Vaginal prostaglandins for the ripe cervix.

OBJECTIVES: To assess the efficacy of vaginal prostaglandin (PGE2) tablets for induction of labor in the presence of a ripe cervix. METHODS: A randomized controlled trial was performed. Two hundred and nine consecutive women undergoing induction of labor with a Bishop Score > or = 5 were randomly assigned to (a). Study group receiving PGE2 tablets (n = 106) and (b). Control group having artificial rupture of membranes only (n = 103). The duration of labor, oxytocin and analgesia requirements, the mode of delivery, complications and duration of confinement were recorded. RESULTS: Mean duration of first stage of labor was shorter in parous patients in the study group (194 min v. 319 min), as was the mean induction delivery interval in primigravidas. Oxytocin was used in 75% of primiparas and 40% multiparas in the study group compared with 100% and 80%, respectively, in the controls. Epidural analgesics and instrumental delivery rates were also reduced. CONCLUSIONS: The use of vaginal PGE2 tablets for induction of labor with a ripe cervix is associated with a shorter first stage of labor and with reduced requirements for oxytocin, analgesia and instrumental delivery.

1000 consecutive laparoscopies in gynaecological practice.

One thousand consecutive laparoscopies were performed by an individual team at University College Hospital, Galway from 1982 to 1990. The mean age of the patients was 34 years (range 15-61). The majority (702) were undertaken for tubal ligation, followed by investigation of infertility (125), pelvic pain (87) and suspected ectopic pregnancy (41). Laparotomies were avoided in 77 patients with pelvic pain and in 26 patients with suspected ectopic pregnancy. A further 73 patients had surgical procedures performed laparoscopically. There were no failed laparoscopies. Minor complications occurred in 1.3% of patients. The commonest difficulty encountered was failed first attempt at pneumoperitoneum (4%). Two patients required laparotomy following laparoscopy, because of intra-abdominal bleeding. Readmissions occurred in 7 patients but again no serious sequelae were recorded. The use of the laparoscope in general gynaecological practice is examined with the safety, diagnostic and therapeutic facilities of the procedure explored.

Classical caesarean section through the posterior uterine wall.

We report a case of myomectomy and classical caesarean section through the posterior uterine wall necessitated by 180 degrees dextro-rotation of a gravid uterus with large fibroids. The non-specific clinical course and rarity of pathological torsion of the gravid uterus makes the preoperative diagnosis difficult. Ultrasound recognition antenatally of a fibroid changing its position should help with the prediction preoperatively of uterine rotation.

Extra-amniotic prostaglandin induction of labour supplemented with intravenous oxytocin following fetal death in utero.

A five year retrospective study (1984-1989) was undertaken on 24 consecutive patients with fetal death to ascertain the efficacy, side effects and complications associated with a combination of extra-amniotic prostaglandin E and intravenous oxytocin to induce labour. Six patients with primigravidae and eighteen multigravidae with inductions carried out at gestations ranging from 16 to 37 weeks (mean 26 weeks and 3 days). The estimated time from fetal death to induction ranged from 1 day to 3 weeks (mean 8 days). Induction was successful in all cases with a mean induction to delivery time of 9 hours and 30 minutes. The mean dose of prostaglandin required was 0.914 gms and of oxotocin 12.78 I.U.s. Minor side effects were experienced by 16% of patients though none were serious. This series confirms the combination of extra-amniotic prostaglandin and intravenous oxytocin as an effective means of inducing labour where fetal death has occurred.

The management of cervical intraepithelial neoplasia by coagulation electrodiathermy.

Of 140 women with cervical intraepithelial neoplasia treated with a single application of coagulation electrodiathermy, 123 (88%) remain cytologically free of disease after a median follow-up of 3 years. The new squamocolumnar junction was colposcopically visible in 70% of the 130 patients assessed after treatment. In 15 of 17 women requiring further treatment, residual disease was suspected at the time of the first postoperative assessment. The incidence of significant morbidity following this procedure was 4%. In selected patients coagulation electrodiathermy is an effective method of treating pre-invasive disease of the cervix.

The treatment of cervical intraepithelial neoplasia by laser vaporization.

Of 711 women with cervical intraepithelial neoplasia (CIN) treated by laser vaporization 675 (95%) remain colposcopically and cytologically free from disease after a median follow-up of 20 months. Thirty-six patients needed other forms of treatment to eradicate suspected residual disease. One patient presented with invasive carcinoma of the cervix 34 months after treatment with the carbon dioxide laser. It is concluded that in selected cases laser vaporization is an effective method of treating pre-invasive disease of the cervix.

Complications of cone biopsy related to the dimensions of the cone and the influence of prior colposcopic assessment.

