The use of the harmonic scalpel to reduce morbidity during open total abdominal hysterectomies with bilateral salpingo-oophorectomy (TAH/BSO).

The ultrasonic scalpel (USS) is a hemostatic surgical instrument used for incising and dissecting tissues. It works by using ultrasonic waves to denature collagen forming a coagulum. This study was designed to examine the effectiveness of the ultrasonic scalpel in open total abdominal hysterectomies with bilateral salpingo-oophrectomies.This study was a nonrandomized study, with 16 cases of total abdominal hysterectomy with bilateral salpingo-oophorectomy being done with the ultrasonic scalpel, and 21 cases being done with the traditional methods of dissection and ligation. The 2 groups were compared in terms of intraoperative blood loss, time, and cost, as well as in terms of postoperative complication and length of stay.Demographically, no significant differences in age or weight existed among the patients in the 2 operative groups. (p = 0.71, p = 0.64, respectively). A statistically significant reduction did occur in the estimated blood loss with the use of the harmonic scalpel (p = 0.05). No significant differences existed between the 2 patient groups in terms of operative time (p = 0.77), intraoperative costs (p = 0.11), or length of hospital stay (p = 0.45). However, 52% of the patients in the traditional method group suffered from postoperative complications that included acute myocardial infarction (N = 1), ileus (N = 5), urinary retention (N = 1), urinary incontinence (N = 1), respiratory failure (N = 1), and failure to thrive (N = 1). Only 25% of the patients undergoing the USS resection suffered from complications. These complications included urinary retention (N = 2), respiratory failure (N = 1), and ileus (N = 1).A statistically significant reduction occurred in estimated blood loss with the use of the USS (p < 0.05). There is also decreased intraoperative time, as well as decreased postoperative complications and length of stay in this same group; however, these differences were not statistically significant. Also, more complications are reported in the traditional resection group (62% compared with 31%). It would be beneficial to accrue a higher patient population and study the use of the USS in this procedure as well as other open abdominal procedures.

Pain after gynecologic surgery.

This article provides a descriptive profile of pain in 80 women during the first 2 days after gynecologic surgery in 4 hospitals. Surgical procedures included abdominal hysterectomy, oophorectomy, and laparotomy. Average pain was moderate on both days, but paired t tests indicated that pain increased significantly during ambulation on day 1 (P = .009, sensation; P < .001, distress) and on day 2 (P = .007, sensation; P = .030, distress). They both (P = .001) decreased significantly during rest on day 1, but not on day 2. Analysis of quartiles indicated that one fourth of the sample suffered severe sensation pain at all points on day 1 (60 to 74 mm on a 100-mm visual analogue scale), and moderate to severe sensation on day 2 (40 to 60 mm). The lowest quartile had mild pain on both days (11 to 28 mm on day 1, and 7 to 14 mm on day 2). Some patients (30%) reported that pain interrupted their sleep on the first 2 nights, and difficulty sleeping on the first postoperative night for any reason (65%) was related to greater pain during the next 2 days (r = .25 to .43). Although 41% of the women had previously used relaxation techniques for stress or pain, only 9% used it for pain after surgery. Results suggest that postoperative patients have moderate to severe pain that is incompletely relieved with patient-controlled analgesia. Nurses should encourage patients to press the patient-controlled analgesia button more often, report unrelieved pain, and use nonpharmacologic interventions.

Combating infant mortality. A hospital collaborates with other groups to offer prenatal care in a rural area.

Prenatal care services are often lacking in poor rural areas. Consequently, rates of infant mortality and negative birth outcomes are relatively high. To address these problems, since 1987 St. Elizabeth Hospital Medical Center (SEHMC), Youngstown, OH, has successfully operated an innovative rural-based prenatal care clinic for indigent women. The Leetonia Clinic serves residents of Leetonia, OH, and about 20 surrounding communities. It offers on-site medical care using SEHMC obstetrics and gynecology residents and volunteer nurses. The local Catholic Charities organization funds a professional social worker. A prolife advocacy group and a women's self-help group offer volunteer counseling and referral services. They also manage paperwork at the clinic. The local Catholic church provides space in one of its school buildings to house the clinic. SEHMC also provides patient education and outreach. Over the past 4 years the clinic has served about 165 patients annually. About half are on welfare, and the rest are primarily self-paying. Studies are under way to assess the program's effect on infant mortality and morbidity.

