharged. She then presented a
uterus and mymectomy. She was counselled and taken up for a
month later with further episode of vaginal bleeding, again
laparotomy and myomectomy under spinal anaesthesia. Multiple
increasing in volume. Her haemoglobin on admission was 81. She
fibroids sub serous and intramural including the sub mucus were
was managed with haemostatic agents and had a pelvic ultrasound
removed. A total of 32 fibroids were removed. She recovered well
which suggested the presence of an AVM. She subsequently had a
in the postoperative period. She did not come for a regular
pelvic magnetic resonance imaging (MRI) scan which confirmed
follow-up. After 4 years she came with mass per abdomen
the diagnosis. She later underwent embolisation to treat the
corresponding to 28 weeks uterus size and menorrhagia. She was
malformation.
married a year ago. Her Haemoglobin was 8 g/dL. USG revealed
Case 2 An 18-year-old girl was admitted 4 weeks following a
innumerable fibroids of various sizes and it was difficult to count
normal delivery at home at 34 weeks of gestation with ongoing
the number.
heavy vaginal bleeding. She had surgical evacuation for retained
Detailed counselling and risk explained to the couple and the
products of conception, two units blood transfusion and had
family. Four units blood reserved after correction of the anaemia.
intravenous antibiotics She returned 10 days later with increasing
She was taken up for surgery under epidural anaesthesia. The
bleeding. Ultrasound showed a vascular uterus with an area
entire uterus was studded with fibroids. Injection vasopressin was
suggestive of AVM. She had a pelvic angiogram which confirmed
injected and multiple myomas were enucleated with tunnelling
the diagnosis and the malformation was embolised.
incisions. The total surgery time was 2½ hours and, with consent,
Conclusion Although rare, AVMs are a potentially hazardous
the entire procedure was video recorded. She had approximately
phenomenon. Early diagnosis and appropriate management are
1000 mL blood loss. She received 4 units of blood intraoperatively
required for safe and effective treatment. A high index of
and 2 units postoperatively.
suspicion should be present with dealing with treatment refractory
The total number of fibroids removed was 80. Haemostasis
uterine bleeding, particularly in patients who have had uterine
secured by suturing the raw areas and obliterating the cavities
instrumentation. Pelvis ultrasound, including Doppler and
with 1-0 Vicryl. The uterus was reshaped. A drain kept
angiography are useful diagnostic tools. The current gold standard
intraabdominally and abdomen closed in layers. She had
of treatment is embolisation, especially when preservation of
antibiotics, analgesics and supportive therapy. She recovered well
fertility is desirable in women of a reproductive age.
and discharged on the 9th postoperative day. Her HPE report was
inconsistent with multiple leiomyoma and no evidence of
malignancy.
Conclusion Myomectomy was performed in this young patient
and a total of 112 fibroids were enucleated and gave her choice to
retain her uterus and conserve her fertility.

