Assessment of the perioperative effect of vasopressin in patients undergoing laparoscopic myomectomy: A double-blind randomised study.

BACKGROUND AND AIMS: Myomectomy is associated with perioperative bleeding. The aim of the study is to evaluate the effect of intramyometrial vasopressin on blood loss and the associated cardiovascular complications during myomectomy. METHODS: The study included 194 patients classified into two groups- 1) Vasopressin group: the vasopressin was diluted as 0.1 unit/ml and 15 ml was injected by the surgeon in the plane between the myometrium and the myoma. 2) Control group: The patients received an equal amount of normal saline. The monitored parameters included the amount of blood loss, required blood transfusion, heart rate, mean arterial blood pressure, the incidence of hypertension, hypotension, bradycardia, tachycardia, electrocardiogram (ECG) changes and the blood troponin I level. RESULTS: The heart rate decreased significantly in both groups, but the decrease was lower with vasopressin than the control group through the time points T3 to T5 (P < 0.05) The mean arterial blood pressure increased significantly in both groups, but the increase was higher with vasopressin than the control group through T3 to T5 (P < 0.05). The amount of blood loss decreased significantly with vasopressin than the control groups (P = 0.001). The number of transfused packed red blood cells was lower with vasopressin than the control group (P = 0.001). The incidence of hypertension, bradycardia and atrial extrasystole was higher with vasopressin than the control group (P = 0.005, P = 0.012, P = 0.033, respectively). CONCLUSION: Intramyometrial vasopressin decreases blood loss and blood transfusion, but it is associated with cardiovascular complications that may be serious as reported in other studies. Therefore, anaesthesiologists and gynaecologists must follow the precautions to avoid and minimise the incidence of complications with intramyometrial vasopressin.

Impact of antenatal oxytocin infusion on neonatal respiratory morbidity associated with elective cesarean section.

INTRODUCTION: This study was designed to estimate respiratory morbidity associated with elective cesarean section (ECS) and to determine the effect of antenatal oxytocin exposure on this morbidity. MATERIAL AND METHODS: Nine hundred and sixty-five neonates ≥ 37 weeks' gestation delivered by cesarean section during 1 year were included in this retrospective study and classified into two groups according to oxytocin exposure before cesarean deliveries. Respiratory morbidity for each group was recorded and statistically analyzed. RESULTS: Transient tachypnea of newborn (TTN) was significantly more frequent in group II (ECS group) than in group I (cesarean section after oxytocin exposure) (8.19% vs. 2.92%; respectively, p = 0.0006). Mechanical ventilation, continuous positive airway pressure (CPAP) and oxygen therapy were significantly more frequent in group II than in group I (1.78%, 2.14% and 4.28% versus 0.44%, 0.58% and 1.46%, respectively; p = 0.039, and p = 0.033 and p = 0.009, respectively). The number of newborns admitted to the neonatal unit and neonatal intensive care unit (NICU) was significantly higher in group II than in group I (6.41% and 2.14% vs. 2.05% and 0.58%, respectively; p = 0.001 and p = 0.033, respectively). Surfactant, fluid therapies and parenteral nutrition were significantly more frequent in group II than in group I (2.14%, 4.28% and 2.49% vs. 0.15%, 1.46% and 0.73%, respectively; p = 0.001, p = 0.009 and p = 0.02, respectively). CONCLUSIONS: Neonatal respiratory morbidity associated with ECS significantly decreased after antenatal oxytocin exposure. A significant reduction of neonatal respiratory morbidity would be achieved if ECS were performed after 39 weeks' gestation.

Unexpected premalignant gynecological lesions in women undergoing vaginal hysterectomy for utero-vaginal prolapse.

AIM OF THE STUDY: Aim of the study was to estimate the incidence of unexpected premalignant gynecological lesions in women undergoing vaginal hysterectomy for utero-vaginal prolapse. MATERIAL AND METHODS: Eighty women with asymptomatic utero-vaginal prolapse were included in this prospective study for vaginal hysterectomy after preoperative preparation and after written informed consent. Women included in this study were screened preoperatively by high vaginal swab, Pap smear, endometrial biopsy and trans-vaginal ultrasound. Surgically removed uteri and ovaries were sent for histopathological examination. Results of histopathological examination as gold standard were compared with conventional gynecological screening methods. RESULTS: Histopathological examination of surgically removed uteri and ovaries after vaginal hysterectomy for uterovaginal prolapse showed abnormal findings in 61.25% (49/80) of studied cases (10 chronic cervicitis; 20 cervical intra-epithelial neoplasia-1 [CIN-1]; 5 CIN-2; 2 CIN-3; 10 simple endometrial hyperplasia without atypia and 2 simple serous ovarian cyst). Also, histopathological examination showed premalignant changes in 33.75% (27/80) of studied cases (20 CIN-1; 5 CIN-2 and 2 CIN-3), which mean 50% sensitivity of pre-operative Pap smear to detect premalignant cervical changes. CONCLUSIONS: Asymptomatic women with utero-vaginal prolapse may have associated premalignant lesions which may not be detected by conventional screening methods, and this should be explained preoperatively for women undergoing surgery, especially if conservative management was considered.

Accuracy of endometrial sampling compared to conventional dilatation and curettage in women with abnormal uterine bleeding.

