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Trial of vaginal birth after caesarean section (VBAC) – a 5-year retrospective analysis
R. IMTIAZ
Aberdeen Maternity Hospital, Aberdeen, UK
Introduction. The safety of vaginal birth after caesarean section has always been subject to intense scrutiny. While most women would be suitable for a trial of vaginal birth after one previous lower segment caesarean section (LSCS), an unsuccessful VBAC attempt may be associated with increased neonatal and maternal morbidity and mortality. There is evidence to suggest that trial of induction of labour (IOL) in women with a previous LSCS is associated with an increased risk of uterine rupture compared with the spontaneous onset of labour.
Aim. To assess the outcome of trial of VBAC after one previous LSCS.
Method. A retrospective analysis of case notes was performed of women who delivered after one previous LSCS during the 5-year period, between January 1998 – December 2002, in Raigmore Hospital, Inverness.
The outcome measures were:
Successful vaginal births after spontaneous onset and induced labour
Risk of scar rupture in spontaneous and induced labour.
Conclusion. Trial of VBAC is safe and successful in carefully selected women. Judicious use of Syntocinon and prostaglandin helps in reducing the number of repeat LSCSs. The use of prostaglandin for IOL is associated with an increase in scar rupture and women need to be adequately counselled regarding this.
What is important to women in the management of miscarriage?
A. J. JESSUP, G. C. PENNEY, & M. CAMERON
Aberdeen Maternity Hospital, Aberdeen, UK
Background. Over 7,500 women require inpatient treatment for miscarriage in Scotland annually. Studies show that traditional management for miscarriage is associated with patient dissatisfaction and psychological distress. In 1996, the Scottish Office Department of Health (SODoH) made recommendations for miscarriage care. National policy documents have since encouraged health organisations to ‘involve people and communities in the design and delivery of health services’.
Aim. To establish if recommendations made by the SODoH for the management of miscarriage agree with what women feel is important.
Methods. Qualitative and quantitative analysis of responses were undertaken from a previous questionnaire survey of women with miscarriage. The survey covered 15 Scottish gynaecology services. The extent to which each service met the SODoH recommendations was summarised as an Early Pregnancy Assessment Unit (EPAU) score (from 0 – 4).
Results. A total of 648 women returned the questionnaire. From the qualitative analyses, staff attitude, waiting time and privacy emerged as important aspects of care. These factors were all significantly associated (p < 0.0001) with the women's overall satisfaction.
A linear relationship was found between overall satisfaction and the extent to which each woman's gynaecological service met the SODoH recommendations (p = 0.0197).
Conclusion. There are two reasons why the SODoH recommendations, which were developed without formal service-user involvement, appear to agree with what women feel is important. First, the individual recommendations that made up the EPAU score (that the EPAU should be a stand alone base and that the ultrasound base, surgical base and postoperative care should all lie within the EPAU) were all structural solutions. Setting up of a dedicated unit for early pregnancy loss will, of its own accord, increase team building, accountability and encourage staff to provide a higher quality of care. Second, the members of the working group were sufficiently empathic to address the emotional and psychological needs of women who miscarry. However, one cannot always rely upon health professionals to be so objective in decision making as they may be biased by personal agendas, issues surrounding pay and working conditions, inter-departmental rivalry, and political imperatives. Therefore, in order to ensure that the service user viewpoint is heard in the NHS, members of the public should be involved in decision making.
An audit of local practice for referral and procedure waiting times for termination of pregnancy in accordance with the RCOG Guidelines ‘The Care of Women Requesting Induced Abortion’
C. RUNDLE, A. KHAN, & K. DUFFY
Ninewells Hospital, Dundee, UK
Methods. A set proforma was used for a total of 223 patients over a 3-month period (1 August 2004 to 31 October 2004). Data were retrieved from the Area 1b Clinic register; Nairn Suite Register. Microsoft Excel was used for data analyses. All women seeking abortion under clause C of The Abortion Act were included. Termination of pregnancy (TOP) for fetal abnormalities were excluded, as separate guidelines exist for these procedures.
