Influence of the mode of delivery on maternal and neonatal outcomes: a comparison between elective cesarean section and planned vaginal delivery in a low-risk obstetric population.

OBJECTIVE: The aim of the study was to compare the maternal and neonatal morbidity associated with elective cesarean sections with planned vaginal delivery. METHODS: A total of 178 women with elective cesarean section were compared with the next parity- and age-matched women presenting in spontaneous labor. Our analysis was restricted to a sample of low-risk obstetrical women. Maternal and neonatal outcomes were the main outcome variables of interest. Maternal morbidity outcome variables included wound infection, trauma, puerperal febrile morbidity and significant blood loss (>500 ml). Neonatal outcomes were captured by Apgar scores, cord pH as well as the occurrence of neonatal infections. RESULTS: A significantly higher rate of puerperal febrile morbidity (n = 46 vs. 14, p = 0.0001) and wound infections (n = 16 vs. 2, p = 0.0001) could be detected in the elective cesarean section group. Additionally, a significant blood loss > 500 ml was more than twice as frequent in the cesarean section group (n = 22 vs. 10, p = 0.03) with non-significant lower postpartum hemoglobin levels being observed (10.4 vs. 11.2 g/dL, p > 0.05). A significant increase for the use of iron supplementation (n = 146 vs. 122, p = 0.002), analgesics (n = 168 vs. 60, p = 0.0001) and antibiotics (n = 48 vs. 18, p = 0.0001) could be found in the puerperal period and hospital admission was prolonged in elective cesarean section (6.8 vs. 3.5 days, p = 0.0001). Additionally, problems in breastfeeding occurred more frequently in this group (n = 18 vs. 4, p = 0.002). Neonatal complications were generally low in both the groups with no significant differences being observed (p > 0.05). CONCLUSION: The increased maternal morbidity in elective cesarean section included puerperal febrile morbidity, wound infections as well as breastfeeding problems in the postpartum period. Women should be sufficiently counseled regarding the increased risk of these complications.

First trimester uterine rupture and scar pregnancy.

Uterine rupture during the first trimester of pregnancy is an extremely rare, but life-threatening cause of intraperitoneal hemorrhage. Up to the knowledge of the authors all reports of first trimester uterine ruptures are related to scar dehiscences following previous cesarean sections or occurred in unscarred uteri of multiparous women. In cases of multiparity silent ruptures cannot be precluded, so that the uterus might be scarred during the following pregnancy. In early pregnancy of approximately 4-5 weeks, vaginal ultrasonography may clearly verify a scar pregnancy, but sonographical diagnostic findings may change with the pregnancy progress. In all cases of reported first trimester ruptures in pregnancies with previous cesarean sections or in pregnancies of multiparous women reported in literature, dating scans were performed too late for to preclude pregnancies in the scar. We postulate our hypotheses, that all first trimester uterine ruptures are caused by scar implantation of the trophoblast.

Fluorescence diagnosis of bladder cancer with new water soluble hypericin bound to polyvinylpyrrolidone: PVP-hypericin.

Although conventional white light endoscopy (WLE) is currently the gold standard for diagnosing bladder tumors, rates of false negative results and residual tumors after transurethral resection are relatively high. The goal of the present clinical study is to investigate whether using new water soluble hypericin (PVP-hypericin) as a fluorescent dye improves bladder cancer detection and diagnosis. Following instillation of PVP-hypericin (total amount of 0.25 mg hypericin bound to 25 mg polyvinylpoyrrolidone [PVP], reconstituted in 50 mL phys. sodium chloride solution), WLE and fluorescence cystoscopy (photodynamic diagnosis; PDD) were performed on patients with suspected primary or recurrent bladder malignancies (n = 57). Incubation time was 1-2 h and biopsies (n = 163) were taken from fluorescing regions and/or from regions which were suspicious under WLE. Histological investigations of the biopsies provided the final proof of malignancy (or the counterevidence). Results indicated that overall sensitivity with PVP-hypericin and PDD is significantly higher (95%) than with WLE (85%). The sensitivity of PDD in the diagnosis of carcinoma in situ (n = 12) was 100% compared with 33% for WLE. In the diagnosis of dysplasia, the sensitivity of PDD was 85% compared with 31% for WLE. PDD has a positive predictive value (PPV) of 0.75% and a negative predictive value (NPV) of 0.86%, in comparison to WLE PPV = 0.66% NPV = 0.58%. Biopsies were not taken from healthy tissues, thus specificity was markedly lower in our study (53%) than that reported in other studies (98-100%). As a conclusion, PDD using PVP-hypericin is superior to WLE in terms of sensitivity in the diagnosis of malignancies of the bladder. Results suggest that PVP-hypericin is a promising formulation for various diagnostic and therapeutic applications.

