The value of sonography in early pregnancy for the detection of fetal abnormalities in an unselected population.

OBJECTIVE: To determine the value of early pregnancy sonography in detecting fetal abnormalities in an unselected obstetric population. DESIGN Prospective cross-sectional study. All women initially underwent transabdominal sonography and when the anatomical survey was considered to be incomplete, transvaginal sonography was also performed (20.1%). Nuchal translucency was measured and karyotyping was performed as appropriate. SETTING: University Department of Obstetrics and Gynaecology. PARTICIPANTS: 6634 sequential unselected women (mean maternal age 29.9 years, range 13-50; mean gestational age 12+4 weeks, range 11+0-14+6), carrying 6443 live fetuses participated in this study. MAIN OUTCOME MEASURE: Detection rate of fetal anomalies and the associated cost per case detected in early pregnancy. RESULTS: The incidence of anomalous fetuses was 1.4% (92/6443) including 43 chromosomal abnormalities. The detection rate for structural abnormalities was 59.0% (37/63, 95% CI 46.5-72.4) and the specificity was 99.9% in early pregnancy. When the first and second trimester scans were combined, the detection for structural abnormalities was 81.0% (51/63, 95% CI 67.7-89.2). Seventy-eight percent (31/40) of chromosomal abnormalities (excluding three cases of XXY) were diagnosed at 11-14 weeks, either because of a nuchal translucency greater than or equal to the 99th centile for gestational age (43%; 17/40, 95% CI 27.4-60.4), or due to the presence of structural abnormalities (35%; 14/40, 95% CI 21.2-52.8). Sixty-five percent (15/23) of cases of trisomy 21 were also diagnosed either because of having a nuchal translucency greater than or equal to the 99th centile (57.0%; 13/23) or due to the presence of a structural abnormality (9.0%; 2/23). Overall, the detection rate of structurally abnormal fetuses was 59% (37/63) in early pregnancy and 81% in combination with the second trimester scan. The cost per abnormality diagnosed in early pregnancy is estimated to be pound sterling 6258 per structurally abnormal fetus, pound sterling 7470 per chromosomal abnormality and pound sterling 4453 per anomalous fetus. CONCLUSION: The majority of fetal structural and chromosomal abnormalities can be detected by sonographic screening at 11-14 weeks, but the second trimester scan should not be abandoned.

Simple technique for rectus sheath closure after laparoscopic surgery using straight needles, with review of the literature.

The increasing use of laparoscopic surgery with more complicated procedures means that the use of multiple and larger ports is becoming commonplace. One well-known risk associated with the use of ports more than 10 mm in diameter is the development of an incisional hernia unless the deep fascia is closed adequately. This complication is estimated to follow 3% of major laparoscopic procedures. Closure of trocar incisions is therefore recommended for large sites. We have developed a closure technique using standard sutures with straight needles, a 5-mm laparoscopic grasper, and a 4-mm hysteroscope which we have found simple and fast, with the added advantage of low cost.

The 'Mickey Mouse' sign and the diagnosis of anencephaly in early pregnancy.

OBJECTIVES: To assess the sonographic screening for anencephaly in the first trimester in a low-risk obstetric population. METHODS: Since 1994, 5388 women attended our clinic for a first-trimester scan (11-14 weeks of gestation) and screening for structural and chromosomal abnormalities. The patients underwent transabdominal scanning, and transvaginal scanning if necessary. RESULTS: The ultrasonographic appearances of anencephaly in the first trimester are different from the familiar second-trimester signs. The cerebral hemispheres are present and exposed to the surrounding amniotic fluid. The ultrasound appearances in the coronal section of the head are best described as 'Mickey Mouse face'. There were six cases of anencephaly (incidence 1.1:1000). All cases were diagnosed in the first trimester and five demonstrated this sign. There were no false-positive diagnoses. The crown-rump length was significantly reduced in all affected fetuses. CONCLUSION: First-trimester ultrasonographic diagnosis of anencephaly is accurate, but sonographers should be familiar with the ultrasound appearances that are different from those in the second trimester.

The cost of a hysterectomy in a UK hospital.

