Vaginal hysterectomies in patients without uterine prolapse: ten-year experience.

OBJECTIVE: To review the results of vaginal hysterectomies in patients without uterine prolapse. DESIGN: Retrospective chart review. SETTING: University affiliated hospital, Hong Kong. PATIENTS: All patients who had vaginal hysterectomies in the absence of uterine prolapse from 1999 to 2005 inclusive (first period) and 2006 to 2009 inclusive (second period). MAIN OUTCOME MEASURES: The number of such hysterectomies, indications, operative procedures, complications, use of preoperative gonadotropin-releasing hormone agonist, and concomitant vaginal salpingo-oophorectomies performed. RESULTS: In all, 94 and 98 patients fulfilling the necessary inclusion criteria within the two respective periods underwent vaginal hysterectomy. The indications for hysterectomy in the respective groups were similar, and 89 (95%) and 90 (92%) of the patients were Chinese. The respective proportions having additional procedures were 11% versus 23% (P=0.018) and the respective vaginal bilateral salpingo-oophorectomy rates were 1% versus 15% (P<0.001). The vault haematoma rate decreased significantly in the second period (from 12% to 1%; P=0.002). There were no significant differences between the periods with respect to mean operative blood losses, uterine weights, and operating times. The use of gonadotropin-releasing hormone agonist resulted in reduced mean uterine sizes (12 weeks vs 10 weeks; P=0.041). A decreasing trend in mean operating times and blood losses was also observed after such use. Vaginal hysterectomy and bilateral salpingo-oophorectomies were successfully performed in 12 (80%) patients without laparoscopic assistance. For this procedure, a learning curve was also evident. CONCLUSIONS: Surgeons' experience can influence the complication rate and the chance of successful vaginal salpingo-oophorectomy. More liberal use of gonadotropin-releasing hormone agonist may further reduce the complication rate and allow more vaginal hysterectomies.

Conservative management of placenta praevia with accreta.

It has been advocated that placenta accreta/percreta should be managed conservatively to avoid massive pelvic bleeding and preserve fertility. Diagnosis of this condition with high-resolution imaging investigations performed during the antenatal period facilitates discussion of management plans with other clinical disciplines (eg interventional radiologists), the patient, and her family. Three cases of placenta praevia with accreta are presented. The three cases were managed by leaving the placenta in-utero after caesarean section, using uterine arterial embolisation to control postpartum haemorrhage only when needed. In all these cases, we succeeded in conserving the uterus without major complications. With improved imaging techniques, accurate antenatal diagnosis of placenta praevia with accreta is now possible. This new approach to conservative management can be considered in order to not only conserve the uterus but also to avoid uncontrolled pelvic haemorrhaging.

Application of transcervical hysterofetoscopy and cord blood collection at first trimester termination of pregnancy for fetal abnormalities.

OBJECTIVE: To examine the applicability of hysterofetoscopy and cord blood collection at first trimester termination of pregnancy for fetal abnormalities. METHODS: From 2004 to 2007, transcervical hysterofetoscopy was performed in seven patients at the same operation setting of surgical termination of pregnancy. The findings were compared with prenatal diagnosis. Feasibility of cord blood collection was also examined. RESULTS: Out of these seven patients, six of them had prenatal ultrasound diagnosis of cystic hygroma. All of them had chromosomal abnormalities. Subcutaneous oedema was confirmed by hysterofetoscopy with good view. Another pregnancy was complicated by homozygous alpha thalassaemia and the diagnosis was confirmed by electrophoresis of fetal haemoglobin collected from umbilical cord vessel. Cord blood collection was also attempted in two other patients yielding fetal blood with minimal maternal contamination. CONCLUSION: Transcervical hysterofetoscopy is a feasible tool in confirming external fetal structural abnormalities before surgical termination of pregnancy. It can be performed under either general anaesthesia or conscious sedation. Umbilical cord blood collection can facilitate confirmation of genetic diseases. It may also allow the potential of isolating fetal mesenchymal stem cell in first trimester.

Isolation of Laribacter hongkongensis, a novel bacterium associated with gastroenteritis, from drinking water reservoirs in Hong Kong.