Parenchymatous pulmonary endometriosis - metastases of a low-grade endometrial stromal sarcoma?

Based on the data of a case of parenchymatous endometriosis of the lung in which three and a half years later a low-grade endometrial stromal sarcoma of the uterus was diagnosed the origin of this disease is discussed. The follow up of this patient gave the impression that the pulmonary nodules were early metastases of low-grade endometrial stromal sarcoma, which was initially not detected in the routine gynecologic examination. Furthermore, as histological and immunohistochemical examinations are not sufficient to distinguish reliable between endometriosis of the lung and pulmonary metastases from low-grade endometrial stromal sarcoma. In literature, in none of the few cases of parenchymatous pulmonary endometriosis a hysterectomy was performed to exclude a low-grade endometrial stromal sarcoma. Thus, parenchymatous pulmonary endometriosis nodules might be metastases and their occurrence should cause the treating physician to consider a distant metastatic spread from low-grade endometrial stromal sarcoma.

Cold-knife conization versus photodynamic therapy with topical 5-aminolevulinic acid (5-ALA) in cervical intraepithelial neoplasia (CIN) II with associated human papillomavirus infection: a comparison of preliminary results.

BACKGROUND: The optimal treatment of preinvasive cervical lesions is still not clear as all surgical techniques cause substantial cervical stroma destruction with the risk of a possible incompetent cervix. Photodynamic therapy can preserve fertility due to selective tissue destruction. The aim of the present study was to compare the efficacy of cold-knife conization versus photodynamic therapy with topical 5-aminolevulinic acid in eradicating cervical intraepithelial neoplasia (CIN) II and associated HPV infection. PATIENTS AND METHODS: Eleven HPV-positive non-pregnant women were selected for photodynamic therapy (PDT). To be eligible for this procedure superficial cervical PAP smears as well as colposcopic biopsies performed before therapy had to show CIN II with the lesion involving at least 15% of the cervix and being colposcopically visible. The deep endocervical PAP smear had to show normal endocervical epithelium. The next (following each PDT) 11 HPV-positive women with CIN II treated with cold-knife conization were used as a control group. The cervical sampling for HPV DNA was performed 3 months after conization and PDT. Patients were followed-up for 1 year with cytological smears and colposcopy at the outpatient department of the hospital. RESULTS: Follow-up at three months revealed that HPV was eradicated by both techniques in 73%. After 12 months follow-up, 100 vs. 91% (conization vs. PDT) of the patients were disease-free. No systemic side-effects and no local necrosis, sloughing or scarring occurred due to PDT. One patient treated with PDT presented with a relapsing suspicious PAP smear and an abnormal white colposcopic lesion after application of acetic acid 6 months post-PDT. A subsequent conization was performed and revealed a CIN I lesion. No statistically significant differences concerning HPV eradication (p > 0.05) and recurrence (p > 0.05) could be observed between the two methods. CONCLUSION: The results presented in this study indicate that topical PDT with 5-ALA is in most cases a successful treatment of CIN II with comparable results to cold-knife conization. In contrast to cold-knife conization, PDT causes no substantial cervical stroma destruction with the risk of a possible subsequent incompetent cervix. Also the feasibility of topical PDT on an outpatient basis, the lack of significant post-treatment complications and the cost effectiveness make the topical approach with PDT preferable in selected circumstances. Due to the potential risk of invasive cancer with metastatic spread, patient's selection criteria must be strict and a pretreatment histological examination is obligatory.

