Induction of labour after 1 previous Caesarean section

The aim of this study was, after induction of labour in women with a previous Caesarean section, to compare the outcome in women with a history of a previous vaginal delivery with women who had never delivered vaginally. A retrospective analysis was performed over a 2-year period, in a Dublin teaching hospital. One hundred and three women who had had 1 previous lower segment Caesarean section had labour induced. Particular attention was given to delivery outcome, history of a vaginal delivery, cervical effacement at induction, influence of epidural analgesia, indication for induction and incidence of uterine rupture. The repeat Caesarean section rate after induction was 20.4%. Of the 51 women who had never previously delivered vaginally, the repeat section rate was 37.3% compared with only 3.9% of the 52 women who had previously delivered vaginally (p < 0.01). Fourteen women who had never delivered vaginally had an uneffaced cervix at induction and the repeat Caesarean section rate in this group was 64.3%. The commonest indication for induction was a postdates pregnancy. The use of epidural analgesia was greater in women who had never delivered vaginally. There were 2 cases of uterine scar rupture. Induction of labour following Caesarean section is associated with a significantly higher incidence of repeat Caesarean section in women who have not had a previous vaginal delivery. If the cervix is not effaced at induction, the repeat Caesarean section rate is higher than if the cervix has started to efface.     

Second-look operative laparoscopy 1 year following reproductive surgery

To evaluate the efficacy of a second-look operative laparoscopy following a reproductive surgery, a randomized study was conducted on women who failed to conceive 1 year following terminal salpingostomy or following salpingo-ovariolysis by laparotomy. There is no significant difference in the cumulative probability of pregnancy at 12, 24, and 36 months follow-up between women who underwent second-look operative laparoscopy 1 year after salpingo-ovariolysis (27%, 67%, and 67%) and women who were continued to be observed expectantly (27%, 45%, and 52%, respectively). The cumulative probability of conception at 12, 24, and 36 months follow-up in women who underwent second-look laparoscopy 1 year after salpingostomy was 6%, 18%, and 18% and in women who were observed expectantly was 5%, 21%, and 27%, respectively (P = no significant). The incidence of ectopic pregnancy which was high (about one-half of patients who conceived) was also not affected by this procedure. This study suggests that second-look operative laparoscopy 1 year after terminal salpingostomy or salpingo-ovariolysis does not increase the pregnancy rate or decrease the incidence of ectopic pregnancy. Women who fail to conceive 1 year after a reproductive surgery still maintain some of their reproductive potential, but the risk of having an ectopic pregnancy is high.     

Women's perspectives on medical abortion in Mexico, Colombia, Ecuador and Peru: a qualitative study

In Latin America, where abortion is almost universally legally restricted, medical abortion, especially with misoprostol alone, is increasingly being used, often with the tablets obtained from a pharmacy. We carried out in-depth interviews with 49 women who had had a medical abortion under clinical supervision in rural and urban settings in Mexico, Colombia, Ecuador and Peru, who were recruited through clinicians providing abortions. The women often chose medical abortion to avoid a surgical abortion; they thought medical abortion was less painful, easier or simpler, safer or less risky. They commonly described it as a natural process of regulating their period. The fact that it was less expensive also influenced their decision. Some, who experienced a lot of pain, heavy bleeding or a failed procedure requiring surgical back-up, tended to be more negative about it. Regardless of legal restrictions, medical abortion was being provided safely in these settings and women found the method acceptable. Where feasible, it should be made available but cost should not have to be women's primary reason for choosing it. Psychosocial support during abortion is critical, especially for those who are more vulnerable because they see abortion as a sin, who are young or poor, who have limited knowledge about their bodies, whose partners are not supportive or who became pregnant through sexual violence.     

The miscarriage clinic: an audit of the first year

We preview the results of the first year in a Miscarriage Clinic set up in 1989 in an effort to improve the support and counselling of women who have a miscarriage. Of 381 patients referred, 79% attended. The only statistically significant difference between the women who attended and those who did not attend was in the proportion of women who had planned their pregnancies (65% versus 33%, P less than 0.01). Of the 300 patients who attended, 4% reported no grief reaction; 75% experienced a reaction which had resolved within one month and 21% experienced a reaction which had not resolved. No factor was identified which could predict the duration of the grief reaction. This audit demonstrates that there is a strong demand and need for this service for couples who experience a miscarriage.     

