Intraoperative injection of prostaglandin F2alpha in a patient undergoing hysteroscopic myomectomy

OBJECTIVE: To present a case of one-step total hysteroscopic myomectomy using prostaglandin F(2alpha). DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 38-year-old woman with a sessile submucous leiomyoma. INTERVENTION(S): Hysteroresectoscopy using an intraoperative injection of prostaglandin F(2alpha) under laparoscopic monitoring. MAIN OUTCOME MEASURES: Endoscopic appearance, clinical symptoms, and imaging diagnosis. RESULT(S): After resection of the protruding portion of the myoma, injection of prostaglandin F(2alpha) was used to cause the remnant to project into the uterine cavity, allowing complete removal. CONCLUSION(S): Intraoperative use of prostaglandin F(2alpha) may allow one-step hysteroresectoscopy of a sessile submucous leiomyoma.     

宫腔镜手术并发症诊治现状及展望

宫腔镜诊治宫腔内病变微创、有效。但子宫穿孔、出血、体液超负荷、低钠血症、空气栓塞及术后妊娠子宫破裂等严重并发症时有发生,文章回顾近年来宫腔镜并发症发生的现状,探讨宫腔镜手术并发症发生原因及预防方法,以提高宫腔镜手术的安全性。     

Reduction of aquaporin-8 on fetal membranes under oligohydramnios in mice lacking prostaglandin F2 alpha receptor

AIM: To investigate the association between aquaporin-8 (AQP-8: a water channel protein) expression in fetal membranes and oligohydramnios during near-term and postdate pregnancy, we set up an oligohydramnios model using prostaglandin F2 alpha receptor (FP)-deficient mice. METHODS: Pregnant FP-deficient mice from 14 to 21 gestational days (GD) were killed to measure the amniotic fluid volume (AFV), and fetal membranes were collected for the analysis of aquaporin-8 expression. RESULTS: The AFV was highest at 14 GD, and was significantly decreased to 28% and 0% at 20 GD and 21 GD, respectively, compared with the volume at 14 GD. Immunohistochemistry and immunoblot analysis showed that aquaporin-8 was expressed in the basal component of fetal membranes, and that the protein level was significantly decreased to 60% at 20 GD compared with that at 14 GD. CONCLUSIONS: We demonstrated that AQP-8 expression in the fetal membrane was decreased at post term in FP-deficient mice. Our findings suggest that aquaporin-8 in fetal membranes may be involved in the regulation of AFV, especially when oligohydramnios occurs.     

Essure: a new device for hysteroscopic tubal sterilization in an outpatient setting

OBJECTIVE: To evaluate the results of hysteroscopic placement of an intratubal device for permanent birth control in 85 women in an outpatient setting. DESIGN: Prospective, observational study. SETTING: Private university hospital. PATIENT(S): Eighty-five premenopausal women who asked for tubal sterilization by hysteroscopy between July 2002 and July 2003. INTERVENTION(S): Hysteroscopic placement of titanium-dacron intratubal devices in an outpatient setting. MAIN OUTCOME MEASURE(S): Procedure feasibility without anesthesia, success rate of device implantation, patient satisfaction, and confirmation of correct placement. RESULT(S): Successful placement was achieved in 81 patients (95%). Mean time elapsed between the start of hysteroscopy, placement of devices, and removal of optics was 9 minutes (range, 1-35 minutes). No intraoperative or postoperative complications were detected. Of 81 patients, 75 (93%) had abdominal x-ray performed at the third month; bilateral correct placement was confirmed in all of them. CONCLUSION(S): Essure is a safe, effective, and minimally aggressive procedure with satisfactory patient acceptance that does not require anesthesia or hospitalization. It seems to be a good alternative to laparoscopic tubal sterilization.     

