腹部手术后盆腹腔粘连发生及相关因素分析

目的:分析前次腹部手术后盆腹腔粘连的发生及相关因素。方法:2002年1月至2005年4月就诊于北京协和医院、有腹部手术史及因各种妇科疾病需行腹腔镜手术的患者170例。记录既往的手术相关情况以及腹腔镜手术中盆腹腔的粘连情况,对粘连进行分级并分析其相关因素。结果:腹壁切口下方粘连总的发生率为40.6%(69/170)。腹腔镜切口粘连发生率为8.7%(2/23)较横切口的46.4%(13/28)、纵切口的42%(34/81)、其他类型切口的52.6%(20/38)相比较低,其差异有显著性(P=0.003,P=0.003,P<0.001)。多次手术是切口下粘连的危险因素(χ2=8.699,P=0.013)。手术野粘连率为77%(131/170)。有不孕史、PID史以及子宫内膜异位症(EM)史者粘连的发生率分别为96.3%,100%及94.4%。与无上述病史的手术者比较,手术野严重粘连的发生率显著增高(P<0.001,P=0.008,P<0.001)。结论:有腹部手术史的患者,切口下方及手术野粘连发生率较高。切口下方粘连与手术方式及手术次数相关。腹腔镜手术切口下方的粘连发生率最低。多次手术史切口下方的粘连尤其是肠粘连发生率较高。手术野粘连与腹壁切口种类无关,与手术种类有关,其中EM、不孕及PID手术史是手术野粘连的危险因素。     

Results of TVT operations alone and combined with other vaginal surgical procedures

We made a study of 61women with genuine stress incontinence (GSI). They all had a tension-free vaginal tape (TVT) and 28 patients had concomitant vaginal surgery. The cure rates and complication rates for the two groups were similar.     

3种手术方式治疗子宫切口憩室的疗效分析

目的:探讨宫腹腔镜联合修补术、阴式修补术和宫腔镜修补术治疗剖宫产术后子宫切口憩室的临床疗效,为临床手术方案的选择提供参考。方法:选择2008年2月至2012年5月在郑州大学第一附属医院收治的因保守治疗失败行手术治疗的剖宫产术后子宫切口憩室患者71例,其中接受宫腹腔镜联合手术治疗38例(宫腹腔镜组),经阴道手术治疗20例(阴式组)及宫腔镜治疗13例(宫腔镜组)。回顾性分析71例患者手术的相关统计指标。结果:宫腹腔镜组、阴式组和宫腔镜组在术中出血量(35.0±17.6 ml、25.0±15.8 ml、10.0±10.2 ml)、手术时间(60.0±12.4分钟、43.0±15.6分钟、20.0±5.6分钟)、术后阴道流血时间(7.9±2.1天、9.5±3.5天、5.5±3.2天)和治疗费(15283.6±756.3元、5269±332.4元、7841.9±965.8元)方面比较,差异均有统计学意义(P0.001)。宫腹腔镜组治疗月经改善有效率(97.14%)与阴式组(94.74%)比较,差异无统计学意义(P0.05),但两组分别与宫腔镜组(63.64%)比较差异均有统计学意义(P0.05)。3组术后妊娠率分别为72.73%(8/11)、60.00%(3/5)、50.00%(2/4),比较差异无统计学意义(P0.05)。结论:宫腹腔镜、宫腔镜术和阴式修补术均是剖宫产术后子宫切口憩室的有效治疗手段,临床上可根据患者的病情及医者水平制定相应的手术治疗方案。     

Patients’ obstetric history in mid-trimester termination of pregnancy with gemeprost: Does it really matter?

OBJECTIVE: The objective was to investigate the importance of previous obstetric history for termination of pregnancy in the second-trimester with gemeprost alone. STUDY DESIGN: A consecutive series of 423 mid-trimester inductions of abortion at our teaching hospital was reviewed. Termination of pregnancy was carried out with 1mg of vaginal gemeprost every 3h up to three doses over a 24-h period, repeated the following day if necessary. Failed induction was defined as women undelivered by 96 h. The study population was then stratified by gestational age, parity, gravidity and previous uterine scars. Main outcome parameters were failed induction and complication rates. Statistical analysis was performed using the chi(2) test or Fisher's exact test for categorical data, and the t-test and linear regression for continuous variables. RESULTS: No significant differences were found in the primary outcome parameters with regard to the obstetric parameters considered. The failed induction rate was 1.2% with an overall incidence of complications of 7.4%. Parity was the main factor that affected clinical response (time to abortion interval and number of pessaries). CONCLUSION: Patients' obstetric history does affect the clinical response to gemeprost, but its safety and effectiveness are preserved. These data provide clinicians with important information for correct counselling.     

