Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.     

Is PCOS an inflammatory process?

PRO--PCOS is associated with low-grade systemic inflammation as evidenced by elevation of multiple markers of inflammation such as C-reactive protein, interleukin-18, monocyte chemoattractant protein-1 and white blood cell count as well as endothelial dysfunction and increased oxidative stress. CON--Current studies examining the evidence for low grade inflammation in PCOS are small, heterogeneous for the diagnosis, confounded by degree of adiposity and do not consistently demonstrate a clinically relevant increase in the above mentioned biomarkers.     

Is preeclampsia an infectious disease?

BACKGROUND: Studies have suggested a strong paternal factor in the etiology of preeclampsia. If preeclampsia is caused by an infectious agent transmitted by the woman's partner, seronegative women who may experience primary infection in pregnancy should be at increased risk of preeclampsia as compared to previously infected women. The aim of this study was to assess the impact of being seronegative for some viruses transmitted by close contact on the risk of developing preeclampsia. METHODS: Nine hundred and seventy-eight women were randomly drawn from a basic study population of 35,940 pregnant women in Norway. A serum sample drawn at the first antenatal visit was analyzed for specific IgG antibodies against herpes simplex virus type-2, cytomegalovirus and Epstein-Barr virus. For comparison, antibody status against Toxoplasma gondii was also assessed. Information on preeclampsia in pregnancy was obtained through linkage to the Medical Birth Registry of Norway. RESULTS: Thirty-three (3%) women developed preeclampsia. The risk of developing preeclampsia seemed to be increased for women who were seronegative for the viruses studied. Seronegativity for Toxoplasma gondii did not show such a pattern. INTERPRETATION: Women who are seronegative for antibodies against viral agents transmitted through close contact seem more likely to develop preeclampsia. This finding indicates that women who are seronegative to such agents may acquire primary infection in pregnancy, and subsequently be at increased risk of preeclampsia. This hypothesis could represent a new approach to the causes of preeclampsia, and encourage search for yet unidentified microbes as a possible causal factor.     

Is pathology examination useful after early surgical abortion?

OBJECTIVE: To study if the pathologist's examination of surgical abortion tissue offers more information than immediate fresh tissue examination by the surgeon. Immediate examination of the fresh tissue aspirate after surgical abortion helps reduce the risk of failed abortion and other complications. Regulations in some states also require a pathologist to analyze abortion specimens at added cost to providers. We conducted this study to evaluate the incremental clinical benefit of pathology examination after surgical abortion at less than 6 weeks' gestation. METHODS: As part of a prospective case series of women who had early surgical abortions at the Planned Parenthood League of Massachusetts during a 32-month period, we collected data on clinical outcomes and the results of postoperative tissue examinations. Using outcomes verified by in-person follow-up as the "gold standard," we calculated the validity of the tissue examinations by the surgeons and the outside pathologists. RESULTS: A total of 676 women had documented outcomes and complete tissue examination data. The sensitivity (ability of the examiner to detect an outcome other than complete abortion) was 57% (95% confidence interval [CI] 35, 76) for the surgeons' tissue inspections and 22% (95% CI 8, 44) for the pathologists' examinations. The predictive value of a positive (abnormal) tissue screen was 14% (95% CI 8, 24) and 7% (95% CI 3, 17) for the surgeons and pathologists, respectively. CONCLUSION: Routine pathology examination of the tissue aspirate after early surgical abortion confers no incremental clinical benefit. Although the surgeons' tissue inspections predicted abnormal outcomes poorly, the pathologists did no better. Our results challenge the rationale for state regulations requiring pathologic analysis of all surgical abortion specimens.     

Is endometriosis an endometrial disease?

