European Journal of Obstetrics & Gynecology and Reproductive Biology

Editor's highlights

J. Drife — 2009-12-18

Next month, International Women's Day on 8th March will be an opportunity to raise awareness of women's health issues around the world. The continuing high rate of maternal mortality is one of most pressing of these and it is encouraging to see an international coalition, the White Ribbon Alliance (WRA), working hard to draw attention to this preventable cause of death. WRA, launched in 1999 and supported by influential women including Sarah Brown, wife of the UK Prime Minister, has members in 143 countries and national alliances in 15, including Burkina Faso, Nepal and Yemen. Political action is vital but critically ill pregnant women need the skills of obstetricians and we hope there will be increasing co-operation between the WRA and our specialty. Raising awareness is essential but it is only the first step in the journey towards low maternal mortality. The complexity of the problem is illustrated by recent figures from the USA, where the WRA is based, and where the maternal mortality rate per 100,000 live births is 36.5 among black women compared with 11.1 among white women.

Preterm birth and low birth weight among in vitro fertilization twins: A systematic review and meta-analyses

2009-10-05

Abstract: Objective: The objective of this systematic review and meta-analyses was to determine the risks of preterm birth (PTB) and low birth weight (LBW) in twins conceived through in vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection (ICSI) compared to spontaneously-conceived twins after matching or controlling for at least maternal age.Study design: The MOOSE guidelines for meta-analysis of observational studies were followed.Search strategy: Medline and Embase were searched using comprehensive search strategies. Bibliographies of identified articles were reviewed.Selection criteria: English language studies of twins conceived by IVF or IVF/ICSI, compared with spontaneously twins, that matched or controlled for at least maternal age.Data collection and analysis: Two reviewers independently assessed titles, abstracts, articles and study quality and extracted data. Statistical analyses were performed using the Review Manager (RevMan 5.0) software using a random effects model. Dichotomous data were meta-analyzed using relative risks (RR) and continuous data with a weighted mean difference.Results: Twelve studies were included which had a total of 4385 twins conceived after IVF or IVF/ICSI (one stillbirth was excluded) and 11,793 spontaneously-conceived twins. After matching or controlling for maternal age and often other factors, compared to spontaneously-conceived twins, IVF twins had increased risks of both our primary outcomes: PTB (RR 1.23, 95% CI 1.09, 1.41) and LBW (<2500g, RR 1.14, 95% CI 1.06, 1.22). They were at increased risk for PTB <32–33 weeks (RR 1.63, 95% CI 1.17, 2.27) although the risks of late PTB (32–36 weeks, RR 1.12, 95% CI 0.85, 1.47), very LBW (<1500g, RR 1.28, 95% CI 0.73, 2.24), extremely LBW (<1000g, RR 0.88, 0.04, 19.40), intrauterine growth restriction (RR 1.06, 95% CI 0.72, 1.55) and the difference in the duration of gestation (−0.5 weeks, 95% CI −1.2 weeks, 0.2 weeks) were not statistically significantly increased compared to spontaneously-conceived twins. IVF twins had significantly lower mean birth weights (−105g, 95% CI −204g, −3g).Conclusions: IVF twins have small but significantly increased risks of PTB, LBW, and lower mean birth weight compared to spontaneously-conceived twins after matching or controlling for at least maternal age.

Natural orifice surgery (NOS)—Toward a single-port transdouglas approach for intra-abdominal procedures

Michael Stark, Gian Carlo Di Renzo, Tahar Benhidjeb — 2009-11-05

Abstract: Objective: To describe a future method for abdominal surgical procedures in women using a single-port Transdouglas Endoscopic Device (TED).Methods and description: The first successful laparotomy was performed in the 19th century, and the first endoscopic operation in the 20th century. The 21st century started with experimental operations using the natural body openings. Various abdominal procedures have already been performed through the stomach, but it seems that the transdouglas pathway in women is the most promising access into the peritoneal cavity, for its safety and cost-effectiveness. The TED is designed to perform operations in the upper and the lower abdomen. The New European Surgical Academy (NESA) founded the first European based interdisciplinary working group in order to plan and design instruments toward future gynaecological, urological and surgical applications.Conclusion: The single-port TED is expected to replace many of today's endoscopic procedures due to its probably higher safety and better ergonomics.

Are there sex differences in Fetal Abdominal Subcutaneous Tissue (FAST) measurements?