60 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

EP4.38 Methods Sixty women with endometriosis (age group: 20–

Thyroid autoimmunity in endometriosis 40 years) and 60 women without endometriosis attending the
Jacob Vatakencherry, RM; L, Saraswathy; Gynaecology Outpatient Department at the Amrita Institute of
Medical Sciences; Kochi from October 2012 to August 2013 were
K, Radhamany; Krishnan, S; KR, Sundaram enrolled in the cross-sectional study. Serum levels of 25 Hydroxy
Amrita Institute of Medical Sciences, Kochi, Kerala, India Vitamin D were assessed.
Results Sixty women with endometriosis and 60 women without
Introduction Endometriosis is a gynaecological condition in endometriosis were recruited. Mean [ SD] levels of 25 Hydroxy
which cells in the endometrium appear and flourish outside the Vitamin D in women with and without endometriosis were
cavity of uterus, mostly on the ovaries. Endometriosis shows 9.1  3.97 and 20.51  6.59 ng/mL, respectively [P ≤ 0.001].
elevated levels of cytokines, decreased apoptosis and cell mediated Statistically significant lower levels of Vitamin D were observed in
abnormalities. Women with endometriosis may have higher rates women with endometriosis.
of autoimmune disorders including hypothyroidism. Our objective Conclusion Women with endometriosis are found to have lower
was to compare the prevalence of hypothyroidism and levels of Vitamin D when compared to women without
autoimmune thyroid disease (AITD) between married women endometriosis.
with endometriosis and married women without endometriosis.
Methods One hundred and fifty married women (age group:
20–40 years) with endometriosis (study group) and 150 married
women (age group: 20–40 years) without endometriosis (control EP4.40
group) attending the Gynaecology Outpatient Department at the Uterine volume: an aid to determine the route and
Amrita Institute of Medical Sciences, Kochi, Kerala, South India technique of hysterectomy
from October 2012 to August 2013 were enrolled in the Raj, S; SR, Shashirekha; DB, Dharma Reddy;
cross-sectional study. Serum levels of thyroid stimulating hormone
TG, Shashidhar
(TSH), free thyroxine(T4) were evaluated. Sixty married women
was randomly selected from both study and control group and JJM Medical College, Davangere, Karnataka, India
anti-thyroperoxidase (anti-TPO) antibody titre was evaluated.
Introduction Our aim was to assess the value of preoperative
Statistical analysis: statistical analysis was done using IBM SPSS
uterine volume estimated sonographically, in decision-making for
Statistics 20.0. Pearson’s chi-square test was applied to test the
route and technique of hysterectomy.
relationship between two categorical variables. P < 0.05 were
Methods This clinical study was carried out in JJM Medical
considered as statistically significant.
College, Davangere, India for a period of 2 years from January
Results Prevalence of hypothyroidism in married women with
2011 to January 2013. Uterine volume was measured
and without endometriosis were 66.67% (100)and 20% (30)
ultrasonographically in 50 cases posted for elective hysterectomy.
respectively. Among 60 married women with endometriosis,
Intraoperative difficulties, accessibility and ease of surgery were
78.33% (47) were hypothyroid and high anti-TPO titre was found
noted. Also, uterine weight postoperatively was compared with the
in 97.9% (46) of hypothyroid women with endometriosis. Among
uterine volume.
60 married women without endometriosis, 13.3% (8) were
Results Vaginal hysterectomy was performed without difficulty
hypothyroid and high anti-TPO titre was found in 12.5% (1) of
for <300 cc uterine volume. With uterine volume >300 cc,
hypothyroid women without endometrisis (P ≤ 0.001).
debulking was required. With uterine volume >500 cc, that is
Conclusion Prevalence of hypothyroidism and autoImmune
approximately >16 weeks pregnant uterus size, the surgeons
thyroid disease (AITD) was high in endometriosis when compared
preferred abdominal rather than vaginal route. Uterine volume
to control group. Screening for thyroid diseases in endometriosis
correlated well with the uterine weight measured postoperatively.
is indicated.
Conclusion Considering the uterine volume rather than the level
of fundal height for assessing the feasibility of vaginal
hysterectomy has proved useful.
EP4.39
Hypovitaminosis D-Risk factor for endometriosis
Jacob Vatakencherry, RM; L, Saraswathy; EP4.41
K, Radhamany; Krishnan, S; KR, Sundaram Febrile morbidity in a gynaecology qard setting: an
Amrita Institute Of Medical Sciences, Kochi, India audit
Surasinghe, RUK; Chinthana HDK; Karunaratne,
Introduction Endometriosis is a gynaecological condition in
K; Madushanka, JKV
which cells in the endometrium appear and flourish outside the
cavity of uterus, mostly on the ovaries. Since Vitamin D is an National Cancer Institute Maharagama, Sri Lanka
immunomodulator, it may have a role in the pathogenesis of
endometriosis. Our aim was to study the role of vitamin D as a Introduction The aim of the study was to conduct a descriptive
risk factor for endometriosis. analysis on possible contributing factors of febrile morbidity

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 61
E-Posters: General Gynaecology

