Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding? National figures

Objectives To describe trends in the use of endometrial ablation and hysterectomy for the treatment of dysfunctional uterine bleeding.
Design Analysis of hospital admissions data.
Setting National Health Service Hospitals in England.
Population Women who underwent a hysterectomy or endometrial ablation for dysfunctional uterine bleeding between 1989 and 1996.
Main outcome measures Annual operation rates and standardised operation ratios for England and for the National Health Service Regions within it, and proportion of operations for dysfunctional uterine bleeding that were endometrial ablations or hysterectomies.
Results There was an initial rise in operation rates for endometrial ablation until 1992/3, since when the rates have fallen. Hysterectomy rates have remained relatively steady since the introduction of endometrial ablation. The total operation rates for dysfunctional uterine bleeding initially increased but have tended to fall since 1992/3. The ratio of hysterectomy to endometrial ablation for dysfunctional uterine bleeding troughed at 3:1 in 1992/3, but by 1995/6 had increased to 4:1.
Conclusions Rather than replacing hysterectomy in the treatment of dysfunctional uterine bleeding, endometrial ablation appears to have added an alternative operative technique. This led to an increase in the total number of operations for this condition, perhaps by lowering the threshold for intervention.     

Hypothermia for the treatment of neonatal ischemic encephalopathy: is the genie out of the bottle?

Evidence suggests that hypothermia for hypoxic ischemic encephalopathy in the term neonate may decrease the risk of death or neurodevelopmental impairment. The objective of this study was to determine how hypothermia has been incorporated into practice. An anonymous survey was sent to medical directors of United States neonatal intensive care units (NICUs) in October 2005. We received completed surveys from 441 (54.5%) of 809 of NICUs. Only 6.4% of respondents used hypothermia. The most common method was total body cooling (64.3%) compared with head cooling (25%) or both (10.7%). At centers that did not offer hypothermia, 29% transferred infants to an institution that did. Centers that offered hypothermia were more likely at academic institutions (76.9%) compared with private practices (11.5%; p < 0.001). Hypothermia was more likely offered at institutions that offered extracorporeal membrane oxygenation (ECMO; 57%) than centers where ECMO was not offered (43%; p < 0.001). There has not been widespread use of hypothermia. There are a variety of protocols used. As results of further outcome studies become available, educational efforts and national practice guidelines will be essential.     

What is the optimal duration of oral misoprostol treatment for cervical ripening?

Objectives: To evaluate the number of misoprostol tablets needed to obtain a Bishop score (BS)?≥?6 or a significant cervical change (≥2 points in BS) during cervical ripening.

Methods: Retrospective study of women with term singleton pregnancies and a BS?Results: We included 400 women, 72% nulliparous, mean age of 31.3?±?5.9 years and 70% with a baseline BS?≤?2. During cervical ripening, 61 (15.3%) achieved a BS?≥?6 and 205 (51.3%) a significant change in BS. The incremental risk to achieve a BS?≥?6 after 4 tablets was low (+3.25%) with an incremental probability of +12.75% for painful uterine contractions and +0.5% for abnormal fetal tracing (AFT). The incremental probability to achieve a significant change in BS after 7 tablets was low (+2.0%). 24.3% women delivered by cesarean section which likelihood significantly increased with maternal age <35 years, BMI?≥?30, nulliparity, AFT, and baseline BS?≤?2.

Conclusions: The marginal benefit of giving more than 7 misoprostol tablets (14?h) during cervical ripening is very low.     

Nonventilatory strategies for prevention and treatment of bronchopulmonary dysplasia--what is the evidence?