Dehydroascorbic acid in urine as a possible indicator of surgical stress.

BACKGROUND/AIM: L-Ascorbic acid (AA) is the predominant circulating form of vitamin C found in human blood. It has been hypothesized that surgical stress increases the vitamin C metabolite dehydroascorbic acid (DHAA). Vitamin C is mainly excreted through the kidneys. In this study, the ratio of AA to DHAA excreted in urine was determined in patients who had undergone total hip joint endoprosthesis surgery (n = 12), and the results were compared with data obtained from healthy controls (n = 12). METHODS: All subjects received 1,000 mg sodium ascorbate intravenously three times a day (every 8 h) for 8 days, starting 2 days prior to surgery. Total urine was collected daily while subsequent determinations of AA and DHAA were performed photometrically. RESULTS: Administration of vitamin C led to average daily excretions of the combined products AA + DHAA of 2,343 +/- 438 mg/day (mean value +/- confidence intervals). The initial average ratio DHAA/AA of all 24 probands was 0.064 (6% DHAA; 153 +/- 76 mg/day). One day after surgery, an increase in the DHAA/AA ratio to 0.165 (15% DHAA; 332 +/- 107 mg/day) was measured in the patients. The ratio decreased 2 days after surgery and returned to normal within 5 days. CONCLUSION: Our data indicate that surgery increases the oxidation of AA and urinary excretion of DHAA, as a result of the enhanced formation of free radicals.

"Z"-plasty of the transverse vaginal septum using Garcia's procedure and the Grünberger modification.

OBJECTIVE: Evaluation of the Grünberger modification of Garcia's "Z"-plasty of the obstructed and nonobstructed transverse vaginal septum. DESIGN: Description of the surgical procedure and record of postoperative results and follow-up evaluations yearly after the operation. SETTING: Department of gynecology and obstetrics at a university hospital. PATIENT(S): The operation was performed over a period of 25 years on 13 patients. INTERVENTION(S): Z-plasty of the obstructed and nonobstructed transverse vaginal septum using Grünberger's modification of Garcia's procedure. MAIN OUTCOME MEASUREMENT(S): Width of the vagina and quality of postoperative sexual life. RESULT(S): In all cases, a functioning vagina with at least a 4-cm width in the former area of the septum was created and no postoperative contractures occurred. Lubrication during copulation is perceived to be adequate. A satisfactory sexual life was reported by all of the patients. Cosmetically, the results were always satisfying. CONCLUSION(S): The Grünberger modification of the Garcia Z-plasty method is a convenient and effective technique for the surgical treatment of transverse vaginal septa.

Vaginoplasty using deepithelialized vulvar transposition flaps: the Grünberger method.

BACKGROUND: One of the most important criteria indicative of the longterm success of vaginal enlargement is the absence of postoperative contracture. Numerous procedures have been developed for reconstruction of an inadequate vagina. Some are technically complex techniques (myo- and fasciocutaneous flaps) with few postoperative complications of vaginal contracture, and others implement autografts with a greater tendency of tissue contraction. STUDY DESIGN: We report here a method of vaginoplasty using deepithelialized vulvar transposition flaps to enlarge the width of narrow vaginas found mainly in cases of congenital adrenogenital syndrome-associated vaginal atresia, but also in cases of acquired vaginal atresia (surgery and radiotherapy-induced). We used deepithelialized dermis from the labia majora to construct an enlarged vaginal entrance and cavity, a technique that is easy to learn and perform. RESULTS: The healing phase of this operation is free of tissue rejection, most likely because of the close embryologic relationship of the cornified, paravaginal squamous epithelium of the labia majora and the noncornified squamous epithelial lining of the lower third of the vagina. The epithelium of the graft loses its cornified layer and becomes nonhair-bearing; its cytology and histology mimic normal vaginal epithelium. Postoperative function and sexual contentment were reported to be satisfying. CONCLUSIONS: The followups of 17 patients who underwent this operation in the last 16 years show optimal cosmetic and functional results.

