Diagnosis of ectopic pregnancy.

The declining death rate from ectopic pregnancy over the last 30 years has resulted not from improvements in operative technique, anesthesia, or blood banking but primarily due to more rapid diagnosis that allows for earlier treatment. Algorithms have been developed to eliminate delays in ordering the various diagnostic tests in the appropriate order. Diagnostic tests include serum human chorionic gonadotropin and progesterone levels, culdocentesis, dilatation and curettage, transvaginal ultrasound, and laparoscopy.

Endometrioma occurring in abdominal wall incisions after cesarean section.

OBJECTIVE: To investigate outcomes following incisional endometrioma after cesarean section and correlate the role of predisposing factors. STUDY DESIGN: Chart review of patients from a 7-year period noting surgical history, previous incisions, uterine exteriorization, and wound irrigation at cesarean section, preoperative and final endometrioma size, mass location, fascial involvement, and mesh placement. RESULTS: All 16 patients had cesarean section as their last surgery and 15 of 16 had transverse incisions. Patients averaged 29.2 years of age, had two prior surgeries with time to symptoms of 25.9 months. Endometriomas were primarily left of midline, extrafascial in 10 patients and intrafascial 3 patients, and involved fascia and muscle in 3 patients. Estimated and actual sizes were similar (p = 0.54) and not correlated with mesh placement (p = 0.21). No patient had concomitant pelvic endometriosis. CONCLUSION: Incisional endometriomas developing after cesarean section occur primarily on the left of transverse incisions. Endometrioma size estimates correlate well with surgical findings but not with the need for mesh placement.

How best to manage dysfunctional uterine bleeding.

Irregular or unusually heavy periods are a common complaint. Most often, the condition is benign and can by managed conservatively. Assess postmenopausal women for cancer by endometrial biopsy, transvaginal ultrasound, or saline infusion sonohysterogram. Treat mild dysfunctional uterine bleeding (DUB) with nonsteroidal anti-inflammatory drugs, levonorgestrel intrauterine device (IUD), or danazol. Treat moderate DUB with oral contraceptive pills, levonorgestrel IUD, danazol, or tranexamic acid.

Preventing electrosurgical energy-related injuries.

Electrosurgery is used on a daily basis in the operating room, but it remains poorly understood by those using it. In addition, the physics of electrosurgery are far more complicated than those of laser. Common belief notwithstanding, electrosurgery has an enormous capacity for patient injury if used incorrectly, even though technology has markedly reduced the likelihood of patient or surgeon injuries. This article is intended to educate the clinician regarding the basis of electrosurgery and provide an explanation on how injuries may occur as well as how they may be prevented.

Diagnosis and management of adnexal masses.

Adnexal masses represent a spectrum of conditions from gynecologic and nongynecologic sources. They may be benign or malignant. The initial detection and evaluation of an adnexal mass requires a high index of suspicion, a thorough history and physical examination, and careful attention to subtle historical clues. Timely, appropriate laboratory and radiographic studies are required. The most common symptoms reported by women with ovarian cancer are pelvic or abdominal pain; increased abdominal size; bloating; urinary urgency, frequency, or incontinence; early satiety; difficulty eating; and weight loss. These vague symptoms are present for months in up to 93 percent of patients with ovarian cancer. Any of these symptoms occurring daily for more than two weeks, or with failure to respond to appropriate therapy warrant further evaluation. Transvaginal ultrasonography remains the standard for evaluation of adnexal masses. Findings suggestive of malignancy in an adnexal mass include a solid component, thick septations (greater than 2 to 3 mm), bilaterality, Doppler flow to the solid component of the mass, and presence of ascites. Family physicians can manage many nonmalignant adnexal masses; however, prepubescent girls and postmenopausal women with an adnexal mass should be referred to a gynecologist or gynecologic oncologist for further treatment. All women, regardless of menopausal status, should be referred if they have evidence of metastatic disease, ascites, a complex mass, an adnexal mass greater than 10 cm, or any mass that persists longer than 12 weeks.