2009-10-26

Abstract: Objective: To determine if Fetal Abdominal Subcutaneous Tissue (FAST) measurements using antenatal ultrasound differ between male and female fetuses.Study design: Women who had an ultrasound examination for fetal growth between 20 and 40 weeks gestation were studied. Women with diabetes mellitus were excluded. The fetal anterior abdominal subcutaneous tissue was measured on the anterior abdominal wall in millimetres anterior to the margins of the ribs, using magnification at the level of the abdominal circumference. The fetal sex was recorded after delivery.Results: A total of 557 fetuses were measured, 290 male and 267 female. The FAST measurements increased with gestational age. The FAST increased at the same rate for both male and female fetuses and at any given week there was no sex difference.Conclusions: The increased fat composition in females reported after birth was not found in abdominal wall subcutaneous fat measurements using ultrasound during pregnancy. Antenatal centile charts for FAST do not need to be based on sex.

Implementation of guidelines on oxytocin use at caesarean section: A survey of practice in Great Britain and Ireland

Sharon R. Sheehan, Lilantha Wedisinghe, Maureen Macleod, Deirdre J. Murphy — 2009-10-26

Abstract: Objective: Caesarean section is one of the most commonly performed major operations on women worldwide. Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death. Various clinical guidelines address oxytocin use at the time of caesarean section. We previously reported wide variation in practice amongst clinicians in the United Kingdom in the use of oxytocin at caesarean section. The aim of this current study was to determine whether the variation in approach is universal across the individual countries of Great Britain and Ireland and whether this reflects differences in interpretation and implementation of clinical practice guidelines.Study design: We conducted a survey of practice in the five individual countries of Great Britain and Ireland. A postal questionnaire was sent to all lead consultant obstetricians and anaesthetists with responsibility for the labour ward. We explored the use of oxytocin bolus and infusion, the measurement of blood loss at caesarean section and the rates of major haemorrhage. Existing clinical guidelines from the National Institute for Clinical Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG) and ALSO (Advanced Life Support in Obstetrics) were used to benchmark reported practice against recommended practice for the management of blood loss at caesarean section.Results: The response rate was 82% (391 respondents). Use of a 5IU oxytocin bolus was reported by 346 respondents (85–95% for individual countries). In some countries, up to 14% used a 10IU oxytocin bolus despite recommendations against this. Routine use of an oxytocin infusion varied greatly between countries (11% lowest–55% highest). Marked variations in choice of oxytocin regimens were noted with inconsistencies in the country-specific recommendations, e.g. NICE (which covers England and Wales) recommends a 30IU oxytocin infusion over 4h, but only 122 clinicians (40%) used this.Conclusions: Clinicians’ approach to the use of oxytocin at the time of caesarean delivery varies between countries. Even in countries with on-site visits to ensure guideline implementation (e.g. Clinical Negligence Scheme for Trusts in England), deviations from guideline recommendations exist. These variations may reflect a lack of robust evidence and the need for future research in this area.

Diagnosis of placental abruption: relationship between clinical and histopathological findings

2009-10-26

Abstract: Objective: We evaluated the extent to which histologic lesions bearing a diagnosis of abruption conform to a diagnosis based on established clinical criteria. We further examined the profile of chronic and acute histologic lesions associated with clinical abruption.Methods: Data from the New Jersey-Placental Abruption Study – a multi-center, case-control study – were utilized to compare the clinical and histologic criteria for abruption. The study was based on 162 women with clinically diagnosed abruption and 173 controls. We examined the concordance between clinical indicators for abruption with those of a histopathological diagnosis. The clinical criteria for a diagnosis of abruption included (i) evidence of retroplacental clot(s); (ii) abruption diagnosed on prenatal ultrasound; or (iii) vaginal bleeding accompanied by nonreassuring fetal status or uterine hypertonicity. The pathological criteria for abruption diagnosis included hematoma, fibrin deposition, compressed villi, and hemosiderin-laden histiocytes in cases with older hematomas. Acute lesions included chorioamnionitis, funisitis, acute deciduitis, meconium stained membranes, villous stromal hemorrhage, and villous edema. Chronic lesions included chronic deciduitis, decidual necrosis, decidual vasculopathy, placental infarctions, villous mal-development (delayed or accelerated maturation), hemosiderin deposition, intervillous thrombus, and chronic villitis.Results: Of clinically diagnosed cases, the sensitivity and specificity for a histologic confirmation of abruption were 30.2% and 100%, respectively. Presence of retroplacental clots remained the single most common finding (77.1%) among clinically diagnosed cases. Among the acute lesions, chorioamnionitis and funisitis were associated with abruption. The only chronic histologic lesion associated with abruption was placental infarctions.Conclusions: The concordance between clinical and pathologic criteria for abruption diagnosis is poor. The criteria for diagnosing a clinical abruption should include sonographic visualization of abruption, evidence of retroplacental clots, or vaginal bleeding accompanied by nonreassuring fetal status or uterine hypertonicity.

