Mode of delivery for breech presentation in grandmultiparous women.

OBJECTIVES: To compare maternal and neonatal outcomes of planned vaginal delivery vs. elective cesarean delivery for breech presentation at term. METHODS: Retrospective study of term breech deliveries from January 1997 through December 2000. A group of 128 women for whom vaginal delivery was planned was compared with a group of 122 women who had an elective cesarean delivery with regard to neonatal mortality and morbidity (birth trauma, birth asphyxia, hyperbilirubinemia, and duration of stay in the neonatal intensive care unit) and maternal morbidity (infections, hemorrhage, hysterectomy, deep venous thrombosis, and pulmonary embolism). RESULTS: There was no difference in neonatal mortality and morbidity between the two groups (13.0% vs. 9.4%). There were fewer maternal complications in the planned vaginal group than in the elective cesarean group (5.5% vs. 18%; P<0.01). In the planned vaginal delivery group 70% of multiparas and 85% of grandmultiparas were delivered vaginally compared with 50% of nulliparas. CONCLUSIONS: In breech presentations at term vaginal delivery can be achieved in 85% of grandmultiparas without significant neonatal morbidity. Elective cesarean section is associated with increased maternal morbidity compared with planned vaginal delivery.

Randomized study of non-closure of peritoneum in lower segment cesarean section.

BACKGROUND: The advantages of non-closure of the visceral and parietal peritoneum at lower segment cesarean section seems to be evident but in the reports published so far, the number of patients studied has been relatively small and the follow-up periods short. It is obviously of value to reconfirm such important observation in several institutions and therefore, in 1991, we decided to study non-closure of the peritoneum in lower segment cesarean section in a large series of patients with long-term follow-up of at least one year. METHODS: A prospective randomized study of 361 patients undergoing lower segment cesarean section in a University Affiliated Hospital, Al-Ain, United Arab Emirates. The operative technique was randomized to include either non-closure of both visceral and parietal peritoneum (study group, n = 179) or closure of both layers (control group, n = 182). Patients were followed up according to a study protocol. The nursing staff and the obstetricians responsible for data collection were unaware as to which of the two groups the patients belonged to. Student-t test and Chi-square test were used for statistical analysis of the results, where appropriate, with a p < 0.05 considered probability level to reflect significant differences. RESULTS: Postoperative febrile morbidity and wound infection were significantly lower in the study group as compared to the control group (p < 0.001 and p < 0.05 respectively). The incidence of wound dehiscence, urinary tract infection and the time to opening of the bowels postoperatively were similar in the two groups. In the non-closure group, the average operating time was significantly shorter by 7.9 minutes (p < 0.01) and the hospital stay was one day less (p < 0.01). There were no patients with late postoperative complications or readmissions during 2-5 years of follow-up that could be attributed to complications associated with lower segment cesarean section. CONCLUSION: Non-closure of the visceral and parietal peritoneum at lower segment cesarean section is associated with fewer postoperative complications, is more cost effective and is simpler than the traditional operative technique of closing both peritoneal layers.

Gestational and neonatal toxoplasmosis: regional seroprevalence in the United Arab Emirates.

Paired maternal/cord blood samples were tested for anti-Toxoplasma IgG or IgM antibodies using Biomerieux Micro-EIA2 IgG and IgM test kits. Of the 1503 women tested at the time of delivery, 344 (22.9%) were IgG seropositive. Three hundred and one maternal sera, including 265 that were IgG positive, were tested for IgM antibodies: 47 were found positive, indicating a gestational toxoplasmosis incidence of 31 per 1000 pregnancies over one year. All but one of the IgM positive maternal sera had tested IgG positive. Cord blood IgG seropositivity was similar to the maternal rate but 18 of the 301 babies had significant levels of anti-Toxoplasma IgM antibodies. As these 18 babies were all born to mothers also positive for IgM antibodies, the calculated rate of transplacental transmission was 38.3% with the estimated prevalence of congenital toxoplasmosis of 12 per 1000 live births. There was no statistically significant positive correlation between maternal seroprevalence and such well-known risk factors as consumption of raw meat and milk, or proximity of cats and other animals. One baby was born with the classical stigmata of congenital toxoplasmosis.

Relapse of endometrial carcinoma related to steroid receptor concentration, staging, histologic grading and myometrial invasion.

Estradiol and progesterone receptor concentrations were positively correlated to the stage of the disease and to the grade of the tumors, but not to myometrial invasion. Myometrial invasion of more than the inner third and degree of differentiation are both important prognostic factors. By combining low estradiol receptor concentration and the degree of myometrial invasion in poorly differentiated adenocarcinomas, stage I-II, it was possible to identify a group of patients containing a high percentage of relapses. This group consisted of 60% of all patients with poorly differentiated carcinoma stage I-II, who had a relapse rate of almost 50%, and were thus suitable for aggressive initial treatment.

