Endometrial balloon ablation under local analgesia and intravenous sedation

We report a series of women (n = 16) with menorrhagia undergoing endometrial balloon ablation under local analgesia with light sedation. Ten women had significant, coexistent medical problems. The median duration of the procedure was 8.6 minutes (range 8.47-9.5 minutes). Postoperative assessment included pain scores assessed by linear analogue scale; requirement for opiate analgesia; length of postoperative stay and patient satisfaction with the procedure. The minimum postoperative follow-up was 6 months. The procedure was well-tolerated and in 80% of cases either no postoperative analgesia or simple analgesia only was required. Two women were admitted overnight, 1 for social reasons and the other for pain control. Three women ages 44, 54 and 55 years were amenorrhoeic at 6 months; 8 women were still menstruating but satisfied with the outcome and 5 women are seeking further treatment for menorrhagia. While the longer-term efficacy of the procedure remains to be established these results indicate that endometrial balloon ablation under local analgesia and light sedation, a simple and acceptable technique, may be a suitable alternative to more difficult procedures such as rollerball ablation. This is most likely to be the case in appropriately selected women who are willing to accept a reduction in menstrual flow rather than amenorrhoea as the treatment outcome. The main disadvantage of balloon ablation is the cost of the disposable balloons and the need for a dedicated electrosurgical unit.     

Experience with the Groshong long-term central venous catheter

A study of the Groshong catheter in a gynecologic oncology population is presented, describing the catheter's ease of insertion, and patient acceptance and compliance in catheter care. From December 1985 through November 1987, 72 Groshong catheters were inserted in 67 patients. The Groshong differs from conventional Hickman-type catheters in design and maintenance. Thirty-two of 72 catheters (44%) were inserted under local anesthesia. The remaining catheters were inserted under general anesthesia at the time of major gynecologic procedures. None of the cases required fluoroscopy. The insertion technique is less traumatic than conventional approaches because of a stainless steel tunneling device. The median duration of use was 191 days. There were no cases of pneumothorax or catheter occlusion. Catheter removal was required in four cases with skin infection unresponsive to local therapy and in two cases with bacteremia. One patient developed thrombosis of the right subclavian vein but was treated without catheter removal. One patient with a skin infection at the exit site accidentally dislodged her catheter. The overall complication rate was 11% (8 of 72 cases).     

Pain relief in labour using transcutaneous electrical nerve stimulation (TENS). A TENS/TENS placebo controlled study in two parity groups

The analgesic effects of transcutaneous electrical nerve stimulation (TENS) in labour and effects on outcome were investigated in a double-blind TENS/TENS placebo controlled trial in 100 primigravidae and 50 women in their third labour. There were no differences between the TENS and the TENS placebo users in terms of pain concept or relief, and only 12 and 13% of primigravidae and 48 and 39% of the para 2 women completed labour without requiring other analgesia in their respective groups. The primigravidae who used either TENS or TENS placebo alone had shorter labours than those who required further analgesia. Although the outcome of labour for mother and infant were similar in the two groups, there was a higher operative delivery rate in women who also had epidural analgesia. There were highly significant differences between the TENS and the TENS placebo users in terms of favourable and unfavourable comments by the mothers and the midwives at 1 and 24 h after delivery. The evident consumer satisfaction for TENS suggests TENS has a part to play in analgesia in labour but the equivocal findings in terms of factors associated with pain relief points to the need for apparatus more specifically designed to cope with the special characteristics of the pain of labour.     

Radical hysterectomy and pelvic lymphadenectomy for stage IB carcinoma of the cervix: 21 years experience