during the postoperative period and the most frequent causes of outpatient setting,under local anaesthesia. It also aims to evaluate
febrile morbidity in the study setting. the relief from symptoms after a period ranging from 6 to
Methods The study setting was ward 8 at National Cancer 18 months after treatment.
Institute Maharagama, Sri Lanka. An interviewer-based Method This study was carried out on patients attending the
questionnaire was used. The first 100 patients who developed outpatient hysteroscopy clinic at Good Hope Hospital. Eighty
fever postoperatively were taken to the study from the date of women who underwent Novasure endometrial ablation as an
audit started (17th April 2013). They were followed-up while at outpatient procedure, for treatment of menorrhagia between
the ward to determine the possible causes for fever. Fever was May 2008 and December 2009 were included in the study and
defined as a temperature of more or equal to 38.0°C that questionnaires were sent out to evaluate satisfaction with the
occurred in any day during the postoperative stay at the ward. procedure and relief of symptoms.
Readings were taken by mouth by a standard technique at least Results 51 patients returned the questionnaire. Pain score during
four times daily. the procedure was 0–4 in 24/51 patients(47%), between 5–8 in 10/
Results In the study sample majority (68%) of the patients are 51(20%) patients and 8–10 in 17/51(33%) patients. 11/51(22%)
>50 years of age and 72% is postmenopausal. The sample patients preferred the procedure under a GA. 19/51 (37%)
contained 52% of laparotomy for ovarian carcinoma, 14% of RH patients achieved amenorrhoea, 21/51(41%) patients had light
for cervical carcinoma 13% of TAH + BSO  PND for periods, there was a 50% reduction in the amount of bleeding in
endometrial carcinoma, 5% of TAH  BSO for benign conditions 6/51 (12%)patients. There was no improvement of the symptoms
like fibroids and 16% of other procedures (dilatation and in 5/51(9%) patients. Out of the 51, 37(72%) patients rated the
curettage etc). Of the study sample, 73% had preoperative overall satisfaction as excellent, 4(8%) were neutral and 4(8%)
anaemia and 44% was given blood transfusions postoperatively. said it was poor.

For 53% of the sample, In-ward stay prior to surgery is Conclusion This study concludes that Novasure endometrial
≤24 hours. Most frequently used (88%) prophylactic antibiotic ablation when used in an outpatient setting under local
combination is metronidazole and cefuroxime. 86% of the study anaesthesia can achieve high patient satisfaction as well as success
sample had day 1 fever, which means it was due to a physiological with the treatment.
cause. Urinary tract infections occurred in 6% whereas surgical
site infections occurred in 3% and chest infections in 4% of the
sample.
Conclusion Surgical site infection rate of 3% in the study setting
EP4.43
(NICE Study 5%) can be attributed to the standard aseptic The combined use of Thermachoice ablation and
techniques followed during surgeries and the proper utilisation of Mirena in the management of heavy menstrual
prophylactic antibiotics. Urinary tract infection rate of 6% in this bleeding
study(International Urogynaecology Journal, Norway 8.3%) can Tan, A1; Basak, S2; Abukhalil, I2
be attributed to the practice of proper catheter insertion and 1
The Dudley Group NHS Foundation Trust, United Kingdom;
maintenance techniques. Considering the aspects to improve, can 2
Sandwell and West Birmingham Hospitals NHS Trust, United
establish a pre-assessment unit to reduce the stay prior to surgery Kingdom
which in turn contributes to reduce febrile morbidity. Moreover,
setting up a re audit cycle to evaluate improvement will be carried Introduction Heavy menstrual bleeding (HMB) commonly affects
out at the same setting in the future. 1.5 million women in the UK, thereby prompting 1 in 20 women
of reproductive age to seek treatment to improve their quality of
life. The NICE guidelines recommend the use of Mirena (Bayer,
Leverkusen, Germany) in treating benign HMB, followed by
EP4.42 endometrial destruction, if medical treatments fail to resolve
Patient satisfaction and tolerance after treatment symptoms. Several studies have shown the efficacy and
with Novasure endomertial ablation technique in cost-effectiveness of using Mirena, endometrial ablation and
an outpatient setting hysterectomy individually, but evidence on the efficacy of
Syeda, NF1; Kumar, M2; Cartmill, RSV2 combining endometrial ablation and Mirena compared with
1
Worcestershire Acute Hospitals NHS Foundation Trust, Worcester other treatments remains inadequate. The objective of this study
United Kingdom; 2Good Hope Hospital, Sutton Coldfield, was to evaluate the efficacy and outcomes of women with HMB
Birmingham United Kingdom via combined use of Thermachoice (Ethicon, Nordersterdt,
Germany) ablation and Mirena.