[Prolapse of the small intestine through the vagina following repeated gynecologic operations]. / Prolaps des Dünndarmes durch die Vagina nach wiederholten gynäkologischen Operationen.

A case of prolapse of the small bowel through the vagina after gynaecologic operations is described. This is a very rare complication and up to date only eleven cases have been described. Measures to prevent this complication are discussed.

Use of an antifibrinolytic agent (tranexamic acid) and lateral sutures with laser conization of the cervix.

One hundred forty patients who underwent laser conization and 220 patients who underwent laser miniconizations were prospectively randomized into two study groups. One treatment group was given antifibrinolytic therapy in the form of tranexamic acid (Cyklokapron, KabiVitrum, Sweden) intraoperatively and for 14 days postoperatively. The other group did not receive antifibrinolytic therapy. In the group of 68 patients with laser conizations who were given antifibrinolytic therapy, no postoperative hemorrhages occurred, whereas there were eight such hemorrhages in 72 conizations (11%) in the untreated patients. This difference is statistically significant (P = .004, Fisher exact test for two proportions). Also, for laser miniconization, the frequency of postoperative hemorrhage was almost halved, from 9.1% in 110 patients not receiving antifibrinolytic therapy to 5.5% in the 110 treated patients. The use of lateral cervical sutures did not reduce the frequency of postoperative hemorrhage at laser conization in the present study.

Operative management of vaginal vault prolapse following hysterectomy.

Nine women suffering from vaginal vault prolapse had an abdominal sacropexy between 1972 and 1983. Marlex mesh was used to anchor the vaginal vault to the promontory of the sacrum and was completely buried retroperitoneally. The women had all had previous attempts at surgical correction. There were no intra- or post-operative complications. No recurrences of vault prolapse occurred during a mean follow-up period of 3.9 years. One woman developed a moderate cystocoele 4 years after sacropexy.

Treatment of condylomata acuminata with the carbon dioxide laser.

Extensive and/or recurrent condylomata acuminata in 78 women were treated with the CO2 laser. Urethra, clitoris or the anal canal were involved in about one-fourth of the cases. Most were treated as outpatients with the more extensive lesions staged for multiple treatments. After a follow-up period of 6-33 months, 91% of women were free from disease and treatment failures occurred in 9%, some of which may have been new infections. No serological investigations were performed.

A comparison of complications of laser and cold knife conization.

A comparison was made of intraoperative and postoperative complications of laser conization and cold knife conization. Of 428 women hospitalized for cold knife conization, 23.6% had one or more complications; 14.3% had postoperative hemorrhages, 6.8% had infections, and 4.7% suffered from stenosis. Two hundred sixteen women were hospitalized for laser conization; 5.1% of them suffered complications. Postoperative hemorrhages occurred in 2.8% and infections in 2.3%. No case of stenosis occurred. Laser conization as an outpatient procedure was undertaken in 240 women; 4.2% had complications. Postoperative hemorrhages occurred in only 2.5%, infections in 1.3%, and stenosis in 0.8%. Laser conization has the same complication rate as laser vaporization and can be safely performed on an outpatient basis, thereby reducing hospital costs.

Laser miniconization in mild and moderate dysplasia of the uterine cervix.

Mass cytologic screening for cervical cancer often reveals only mild dysplasia not indicating conization but necessitating continual checkup. Such routine checkups are often insufficient, beside which the patients find them frustrating. Therefore a new method, called miniconization, for treatment of patients with vaginal smears showing mild or moderate dysplasia (cervical intraepithelial neoplasia/CIN/I-II), was developed. With the CO2 laser handpiece a 5-mm-thick disc of the cervix, including the whole transformation zone, was removed. This was followed by endocervical curettage. The advantage of the method over cryosurgery, electrocoagulation, and laser vaporization, for example, is that the tissue specimen as a whole disc including the transformation zone can be sectioned and examined histologically. Another advantage is the decreased risk of postoperative bleeding, which enables ambulant care. One hundred and fifty-one patients have hitherto been treated and carcinoma in situ has been found in 15.2% and microinvasive carcinoma in 1.3% of all these patients in whom vaginal smears showed mild or moderate dysplasia (CIN I-II).

Prognostic factors in early invasive carcinoma of the uterine cervix. A clinical, histopathologic, and statistical analysis of 343 cases.

Three hundred forty-three cases of early invasive carcinoma of the uterine cervix were analyzed. Depth of infiltration and lateral extension of the tumors varied between 0.2 and 9.0 mm and 0.4 and 17.2 mm and were found to be of no prognostic importance. A multivariate statistical analysis revealed several risk factors: an epithelialized portio at diagnosis, suspected or evident tumor invasion in capillary-like spaces, absence of tumor-free margins at conization, and treatment with conization or simple hysterectomy, especially in the presence of the above-mentioned factors. Tumors of a large cell keratinizing type were prognostically favorable. Confluent growth was not associated with increased risk of recurrence or death from recurrence. Cervical biopsies proved to be inadequate as diagnostic material. Recurrences were almost always local and developed late. In absence of risk factors conization is sufficient treatment. In the presence of risk factors treatment should be the same as that performed for frankly invasive Stage IB carcinomas.

