Infracoccygeal sacropexy or sacrospinous suspension for uterine or vaginal vault prolapse.

OBJECTIVE: To compare infracoccygeal sacropexy (IS) and sacrospinous suspension (SS) for the treatment of uterine or vault prolapse. METHODS: A randomized trial of 49 women assigned to either the IS group using IVS tape (n=24) or SS group (n=25). Concomitant hysterectomy and repairs were performed as appropriate. Evaluations included prolapse staging using the POP-Q system and validated questionnaires for symptoms (PFDI), quality of life (PFIQ), and sexuality (PISQ-12). The primary outcome measure was postoperative pain. RESULTS: Patients' characteristics were similar in both groups. IS was quicker, easier, and less painful than SS (P<0.01). Hemorrhage or hematoma rates were similar. Neither rectal injury nor vaginal erosion occurred. Mean follow-up was 16.8 months. Prolapse cure rates, symptom scores, and quality of life were similar. Postoperative cystocele occurred in 4.8% of women after IS and 25% after SS (P>0.05). CONCLUSION: Infracoccygeal sacropexy is equivalent to sacrospinous suspension, with a decreased rate of postoperative pain and cystocele recurrence.     

血清绒毛膜促性腺激素值联合阴道流血时间对选择输卵管妊娠治疗方案的意义

目的探讨血清绒毛膜促性腺激素β亚基(β-HCG)值联合阴道流血时间对选择输卵管妊娠治疗方案的临床意义。方法选择我院2005年1月1日—12月31日诊断为异位妊娠的住院患者181例,根据血清β-HCG水平,分为≥128、43～127、<43 nmol/L 3组,根据阴道流血时间分为≤7 d和>7 d,最终进行输卵管妊娠治疗结果的比较。结果血清β-HCG≥128 nmol/L组中,无论阴道流血时间长短,50例(94.3%)行手术治疗,3例(5.7%)予药物保守治疗成功。血清β-HCG 43～127 nmol/L组中,27例(75.0%)行手术治疗;9例(25.0%)予药物保守治疗或期待治疗成功,而且阴道流血时间均>7 d。血清β-HCG<43 nmol/L组中,32例(34.8%)行手术治疗,60例(65.2%)予药物保守治疗或期待治疗成功,阴道流血时间>7 d 57例。结论血清β-HCG≥43 nmol/L且阴道流血时间≤7 d时,应尽量避免选择药物保守治疗;血清β-HCG 43～128 nmol/L且阴道流血时间>7 d,或β-HCG<43 nmol/L,可选择药物保守治疗或期待治疗。     

腹腔镜辅助阴式子宫切除术38例

目的分析和评价腹腔镜辅助阴式子宫切除术（LAVH）的临床价值。方法回顾性分析2004年4月～2006年4月在该院妇科施行LAVH的38病例资料。结果38例均顺利完成手术,无中转开腹。平均手术时间为（90.8±13.1）min,平均术中出血量（80.6±16.4）ml。平均术后住院天数（5.3±0.8）d。38例术后平均随访（4±2）月,阴道残端愈合良好,无并发症。结论LAVH具有安全、微创、患者出血少、术后病率低、康复快等优点。术者具有熟练腹腔镜,阴式手术操作经验,腹腔镜辅助阴式子宫切除术是安全可行的。     

剖宫产与阴道分娩的临床探讨

目的探讨近年来剖宫产率上升的原因、剖宫产指征的变化以及不同分娩方式对母儿的影响,寻找降低剖宫产率的有效措施。方法回顾性分析828例产妇（阴道分娩371例,剖宫产457例）,剖宫产率的变化、相关因素及不同分娩方式与产后出血、产褥感染、新生儿窒息等的关系。结果在剖宫产指征中社会因素占首位,其次为胎儿窘迫、巨大儿、难产等。剖宫产组产后出血的发生率高于阴道分娩组,差异有显著性（P〈0.01）。产褥感染率及新生儿窒息率剖宫产组亦高于阴道分娩组（P〈0.01）。结论剖宫产率明显增加,其并发症明显高于阴道分娩,应降低剖宫产率。     

产妇分娩方式选择及其影响因素研究

[目的]探讨影响产妇分娩选择方式的相关因素及其相关程度。[方法]采用“产妇分娩方式的选择及其影响因素问卷”,对213名产妇进行调查,并对产妇选择顺产或剖宫产及主观、客观因素进行分析。[结果]观察人群总剖宫产率为81.2%。除符合剖宫产手术指征外,社会因素已成为影响剖宫产率上升的主要原因之一。[结论]来自孕妇及医生的主观意愿影响着分娩方式的合理选择,剖宫产的手术指征已远远超过单纯医学指征的范围,并导致剖宫产率的大幅度上升。因此降低剖宫产率应首先降低社会因素剖宫产,这也是当前需要解决的一大难题。     

含部分肌肉的纵行腹直肌肌皮瓣阴道形成术

Objective To evaluate the method for vaginal treconstruction with muscle sparing verti-cle rectus abdominis myocutaneous flap(MS-VRAM flap). Methods From September 2006 to April 2008, MS-VRAM flaps were used for vaginal reconstruction in 9 patients (20 to 35 years old), ancl all ca-ses were congenital absence of vagina. Before operation, the inferior epigastrie arteries were detected by the Doppler and the flaps based on the perforators ranged from 6 cm×20 cm. MS-VRAM flaps were ele-vated and then transferred to reconstruct the vagina. Results All 9 cases of MS-VRAM flaps survived completely. No complications occurred at donor site of abdominal wall. With 2-12 months' follow-up, the patients were satisfied with the results. Conclusion Despite technical difficulties in elevating the MS-VRAM flap, the flap is a good choice for vaginal reconstruction.     

Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?

OBJECTIVE: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.     

Low risk of ureteral obstruction with "deep" (dorsal/posterior) uterosacral ligament suture placement for transvaginal apical suspension

OBJECTIVE: Transvaginal uterosacral ligament fixation (USLF), often called "high" USLF, is associated with a 1.0% to 10.9% ureteral obstruction rate. Anatomic relations and pelvic rotation with positioning imply "high" (cephalad) suture placement may bring sutures closer to the ureter. We examined the ureteral obstruction rate with a "deep" (dorsal/posterior) uterosacral ligament suture placement modification of a standard USLF procedure. STUDY DESIGN: At the University of Massachusetts and Tufts, 411 consecutive patients underwent Mayo culdoplasty utilizing > or = 3 uterosacral sutures placed "deep" bilaterally. Intraoperative cystoscopy was performed. RESULTS: One patient (0.24% [.01%-1.35%]) had ureteral obstruction attributable to USLF. Two had obstruction secondary to concomitant procedures. Compared with previous published series, the odds of ureteral injury secondary to USLF was 4.6 times lower (95% CI 2.31-9.24; P < .0001). CONCLUSION: Placement of USLF sutures "deep" (dorsal/posterior) increases the margin of safety for the ureter and, in this study, decreased the ureteral injury rate nearly 5-fold.     

Do alterations in vaginal dimensions after reconstructive pelvic surgeries affect the risk for dyspareunia?

OBJECTIVE: The purpose of this study was to determine whether changes in vaginal dimensions after transvaginal reconstructive pelvic surgeries affect the risk for postoperative dyspareunia. STUDY DESIGN: Charts of all sexually active patients who underwent transvaginal reconstructive pelvic surgeries in our institution between July 1998 and June 2002 with 1 year of follow-up evaluations were reviewed. Data were analyzed with the Student t, chi2, Pearson's correlation tests and a logistic regression model. RESULTS: Two hundred twenty-eight women aged 44 to 83 years were included. Dyspareunia increased after operation (16% vs 7%; P = .001); total vaginal length (7.6 vs 8.8 cm; P = .001) and genital hiatus (2.7 vs 3.5 cm; P = .001) dimensions significantly decreased after operation, with no predilection for any specific procedure. No correlation was found between these changes in vaginal dimensions and the risk for dyspareunia. CONCLUSION: The prevalence of dyspareunia increases after transvaginal reconstructive pelvic surgeries. Despite a postoperative decrease in vaginal dimensions, a causal relationship between dyspareunia and changes in vaginal dimensions may not exist.     

Decreased anal sphincter lacerations associated with restrictive episiotomy use

OBJECTIVE: To determine whether restrictive episiotomy use was associated with decreases in anal sphincter lacerations and the risk of anal sphincter laceration attributable to episiotomy. STUDY DESIGN: This was a retrospective database study. Rates of episiotomy, anal sphincter laceration (third- or fourth-degree tear), and other confounding variables were compared among vaginal deliveries before (1999) and after (2002) restrictive episiotomy use was implemented at our institution. Logistic regression was used to estimate the odds ratio of anal sphincter laceration that was due to episiotomy and other variables. RESULTS: The episiotomy rate decreased 56% (37% to 17%, P < .001) between 1999 and 2002, whereas the anal sphincter laceration rate decreased 44% (9.7% to 5.4%, P < .001). There were no changes in age, race, nulliparity, prolonged second stage of labor, operative vaginal deliveries, birth weight, or macrosomia, although oxytocin use and epidural use decreased slightly (37% to 31%, P < .001, and 80% to 76%, P = .02, respectively). The adjusted odds ratio of anal sphincter laceration attributable to episiotomy decreased 55%, from 6.5 (95% CI: 3.8, 11.1) to 2.9 (95% CI: 1.7, 5.0), between 1999 and 2002. Conversely, the adjusted odds ratios of anal sphincter laceration attributable to the other independent risk factors all increased or remained the same: operative vaginal delivery, which increased from 4.4 (95% CI: 2.7, 6.9) to 6.3 (95% CI: 3.6 11.1); nulliparity, from 2.9 (95% CI: 1.8, 4.8) to 2.9 (95% CI: 1.4, 5.9); macrosomia, from 1.9 (95% CI: 1.1, 3.4) to 2.6 (95% CI: 1.3, 5.4); and prolonged second stage, from 2.0 (95% CI: 1.3, 3.0) to 2.1 (95% CI: 1.2, 3.7). CONCLUSION: With restrictive episiotomy use, the episiotomy rate, anal sphincter laceration rate, and risk of anal sphincter laceration attributable to episiotomy were all reduced by approximately 50%.