Endometrial Resection -A Comparison of Techniques

Summary: To assess the long-term effectiveness and safety of endometrial resection, an ongoing prospective study of 927 patients, followed for 1 to 5 years, was carried out. The patients met criteria previously adopted, for vaginal hysterectomy. Three techniques were used, modified over time with experience gained and failures encountered: Technique 1: Resection alone; Technique 2: Resection, followed by roller-ball cautery of the whole endometrium; Technique 3: Laparoscopic control, resection, roller-ball cautery, further resection especially in the comua and fundus and finally laparoscopic cautery of the cornual region of the uterus. Various parameters were measured including preparation of the endometrium, pathology present, complications and outcomes. There was a marked improvement in the success of the procedure with changes from Technique I to 2 to 3. There was a fall in the failure rate from 22% to 5%. These results were statistically highly significant (p<0.0001). The best results obtained were in women with endometrial polyps and pure dysfunctional bleeding with good results in cases of intramural fibroids and adenomyosis. There were no deaths and no cases of long-term adverse sequelae resulting from complications, but the following were encountered: perforation of the uterus, hyponatraemia, pregnancy, infection, unanticipated malignancy and cervical stenosis. It is concluded that in view of the high success rate and relative lack of serious complications, endometrial ablation should be considered the treatment of choice in cases of dysfunctional bleeding in women who have completed their families.     

Pulsatile Ovarian Fossa Ectopic and the 'Morning After' Pill

EDITORIAL COMMENT: This case report was accepted for publication mainly to remind readers that withdrawal haemorrhage does not exclude pregnancy, in-trauterine or extrauterine, when 'morning after' pills are prescribed. These patients also require an appropriately-timed HCG assay, oestrogen and/or progesterone assay or ultrasonography. The pulsatile nature of this ectopic gestation, whether ovarian or primary peritoneal, is unusual. Conjecture on aetiology is unwarranted without knowledge of the time in the menstrual cycle that morning after pills were taken.     

Ovarian epithelial cancer and chemical carcinogenesis

Ovarian cancer is the most common fatal gynecological malignancy and is on the increase in industrialized countries. At this moment it is almost impossible to identify the high-risk patient. This cancer could be initiated by a chemical carcinogen via the vagina, uterus, and tubes and the substance promoting the cancer could be steroid-rich antral fluid from ruptured follicles. There is ample clinical evidence available for migration of chemical substances from the vagina to the peritoneal cavity and ovaries. By use of the radionuclide ^99mTc-HAM upward migration was also demonstrated. Many different chemical substances are regularly used in the vulvo-vaginal areas and some of these could be implicated in carcinogenesis.     

Comparison of two amoxicillin/clavulanic acid-resistant profiles employing two types of assay disks: A pilot study in 50 isolates from a tertiary care hospital in India

Background: During a period from January to March 2005, there was a sudden 3.85-fold increase in isolates with in vitro resistance to amoxicillin/clavulanic acid at Sant Parmanand Hospital, a private tertiary care hospital in Delhi, India, without an increase in treatment failures.Objective: This pilot study was designed to assess whether 2 different brands (one exclusively used during the last quarter of 2004, one exclusively used during the first quarter of 2005) of antibiotic disks used at the hospital were related to the reported change in resistance pattern.Methods: During April 2005, 50 consecutive hospital isolates, 45 gram negative and 5 gram positive, were tested in parallel, employing 2 brands of amoxicillin/clavulanic acid disks: HiMedia disks (HiMedia Laboratories, Mumbai, India) and BBL^TM Sensi-Disc^TM Antimicrobial Susceptibility Test Discs (BD Diagnostic Systems, Sparks, Maryland).Results: Of 50 consecutive hospital isolates tested with the HiMedia disks, 40 were resistant and 10 were susceptible. Of those tested with the BBL disks, 10 were resistant and 40 were susceptible. The susceptibility profiles observed were significantly different (P<0.001).Conclusion: In this study, significantly different susceptibility results were found when 2 different brands of antibiotic disks were used to test the amoxicillin/clavulanic susceptibility of 50 consecutive isolates in this private hospital in India.     

Is the Vacuum Extractor Really the Instrument of First Choice?

This study was a retrospective analysis of the pattern of usage of both the forceps and vacuum extractor as well as the neonatal outcome on all the instrumental deliveries conducted in 1995 at the Kandang Kerbau Hospital, Singapore. There were a total of 927 forceps deliveries and 495 vacuum extractions but neonatal data was available for only 481 forceps and 255 vacuum extractor babies. (There were 2 neonatal units which accepted admissions on alternate days; all of the data were collected from 1 of the units only). Demographic data were comparable in most aspects except that vacuum deliveries were significantly associated with higher parity and shorter labours. There was a trend towards using the vacuum extractor in less difficult cases. Almost all the instrumental deliveries were conducted by specialists. Birth trauma was significantly more likely to occur with the vacuum extractor. Almost all the deliveries were conducted with similar expertise in both groups, yet the use of the vacuum extractor resulted in more birth trauma even in the presence of 'easier' cases. This may suggest an inherent risk in using the vacuum extractor.     

Vaginal Dinoprostone Versus Oral Misoprostol for Predilatation of the Cervix in First Trimester Surgical Abortion

Summary: Prostaglandins are effective in predilatation of the cervix prior to first trimester surgical termination of pregnancy under local analgesia. A randomized open comparative trial was devised to compare the effectiveness and acceptability of vaginal dinoprostone with oral misoprostol. Two groups were randomized to control for age, parity and ethnicity. The operation was easier and less painful in older, parous, and Polynesian women. Both methods were effective with respect to ease of dilatation. Both were acceptable and equal with respect to the level of pain experienced by the woman during the operation. Vaginal dinoprostone is more gradual in its action, but it is more expensive, has to be refrigerated and self-insertion may sometimes cause problems. Oral misoprostol is considerably cheaper and does not require refrigeration, but it was associated with more preoperative nausea, cramping and occasional heavy bleeding.