The management of pulsion enterocoele with the Zacharin abdominoperineal technique (and mesh sacrocolpopexy).

Our aim was to evaluate the technique, results and complications in 126 women with pulsion enterocoele treated with the combined abdominoperineal repair. Mean follow-up was 25 months with a range of 0-83 months. Operative morbidity included bladder trauma (0.7%), bowel injury (3.1%), wound breakdown (0.7%), infection (10%), pulmonary embolus (0.7%) and blood transfusion (40%). Longterm complications included prolonged urinary retention (11%), incisional hernia (4.7%) and constipation (40.4%). 92.4% of women were cured.

Ureteric injury at Burch colposuspension. 4 case reports and literature review.

The Burch colposuspension operation is an accepted and effective technique for the correction of genuine stress incontinence. It is, however, associated with a number of well-recognized complications. Ureteric injury at the time of colposuspension is a potentially severe, if uncommon, complication of this procedure with legal ramifications for the surgeon as well as health risks for the patient. To date, only 19 cases have been described in the literature. This paper highlights 4 cases of this injury occurring amongst the patients of 1 urogynaecologist (2) and gives an incidence for its occurrence as well as discussing the aetiology and management of this complication.

Abdomino perineal repair of pulsion enterocele.

OBJECTIVES: To review the techniques, results and complications of the combined abdomino perineal repair and mersilene mesh sacrocolpopexy. METHODS: From March 1988 to December 1993; 45 cases of pulsion enterocele were treated by a combination of the Zacharin type abdomino perineal repair and mersilene mesh sacrocolpopexy. Forty cases were followed from between 1 month and 18 months (mean 5.95 months). The notes were reviewed retrospectively. RESULTS: There were 3 recurrences (7.5%). Complications were not insignificant: wound infection in 3, urinary tract infection in 6, bowel dysfunction in 8, ventral hernia, vaginal stricture necessitating surgical release, and brachial nerve plexus injury occurred once. In one patient a peritoneal cyst developed necessitating laparoscopic aspiration. CONCLUSIONS: The combined abdomino perineal and sacrocolpopexy procedure offers the restoration of normal anatomy and the relief of the symptoms of prolapse in 92.5% of patients. The complication rate is significant and it should be undertaken as a secondary procedure.

Early blood pressure control improves pregnancy outcome in primigravid women with mild hypertension.

OBJECTIVE AND DESIGN: The aim of this study was to evaluate treatment of mild to moderate hypertension (less than 170/110 mmHg) in pregnancy in a prospective, randomised, double-blind trial. SETTING AND PATIENTS: Pregnancy outcome was studied for 52 primigravid women, managed in hospital from early in the third trimester. INTERVENTIONS: Patients were randomly allocated either to placebo or to active treatment (clonidine plus hydralazine). MAIN OUTCOME MEASURES AND RESULTS: Maternal deterioration dictated withdrawal from trial therapy for eight patients receiving placebo, but for only one receiving active treatment. Maternal proteinuria occurred only in the placebo group. Intention-to-treat analysis showed a significant increase in premature delivery for complications in the placebo group (P less than 0.05), despite active blood pressure treatment for those withdrawn from the group because of severe hypertension (170/110 mmHg or higher). Neonatal respiratory distress requiring intensive care occurred only in babies born to women in the placebo group. There were no perinatal deaths and no adverse effects of treatment in the neonates. CONCLUSIONS: The study indicates that early control of mild hypertension in pregnancy can prevent progression to emergency premature delivery.

The effect of intra-amniotic injection of triiodothyronine on pulmonary maturity in lambs at 130 days gestation.

Saline or triiodothyronine (T3) (50-1000 micrograms) was injected into the amniotic sac of 17 pregnant ewes under general anesthesia at 130 days gestation. Forty-eight h later, the lambs were delivered by hysterotomy. Cord plasma T3 and cortisol and amniotic fluid T3 were assayed, and the maturity of the fetal lung was assessed in terms of its pressure-volume response and its surfactant (lamellar body phospholipid) content. With the highest dose of T3, cord plasma T3 and cortisol were raised, and lung maturity was enhanced compared with saline-treated controls; the pressure-volume curve showed increased hysteresis on inflation and deflation, and the lung retained air on return to zero pressure. There was also an apparent, but not statistically significant, increase in the lamellar body phospholipid content of the lung. Irrespective of treatment, lungs which were more mature, in terms of their pressure-volume characteristics, tended to contain a higher proportion of lamellar body phospholipid relative to total phospholipid.

Acute severe hypertension in pregnancy.

Acute severe hypertension is a significant cause of fetal and maternal morbidity and mortality. The rationale for treatment and the various modes of management are reviewed. The importance of timely delivery is stressed.

Tubal anastomoses by means of modified microsurgical technique.

Twenty tubal anastomoses using a modified microsurgical procedure have been performed on 18 women who requested reversal of sterilization. Follow-up exceeded one year in 10 patients and was less than a year in five patients; three patients have deferred attempting pregnancy. Intrauterine pregnancy has been achieved in eight of the 10 patients who were followed up longer than one year; there have been five term deliveries, five abortions, one ectopic pregnancy and one patient was pregnant at the time of writing. The only pregnancies of three patients have terminated in abortions. Anastomotic dehiscence occurred in one patient, and tubal patency after a reanastomosis has been achieved, but she has failed to become pregnant as has one other patient with confirmed tubal patency. Tubal patency has been demonstrated in the three patients who have deferred pregnancy, and there has been one failure in the five patients who were followed up for less than a year. A second successful reanastomosis was performed in another patient in whom pelvic inflammatory disease followed an abortion which was performed in a country centre. Despite tubal patency, she also remains infertile. The possible reasons for failure and the abortions are discussed.

