摘要:

Because the rate of cesarean delivery has grown markedly in recent decades and recent research indicates that patient requests may be one of the strongest indications, a prospective study was undertaken to audit indications for operative delivery. A total of 9138 deliveries at an Australian teaching hospital in a 2-year period were reviewed. The cesarean delivery rate was 17.8 percent, and of the 1624 caesarean deliveries, 39 percent were elective.More than one fourth of elective cesarean deliveries (27 percent) were done solely because of the mother’s request, and this was the leading indication for elective surgery. In 103 of 170 cases, the woman had previously had a cesarean delivery, but the current pregnancy was otherwise suitable for a trial of labor. All 56 women with breech presentation also were otherwise suitable for attempted vaginal birth. Only five women presented no particular reason for requesting elective delivery. The most common medical indication for elective cesarean delivery was more than one previous cesarean delivery. Other medical indications included a previous complicated cesarean delivery, a term breech presentation in which a trial of labor was considered inadvisable, placenta previa, severe intrauterine growth retardation with abnormal placental function, transverse and unstable fetal lie, suspected cephalopelvic disproportion, and preeclampsia. Preterm breech presentation, active herpes simplex, multiple gestation, and abruptio placenta were other indications. Nonelective cesarean deliveries were most often done because of suspected fetal distress or failure to progress in labor.The investigators believe that current maternal decision-making may well be influenced by the modern emphasis on patient advocacy and consumer choice. Attempts to lower the cesarean delivery rate should focus on promoting a trial of vaginal delivery in cases of a history of past cesarean delivery and also in cases of breech presentation. It also would help to develop better means of detecting fetal acidosis during labor.Aust NZ J Obstet Gynaecol 1999;39:207–214

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Vaginal hysterectomy offers advantages over an abdominal approach; but, because it is considered difficult or dangerous in many women, it is used for only one fourth of all hysterectomies. This article reports on a series of 300 consecutive women who underwent vaginal hysterectomy for benign gynecological conditions. To be eligible, patients had to have no vaginal prolapse, suspected adnexal disease, or suspected cancer.Vaginal hysterectomies were done using the classic Heaney technique or the Pelosi technique, which involves cutting the uterosacral and cardinal ligaments after injection of a dilute solution for hemostasis. Morcellation was required in 56.7 percent of cases (Figs. 1 and 2).Fig. 1. Pelosi vaginal hysterectomy: cervicocolpotomy.A, the posterior cervical wall is injected with a vasoconstrictor.B, the cervix is drawn upward, and midline division of cervix and vagina wall is initiated.C, cervicovaginal incision is continued.D, further continuation of incision results in cul-de-sac entry. Used with permission.Fig. 2. Pelosi vaginal hysterectomy: division of the paracervical ligament complexes.A, a narrow anterior colpotomy is made, bladder and rectum are retracted through the narrow colpotomies, creating left- and right-lateral vaginal pillars.B, the vaginal pillars (including the uterosacral-cardinal ligament complexes) are transected in their entirety with heavy scissors.C, the uterine vessels appear and are easily clamped with strong traction on the cervix.D, if the uterus fails to descend, uterine bisection is done and vaginal hysterectomy is continued conventionally. Used with permission.The majority of the women were obese, with a mean body mass index of 27 kg/m2(69 >30 kg/m2), and had a history of previous pelvic surgery (73 percent, of which 50 percent were cesarean section). Mean parity was 3.1, mean age was 46 years, and 7 percent were nulliparous.Mean operating time was 51 minutes (range, 20–130 min), and patients were discharged after an average of 22 hours (range, 16–720 hours; 12 patients). Average estimated blood loss was 180 ml (range, 50–1050 ml), and one blood transfusion was required. The Pelosi technique was used in 40 cases, the Heaney technique in 260, and morcellation was performed in 170 cases. Forty women underwent bilateral oophorectomy at the time of the hysterectomy. The mean uterine weight was 186 gm (range, 30–1160 gm). No patient had a malignancy.There were three intraoperative complications. In two instances, the bladder was sharply perforated, and in one, the anterior rectal wall was perforated. All were successfully repaired transvaginally. The only postoperative complications were 11 urinary tract infections. Only three (1 percent) of the 300 vaginal operations had to be converted to abdominal procedures. In two patients, hemostasis at the level of infundibulopelvic ligaments could not be controlled and laparotomy was required, and one laparoscopy was performed to remove an endometriotic ovary.Obstet Gynecol 1999;94:348–351