Arterial balloon occlusion of the internal iliac arteries for treatment of life-threatening massive postpartum haemorrhage: a series of 15 consecutive cases

J.P.M. Penninx, H.L.M. Pasmans, S.G. Oei — 2009-11-02

Abstract: Objective: To evaluate arterial balloon occlusion of the internal iliac arteries for treatment of life-threatening massive postpartum haemorrhage.Study design: Retrospective cohort study at a tertiary referral perinatal centre in a teaching hospital in the Netherlands. All patients who delivered in our hospital between January 1998 and January 2008 were included in the study. A retrospective analysis of all cases of postpartum haemorrhage was performed. All 15 consecutive cases of massive postpartum haemorrhage were selected from an electronic database. The patients with massive postpartum haemorrhage (blood loss>5000ml) and the patients with postpartum haemorrhage treated with arterial balloon occlusion of internal iliac arteries were analyzed.Results: In the study period 1246 (7%) of all 17,308 deliveries were complicated by postpartum haemorrhage. 15 (0.1%) patients suffered from massive postpartum haemorrhage. They were all treated with balloon occlusion of the internal iliac arteries. Hysterectomy was performed in 4 patients. All patients survived without any complications.Conclusion: Arterial balloon occlusion of the internal iliac arteries is a safe and in most cases effective procedure for treatment of massive life-threatening postpartum haemorrhage.

Possible association of folic acid supplementation during pregnancy with reduction of preterm birth: a population-based study

A.E. Czeizel, E.H. Puhó, Z. Langmar, N. Ács, F. Bánhidy — 2009-11-05

Abstract: Objective: Periconceptional folic acid or multivitamin supplementation is recommended for prospective pregnant women to prevent neural-tube defects. The question is whether it is worth continuing these supplementations after the first trimester of pregnancy or not. Thus the possible fetal growth promoting and/or preterm birth reducing effect of vitamin supplements in the second and mainly in the third trimester was studied.Study design: Comparison of birth outcomes of singletons born to primiparous pregnant women with prospectively and medically recorded vitamin supplement in the population-based data set of the Hungarian Case-Control Surveillance of Congenital Abnormalities (HCCSCA), 1980–1996 contained 6293, 169, and 311 primiparae with folic acid alone, multivitamins and folic acid+multivitamin supplementation, respectively, and their data were compared to the data of 7319 pregnant women without folic acid and folic acid-containing multivitamin supplementation as reference.Results: Mean gestational age was 0.3 week longer and mean birth weight was by 37g higher in the group of folic acid alone, than in the reference group (39.2 weeks; 3216g). The rate of preterm births (7.6%) was significantly lower compared with the reference sample (11.8%), but the rate of low birth weight newborns did not show significant reduction. Folic acid alone in the third trimester associated with 0.6 week longer gestational age and a more significant reduction in the rate of preterm births (4.8%).Conclusions: Minor increase in mean birth weight after high dose of folic acid supplementation during pregnancy would not be expected to result in too large babies; however, the significant reduction in the rate of preterm births may have great public health benefit.

Study of fetal tracheal fluid velocities using Doppler ultrasound

Gilles Grangé, Céline Bernabé-Dupont, Dominique Cabrol — 2009-11-09

Abstract: Objective: To characterize tracheal fluid flow during fetal breathing movements by Doppler ultrasound.Study design: To use pulsed Doppler to measure flow velocity during inspiration and expiration in a cross-sectional study of 15 normal fetuses and determine the correlation, if any, between flow velocity and gestational age.Results: Cyclic respiratory profiles – both regular and irregular – were observed. Intratracheal flow velocity was very elevated during inspiration, ranging from 10 to 80cm/s and from 5 to 20cm/s during expiration.Conclusion: This technique enables the noninvasive semiquantitative evaluation of fetal breathing movements. This Doppler application opens the field for future studies to characterize the extent of pulmonary hypoplasia.