PIP: 20 tubal anastomoses using a modified microsurgical procedure have been performed on 18 women who requested reversal of sterilization. Followup exceeded 1 year in 10 patients and was less than a year in 5 patients; 3 patients have deferred attemping a pregnancy; intrauterine pregnancy has been achieved in 8 of 10 patients who were followed longer than 1 year; there have been 15 term deliveries; 5 abortions; 1 ectopic pregnancy; and 1 patient pregnant at the time of writing. The only pregnancies of 3 patients have terminated in abortions. Anastomotic dehiscence occurred in 1 patient and tubal patency after a reanastomosis has been achieved but she has failed to become pregnant as has 1 other patient with confirmed tubal patency. Tubal patency has been demonstrated in the 3 patients who have deferred pregnancy, and there has been 1 failure in the 5 patients who were followed for less than 1 year. A 2nd successful reanastomosis was performed in another patient in whom pelvic inflammatory disease followed an abortion which was performed in a country center. Despite tubal patency, she also remains infertile. The possible reasons for failure and the abortions are discussed.

The prevention of prematurity.

The prevention of prematurity requires identification of the patients most likely to go into labour prematurely and early recognition of threatened premature labour. There are unfortunately few clinical signs to help identify these patients, but certain features in the history are helpful. As soon as premature labour is diagnosed, energetic and active treatment with corticosteroids to advance pulmonary maturity and uterine suppression should be instituted. It is important to bear in mind that these patients should be managed in units, where not only is such treatment feasible, but neonatal intensive care is available, if labour cannot be suppressed.

Plasma unconjugated 15alpha-hydroxyoestriol (oestetrol) levels in normal human pregnancy.

Serial measurements were made of the concentration of plasma unconjugated oestetrol in normal human pregnancy. The mean curve and limits of normal variation have been established. Plasma levels rose from just below 2 ng/ml at 20 weeks to approximately 5 ng/ml at term.

Assessment of placental function in normal and pathological pregnancies by estimation of plasma oestradiol levels after injection of dehydroepiandrosterone sulphate.

A test of placental function was assessed by measurement of plasma oestradiol levels in 32 patients after intravenous injection of 50 mg dehydroepiandrosterone sulphate (DHAS). Every pregnant patient showed a rise in plasma oestradiol after DHAS; two puerperal patients showed no rise. It was not possible to distinguish the variable response in normal pregnancy from that in patients with severe hypertension and proteinuria or with retarded intrauterine fetal growth. The test was of no value in one hypertensive patient as a predictor of fetal death eight days later or, in another, to confirm fetal death of two days duration. Our results do not suggest that this test is a useful addition to currently available tests of placental endocrine function.

The effect of intra-uterine prostaglandin F-2alpha on corpus luteum function in the human.

Prostaglandin F-2alpha (PGF-2alpha) was administered via a Foley catheter over a 12 hour period to 8 healthy volunteers awaiting laparoscopic sterilisation. The amount of PGF-2alpha infused varied between 500 mu-g and 2000 mu-g every 2 hours for 6 doses. Plasma progestins and oestradiol 17beta, and urinary estrogens and pregnanediol were assayed throughout the study period. There was no evidence of luteolysis in any patient although vaginal bleeding of varying duration occurred in all women within 36 hours of administration of PGF-2alpha.

Assessment of possible luteolytic effect on intra-ovarian injection of prostaglandin F-2ALPHA in the human.

A group of five patients awaiting laparoscopic tubal diathermy were followed by daily assay of luteinising hormone (LH) and progesterone. Between five and eight days after the LH peak, prostaglandin F-2ALPHA (PGF-2ALPHA) was injected into either the corpus luteum or the ovarian stroma. Doses of 100 mu-g into the corpus tuteum, 1000 mu-g into the adjacent stroma and 500 mu-g into an indeterminate ovarian structure had no effect on peripheral plasma progesterone levels or uterine bleeding. An injection of 500 mu-g or 1000 mu-g given unequivocally into the corpus luteum produced a rapid and profound fall in plasma progesterone levels, the nadir coinciding with the onset of uterine bleeding which commenced 24 hours after the injection and persisted for more than seven days. Injection of 100 mu-g in the same volume of saline had no such effect. Despite continued bleeding plasma progesterone levels returned to normal luteal levels for three days and then fell again.

PIP: A group of 5 patients awaiting laparoscopic tubal diathermy were followed by daily assay of luteinizing hormone (LH) and progesterone. Between 5 and 8 days after the LH peak, prostaglandin F2alpha (PGF2alpha) was injected into either the corpus luteum or the ovarian stroma. Doses of 100 mc into the corpus luteum, 1000 mc into the adjacent stroma, and 500 mc into an indeterminate ovarian structure had no effect on peripheral plasma progesterone levels or uterine bleeding. An injection of 500 mc or 1000 mc given unequivocally into the corpus luteum produced a rapid and profound fall in plasma progesterone levels, the nadir coinciding with the onset of uterine bleeding which commenced 24 hours after the injection and persisted for more than 7 days. Injection of 100 mc in the same volume of saline had no such effect. Despite continued bleeding plasma progesterone levels returned to normal luteal levels for 3 days and then fell again.