Vaginosonographic measurement of endometrial thickness in the evaluation of amenorrhea.

The progestin-induced withdrawal bleeding test has often been used in patients with amenorrhea to assess endogenous estrogen (E) production. The endometrial thickness measured by vaginal ultrasonography with a 5 MHz transducer is also dependent on E stimulation of the endometrium. In this study, 70 consecutive patients were evaluated with both the progestin-induced withdrawal bleeding test and a measurement of the endometrial thickness by vaginosonography. An endometrial thickness of 1.5 mm or less was selected to predict absence of bleeding after a progesterone (P) challenge test. This resulted in a sensitivity of 94% with a 95% confidence interval (CI) of 0.70 to 1.00 and a specificity of 93% with a 95% CI of 0.82 and 0.98. The positive and negative predictive values were 79% and 98%, respectively. This study shows that the endometrial thickness measured by vaginosonography can predict the results of the P challenge test in patients with amenorrhea.

The effect of lithium carbonate on chemotherapy-induced neutropenia and thrombocytopenia.

Lithium carbonate ameliorates neutropenia associated with cancer chemotherapy. The effect of lithium on platelet suppression has not, however, been well established. In the present study, five patients with ovarian carcinoma received daily lithium during alternate cycles of treatment with hexamethylmelamine, cyclophosphamide, adriamycin, and cis-platinum. Analysis of myelosuppression was performed on 24 paired consecutive cycles given at identical doses, one with and one without lithium. During lithium cycles, nadir leukocyte, neutrophil, and platelet counts were significantly higher (P less than 0.01, less than 0.01, less than 0.05 respectively) and the interval between treatments was shorter (P less than 0.01). One patient who has received 11 cycles of chemotherapy continues to receive 100% doses owing to the beneficial effect of lithium on chemotherapy-induced thrombocytopenia. Lithium was poorly tolerated by some patients because of either tremor or nausea and vomiting, in spite of nontoxic serum lithium levels. The amelioration of drug-induced platelet suppression as well as neutrophil suppression noted in this study suggests that lithium's effect on hematopoiesis is not limited to stimulation of neutrophil production. The ability of lithium to decrease chemotherapy-induced myelosuppression suggests that lithium administration may facilitate escalation of chemotherapy doses in selected patients.

Reproductive and gynecologic surgical experience in diethylstilbestrol-exposed daughters.

Information on reproductive history, gynecologic operations, and examinations was analyzed for 338 diethylstilbestrol (DES)-exposed and 298 unexposed women whose mothers participated in an evaluation of DES use in pregnancy 28 years ago. A history of infrequent menses (less often than every 36 days) was reported more commonly by the exposed women (32%) than by the unexposed women (15%) and the mean duration of menstrual flow was also less. A greater number of exposed women than unexposed women experienced primary infertility (53 versus 19). The reasons for these differences are not currently known. Comparison of the outcomes of first pregnancies showed a higher proportion of premature births, spontaneous abortions, and ectopic pregnancies in the exposed women (P less than 0.001). The difference in the occurrence of ectopic pregnancies was statistically significant (8 versus 0; P less than 0.005). An adverse pregnancy outcome was more likely in DES-exposed women with cervicovaginal ridges. However, when the outcome of all pregnancies were considered, 81% of the exposed women had at least one living child. More exposed women than unexposed women had gynecologic surgical procedures, which may, in part, be due to the increased medical surveillance of the exposed group. The spectrum of diseases at operation in both groups was similar. Adnexal masses and pelvic inflammatory disease were more commonly reported among the exposed women while the occurrence of endometriosis in both groups was similar. For the exposed women who had been examined at the Chicago Lying-In Hospital over a 4-year period, epithelial changes in the vagina had disappeared in 32% and cervicovaginal ridges had disappeared in 57%.

Interstitial twin pregnancy.

A rare case of interstitial twin pregnancy is presented. The attendant difficulties of ultrasonography and the important role of laparoscopy in the diagnosis and management of this unusual condition are discussed.