Pregnancy outcome after laparoscopy or laparotomy in pregnancy.

STUDY OBJECTIVE: To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN: Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING: Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS: Three hundred eighty-nine pregnant women. INTERVENTION: Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS: Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION: Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

[Pelvic floor exercise and biofeedback in women with urinary stress incontinence].

Stress urinary incontinence is a medical and social problem. In the past decade there has been increased awareness of this condition and the number of those affected who seek help is increasing. Treatment is usually surgical-elevation of the bladder neck. Pelvic floor exercise is an accepted conservative treatment modality used for mild to moderate cases who have not yet completed their families. We present our results in 30 women, aged 28-71 years, av. 49% with genuine stress incontinence treated with pelvic floor exercise and biofeedback. 14 patients (46.7%) were completely cured and 15 (50%) were improved. In only 1 was there no improvement. Our results show significant improvement in the duration and intensity of pelvic floor contractions after treatment. Pelvic floor exercise with biofeedback is a very important treatment modality, requiring a highly motivated patient and a physiotherapist specialized in pelvic floor exercise.

The effect of early epidural block administration on the progression and outcome of labor.

This study was undertaken to prospectively evaluate the effect of early administration of epidural bupivacaine (0.25%) on the progression and outcome of labor in 60 nulliparous patients. Patients were randomly divided into two groups. In group 1 (30 patients, early administration), the epidural catheter was sited and the first epidural injection of 0.25% bupivacaine administered at a cervical dilatation of <4 cm; group 2 (30 patients, late administration) received the epidural catheter and first epidural injection of 0.25% bupivacaine at a cervical dilatation of >or=4 cm. The progression and outcome of labor were compared between the two groups. There were no statistically significant differences between the two groups in rate of cervical dilatation, duration of the second stage, numbers of instrumental deliveries or cesarean sections or Apgar scores at 1 and 5 min. We conclude that there is no need to restrict epidural top-ups until cervical dilatation of 4 cm, when active management of labor is advocated.

Uterine metastasis from vulvar malignant melanoma. A case report.

BACKGROUND: Malignant melanoma is the second most common vulvar malignancy. The superficial inguinal lymph nodes are the main site of metastases. Endometrial metastasis of vulvar malignant melanoma has not been previously reported. CASE: Vulvar malignant melanoma was diagnosed in a 60-year-old, postmenopausal woman. Immunohistochemical stains were positive for vimentin and S-100 protein and negative for HMB-45. Six months following vulvectomy, right inguinal lymphadenectomy and immunotherapy, curettage was performed due to postmenopausal bleeding. Histologic and immunohistochemical examinations revealed metastatic malignant melanoma with the same staining reactivity as the primary vulvar neoplasm had. Hysterectomy and bilateral salpingo-oophorectomy was performed, disclosing invasion of the endometrium and the inner two thirds of the myometrium. CONCLUSION: Only 10 other cases of endometrial metastases from malignant melanoma have been previously reported. All those cases involved a primary tumor occurring in the trunk and extremities. This is presumably the first report on endometrial and myometrial metastases from vulvar malignant melanoma.

Unilateral vulvar edema associated with paracentesis in patients with severe ovarian hyperstimulation syndrome. A report of nine cases.

BACKGROUND: Severe ovarian hyperstimulation syndrome is a life-threatening complication of ovulation induction. The clinical picture includes ovarian enlargement, accumulation of ascites and pleural effusion, increased coagulability and electrolyte disorders. Accumulation of ascites increases the intraabdominal pressure so that breathing difficulties ensue. Paracentesis is the only treatment that can immediately prevent respiratory deterioration. CASES: Nine women with severe ovarian hyperstimulation syndrome were treated by paracentesis for the drainage of massive ascites. Unilateral vulvar edema developed in all cases in which the lower abdomen was the puncturing site. This phenomenon was not observed when paracentesis was carried out through the upper abdomen. The edema resolved spontaneously over the subsequent 10 days. CONCLUSION: Apparently the puncturing needle created a fistulous tract through which the ascitic fluid was forced, by the increased intraabdominal pressure, into the subcutaneous tissues, presenting as unilateral vulvar edema. This can be prevented by using one of the abdominal hypochondriac regions as the puncturing site. This phenomenon is self-limited and causes only mild discomfort without late sequelae.