OBJECTIVES: To compare the diagnostic accuracy of brush endometrial sampling with conventional dilatation and curettage in women with abnormal uterine bleeding. PATIENTS AND METHODS: Two hundred and twenty (220) women with abnormal uterine bleeding were included in this comparative study; endometrial sampling was done before cervical dilatation using Tao Bruch followed by conventional dilatation and curettage (D&C). The histopathology report of the Tao Bruch samples was compared with that of the D&C samples and the D&C results were considered as the gold standard. RESULTS: 100% of samples obtained by conventional D&C, while 98.2% of the samples obtained by Tao Brush were adequate for histopathology examination. In this study; Tao Brush had 100% sensitivity, 100% specificity, 100% predictive values and accuracy for diagnosing endometrial hyperplasia, endometrial carcinoma, proliferative and secretory endometrium, also, it had 86.7% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 99% negative predictive value (NPV) and accuracy for diagnosing endometritis (no significant difference compared to conventional D&C), while, it had 77.8% sensitivity, 100% specificity, 100% PPV and 99% NPV and accuracy for diagnosing endometrial polyps (no significant difference compared to conventional D&C) CONCLUSION: Endometrial sampling using endometrial brush cytology (EBC) is safe, accurate, cost-effective outpatient procedure, avoids general anesthesia with high sensitivity and specificity for detection of endometrial hyperplasia and endometrial carcinoma. EBC could be used as complementary diagnostic tool when hysteroscopic biopsies or other blinded procedures for endometrial sampling are unwanted or not available.

Ovarian function and ovarian blood supply following premenopausal abdominal hysterectomy.

INTRODUCTION: The issue of conserving the ovaries at hysterectomy in premenopausal women with benign gynecologic disease has been the subject of considerable controversy. Some clinicians prefer prophylactic oophorectomy in premenopausal women during hysterectomy to prevent future development of malignant changes in conserved ovaries. Other clinicians prefer to conserve apparently normal ovaries, because bilateral oophorectomy in premenopausal women results in an abrupt imbalance, sudden onset of menopausal symptoms, decreased libido, increased cardiovascular risk and osteoporosis. MATERIAL AND METHODS: Two hundred and twenty multipara women (who had completed their families), with benign uterine pathology were included in this prospective study for abdominal hysterectomy with bilateral ovarian preservation. Pre-operative vaginal ultrasound, Doppler studies, diagnostic hysteroscopy and endometrial biopsy were done followed by laboratory studies including Anti-mullerian hormone (AMH), follicle stimulating hormone (FSH) and estradiol for all studied women. Doppler studies, AMH, FSH and estradiol were repeated 6 and 12 months post-operative for assessment of the ovarian function and ovarian blood supply after hysterectomy. RESULTS: Pre-operative AMH, FSH and estradiol of the studied women were statistically insignificant compared to AMH, FSH and estradiol 6 and 12 months post-operative. Twelve months post-operative right and left ovarian volumes (6.92 ± 0.18 and 6.85 ± 0.19 cm(3), respectively) were significantly larger than pre-operative right and left ovarian volumes (6.19 ± 0.22 and 5.86 ± 0.23 cm(3), respectively), and, 12 months post-operative right and left ovarian pulsatility indices (2.92 ± 0.15 and 2.96 ± 0.16 cm/s, respectively) were significantly lower than pre-operative right and left ovarian pulsatility indices (3.45 ± 0.19 and 3.36 ± 0.2 cm/s, respectively). Eight (3.6%) cases of the studied women developed an ovarian cyst 6 months after hysterectomy, 3 were spontaneously resolved and the remaining 5 (2.27%) cases underwent exploratory laparotomy. CONCLUSIONS: There is no evidence of ovarian dysfunction affecting conserved ovaries one year after hysterectomy in premenopausal women as evident by AMH, FSH and estradiol. Furthermore, an increased ovarian volume and reduced ovarian pulsatility indices indicate a possible increase in ovarian blood supply, and preserved non-compromised ovarian function.

Maternal and obstetrical factors associated with a successful trial of vaginal birth after cesarean section.

OBJECTIVE: To detect the maternal and obstetrical factors associated with successful trial of vaginal birth among women with a previous cesarean delivery. MATERIAL AND METHODS: A total of 122 women who were eligible for a trial of labor after cesarean section (TOLAC) according to departmental protocol were included in this comparative prospective study. After informed consent, the women included in this study were subjected to a thorough history to detect maternal and obstetric characteristics and a standard examination to estimate fetal weight, engagement of the fetal head, intra-partum features of fetal membranes, and cervical dilatation. After delivery, data on duration of labor, labor augmentation, mode of delivery, birth outcome, and neonatal intensive care (NICU) admission were recorded and analyzed. RESULTS: Trial of labor after cesarean section was successful in 72.13% and was unsuccessful in 27.87%. Body mass index (BMI) was significantly lower in the successful TOLAC group compared to the unsuccessful group (23.8±0.03 versus 26.2±0.02 kg/m(2)), and the number of women with BMI >25 kg/m(2) was significantly high in the unsuccessful group; also, mean gestational age was significantly lower in the successful TOLAC group compared to the unsuccessful group (37.5±0.04 versus 38.5±0.03 weeks), and the number of women admitted in labor with gestation ≥40 weeks was significantly high in the unsuccessful group. The number of women admitted with >2/5 of fetal head palpable abdominally and fetal head station ≥-2 was significantly high in the unsuccessful TOLAC group. CONCLUSION: In carefully selected cases, TOLAC is safe and often successful. Presence of BMI >25 kg/m(2), gestation ≥40 weeks, and vertex station ≥-2 were risk factors for unsuccessful TOLAC.