Polymorphisms of FAS and FAS ligand genes in preeclamptic women

2009-11-09

Abstract: Objectives: This study investigated the influence that Fas and Fas ligand gene polymorphisms might have on preeclampsia. The pathogenesis of preeclampsia is still enigmatic and several studies have proposed that it may, in part, be determined by genetic susceptibility. Therefore, the identification of a gene polymorphism associated with an increased risk of preeclampsia might well represent a useful tool in the identification of at risk pregnant women enabling the setup of preventive therapy.Apoptosis has also been implied in the pathogenesis of preeclampsia and since Fas and Fas ligand are the main apoptotic pathway members, they may represent candidate genes involved in the development of preeclampsia.A polymorphism at the 670 position (A–G) in the Fas gene has been found more frequently in Hungarian women with preeclampsia.Study design: The study cohort was a group of 50 women with preeclampsia and 142 healthy control subjects from the general Italian population. They were studied, by RFLP analysis, to validate the role that the 670 G Fas gene polymorphism plays in preeclampsia, and to evaluate the Fas ligand IVS2nt 124 G polymorphism. The Fisher's exact test was used to compute the statistical difference between groups.Results: The presence of the 670 G Fas gene variant was observed in 42 preeclamptic patients (84%) and 96 members of the general population control group (67.6%) (p=0.029). Regarding the Fas ligand gene, the IVS2nt 124 G variant was present in 14 preeclamptic patients (28%) and in 47 of the general population control subjects (33.1%) (p=0.6).Conclusions: The present study validated the hypothesis that the Fas 670 G variant may have an influencing role in preeclampsia.

Amniotic fluid interleukin-6 and tumor necrosis factor-α at mid-trimester genetic amniocentesis: Relationship to intra-amniotic microbial invasion and preterm delivery

2009-11-12

Abstract: Objective: To determine the value of amniotic fluid interleukin-6 (AF IL-6) and tumor necrosis factor-α (AF TNF-α) in the diagnosis of microbial invasion of the amniotic cavity and in the prediction of preterm delivery (PTD).Study design: Following amniocentesis, a sample of amniotic fluid was sent for aerobic and anaerobic bacterial cultures along with Ureaplasma urealyticum culture and it was also assessed for IL-6 and TNF-α.Results: Forty-eight women who delivered preterm (<37 weeks) were matched with 96 controls. The AF IL-6 and TNF-α concentrations of women with spontaneous PTD were significantly higher than those who delivered at term (IL-6: 176.3pg/ml [130.6–208.6] vs. 52.3pg/ml [37.2–92.3]; TNF-α: 8.8pg/ml [7.2–10.7] vs. 5.5pg/ml [5.0–6.3]). AF IL-6 and TNF-α concentrations of >99.3pg/ml and of >6.6pg/ml respectively, had a sensitivity of 89.6% and 81.3% and a specificity of 80.3% and 79.2% for the prediction of spontaneous PTD. Moreover, AF IL-6 and TNF-α concentrations of >99.3pg/ml and of 6.3pg/ml respectively, had a sensitivity of 91.9% and 78.4% and a specificity of 73.8% and 70.1% for the prediction of a positive AF culture.Conclusions: Elevated mid-trimester concentrations of AF IL-6, or/and of TNF-α can identify women at risk for intra-amniotic infection and for spontaneous PTD.

“Early rupture of membranes” after the spontaneous onset of labor as a risk factor for cesarean delivery

Seung Mi Lee, Kyung A Lee, JoonHo Lee, Chan-Wook Park, Bo Hyun Yoon — 2009-11-19

Abstract: Objective: The objective of this study was to examine if patients with “early rupture of membranes (ROM)” after spontaneous onset of labor are at increased risk of cesarean section.Study design: The rate of cesarean section was examined in 447 term singleton nulliparas who were admitted after the spontaneous onset of labor. The cases were divided into 2 groups: (1) “early ROM”, defined as ROM at a cervical dilatation <4cm (n=109); and (2) “late ROM”, ROM at a cervical dilatation ≥4cm (n=338).Results: (1) “Early ROM” occurred in 24.4% of the cases and the overall cesarean section rate was 5.6%; (2) there were no significant differences in the clinical characteristics including prepregnancy BMI, proportion of complicated pregnancies, total duration of labor, proportion of regional anesthesia, gestational age at delivery, and birthweight between the two groups of cases. However gravidas with “early ROM” were of advanced maternal age and had less cervical dilation on admission, shorter duration of 1st stage of labor, and more frequent use of oxytocin augmentation; (3) patients with “early ROM” had a threefold higher rate (11.9% vs. 3.6%) of cesarean section and a fourfold higher rate (11.9% vs. 3.0%) of cesarean section due to failure of progress than did those with “late ROM” (p<0.005 for each); (3) 92% (23/25) of cesarean sections were performed due to failure to progress; and (4) there was no significant difference in the rate of histologic chorioamnionitis between the two groups of cases.Conclusion: “Early ROM” after the spontaneous onset of labor is a risk factor for cesarean section in term singleton nulliparas.