Laparoscopic conservative removal of ovarian dermoid cysts.

We compared the efficacy of two dissection methods of ovarian dermoid laparoscopic cystectomy in 41 women (age 17-38 yrs) who desired future fertility. Blunt dissection and scissors were used in 21 patients (group A), and aquadissection in 20 (group B). The mean size of the cysts was comparable in both groups. The mean operating time for aquadissection was 59.3 minutes compared with 78.4 minutes for blunt dissection and scissors (p <0.05). Intraoperative spillage was significantly less common with aquadissection because with this method it is easier to avoid cyst rupture. No complication occurred with either method. Hospital stay was similar in both groups. Operative laparoscopy is a safe and effective method in the management of ovarian dermoid cysts.

Effect of second-stage 0.25% epidural bupivacaine on the outcome of labor.

OBJECTIVE: To evaluate the effect of second-stage epidural bupivacaine on the outcome of labor. METHODS: Two groups of 35 patients each were randomly allocated to receive continuous epidural bupivacaine throughout labor (group 1) or until an 8-cm dilatation of the cervix (group 2). RESULTS: There was no significant difference between the 2 groups in the rates of instrument deliveries and in their Apgar scores. CONCLUSIONS: The administration of continuous epidural bupivacaine (0.25%) throughout labor and delivery does not seem to affect the outcome of labor.

Gas embolism complicating obstetric or gynecologic procedures. Case reports and review of the literature.

Gas embolism is a rare life-threatening complication of obstetric or gynecologic procedures, arising as a result of gas bubbles being introduced into the circulation via severed blood vessels. Extensive brain damage and acute cardiovascular collapse will lead to a fatal outcome. A favourable outcome depends on early diagnosis and prompt treatment. Hyperbaric oxygenation, which reduces bubble size and increases the supply of oxygen to hypoxic tissues, is the definitive treatment for gas embolism. We report four cases of gas embolism complicating obstetric or gynecologic procedures which were treated at the Israel Naval Medical Institute followed by an updated review of the literature.

Ultrasonic "honeycomb" appearance of uterine submucous fibroids undergoing cystic degeneration.

Uterine fibroids are the most common of uterine benign tumors. Generally, the ultrasonic appearance of uterine fibroids is typical, and diagnosis is uncomplicated. However, the sonographic characteristics of fibroids undergoing cystic degeneration, and especially those of the submucous type, may be misleading. We present a series of submucous fluids with cystic degeneration in peri- and postmenopausal women showing a distinct sonographic "honeycomb" pattern erroneously diagnosed as endometrial hyperplasia. The correct diagnosis was established by hysteroscopy.

Impetigo herpetiformis during pregnancy: case report and review of the literature.

A case of impetigo herpetiformis in pregnancy is reported together with a review of the literature. The patient was a 25-year-old primigravida with pregnancy-induced hypertension (PIH). At 35 weeks' gestation, the patient developed a severely pruritic pustular rash with fever and leukocytosis. The skin of the affected areas was biopsied and showed intraepidermal pustules with a neutrophilic infiltrate. Treatment commenced with intravenous fluids, oral prednisone, and steroid creams. Labor was induced, and a normal delivery of a healthy infant was effected, following which the patient's condition improved rapidly. The clinical and laboratory features were typical of impetigo herpetiformis as described in the literature. Impetigo herpetiformis is a rare, potentially serious skin disorder occurring particularly during pregnancy, and must be diagnosed early to allow prompt, aggressive treatment.

In vitro fertilization for women with pure tubal occlusion: the impact of short gonadotropin-releasing hormone agonist treatment.