AIMS: Freshwater fish has been found to be the reservoir of Laribacter hongkongensis, a recently discovered bacterium associated with community-acquired gastroenteritis. However, little is known about the ecology of this bacterium in the aquatic environment. We carried out a surveillance study to investigate the presence of L. hongkongensis in water and freshwater fish from 10 drinking water reservoirs in Hong Kong. METHODS AND RESULTS: Using membrane filtration, L. hongkongensis was isolated from the waters of six reservoirs, with numbers ranging from 1 to 12 CFU l(-1). Higher recovery rates were observed in summer and during days of higher water and ambient temperatures. Of 27 freshwater fish collected from the reservoirs, L. hongkongensis was recovered from the intestines of two fish, a Goldfish and a Nile tilapia. Overall, 35 different pulsed-field gel electrophoresis patterns are found among the 59 isolates recovered from water and the two isolates from freshwater fish. CONCLUSIONS: The present report represents the first to demonstrate the presence of L. hongkongensis in natural water environments. SIGNIFICANCE AND IMPACT OF THE STUDY: Although it is unlikely that treated, drinking water is an important source of L. hongkongensis-associated gastroenteritis, one should be aware of the possibility of other contaminated water as a source of human infection.

Vaginal hysterectomies in patients without uterine prolapse: a local perspective.

OBJECTIVE: To review the results of vaginal hysterectomies in patients without uterine prolapse. DESIGN: Retrospective chart review. SETTING: University affiliated hospital, Hong Kong. PATIENTS: Patients who had vaginal hysterectomies in the absence of uterine prolapse, from 1999 to 2005 inclusive. MAIN OUTCOME MEASURES: The number, indications, operative procedures, and complications of such hysterectomies. RESULTS: A total of 94 patients who underwent vaginal hysterectomy fulfilled the inclusion criteria. They accounted for 4.3 to 8.2% of all hysterectomies performed annually for benign diseases in the department, over the inclusive period 2000 to 2004. The incidences of complications, except bladder injuries, were comparable to those reported in other studies. The incidence of vault haematoma decreased as each surgeon's experience increased and more attention was paid to 'bleeders' at the 'four and eight o'clock areas' and more cephalic regions of the vaginal incision. Increased size of the uterus was an important determinant of the risk of complications. CONCLUSIONS: Vaginal hysterectomy is an underutilised approach in Hong Kong. With more experience and better patient selection, complication rates can be further reduced. Further evaluation is suggested for the role of bleeders at 'four and eight o'clock regions' as potential causes of vault haematoma.

Continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries after the study period: was this the Hawthorne effect?

BACKGROUND: The incidence of birth trauma and birth asphyxia related to instrumental deliveries in our obstetric unit was high (2.8%) in 1998-1999. A study was performed in 2000 to identify the risk factors. Unexpectedly, the incidence (0.6%) was reduced significantly during the study period. We attributed this phenomenon to the famous Hawthorne effect (tendency to improve performance because of awareness of being studied). OBJECTIVES: The objectives were to study whether there is a continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period (2001-2003) and to investigate the presence of underlying confounding factors apart from the Hawthorne effect. METHOD: To compare the hospital obstetric statistics among the pre-study period (1998-1999), the study period (2000) and the post-study period (2001-2003), in particular the incidence of birth trauma and birth asphyxia related to instrumental deliveries, the instrumental delivery rate, the overall Caesarean section rate, the Caesarean section rate for no progress of labour, the incidence of failed instrumental delivery, the incidence of attempted instrumental delivery in the operating theatre, and incidence of direct second-stage Caesarean sections. RESULTS: The incidence of birth trauma and birth asphyxia related to instrumental deliveries (0.6%) during the study period (2000) was significantly lower than that (2.8%) during the pre-study period (1998-1999; RR 0.27, 95% CI 0.11-0.70). This phenomenon continued into the post-study period (2001-2003) when the incidence of 1.0% was similarly lower than that in the pre-study period (RR 0.35, 95% CI 0.20-0.64). The instrumental delivery rate decreased further in the post-study period (13.5%) compared with those in the study (16.6%) and pre-study (19.5%) periods (RR 0.81, 95% CI 0.75-0.89 and RR 0.69, 95% CI 0.65-0.74, respectively). There was a marked increase in the direct second-stage Caesarean section rate in the post-study period (7.1%) compared to those in the study (0.4%) and pre-study (0.7%) periods (RR 15.9, 95% CI 5.05-49.73 and RR 9.77, 95% CI 5.28-18.08, respectively). CONCLUSION: A change in obstetric practice was identified that may explain the continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period.

The practice of episiotomy in public hospitals in Hong Kong.