Cure rates after laser conization for early cervical neoplasia.

Follow-up results by vaginal cytology and colposcopy after laser conization for early cervical neoplasia in 333 patients are reported. 95.7% of all the women were free from disease after 4-24 months. The separate figure for very early invasive carcinoma was 96.4% and for CIN III through CIN I it was 96.6%, 94.9% and 90.6% respectively. The cure rate depended on whether or not the resection margins of the cones were free from epithelial cells with atypia. The highest cure rate, 97.8%, was noted for CIN III with margins free from atypical cells. Out of patients not free from disease, 92.9% were detected at the first follow-up at 4--6 months after conization and represent persistent disease. Laser conization seems to give at least as good cure rates as laser vaporization and has the chief advantage that histopathological evaluation is available both for the whole lesion and the resection of the cones. The procedure can be safely performed on an out-patient basis.

[Laser miniconization - a new method of treating mild and moderate cervix dysplasia]. / Laser-Minikonisation - Eine neue Methode zur Behandlung der leichten und mässigen Zervixdysplasie.

The miniconization by carbon dioxid laser is a non-destructive method for treatment of mild and moderate dysplasia of the uterine cervix permitting an adequate histopathological interpretation of the whole transformation zone. The risk of postoperative haemorrhage is minimal which enables ambulant care. 413 patients have hitherto been treated and we have found carcinoma in situ in 16.7%, micro-invasive carcinoma in 1.2% and invasive carcinoma in 0.25%.

Correlation between estradiol-17 beta and progesterone cytosol receptor concentration, histologic differentiation and 3H-thymidine incorporation in endometrial carcinoma.

Women treated with estrogen exhibit a higher risk of developing endometrial cancer. steroid hormones exert their effects on target tissue through specific cytosol receptor protein. Knowledge of this steroid receptor concentration in endometrial carcinoma might facilitate the treatment of recurrences. We have compared the concentrations of endometrial estrogen and progesterone cytosol receptors with the histologic grade of endometrial carcinoma as well as the rate of 3H-thymidine incorporation. We found a significant difference in receptor concentration between well-moderately differentiated tumours and poorly differentiated ones. No correlation was found between 3H-thymidine incorporation rate and differentiation. A positive correlation between thymidine incorporation rate and progesterone receptor concentration was noticed. The concentration of receptors varies within a wide range of each group of differentiation; thus 23% and 4% of the poorly differentiated tumours had higher concentration of estradiol and progesterone receptors respectively than the median values for well differentiated tumours.

A modified laparoscopic entry technique using a finger.

In an effort to reduce the complication rate at laparoscopy, especially in patients who have previously undergone laparotomy, the so-called open laparoscopy technique was developed by Hasson and Grimes. Both investigators use minilaparotomy to enter the abdominal cavity. Hasson has developed a special laparoscopic instrument, whereas Grimes uses conventional instrumentation. For 1 year the authors have been using an extremely simple and safe method in performing laparoscopy: After incision of the skin and fascia infraumbilically, the index finger is introduced through these incisions, and the preperitoneal fat and the peritoneum are perforated with the finger, which is also used to explore the area around the incision for adhesions. After insufflation of CO2 through the sleeve, the optics are introduced in the usual manner.

Laser conization versus cold knife conization.

This prospective, randomized study compares, for the first time, measured blood loss at conization and within 24 hours after using either the cold knife technique or the carbon dioxide laser scalpel. One hundred and ten consecutive patients were evaluated. The median blood loss in the laser group of 55 patients was 4.6 milliliters at, and within, 24 hours after operation compared with 30.1 milliliters in the cold knife group of 55 patients. More important, however, is that the corresponding figures for the range of bleeding were 0.4 to 155.4 milliliters and 5.6 to 1,570.9 milliliters, respectively. The incidence rate for bleeding complications requiring surgical intervention was 1.8 per cet for the laser group and 14.6 per cent for the cold knife group. This difference was statistically significant, p less than 0.015--Fischer's exact test. Conization for treatment of premalignant changes of the cervix uteri will probably remain the treatment of choice for some time to come. It is our opinion that, in the future, laser conization will replace cold knife conization.

Outcome of pregnancy after conization.

The outcome of 635 pregnancies in 197 women before and after conization is reported. After conization a significant increase in premature deliveries occurred in young women (age 21-25), nulliparae representing the highest risk. The rate of premature deliveries in this age group was 4.4% before conization and 30.6% after conization. No such increase could be found in any other age group. Labor was notably short in non-parous women and in parous women it started with rupture of the membranes significantly more often after conization. In addition, a significant increase in the frequency of cervical stenosis was observed, but this was of clinical significance in only one case. Treatment in the form of prophylactic cerclage did not reduce the incidence of either premature delivery or of late spontaneous abortion.