Vaginal extraction of pelvic masses following operative laparoscopy.

OBJECTIVE: To investigate the clinical outcome of patients undergoing operative laparoscopy for a benign pelvic mass followed by vaginal extraction of the surgical specimen. METHODS: Patients presenting with a suspected benign mass greater than 5 cm or an extrauterine pregnancy undergoing operative laparoscopy were considered eligible. Patients with endometriosis, pelvic inflammatory disease, and previous hysterectomy were excluded. In all cases the surgical specimen was removed through a colpotomy performed in laparoscopy at the level of the posterior vaginal fornix. Additionally, a review of the literature has been conducted to specifically address the incidence of colpotomy-related complications. RESULTS: Sixty-three patients were included in the study. The median (range) time required to extract the freed mass to the complete suture of the colpotomy was 15 min (5-31). This time was significantly longer in patients with myomas than for others [median 21 min (range: 10-31) vs median 10 min (5-13), p<0.05]. No intra- and postoperative colpotomy related complications occurred. No patients complained dyspareunia at follow-up visits. A total of 23 studies were reviewed for a total of 501 patients and only one (0.2%) complication (severe vaginal bleeding) was directly attributable to the colpotomy. CONCLUSION: Removal of a pelvic mass through a laparoscopic colpotomy is feasible, safe, and offers better cosmetic results than transabdominal extraction of the surgical specimen.

Minimal invasive laparoscopic hysterectomy with ultrasonic scalpel.

BACKGROUND: The purpose of the study was to assess whether total laparoscopic hysterectomy with the ultrasonic scalpel offers advantages in term of intraoperative and postoperative outcomes over the conventional abdominal hysterectomy. METHODS: A case-control study to compare patients undergoing total laparoscopic hysterectomy and women undergoing abdominal hysterectomy for benign conditions was designed. Matching criteria were the menopausal status, the need of adnexectomy, and the uterus weight. The laparoscopic procedure was carried out using an ultrasonically activated scalpel and the amputated uterus was removed transvaginally. Every part of the operation was carried out via laparoscopy, from the adnexal phase to the colpotomy. Abdominal hysterectomy was performed using a conventional laparotomic technique. Intraoperative and postoperative characteristics were analyzed. RESULTS: One hundred forty-four patients were enrolled, of whom 48 underwent total laparoscopic hysterectomy and 98 abdominal hysterectomy. No difference was found between groups in terms of operating time or intraoperative and postoperative infectious and noninfectious complications. The median (range) total consumption of morphine (0 mg [0 to 16] versus 15 mg [0 to 100], P <0.01) during the first 3 postoperative days was significantly lower in the laparoscopic group than in the laparotomic group. The median (range) time to regular diet (1[0 to 4] versus 2 [0 to 5], P <0.05) and the time to passage of stool (1[1 to 2] versus 2 [1 to 5], P <0.05) was shorter in the laparoscopic than in the laparotomic group. CONCLUSIONS: Total laparoscopic hysterectomy with the ultrasonic scalpel is feasible and safe, and offers not only cosmetic benefits but also reduces the need of analgesia and the time to return to a normal gastrointestinal function in comparison with the conventional abdominal hysterectomy.

Association between weather conditions and the incidence of emergency gynecological consultations.

OBJECTIVE: This study examined the influence of weather conditions on the incidence of outpatient emergency consultations at the Department of Obstetrics and Gynecology at the Regional Hospital in Lugano, Switzerland. STUDY DESIGN: The medical records of all women who attended the outpatient emergency unit at the Department for Obstetrics and Gynecology over the 1-year study period were reviewed. The final diagnosis was pelvic pain of unidentified origin in 180 cases, menorrhagia and/or metrorrhagia in 95 cases, threatened abortion in 56 cases and spontaneous abortion in 54 cases. The meteorological factors considered were atmospheric pressure, temperature, humidity and global radiation. A logistic regression model was used to correlate the occurrence of symptoms with the chosen weather factors. RESULTS: High mean daily temperature was found to be a significant predictor of pelvic pain (p < 0.001). A rise in barometric pressure compared to the previous day increased the probability of menorrhagia and/or metrorrhagia (p = 0.001). Higher minimal temperature (p = 0.011) and an increase in atmospheric pressure (p = 0.006) were identified as positive predictors of threatened abortion. None of the meteorological factors considered seemed to influence the frequency of spontaneous abortions. CONCLUSION: Meteorological factors such as temperature and barometric change appear to affect the probability of emergency admissions for gynecological symptoms including uterine bleeding, threatened abortion and pelvic pain.

[Laparoscopic cholecystectomy during pregnancy]. / La colecistectomia laparoscopica durante la gravidanza.