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The suburethral sling created from a patch of the fascia lata has been used with success to treat recurrent or severe stress urinary incontinence. The authors reviewed their own experience with 46 patients who underwent this procedure between 1989 and 1995 to evaluate long-term results and outcomes related to continence and voiding dysfunction. All of the patients had confirmed genuine stress incontinence thought to be associated with intrinsic sphincter deficiency, and all had undergone a modified transvaginal fascia lata sling procedure as described by the authors of this article (Fig. 1).Fig. 1. The fascia lata patch sutured to the vesical neck with delayed-absorbable sutures. Permanent sutures are transferred to the anterior rectus fascia with a needle ligature carrier. Placement of a right-angle clamp between the patch and the pubovesical fascia allows the surgeon to prevent the permanent sutures from being tied with undue tension. Used with permission.Thirty-six of the 46 patients could be found and consented to participate in a telephone interview using the Incontinence Impact Questionnaire/Urogenital Distress Inventory short form. The women were requested to return for a physical examination and evaluation; 24 agreed. The average length of time since surgery was 36 months (31 months for the women who returned for examination and 46 months for those who participated in the telephone interview only). The 36 women had a mean age of 53 years and an average parity of 3.4.The group had an overall objective cure rate (negative standing stress test at maximum bladder capacity) of 79 percent. Sixty-seven percent of those who returned for examination reported a subjective cure (mild or no stress-related incontinence on the Incontinence Impact Questionnaire/Urogenital Distress Inventory), compared with 83 percent of those who chose not to return (overall subjective cure rate for the group, 72 percent). Self-catheterization had continued for an average of less than 3 weeks for all patients.In the patients who returned for objective examination, a significant reduction in the maximum cotton swab angle (from a mean of 340 to 210 above the horizontal) had been achieved, and the bladder neck remained stabilized. However, 17 percent of the patients who were reexamined had a uterine prolapse to the level of the introitus.Nineteen of the 24 (79 percent) women in the reexamined group had an objective cure, but 35 percent of them reported moderate to severe stress and urge incontinence symptoms; overall, 32 percent of patients reported these symptoms. Of the five patients in whom signs of stress incontinence were present, two had moderate to severe urge incontinence symptoms, and another also had uninhibited detrusor activity during office cystometry. One patient who had cystometric detrusor instability preoper atively did not show any signs of stress incontinence or urge-related loss.Urinary tract infection confirmed by positive culture was seen in 5 of the 24 patients (21 percent) who returned for examination; one of these women was completely asymptomatic. Postvoid residuals at examination were similar for these patients and those without infection. More than half of the reexamined subjects had moderate to severe urge incontinence symptoms. One-third of these were positive for urinary tract infection, and half of this group had resolution of their urge incontinence symptoms after treatment for infection. Overall, 64 percent of participants reported moderate to severe urge incontinence symptoms.Overall, 72 percent of patients reported some degree of urge incontinence symptoms, and frustration with these symptoms was expressed by 42 percent. The level of frustration was the same in both the women who were reexamined and those who were not.Patients with objective stress incontinence had significantly increased maximum flow rates compared with those who showed no signs of stress incontinence. Average flow rates were similar for both groups. Eighty-six percent of the women who returned for examination had parabolic postoperative uroflow curves, 10 percent had intermittent uroflow curves, and 4 percent had obstructed uroflow curves.One patient developed an abdominal sinus tract after suprapubic trauma and underwent removal of the permanent sutures with no diminution of continence. Another women had a suprapubic cellulitis that was treated successfully with antibiotics, and a third developed a hernia at the fascia lata harvest site that was repaired with synthetic mesh.J Pelvic Surg 1999;5:196–202