Bowel injury in septic abortion: the need for more aggressive management

An analysis of bowel injury in cases of septic abortion treated over a six-year period at the University of Nigeria Teaching Hospital at Enugu is presented. Seventy-three percent (11/15) of the patients who underwent laparotomy had concomitant injury to the bowels. Overall, 16.4% of the 67 patients with septic abortion had intestinal injuries (this does not include the patients who died as a result of fulminating peritonitis before surgery could be performed). The survival of those patients with intestinal injuries was very much dependent on the operative procedures adopted. When a dysfunctioning colostomy was raised, the mortality was nil. In patients who had simple closure of the perforation and in those who had primary resection and anastomosis, mortality was 66.6%. The importance of performing laparotomy much sooner than usual is discussed.     

The miscarriage clinic: an audit of the first year

Summary. We preview the results of the first year in a Miscarriage Clinic set up in 1989 in an effort to improve the support and counselling of women who have a miscarriage. Of 381 patients referred, 79% attended. The only statistically significant difference between the women who attended and those who did not attend was in the proportion of women who had planned their pregnancies (65% versus 33%,   P <0.01  ). Of the 300 patients who attended, 4% reported no grief reaction; 75% experienced a reaction which had resolved within one month and 21% experienced a reaction which had not resolved. No factor was identified which could predict the duration of the grief reaction. This audit demonstrates that there is a strong demand and need for this service for couples who experience a miscarriage.     

Cell-free fetal DNA in the cerebrospinal fluid of women during the peripartum period

OBJECTIVE: The purpose of this study was to determine whether cell-free fetal DNA is detectable in the cerebrospinal fluid of women during pregnancy and after delivery. STUDY DESIGN: Cerebrospinal fluid was collected from 39 women who underwent an indicated spinal anesthesia procedure. Twenty-six samples were from women who carried at least 1 male fetus, and 13 samples were from women with only a female fetus. DNA was analyzed with the use of real-time polymerase chain reaction for DYS-1 (which represented male fetal DNA) and beta-globin (which represented maternal and fetal DNA). RESULTS: beta-Globin DNA was detected in all cerebrospinal samples. DYS-1 gene sequences were detected in 4 cerebrospinal fluid samples from women who had male fetuses (2 samples were from women who underwent cesarean delivery of singleton pregnancies, 1 sample was from a triplet pregnancy, and 1 sample was from a woman after delivery). No male DNA was detected in the cerebrospinal fluid of women who carried female fetuses. CONCLUSION: Male fetal cells and/or cell-free fetal DNA is detectable in the cerebrospinal fluid of some pregnant women or some women after delivery.     

Are women who are Jehovah's Witnesses at risk of maternal death?

OBJECTIVE: The purpose of this study was to determine the rates of obstetric hemorrhage and maternal mortality in women who are Jehovah's Witnesses and to evaluate a protocol that uses erythropoietin to optimize the red blood cell mass before delivery. STUDY DESIGN: Obstetric outcomes were described for all of the women who were Jehovah's Witnesses and who delivered at Mount Sinai Medical Center during an 11-year period. The risk of maternal death was compared with our general obstetric population during this interval. RESULTS: A total of 332 women who were Jehovah's Witnesses had 391 deliveries. An obstetric hemorrhage was experienced in 6% of this population. There were 2 maternal deaths among the women who were Jehovah's Witnesses, for a rate of 512 maternal deaths per 100,000 live births versus 12 maternal deaths per 100,000 live births (risk ratio, 44; 95% CI, 9-211). Erythropoietin was associated with a nonsignificant increase in hematocrit level. CONCLUSION: Women who are Jehovah's Witnesses are at a 44-fold increased risk of maternal death, which is due to obstetric hemorrhage. Patients should be counseled about this risk of death, and obstetric hemorrhage should be aggressively treated, including a rapid decision to proceed to hysterectomy when indicated.     

Pelvic endometriosis and tubal inflammatory disease

The incidence of tubal inflammatory disease in women with endometriosis who had undergone surgery was compared with that in women who had undergone similar operative procedures but who did not have endometriosis and with that in a group of clinically healthy women undergoing tubal sterilisation. The incidence of tubal inflammatory lesions was much higher in all women who had undergone surgery than in those undergoing sterilisation, but there was no difference in the incidence of tubal lesions between those women with endometriosis and those not suffering from this disease. Women with endometriosis and tubal inflammatory disease did not have a significantly lower mean gravidity than did those with healthy tubes. It is concluded that there is no specific association between endometriosis and tubal inflammation and that tubal inflammatory disease is unlikely to be a significant factor contributing to infertility in endometriosis.     