Opinions concerning pre-implantation genetic diagnosis and sex selection among gynecologist-obstetricians in Brazil

2009-11-09

Abstract: Objective: The aim of this study was to assess a sample of obstetrician-gynecologists on their technical knowledge of PGD as well as their views of PGD and sex selection (SS).Study design: Cross-sectional observational study, carried out during a Congress on Gynecology and Obstetrics. A self-report questionnaire was offered to all professionals registered to attend the Congress and answers of 723 physicians were analyzed.Results: Of the participants, 436 (60.3%) were female and 287 (39.7%) were male; 517 (71.5%) had children. Regarding knowledge of PGD techniques, 63.2% had heard something about PGD and/or preconception SS. Concerning SS, physicians believed that SS is always the couple's choice (36.4%), should be the couple's choice only in specific situations (42.6%), or did not agree that SS should be a couple's choice (17.4%). A majority of the respondents were in favor of PGD and believed that pre-embryos with 6–8 cells are human life in potency.Conclusions: In spite of a small percentage of gynecologists-obstetricians in Brazil had knowledge of PGD techniques, many of them recognized it to be a method to prevent genetic diseases and agreed with its use. The SS appears to be highly accepted for use in specific situations.

Mannan-binding lectin in women with a history of recurrent vulvovaginal candidiasis

Emir Henić, Steffen Thiel, Per-Anders Mårdh — 2009-10-30

Abstract: Objectives: To determine the serum concentration of mannan-binding lectin (MBL), a component of the innate immune system, in women with a history of recurrent vulvovaginal candidiasis (RVVC) and to correlate the result to candida-cultures, contraceptive use, if any, and to different antifungal therapies.Study design: Twenty-nine women with a history of RVVC were investigated. Cultures of vulvar and vaginal samples were grown on chromogenic agar. Serum levels of MBL were determined by a sandwich time-resolved immunofluorometric assay, using anti-MBL coated microtiter wells containing samples, which were washed, incubated with biotinylated anti-MBL followed by europium-labeled streptavidin and measured by time-resolved flourometry.Results: The median MBL level was higher in the RVVC cases than in 30 women with no history of genital candida infection who served as a comparison group (p=0.006). It was also higher in the candida-positive than in the culture-negative RVVC (p=0.02). The median concentration of MBL was also higher in hormonal contraceptive users as compared to condom-users and those using no contraceptive at all (p=0.03).Conclusion: The result indicates a role of MBL in RVVC and the production may correlate to vulvar/vaginal colonization by Candida, hormonal contraceptive use, and antifungal therapies.

Experiences with a specific screening instrument to identify psychosocial support needs in breast cancer patients

2009-11-05

Abstract: Objective: In order to determine the need for professional psychosocial support in breast cancer patients, we used the physician-administered Basic Documentation for Psycho-Oncology (PO-Bado), which is an expert rating scale containing 12 items belonging to somatic and psychological problems. Furthermore, we investigated sociodemographic and medical predictors of somatic and psychological distress and need for psychosocial support.Study design: From 2/2005 to 09/2007, n=333 consecutive patients with breast cancer were included in the study. The majority of the patients suffered from early-stage breast cancer. The mean age of the participants was 59.9 years (SD=12.6, range 24–92). Two physicians rated patients’ psychosocial distress and evaluated their need for psychosocial support according to the PO-Bado guidelines.Results: Exhaustion/tiredness was the item rated highest in the physical distress dimension. In the psychological distress dimension, the items anxiety/worries/tension and grief/despondency/depression obtained the highest mean. Younger age and a history of psychiatric/psychotherapeutic treatment in the past were associated with higher current distress. Women who planned to undergo mastectomy were rated as showing more somatic distress than women for whom breast conserving therapy was planned, but the two groups did not differ with regard to psychological distress. Objective cancer-related variables (tumour size and grading) were not associated with distress. Need for professional psychosocial support was seen in 23% of the patients. Previous psychiatric/psychotherapeutic treatment was the only variable associated with current need for psychosocial support. Forty-six percent of the patients with need for psychosocial support accepted the counselling offered.Conclusions: The structured assessment of breast cancer patients’ psychosocial distress with the interviewer-administered PO-Bado assists the physician to arrive at a detailed expert evaluation. This might help to improve the psychosocial care of breast cancer patients.

A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease

2009-11-09

Abstract: Objectives: To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).Study design: A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.Results: Vaginal hysterectomy had the shortest operating time (66min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.Conclusions: Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.