Main outcome measures
Time from referral to assessment at clinic
Time from assessment to TOP
Total time from referral to TOP
Type of TOPs performed
Previous TOPs
Contraception pre- and post-TOP
Types of TOP
Outcome of hysteroscopy in patients with uterine polyps who presented with post menopausal bleeding
S. J. SNEDDEN & D. K. M. KOH
Maternal and Child Health Sciences, University of Dundee, UK
Objective. To evaluate the proportion of patients who presented with postmenopausal bleeding who were shown to have uterine polyps and to see what investigations were performed; whether they went on to have hysteroscopy and what the outcome was.
Study design. A retrospective study of 50 patients who were referred to the postmenopausal bleeding clinic in 2003 was carried out.
Results. All 50 patients reviewed had transvaginal ultrasound (TVS) performed on them. Ten patients (20%) had suspicion of a polyp on ultrasound; 11 patients (22%) had suspicion of fibroids and 5 (10%) had suspicion of endometrial cancer. Of the 10 patients with suspicion of polyps on TVS, nine went on to have hysteroscopy and one patient went straight to surgery as a Pipelle biopsy was reported as a grade 1 endometrial adenocarcinoma. Of the nine patients who had hysteroscopy, 55.6% of these were performed as outpatient and 44.4% were performed as inpatient. Of the five patients who had outpatient hysteroscopy, 40% went on to have inpatient hysteroscopy and polypectomy and pathology confirmed endometrial polyps; a fibroid was found in one (20%) patient and no polyps were seen in the remaining two (40%) patients. Of the four patients who had inpatient hysteroscopy, one patient had a grade 2 endometrial carcinoma confirmed by pathology; two patients had polyps confirmed by pathology and had polypectomy performed at the time of hysteroscopy; and one patient had a diagnosis of endometrial polyp and had a polypectomy although pathology did not confirm the mass as an endometrial polyp. Of the five patients with suspicion of cancer on TVS, one (20%) patient went on to have inpatient hysteroscopy, which revealed an endometrial polyp and a polypectomy was performed. Pathology confirmed this was an endometrial polyp. Therefore, out of the 50 patients reviewed, 10% were confirmed as having endometrial polyps by pathology; 40% patients had outpatient hysteroscopy performed and then went on to have inpatient hysteroscopy and polypectomy and the remaining 60% went straight to inpatient hysteroscopy and polypectomy.
Conclusions. As all patients with endometrial polyps eventually had inpatient hysteroscopy and polypectomy, it could be argued that if there is a high suspicion of endometrial polyp on TVS, patients should go straight to have inpatient hysteroscopy rather than have outpatient hysteroscopy first. This study also shows the importance of fully investigating suspected polyps as out of the 10 patients with suspected as polyps on TVS, two turned out to be endometrial carcinoma.
Outcome of patients registered with suspected molar pregnancy
A. WIJESIRIWARDANA, P. ASHOK, & A. TEMPLETON
Aberdeen Maternity Hospital, Aberdeen, UK
Introduction. Gestational trophoblastic neoplasia (GTN) (hydatidiform mole, invasive mole, choriocarcinoma and placental site trophoblastic tumour) are rare in the UK, with an incidence of 1/714 live births. In the UK, there is an effective registration and treatment programme, which has achieved high cure (98 – 100%) and low (5 – 8%) chemotherapy rates (RCOG Citation2004). The health departments of England, Scotland, Wales and Northern Ireland and the RCOG have agreed that women with a molar pregnancy should be registered with a regional centre (RCOG Citation2004).
Women with a suspected molar pregnancy within Grampian are registered with the regional trophoblastic tumour-screening centre in Dundee, Scotland and monitored with serial HCG levels. Should the post-evacuation HCG levels return to normal within 56 days of evacuation of uterus, women are followed-up for a 6-month period and for those whose HCG levels take longer than 56 days to return to normal, the follow-up period is 2 years (Bagshawe et al. Citation1986; Newlands Citation2003). Women in Grampian are registered on the basis of the initial histology diagnosis, prior to confirmation of the diagnosis by flow cytometry from Dundee.
Objective. To determine the accuracy of initial histopathological diagnosis of molar pregnancies and delay registration with the regional centre until final diagnosis is available, in order to avoid anxiety in women.
Methods. Retrospective analyses of prospectively collected data of patients with a suspected molar pregnancy at Aberdeen Maternity Hospital and Aberdeen Royal Infirmary, based on initial histological diagnosis over a period of 1 year from 1 May 2003 to 30 April 2004.
