Prenatal diagnosis of lipomyelomeningocele by ultrasound and magnetic resonance imaging (MRI).

OBJECTIVE: The authors report a case of a lipomyelomengocele with tethered cord, revealed on prenatal ultrasonography and confirmed by fetal magnetic resonance imaging (MRI). MATERIALS AND METHODS: A 32-year-old woman, gravida 1 para 1 underwent the routine second trimester prenatal ultrasound scan at 22(+5) weeks of gestation at the present hospital. RESULTS: The scan indicated an echoic semisolid subcutaneous mass covered by skin, posterior to the lumbosacral spinal canal of the fetus. Based on the findings indicating occult dysraphism, a fetal MRI examination was conducted, revealing that the mass was extending to the spinal cord, tethering the cauda equina. The diagnosis of lipomyelomeningocele was established. CONCLUSION: Lipomyelomeningocele is a form of closed neural tube defect with unclear predisposing factors. Its prevalence ranges between 0.3 and 0.6 per 10,000 live births. It leads to progressive conus tethering with associated neurological, urinary, and gastrointestinal deficits, demonstrating the importance of prenatal diagnosis.

Mild ovarian hyperstimulation syndrome coexisting with ectopic pregnancy after in vitro fertilization.

Ovarian hyperstimulation syndrome (OHSS) is an entity arising in women undergoing assisted reproductive techniques (ART). The simultaneous presence of two different clinical complications such as OHSS and ectopic pregnancy (EP) is not frequent. The diagnosis of an extrauterine pregnancy can be obscured by the stimulated ovaries and ascites, and actually be missed, especially in women with increased body mass index. We report a case of a woman who presented with mild OHSS after in vitro fertilization (IVF), (intracytoplasmatic sperm injection (ICSI) and embryo transfer). The ectopic pregnancy was ascertained soon after by transvaginal ultrasound (TVS) and right salpingectomy was performed.

Outpatient hysteroscopy: traditional versus the 'no-touch' technique.

OBJECTIVE: To assess whether outpatient hysteroscopy using the 'no-touch' technique confers any advantages in terms of patient discomfort over the traditional technique. DESIGN: Prospective randomised controlled study. SETTING: Outpatient hysteroscopy clinic in a large university undergraduate teaching hospital. POPULATION: All women referred for outpatient hysteroscopy in a 12-month period. INTERVENTIONS: Women were randomised to undergo either traditional saline hysteroscopy requiring the use of a speculum and tenaculum, or a 'no-touch' vaginoscopic hysteroscopy which does not require a speculum or tenaculum. Each group was further subdivided to have hysteroscopy with either a 2.9-mm or 4-mm hysteroscope. Patients were asked to complete pre- and postprocedure questionnaires ranking pain scores. MAIN OUTCOME MEASURES: The relative success of each of these techniques, requirement for local anaesthetic and pain scores at different times during the hysteroscopy were recorded at the end of the procedure. The time taken to carry out each procedure was also measured. RESULTS: One hundred and twenty women were recruited in this study: 60 were randomised to traditional hysteroscopy and 60 to 'no-touch' hysteroscopy. The overall success rate for hysteroscopy was 99%. There was no significant difference in the requirement for local anaesthetic between the two groups, but those who underwent 'no-touch' hysteroscopy with a 2.9-mm hysteroscope had the lowest requirement of local anaesthetic (10% compared with 27% in the no-touch hysteroscopy with a 4-mm hysteroscope group). The time taken to perform hysteroscopy and biopsy was significantly shorter with 'no-touch' hysteroscopy (5.9 vs 7.8 min; difference 1.9, 95% CI 0.7-3.1). There were no differences in pain scores between the groups at different times during hysteroscopy. CONCLUSIONS: 'No-touch' or vaginoscopic hysteroscopy is significantly faster to perform than the traditional technique. Although there was no difference in pain scores between the two techniques, local anaesthetic requirements were least in those who underwent 'no-touch' hysteroscopy with a narrow bore hysteroscope.

Ectopic missed abortion after laparoscopic sterilization with the harmonic scalpel.

A case of a patient who presented with ectopic pregnancy and subsequent missed abortion one year after laparoscopic sterilization with the harmonic scalpel is reported. According to our knowledge of the relevant literature, this is the first time that a case of ectopic pregnancy after sterilization with a harmonic scalpel has been reported.

One stop fertility clinic.

UNLABELLED: The objective of this study was to determine the feasibility and acceptability of out-patient based investigation of infertile couples using a prospective observational study based in a large undergraduate teaching hospital. We studied couples referred to secondary care for investigation of their infertility. Investigations involved pelvic ultrasound, diagnostic hysteroscopy and culdoscopy. The main outcome measures were feasibility of investigations, findings, patient views, and a management plan. RESULTS: 199 of 347 (57.3%) couples referred met our selection criteria, and 162 of this group have attended. Thirty-one (19.1%) were judged to be unsuitable for culdoscopy, and culdoscopy failed in a further 29 (17.9%). The average time for the three procedures was 41.2 (SD 17.2) minutes, and over 1/3 of patients were found to have pelvic pathology. The investigations were well tolerated and there was only one complication necessitating admission to hospital. Most patients appreciated the need for a single hospital visit and the availability of immediate results. CONCLUSIONS: A One Stop approach to the investigation of infertility is attractive but not suitable for or desired by all infertile couples. Organisational issues were also identified.

Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial.

OBJECTIVES: To evaluate triple tourniquets in controlled conditions and for the first time to investigate the hypothesis that leaving a semi-permanent tourniquet around the uterine artery reduces post-operative bleeding from the uterine incisions. DESIGN: A randomised controlled trial. SETTING: Two University teaching hospitals. POPULATION: Twenty-eight patients with symptomatic fibroids and uterine sizes ranging from 14 to 24 weeks of gestation undergoing open myomectomy. METHODS: A number 1 polyglactin suture was tied around the cervix to occlude the uterine arteries, and polythene tourniquets were tied around the infundibulopelvic ligament to obstruct the ovarian vessels. At the end of the procedure, the ovarian ties were released but the uterine artery suture remained in situ. MAIN OUTCOME MEASURES: Intra-operative blood loss, post-operative blood loss, blood transfusion rates, operative morbidity, uterine blood flow and ovarian function. RESULTS: There was significantly less blood lost in the tourniquet group than in the control group (difference between means 1870 mL, 95% CI 1159-2580 mL, P < 0.0001; transfusion rates of 7% and 79%, P= 0.0003). The volume in the pelvic drain 20 min post-operatively and after 48 hours failed to reach statistical significance between the two groups (P= 0.10 and P= 0.165). There were no differences in uterine artery Doppler resistance indices at five days (P= 0.54), six weeks (P= 0.47), three months (P= 0.49) and at six months (P= 0.18). Day two serum FSH concentrations after surgery were unchanged (P= 0.45), compared with baseline values. CONCLUSIONS: Triple tourniquets are effective in reducing bleeding and transfusion rates. There appears no obvious adverse effect on uterine perfusion or ovarian function.

Evaluation of fetal heart monitoring in the first stage of labor.

OBJECTIVE: To evaluate the usefulness of continuous electronic fetal heart rate (FHR) monitoring in the first stage of labor. METHODS: A total of 814 pregnant women in labor without identifiable risk factors was divided into two groups. In group A (468 cases), continuous FHR monitoring began in the earliest phase of the first stage of labor (cervical dilatation < or = 4 cm), while in group B (346 cases) it began when the cervical dilatation was > 4 cm. Initial FHR tracings were normal in all 814 cases. The fetal monitoring findings were analyzed at 10-min intervals, and comparisons were made between the two groups concerning FHR findings and their correlation with the state of the newborns. RESULTS: No significant difference was found between the two groups in the incidence of repetitive variable decelerations (1.9% and 1.7%, respectively); sporadic variable decelerations (9.2% and 8.7%, respectively); persistent repetitive late decelerations that resulted in Cesarean section (1.1% and 1.4%, respectively); or sporadic late decelerations (8.3% and 8.1%, respectively). One newborn from each group required intensive neonatal care. CONCLUSIONS: The same tracing sufficiency of fetal stress was observed in the two groups. However, the manner of labor supervision in group B seemed to be more beneficial, because of greater maternal comfort, a lower necessity for personnel, lower consumption of cardiotocographic materials and the possibility of labor induction for more women. Since fetal monitoring is widely used, it is preferable to start continuous FHR monitoring when the dilatation of the cervix approximates 4-5 cm (second phase of the first stage of labor) without risk of fetal loss.

Maternal prolactin secretion during labor. The role of dopamine.

BACKGROUND: To investigate the role of dopamine on the mechanisms of maternal prolactin secretion during labor and in the first six hours following delivery. METHODS: The study included 30 pregnant women with normal pregnancies, who were meeting the same criteria. They were divided into three subgroups of 10 patients each and they delivered healthy newborns. Group A was the control group. Metoclopramide 10 mg/h intravenously was given in Group B, while bromocryptine 5 mg per os was given in Group C. Maternal blood samples were obtained every hour during labor and in the six hours postpartum. Prolactin values were determined by using a radioimmunoassay method. RESULTS: Metoclopramide infusion caused an initial significant (p<0.01) rise in PRL level in Group B. Prolactin levels showed the same multiphasic pattern during labor and first h postpartum in both Groups A and B. PRL levels decreased until 1-2 h antepartum, then increased for about 3 h and they finally decreased, starting at 2 h postpartum and reaching values lower than the basic at 6 h postpartum. However, absolute PRL values were higher in Group B (where metoclopramide was given) than in Group A, in every time point. Bromocryptine (Group C) markedly lowered PRL levels, but PRL fluctuation still followed the same trends as in the other two groups. CONCLUSIONS: The different PRL values between the three groups show that maternal PRL is still under dopaminergic influence during labor. However, the fact that PRL levels exhibit the same multiphasic pattern, suggests that there are factors other than dopamine, which strongly influence this pattern.