Introduction Novasure (Hologic, Inc. Bedford, MA, USA) Methods Forty-nine patients with persistent HMB following
endometrial ablation is a second generation endometrial ablation initial treatment involving either Mirena, Thermachoice
technique used to treat menorrhagia and dysfunctional uterine ablation or medical treatments were randomly selected from the
bleeding. It has been shown to achieve high rates of amenorrhoea, sample population between 2005 and 2011 and consented to have
and low rates of surgical reintervention in several observational combined Thermachoice ablation and Mirena. Our primary
and randomised trials. This study aims to evaluate patient outcome measures were satisfaction levels 6 months
satisfaction and tolerance when this procedure is carried out in an

62 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
 E-Posters: General Gynaecology

post-treatment, amenorrhoea rates and rates of subsequent Our aim of this study was to assess laparoscopy rates and
hysterectomy. outcomes and also comparison of younger women with older
Results There were similar number of patients in the each age group.
group, including aged 35–40 (15 patients), 41–45 (17 patients) Methods This was a prospective study on all women attending
and 46–50 (15 patients), except for 2 patients aged beyond 50. 33 the Gynaecology Outpatient Department with symptoms
of 49 patients had at least two live births and BMI of above 30 suggestive of endometriosis at George Eliot Hospital, Nuneaton
respectively. 36 (73%) patients had normal pelvic scan findings, over a 3-month period. In total, 84 women were included in our
10 patients had benign findings and subsequent histology study.
specimen excluded hyperplasia, atypia and malignancy, and 3 Results 40% of women were <25 years of age and 24 years was
patients had inconclusive findings due to high BMI. Out of 49 the most common age. In younger women with positive family
patients, 18 (37%) had Mirena, 2 (4%) had Thermachoice history 66% had endometriosis versus 25% with negative family
ablation and 29 (59%) had medical treatments after declining history. It was not significant for older group. In younger group,
Mirena initially. Following initial treatment, 16 patients with women with endometriosis hormonal contraception were
Mirena and all patients who had ablation and medical commonest method but in women with negative laparoscopy
treatments (96%) developed initial spotting that persisted to nonhormonal contraception was more common. This was
severe loss. Following subsequent counselling and combined opposite in older group. In younger group there were no
treatment of Thermachoice ablation and Mirena, 38 (78%) differences with regularity of menstrual cycle. Amongst older
patients were very satisfied with their symptoms (3 of 3 women, women with a regular menstrual cycle were more likely
satisfaction ratings), 36 (73%) patients had high amenorrhoea to have endometriosis than those with irregular menstrual cycles
rates and only 11 (22%) patients had persistent spotting that led (53% versus 27%). In younger women symptoms predicting
to a hysterectomy. No other serious complications occurred in endometriosis were in order – acute pelvic pain (APP), chronic
these patients following subsequent treatment. pelvic pain (CPP), dysmenorrhea and dyspareunia. In older group

Conclusion The combined use of Thermachoice ablation and these were APP, dyspareunia, dysmenorrhea and CPP. In younger
Mirena in treating HMB remains justified based on the overall women with IBS symptoms 54% had endometriosis compared to
outcomes and a large prospective study is required to compare its 62% in women who denied IBS. The corresponding percentages
efficacy with other treatments. for other group were 27% and 47%. Investigations: USS was done
in 49/84 – sensitivity 61%, specificity 74%, PPV 74%, and NPV
61% overall laparoscopy rate was 77% with negative laparoscopy
rate of 31% and endometriosis in laparoscopy was present in 55%
EP4.44 with overall endometriosis rate was 43%. In younger group 79%
Do women with endometriosis type symptoms at had laparoscopy of whom 74% had some pathology and 63% had
younger age (under 25 years) differ from women confirmed endometriosis. This group had negative
presenting above 25 years of age? laparoscopy-26% and endometriosis rate in this group is 53% In
Cheema, D1; Woollett, P1; Okojie, P2; older group 76% had laparoscopy, of whom 63% had pathology
Juneenath, D2 and 50% had endometriosis, negative laparoscopy rate-34% and
1 endometriosis rate in this group was 38%.
UHCW, Coventry, UK; 2George Eliot Hospital Nuneaton, UK
Conclusion There are differences in prevalence of type of

Introduction Suspected endometriosis is common cause of referral

symptoms suggestive of endometriosis, family history, use of
to general gynaecology clinics in the UK. There appears to be contraception, regularity of menstrual cycle and IBS. Women in
rising trend particularly in younger women. Diagnostic either group were more likely to have laparoscopy than not but
laparoscopy is the gold standard investigation for endometriosis pathology was more likely to be found in younger woman
and rightly there are reservations in uptake of this invasive compared to older. Negative laparoscopy rates were significantly
investigation due to concerns of operative complications and high lower than those reported in literature.
risk of negative findings. Thus careful selection of patient is vital.

ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 63