Results. A total of 52 women were suspected to have a molar pregnancy on initial histology. The mean age (± SD) was 30.6 years (± 6.6). Following flow cytometry only 23 women (44.2%) had a molar pregnancy confirmed, with 29 (55.8%) having a non-molar pregnancy. Of those with a confirmed molar pregnancy, nine (39.1%) women had a complete mole and 14 (60.9%) a partial mole. The median (range) time interval between uterine evacuation and registration and uterine evacuation and final diagnosis was 31 (13 – 95) and 57 (30 – 120) days, respectively.
Conclusions. More than half of the women who were registered with a suspected molar pregnancy did not have the diagnosis confirmed by flow cytometry. Registration can be delayed until final diagnosis to avoid possible undue anxiety in women.
Does centralisation of women with endometrial cancer to a gynaecological oncology service improve staging? An audit of practice in the Grampian region 2002 – 2003
Q. A. WARRAICH & D. E. PARKIN
Aberdeen Royal Infirmary, Aberdeen, UK
Background. Endometrial cancer is the fifth most common female cancer in Scotland and though cure rates are good, 25% of women still die of their disease. Staging has been shown to be poorly performed in a Scotland-wide audit and inadequate staging is a predictor of worst outcome. Only 12% of women in Scotland are operated upon by a specialist gynaecological oncologist.
Aims. To determine if the quality of staging information in endometrial cancer is improved in a region where all cases are managed by specialist gynaecological oncologists.
Methods. All 108 women diagnosed and treated with endometrial cancer in Grampian in 2002 and 2003 had a retrospective case note assessment of the completeness of staging information. This was compared with previously published Scottish results.
Results. Completeness of staging was high. The FIGO stage was available in 100% of women. Chest X-ray was performed in 85% and peritoneal cytology in 93%. Pelvic lymphadenectomy was performed in 28%. All these results were significantly better than in the Scottish audit.
Conclusion. Centralisation of women with endometrial cancer results in more accurate staging information.
Tension free vaginal tape (TVT): A 5-year follow-up study
R. RAJAGOPAL, K. POPLI, C. MCKINLEY, D. LYTHE, & T. A. MAHMOOD
Forth Park Hospital, Kirkcaldy, Fife, UK
Aim. To assess the effectiveness of TVT subjectively during the following years (range 1 – 5 years) following surgery.
Method. A postal questionnaire was sent to all women who underwent TVT during the period between 1 March 1999 to 31 March 2004, retrospectively.
Main outcome measures. Following surgery, occurrence of urgency, straining to void, abdominal pain, frequency of micturition, improvement in bladder problems (on a scale of 10), change in quality of life, advise a friend/relative with similar problem to undergo TVT.
Results. The questionnaire was sent to all the 200 women who underwent TVT. A total of 162 responded (81%) to the questionnaire. Urgency was experienced by 26% (42) of women; 23% (10) developed this problem after surgery; 20% (33) had to strain to empty their bladder initially and of this, 27% (9) needed self catheterisation for a short-term period. Nearly 61% reported increased frequency of micturition and of this 50% (81) had a nocturnal increase. Intermittent abdominal pain was experienced by 12% (20) of women, but this did not affect their lifestyle. Significant improvement in bladder problems was reported by 90% (146) of women following surgery when assessed on a scale of 10. Surgery has had a remarkable effect on the quality of life in 81% (132) of women and only 0.6% (1) stated that the operation had the worst effect on their quality of life; 17% (28) felt their quality of life remained the same and TVT had not made a difference. With regard to their advice to a friend/relative to undergo TVT if they have a similar problem, 91% (148) said they would certainly advise to have the operation. Only 3% (5) said they would not recommend it and 5% (8) were not sure if they would recommend or not.
Conclusion. Our results reveal that the majority experienced cure or improvement in bladder symptoms after TVT and remain continent following surgery.
Management and outcome of patients with obstetric cholestasis
R. KUMAR & J. BRENNAND
Queen Mothers Hospital, Glasgow, UK
Aim. To determine the management and outcome of patients with obstetric cholestasis in our unit.
