Risk factors and midwife-reported reasons for episiotomy in women undergoing normal vaginal delivery

Purpose

In Singapore, a developed Asian nation, a relatively high proportion of women undergo episiotomy. We assess risk factors and midwife-reported reasons for episiotomy among women undergoing normal vaginal deliveries (NVDs) conducted by midwives and ascertain the association between episiotomy and degree of perineal tear.

Methods

Participants included 77 midwives from a high-volume delivery unit in Singapore. The study had three sequential phases: (1) medical record review of women undergoing NVDs conducted by midwives over a 1-month period to document the proportion with episiotomy; (2) focus group discussions with midwives to form a checklist of reasons for episiotomy; (3) checklist-based documentation of midwife-reported reasons for episiotomy and data collection on maternal, neonatal, practice and midwife factors, and degree of perineal tear among women undergoing NVDs conducted by midwives over a 2-month period. Risk factors for episiotomy were assessed through logistic regression.

Results

Primiparity, advanced maternal age, Indian ethnicity, higher birth weight and older midwife age were associated with episiotomy. The most common midwife-reported reason for episiotomy among primiparous women was primiparity (55.1 %), and among multiparous women was fetal distress (20.0 %) and poor maternal effort (20.0 %). All women with episiotomy sustained at least a second-degree perineal tear versus 27.1 % among women without episiotomy.

Conclusion

Most midwife-reported reasons for episiotomy were not congruent with international practice guidelines. Women without episiotomy have lesser tears than those with episiotomy. Practice protocols and educational programs are needed to change episiotomy practice.     

Ultra short-term antimicrobial prophylaxis in patients undergoing surgery for gynecologic cancer

OBJECTIVE: To evaluate the efficacy of ultra short-term antimicrobial prophylaxis with ceftazidime in patients undergoing radical gynecologic surgery. PATIENTS AND METHODS: Two hundred patients undergoing surgery for a malignant disease of the female genital tract were enrolled in a prospective trial to receive 2.0 g ceftazidime as a single dose, 30 minutes before induction of anaesthesia. After surgery, each patient was assessed to confirm febrile status and the presence of infections at the surgical site, urinary tract and respiratory tract. RESULTS: Postoperative morbidity occurred in 23 patients (11, 5%). Ten patients (5%) developed febrile morbidity, five (2, 5%) vaginal cuff infections, four asymptomatic bacteriuria and two each wound infiltration and urinary tract infection. Twelve patients had microbiological evidence of infection and Staphylococccus aureus was the most common pathogen isolated. Univariate analysis demonstrated that pre-existing systemic disease, extensive blood loss (more than 500 ml) and long duration of surgery (more than 150 minutes) were the only factors associated with a significant increase in postoperative febrile morbidity. CONCLUSIONS: Ultra short-term antimicrobial prophylaxis with ceftazidime is safe and effective in patients undergoing surgery for gynecologic cancer.     

Moral dilemmas of women undergoing pregnancy termination for medical reasons in Poland

Objectives: We explored the religious views and dilemmas of Polish women making the decision to terminate a pregnancy. The article discusses the highly restrictive legislation and significant influence of the Church on the lives of Polish citizens.

Methods: This study was designed to investigate the effect of religious and political beliefs, social and moral conditioning and professional support on the decision to abort a fetus. A 65-item questionnaire was administered to 60 participants at the time of their pregnancy termination.

Results: Pregnancy termination was performed outside the resident county in 32% of cases. Approximately 88% of respondents declared themselves Catholic, but only 22% intended to admit to the pregnancy termination during confession. Five percent of respondents feared the reaction of the priest, while the remaining respondents did not perceive termination of pregnancy for medical reasons as a sin. Of the women who had previously opposed pregnancy termination, 27% changed their mind once they were personally involved.

Conclusions: The decision to abort a pregnancy for medical reasons is sensitive to religious and social determinants, especially in the current political situation in which abortion may become prohibited in Poland. The high response rate (100%) was probably the result of the patients’ attitudes: they repeatedly emphasised they were thankful for the help and empathy of the medical personnel and for being allowed to undergo the procedure. In Poland, the majority of centres use conscience clauses to justify their refusal to terminate a pregnancy.     