From September 1971 through December 1982, 153 patients with Stage IB carcinoma of the cervix underwent radical hysterectomy and pelvic lymphadenectomy at two of the teaching hospitals of the Uniformed Services University of the Health Sciences. Records were retrospectively analyzed and independent pathologic review was performed. All surgical procedures were performed by fellows or senior residents under the direct supervision of the gynecologic oncology staff of the Walter Reed Army Medical Center or the Naval Hospital, Bethesda, Maryland. In this series, IB carcinoma was defined as squamous carcinoma clinically confined to the cervix with invasion greater than 5 mm from the basement membrane or any adenocarcinoma confined to the cervix. The average age of the patients was 38.3 years. The histologic types were squamous in 72%, adenocarcinoma in 16%, and adenosquamous in 10.5%. The mean operating time was 5 hr and 40 min with an average blood loss of 1800 cc. There were two ureterovaginal and two vesicovaginal fistulae for an overall fistula rate of 2.6%. Actuarial survival for these 153 patients is 84%. This extends the previous series of R. C. Park, W. E. Patow, R. E. Rogers, and E. A. Zimmerman, Obstet. Gynecol. 41, 117-122 (1973) of 122 cases collected from 1961 to September 1971 to 275 cases. In comparing the two time periods, no significant differences were found in operative technique or complications, but there was a change in the incidence of adenocarcinoma and mixed cell types and a difference in survival. A relatively higher incidence of more aggressive tumors may indicate the need for different therapeutic approaches in the future.     

芬太尼用于腰硬联合阻滞分娩镇痛最佳剂量的临床研究

目的:比较不同剂量芬太尼用于腰硬联合阻滞分娩镇痛的效果及安全性。方法:随机将120例产妇等分为6组:芬太尼2.5μg(A组)、芬太尼5μg(B组)、芬太尼10μg(C组)、芬太尼15μg(D组)、芬太尼20μg(E组)、芬太尼25μg(F组),各组均复合罗哌卡因3mg。记录蛛网膜下腔镇痛起效及维持时间,注药前及注药后5、10、30、60min、宫口开至10cm和分娩时、分娩后24h的VAS评分,记录产妇的MBS评分、Ramesay评分、新生儿Apgar评分及镇痛对呼吸、循环、产程、分娩方式的影响等。结果:A、B组起效慢、维持时间短;D、E、F组起效快、维持时间长,与A、B组比较有统计学差异。6组注药后5、10、30、60min时,宫口开全时、分娩时及分娩后24h与注药前的VAS评分差异有统计学意义;D、E、F组蛛网膜下腔阻滞镇痛完善,C组欠佳,A、B组差,组间比较有统计学差异。6组产妇运动阻滞轻,各时相SpO2及各时相MAP、HR、RR均在正常范围,剖宫产、器械助产及不良反应例数少。A、B、C组在5、10、30min时镇静评分低,D、E、F组在30、60min时镇静评分较高。各组新生儿Apgar评分1min均在8分以上,5min均为10分。结论:芬太尼复合罗哌卡因腰硬联合阻滞分娩镇痛安全、有效。国人蛛网膜下腔分娩镇痛时芬太尼最佳剂量为15μg。     

Evaluation of sperm immobilizing and sperm agglutinating seric activity in male subjects with or without positive IgG M.A.R.-test belonging to sub-fertile couples with negative or doubtful P.C.T

In this study we have compared the results of autoagglutination, IgM M.A.R.-test, seric S.I.T. and seric T.A.T. in 75 men with normal seminal parameters belonging to sub-fertile couples in whom the only evident anomaly was the presence of negative or doubtful P.C.T. We compared a tight correlation between IgG M.A.R.-test and autoagglutination (IgG M.A.R.-test clinically positive in 82.8% of subjects with positive spermagglutination); between seric S.I.T. and IgG M.A.R.-test (S.I.T. positive in 58.3% of subjects with IgG M.A.R.-test clinically positive); between seric T.A.T. and IgM M.A.R.-test (T.A.T. positive in 69.4% of subjects with positive IgG M.A.R.-test). Such results proved the reliability of IgG M.A.R.-test as a screening test in the determination of male autoimmunization. Moreover, the possibility that they were the cases in which only the local antisperm activity was shown, underlines the necessity not to limit immunological research to only seric antibody titrations. The analyses of the types of mixed agglutination present in cases of positive IgG M.A.R.-test make us suspect that a quota of the agglutination type emh was due to the impossibility with such type of test to specify adequately the zones of G.R. sperm interaction involved in the formation of mixed agglutinates.     