Maternal risk factors for preterm birth: a country-based population analysis

Objective

The aim of this study was to identify maternal risk factors for spontaneous preterm birth (PTB) compared to delivery at term, in order to recognize high risk women and to provide a global overview of the Italian situation.

Study design

A multicenter, observational and retrospective, cross-sectional study was designed. The study population comprised 7634 women recruited in 9 different University Maternity Hospitals in Italy. The main criteria for inclusion were: women having had vaginal preterm or term spontaneous delivery in each participating centre during the study period. The records related to deliveries occurring between April and December 2008. A multivariable logistic regression was employed to identify independent predictors of spontaneous preterm birth. Odds ratios (ORs) and 95% confidence intervals (95% CI) were reported with two-tailed probability (p) values. Statistical calculations were carried out using SAS version 9.1. A two-tailed p-value of 0.05 was used to define statistical significant results.

Results

A significant increased risk of PTB was found in women with BMI > 25 (OR = 1.662; 95% CI = 1.033–2.676; p-value = 0.0365) and in women employed in heavy work (OR = 1.947; 95% CI = 1.182–3.207; p-value = 0.0089). Moreover there was a significant association between PTB and previous reproductive history. In fact a history of previous abortion (OR = 1.954; 95% CI = 1.162–3.285; p-value = 0.0116) or previous cesarean section (OR = 2.904; 95% CI = 1.066–7.910; p-value = 0.0371) was positively correlated to the increased risk of PTB and an important statistically significant association was calculated between PTB and previous pre-term delivery (OR = 3.412; 95% CI = 1.342–8.676; p-value = 0.0099). All the other covariates examined as potential risk factors for PTB were not found to be statistically significantly related (p-value > 0.05).

Conclusions

The present study, applied to a substantial sample of Italian population, demonstrates that there are peculiar risk factors for spontaneous PTB in the Italian population examined. It shows an association between preterm delivery and certain maternal factors as: BMI, employment, previous abortions, previous PTBs and previous cesarean section.     

The Maternal-Fetal Medicine Unit cesarean registry: trial of labor with a twin gestation

OBJECTIVE: The purpose of this study was to identify the success rates and risks in women with a twin pregnancy who attempt a trial of labor after cesarean delivery. STUDY DESIGN: Cases were identified in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network's Cesarean Registry with a woman with a twin pregnancy who had had at least 1 previous cesarean delivery. RESULTS: During the study period (1999-2002), 412 women fulfilled the study criteria, and 226 women had elective repeat cesarean delivery. Of the 186 women (45.1% of total) who attempted a trial of labor, 120 women were delivered successfully (success rate, 64.5%), and 66 women (35.5%) had a failed trial of labor. Thirty of the failed trials of labor involved a vaginal delivery for twin A and cesarean delivery for twin B. Women who attempted a trial of labor with twins had no increased risk of transfusion, endometritis, intensive care unit admissions, or uterine rupture when compared with elective repeat cesarean delivery. Fetal and neonatal complications were uncommon in either group at>or=34 weeks of gestation. CONCLUSION: A trial of labor with twins after previous cesarean delivery does not appear to increase maternal morbidity. Perinatal morbidity is uncommon at>or=34 weeks of gestation.     

Preoperative determinants for failure of transobturator tapes in the management of female urodynamic stress incontinence

Objectives

To determine significant preoperative risk factors for failure of transobturator tapes.

Methods

Secondary analysis of data from the E-TOT (Evaluation of Transobturator Tapes) study. Patient-reported outcomes (n = 310) and objective outcomes (n = 297) were analyzed using univariate and multivariate analyses.

Results

On univariate analysis, body mass index (BMI) ≥  35, maximum urethral closure pressure (MUCP) ≤ 30 cm H₂O, preoperative mixed incontinence on urodynamics, history of at least one previous incontinence procedure, and preoperative symptoms of urgency, nocturia, or urgency incontinence were associated with failure. On multivariate regression, BMI ≥ 35 (OR 6.37; 95% CI, 1.73-23.44; P = 0.005), nocturia (OR 2.18; 95% CI, 1.04-4.58; P = 0.039), urgency incontinence (OR 3.35; 95% CI, 1.07-10.51; P = 0.039), and previous incontinence surgery (OR 2.33; 95%CI, 1.1-5.48; P = 0.048) were independently associated with patient-reported failure. MUCP ≤ 30 cm H₂O (OR 7.06; 95% CI, 2.85-17.48; P < 0.001) and previous incontinence procedure (OR 6.22; 95%CI, 2.34-16.52; P < 0.001) were independently associated with objective failure.

Conclusion

History of previous incontinence surgery was the only independent risk factor for failure of transobturator tapes based on both the patient-reported and objective outcome.     