Clinical and morphological factors predictive of occult involvement of the nipple-areola complex in mastectomy specimens

2009-11-09

Abstract: Objective: To evaluate characteristics predictive of nipple-areola complex (NAC) involvement by the breast tumor.Study design: Cases of infiltrative ductal carcinoma (stages I, IIA and IIB) treated by mastectomy in which the distance between the tumor and the NAC was ≥2cm were included. NAC involvement was evaluated using serial histological sections. The distance between the tumor and the NAC was measured on mammograms. Other parameters taken into consideration were: tumor size, histological and nuclear grades, vascular invasion, and the presence of an in situ component. For comparisons between categorical variables, the chi-square test or Fisher's exact test were used. Student's t-test was used for numerical variables with normal distribution and the Mann–Whitney U-test was applied when distribution was not normal.Results: Fifty patients were included. NAC was affected in 12 and unaffected in 38. There was no statistically significant difference in mean age between the unaffected and affected groups (58.9±13.5 years versus 55.8±12.5 years, p=0.477); however, 13.2% and 58.3% (p=0.046) in the NAC-unaffected and NAC-affected groups, respectively, were <50 years of age. Distance ≤3cm between the tumor and the NAC on mammograms was found in 60.5% of the NAC-unaffected group and in 100% of the NAC-affected group (p=0.007). With respect to the in situ component, there was a difference between the NAC-unaffected and NAC-affected groups regarding micropapillary pattern (13.2% versus 50.0%; p=0.014) and extensive in situ component (13.2% versus 41.7%; p=0.046). No statistically significant difference was found for any of the other parameters analyzed.Conclusions: A distance between the tumor and the NAC ≤3cm, age <50 years, and ductal carcinoma in situ with micropapillary pattern or with an extensive in situ component were factors significantly associated with a higher likelihood of NAC involvement.

Preoperative assessment of complete tumour resection by magnetic resonance imaging in patients undergoing pelvic exenteration

Dirk Michael Forner, Ansgar Meyer, Bjoern Lampe — 2009-11-09

Abstract: Objectives: To evaluate whether preoperative magnetic resonance imaging (MRI) allows prediction of complete tumour resection in patients planned for pelvic exenteration (PE).Study design: Data of all patients treated by PE at a gynaecologic cancer centre between 6/1999 and 5/2005 were studied retrospectively. Preoperative MRI scans were re-analysed blindly with respect to invasion of neighbouring organs, muscular pelvic side wall, vessels and lymph nodes by an experienced team of radiologist and gynaecologic oncologist, finally also giving estimation whether complete removal of tumour would be feasible.Results: 43 patients were identified: all of them underwent PE. The histopathological investigation of the exenteration specimen demonstrated microscopic complete resection status in 20 cases (46.5%). None of the investigated parameter showed a correlation to complete resection of tumour. Sensitivity for final microscopic results relative to preoperative prediction by radiographic findings was 85%, specificity was 52%. The positive predictive value for tumour-free status was 60% (17/28), the negative 80% (12/15).Conclusions: Preoperative MRI cannot predict the surgical outcome with sufficient accuracy, hence on its own is inappropriate for prediction of complete tumour resection and final histological margin status in patients undergoing PE.

Eligibility and willingness of first-year students entering university to participate in a HPV vaccination catch-up program

Françoise Mehu-Parant, Roman Rouzier, Jean-Marc Soulat, Olivier Parant — 2009-11-09

Abstract: Objectives: In France, human papillomavirus (HPV) vaccine is routinely recommended for 14-year-old girls; a catch-up vaccination should be offered to girls and women 15–23 years of age before the first time they have sex or within the first year after sexual activity begins. The aim of the present study was to examine the eligibility and willingness of first-year college students of Toulouse University (France) to participate in a HPV vaccination catch-up program, and to estimate their knowledge of HPV vaccination and cervical cancer screening.Study design: The study was conducted from January to April 2008 simultaneously at the three university medical centres (Science, Literature-Psychology, Law-Social Sciences). Female students entering the University were asked to complete an anonymous questionnaire at the time of their preventive medical visit. The questionnaire included questions on demographics, knowledge about HPV vaccination, sexual behaviour, and willingness to participate in the French vaccination program.Results: In total, 606 women from the 3 colleges were included. The response rate of the questionnaire was 93.1%. The median age of participants was 19 and 8.3% of them had already been vaccinated. Of the respondents, 67.2% were sexually experienced and 25.3% of sexually experienced students had their first intercourse less than 1 year prior. Knowledge of HPV infections, associated diseases, and prevention was limited, a finding that indicates the need to pursue educational campaigns. Among respondents, 42.7% were eligible for catch-up vaccination, and 64.1% of them were willing to be vaccinated. We did not observe significant differences among the three colleges.Conclusions: First-year college preventive consultation is an opportunity to vaccinate near 43% of women according to French recommendations. Improved education about HPV-related diseases and their prevention is needed.

Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Verres needle

2009-11-09

Abstract: Objective: : Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques.Study design: : 194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p-value<0.05 was considered as significant.Results: : No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group.Conclusions: : The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.