Pain relief in labour using transcutaneous electrical nerve stimulation (TENS). A TENS/TENS placebo controlled study in two parity groups

Summary. The analgesic effects of transcutaneous electrical nerve stimulation (TENS) in labour and effects on outcome were investigated in a double-blind TENS/TENS placebo controlled trial in 100 primigravidae and 50 women in their third labour. There were no differences between the TENS and the TENS placebo users in terms of pain concept or relief, and only 12 and 13% of primigravidae and 48 and 39% of the para 2 women completed labour without requiring other analgesia in their respective groups. The primigravidae who used either TENS or TENS placebo alone had shorter labours than those who required further analgesia. Although the outcome of labour for mother and infant were similar in the two groups, there was a higher operative delivery rate in women who also had epidural analgesia. There were highly significant differences between the TENS and the TENS placebo users in terms of favourable and unfavourable comments by the mothers and the midwives at 1 and 24 h after delivery. The evident consumer satisfaction for TENS suggests TENS has a part to play in analgesia in labour but the equivocal findings in terms of factors associated with pain relief points to the need for apparatus more specifically designed to cope with the special characteristics of the pain of labour.     

Pain relief in labour using transcutaneous electrical nerve stimulation (TENS). A TENS/TENS placebo controlled study in two parity groups

Summary. The analgesic effects of transcutaneous electrical nerve stimulation (TENS) in labour and effects on outcome were investigated in a double-blind TENS/TENS placebo controlled trial in 100 primigravidae and 50 women in their third labour. There were no differences between the TENS and the TENS placebo users in terms of pain concept or relief, and only 12 and 13% of primigravidae and 48 and 39% of the para 2 women completed labour without requiring other analgesia in their respective groups. The primigravidae who used either TENS or TENS placebo alone had shorter labours than those who required further analgesia. Although the outcome of labour for mother and infant were similar in the two groups, there was a higher operative delivery rate in women who also had epidural analgesia. There were highly significant differences between the TENS and the TENS placebo users in terms of favourable and unfavourable comments by the mothers and the midwives at 1 and 24 h after delivery. The evident consumer satisfaction for TENS suggests TENS has a part to play in analgesia in labour but the equivocal findings in terms of factors associated with pain relief points to the need for apparatus more specifically designed to cope with the special characteristics of the pain of labour.     

Spring clip tubal occlusion: a report of the first 400 cases.

Between September 1972 and March 1974, laparoscopic tubal sterilization was performed on 394 patients with the use of a spring-loaded plastic clip under local analgesia and on an outpatient basis. Intravenous fentanyl and infra-umbilical infiltration and tubal spray with 1% lidocaine were found to be very acceptable and effective forms of analgesia. The average time spent by a patient in the hospital was 4 hours, 26 minutes. There was no major immediate complications apart from vasovagal reactions in 34 patients. Up to June 30, 1974, six patients in the series had become pregnant, not as a failure of the clip per se, but as a result of improper application of the clips. This seems to be a safe, simple, and effective method of female sterilization with great potentials of reversibility.     

Combined spinal–epidural analgesia for labor pain: best timing of epidural infusion following spinal dose

Objectives  The combined spinal–epidural analgesia (CSEA) technique for labor pain has attained wide spread popularity in obstetric anesthesia. The onset of analgesia is rapid and reliable, and maternal satisfaction is very high. However, the best timing of an epidural infusion following the spinal dose and its effect on the total local anesthetics consumption has not been well determined. Methods  A total of 144 consenting healthy nulliparous parturients whose labor was induced and who labored under regional analgesia were enrolled in this study. Following induction of the CSEA with intrathecal injection of bupivacaine, 2.5 mg and fentanyl, 25 μg, the patients were randomized into one of four groups to receive a subsequent continuous epidural infusion [E (3), E (30), E (60) and E (90)], depending on the timing of the initiation of epidural infusion of 0.1% ropivacaine, 0.0002% fentanyl and 1:500,000 epinephrine at the rate of 10 ml/h. In study Groups E (3), E (30), E (60) and E (90), epidural infusion was initiated 3, 30, 60 and 90 min, respectively following spinal induction dose. Patients requesting additional labor analgesia were given an epidural bolus (8 ml) of ropivacaine, 0.2%. The number of parturients requesting additional boluses of ropivacaine and the total dose of ropivacaine required for labor analgesia were registered. Results  The numbers of patients who required additional boluses of ropivacaine in Group E (3) and Group E (30) were significantly less than those in Group E (60) and Group E (90). The total dose of ropivacaine required for labor pain in Group E (3) and Group E (30) was insignificantly smaller than the total dose required in Group E (60) and Group E (90). Conclusion  Our results suggest that the best timing of epidural infusion following spinal dose was within 30 min of spinal induction dose. Presented in a part at the Annual Meeting of the American Society of Anesthesiologists (ASA) in Las Vegas, NV, USA, October 2004.     

