A randomised controlled trial of antibiotic prophylaxis in elective caesarean delivery

Objective To determine whether prophylactic antibiotic administration using cefoxitin at the time of elective caesarean section significantly reduces infectious morbidity.
Setting A tertiary teaching hospital in a large urban city in South Africa.
Participants Women undergoing elective caesarean section.
Design A prospective, double-blind randomised placebo-controlled trial.
Methods Four hundred and eighty women undergoing elective caesarean section had cefoxitin or placebo administration after umbilical cord clamping. Postpartum complications including febrile morbidity, wound infection, endometritis, urinary tract infection, pneumonia and transient postpartum fever were recorded, as were the duration of hospital stay and the need for therapeutic antibiotics.
Results Wound infection was the most common complication occurring in 13.3% and 12.5% of women in the placebo and cefoxitin groups, respectively. Prophylactic antibiotics did not decrease febrile morbidity, wound infection, endometritis, urinary tract infection and pneumonia. Women who received cefoxitin stayed on average a day less in hospital than those who received placebo (6.9 vs 7.8 days, risk difference −0.94 CI 1.57 –−0.31 days). Eleven women (4.6%) in the placebo group and eight (3.4%) in the cefoxitin group had microbiological evidence of wound infection. Staphylococcus aureus was the most common pathogen (43%) isolated. Similar proportions in both groups (6.3% placebo and 5.1% cefoxitin) required a course of therapeutic antibiotics.
Conclusion Antibiotic prophylaxis with cefoxitin in elective caesarean section did not reduce post-operative infectious morbidity in this double-blind randomised placebo controlled trial.     

Two-stage repair of giant vesico-vaginal fistula

A review of 840 bladder fistulae over 10 years revealed that 64 (7.6%) were giant vesico-vaginal fistulae. Association with vaginal stenosis and recto-vaginal fistulae were 23.4% and 4.6%, respectively. The results of direct one-stage repair were poor at 35% for the first attempt while the two-stage repair achieved 80% success at the first attempt. Advantages of the two-stage repair include change in the direction of repair for maximum protection of the terminal ureters and also the possibility of change in patient positioning and approach to the repair of the fistula after the first stage.     

Effectiveness of nitrous oxide for postpartum perineal repair: a randomised controlled trial

Objective

To compare the effectiveness of self-administered 50% nitrous oxide and conventional infiltrative anaesthesia with 1% prilocaine hydrochloride in postpartum perineal repair.

Study design

A total of 100 women were prospectively enrolled and randomised to receive either infiltrative anaesthesia or a self-administered nitrous oxide mixture (Livopan^©) for pain relief during postpartum perineal suturing. Besides data concerning anaesthesia, characteristics of patients and labour were documented for statistical analysis. Pain experienced during perineal repair was assessed using the short form of the McGill Pain Questionnaire (SF-MPQ).

Results

Forty-eight women received nitrous oxide and 52 underwent perineal suturing after infiltrative anaesthesia. There were no statistically significant differences regarding maternal age, body mass index (BMI), duration of pregnancy and suturing time between the groups. The most frequent birth injury was second-degree perineal laceration in the study group [22/48; 46%] and episiotomy in the control group [18/52; 35%]. Pain experienced during genital tract suturing and patients’ satisfaction showed no statistically significant differences between the groups. Thirty-seven women in the study group and 47 in the control group were satisfied with the anaesthesia during perineal repair and would recommend it to other parturients [37/48, 77% vs. 47/52, 90%; p = 0.0699).

Conclusion

Nitrous oxide self-administration during genital tract suturing after vaginal childbirth is a satisfactory and effective alternative to infiltrative anaesthesia.     

A randomised controlled trial of moxibustion for breech presentation

OBJECTIVES: To evaluate the efficacy of moxibustion for the correction of fetal breech presentation in a non-Chinese population. DESIGN: Single-blind randomised controlled trial (RCT). SETTING: Six obstetric departments in Italy. SAMPLE: Healthy non-Chinese nulliparous pregnant women at 32-33 weeks + 3 days of gestational age with the fetus in breech presentation. METHODS: Random assignment to treatment or observation. Treatment consisted of moxibustion (stimulation with heat from a stick of Artemisia vulgaris) at the BL 67 acupuncture point (Zhiyin) for one or two weeks. Two weeks after recruitment, each participant was subjected to an ultrasonic examination of the fetal presentation. MAIN OUTCOME MEASURE: Number of participants with cephalic presentation in the 35th week. RESULTS: The study was interrupted when 123 participants had been recruited (46% of the planned sample). Intermediate data monitoring revealed a high number of treatment interruptions. At this point no difference was found in cephalic presentation in the 35th week (treatment group: 22/65, 34%; control group: 21/58, 36%; RR 0.95; 99% CI 0.59-1.5). CONCLUSIONS: The results underline the methodological problems evaluating of a traditional treatment transferred from a different cultural context. They do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.     