This review briefly summarizes the evidence for a number of mainly drug-related strategies to prevent or treat bronchopulmonary dysplasia (BPD). Oxygen supplementation is frequently used in neonatal units and oxygen toxicity plays an important role in the pathogenesis of BPD. However, current evidence for an optimal oxygen saturation for extremely premature infants is scarce. This gap in knowledge will hopefully be closed by a number of ongoing or prospective trials addressing this issue. The role of inhalational nitric oxide in the prevention of BPD is still unclear despite existing data from a number of large randomized trials. Early administration of caffeine seems to confer a benefit with regard to BPD. Prophylactic or early application of surfactant may also be beneficial. High intramuscular doses of vitamin A slightly reduce the incidence of the disease. There is currently no evidence supporting other nutritional interventions to prevent BPD. Anti-inflammatory drugs, like alpha(1)-proteinase inhibitor, pentoxifylline and azithromycin, and antioxidants, like N-acetylcysteine and superoxide dismutase, have not been proven effective yet. Diuretics can ameliorate lung function, but there is no evidence supporting their long-term use. Ureaplasma urealyticum colonization of airways is associated with an increased risk of BPD. However, there is no proof for an effect of erythromycin on BPD. The potential roles for therapies like bombesin-like peptide-blocking antibodies or Clara cell 10-kDa protein have yet to be defined.     

Total fertilization failure: is it the end of the story?

Purpose

To study parameters that could predict in-vitro fertilization (IVF) success in patients who experienced total fertilization failure (TFF) with intracytoplasmic sperm injection (ICSI) in their previous cycles.

Methods

Cycle characteristics of patients with TFF (Group I, n = 136 cycles), cycles resulting in embryo transfer (ET) following TFF (Group II, n = 36 cycles) and recurrent TFF (Group III, n = 25 cycles) and were studied retrospectively. Demographic features, cycle characteristics of three groups were compared.

Results

Follicle count measuring 15–17 mm was significantly higher in group II when compared to group I (p = 0.02). Total number of retrieved oocytes and mature oocytes were significantly higher in group II when compared to groups I and III (p = 0.001). Estradiol level at oocyte pick up (OPU) day was significantly higher in group II when compared to group I (p = 0.02). When the characteristics of ET cycles and preceding TFF cycles of the same patient were compared, total number of retrieved oocytes (5.11 ± 0.72 (95 % CI 3.69–6.52) vs. 11.44 ± 1.60 (95 % CI 5.29–17.59)) and mature oocytes (3.26 ± 3.66 (95 % CI 2.04–4.47) vs. 6.92 ± 5.61 (95 % CI 5.09–8.75)) were found to be significantly lower in TFF cycles (p = 0.001). Five biochemical and 5 clinical pregnancies occurred while only 2 healthy babies were born, corresponding to a live birth rate 5.5 %.

Conclusions

Increasing the number of retrieved and mature oocytes may increase the success of fertilization in patients with a history of previous failed fertilization. However, live birth rate is still low in embryo transfer cycles.     

Development of leiomyomas on the uterine remnants of two women with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE: To describe two cases of leiomyoma development in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome). DESIGN: Case report. SETTING: Second Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece. PATIENT(S): A 42-year-old woman with MRKH syndrome presented with lower abdominal pain, and a 38-year-old woman with MRKH syndrome presented with an asymptomatic left adnexal mass. INTERVENTIONS(S): Clinical examination, transabdominal ultrasonography, IV urography, laparoscopy. MAIN OUTCOME MEASURE(S): Ultrasound. RESULT(S): In both cases, laparoscopy revealed a leiomyoma originating from the left uterine remnant. The leiomyomas and the adjacent uterine remnants were laparoscopically excised. CONCLUSION(S): In rare cases, leiomyomas can originate from the fibromuscular tissue of uterine remnants in patients with MRKH syndrome.     

Is uterine artery embolization for cervical ectopic pregnancy always safe?

The study objective was to assess the feasibility and the efficacy of bilateral uterine artery embolization (BUAE) for the treatment of cervical pregnancy. The design was a series of 3 cases of viable cervical pregnancy diagnosed by transvaginal ultrasonography and treated by means of BUAE and subsequent uterine curettage. Three women with viable cervical pregnancy underwent BUAE and subsequent uterine curettage in the department of obstetrics and gynecology, High Risk Pregnancy Center, University "Federico II" of Naples. Measurements included surgical outcomes and preservation of fertility. The treatment was effective in all cases. Two patients resumed normal menstruation about 1 month after the procedure, whereas 1 patient underwent a hysterectomy 2 weeks after embolization because of acute ischemic degeneration of a concomitant myoma. The conservative management of cervical pregnancy with angiographic BUAE is a feasible and effective option, even if subsequent hysterectomy may be required. Counseling is necessary.     