Should outpatient hysteroscopy replace conventional diagnostic dilatation and curettage in gynecologic practice?

Three hundred fifty patients attending gynecology outpatient clinics between 1984 and 1989 warranting a diagnostic D & C were offered instead a diagnostic hysteroscopy under local anesthesia (with or without intravenous Midazalom) or under general anesthesia. Subjective assessment of complications was performed by direct questioning of the patient during the procedure when the hysteroscopy was done under local anesthesia and by asking the patient to complete a questionnaire in the first 48 h after the operation. Objective assessment was performed by monitoring the pulse and blood pressure before and during the procedure and for an hour postoperatively. Subjective assessment of complications was significantly more in patients who had the hysteroscopic examination under general anesthesia (pain p less than 0.0001, nausea and/or vomiting p less than 0.0001, headache p < 0.0001, and general malaise p < 0.0001). There was no difference in objective measures of complications in the two groups. Patient acceptability was significantly higher for hysteroscopic examination under local anesthesia (p less than 0.0001). Diagnostic hysteroscopy under local anesthesia is a reliable and uncomplicated procedure. Patient acceptability is excellent. Hence, this examination can be performed in gynecologic outpatient clinics under local anesthesia.     

The Use of Large Loop Excision of the Transformation Zone in Management Problems of Cervical Intraepithelial Neoplasia

Summary: We studied 2 groups of women whose management is controversial: those with cervical intraepithelial neoplasia (CIN) grade 2 or 3 on smear, but only CIN grade 1 or no abnormality on target biopsy (Group 1), and those with persistent CIN grade 1 on smear and up to CIN 1 on biopsy (Group 2). We set out to assess whether large loop excision of the transformation zone (LLETZ) was an acceptable method of treating these 2 groups of women. A review of 100 consecutive patients was undertaken. There were 71 women in Group 1 and 29 women in Group 2. The LLETZ procedures were performed under local analgesia and no immediate problems were encountered. Delayed haemorrhage requiring vaginal packing and admission to hospital occurred in 1 patient. In Group 1, histopathology of the LLETZ biopsies showed CIN 2 or 3 in 29 (40.8%) of the women, CIN 1 in 24 (33.8%) and no CIN in 18 (25.3%), and in Group 2, CIN 2 or 3 was seen in 5 (17.2%) of the women, CIN 1 in 11 (37.9%) and no CIN in 13 (44.8%). At 12 months completed follow-up, 4 patients in Group 1 had recurrent CIN 1 or equivocal CIN 1 and 1 patient from Group 2 had recurrent CIN 1, giving an overall recurrence rate of 5 of the 94 patients who completed follow-up (5%). We concluded that LLETZ was a useful procedure in both groups. In Group 1 the provision of a histological diagnosis on the LLETZ biopsy was a check on the accuracy of the cervical smear report. In Group 2, LLETZ offered the advantage of rapidly returning the smear to normal in most patients, and the diagnosis and treatment of those women who actually had a high-grade lesion.     