OBJECTIVE: To review the use of episiotomy during vaginal delivery in Hong Kong public hospitals. DESIGN: Prospective observational survey. SETTING: Public hospitals, Hong Kong. PARTICIPANTS: Women who underwent normal vaginal delivery of a singleton foetus with cephalic presentation. MAIN OUTCOME MEASURES: Number of women having an episiotomy, severe-degree (third- or fourth-degree) tear, other types of tear, blood loss at delivery, postpartum haemorrhage, need for blood transfusion, puerperal pyrexia, wound infection, gaping wound that required suture removal, and drainage or resuturing of a perineal wound. RESULTS: Between 1 January and 31 March 2003, there were 6222 singleton spontaneous normal vaginal deliveries in the public hospitals of Hong Kong. Of the 6167 women in whom the status of the perineum was known, episiotomy was performed in 5274 (85.5%). Primiparous women were more likely to undergo episiotomy at delivery than multiparous women (97.9% vs 71.4%). Women with episiotomy had significantly less perineal tearing of any kind than those without. The occurrence of any type of perineal tear and severe-degree (third- or fourth-degree) tear was significantly lower in primiparous women who had an episiotomy than those without (P<0.05). Women with episiotomy had increased mean blood loss at delivery but other complications were not significantly increased. CONCLUSIONS: In Hong Kong, episiotomy is routinely performed during normal vaginal delivery. It is associated with a significantly lower overall rate of perineal tearing. This study was observational, nonetheless the occurrence of other complications was likely to increase when episiotomy was performed. Firm evidence from several randomised controlled studies shows that routine episiotomy is unjustified and possibly harmful. Routine episiotomy should not be promoted in Hong Kong without further randomised controlled study.

Efficacy of preemptive analgesia for wound pain after laparoscopic operations in infertile women: a randomised, double-blind and placebo control study.

OBJECTIVE: To compare preemptive analgesia and preclosure analgesia in reducing wound pain after laparoscopic operation. DESIGN: Randomised, double-blind and placebo control. SETTING: University referral centre. POPULATION: Infertile women undergoing diagnostic laparoscopy with or without additional procedures. METHODS: One hundred and forty-four women were randomised to receive 10 mL of 1% lignocaine at the surgical sites before incision and 10 mL of normal saline before closure of incision (the preemptive group), saline before incision and lignocaine before closure of incision (the preclosure group) and saline at the surgical sites both before incision and closure of incision (the placebo group). MAIN OUTCOME MEASURES: Post-operative wound pain measured by linear visual analogue scale and amount of analgesic use. RESULTS: The women in the preclosure group had significantly lower pain scores at 2, 4 and 24 hours than those in the placebo group, whereas the women in the preemptive group only showed significantly lower pain scores at 2 hours than the placebo group. The pain score at 24 hours in the preclosure group was significantly lower than that in the preemptive group. There was no significant difference in the post-operative analgesic requirement among the three groups. CONCLUSION: The preclosure analgesia is better than preemptive analgesia and no analgesia in reducing post-operative wound pain.

A pilot study on the acceptability of levonorgestrel-releasing intrauterine device by young, single, nulliparous Chinese females following surgical abortion.

This study investigated the acceptability of the levonorgestrel-releasing intrauterine device (LNG-IUS) as contraception among young, single women after termination of pregnancy. Twenty subjects, with a median age of 21 years, had LNG-IUS inserted immediately after suction termination of first-trimester pregnancy. The subjects were followed-up at 6 weeks, 3 months, 6 months and 12 months. Fifteen subjects (75%) had other pregnancies terminated in the past. There were no serious complications or pregnancies. The acceptability of the LNG-IUS was generally above 86% during each follow-up visit. A total of seven (35%) subjects were lost to follow-up at different periods of the study. Overall, four subjects (22%) had the LNG-IUS removed. Nine subjects were seen at the end of the 1-year study period and all continued with the LNG-IUS for contraception. Side effects were commonly observed and irregular vaginal bleeding was the most common. We conclude that the LNG-IUS may be an acceptable method among selective young, single, nulliparous clients after termination of pregnancy and could be offered as an option of contraception to them. However, the small sample size and the high lost-to-follow-up rate are the major limitations of this study.

A retrospective review on atypical glandular cells of undetermined significance (AGUS) using the Bethesda 2001 classification.