Reproductive preservation for treatment of stage IA endometrial cancer in a young woman: hysteroscopic resection

Uterine cancer is the most common type of gynecological neoplasm. Conventionally, the standard treatment for early-stage endometrial cancer is surgical staging with hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment. However, this leads to definitive sterilization in reproductive-age women. We report a rare case of a young woman with endometrioid endometrial adenocarcinoma successfully treated with reproductive preservation therapy in order to preserve her uterus. Pretreatment evaluation including tumor grade, depth of myometrial invasion, tumor size, and hormone-receptor status indicated a favorable prognosis. The patient was treated with hysteroscopic resection of the endometrial cancer, of the endometrium near lesion, and of the myometrium under lesion plus hormone therapy. Thirty months after operative hysteroscopy, the patient has given birth by cesarean section at 39 weeks of gestation to a male child of 3.2 kg and is now completely free of disease. We therefore conclude that there may be a role for effective treatment of endometrioid carcinomas with preservation of reproductive capacity, even if our preliminary result should be validated by a longer follow-up.     

ICSI pregnancy outcomes following hysteroscopic placement of Essure devices for hydrosalpinx in laparoscopic contraindicated patients

This study investigated the use of hysteroscopic Essure device placement for the treatment of hydrosalpinx-related infertility in patients with laparoscopic contraindications and compared their pregnancy outcomes following assisted conception treatment with those of patients having had laparoscopic tubal ligation. A total of 102 infertile patients were diagnosed with unilateral or bilateral hydrosalpinges: 26 patients had laparoscopic contraindications and were treated hysterscopically and 76 patients were treated laparoscopically. In total, 66 intracytoplasmic sperm injection (ICSI) and 39 frozen embryo transfer (FET) procedures were performed. In the hysteroscopy group, 13 ICSI and eight FET in 16 patients resulted in 10 pregnancies (pregnancy rates 47.6% per transfer and 62.5% per patient), and in the laparoscopy group, 53 ICSI and 31 FET embryo transfers in 54 patients resulted in 36 pregnancies (pregnancy rates 42.9% per transfer and 66.7% per patient). Live birth rates per assisted reproduction procedure were 23.8% (5/21) in the hysteroscopy group and 32.1% (27/84) for the laparoscopy group. The hysteroscopic placement of Essure devices to isolate hydrosalpinx prior to assisted conception treatment produced pregnancy outcomes comparable to those produced following laparoscopic tubal ligation. The live birth rates indicate that a larger, more comparative, prospectively randomized study is required.Infertile patients with tubal disease require surgical treatment before they can continue with fertility treatment. There are two main surgical methods that can be used, hysteroscopic and laparoscopic, the latter being the standard surgical method. However, some patients have disease that makes the use of laparoscopy inappropriate. For these patients the placement of Essure® devices by hysteroscopic surgery maybe the most suitable treatment method. One hundred and two patients were diagnosed with unilateral or bilateral hydrosalpinges – tubal disease. Twenty six patients had to have hysterscopic surgery and 76 patients had laparoscopic surgery. After their tubal surgery some patients continued to have fertility treatment, 66 ICSI and 39 frozen embryo transfers (FET) were performed. Thirteen ICSI and 8 FET embryo transfers in 16 patients from the hysteroscopy group resulted in 10 pregnancies, a 47.6% per transfer and 62.5% per patient pregnancy rate. Fifty three ICSI and 31 FET embryo transfers in 54 patients from the laparoscopic group resulted in 36 pregnancies, a 42.9% per transfer and 66.7% per patient rate. Live birth rates per ART procedure were 23.8% (5/21) in the hysteroscopic group compared with 32.1% (27/84) for the laparoscopic group. The hysteroscopic placement of Essure® devices for tubal disease prior to fertility treatments resulted in pregnancy outcomes that were comparable to the outcomes obtained following laparoscopic surgery.     