Methods. We did a retrospective analysis of notes of 40 women diagnosed with obstetric cholestasis at Queen Mothers Hospital, Glasgow between January 2000 and September 2004. Pregnant women with pruritus with abnormal liver function (one or more abnormality in alanine amino-transferase, aspartate amino-transferase, gamma-glutamyl transpeptidase and total bile acids), in the absence of other pathology were included.
Results. A total of 40 women were included in the study. Most patients complained of a generalised itch. An equal number of patients had mild and severe pruritus. All patients had alanine amino-transferase, aspartate amino-transferase and alkaline phosphatase performed but only 57.5% had bile acids performed and no patient had gamma-glutamyl transpeptidase performed. The mean gestational age at diagnosis was 34.2 weeks. A total of 47.5% of patients were seen by the registrar and 52.5% were reviewed by the consultant. When the registrar reviewed the patient, the consultant was informed in 84% of cases. Decision for delivery was made by the consultant in 82.5% of patients, by the registrar in 10% of patients and 7.5% of patients went into spontaneous labour before a decision was made.
Regarding treatment, 30% had chlorpheniramine for symptomatic relief of pruritus. Ursodeoxycholic acid was prescribed only in 40% of patients, and only 20% received vitamin K supplements. There were no stillbirths or neonatal deaths. A total of 12.5% had elective caesarean section, and in 40% of these cases, obstetric cholestasis was the primary indication. A total of 17.5% had emergency caesarean section out of which 14.3% were performed for fetal distress. A total of 14 women delivered before 37 weeks, of which 64.2% were iatrogenic and 35.7% spontaneous pre-term deliveries. Eight (20%) infants required admission to the Special Care Baby Unit, of which seven (87.5%) were pre-term, and none required ventilation.
Conclusions. Bile acids were performed in only just over 50% of the patients, probably because of the limited facilities available. Only a small percentage was being treated with ursodeoxycholic acid, which improves symptoms and liver functions including serum bile acid levels. Similarly, only a minority were getting vitamin K supplements which reduce the incidence of postpartum haemorrhage. Clearly, there is a need for a protocol so that management of these patients can be more effective. This has been circulated and hopefully along with in-house assays of bile acids, will contribute to better management of patients with obstetric cholestasis in our unit.
The use of D-dimers as a predictive indicator of thromboembolic disease during pregnancy
J. R. BURT & L. CAIRD
Raigmore Hospital, Inverness, UK
Objective. To determine whether D-dimer testing is of use at predicting thromboembolic disease in pregnancy.
Design. Retrospective analysis of 64 sets of patients' notes who attended Raigmore Hospital, Inverness, over a 15-month period and had a D-dimer taken because of suspected thromboembolic disease.
Population. Women who were over 16 weeks' pregnant and less than 10 days' postnatal.
Results. A total of 92.2% of the women studied had a positive D-dimer (>250 ng/ml). Of all the women tested regardless of a positive or negative D-dimer result, 75% went on to have further investigations (Doppler US, VQ scans). A total of 12.5% of these women were shown to have thromboembolic disease. None of these women had a negative D-dimer.
Conclusions. The study did indicate that a negative D-dimer is effective at excluding thromboembolic disease in pregnancy. The number of women with a negative D-dimer in this study however, was too small to suggest a definite correlation. The fact that the majority of women had a positive D-dimer in this study and yet only a small percentage had actual thromboembolic disease, suggests that D-dimers are a poor screening tool in pregnancy. Studies in non-pregnant subjects have shown that it is not acceptable to use negative D-dimer results alone to screen patients suspected of having thromboembolic disease. Current practice at present in non-pregnant patients is to use D-dimers and clinical probability scoring charts to assess risk and thus decide on the need for further investigation. At present, no clinical probability scoring tool exists for pregnant women.
The relationship between HbA1c and birth weight in pregnancies complicated by type I diabetes
D. KERNAGHAN1, G. C. PENNEY1, & D. W. M. PEARSON2
1Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH), Aberdeen Maternity Hospital and 2Aberdeen Royal Infirmary, Aberdeen, UK
Introduction. The relationship between glycaemic control and birth weight in diabetic pregnancies is complex. Studies differ as to the time period for which glycaemic control has the strongest relationship with birth weight.
We examined the relationship between maternal HbA1c at different time points and birth weight in pregnancies complicated by pre-existing Type 1 diabetes.