Yolk sac on transvaginal ultrasound as a prognostic indicator in the treatment of ectopic pregnancy with single-dose methotrexate.

OBJECTIVE: To determine whether yolk sac on transvaginal ultrasound was an independent predictor for single-dose methotrexate failure for tubal ectopic pregnancies. STUDY DESIGN: Seven hundred sixty-six consecutive methotrexate-treated ectopic pregnancy patients were reviewed. After excluding 25 oral and 97 multidose methotrexate patients, 18 cornual, 4 cervical pregnancies, and 63 patients with ectopic cardiac activity, 559 study patients remained. Variables studied included age, gravidity, parity, previous ectopic pregnancy, serum human chorionic gonadotropin and progesterone levels, ectopic size, ectopic volume, body surface area, and yolk sac presence. RESULTS: Sixteen of 73 (21.9%) patients with yolk sac failed treatment vs 36 of 486 (7.4%) patients without yolk sac (P = .0003). Other significant variables on single factor analysis were previous ectopic (P = .0005), human chorionic gonadotropin (P < .0001), and progesterone (P = .003). Only previous ectopic and human chorionic gonadotropin remained significant on logistic regression analysis. CONCLUSION: The presence of a yolk sac, although a risk factor for failure of single-dose methotrexate in treatment of tubal ectopic pregnancy, is not an independent predictor.

Retained fetal parts after elective second-trimester dilation and evacuation.

BACKGROUND: Extrusion of fetal parts into the abdomen after second-trimester pregnancy termination is rare. CASE: We report a case of extrusion of fetal parts into the broad ligament at the time of second-trimester pregnancy termination that remained undetected for 10 days. CONCLUSION: In cases of perforation during second-trimester pregnancy termination, meticulous evaluation of the abdomen and pelvis with ultrasonography or computerized tomography should be performed if complete fetal evacuation cannot be confirmed.

A trial that compares Monsel's paste with ball electrode for hemostasis after loop electrosurgical excision procedure.

OBJECTIVE: The purpose of this study was to compare Monsel's paste with fulguration with ball electrode for hemostasis after loop electrosurgical excision procedure. STUDY DESIGN: One hundred healthy women were assigned randomly by computer-generated random numbers to ball electrode or thickened Monsel's paste for hemostasis after loop electrosurgical excision procedure. Patients rated pain during hemostasis using a visual analog scale. At 2 weeks, postprocedural vaginal discharge was rated on a Likert scale. Pathology was reviewed for dysplasia grade and margin status. Recurrent dysplasia on repeat Papanicolaou tests was noted. RESULTS: Six patients (2 Monsel's and 4 fulguration) required an alternate method of hemostasis. Patient demographics, postprocedural discharge, and recurrent dysplasia were comparable between the 2 groups. Visual analog scale scores and hemostasis time were significantly higher in the fulguration group. Estimated blood loss, although higher in the fulguration group, was not significant between groups. CONCLUSION: Monsel's paste and fulguration with ball electrode appear be equally effective as hemostatic agents after loop electrosurgical excision procedure.

Comparison of multidose and single-dose methotrexate protocols for the treatment of ectopic pregnancy.

OBJECTIVE: The purpose of this study was to compare success rates of 643 patients who had ectopic pregnancy from the same database who were treated with multidose or single-dose methotrexate protocols. STUDY DESIGN: We compared demographics, gestational age, serum human chorionic gonadotropin, progesterone levels, ectopic sac size and volume, overall ectopic mass size and volume, ectopic cardiac activity, history of ectopic pregnancy, number of treatment days, methotrexate doses, and outcome in consecutive patients with ectopic pregnancy who were treated with methotrexate. RESULTS: Success rates were comparable between patients with multidose and single-dose therapy (95% vs 90%, respectively) as were human chorionic gonadotropin and progesterone levels, history of ectopic pregnancy (21.4% vs 21.7%, respectively), number of treatment days, gestational age, ectopic size, ectopic volume, and ectopic mass volume. Patients who received single-dose therapy were significantly heavier (146 vs 159 pounds), had greater ectopic cardiac activity (3.1% vs 10.3%), and received fewer methotrexate doses. CONCLUSION: This study suggests single-dose methotrexate therapy is as effective as multidose methotrexate therapy for the treatment of ectopic pregnancy.