OBJECTIVE: The Bethesda system for reporting cervicovaginal cytologic diagnoses was recently revised in 2001. Pathologists are required to report not only whether the smear favors neoplastic changes, but also the origin of the abnormal cells. In this study, archival smears were reviewed to evaluate the usefulness of the new classification. METHODS: Smears having atypical glandular cells taken between January 1995 and December 1997 were reviewed and subclassified according to the revised Bethesda classification. Case records were then reviewed and cases with discrepancies between the cytological evaluation and corresponding final histological diagnoses were further reviewed. RESULTS: There were 138 smears reviewed. The mean age of the patients was 47 (range, 18 to 78). Thirty-four smears favored neoplasia and 104 favored "NOS" ("not otherwise specified"). Sixty smears favored endocervical origin and 78 endometrial origin. Forty-three patients (31%) had significant pathologies, including 12 (8.7%) patients with high-grade CIN, 2 (1.4%) with low-grade CIN, 5 (3.6%) with HPV infection, 7 (5.1%) with carcinoma of the corpus, 1 (0.7%) with cervical adenocarcinoma in situ, 4 (2.9%) with adenocarcinoma of the cervix, 3 (2.2%) with endometrial hyperplasia, and 5 (3.6%) with carcinoma of the ovary. Two (1.4%) patients had double primary female genital malignancies and 2 patients (1.4%) had extragenital malignancies. Significant correlation was found between smears "favor neoplasia" and a final diagnosis with significant pathology (chi(2) test, P < 0.05). Significant association was found between AGC favored endocervical origin and a final diagnosis with cervical diseases (chi(2) test, P < 0.05). Four of the 43 patients who had significant pathologies had lesions found during their subsequent visits and all of them had cervical smears classified as AGC "favor neoplasia". CONCLUSION: AGC found on cervical smears are an indication for early and intensive investigation.

Left upper quadrant approach in gynecologic laparoscopic surgery using reusable instruments.

STUDY OBJECTIVE: To determine the usefulness of the left upper quadrant approach in gynecologic laparoscopic surgery. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University referral center. PATIENTS: Twenty-four women with longitudinal scars from previous laparotomy through or close to the umbilicus. INTERVENTION: Left upper quadrant was chosen as the site of primary entry of the reusable Veress needle (ninth or tenth left intercostal space) and reusable primary cannula (left upper quadrant just below the left subcostal margin). MEASUREMENTS AND MAIN RESULTS: Intraabdominal adhesions between old longitudinal scars and underlying bowel or omentum were present in 14 patients. Adhesions involving omentum only were present in 10 patients, bowel only in 2, and both omentum and bowel in 2. The only intraoperative complication was emphysema in one woman. All operative procedures were completed laparoscopically. CONCLUSION: The left upper quadrant approach is a safe entry point for reusable instruments at laparoscopic surgery in patients with midline incisions close to the umbilicus.

Preterm birth unrelated to maternal height in Asian women with singleton gestations.

OBJECTIVE: To determine whether maternal height has a significant effect on the length of gestation or the incidence of preterm birth in Asian women with singleton gestations. METHODS: We retrospectively studied a cohort of consecutive adult Asian women with singleton gestations who delivered in a 2-year period, to determine the relationship between maternal height, expressed in quartiles, and the mean gestational age and incidence of preterm birth. RESULTS: Of the 9819 deliveries during that period, 449 were excluded from analysis because of multiple gestation, maternal age less than 20 years, or incomplete data because of no antenatal care in our hospital. The 25th, 50th, and 75th percentile values of maternal height were 152, 156, and 160 cm, respectively. Significant differences were found in the maternal age, weight and body mass index (BMI), birth weight, and birth weight as a percentage of maternal weight, among the four quartiles, but the trend for age, BMI, and birth weight percentage was opposite to that of maternal weight and birth weight. However, there was no significant difference in the mean gestational age or incidence of preterm birth at less than 28, 28-31, or 32-36 weeks' gestation. There was no difference in the incidence of pregnancies beyond 41 weeks' gestation. CONCLUSION: Maternal stature does not have a significant influence on the mean gestational age or incidence of preterm birth in adult Asian women with singleton gestations.

7Alpha-methyl-19-nortestosterone maintains sexual behavior and mood in hypogonadal men.