Data were collected prospectively on all deliveries in Scotland of women with pre-gestational Type 1 diabetes. Data were collected during two separate periods: 1 April 1998 to 31 March 1999, and 1 April 2003 to 31 March 2004.
Standardised birth weight (Z scores) could be calculated for 351 of 372 singleton live born infants. HbA1c concentrations were standardised to correct for assay differences among hospitals.
Results. HbA1c results were available for differing numbers of cases in different time periods: pre-pregnancy, 213 cases; 1st trimester, 315 cases; 2nd trimester, 333 cases; and 3rd trimester, 324 cases. Standardised birth weight showed a unimodal distribution shifted to the right relative to a reference population (Mean + 1.64 SD). There was a significant negative correlation between pre-pregnancy HbA1c and birth weight (Spearman's Rho − 0.174 p = 0.011). There were no statistically significant correlations at other time points.
Conclusions. Standardised birth weight scores of the infants of diabetic mothers are higher than those of a reference population. There is no simple relationship between maternal glycaemic control and birth weight, but there appears to be a paradoxical negative relationship between pre-pregnancy glycaemic control and standardised birth weight.
A review of the outcomes of ‘low risk’ spontaneous primigravid labours (Robson Group One) and subsequent introduction of guidelines for management of this group
L. STOFBERG, S. CARSWELL, & D. HERD
Raigmore Hospital, Inverness, UK
Introduction. Primigravid women who present in spontaneous term labour and who have experienced an uncomplicated pregnancy are considered low risk. These women can be classified as Group One in the Robson Criteria. Despite the considered ‘low risk’ that these women carry, the caesarean section rate for this group has risen and makes up the largest proportion of all women undergoing sections in Raigmore Hospital (21%) (much higher than the proposed 10 – 15% of the WHO). A retrospective review was carried out identifying all Robson Group One women who delivered in the 4-month period August 2004 to December 2004. Duration of labour was reviewed for each case and the outcomes documented for all prolonged labours using three parameters (maternal pyrexia, admission to SCBU and caesarean section). Information was obtained from the labour suite logbook and case notes.
Results. The total number of Robson Group One deliveries for the stated period was 183. A total of 37 (20.2%) caesarean sections, 25 (13.66%) Ventouse deliveries and 13 (7.1%) forceps deliveries were performed. A total of 47 (25.68%) women had prolonged labour (longer than 12 h).
Duration of labour for all 183 women was grouped into 2-hourly intervals. One labour was less than 2 h; nine were 2 – 4 h; 23 were 4 – 6 h; 38 labours fell into the 6 – 12 h category; 35 were 8 – 10 h; 27 were 10 – 12 h; 37 were 12 – 18 h; 10 > 18 h and three unknown.
Prolonged labour was subdivided into two groups. Those between 12 – 18 h and more than 18 h, respectively and the outcomes were evaluated. In labours of 12 – 18 h, maternal pyrexia was found in 17% of deliveries, admission to SCBU was necessary in 3% and caesarean sections were carried out in 33%. In labours lasting more than 18 h, maternal pyrexia was found in 40%, admission to SCBU in 10% and caesarean sections were carried out in 60%.
Conclusions. The current caesarean section rate for Robson Group One patients in the unit is 20.2%, which is higher than some other units in Scotland, without any obvious difference in management. This review has highlighted the fact that adverse outcomes are not unexpected in women with prolonged labour, especially in those with labours lasting more than 18 h. A new guideline for managing this group of women was subsequently introduced in December 2004 with the aim to provide a more uniform management in the department, to aid decision making and thus improving outcomes.
Randomised controlled trial comparing efficacy of same day administration of mifepristone and misoprostol for termination of pregnancy with the standard 36 – 48 h protocol
J. GUEST, P. CHIEN, M. THOMSON, & M. L. KOSSEIM
Ninewells Hospital and Medical School, Dundee, UK
Background. Medical termination of pregnancy has been shown to be a safe and effective alternative to a surgical procedure. The current, widely adopted practice utilises a single oral dose of 200 mg mifepristone followed 36 – 48 h later by another single vaginal dose of 800 μg misoprostol. Following the administration of misoprostol, patients are then observed for 6 h in order to verify the expulsion of the conceptus. If this does not occur within this time interval, the patient is discharged home with a follow-up ultrasound scan 2 weeks later to confirm that the termination is complete. This regimen requires at least two hospital visits to receive the two drugs on two different days.