Expression of Syndecan-1 in histologically normal breast tissue from postmenopausal women with breast cancer according to mammographic density.

OBJECTIVE: To analyze the expression of Syndecan-1 in dense and non-dense human breast tissue. METHODS: Specimens of histologically normal tissue were obtained from postmenopausal women undergoing surgery for breast cancer. Each tissue block was subject to radiological examination and pair-wise samples of dense and non-dense tissue were collected. Semi-quantitative assessment of immunohistochemical staining intensity for Syndecan-1 and estrogen receptor subtypes was performed. RESULTS: The expression of Syndecan-1 in all tissue compartments was significantly higher in dense than in non-dense specimens. The strongest staining was recorded in stromal tissue. There was a strong correlation between epithelial estrogen receptor alpha and stromal cell Syndecan-1 expression in dense tissue (rs = 0.7; p = 0.02). This association was absent in non-dense tissue. CONCLUSION: An increase of Syndecan-1 in all tissue compartments and a redistribution from epithelium to stroma may be a characteristic feature for dense breast tissue.     

Serum leptin and leptin receptor isoforms in omental adipose tissue of nondiabetic women undergoing gynecologic surgery for benign disease.

BACKGROUND AND PURPOSE: Leptin is important in the regulation of fat mass and body weight. Adipose tissue not only secretes leptin but also serves as a site of action for leptin. This study was designed to examine the relationships among tissue expression of leptin receptors, serum leptin, and body mass index. METHODS: Omental adipose tissue and fasting blood samples were obtained from 57 nondiabetic women who underwent surgery for either myoma of the uterus or ovarian cyst. Tissue RNA was extracted using Trizol reagent and serum leptin concentrations were determined with commercial kits. The leptin receptor isoforms in tissues were quantified using real-time Taqman technology. RESULTS: Three leptin receptor isoforms, Ob-Rb, HuB219.1, and HuB219.3, were found in human omental adipose tissue. The amounts of HuB219.1 and HuB219.3 mRNA relative to that of Ob-Rb were 1314.2 and 16.7, respectively. Higher body mass index was significantly correlated with an increase in serum leptin concentration and a decrease in leptin receptor HuB219.1 isoform in omental fat, even after adjustment for age and menopausal status. There was no direct association between serum leptin concentration and tissue HuB219.1 mRNA level. CONCLUSIONS: HuB219.1 is the major isoform of leptin receptor expressed in human omental adipose tissue. Our findings suggest that the shorter leptin receptor isoforms in human omental adipose tissue might play an important role in body weight control. Further studies on the inter-relationship between leptin concentrations and multiple leptin receptor isoforms are needed to elucidate the exact mechanism of obesity.     

Short term outcomes following breast cancer surgery in pregnant women

ObjectiveBreast cancer is the most common malignancy in pregnancy with an estimated prevalence of 1 per 3000 pregnancies. The National Comprehensive Cancer Network (NCCN) guidelines advocate for surgical management in all trimesters for pregnant women with breast cancer but few studies have examined the impact breast cancer surgery has on outcomes in pregnant women. We aimed to identify differences in short term outcomes after breast cancer surgery between age-matched pregnant and non-pregnant women.MethodsThis was a retrospective, cross-sectional study utilizing the Health Care Utilization Project-Nationwide Impact Sample (HCUP-NIS) database from 1999 to 2006. All pregnant women with breast cancer undergoing lumpectomy or mastectomy were compared to age-matched non-pregnant women. Demographics, in-hospital mortality, length of stay, hospital cost, and discharge disposition were reviewed. Statistical analysis was performed with chi-square, Student's t-test, and ANOVA with p < 0.05 deemed significant.ResultsOver an 8 year period, 185 pregnant women (mean age 35 years) and 47,985 non-pregnant age-restricted women (mean age 45 years) who underwent breast cancer surgery were identified. There was no significant difference between in-hospital mortality, length of stay, cost of hospitalization, or discharge disposition in these women.ConclusionPregnant and non-pregnant women undergoing breast surgery for cancer have similar short-term outcomes.     