The synthetic steroid 7alpha-methyl-19-nortestosterone (MENT) is a potent androgen that is resistant to 5alpha-reductase. It thus has decreased activity at the prostate and may have advantages over testosterone-based regimens in long term treatment or as part of a male contraceptive. Administration to eugonadal men results in suppression of gonadotropins, but its ability to support androgen-dependent behavior has not been investigated. For sustained release administration, MENT acetate was used, because its diffusion characteristics were more suitable for use in implants. However, upon release the acetate is rapidly hydrolyzed, and MENT is the biologically active moiety in circulation. We studied the effects of MENT on sexual interest and activity, spontaneous erection, and mood states in comparison with testosterone enanthate (TE) in 20 Caucasian and Chinese hypogonadal men recruited in Edinburgh and Hong Kong (n = 10 in each center). Outcomes were measured using a combination of daily diaries, semistructured interviews, and questionnaires. Nocturnal penile tumescence (NPT) was also recorded in the Edinburgh group. After withdrawal of androgen replacement treatment (wash-out phase) for a minimum of 6 weeks, subjects were randomized to two groups in a cross-over design. Drug treatment regimens were of 6-week duration and consisted of two implants, each containing 115 mg MENT acetate, inserted s.c. into the upper arm and removed after 6 weeks and two injections of TE (200 mg, i.m.) 3 weeks apart. MENT treatment resulted in stable plasma MENT concentrations of 1.4 +/- 0.1 nmol/L after 3 weeks and 1.3 +/- 0.1 nmol/L after 6 weeks (mean +/- SEM; all men). Nadir testosterone concentrations were 3.6 +/- 0.6 nmol/L at the end of the wash-out phase and 9.4 +/- 0.6 nmol/L 3 weeks after each injection. There were no differences in hormone concentrations between centers. There were no adverse toxicological effects. There were only minor differences between the two treatments. Both MENT and TE treatment resulted in significant increases in sexual interest and activity, spontaneous erection (both by self-report and NPT measurement), and increases in positive moods, with decreases in negative moods in the Edinburgh group. In the Hong Kong group, both treatments increased waking erection, with a trend toward increased sexual interest and activity. Mood states appeared to be less affected during the wash-out phase than in Edinburgh men and showed no significant response to either treatment. These results demonstrate that MENT has similar effects on sexual activity and mood states as testosterone in hypogonadal men. As NPT is a physiological androgen-dependant outcome, these data provide further evidence for the androgenicity of MENT. The lack of detected effect of either androgen in Hong Kong men other than on waking erection illustrates the importance of the cultural context of symptomatology and its measurement. The appropriate dose of MENT remains to be determined, but these results support its development as a potential androgen replacement therapy.

Prevention of postoperative nausea and vomiting in gynaecological laparotomies: a comparison of tropisetron and ondansetron.

In a randomized, double-blind study, the antiemetic efficacy of a single bolus of tropisetron 5 mg (group T, 37 patients), ondansetron 4 mg (group O, 39 patients) or saline (group C, 45 patients) given at induction was compared in a homogeneous group of 121 patients undergoing gynaecological laparotomy and receiving postoperative patient-controlled intravenous morphine for 24 to 48 hours. Fewer group T and group O patients developed severe nausea compared to group C (P < 0.01, log rank test in Kaplan-Meier analysis). Group T patients also had lower nausea scores than group O at 8 to 16h (P < 0.05). The overall incidences of severe nausea in groups T, O, and C were 5.4%, 17.9%, and 44.4% respectively (P < 0.001, group T vs group C; P < 0.05 group O vs group C). In conclusion, the 5-hydroxytryptamine 3 receptor antagonists tropisetron and ondansetron were superior to placebo in preventing PONV.

Undiagnosed breech revisited.

OBJECTIVES: To study the incidence of undiagnosed breech and to compare the obstetric outcome with those diagnosed before the onset of labour in a local teaching hospital where external cephalic version at term is routinely offered. DESIGN: A retrospective casenote analysis. SETTING: Tsan Yuk Hospital, a teaching hospital in Hong Kong. PARTICIPANTS: One hundred and thirty-one women with a singleton breech presentation at term, delivered in a local teaching hospital from 1 January 1997 to 31 December 1997. The group of 22 women who had successful external cephalic version performed was included. RESULTS: Breech presentation was diagnosed at the antenatal clinic in 103 women (79%). In the remaining 28 women (21%), breech presentation was diagnosed for the first time after the onset of labour. Undiagnosed breech presentations were more likely to deliver vaginally (42%) than those diagnosed at the antenatal clinic (11%) (P < 0.001). Vaginal delivery was still more common in the undiagnosed group (46%) than the diagnosed group (26%), even when the group with successful external cephalic version was included (P < 0.05), although the difference became less obvious. The demographic characteristics, birthweight, type of breech and short term neonatal outcomes were comparable between the two groups. CONCLUSION: It is important to include women who had successful external cephalic version when comparing the obstetric outcome of undiagnosed and diagnosed breeches. Careful assessment for vaginal delivery is still very useful even when breech presentations are first diagnosed after the onset of labour because the infants are even more likely to deliver vaginally with no great excess of neonatal morbidity.