A case-control study of methylenetetrahydrofolate reductase polymorphisms in cervical carcinogenesis

OBJECTIVES: Polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene are thought to be associated with a varying risk of cervical dysplasia. The purpose of this trial was to study the role of the two common functional MHTFR polymorphisms in a large multiracial population at risk for cervical dysplasia and cancer. METHODS: This is a nested case-control study of 376 subjects obtained from cohorts enrolled in an ongoing prospective cervical carcinogenesis protocol. Cases included invasive cancers (n = 51), and high (n = 50) and low (n = 50) grade dysplasia. There were 225 normal controls. Functional MTHFR 677C-->T and 1298A-->C genotypes were identified. Follow-up cytology data were reviewed for the control subjects from the time of study entry until August 2004. RESULTS: There is a significant racial difference in allele frequency of the 677C-->T polymorphism (P < 0.005). African-American women had an extremely low prevalence of the 677T allele (8%). There was no significant difference in the frequency of the 677T allele between cases and controls. There is no racial difference in allele frequency of the 1298A-->C polymorphism. Also, no significant difference was found between cases and controls. Of the 51 cancers, no case was homozygous for both aberrant polymorphisms (677T, 1298C), and only 3 cases were heterozygous for both. Follow-up data were available for 129 of 225 control subjects (57%). Only 15 (12%) have had a subsequent abnormal pap, and there was no association with the 677C-->T polymorphism. CONCLUSIONS: We confirm a significant difference in the 677T allele frequencies among racial groups. However, there is no association of either the 677C-->T or 1298A-->C polymorphisms in cervical carcinogenesis. There is no role of the combined polymorphism effect in cervical cancer or evidence of prediction for future Pap abnormalities.     

Simplified postoperative patient-controlled analgesia on a gynecologic oncology service

Twenty-nine women who underwent various abdominal operations for gynecologic malignancies self-administered postoperative analgesia by means of disposable Travenol Infusors with Patient Control Modules. Administration of morphine sulfate at a rate of 1 mg per injection and a maximum of 10 mg per hour via patient-controlled analgesia was judged satisfactory by all 29 patients. The mean dose rate administered ranged from 1.2 to 1.5 mg per hour per day during the first 3 days postoperatively. No respiratory depression occurred and excessive sedation was reported by only 2 patients after the first 24 hr postoperatively. If further surgeries were required, more than 90% of these patients would prefer patient-controlled analgesia to intramuscular injections.     

Patient-controlled epidural analgesia during labor

This study compared the safety, efficacy, local anesthetic usage, patient satisfaction, and anesthesia manpower demands of patient-controlled epidural analgesia and continuous epidural infusion during labor. After establishment of epidural analgesia, 88 parturients with vertex presentation were assigned randomly to receive either patient-controlled epidural analgesia or continuous epidural infusion, using 0.125% bupivacaine containing 1 microgram/mL of fentanyl. Inadequate analgesia was treated in both groups with a 10-mL "top-up" of 0.25% bupivacaine. Patients receiving patient-controlled epidural analgesia required significantly fewer supplemental top-up doses (36 versus 71%; P less than .05) and insignificantly less local anesthetic (13.6 +/- 0.6 versus 14.6 +/- 0.5 mL/hour; P = .10). The two groups did not differ in incidence of hypotension, high sensory blockade (above T8), mode of delivery, or patient satisfaction assessed by questionnaire. Use of local anesthetic solution was examined with respect to cervical dilatation and did not increase late in labor. Patients generally viewed infusion technology favorably. These findings suggest that patient-controlled epidural analgesia is safe and effective, reduces anesthesia manpower needs, and is well accepted.     

The assessment of the safety of vacuum extraction deliveries under routine epidural block

To assess the safety of vacuum extraction (V.E.) deliveries under continuous lumbar epidural block (E.B.) with Bupivacain, the modified Krebs score in CTG, Apgar score, cord arterial blood acid-base balance, hypoxanthine, CPK, CPK-BB, Neuron specific enolase and c-AMP were examined. A total of 74 full term oxytocin-induced labors were divided into three groups: A) 21 cases by V.E. under E.B., B) 34 cases under E.B. only, and C) 19 cases without V.E. or E.B. There was no difference in age, gestational weeks in the three groups. However, the incidence of primiparas was highest in group A. Though CTG showed a temporary low Krebs score in group A within 30 minutes after the initiation of E.B., it was found that there was no significant difference between the three groups 30 minutes before parturition. The apgar score, cord arterial blood pH, PO2 and B.E. were also found to be similar in all three groups. Among various kinds of substances in the cord blood, both CPK-BB and c-AMP showed a striking rise in group A, compared to groups B and C. Therefore, the use of V.E. under E.B. might be hazardous to the well-being of the newborn infant.     