Postoperative analgesic requirements - total laparoscopic hysterectomy versus vaginal hysterectomy

BACKGROUND: There is limited information available on the requirement for postoperative analgesic drugs in patients submitted to total laparoscopic hysterectomy (TLH) compared with patients undergoing vaginal hysterectomy (VH). AIM: To compare the postoperative analgesic requirements in patients who underwent a TLH with patients who had a VH. METHODS: Chart review of 53 patients who had TLH and 47 who had VH and were seen postoperatively by an acute pain management service in order to assess postoperative analgesic requirements. Patient controlled analgesia (PCA) was part of the standard protocol for postoperative pain management. Analgesic requirement was recorded as the mean doses of morphine and number of days that patients used non-steroidal anti-inflammatory drugs (NSAIDs), oxycodone and tramadol. RESULTS: The requirement for total morphine was approximately half the dose in patients who had a TLH (10.8 +/- 12.6 mg) compared with patients who had a VH (19.4 +/- 21.9 mg) (P 0.017). The length of use of NSAIDs was significantly reduced in patients who had undergone a TLH (2.0 +/- 0.95 days) as compared with patients who had a VH (2.85 +/- 1.1 days) (P < 0.0001). CONCLUSIONS: Patients submitted to TLH require less postoperative analgesic drugs when compared with patients who had VH. Prospective randomised trials are warranted to compare analgesic requirements between patients submitted to TLH and VH.     

Hysterectomy is associated with stress incontinence in women who previously had a transcervical endometrial resection

OBJECTIVES: To compare the prevalence of urological symptoms in a population of women, who had a transcervical endometrial resection (TCER) only, and a population of women, who had a TCER and a subsequent hysterectomy. The superior goal was to evaluate the possible association between hysterectomy and urinary incontinence. DESIGN: All women, who had a TCER at our department during the period of 1990-1996 received a questionnaire with focus on urological symptoms. The answers from women, who later had a hysterectomy were compared to the answers from women, who were sufficiently treated with TCER only. RESULTS: Of 356 women, who were alive, 16 were lost to follow-up, leaving 340 women to receive the questionnaire, which was returned by 310 women (85%). Ninety-three (31%) had a subsequent hysterectomy mainly indicated by metrorrhagia or dysmenorrhea. Of the hysterectomized women 24% reported bothersome stress incontinence against 14% in the group of women, who had TCER only (p = 0.03). No significant difference was seen with respect to urge incontinence, urgency, pollakisuria or nocturia. Significantly more women with a normal sized uterus reported bothersome stress incontinence after the hysterectomy compared to women with a slightly enlarged uterus. CONCLUSION: Hysterectomy is significantly associated with stress urinary incontinence in women, who previously had a TCER.     

Trial of Labour after Previous Caesarean Section: Obstetric Outcome

Of 305 patients with a previous lower segment Caesarean section scar admitted over a 28-month period, 207 were allowed a trial of labour. A successful trial of labour was achieved in 63.3% of patients with a recurrent indication and 73.4% with a nonrecurrent indication. Of 75 patients who received oxytocin for augmentation and 22 for induction of labour, 70.5% achieved vaginal delivery. This was similar to the vaginal delivery rate in patients who did not require augmentation in induction. Three cases of scar dehiscence occurred in patients who had oxytocin, but in whom the recommended management protocol was ignored. The events that led to these 3 dehiscences is described. Analysis of birth-weights revealed a trend towards more repeat Caesareans with increasing birth-weight beyond 2,500 g. This was especially reflected by the higher emergency Caesarean section rate in those who had a trial of labour. A trial of labour in patients with a previous Caesarean scar is safe, and can be allowed even in patients who had the previous Caesarean for cephalopelvic disproportion, although malpresentation and obvious disproportion must be excluded. Judicious use of oxytocin for a limited period of time should help in reducing the number of repeat Caesarean sections.     