Photodynamic action of some sensitizers by photooxidation of luminol.

We report the development of a novel simple experimental method which allows the comparison of new photosensitizers based on their production of reactive oxygen species. A high-performance liquid chromatography (HPLC) assay permits the monitoring of several substances (sensitizer, reactant and oxidized end product) simultaneously on a single chromatogram. Photoreactions were monitored throughout their course by the HPLC assay surveying the sensitizers' efficiency of singlet oxygen production by the oxidative decomposition of luminol. Several photosensitizers were tested: Rose Bengal, Methylene Blue, Protoporphyrin IX, Photosan III, Photofrin, Hypericin and Pseudohypericin. Additionally, photoreactions were monitored by a standard pO(2) detection system. The measurements of the two detection methods were strongly correlated. Rose Bengal proved to be the most efficient photosensitizer, clearly decreasing the luminol concentration and causing a corresponding increase in aminophthalic acid. Our experiments show that when factors necessary for photochemical reactions are absent or are blocked (antioxidants), no reaction can be detected.

Intravenous leiomyomatosis of the uterus.

BACKGROUND: Intravenous leiomyomatosis is a rare uterine tumor defined as an intraluminal growth of benign smooth muscle cells in either venous or lymphatic vessels outside the confines of, or even in absence of leiomyomas. We report a case of intravenous leiomyomatosis of the uterus managed at our institution. CASE REPORT: The patient, a 47-year-old woman; gravida 2 para 2, presented without complaints for a routine gynecological examination. An irregular-shaped enlarged uterus with a nodular pelvic mass extending into the broad ligament was found Laparotomy revealed a large retroperitoneal, moderately firm tumor which demonstrated fingerlike projections into the pelvic veins. Due to great blood loss, surgery had to be discontinued with substantial residual disease and our patient was set on a regimen of the GnRH analogue Leuprolide, which was applied over 5 months. This led to a reduction of the tumor which facilitated successful surgery. The primary tumor as well as the residual disease were classified as a leiomyoma with intravenous extension consisting of uniform, spindle-shaped smooth muscle cells in a whorled arrangement. Mitotic activity was low and pleomorphism was missing. Areas with degenerative changes were found, as well as prominent vascularity. At the right parametrium, the lumina of the dilated veins were filled with tumor. Immunhistochemically, the intravascular parts of the tumor revealed a positive staining reaction for vimentin, desmin and alpha-smooth muscle actin. The tumor also reacted for antibodies against estrogen- and progesterone-receptors. CONCLUSION: Knowledge about this rare uterine tumor is important for adequate treatment and exact differential diagnosis. Though intravenous leiomyomatosis imitates a malignant neoplasm regarding its pattern of growth and extension, it must be differentiated histologically from malignant tumors to prevent overtreatment. Since intravenous leiomyomatosis demonstrates a tendency to recur, long-term follow-up of the patient is recommended.

Malignant fibrous histiocytoma (MFH) of the mesentery: a case report.

BACKGROUND: Primary tumors of the mesentery are rare; only a few cases of malignant fibrous histiocytoma have been reported in the literature. This case report presents the management of a patient with malignantfibrous histiocytoma of the mesentery. CASE REPORT: A 48-year-old woman presented with mild abdominal pain and a palpable tumor in the lower abdomen. Laparatomy revealed a 12x9 cm tumor located in the mesentery and an enlargement of the paraaortic lymph nodes. The tumor was histologically classified as a malignant fibrous histiocytoma, showing a heterologeous picture consisting of large, multinucleated cells and spindle-shaped cells forming a storiform-like growth pattern. A radical excision of the tumor and the lymphnodes was performed and the patient received adjuvant irradiation therapy. Approximately three months later she presented with a great multilobated pelvic mass infiltrating the uterus and the adnexa. The patient underwent total abdominal hysterectomy and bilateral salpingo-oopherectomy to reduce the tumor mass. Two courses of palliative cytotoxic polychemotherapy were applied, but the patient died two months later due to progression of disease. CONCLUSION: Malignant fibrous histiocytoma of the mesentery is an extremely rare, highly malignant neoplasm with early metastatic spread. The treatment of choice is wide surgical excision, while the role of adjuvant chemotherapy and irradiation still remains controversiaL

Effects of water birth on maternal and neonatal outcomes.