BACKGROUND: We evaluated the advantages and risks of laparoscopic cholecystectomy during pregnancy in symptomatic patients. MATERIAL AND METHODS: Three gravid women at an estimated 14 to 26 weeks gestational age underwent laparoscopic cholecystectomy for symptomatic cholelithiasis or biliary pancreatitis. One patient was obese. The operation was successfully completed under tocolytic medication. DISCUSSION: Although rare, gallbladder disease is the second most common abdominal condition during pregnancy requiring operation, being second only to appendicitis. Medical management is the most common approach to treatment, and the surgical intervention is reserved for patients who fail to respond to conservative methods or who have choledocholithiasis, biliary obstruction or pancreatitis. The laparoscopic approach is controversial, and some authors still agree that pregnancy is a contra indication to laparoscopic cholecystectomy. We report our experience with three laparoscopic cholecystectomies performed without complication during pregnancy. On the basis of our experience and a review of the literature, we believe that the laparoscopic cholecystectomy, undertaken preferentially during the second trimester, is a valid alternative to classic management in terms of risks for the foetus and comfort for the mother.

Cecal volvulus in pregnancy. Case report and review of literature.

We report a 23 year old woman at 24 weeks of gestation with known bulimia and gastritis who was admitted to the hospital with acute abdominal pain. Laparotomy confirmed the clinical diagnosis of cecal volvulus and a right hemicolectomy was performed.

[Toxoplasmosis in pregnancy: prevention, prenatal diagnosis and treatment]. / Toxoplasmose en cours de grossesse: prévention, diagnostic prénatal et traitement.

Maternal infection with Toxoplasma gondii acquired during pregnancy occurs in more than 500 women per year in Switzerland. Systematic screening at the beginning of pregnancy allows the introduction of health education programs. The screening during pregnancy is performed to diagnose primary maternal infections and to propose prenatal diagnosis and treatment. The administration of specific antibiotherapy during pregnancy (spiramycine or the association of pyrimethamine and sulfonamides) significantly reduces the risk of fetal infection. Prenatal diagnosis of congenital toxoplasmosis is possible and reliable. It avoids unnecessary termination of pregnancy when the fetus is not infected and specific therapy in case of infection (association of pyrimethamine and sulfonamides). Prenatal treatment may be proposed without prenatal diagnosis as of the 16th week of gestation. In any case, prenatal treatment seems to reduce the incidence of severe congenital toxoplasmosis.

[Triplet pregnancy with HELLP syndrome and transient diabetes insipidus]. / Drillingsschwangerschaft mit HELLP-Syndrom und transientem Diabetes insipidus.

A 35 year old primigravida with a triplet pregnancy developed polyuria and epigastric pain in the 31st week of pregnancy. During that week, emergency cesarean section was performed due to evidence of liver disease and imminent fetal hypoxia. Three girls were delivered who were healthy apart from transient neonatal respiration distress syndrome. Following surgery, the mother developed HELLP syndrome with hemolysis, increased transaminases and thrombocytopenia. She also developed diabetes insipidus with daily urine outputs of up to 7000 ml and poor response to desmopressin. Both the HELLP syndrome and the diabetes insipidus resolved spontaneously within ten days. In pregnant patients with right upper quadrant pain, HELLP syndrome or acute fatty liver of pregnancy should be considered. The association of diabetes insipidus with acute fatty liver of pregnancy is an established, but rare phenomenon. As far as is known, this is the first report of a patient presenting with a combination of HELLP syndrome and diabetes insipidus. Patients with HELLP syndrome have a good prognosis, if the diagnosis is early and the pregnancy terminated at the right time. With close supervision further pregnancies are possible.

[Methods, techniques and assessment criteria in obstetric pelvimetry]. / Methoden, Techniken und Beurteilungskriterien der geburtshilflichen Pelvimetrie.

Size and shape of the bony pelvis are important factors determining the progress of labor and delivery. Clinical evaluation of the pelvis and sonographic examination of the fetal size are important tools for the planning of labor and in most cases allow to diagnose cephalopelvic disproportion. Pelvimetry by computed tomography (CT) and by magnetic resonance imaging (MRI) are exact and simple techniques with low or absent ionizing radiation. These new techniques offer distinct advantages over conventional X-ray pelvimetry. However, the value of the measurements of the pelvic dimensions in predicting labor outcome and in the diagnosis of cephalopelvic disproportion remains limited. Only if the pelvimetric data are combined with data on fetal dimensions obtained by ultrasound or by postpartum measurements, the efficacy of the examination in predicting the success of labor and identifying the presence or absence of cephalopelvic disproportion is increased. This combination therefore may confirm the diagnosis of cephalopelvic disproportion after operative delivery, which is important with respect to subsequent deliveries. Furthermore this method could play and important role in selecting patients with term breech presentation for possible vaginal delivery.

Permeation of human chorioamniotic membranes by Escherichia coli in vitro.