If the time interval between the administration of these two drugs can be reduced to 6 h and efficacy can still be maintained, then potentially, the whole termination procedure can be undertaken within 1 day.
Methods and design. This is a two-arm parallel design randomised controlled trial. The trial was conducted at a single hospital site. At the initial clinic visit for counselling and medical assessment, an ultrasound scan for gestation was performed. Eligible women up to 63 days' gestation were invited to participate in the study. Those willing were randomised to either the experimental group (6 h administration of misoprostol) or the control group (36 – 48 h administration of misoprostol). The randomisation was computer generated in blocks of 20 and contained in sealed, opaque envelopes. Blinding was not possible with this study. Compliance with treatment was ensured since the two drugs had to be administered at a hospital.
All participants took 200 mg mifepristone orally. At the time determined by the study group allocation 800 μg misoprostol was given intravaginally together with 100 mg diclofenac pr. Antibiotic prophylaxis as per the usual protocol was given to each group. The control group remained in hospital for 6 h as is current policy and the study group returned home in 1 – 3 h. An ultrasound scan was carried out in all participants after 48 h to ensure that the termination was complete and a questionnaire was completed reporting bleeding, pain, side-effects and acceptability. If a continuing pregnancy was diagnosed, suction termination would be performed. If a gestation sac was still present without a viable pregnancy, then a further vaginal dose of misoprostol was given and a further follow-up ultrasound performed 2 weeks later. In those with an incomplete procedure, patients could opt for a suction evacuation at any stage if clinically appropriate.
Assuming a success rate of 90% at a 48 h interval and a randomisation ratio of 1:1 then a total of 450 patients would need to be recruited to demonstrate at least an 80% expulsion rate using the 6 h regimen with an α value of 0.05 and a β value of 0.5.
Results. Recruitment to the study and follow-up of participants is now complete. The data are currently undergoing analysis and will be complete prior to abstract publication and presentation of the data at NOGS. The outcomes to be measured are as follows:
Primary outcome
Efficacy of drug regimen defined as successful complete medical abortion without need for further misoprostol or surgical evacuation
Duration of bleeding related to the procedure
Incidence of side-effects
Acceptability based on questionnaire
Does hysteroscopy induce undue delay in the commencement of treatment for endometrial carcinoma?
M. CAIRNS, T. KAYE, & I. DUNCAN
Ninewells Hospital, Dundee, UK
Introduction. Endometrial cancer is the most common gynaecological cancer in the UK and the majority of patients present with early stage disease due to symptoms. Despite this, 25% of all women with endometrial cancer die within 5 years of initial diagnosis.
Patients are diagnosed with endometrial carcinoma on the basis of a histological sample either obtained by hysteroscopy or a blind sampling device, e.g. Pipelle. Hysteroscopy is deemed to be the current gold standard but the evidence base is poor.
Objective. The aim of our study is to evaluate whether hysteroscopy causes significant delay in the diagnosis and the commencement of definitive treatment in women with endometrial carcinoma.
Stage and grade of disease was analysed to assess any impact this delay may have had.
Design. Retrospective unmatched case control study of women diagnosed with endometrial carcinoma in Tayside between 1 January 2001 and 31 December 2004.
Results. A total of 150 women were identified over the above period. Some 94 (63%) were diagnosed in the outpatient setting using Pipelle biopsy. A small number of these (18; 12%) had an outpatient hysteroscopy and 56 (37%) had an inpatient hysteroscopy with endometrial sampling to establish the diagnosis. In the outpatient group, the time from being assessed at the clinic until surgery, ranged from 5 – 106 days. The median time was 32 days. In the inpatient group, the time ranged form 15 – 169 days, with a median of 95 days.
There was no difference between the groups in terms of FIGO staging and tumour grade.
Conclusions. There is an appreciable delay in definitive surgical treatment for endometrial carcinoma in patients undergoing inpatient hysteroscopy. If targets regarding waiting times are to be met, inpatient hysteroscopy must be quickly and readily available. Whether this delay is clinically significant is difficult to assess, however, as these patients had a similar FIGO stage to those investigated in the outpatient setting.