Successful Third Consecutive TVT in a Patient With Two Previous TVT Failures

BackgroundDuring 10 years of use, the transvaginal tape (TVT) technique has proved highly effective for the treatment of stress urinary incontinence. There is limited published information about experience with repeated TVT placementsCaseA 47-year-old multiparous woman presented with a history of two previous TVT sling procedures but persistent urinary incontinence. Persisting urinary incontinence was noted at six months after the first placement, and a second TVT placement was also unsuccessful. The preoperative urodynamic assessment showed type II and III urinary incontinence. The uterus was enlarged to the size of a 16-week pregnancy, and a hysterectomy was performed. At the same time, a third TVT sling procedure was performed using the standard free tension sling technique, leaving the arms uncut for 24 hours. The patient has remained continent during ten months of follow-up.ConclusionAccording to our experience with this patient, the placement of a third TVT after two failures is safe and effective.     

宫腔镜注水膨宫下经腹超声评估子宫瘢痕憩室的应用价值

目的:探讨宫腔镜注水膨宫时经腹超声评估剖宫产术后子宫切口憩室大小、残余肌层厚度的应用价值。方法:选取剖宫产术后出现月经经期改变,伴随月经前后点滴出血的患者37例,同时采用经阴道超声及宫腔镜注水膨宫下经腹超声测量憩室长、宽、高、深及残余肌层厚度,比较两种检测手段对于评估子宫切口愈合情况的优劣。结果:宫腔镜注水膨宫时经腹超声检测憩室长、宽、高各径线均大于普通阴道超声(P0.05),而残余肌层厚度更薄(P0.05)。3例患者普通阴道超声未检测出憩室,而宫腔镜膨宫下能观察到典型的憩室形态。结论:宫腔镜注水膨宫时经腹超声在测量憩室大小的同时能直观地观察憩室内部形态,取得病理,排除子宫内膜其他良恶性病变,与普通经阴道超声相比,能更好地评估憩室。     

前置胎盘附着位置对剖宫产后再次妊娠母婴结局的影响

目的研究前置胎盘附着位置对剖宫产后再次妊娠母婴结局的影响。 方法回顾性分析2008年6月至2013年6月就诊于中山大学附属第一医院产科剖宫产后再次妊娠合并前置胎盘62例患者临床资料,其中附着于子宫前壁的前置胎盘33例(前壁组),附着于子宫后壁的前置胎盘29例(后壁组),比较两组患者的一般情况、前置胎盘类型、并发症、妊娠结局及新生儿情况。计量资料采用t检验,计数资料采用χ²检验。 结果前壁组与后壁组患者的产前出血率分别为45.5%和17.2%(χ²＝4.554,P＝0.033),产后出血发生率分别为69.7%和13.8%(χ²＝17.348,P<0.001),胎盘粘连发生率分别为48.5%和20.7%(χ²＝4.151,P＝0.042),胎盘植入发生率分别为33.3%和10.3%(χ²＝4.028,P＝0.045),子宫切除率分别为27.3%及0.0%(χ²＝8.434,P＝0.004),弥散性血管内凝血(DIC)发生率分别为27.3%和0.0%(χ²＝8.434,P＝0.004),早产发生率分别为63.6%和27.6%(χ²＝4.464,P＝0.035)。 结论剖宫产后再次妊娠合并前置胎盘中,胎盘附着于前壁者导致产前出血、产后出血、胎盘粘连、胎盘植入、子宫切除、DIC及早产的风险显著增高,分娩前应明确胎盘附着位置。     

Pre-pubic TVT: an alternative to classic TVT in selected patients with urinary stress incontinence

OBJECTIVES: To evaluate in a prospective open study a pre-pubic route of TVT for surgical treatment of female stress incontinence. STUDY DESIGN: Consecutively, 74 patients were operated using a pre-pubic TVT tape application. All women were suffering subjectively and objectively from female stress urinary incontinence. The mean post-operative follow-up time was 5 months (range 2-10 months). The pre- and post-operative evaluations were performed according to a standard protocol. RESULTS: According to the protocol, 60 patients (81%) were cured of their stress incontinence symptoms. Another 10 patients (13%) were improved. Four patients (6%) were considered failures. There were no significant intra- or post-operative complications. CONCLUSION: The short-term results of pre-pubic TVT are consonant with those of classic TVT. The risks of intra-operative complications should be reduced by the pre-pubic route. If the long-term results of pre-pubic TVT are the same as those after classic TVT, then this surgical approach may be a tentative alternative in selected high-risk patients.     