Endometriosis is characterised by the presence of abnormally located tissue resembling the endometrium with glands and stroma. Several hypotheses have attempted to explain the development of such tissue. The most often cited theory, that of implantation, proposes that the physiological phenomenon of endometrial reflux in the fallopian tubes during menstruation may, in certain conditions, overcome local defense mechanisms, implant, and proliferate. The implantation theory does not explain why endometriosis will develop only in approximately 10-15% of women, while the reflux of endometrial tissue via the fallopian tubes during menstruation is a quasi-universal phenomenon. The endometrium of women affected by endometriosis could be abnormal compared with endometrium of healthy women. The abnormal endometrium could be able to protect itself from harmful effects of immune cells by expressing specific antigens, by harbouring a different immune cell population and by synthetizing and secreting immunosuppressive factors. Several others characteristic features of endometrium have been described in women with endometriosis: (1) production of its own estrogens in too heavy amount; (2) aptitude for setting up on peritoneum; (3) tendencies to proliferate and to invade tissue; (4) aggressiveness for the peritoneum; (5) auto-protection from physiological apoptosis; (6) abnormal expression of heat shock proteins; and (7) excessive angiogenesis.     

Is a Chlamydia vaccine a reality?

Chlamydia trachomatis is a leading cause of sexually transmitted bacterial infections with severe sequelae such as tubal factor infertility and ectopic pregnancy; infections can also be asymptomatic. So far no vaccine has been developed but studies that may lead to the development of a highly warranted vaccine have been performed. The first attempt to vaccinate children with a whole-cell vaccine initially resulted in protection but the protection was short-lived. In animal models whole-cell vaccination resulted in hypersensitivity reactions, so that new strategies were devised. The first immunogenic molecule described was the major outer membrane protein (MOMP), and this molecule has therefore been studied in great detail as a candidate vaccine. Even though complete protection was not obtained, reduced shedding was observed and vaccine trials in animal models using naked DNA as a vaccine resulted in stimulation of both the humoral and cellular immune response, indicating progress in the development of a vaccine.     

Is the formation of a bladder flap at cesarean necessary? A randomized trial.

OBJECTIVE: To evaluate the effects of not forming a bladder flap at lower-segment cesarean delivery. METHODS: A total of 102 women who underwent cesarean delivery were prospectively randomized to one of two groups. In the study group (n = 53), a cesarean was performed without formation of a bladder flap. In the control group (n = 49), cesarean was performed with formation of a bladder flap before the uterine incision. RESULTS: There were differences of median skin incision-delivery interval (5 versus 7 minutes, P <.001), median total operating time (35 versus 40 minutes, P =.004), and median blood loss (Delta hemoglobin 0.5 versus 1 g/dL, P =.009) in favor of the study group. Postoperative microhematuria was reduced in the study group (21% versus 47%, P <.01). The median need for analgesics was reduced in the study group (75.0 mg diclofenac versus 150.0 mg, P <.001), and there was a lower percentage of patients receiving analgesics 2 or more days after cesarean in the study group (26.4% versus 55.1%, P =.006). There was no difference in bowel function. CONCLUSION: Omission of the bladder flap provides short-term advantages such as reduction of operating time and incision-delivery interval, reduced blood loss, and need for analgesics. Long-term effects remain to be evaluated.     

Is miscarriage a coagulopathy?

PURPOSE OF REVIEW: Pregnancy is a hypercoaguable state. The hypothesis has been developed that many cases of recurrent miscarriage and of later pregnancy complications are caused by a defective maternal haemostatic response leading to thrombosis of the uteroplacental vasculature and subsequent fetal loss. The evidence upon which this hypothesis is based is reviewed. RECENT FINDINGS: The majority of studies report an increased prevalence of genetic thrombophilic mutations in the female partner of couples with recurrent miscarriage. It is important to note, however, that this is not a uniform finding. A sub-group of women with recurrent miscarriage has been demonstrated to be in a prothrombotic state before pregnancy, and that women in such a state are at an increased risk of miscarriage in future untreated pregnancies. Furthermore, the long-term health implications of this hypercoaguability have been highlighted in a large retrospective study reporting an increased risk of ischaemic heart disease among women with a history of pregnancy loss. SUMMARY: Although recurrent miscarriage is a heterogeneous condition and no single abnormality will account for all cases of pregnancy loss, the relationship between abnormalities in the haemostatic pathways and pregnancy outcome is increasingly recognized. The challenges we face are how to discriminate between women with a thrombophilic defect who are destined to miscarry from those whose pregnancy will be successful, the pathology of pregnancy loss associated with thrombophilic defects, the role of the fetal genotype in determining pregnancy outcome, and the management of women with thrombophilic defects both during and beyond their reproductive years.     