BACKGROUND: Our purpose was to assess benefits and possible disadvantages of water births and to compare maternal and neonatal outcomes with normal vaginal deliveries. METHODS: This case-controlled study was carried out between January 2000 and July 2001. A total of 140 women who wanted water births were enrolled into the study. Our analysis was restricted to a sample of women with a gestational age > 37 weeks, a normal sized foetus, a reactive admission cardiotocography, drainage of clear amniotic fluid (if the membranes were already ruptured) and a pregnancy with cephalic presentation. Women with medical or obstetric risk factors were excluded. 140 controls were selected from the delivery database as the next parity-matched normal spontaneous vaginal delivery. RESULTS: A statistically significant lower rate of episiotomies (p = 0.0001) and vaginal trauma (p = 0.03) was detected in the group assigned to water birth, whereas the frequency of perineal tears and labial trauma remained similar in both groups (p > 0.05). A statistically significant decrease in the use of medical analgesia (p = 0.0001) and oxytocin (p = 0.002) was observed in women who had water births. A trend towards a reduction of the length of the first stage of labour was only observed in primiparous women bearing in water, but this reduction did not reach statistically significance (p > 0.05). Manual placenta removal (p = 0.017), severe postpartum haemorrhage (blood loss > 500 ml; p = 0.002) and maternal infection rate (p = 0.03) were statistically significant lower in women who delivered in water. When analysing the postpartum haemoglobin, no statistically significant differences could be observed between the two groups (p > 0.05). No statistically significant differences were detected for neonatal parameters (p > 0.05) between women who had had water births and those choosing conventional vaginal delivery.

Is therapeutic conization sufficient to eliminate a high-risk HPV infection of the uterine cervix? A clinicopathological analysis.

BACKGROUND: High-risk human papillomavirus infection plays a predominant role in the pathogenesis of preinvasive and invasive cervical cancer. One of the recognized treatments of cervical intraepithelial neoplasia is conization. The aim of this study was to evaluate if cold-knife conization is sufficient to eliminate cervical intraepithelial neoplasia and the associated high-risk HPV infection. PATIENTS AND METHODS: Thirty-seven high-risk HPV-positive women who underwent cold-knife conization entered this study. The cervical sampling for HPV DNA was performed using the Digene cervical sampler. Smears were taken immediately before and 3 months after conization and the patients were followed-up for 2 years. RESULTS: High-risk HPV was identified in all 37 patients before conization. In 4 out of 37 patients a coincidence of low/intermediate and high-risk HPV types was present. A CIN II was detected in 5 out of 37, a CIN III in 25 out of 37 and a carcinoma in situ in 7 out of 37 cases. Follow-up at three months revealed that HPV was eradicated by conization in 73%. Patients with persistent HPV infection tended to be older compared to patients with eliminated HPV infection (mean: 34 vs. 36 years; p = 0.25) and showed a higher rate of severe dysplasia (p = 0.07). A high HPV prevalence among patients with positive resection margins and/or recurrence disease was detected (83% and 100%, respectively). A statistically significant higher rate of positive margins and recurrences was observed in patients with persistent compared to patients with eliminated HPV infection (50% vs. 4%. p = 0.001 and 30% vs. 0%, p = 0.003). CONCLUSION: The data of the present study demonstrated that a high-risk HPV infection is successfully eliminated by conization in most cases. A high HPV prevalence in patients who had positive cone margins and/or disease recurrence was observed. Patients with persisting HPV infection after conization show statistically significant higher rates of positive resection margins and are at increased risk of disease recurrence. HPV testing seems to be, therefore, a valuable tool to monitor the therapeutic results of conization and to discriminate patients who have a higher risk of disease recurrence.