宫腔镜手术治疗剖宫产术后子宫瘢痕妊娠64例临床分析

目的 探讨宫腔镜手术治疗剖宫产术后子宫瘢痕妊娠(CSP)的合理方案.方法 回顾性分析中国医科大学附属盛京医院2006年1月至2009年4月收治的64例CSP患者的治疗情况.27例患者入院前曾在外院误诊为早孕、不全流产、宫颈妊娠等而采用不同的治疗(均失败),37例患者因阴道不规则流血且有剖宫产史首诊于本院.所有患者入院后行血清人绒毛膜促性腺激素β亚单位(β-hCG)测定、阴式三维彩超检查.结果 63例CSP患者采用超声监测下宫腔镜CSP病灶切除术,1例采用腹腔镜监测下宫腔镜CSP病灶切除术,均收到了良好的治疗效果.27例外院转诊患者经本院宫腔镜手术处置后血清β-hCG降至正常时间及包块完全吸收时间明显缩短[分别为(11±4)、(35±10)d],而本院首诊患者分别为(22±7)、(49±11)d,分别比较,差异均有统计学意义(P<0.05).64例CSP患者中,有7例进行了二次宫腔镜手术;1例经术后病理检查证实为绒毛膜癌,其余患者术后诊断与术前的CSP诊断符合.结论 有剖宫产史的妇女再次妊娠时,有发生CSP的可能,诊断时要注意CSP的临床特点,减少误诊,并对确诊病例采取个体化治疗;超声监测下宫腔镜CSP病灶切除术是治疗CSP的有效措施,病灶切除确切,可保留子宫.经术后随访,血清β-hCG水平下降迅速,局部包块吸收较快.     

The combination of 13-cis-retinoic acid and interferon α2a with radiation therapy in squamous cell carcinoma of the cervix

Cervical cancer remains a major cause of cancer mortality and morbidity in many countries. Locally advanced disease often recurs despite many modifications of radiation therapy. Since the combination of interferon α2a and 13- cis -retinoic acid has resulted in a 50% response rate in locally advanced cancer of the cervix, we designed a study to define a tolerable dose of these biologics with standard radiation therapy. The tolerable therapy consisted of interferon α2a 6 MU subcutaneous daily and 13- cis -retinoic acid orally 1 mg kg⁻¹ day⁻¹ for 8 weeks prior to the initiation of irradiation. This was followed by radiotherapy administered concurrently with interferon 3 MU administered three times per week and 13- cis -retinoic acid 0.5 mg kg⁻¹ day⁻¹. This dose of the biologics was continued for 4 weeks after the completion of irradiation. Hemorrhagic proctitis was the dose limiting toxicity. Among 23 patients evaluable for response to biologic therapy there were nine responses (39%; 95% CI: 19–59%), with two being complete. Twenty-one patients were evaluable for efficacy of the bioradiotherapy. Eleven of 21 patients (52%; 95% CI: 20–85%) had a remission with the combined bioradiotherapy. This combination of bioradiotherapy is tolerable and appears active. A phase II study of this combination is warranted to confirm its activity and tolerability.     

Preoperative hypoalbuminemia is an independent predictor of poor perioperative outcomes in women undergoing open surgery for gynecologic malignancies

Objective

To quantify the impact of preoperative hypoalbuminemia on 30-day mortality and morbidity after gynecologic cancer surgery.

Methods

Patients included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent any non-emergent surgery for gynecologic malignancy between 1/1/2008 and 12/31/2010 were identified. Analysis was conducted with albumin both as a dichotomous variable (< 3.5 g/dl was defined as low albumin) and as a continuous variable to determine a clinically relevant cut-off value.

Results

Of the total 3171 patients identified, 2110 had preoperative albumin levels available for analysis. In addition, 279 (13.3%) of these patients had low albumin levels.According to multivariate analysis, the low albumin group had significantly higher odds of developing one or more post-operative complications (OR-2,CI: 1.47–2.73, p < 0.0001), three or more complications (OR-4.1,CI: 2.31–7.1, p < 0.0001), surgical complications (OR-2.39,CI: 1.59–3.58, p < 0.0001), thromboembolic complications (OR-2.59,CI: 1.33–5.06, p < 0.0001), pulmonary complications (OR-4.06,CI: 2.05–8.03, p < 0.0001), or infectious complications (OR-1.84,CI: 1.26–2.69, p < 0.0001) and a higher 30-day mortality (OR-6.52,CI: 2.51–16.95, p < 0.0001). Upon subgroup analysis, this difference was not found in patients undergoing laparoscopic surgery.In patients undergoing open surgery, the probability of experiencing one or more post-operative complications increased linearly with the decrease in albumin level; however, the probability of patients experiencing three or more complications and 30-day mortality increased sharply as soon as the albumin level decreased below 3 g/dl.