Vaginal hysterectomy has been demonstrated to be the cheapest route to perform a hysterectomy but no detailed costing has been performed in the United Kingdom. In this study the costs incurred by a UK teaching hospital for 30 women aged between 40 and 50 years of age undergoing either abdominal (AH), laparoscopically assisted vaginal hysterectomy (LH) were compared with vaginal hysterectomy (VH). VH was significantly the cheapest procedure (993.00 Pounds, 95th Cl 883.20 Pounds to 1124.80 Pounds) and there was a tendency for LH (1148.00 Pounds, 95th Cl 1006.80 Pounds to 1289.20 Pounds) to be less expensive than AH (1340.00 Pounds, 95th CI 1080.80 Pounds to 1595.20 Pounds); this difference may be reversed if disposable laparoscopic instruments were to be used for LH. Our study agrees with data from other countries showing that VH is the cheapest type of hysterectomy. With the added benefits of shorter hospital stay, convalescence and return to work, effort should be directed towards increasing the proportion of hysterectomies performed vaginally in the UK.

The "remote control" laparoscopic bag: a simple technique to remove intra-abdominal specimens.

BACKGROUND: To facilitate extraction and avoid intra-abdominal spillage during laparoscopic removal of adnexal masses, various designs and sizes of endopouches (bags) have been used. We describe a simple technique using a special laparoscopic bag that requires no additional instruments to hold, open, or close the bag. TECHNIQUE: The laparoscopic bag can be prepared from the sterile wrapping of disposable surgical items (eg, suction tubing) and two long sutures. The bag is introduced through the cannula of the laparoscope and is unfurled. By manipulation of the two long sutures threaded through the neck of the bag, the surgeon can easily open and close it. EXPERIENCE: We have performed this procedure "in vitro" on many occasions to ensure that the drawstring technique works. The laparoscopic bag has been used successfully in three patients undergoing oophorectomy and salpingo-oophorectomy. Our experience shows that this type of laparoscopic bag is easy to use and safe, reduces operative time, and is cost effective. Because the bag can be large, operating inside the bag is also possible. CONCLUSION: Our drawstring design allows easy manipulation of a laparoscopic bag to facilitate its opening and closure.

The effect of fetal neck position on nuchal translucency measurement.

OBJECTIVE: To determine the influence of the position of the fetal neck on nuchal translucency measurement. DESIGN: A prospective cross-sectional study. POPULATION: One hundred and ninety-six. METHODS: Nuchal translucency was measured in the mid-sagittal plane, with the fetal neck in the flexed, neutral and extended positions. Measurements were made to the nearest 0.1 mm. Statistical analysis used the paired t-test for differences between the extended and neutral positions, [delta extended nuchal translucency] and the flexed and neutral positions [delta flexed nuchal translucency]. RESULTS: The mean extended nuchal translucency was 0.62 mm greater than the mean neutral nuchal translucency value [95% confidence interval 0.53 to 0.70, T = 14.33, P < or = 0.00001]. The mean flexed nuchal translucency was 0.40 mm less than the mean neutral nuchal translucency value [95% CI 0.34 to 0.47, T = 11.99; P = < 0.00001]. The repeatability coefficient was lower in the case of neutral nuchal translucency measurements [0.48] and was higher in the other groups [extended = 1.04, flexed = 0.70]. CONCLUSION: Fetal neck position can make a significant difference to nuchal translucency measurements. Repeatability of measurements are more accurate with the fetal neck in the neutral position. These findings have important implications for clinicians using nuchal translucency to screen the general obstetric population.

A simple technique of securing inferior epigastric vessels and repairing the rectus sheath at laparoscopic surgery.

Trauma to the inferior epigastric artery during insertion of ports for laparoscopic surgery can be associated with major hemorrhage. Several techniques have been developed to deal with this emergency, but most require special and expensive instrumentation that may not be readily available. We describe a simple and quick method to deal with this complication using only standard sutures and a laparoscopic needle holder. Two sutures with straight needles are inserted below laterally and medially to the vessels and pulled out via a contralateral port. The sutures are tied together and pulled back into the abdominal cavity and tied to secure the vessels. The procedure is repeated above the vessels to produce complete hemostasis. The technique also can be applied easily to repair the rectus sheath after using large trocars and cannulas and thereby prevent herniation.