This study correlates the transvaginal ultrasound findings with histopathology results in women who present with unscheduled bleeding on hormone replacement therapy. Study design: Retrospective analysis of 469 consecutive cases with unscheduled bleeding on hormone replacement therapy (203 patients on sequential hormone replacement therapy (seq-HRT) and 266 patients on continuous combined hormone replacement therapy (con-HRT)). Main outcome measures: Outcomes of endometrial assessment in women with unscheduled bleeding on hormone replacement therapy. Results: Normal appearance of the endometrium on pelvic ultrasound was seen in 62% patients on seq-HRT and 43% of women on con-HRT. These women required no further assessment and were discharged. Histological assessment showed normal endometrial tissue in 22% of women on seq-HRT and 22% of con-HRT group. Benign endometrial polyps were noted in 8% of women on seq-HRT versus 18% of women on con-HRT. Hyperplasia without atypia was noted in 0.5% of woman on seq-HRT versus 0.4% of women on con-HRT while atypical hyperplasia/endometrial cancer was noted in 2% of women on seq-HRT versus 1% of women on con-HRT. Conclusion: Women who present with unscheduled bleeding on hormone replacement therapy both on sequential and continuous combined regimens can be reassured that the risk of pathology is low.

Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the UK. Therefore, timely VTE risk assessment is essential in all obstetrics patients. The Commissioning for Quality and Innovation (CQUIN) payment framework set a target for trusts to complete a VTE risk assessment within 24 hours of admission for 95% of patients. A combination of factors, including lack of integration between multiple IT systems, means that this CQUIN target is currently not being met for obstetric patients in the Hospital Birth Centre at Guys and St Thomas' NHS Trust.This project aims to increase staff awareness of this issue and educate them regarding the correct procedure for VTE assessment. Trialled methods included reminders at staff handovers, use of magnets on the patient whiteboard, posters and stickers displayed around the unit and a loyalty card scheme as incentive to complete assessments. Initial average completion rate was 20.7%, which increased to 67.5% after the first plan, do, study, act (PDSA) cycle with a slight drop to 65.7% after the second cycle. Completion rates increased to 92.3% on the last day of the third PDSA cycle. Although we did not reach the 95% target, we have raised awareness of the importance of recording VTE assessment on electronic systems, and hope we have created sustainable change.

Virtual poster abstracts at the rate of 0.15% were diagnosed by trans-vaginal scan. Group A comprised 15 patients with embryonic/fetal cardiac activity and Group B comprised 6 patients without embryonic cardiac activity. Group A: 46% had intra-gestational injection of KCL and methotrexate with full resolution. 20% had Uterine Artery Embolisation followed by surgical evacuation. 10.3 % had systemic methotrexate 2 doses which later needed intra-gestational KCL and methotrexate. Only 3% had resolution with 2 doses of systemic methotrexate. 6.6 % had intra-gestational KCL/methotrexate with Foleys catheter tamponade. 6.6% had hysterectomy who presented at 18-20wks with intraperitoneal bleeding. 6.6 % lost follow up. Group B: 63.3 % had intra-gestational methotrexate and had full resolution. 20 % had systemic methotrexate with full resolution in 3-4 months duration. 16.6 % lost follow up. Conclusions: The incidence of CSP is increasing and previous Caesarean section is an important risk factor. There is a need to keep the primary Caesarean section rates at a low level. There is no consensus regarding the best treatment for CSP. Trans-vaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis before 8wks. Medical management using intra-gestational injection of KCL with methotrexate appears to be an acceptable treatment in clinically stable women. The use of single treatment modalities like surgical evacuation or systemic methotrexate alone is not recommended.

Virtual poster abstracts at the rate of 0.15% were diagnosed by trans-vaginal scan. Group A comprised 15 patients with embryonic/fetal cardiac activity and Group B comprised 6 patients without embryonic cardiac activity. Group A: 46% had intra-gestational injection of KCL and methotrexate with full resolution. 20% had Uterine Artery Embolisation followed by surgical evacuation. 10.3 % had systemic methotrexate 2 doses which later needed intra-gestational KCL and methotrexate. Only 3% had resolution with 2 doses of systemic methotrexate. 6.6 % had intra-gestational KCL/methotrexate with Foleys catheter tamponade. 6.6% had hysterectomy who presented at 18-20wks with intraperitoneal bleeding. 6.6 % lost follow up. Group B: 63.3 % had intra-gestational methotrexate and had full resolution. 20 % had systemic methotrexate with full resolution in 3-4 months duration. 16.6 % lost follow up. Conclusions: The incidence of CSP is increasing and previous Caesarean section is an important risk factor. There is a need to keep the primary Caesarean section rates at a low level. There is no consensus regarding the best treatment for CSP. Trans-vaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis before 8wks. Medical management using intra-gestational injection of KCL with methotrexate appears to be an acceptable treatment in clinically stable women. The use of single treatment modalities like surgical evacuation or systemic methotrexate alone is not recommended.

Objective To explore the views of members of the British Menopause Society on the management of women with unscheduled bleeding on hormone replacement therapy. Study design An electronic cross-sectional questionnaire survey. Main outcome measures Investigations, treatment options and preferences for the management of women with unscheduled bleeding on hormone replacement therapy. Results A total of 91/178 (51%) clinicians investigate patients with unscheduled bleeding within three to six months of starting sequential hormone replacement therapy (seq-HRT) versus 83/178 (47%) for continuous combined hormone replacement therapy (con-HRT). A total of 52/178 (29%) versus 54/178 (30%) would investigate unscheduled bleeding continuing beyond six months while 18/178 (10%) versus 26/178 (15%) would investigate within three months. Assessment is requested as urgent by 88/176 (50%) clinicians, routine by 47/176 (27%) and a two-week-wait-suspected cancer referral by 41/176 (23%). A total of 97/178 (55%) clinicians would continue seq-HRT and refer versus 117/178 (66%) for con-HRT. A total of 46/178 (26%) clinicians would change the progestogen preparation in women with unscheduled bleeding on seq-HRT. For women on con-HRT, 12/178 (7%) clinicians would change to seq-HRT and 8/178 (5%) to the Mirena IUS. The Mirena IUS is the preferred progestogen for 81/178 (45%) of clinicians when prescribing hormone replacement therapy. Conclusions There is a varied approach in the practise amongst British Menopause Society members to managing women with unscheduled bleeding on hormone replacement therapy. Further research is needed to determine the optimal assessment pathways for women with unscheduled bleeding on hormone replacement therapy.