The aetiology and outcome of abruptio placentae.

A series of 193 cases of abruptio placentae in a hospital population of 35,217 is described. This is an incidence of 0.55%. In the series both age and parity, but not pre-eclampsia or anaemia, are significant associated factors. The recurrence rate of abruptio placentae was 5.6%. There were no maternal deaths and the perinatal mortality was 35%. Epidural analgesia does not abolish the pain of the abruptio placentae in spite of abolishing the pain of labour.     

Laparoscopic surgical treatment of tubal pregnancy. A safe, effective alternative to laparotomy.

This study analyzed the intraoperative morbidity, postoperative course, postoperative hospital stay and fertility outcome in 216 consecutive tubal pregnancies treated with either laparoscopy (n = 98) or laparotomy (n = 118). Among the 98 cases treated with laparoscopy, the procedure was successfully completed in 95 (97%). In three cases laparotomy had to be performed to conclude the procedure. Retained trophoblast was observed in 3.8% of cases treated conservatively with laparoscopy and 1.3% of cases treated conservatively with laparotomy (P greater than .05). The total anesthesia time, amount of postoperative analgesia required and postoperative hospital stay were significantly less in cases treated with laparoscopy (P less than .001). The subsequent fertility outcome was similar in both groups. Laparoscopic treatment of tubal pregnancy is a safe and effective alternative to laparotomy, yielding similar fertility outcomes and requiring significantly less postoperative analgesia and a significantly shorter hospital stay.     

Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment

Objective: To evaluate medical treatment of interstitial pregnancy. Methods: This series was a retrospective study of medical treatment of interstitial pregnancies which was managed in two French Departments of Obstetrics and Gynecology (Bichat public Hospital, Paris and A. Béclère public Hospital, Clamart, France). Fifteen patients with clear evidence of an unruptured interstitial pregnancy were treated by injection of methotrexate (MTX) or potassium chloride (KCL) without surgery since January 1988. The diagnosis was established either by sonography and laparoscopic confirmation in eight cases or by only transvaginal ultrasound in seven cases. Three out of 15 cases in this series, had a heterotopic pregnancy who were treated by transvaginal ultrasound-guided injection of KCL. Others received systemic MTX injection in four cases, and local MTX injection in eight cases under either laparoscopy or transvaginal ultrasound guidance. Four different protocols of MTX (Ledertrexate^R) administration was performed in this series with time: at the beginning of our experience, MTX1 protocol, 15 mg i.m. daily for 5 days was used; and after MTX2 protocol, 1 mg/kg body weight i.m. daily for 4 days; MTX3 protocol, 1 mg/kg body weight intratubal associated with 1 mg/kg body weight i.m. daily for 3 days; and now MTX4 protocol, only intratubal 1 mg/kg body weight is especially used. The success was defined as declining serum human chorionic gonadotropin (hCG) to undetectable levels, and no further surgical management was required. Outcome of subsequent fertility was also evaluated. Results: Complete resolution was obtained in 13 (86.6%) out of 15 interstitial pregnancies. Two out of 15 patients, with medical treatment's failure required secondary surgery. No severe side effects of medical treatment were observed. Follow-up hysterosalpingography was performed in 12 patients showing 91.7% tubal patency on the side of interstitial pregnancy. Outcome of intra-uterine pregnancy of the three patients who had heterotopic gestation, was two miscarriages and one delivery at term. Out of the other 12 patients in this series, nine became pregnant within 1 year: eight pregnancies at term, and one induced abortion. At present, among the last three patients, two have no desire to conceive. Conclusion: Our results suggest that unruptured interstitial pregnancies now can be managed with local MTX administration of 1 mg/kg body weight under transvaginal ultrasound or under laparoscopy procedure. This approach is particularly attractive in these patients, where the only alternative to therapy is laparotomy with cornual resection.