Pregnancy outcome following exposure to permethrin and use of teratogen information

NIX is a 1% permethrin creme rinse used for the treatment of head lice. There are no studies regarding human exposure during pregnancy. The primary objective of this study was to examine the safety of permethrin exposure during pregnancy. The secondary objective was to examine how teratogen information is perceived and used by women who requested information regarding this product. Women who had called the Motherisk and MotherSafe Programs to inquire about exposure to permethrin during pregnancy were followed-up to ascertain the outcome of their pregnancies. These women were compared with another group who had not been exposed to any known teratogenic drugs. Women who decided not to use permethrin were administered an additional questionnaire. We enrolled 147 women and completed outcomes on 113 pregnancies of women who had used permethrin some time during their pregnancy. There were 106 live births, six spontaneous abortions, one therapeutic abortion, and one major malformation in the women who used permethrin in the first trimester. The mean birthweight was 3540 +/- 492 g and the mean gestational age was 40 +/- 1 weeks. There were no statistically significant differences between the exposed and comparison groups in any of the pregnancy outcomes. Of the 34 women who chose not to use permethrin and who completed the additional questionnaire, 18 (52%) did not use permethrin because they did not feel the information was sufficiently reassuring. The results of this study suggest that the use of permethrin products during pregnancy appears to be relatively safe because there was no increase in the rates of major malformations. We also found that some women will not use a product during pregnancy unless they can receive a 100% guarantee that it will not harm their baby.     

Whole-abdomen, single-dose consolidation radiotherapy in patients with pathologically confirmed complete remission of advanced ovarian epithelial carcinoma: a long-term survival analysis

The value of consolidation therapy in advanced epithelial ovarian carcinoma patients is controversial. The aim of the present study was to assess the long-term survival of patients with a pathologically confirmed complete remission who had consolidation by single-dose, whole-abdominopelvic radiotherapy. Of 96 histologically confirmed stage II-IV epithelial ovarian carcinoma patients who underwent cytoreductive surgery followed by high-dose, platin-based chemotherapy, 57 were in complete clinical remission at the end of therapy and 50 underwent a second-look laparotomy. The study group comprises 32 consecutive patients who had no pathological evidence of disease and who received 800 cGy single-dose, whole-abdominal radiotherapy by an 8 MEV linear accelerator in a single fraction. The absolute 5-year survival and the actuarial 10-year survival were 78.7 and 63.3%, respectively. The survival was significantly better in patients who had < or =2 cm residual disease at the completion of the original operation. No severe postradiation complications were encountered. Mild complications were seen in three (9.4%) patients. Our data indicate a favorable long-term survival of patients with a negative second-look laparotomy who had consolidation with single-dose, whole-abdominal radiotherapy. These results seem to suggest that a collaborative, prospective, randomized multiarm study is indicated to solve the controversial issue of consolidation therapy.     

Postpartum contraception: subsequent pregnancy, delivery, and abortion rates.

The first subsequent pregnancy rate in a group of women who accepted a variety of contraceptive methods after delivery and after therapeutic abortion is reviewed. Regardless of method chosen, 20 to 30% of postdelivery and 18 to 20% of postabortion patients were pregnant again after 1 year. In those patients who chose no method, 30 to 40% of postdelivery patients and 19 to 30% of postabortion patients were pregnant again 1 year later. When the postdelivery and postabortion patients were compared by outcome of this first subsequent pregnancy, there was no indication that subsequent therapeutic abortion was utilized to a greater extent by those who had had a prior therapeutic abortion than by those who had had a prior delivery.     

Thrombophilia and stillbirth: possible connection by intrauterine growth restriction

OBJECTIVE: To define the association between thrombophilia and unexplained stillbirth. DESIGN: A case-control study. SETTING: Obstetric department in a university affiliated hospital (Ha'Emek Medical Center, Afula). POPULATION: A total of 53 women who delivered stillborns between March 1998 and June 2002 and 59 women with unremarkable obstetric history who delivered at the same period. METHODS: Presence of genetic and acquired markers of thrombophilia was investigated. MAIN OUTCOME MEASURE: Presence or absence of thrombophilia. RESULTS: Thrombophilia was found in 34% of the women who delivered stillborns and in 20% of the 59 women with normal pregnancies (non-significant). However, significantly higher prevalence of thrombophilia (73%) was found in women who delivered small for gestational age stillborns compared with women who delivered normal birthweight stillborns (73%vs 18.4%, P < 0.0001). CONCLUSIONS: There is no association between thrombophilia and stillbirth, overall. However, there is a clear association between thrombophilia and stillbirth of extremely growth restricted infants.     