Previous ectopic pregnancy as a predictor of failure of systemic methotrexate therapy.

OBJECTIVE: To investigate whether a history of previous ectopic pregnancy is an independent risk factor for failure of methotrexate therapy in subsequent ectopic pregnancies and whether the previous treatment method influenced failure. SETTING: Inner-city teaching hospital. DESIGN: Retrospective case review. PATIENT(S): Five hundred four consecutive patients treated with "single-dose" methotrexate for ectopic pregnancy. Nine patients electing surgery after beginning medical therapy were excluded from analysis. INTERVENTION(S): Systemic methotrexate 50 mg/m(2). MAIN OUTCOME MEASURE(S): Failure of methotrexate therapy. RESULT(S): Twenty-one (18.6%) of 113 of previous ectopic patients and 26 (6.8%) of 382 first-time ectopic patients failed methotrexate therapy (odds ratio, 3.12). The overall success rate was 90.5% (448/495 patients). Univariant analysis showed that treatment hCG and progesterone (P) levels and ectopic cardiac activity were significantly different between successful and failed therapy. Logistic regression analysis for these four variables showed that only hCG and history of previous methotrexate remained significant risk factors for failure of methotrexate therapy. The likelihood of failure in patients with a previous ectopic was not influenced by previous treatment with salpingostomy, salpingectomy, or medical treatment. CONCLUSION(S): A history of previous ectopic pregnancy appears to be an independent risk factor for failure of systemic methotrexate treatment, but failure is not affected by previous treatment method.

Is a resident's score on a videotaped objective structured assessment of technical skills affected by revealing the resident's identity?

OBJECTIVE: The purpose of this study was to determine whether knowledge of resident's identity affects the evaluation of surgical skills. STUDY DESIGN: During an objective structured assessment of technical skills, 33 residents in obstetrics and gynecology who performed 10 surgical skills were videotaped with two digital cameras simultaneously. One camera videotaped "hands only," concealing resident identity; the other camera videotaped from the "waist up," revealing identity. Residents wore opaque gowns and gloves. Four faculty reviewers with previous clinical experience with the residents scored the "hands only" videos first. The scoring was based on the total of a global rating scale and a task-specific checklist. RESULTS: The combined scores for all reviewers was significantly different between the two views (P=.03). When the video tapes were analyzed individually, two reviewers scored the views differently; one reviewer scored higher, whereas the other reviewer scored lower. CONCLUSION: Bias can occur in evaluation of surgical skills but is dependent on the individual reviewer. Resident identification can alter the score, depending on the evaluator.

A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery.

OBJECTIVE: The purpose of this study was to investigate the efficacy of continuous local anesthetic infusion system for pain control after cesarean delivery. STUDY DESIGN: This was a randomized prospective double-blind study. Patients who underwent cesarean delivery had a pain system implanted subcutaneously after closure of the fascia. Patients were randomized to receive an infusion of either 0.25% bupivacaine (n = 20) or normal saline solution (n = 16) into the wound for 48 hours. Postoperative pain (determined with a visual analog scale) and postoperative morphine use were assessed at 12, 24, and 48 hours. RESULTS: There were no significant differences in patient demographics or visual analog pain scores at any time interval between the bupivacaine versus the placebo group. However, narcotic requirements to produce this amount of pain relief were significantly less in patients who received bupivacaine infusion rather than normal saline solution at all time intervals. CONCLUSION: The continuous local anesthetic infusion system appears to be effective in reducing postoperative morphine use after cesarean delivery.