OBJECTIVE: To evaluate the impact of a short GnRH agonist (GnRH-a) protocol on follicular and luteal characteristics and treatment outcome in women undergoing IVF for isolated pure tubal occlusion. DESIGN: A prospective randomized study. PATIENTS: Eighty patients with pure tubal occlusion undergoing IVF for the first time. INTERVENTIONS: Patients in group 1 (control group) were administered hMG from day 3 of the menstrual cycle. Patients in group 2 were administered 900 micrograms/d buserelin acetate intranasally from day 1 of the menstrual cycle, followed by hMG administration from day 3. Buserelin acetate was discontinued on the day of hCG administration. MAIN OUTCOME MEASURES: Information collected included E2 levels and follicular growth throughout cycle, amount of hMG required for stimulation, number of oocytes retrieved, fertilization, pregnancy, and cancellation rates. RESULTS: The short GnRH-a protocol resulted in significantly higher E2 levels and required less hMG for stimulation. However, the number of follicles aspirated, number of oocytes retrieved, fertilization rate, number of embryos transferred, pregnancy rate, and cancellation rate in both groups were comparable. CONCLUSIONS: The findings suggest that administration of a short protocol of GnRH-a to patients with pure tubal occlusion has no obvious superiority in comparison with hMG alone, except for the lower amount of hMG required for ovarian stimulation.

Pseudo-sinusoidal heart rate associated with major cardiac anomalies.

Pseudo-sinusoidal fetal heart rate (pseudo-SHR) pattern, characterised by intermittent episodes of sinusoidal heart rate and normal fetal heart rate (FHR), is considered benign although its pathophysiologic mechanism remains obscure. We present a case of pseudo-SHR episodes throughout all stages of labor associated with multiple major cardiac anomalies. We suggest that when confronted with repeated episodes of pseudo-SHR pattern, the possibility of an underlying cardiac anomaly should be considered.

Sonohysterography for the Diagnosis of Endometrial Thickening in Postmenopausal Bleeding-A Preliminary Report

Sonohysterography or sonographic uterine cavity visualization by uterine cavity distension may help in distinguishing true endometrial thickening from other intracavitary pathologic conditions assuming the same appearance on conventional sonography. We examined 15 women with thickened endometrium (range 10-25 mm) on sonography performed for postmenopausal bleeding. Subsequent sonohysterography with saline revealed a polypoid structure in seven women, a normal uterine cavity in four, and thickened endometrium in four. All patients underwent hysteroscopic evaluation of the uterine cavity. Hysteroscopy confirmed the sonohysterographic findings in 14 patients (93.3%). Hysteroscopic resection of the polypoid structures was performed while the remaining patients underwent diagnostic curettage. Histologic examination of the seven polypoid structures revealed benign endometrial polyp in six and one pedunculated submucous fibroid. In patients undergoing diagnostic curettage, histologic examination revealed three cases of glandular hyperplasia, one case of cystic (atrophic) hyperplasia, one case of papillary endometrial adenocarcinoma, and two cases were inadequate for diagnosis. The advantage of sonohysterography in distinguishing endometrial thickening from intracavitary polyp or fibroid is clearly demonstrated. This technique can help in tailoring the correct treatment in various conditions presenting as postmenopausal bleeding.