Cocaine use in pregnant women in a large public hospital

Cocaine has been reported to be associated with several pregnancy complications such as abruptio placentae, an increase in the incidence of low birthweight infants, and congenital malformations in the newborn. With the increasing frequency of cocaine abuse of women of childbearing age in the United States, clinicians can reasonably be expected to encounter increasing numbers of pregnant women who use cocaine. The exact prevalence of cocaine use during pregnancy is not known. In the present series of 102 pregnant women, the prevalence of cocaine use was 9.8%, with a 95% confidence interval of 3.9 to 15.7%. There was one mother who had an abruptio placentae and there was one infant who had a congenital malformation among the ten women with a history of cocaine use during pregnancy. The mean birthweight was 3180 +/- 380 gm for infants born to mothers who used cocaine compared with 3250 +/- 422 gm (p = NS) for the infants born to mothers who did not use cocaine. A significant number of pregnant women in our population use cocaine during pregnancy.     

Differences in Women's Psychological Well‐being Based on Infertility Treatment Choice and Outcome

Introduction: The empirical foundation regarding women's experiences with infertility is influenced by the use of clinically based populations of women who are seeking medical assistance to conceive. Although the experience of infertility and involuntary childlessness is recognized as a significant life stressor characterized by a loss of control, bodily integrity, and identity, little is understood about women who perceive an infertility problem but do not seek treatment. Methods: A secondary analysis was conducted by using a national probability sample from the National Survey of Fertility Barriers. Women (N = 142) who self‐reported perceptions of fertility problems were placed in 1 of 3 groups based on the decision to seek/not seek treatment and treatment outcome. Results: When we controlled for marital status, women who conceived with medical assistance reported significantly higher levels of life satisfaction and held parenting as more important than women who sought treatment and did not conceive and women who did not seek treatment. Discussion: Women who did not seek treatment for perceived infertility problems reported a decreased sense of the importance of parenthood but also reported lower levels of self‐esteem and life satisfaction than women who sought treatment, regardless of treatment outcome.     

Impact of second look laparotomy and secondary cytoreductive surgery at second-look laparotomy in ovarian cancer patients

OBJECTIVE: Currently, no prospective study supports or refutes the value of secondary cytoreductive surgery in patients with ovarian cancer. We therefore reviewed the surgical data of patients who underwent second-look laparotomy (SLL) with or without secondary cytoreductive surgery at our department. METHODS: Analysis is based on the data of 179 patients who had FIGO stage II (suboptimally staged), stage III or IV ovarian cancer, who received a platinum-based first-line chemotherapy, who were clinically considered to be tumor-free or had at least a clinically partial response to first-line chemotherapy, and who underwent SLL. In patients with macroscopic tumor the diagnostic SLL was followed by a secondary cytoreductive surgery in order to remove as much tumor as possible. Patients with a positive SLL were given second-line chemotherapy. Survival from SLL until death was considered the primary statistical endpoint. RESULTS: In 78 out of 179 (43.5%) a negative SLL could be confirmed pathologically. Patients with negative findings, with microscopic, and macroscopic disease at SLL had a median survival of 66.6, 57.2, and 19.0 months, respectively (p=0.0001). In patients who underwent a secondary cytoreductive operation and in whom residual tumor was none, less than 2 cm, or more than 2 cm, the median survival was 22.9, 17.8, and 15.5 months, respectively (p=0.325). CONCLUSIONS: The presence of macroscopic tumor at SLL is an adverse prognostic factor whereas the role of secondary cytoreductive surgery at SLL appears to be limited in the routine management of ovarian cancer patients.     

Risk of recurrence after myomectomy

Summary. The risk of recurrence of uterine myomas was analyzed in 622 patients who underwent myomectomy between 1970 and 1984 at the First Department of Obstetrics and Gynecology of the University of Milan. The cumulative 10-year recurrence rate was 27%, and this increased steadily up to the end of the observation period. Differences were not observed in frequency of recurrence by age at diagnoses or by the site of the myomas at surgery. Patients with a single myoma tended to experience a lower rate, but this finding was not statistically significant. Women who gave birth to a child after myomectomy had a 10-year recurrence rate of 15%, against 30% for those who did not; this difference was statistically significant.