OBJECTIVE: Our goal was to study the permeation of Escherichia coli through human chorioamniotic membranes in vitro. STUDY DESIGN: Medium was placed in two compartments separated by chorioamniotic membranes obtained from six cesarean sections at term. The compartment faced by the chorion was inoculated with E. coli. Both compartments were sampled over 12 hours for observation of bacterial growth. Controls were performed without membranes. RESULTS: In the compartment that was inoculated, concentration of E. coli increased from 10(6) to 10(10) colony-forming units per milliliter. In the compartment faced by amnion, bacterial growth was observed after 6 hours and reached 10(3) colony-forming units per milliliter. Permeation of E. coli was confirmed histopathologically. The change of glucose and lactate was linear. In the controls the concentration of E. coli increased to 10(7) (p < 0.001). CONCLUSIONS: E. coli organisms permeate viable chorioamniotic membranes. The membranes constitute a weak barrier against ascending infection and do not inhibit bacterial growth.

[Chlamydia and mycoplasma infections in men of couples with involuntary sterility]. / Chlamydien- und Mykoplasmeninfekte bei Männern von Paaren mit unfreiwilliger Kinderlosigkeit.

There is conflicting evidence on the influence of infections with Chlamydia trachomatis and Mycoplasma hominis on male and female infertility. We studied the prevalence of Chlamydia and Mycoplasma in male partners of 165 infertile couples. 25% of couples with tubal and/or andrological sources of infertility showed positive cultures for Chlamydia and/or Mycoplasma compared with 10% of couples with other causes of infertility. Our data suggest, that screening for Chlamydia and Mycoplasma in infertility patients may be of assistance.

Combined bilateral tubal and multiple intrauterine pregnancy after ovulation induction.

Over the last 20 years, the frequency of multiple pregnancy has increased mainly because of the introduction of exogenous pituitary gonadotropins in the treatment of sterility. The incidence of ectopic pregnancies also increased during the same period of time. This paper describes the first reported case of a simultaneous bilateral tubal and multiple intra-uterine pregnancy after ovulation induction with human gonadotropins.

Lasers in endoscopic surgery.

Lasers provide the endoscopic surgeon with a sophisticated tool for high precision cutting, destruction of tissue and coagulation. The laser allows efficient and time-saving operating techniques. Various laser systems emitting at different wavelengths are available. The absorption of the laser is determined by the tissue properties, such as water content or pigmentation, and varies strongly with the wavelength. Each laser offers advantages for the treatment of specific disorders. Further data from clinical studies are required to evaluate whether the advantages found in experimental studies are of significance in clinical use.

[Induction of labor with a new intracervically administered prostaglandin E2 gel. Report of initial experience]. / Geburtseinleitung mit einem neuen intrazervikal applizierbaren Prostaglandin E2-Gel. Ein erster Erfahrungsbericht.

We report on our experience with the induction of labour using 0.5 mg of prostaglandin E2 gel (Cerviprost, Organon) intracervically. Out of 43 cases, 27 were primiparae. Indication for induction was: 10 post-term pregnancies, 9 PROM's > 24h, 12 foetal and 11 maternal indications. Mean Bishop score before induction was 3.1 and 9 hours later or at the beginning of regular contractions 6.7. In 9 of the 43 cases induction was unsuccessful. There were 23 spontaneous vaginal deliveries, 6 forceps and 5 Caesarean sections. Uterine hyperstimulation was found in 6 cases, 5 of which occurred during the first 16 inductions, and only one was seen during the following 27. A possible reason may be unrecognised extra-amniotic application of the gel. Intracervical prostaglandin seems to be an appropriate method not only for cervical ripening but also for induction of labour in cases with a low Bishop score. Although side effects are rare, sufficient monitoring and control of mother and foetus are mandatory.

Lethal Pena-Shokeir 1 syndrome in three male siblings.

A consanguineous family with no living children and three male siblings with Pena-Shokeir 1 syndrome is described. Two children died antepartum and the third shortly after delivery. The importance of early prenatal diagnosis, appropriate counseling and thorough evaluation of the neuromuscular system is discussed.

[Infection screening in pregnancy]. / Infektscreening in der Schwangerschaft.

The aim of screening for infectious diseases in pregnancy is to identify subjects who are at risk of a specific infection, which lends itself to effective intervention. The value of routine screening is determined by the validity of the test and the prevalence of the disorder in the population. During pregnancy, serological screening for rubella, syphilis, toxoplasmosis, HIV, hepatitis B and bacteriological screening for asymptomatic bacteriuria and gonorrhea is recommended. The search for additional infections is reserved for patients presenting special risk factors or clinical symptoms.

[Regionalization of obstetrics exemplified by the Bern University Obstetric Clinic]. / Regionalisierung der Geburtshilfe am Beispiel der Universitäts-Frauenklinik Bern.

Report about practical experience with concentration of high risk pregnancies in a regional center. It is better to transport the fetus in utero than to transport the neonate.