Conclusion

Preoperative albumin levels < 3 g/dL identify a population of patients at a very high-risk of experiencing perioperative morbidity and 30-day mortality after open surgery.     

Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement.

OBJECTIVES: Percentage of deliveries assisted by a skilled birth attendant (SBA) has become a proxy indicator for reducing maternal mortality in developing countries, but there is little data on SBA competence. Our objective was to evaluate the competence of health professionals who typically attend hospital and clinic-based births in Benin, Ecuador, Jamaica, and Rwanda. Methods: We measured competence against World Health Organization's (WHO) Integrated Management of Pregnancy and Childbirth guidelines. To evaluate knowledge, we used a 49-question multiple-choice test covering seven clinical areas. To evaluate skill, we had participants perform five different procedures on anatomical models. The 166 participants came from facilities at all levels of care in their respective countries. Results: On average, providers answered 55.8% of the knowledge questions correctly and performed 48.2% of the skills steps correctly. Scores differed somewhat by country, provider type, and subtopic. Conclusion: A wide gap exists between current evidence-based standards and current levels of provider competence.     

Laminin-5 γ 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract

Abstract. Nordström B, Einhorn N, Silfverswärd C, Sjövall K, Tryggvason K, Auer G. Laminin-5 γ 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract.
During recent decades it has become apparent that there are two types of vulvar disease: the classic type found in elderly women with unicentric and unifocal lesions, and the type found in younger women, in which precancerous and invasive changes develop in the anogenital lower tract in a multicentric and multifocal fashion, often over a long period of observation.
The laminin-5 γ 2 chain is an extracellular protein that is a component of the basement membrane. Recently its expression has been recognized as a marker in cervical cancer that permits identification of invasive capacity.
The aim of our study was to determine if laminin-5 γ 2 chain antibody can act as a sensitivity marker of invasive capacity in precancerous and invasive carcinoma in women with uni- and multifocal changes in the anogenital tract. The result showed that all patients in the older group of women with invasive carcinoma of the vulva had moderate to high positive expression of the laminin-5 γ 2 chain. In the group of younger patients with multifocal precancerous changes observed over long periods, most of the patients with vulva intraepithelial neoplasia (VIN) 3 showed laminin-5 γ 2 chain positivity already in the precancerous changes, and all of them developed invasivity during the period of observation. Normal epithelium without atypia was mostly negative or of low immunoreactivity of laminin-5. In conclusion, positive laminin-5 γ 2 chain expression seems to indicate the invasiveness potential of precancerous lesions and is also expressed in all investigated invasive carcinomas of the anogenital tract.     

Customised birthweight centiles are useful for identifying small-for-gestational-age babies in women with type 2 diabetes

Background: Customised birthweight centiles identify small-for-gestational-age (SGA) babies at increased risk of morbidity more accurately than population centiles, but they have not been validated in obese populations.
Aims: To compare the rates of SGA by population and customised birthweight centiles in babies of women with type 2 diabetes and examine perinatal outcomes in customised SGA infants.
Methods: Data were from a previous retrospective cohort study detailing pregnancy outcomes in 212 women with type 2 diabetes. Customised and population birthweight centiles were calculated; pregnancy details and neonatal outcomes were compared between groups that delivered infants who were SGA (birthweight < 10th customised centile) and appropriate weight for gestational age (AGA) (birthweight 10–90th customised centile).
Results: Fifteen (7%) babies were SGA by population centiles and 32 (15%) by customised centiles. Two babies of Indian women were reclassified from SGA to AGA by customised centiles. Nineteen babies were reclassified from AGA to SGA by customised centiles; of these, 15 (79%) were born to Polynesian women, five (26%) were born less than 32 weeks and two (11%) were stillborn. Customised SGA infants, compared with AGA infants, were more likely to be born preterm (19 (59%) vs 20 (16%), P  < 0.001) and more likely to be stillborn (4 (13%) vs 0 P  = 0.001). After excluding still births, admission to the neonatal unit was also more common (19 of 28 (68%) vs 43 of 127 (34%), P  < 0.001).
Conclusions: In our population more babies were classified as SGA by customised compared with population centiles. These customised SGA babies have high rates of morbidity.     