Changes in the MRI morphology of the stress continence control system after TVT (tension-free vaginal tape) insertion

OBJECTIVE: Magnetic resonance imaging (MRI) was used to investigate whether tension-free vaginal tape (TVT) insertion (according to Ulmsten) leads to morphologic changes of the stress continence control system. METHODS: Twenty women (mean age 53.4 years) with clinically and urodynamically proven stress urinary incontinence without prolapse were examined by MRI before and 13 months after TVT insertion. RESULTS: Postoperative MRI showed a signal intensity loss of the suburethral portion of the endopelvic fascia in the area of the anterior vaginal wall in 9/20 women with additional signal loss of the paraurethral portion of the fascia in 3/20 women. No morphologic changes of the levator ani muscle and the urethra were seen postoperatively. CONCLUSIONS: TVT insertion does not damage the structures of the stress continence control system or impact on their topographic relationships. MRI identified no excessive scar formation resulting from integration of the TVT.     

An Observational Study of Various Predictors of Success of Vaginal Delivery Following a Previous Cesarean Section

Objectives

To study the various predictors of success for vaginal birth after cesarean (VBAC) and to study the maternal and fetal outcomes in them and their comparison with control group.

Methods

This prospective observational study included 100 women with previous cesarean section in the study group and 100 primigravidas in the control group. Various predictors for success of VBAC were analyzed and maternal and fetal outcomes were compared with the control group using student t test, Pearson χ ² test, and Mann–Whitney U test.

Results

Of 100 women with prior cesarean Sect. 65 had successful trial of labor, while 35 underwent a repeat cesarean section. Maternal complications in the previous CS group were 15 % as compared to only 2 % in the control group (p < 0.001).

Conclusion

Maternal pre-pregnancy BMI, non-recurring indications of previous cesarean section, good Bishop’s score at the time of admission, spontaneous onset of labor, and neonatal birth weight were significantly related to high chances of success of vaginal birth after previous cesarean section. Maternal complications were more common in study group, but the fetal outcomes were similar.     

Ideas to make the TVT progress

Because of the bladder injuries risk and subsequent increase of the intervention time due to the bladder integrity checking, many surgeons have abandoned TVT. Based on a demonstrative clinical case, we report a simple, fast and effective method meant to minimize the risk of bladder injuries and to wonder about the mandatory bladder checking by cystoscopy during the TVT sling installation. An infiltration of 1% Xyloca?ne half diluted is carried out in the area laterally to the urethra and the bladder, through vaginal and pubic ways. A 360 ml blue of methylene solution bladder filling may show quickly and safely a bladder injuries occurrence, either a true transfixion or an under mucous route. Using this procedure, TVT technique could be no more dangerous or longer than the TOT technique.     

Laparoscopic excision of rudimentary horn pregnancy in a patient with previous caesarean section

A rudimentary uterine horn is extremely rare and often difficult to diagnose. The frequency of this pathology is approximately 1:100,000. The diagnosis is sometimes elusive even at surgery. We present a case report of pregnancy in a rudimentary horn in the patient with one caesarean and one normal vaginal delivery, and we successfully conduct a removal of the rudimentary horn pregnancy laparoscopically.     

既往分娩史对剖宫产后阴道试产结局的影响

目的:探讨既往分娩史对剖宫产后阴道试产(TOLAC)患者成功率的影响。方法:回顾性分析2013年7月至2016年3月尝试TOLAC的瘢痕子宫孕妇的资料(妊娠≥28周),共506例,其中阴道分娩成功414例(TOLAC成功组),中转剖宫产92例(TOLAC中转剖宫产组)。比较两组前次剖宫产时间、剖宫产指征、阴道分娩史、新生儿存活情况等。结果:TOLAC中转剖宫产组的孕前体质量指数(BMI)及新生儿出生体质量大于TOLAC成功组(P0.05),两组平均妊娠间隔时间比较差异无统计学意义(P0.05),两组在妊娠间隔1年、1~2年、2~3年、3年的比例分别比较,差异无统计学意义(P0.05)。两组的前次剖宫产指征分别比较,差异均无统计学意义(P0.05)。TOLAC成功组有阴道分娩史患者比例明显高于TOLAC中转剖宫产组(P0.05),新生儿未存活的比较差异无统计学意义(P0.05)。结论:既往有阴道分娩史是TOLAC成功的有利因素,而既往分娩史的其他因素对TOLAC的成功率影响较小。     

Bladder erosion few years after TVT procedure

The surgical treatment of the stress urinary incontinence mainly use tension free vaginal tape done through the Retzius space: a case of bladder erosion occurring 5 years after a TVT^® (Gynecare-Ethicon, USA) procedure is reported. First clinical signs occur 2 years after the operation and the removal of the tape (included in the muscle of the bladder) by vaginal and sus-pubic route was necessary 5 years later because the quality of life was dramatically altered. This complication could be related to the patient (past hysterectomy, history of fibrosis surrounding a mammary implant, Gougerot-Sjögren disease) or to the surgeon with a technical defect during the TVT procedure. The late complications of TVT procedure should be recorded in a national register.