Laparoscopic myomectomy for fibroids penetrating the uterine cavity: is it a safe procedure?

Objective The purpose of the study was to evaluate the post-operative course and follow up of women who had undergone laparoscopic removal of intramural fibroids penetrating the uterine cavity.
Design Retrospective study.
Setting Center for Reconstructive Pelvic Endosurgery, Italy.
Population Thirty-four women with fibroids penetrating the uterine cavity.
Methods Laparoscopic myomectomy.
Main outcome measures Feasibility and safety of surgical technique, length of operation, blood loss, intra- or post-operative complications, length of hospital stay, resolution of symptoms and future obstetric outcome.
Results The mean operative time was 79 (SD 30) minutes; the mean reduction in haemoglobin was  1.1 ± 0.9 g/dL  . No intra- or post-operative complications were observed. The average post-operative stay in hospital was 54 (SD 22) hours. Nineteen (73%) out of 26 patients who had experienced symptoms prior to surgery reported resolution of these symptoms post-operatively. All patients resumed work within a mean time of 20 (SD 8) days. Among 23 of the 32 patients attempting pregnancy during the follow up period, nine (39%) conceived within one year. Seven pregnancies went to term without complications.
Conclusion The clinical results of this study suggest that laparoscopic myomectomy for intramural fibroids penetrating the uterine cavity is a safe procedure, providing well known advantages of minimal access surgery.     

Uterine artery occlusion: what is the evidence?

Symptomatic uterine fibroids are a relatively common gynecologic condition. In the past, fibroids were exclusively treated by myomectomy and/or hysterectomy. With the advent of uterine artery embolization or uterine artery occlusion, there now exist minimally invasive approaches to fibroid therapy especially for women in whom surgery is contraindicated or for those who wish to retain their uterus and possibly fertility. Fertility and pregnancy outcomes after these minimally invasive therapies are currently being evaluated.     

Management of leiomyomas: is there a panacea in Pandora's box?

New procedures and medications continue to be developed for the treatment of women with uterine leiomyomas; however, most are not adequately evaluated, and none is applicable in all circumstances. Appropriate management of uterine leiomyomas should be individualized, considering the related symptoms, as well as the number, size, and location of the tumors and the patient's desire regarding uterine conservation.     

Myolysis of uterine fibroids: is there a role?

Myolysis is among the new procedures under development for the treatment of symptoms related to uterine leiomyoma. The procedure targets the destruction of fibroids using one of a number of focused energy delivery systems including those based upon radiofrequency electricity, supercooled cryoprobes, and, most recently, focused ultrasound monitored by real time magnetic resonance imaging. For thermomyolysis and cryomyolysis, delivery of the energy requires access to the tissue by laparoscopy, and, in some instances, hysteroscopy. For focused ultrasound, the patient is detached from the energy source, which is delivered by an array of external beams. Clinical evaluation has been confined to case series, but it is evident that the approach results in a variable degree of reduction of the total uterine mass, and, usually, a reduction in uterine bleeding. Clearly, longer term appropriately designed comparative trials are required that evaluate and compare myolysis with myomectomy, uterine artery embolization, and hysterectomy, to name a few.     

In the management of abnormal uterine bleeding,is office hysteroscopy preferable to sonography? The case for hysteroscopy

Office hysteroscopy for the diagnosis and management of abnormal uterine bleeding has developed into an easily performed procedure, with minimal discomfort and significantly reduced risks and expense. Miniaturization of instruments and safer liquid distention media, along with effective local analgesia, have made the procedure a fast, effective, and much more precise way to detect intrauterine abnormalities, as well as to better define the correct plan for any proposed operative management. In addition to the above, hysteroscopy is considered the "gold standard" for evaluating the uterine cavity. Numerous studies comparing hysteroscopy to sonography, with or without saline solution infusion are cited, along with other studies comparing hysteroscopy to blind biopsy and curettage, all indicating that hysteroscopy is more accurate, with fewer false-positive and false-negative results.