Appendectomy in patients undergoing laparoscopic surgery for pelvic pain.

STUDY OBJECTIVE: To evaluate pathologic findings in appendixes of women undergoing laparoscopic surgery for pelvic pain. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Private practice specializing in gynecologic endoscopic surgery. PATIENTS: One hundred ninety women. INTERVENTION: Prophylactic appendectomy. MEASUREMENTS AND MAIN RESULTS: On pathologic evaluation, 154 appendixes were diagnosed as having one or more abnormal findings, such as endometriosis, carcinoid, chronic appendicitis, periappendicitis, fibrous obliteration, and lymphoid hyperplasia. CONCLUSION: Women undergoing laparoscopic surgery for pelvic pain should be counseled on the high frequency of abnormal findings in the appendix, including endometriosis. Prophylactic appendectomy appears to be a worthwhile consideration in these patients.     

Massage therapy alone and in combination with meditation for breast cancer patients undergoing autologous tissue reconstruction: A randomized pilot study

This study explored whether massage combined with meditation is more helpful than massage alone for women recovering from autologous tissue reconstruction after mastectomy for breast cancer. Forty patients were randomly assigned to either massage therapy or massage plus meditation on postoperative days 1 through 3. Outcome measures were 1) visual analog scale (VAS) scores for stress, anxiety, relaxation, insomnia, alertness, fatigue, tension, pain, mood, and energy, and 2) Perceived Stress Scale-14 scores. Nineteen patients in each group finished the study. Preintervention and postintervention mean total VAS scores improved significantly in both groups (P < .001), but no significant difference occurred between groups.     

Estrogen biosynthesis in breast adipose tissue during menstrual cycle in women with and without breast cancer

Abstract

Circulating estrogens fluctuate during the menstrual cycle but it is not known whether this fluctuation is related to local hormone levels in adipose tissue. We analyzed estrogen concentrations and gene expression of estrogen-regulating enzymes in breast subcutaneous adipose tissue in premenopausal women with (n?=?11) and without (n?=?17) estrogen receptor-positive breast cancer. Estrone (E₁) was the predominant estrogen in premenopausal breast adipose tissue, and E₁ and mRNA expression of CYP19A1 in adipose tissue correlated positively with BMI. Adipose tissue estradiol (E₂) concentrations fluctuated during the menstrual cycle, similarly to the serum concentrations. In women with breast cancer median adipose tissue E₁ (1519 vs. 3244, p?<?.05) and E₂ (404 vs. 889?pmol/kg, p?<?.05) levels were lower in the follicular than in the luteal phase whereas in control women no significant differences were observed. In the follicular phase, mRNA expressions of HSD17B1 (median 0.06; interquartile range 0.05–0.07 vs. 0.17; 0.03–0.2, p?=?.010) and CYP19A1 (0.08; 0.07–0.14 vs. 0.22; 0.09–0.54, p?=?.025) were lower in women with breast cancer than in controls. In conclusion, the changes in adipose tissue E₁ and E₂ concentrations and the estrogen-regulating CYP19A1 and HSD17B1 during the menstrual cycle may be related to dysfunctional local estrogen metabolism in women with breast cancer.     

Breast cancer in ectopic breast tissue.

Ectopic breasts usually develop along the mammary ridges. Their incidence has been reported as up to 5-6%. Development of malignancy is rare. We report three cases of postmenopausal female patients with breast cancer which developed in the axillary accessory breast. They were all successfully treated by surgery and adjuvant therapy. A review of the literature on the incidence and pathology of ectopic mammary tissue is also presented.     