Is there a survival benefit to adjuvant radiotherapy in high-risk surgical stage I endometrial cancer?

OBJECTIVE: The aim of this study was to examine the effects of therapeutic modalities on survival of stage I endometrial cancer and also to evaluate the surgical morbidity and the prognostic importance of surgicopathological variables. METHODS: A hundred and ninety-six stage I endometrial cancer patients treated at Hacettepe University Hospital between 1982 and 1997 were included. After initial diagnosis all patients underwent surgical procedures including peritoneal cytology, infracolic omentectomy, total abdominal hysterectomy, bilateral salphingoopherectomy, and complete pelvic-paraaortic lymphadenectomy. The mean age at initial diagnosis was 56 years (SD = 9.9 years) and the patients were followed 3-18 years (median, 8 years). All patients had endometrioid carcinoma. Stage IC and/or grade 3 tumors were considered high-risk factors and by this definition 147 (75%) patients were low risk and 49 (25%) patients were high risk. Forty-nine percent of high-risk patients received adjuvant radiotherapy compared with 3.5% of patients in the low-risk group. RESULTS: The 10-year disease-free and overall survival rates of the entire group were 97 and 98%, respectively. Ten-year overall survival rate for the low-risk group was 100% compared with 94% for patients with high-risk features (P = 0.002). The 10-year disease-free survival rate in the high-risk group was 96% for 24 patients who received adjuvant radiotherapy versus 92% for 25 patients who did not receive adjuvant therapy (P = 0.53). Only high grade was a significant predictor of poor survival (P = 0.0004). Overall surgical morbidity rate was 8.1% without mortality related to surgery. CONCLUSIONS: Surgical staging achieved excellent survival for stage I endometrial cancer patients without incurring untoward morbidity and mortality. No survival advantage of adjuvant radiotherapy was detected even for high-risk patients, so we suggest the use of radiotherapy may be reserved for relapse.     

Is ureteral endometriosis an asymmetric disease?

Six cases of endometriosis obstructing the left ureter were observed among 1054 consecutive patients undergoing surgery in an eight-year period. In addition, 125 women with ureteral endometriosis (left-sided,   n = 66  ; right-sided,   n = 40  ; bilateral,   n = 19  ) were described in 62 articles identified in a systematic review of the English language literature between 1980 and 1998. Considering only the patients with unilateral ureteral endometriosis and combining the published figures with those of our surgical series, the observed proportion of left lesions (72/112, 64%; 95% CI 55% to 73%) was significantly different from the expected proportion of 50% (χ²i, 9.14,   P = 0.002  ). The lateral asymmetry found in the location of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomical differences of the left and right hemipelvis     

What Is a Good Teaching Video? Results of an Online International Survey

Study ObjectiveTo analyze surgeon views on criteria for a good teaching video with the aim of determining guidelines.DesignAn online international survey using a self-developed questionnaire.SettingA French university tertiary care hospital.PatientsThree hundred eighty-eight participants answered an online questionnaire (154 women [40.53%] and 226 men [59.47%]).InterventionsA questionnaire on the criteria for a good quality teaching surgery video was developed by our team and communicated via an online link.Measurements and Main ResultsThe responses of 388 respondents were analyzed and highlighted the pedagogical benefits of teaching videos. The video duration may vary according to the type of media or surgical procedure but should not exceed 10 to 15 minutes for complex procedures. Providing information on the surgical setup (body mass index of the patient, Trendelenburg position degree, pressure of pneumoperitoneum, etc.) is essential. Surgical videos should be reviewed and divided into clearly defined steps with continued access to the entire nonmodified video for reviewers and be accessible on both educational and open platforms. Patient consent and relevant information should be made available. Reviews should include “bad procedure” videos, which are highly appreciated, especially by young surgeons.ConclusionThe many advantages of the video format, including availability and rising popularity, provide an opportunity to reinforce and complement current surgical teaching. To optimize use of this surgical teaching tool, standardization, updating, and ease of access of surgical videos should be promoted.