Efficacy of montelukast, a leukotriene receptor antagonist, for the treatment of dysmenorrhea: A prospective, double-blind, randomized, placebo-controlled study

2009-11-19

Abstract: Objective: To investigate the effectiveness of montelukast, a leukotriene receptor antagonist, in alleviating the symptoms of dysmenorrhea.Study design: This prospective, double-blind, randomized, placebo-controlled study was comprised of 62 patients with dysmenorrhea who were randomly divided into 2 groups (montelukast and placebo). Data obtained from 50 patients were analyzed (montelukast: 24; placebo: 26). Using visual analog scale (VAS) scores and nonsteroidal anti-inflammatory drug (NSAID) usage per menstrual cycle, values before treatment were compared to average scores over two menstrual cycles with treatment.Results: Both the VAS scores and NSAID usage decreased significantly in both groups. The decreases were greater in the montelukast group compared to the placebo group, but the differences were not statistically significant. Nevertheless, in “highly effective cases,” which were defined as having a post-treatment value less than half of the pre-treatment value, the decreases were significantly greater in the montelukast group than in the placebo group (VAS: montelukast, 4 vs. placebo, 0 (P=0.029); NSAID: montelukast, 9 vs. placebo, 3 (P=0.031)).Conclusions: The present study found that montelukast may be effective in alleviating pain associated with dysmenorrhea in some women. Montelukast is safe and does not influence hormonal levels. Therefore, montelukast is a clinically reasonable management option to consider before prescribing a hormonal agent.

Efficacy of inside-out transobturator vaginal tape (TVTO) at 4 years follow up

A. Liapis, P. Bakas, G. Creatsas — 2009-11-30

Abstract: Objectives: To assess the efficacy and complications of TVTO with or without anterior colporrhaphy in women with urodynamic stress incontinence at 4 years follow up.Study design: Seventy-four patients were subjected to TVTO operation and 41 patients to TVTO and anterior colporrhaphy. Subjective and objective cure and improvement rates and the incidence of complications were assessed.Results: The objective cure rate based on the pad test findings for the TVTO-only patients was 82.4% and the improvement rate was 6.8%. The objective cure rate for the group undergoing TVTO and anterior colporrhaphy was 80.5% and the improvement rate was 7.4%.Conclusions: At 4 years follow up TVTO procedure alone or with anterior colporrhaphy maintains a high cure and improvement rate with a very low complication rate and appears to be a promising technique, but long term results should be published for safer conclusions to be made.

Perineal trauma following operative vaginal delivery without episiotomy

Felicity Watson, Philip Owen — 2009-10-05

Traditionally, an episiotomy is routinely performed at the time of an operative vaginal delivery (OVD) but recently some obstetricians are applying a more selective approach. Uncertainty regarding the influence of withholding episiotomy upon the incidence and nature of perineal injury and specifically obstetric anal sphincter injury (OASIS) prompted us to examine the practice within our department, a city centre, teaching maternity unit delivering approximately 5500 women per annum.

An uncommon cause of dyspnea during pregnancy

Nicolas Mariotti, Michel-Ange Morales, Guy Haller — 2009-10-19

We report an acute episode of dyspnea in a 37-year-old woman, 32 weeks pregnant, who was admitted to our hospital in preterm labour. She had no past history of dyspnea, lung disease or diaphragmatic hernia. She was prescribed bed rest and an intravenous infusion of hexoprenaline. The tocolytic agent was initiated at 15μg/h and progressively reduced to 6μg/h over the following 48h. She also received two intra-muscular injections of betamethasone 12mg for fetal lung maturation. As she declared she was suffering from anxiety and sleeping difficulties she received bromazepam 1.5mg p.o. in the evening. In the middle of the night she complained of sudden shortness of breath, thoracic oppression, heartburn and regurgitation. On examination she had no fever but was actively coughing and tachypneic. Crepitations and reduced breath sounds were found on right lower chest auscultation. Findings on blood gas analysis were pH 7.43, PaO2 10.4kPa, PaCO2 4.2kPa, HCO3 22.6mmol/L and oxygen saturation 97% on FiO2 of 40%. Blood pressure and heart rate were within the normal range. There were no electrocardiographic features of acute cardiac ischemia. Chest radiography showed an infiltrate of the right lower pulmonary lobe () and the diagnosis of aspiration pneumonitis was made. The patient was transferred to the high-dependency care unit and intensive respiratory care was initiated with high concentration oxygen therapy, positive end-expiratory pressure ventilation and anti-acid medication (esomeprazole 40mg/day). She recovered after 4 days without developing pulmonary oedema or pneumonia. She was discharged home after 10 days and was admitted again 6 weeks later for an uneventful delivery.