A comparison of intrauterine balloon,intrauterine contraceptive device and hyaluronic acid gel in the prevention of adhesion reformation following hysteroscopic surgery for Asherman syndrome: a cohort study

Objective

To compare the efficacy of intrauterine balloon, intrauterine contraceptive device and hyaluronic acid gel in the prevention of the adhesion reformation after hysteroscopic adhesiolysis for Asherman's syndrome.

Study design

Retrospective cohort study of 107 women with Asherman's syndrome who were treated with hysteroscopic division of intrauterine adhesions. After hysteroscopic adhesiolysis, 20 patients had intrauterine balloon inserted, 28 patients had intrauterine contraceptive device (IUD) fitted, 18 patients had hyaluronic acid gel instilled into the uterine cavity, and 41 control subjects did not have any of the three additional treatment measures. A second-look hysteroscopy was performed in all cases, and the effect of hysteroscopic adhesiolysis was scored by the American Fertility Society classification system.

Results

Both the intrauterine balloon group and the IUD group achieved significantly (P < 0.001) greater reduction in the adhesion score than that of the hyaluronic acid gel group and control group. The efficacy of the balloon was greater than that of the IUD (P < 0.001). There was no significant difference in results between the hyaluronic acid gel group and the control groups.

Conclusion

The insertion of an intrauterine balloon or intrauterine device is more effective than the use of hyaluronic acid gel in the prevention of intra-uterine adhesion reformation.     

Comparison of the safety and efficacy of intravaginal misoprostol (prostaglandin E1 ) with those of dinoprostone (prostaglandin E2 ) for cervical ripening and induction of labor in a community hospital

Objective: This clinical trial evaluated the efficacy of intravaginal misoprostol (prostaglandin E₁ ) and compared it with that of dinoprostone (prostaglandin E₂ ) for cervical ripening and induction of labor in a community hospital. Study Design: This study involved a retrospective analysis of 81 patients undergoing cervical ripening and induction of labor with prostaglandin E₂ from May 1, 1996, to May 1, 1997. A comparison prospective analysis of 145 patients undergoing the same procedure with prostaglandin E₁ from May 1, 1997 to May 1, 1998, was performed. Results: The mean time to delivery was significantly shorter with misoprostol (19.8 ± 10.4 hours) than with prostaglandin E₂ (31.3 ± 13.0 hours, P < .001). Delivery within 24 hours of induction was significantly more frequent with misoprostol (71.9% of subjects vs 31.3%, P < .001). There was no difference in the cesarean delivery rate with misoprostol (25.6% vs 22.2%, P < .67). The incidence of uterine hyperstimulation was higher with prostaglandin E₂ (7.4% vs 0.7%, P < .007). There were no uterine ruptures with prostaglandin E₂ . There were 2 uterine ruptures and 1 dehiscence with prostaglandin E₁ in 3 patients with previous cesarean deliveries and 1 rupture in a patient without a history of uterine scarring. There was no difference in neonatal outcome, with the exception of a fetal death related to uterine rupture in the misoprostol group. Conclusions: Compared with prostaglandin E₂ , misoprostol is more effective in cervical ripening and induction of labor, is as safe for patients who do not have a history of cesarean birth, may carry a higher incidence of uterine rupture, and should not be used for patients attempting vaginal birth after previous cesarean delivery. (Am J Obstet Gynecol 1999;180:1551-9.)