Vaginal repair with mesh versus colporrhaphy for prolapse: a randomised controlled trial

Objective  To compare vaginal repair augmented by mesh with traditional colporrhaphy for the treatment of pelvic organ prolapse.
Design  Prospective randomised controlled trial.
Setting  Tertiary teaching hospital.
Population  One hundred and thirty-nine women with stage ≥2 prolapse according to the pelvic organ prolapse quantification (POP-Q) system requiring both anterior and posterior compartment repair.
Methods  Subjects were randomised to anterior and posterior vaginal repair with mesh augmentation (mesh group, n  = 69) or traditional anterior and posterior colporrhaphy (no mesh group, n  = 70).
Main outcome measures  The primary outcome was the absence of POP-Q stage ≥2 prolapse at 12 months. Secondary outcomes were symptoms, quality-of-life outcomes and satisfaction with surgery. Complications were also reported.
Results  For subjects attending the 12-month review, success in the mesh group was 81.0% (51 of 63 subjects) compared with 65.6% (40/61) in the no mesh group and was not significantly different ( P -value = 0.07). A high level of satisfaction with surgery and improvements in symptoms and quality-of-life data were observed at 12 months compared to baseline in both groups, but there was no significant difference in these outcomes between the two groups. Vaginal mesh exposure occurred in four women in the mesh group (5.6%). De novo dyspareunia was reported by five of 30 (16.7%) sexually active women in the mesh group and five of 33 (15.2%) in the no mesh group at 12 months.
Conclusion  In this study, vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy 12 months following surgery.     

Postcoital vesico-vaginal fistula following surgery for cancer cervix

A 25-year-old parous woman was treated with radical hysterectomy for cancer of the cervix. Six months later she developed a vesico-vaginal fistula following coitus. The fistula was repaired and vaginal reconstruction performed. Sexual dysfunction and the need for vaginal reconstruction are discussed.     

Local antibiotic prophylaxis in inguinal hernia repair.

We compared the effects of single dose (750 milligrams) prophylactic cefamandole delivered directly into the operative wound with local anesthesia (n = 162) with a control group (no antibiotics) (n = 162) in a randomized trial. No adverse effects were observed. There were seven wound abscesses in the untreated group compared with none in the group receiving antibiotic prophylaxis (p = 0.007). Six of the seven abscesses occurred as late as one month after the patient was discharged from the hospital. The costs of antibiotics used were ten times less than the costs of treatment of wound complications in the control group.     

Late vesico-vaginal fistula after colporrhaphy for urinary incontinence]

We present a case of a 65 year-old woman with a late vesicovaginal fistula after colporrhaphy. Too late proper diagnosis of that complication caused perivesical tissue inflammation and led to damage to the urinary bladder, occlusion of the urethra as well as created a massive inflammatory tumor in the minor pelvis, which suggested a cancerous process. Bilateral hydronephrosis forced us to make bilateral nephrostomy. After intensive antiinflammatory therapy, anterior exenteration and Bricker's operation were performed with a finally good effect.     

Continuous versus interrupted sutures for repair of episiotomy or second-degree perineal tears: a randomised controlled trial

Objective  To evaluate the repair techniques of continuous and interrupted methods for episiotomy or perineal tears.
Design  A randomised controlled trial.
Setting  The Hospital Universitario Principe de Asturias, a state hospital belonging to the community of Madrid.
Sample  Four hundred forty-five women who had undergone vaginal deliveries with episiotomies or second-grade tearing of the perineum between September 2005 and July 2007.
Methods  One group was repaired with continuous, nonlocking sutures involving the vagina, perineum, and subcutaneous tissues. The other group had continuous, locking sutures of the vagina, interrupted sutures in the perineal muscles, and interrupted transcutaneous sutures. The threads used for stitching were identical in both groups.
Main outcome measures  The participants were questioned regarding the sensation of pain and the use of painkillers on the second and the tenth days, and 3 months postpartum.
Results  When comparing the group with continuous suture to the group with interrupted sutures, the differences included less repair time (1 minute; P = 0.017) and less suture material used (relative risk [RR], 3.2, 95% CI: 2.6–4.0). The comparison of pain on the second and tenth days, and 3 months postpartum were not statistically different between the two techniques (RR, 1.08, 95% CI: 0.74–1.57; RR, 0.96, 95% CI: 0.59–1.55; and RR, 0.68, 95% CI: 0.19–2.46, respectively).
Conclusions  Although we did not demonstrate that one technique was better than the other in the incidence of pain in the short or long term, we showed that episiotomy and perineal tear repairs with continuous suturing were quicker and used less suture material without an increase in complication than interrupted suturing.     

Metronidazole prophylaxis in abdominal hysterectomy. A double-blind controlled trial

The use of prophylactic metronidazole in electric total abdominal hysterectomy was evaluated in a prospective, double-blind randomized study. The rate of complicated wound healing was 18% in the metronidazole group and 13% in the placebo group. The bacteriologically confirmed wound infection rate was 3.9% in both the metronidazole and the placebo group. Only one of the infections was anaerobic and it appeared in the placebo group. No pelvic infections were observed in either of the groups and hospital stay was the same in both. Peroperative investigations of the vaginal flora showed significantly fewer anaerobic strains in the metronidazole group than in the placebo group.