Androgens in breast cancer. I. Atypical endometrial hyperplasia and breast cancer in married premenopausal women

This report is based on a study of 19 patients with breast cancer, 11 patients with atypical endometrial hyperplasia, and 7 women as controls. Single 24-hour urine collections were made for steroid determinations on Days 22 or 23 of the menstrual cycle. Among the patients with atypical endometrial hyperplasia, with or without breast cancer, a high incidence of involuntary sterility was noted. The range of testosterone excretion values with atypical endometrial hyperplasia w as significantly increased (p less than .01). In the breast cancer patients in whom the menstrual cycle was anovulatory and the endometrium obtained at the premenstrual period showed an atypical endometrial patte rn the testosterone excretion level was markedly increased (p less than . 01). During the follow-up period of 2-3 years, 5 of the 10 breast cancer patients with atypical endometrial patterns had developed distant metastases. Of the 9 breast cancer patients with ovulatory menstrual cycles, as shown by normal progestational endometrium, only 1 developed distant metastases. This patient had the highest urinary testosterone value in the group. In view of the high testosterone excretion levels, 7 cancer patients were offered ovariectomy. 4 refused but then underwent ovariectomy 4-8 months later for metastases. Of the 3 who accepted early ovariectomy, none have yet had metastases. The removed ovaries were shown to have polycystic ovarian disease with luteinized theca cells in the follicular cysts and marked interstitial cell hyperplasia. It was thought that androgens must play an important role in the development of breast cancer and endometrial hyperplasia. The in creased level of estrogens may have resulted from peripheral conversion. Ovarian interstitial tissue has been suggested as being a distinct gland of internal secretion that is principally concerned with the formation of androgens.     

Perioperative fluid status and surgical outcomes in patients undergoing cytoreductive surgery for advanced epithelial ovarian cancer

Objective

The objective of this study is to investigate the impact of fluid status on perioperative outcomes of patients undergoing cytoreductive surgery (CRS) for advanced epithelial ovarian cancer (EOC).

Individual free fatty acids in amniotic fluid and in plasma of pregnant women.

Individual free fatty acids (FFA) were measured in 77 amniotic fluid samples and in 57 maternal plasma samples. Gestational age ranged from 16 to 40 weeks. Amniotic fluid FFA decreased from 20-4 +/- 6-0 mumol/l in the second trimester to 17-0 +/- 6-0 mumol/l in the last six weeks of pregnancy. This was almost entirely accounted for by a decrease in the concentration of free stearic acid, while oleic acid increased slightly. No correlation between amniotic fluid FFA and maternal plasma FFA was found in samples obtained on the same day. It is suggested that amniotic fluid FFA may partly derive from renal excretion by the fetus.     

Cryopreservation of ovarian tissue for fertility preservation: no evidence of malignant cell contamination in ovarian tissue from patients with breast cancer

Cryopreserved ovarian cortical biopsies from 51 patients with breast cancer were examined by histologic and immunohistochemical analysis and showed no sign of metastases. Autotransplantation of ovarian cortex to patients with low-stage breast cancer disease appears safe, but confirmatory studies are required, including xenotransplantation studies.     

Uterine pathologies in patients undergoing tamoxifen therapy for breast cancer: ultrasonographic, hysteroscopic and histological findings

PURPOSE OF INVESTIGATION: To evaluate endometrial abnormalities by ultrasonography, hysteroscopy and biopsy in postmenopausal patients treated with tamoxifen as adjuvant therapy for breast cancer. METHODS: The study was carried out on 113 patients who underwent vaginal ultrasonography, hysteroscopy and endometrial biopsy. RESULTS: There was a significative relation between ultrasonographic and hysteroscopic features (p < 0.001); 58 polyps were diagnosed at hysteroscopy, although 35 were not found at ultrasonography. A significant relation between ultrasonographic and histological findings was also documented (p < 0.005). A significant relation between histological findings and symptomatology was found (p < 0.05), although pathologies were also present in asymptomatic women. CONCLUSIONS: These results show that long-term tamoxifen therapy in breast cancer patients is associated with a higher incidence of uterine pathology. No significant relation has been documented between duration of treatment and grade of endometrial lesion (p > 0.05). Ultrasonography alone is useful in asymptomatic patients because it selects patients with increased endometrial thickness who should undergo hysteroscopy. Hysteroscopy is more accurate in detecting polyps, hyperplastic and neoplastic changes. Asymptomatic tamoxifen treated women should be evaluated as symptomatic patients.