A retrospective study of the complications of cone biopsy showed that among 915 women examined between the years 1976 and 1982, 121 (13%) had primary or secondary haemorrhage, 153 (17%) cervical stenosis and 39 (4%) subsequent infertility or an abnormal pregnancy. Cervical stenosis was commonest among women who had had long cones removed. Stenosis occurred more often in the group of women who had been assessed by colposcopy before operation but this was due to the fact that prior colposcopy selected a favourable group of patients with lesions of limited extent that were susceptible to treatment by local destructive therapy, so that prior colposcopic assessment resulted in the removal of longer cones.

Interim insertion of Multiload Cu 250 IUCD.

Two hundred and ninety nine women (58 nulliparous) were fitted with Multiload Cu 250 IUCDs in five family planning clinics and followed up for 1 year. Women months (2425) of use were computerized and analyzed according to the life-table method, yielding a zero pregnancy rate and an expulsion rate of 5.0. No serious complications were observed and there was a low incidence of difficulty in fitting or removal.

Laparoscopic removal of translocated intrauterine contraceptives devices.

Over a 6 year period, 67 women had a translocated intrauterine contraceptive device (IUCD) removed from the peritoneal cavity or uterovesical fold under general anaesthesia. In 40 patients removal of the IUCD at laparoscopy succeeded, whereas in 24 laparotomy proved necessary and three IUCD were removed per vaginam. Compared with the inert plastic device a larger proportion of copper-containing IUCD in the peritoneal cavity required laparotomy for removal, however, 44% could be removed by laparoscopy, the less traumatic procedure.

PIP: A retrospective analysis was conducted of patients' records at the Birmingham and Midland Hospital for Women (Ireland) during the 1974-1979 period inclusive, who required admission to the hospital for removal of an IUD which had perforated the uterus. The hospital records of 67 patients who had an IUD translocated through the uterine wall were found and studied. 17 IUD were copper-containing and 60 were inert plastic (46 Lippes loops, 3 Dalkon shields, and 1 Saf T Coil). In 54 patients the time of insertion in relation to pregnancy was recorded, and of these 47 (87%) were fitted in the postpartum or postabortion period. The mean time interval between insertion and diagnosis of translocation was 7 months (range 24 hours-6 years). This time interval was not related to difficulty with insertion or pain afterwards. 12 of the 25 pregnancies were conceived within 3 months of IUD insertion. Confirmation of IUD translocation was obtained by X-ray taken with an intrauterine sound in position in 62 patients. In 3 patients the translocated devices were palpated in the pouch of Douglas, 1 was discovered at laparoscopy to exclude an ectopic pregnancy, and 1 was located by ultrasound. Of the 43 subjects with inert plastic devices where laparoscopy was attempted, 33 (77%) were successfully removed. Of the 16 subjects with copper-containing devices where laparoscopy was attempted, 7 (44%) were successfully removed. The time interval between insertion and removal was similar in subjects where laparoscopic removal succeeded and in those where it failed. The largest single group of failures was because of the fact that the IUD was in the omentum and could not be seen. The feasibility of IUD retrieval via the laparoscope depends on both the ability of the laparoscopist to spot the device within the peritoneal cavity and the degree of attachment of the device to intraperitoneal structures, particularly vascular and intestinal.

Colposcopy in pregnancy. A twelve year review.

In a 12-year period, 195 patients with abnormal cervical cytology in pregnancy had colposcopy, of whom 73 had Grade IV cytology. Colposcopic findings in pregnancy correlated closely with the postpartum colposcopic assessment and this in turn predicted the ultimate histological diagnosis. Wedge biopsies were taken in two women in whom invasive disease could not be excluded colposcopically. Cone biopsy was avoided in all patients. No frank or occult invasive disease was missed but one patient was ultimately found to have a small focus of microinvasive disease six months post partum. Postpartum cytology gave a reasonable guide to the ultimate histology, although postpartum colposcopy was found to be of value even where cytology had by then reverted to normal.

Reticulin antibodies in patients with coeliac disease and their relatives.

The sera of 69 index coeliac patients, 121 of their first-degree relatives, and 104 controls were screened for the presence of reticulin antibodies. Among the untreated coeliac patients 75% of adults and 93% of children had reticulin antibody in their serum. Reticulin antibody was not present in any adequately treated coeliac patient. Of the first-degree relatives, 21 were reticulin antibody positive; 17 of these were biopsied and 12 were shown to have coeliac disease. Sixty-five of the coeliac relatives who did not have reticulin antibodies in their sera were biopsied and two had coeliac disease. Of the 68 relatives and 63 controls with normal biopsies, five of the relatives and four of the controls were reticulin antibody positive.