Laparoscopic Conservative Cystectomy of Ovarian Benign Cystic Teratoma

Laparoscopic surgery has almost totally replaced laparotomy in the management of benign adnexal conditions. Benign cystic teratoma (dermoid cyst) is one of the most common ovarian neoplasms in young women. A prospective non-randomized clinical trial was conducted. To compare the efficacy of two different methods of removal of benign cystic teratoma enucleated laparoscopically. Between January 1991 and June 1993, 37 women, all reproductive-age and desiring future fertility, underwent resection of dermoid cysts between 4 and 8 cm in diameter via laparoscopy using the three-puncture-technique. The removal of the cysts from the abdominal cavity was carried out by traction through an extended incision of one of the puncture sites in the first 17 cases (group A), and the other 20 cases (group B) were managed by embedding the cyst in a plastic bag inserted through one of the trocars, aspirating its contents, and subsequent extraction of the bag without extension of abdominal wall stab wounds. The operating time in both groups was comparable (from 35-130 minutes in group A, and 45-120 minutes in group B. However, the time required for removal of the cyst from the abdominal cavity was significantly shorter in group B (10-15 minutes) compared with group A (20-35 minutes). Spillage of cyst contents occurred in six cases in group A, and in two cases in group B. The average hospital stay in both groups was similar (22.8 hours in group A and 23.4 hours in group B). Postoperative complications in group A included one case of excessive bleeding from the extended incision, and three cases of wound infection. None of the patients in group B had short- or long-term postoperative complications. Operative laparoscopy is a safe and effective method in the management of benign cystic teratoma. We found that removal of the enucleated cyst from the abdominal cavity using a plastic bag is advantageous in terms of operating time and postoperative complication as well as in the cosmetic results compared to extraction of the cyst through an extended abdominal incision.

Sonohysterography for distinguishing endometrial thickening from endometrial polyps in postmenopausal bleeding.

Sonohysterography, or sonographic uterine cavity visualization by uterine cavity distension, may help to distinguish true endometrial thickening from other intracavitary pathological conditions, assuming the same sonographic appearance. We examined 1.5 women with a thickened endometrium (range 10-25 mm) in sonography performed for postmenopausal bleeding. Sonohysterography revealed a polypoid structure in seven women, a normal uterine cavity in four women, and a thickened endometrium in four women. All the women underwent hysteroscopic evaluation of the uterine cavity. Hysteroscopy confirmed the sonohysterographic findings in 14 women (93.3%). Hysteroscopic resection of the polypoid structure was performed while the other patients underwent diagnostic curettage. Histological examination of the seven polypoid structures revealed benign endometrial polyps in six patients, and one pedunculated submucous fibroid. In the patients undergoing diagnostic curettage, histological examination revealed three cases of glandular hyperplasia, one of cystic (atrophic) hyperplasia, and one of papillary endometrial adenocarcinoma. Two cases were inadequate for diagnosis. The advantage of sonohysterography in distinguishing endometrial thickening from intracavitary polyps or fibroids was clearly demonstrated. This technique can help in tailoring the correct treatment in various conditions presenting as postmenopausal bleeding.

Cystadenofibroma of the ovary in young women.

Cystadenofibroma of the ovary, a relatively rare benign tumor, usually appears during the fourth and fifth decades. This tumor has malignant ultrasonographic features and may also macroscopically appear as malignant during surgery. Since this tumor has a rare malignant potential, it is well-advised to be aware of the possibility of a cystadenofibroma before selecting an aggressive surgical approach in young patients. We present five cases of young patients with cystadenofibromas of the ovary.

[Pelvic inflammatory disease in pregnancy].

Although pelvic inflammatory disease (PID) is a common complaint in young, fertile women, it is quite rare during pregnancy. Clinically it is characterized by abdominal pain, sometimes presenting as an acute abdomen with fever. Since PID has no characteristic clinical or laboratory findings, and is rare during pregnancy, it is understandable why the diagnosis is missed in most cases, and the patient is treated as an abdominal emergency. Since surgery during pregnancy in the presence of an infection leads to abortion in most cases, accurate diagnosis and appropriate treatment is of the greatest importance. A case of PID during pregnancy is presented.

The postmenopausal adnexal mass: correlation between ultrasonic and pathologic findings.

One hundred two postmenopausal women underwent ultrasonographic evaluation of adnexal masses before surgery. Twenty-nine (28%) had malignant tumors and 73 (72%) had benign tumors. Two of 33 patients with a "simple cyst" smaller than 5 cm in diameter by ultrasound had malignant ovarian tumors. Twenty-two of the 52 women (42%) with "complex masses" by ultrasound and five of the 17 (29%) with solid tumors had ovarian cancer. For predicting malignancy in ovarian tumors, abdominal ultrasonography had a positive predictive value of 39% and a negative predictive value of 94%. If a negative sonogram had been relied upon, 6% of malignant ovarian tumors in postmenopausal women might have been missed.