Intra-abdominal hemorrhage due to previously unknown endometriosis in the third trimester of pregnancy with uneventful neonatal outcome: A case report

Charlotta Grunewald, Anneli Jördens — 2009-10-26

We found that a minor spot of endometriosis in a 33-year-old gravida 3, para 2 with previously unknown endometriosis, caused spontaneous hemoperitoneum during the third trimester in pregnancy, resulting in hypovolemic shock necessitating exploratory laparotomy. The woman presented at 27 gestational weeks + 4 days complaining of severe abdominal pain. She denied vaginal bleeding, loss of amniotic fluid or any kind of traumatic event. Her medical history was uneventful without medical treatment or surgery apart from one caesarean section. Her prenatal course was unremarkable until 1h before admission, when she experienced the sudden onset of both epigastric and lower abdominal pain. Blood pressure was 100/50mmHg, temperature 36.4°C. The abdomen, uterus included, was soft and not tender, and the cervix was unaffected. A urinary dipstick was normal and fetal cardiotocography (CTG) revealed a reactive pattern. Hemoglobin and hematocrit were 84g/L and 0.27, respectively. Liver enzymes, creatinine and electrolytes were normal. Tocolysis and mild analgesics were administered and fetal pulmonary enhancement with betamethasone was started. Twenty-four hours later the pain had worsened and the abdomen was found diffusely tender. Hemoglobin and hematocrit were slowly decreasing (63 and 0.21, respectively). CTG and fetal movements were normal. An ultrasound scan showed intra-abdominal fluid and free blood was confirmed by percutaneous puncture. Due to developing signs of hypovolemic shock the patient was transfused and an exploratory laparotomy under general anesthesia was performed. Free blood (900mL) and clots in the abdomen were evacuated. The anterior part of the uterus and the adnexa were unaffected. The uterus was exteriorised and the posterior part was visualised. At the right sacro-uterine ligament a small (3–4mm) but active bleeding spot was discovered. A biopsy sample was taken and the bleeding site was secured by coagulation and hemostatic agents. Tocolysis was intravenously administered during the procedure and the fetal heart rate was monitored by doptone. The postoperative course of both mother and fetus was uneventful and she was discharged seven days after the exploration. Her pregnancy continued without complications and she was ultimately vaginally delivered at 42 gestational weeks. A 4665g female was born with Apgar scores of 9-10-10. The pathologic results confirmed endometriosis.

Case report of asymptomatic peritoneal leiomyomas

A. Pezzuto, G. Pontrelli, M. Ceccaroni, B. Ferrari, G.B. Nardelli, L. Minelli — 2009-10-26

We would like to report the history of a fertile 45-year-old woman, referred for persistent metrorrhagia with sonographic evidence of multiple uterine myomas. An endometrial biopsy was performed and a normal endometrium was found from a histological point of view. In due time, she underwent laparoscopic-assisted vaginal hysterectomy with preservation of the ovaries. During surgery, evidence of several intramural fibroids was recorded along with two large pedunculated myomas. After colpotomy, two further myomas of 5 and 3cm were identified as completely detached from the uterus. They appeared pedunculated (with their vascularization) to the perirectal peritoneum (). Therefore the two fibroids were removed and extracted through the vagina after diathermy coagulation of their vascular stems. From a histological point of view these fibroids were identical to a normal leiomyoma, consisting of fascicles of smooth muscle cells without mitotic figures or nuclear pleomorphism.

Transient ureteric obstruction as a possible complication of resection of submucous fibroid and endometrial rollerball ablation

R. Youssef, P.F.W. Chien, P. Coates, A. McCulloch — 2009-11-02

We report a case of transient unilateral hydronephrosis due to ureteric obstruction at the bladder trigone area following resection of submucous fibroid and endometrial ablation. A 41-year-old woman was referred with a 3 year history of menorrhagia that was unresponsive to treatment with a levonorgestrel-releasing intrauterine contraceptive device (Mirena IUS®, Schering Health).

Follow-up of patients with SMILE (stratified mucin producing intraepithelial lesion) on the cervix—A dilemma

Sweta Gupta, Patricia Parsons, Arabinda Saha, Catherine Wight — 2009-11-02

We wish to discuss three cases of SMILE (stratified mucin producing intraepithelial lesion), none of which had a history of in utero exposure to progestin such as DES, or high risk HPV status known at the time of diagnosis. SMILE is a rare variant of endocervical columnar cell neoplasia in which conspicuous mucin is present throughout the epithelium (). Further staining of the sections with alcian blue (stains acidic mucins), PAS (Periodic Acid Schiff stains neutral mucins) and Ki67 (a proliferation marker) helps confirm the diagnosis ().