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Women infected with human immunodeficiency virus (HIV) are at greater risk of developing cervical neoplasia and of having rapidly progressing disease. This study was designed to assess the prevalence of and to identify risk factors for cervical intraepithelial neoplasia (CIN) in women with HIV who were enrolled in the Women’s Interagency HIV Study in Chicago. All patients who presented to the clinic over a 1-year period completed a questionnaire aimed at assessing risk factors for CIN. A subsequent clinical examination included cervical cytology and testing for HIV. Colposcopy was performed routinely at two of the study sites as part of all initial examinations, but in the other locations, colposcopy was performed only when a cytologic abnormality was found.Seventy-six of 103 women fulfilled inclusion criteria for this study. Forty-three were white, 23 African American, and 10 Hispanic. Twenty-eight had never smoked cigarettes, and 31 were current smokers. Fifty-six women reported fewer than 10 male sexual partners, and 20 said they had had at least 11 partners, with the numbers ranging above 100 for three of these women. Thirty-two reported previous abnormal cervical cytology.A cytologic diagnosis of a squamous intraepithelial lesion (SIL) was made in 10 patients, eight low grade and two high grade. Thirteen cases of CIN1 were identified by colposcopically directed biopsy (Table 1). No disease more serious than CIN1 was seen.Table 1. Distribution of colposcopic findings according to cytological resultHPV = human papillomavirus; CIN = cervical intraepithelial neoplasia; ASCUS = atypical squamous cells of undetermined significance; LGSIL = low-grade squamous intraepithelial lesions; HGSIL = high-grade squamous intraepithelial lesions.* Patients with no colposcopic lesions were combined with those having benign histological results.† Two women also had atypical glandular cells of uncertain significance (AGUS).‡ One woman also had AGUS.§ One woman also had AGUS.NOTE: Row percentages may not add to 100% because of rounding.When a broad definition of abnormal cytology including atypical squamous cell of undetermined significance and high- and low-grade SIL was used, the sensitivity of cytology for predicting SIL was 65 percent, the specificity was 68 percent, the positive predictive value was 37 percent, and the negative predictive value was 89 percent. Corresponding values for the ability of cytology to predict CIN1 were a sensitivity of 62 percent, specificity of 65 percent, positive predictive value of 27 percent, and negative predictive value of 89 percent.In all, 35 women had human papilloma virus detected on the cervix. The correlation of cytology with human papilloma virus detection was significant (P < 0.001), but neither colposcopy nor histology had a significant association with human papilloma virus findings.A multivariate logistical regression analysis found that a cytology result of atypical squamous cell of undetermined significance or SIL was an independent predictor of biopsy-proven CIN (odds ratio versus benign smear, 6.6; P < 0.04). The only behavioral characteristic that reached significance was a history of trading sex for money or drugs (odds ratio versus no such history, 18.4; P < 0.02).J Lower Genital Tract Dis 1999;3:185–190

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

In 1995, the International Federation of Gynecology and Obstetrics (FIGO) defined stage IA cervical cancer as superficially invasive tumors with a horizontal spread of 7 mm or less; stage IA1 tumors have stromal invasion of 3 mm or less, and stage IA2 tumors have 35 mm of stromal invasion. No consideration is given to vascular space involvement or to special invasion patterns. This study was designed to evaluate the adequacy of these classifications.Four hundred two patients underwent surgical treatment for FIGO stage I squamous cell cancer of the cervix at the Cancer Institute Hospital in Tokyo, Japan, between 1970 and 1995. Those whose surgical specimens showed stromal invasion of 5 mm or less served as the study subjects. One hundred fifty-five women were treated with radical hysterectomy, and 247 were treated with simple hysterectomy. Patients who underwent simple hysterectomy and were subsequently found to have invasive disease greater than 3 mm received external radiation therapy.Three hundred thirty women had stage IA disease according to the FIGO definition; 297 of these were stage IA1, and 33 were stage IA2. Of the 72 women with horizontal tumor spread of more than 7 mm (stage IB), 20 had tumor invasion of 3.0 mm or less, and 52 had tumor invasion of 3.1 to 5.0 mm. Seventy-two of the 297 stage IA1 patients underwent radical hysterectomy, and 225 were treated with simple hysterectomy.Six positive lymph nodes were found among the 155 patients who had undergone radical hysterectomy (stage IA1, 1 of 72; stage IA2, 1 of 29; stage IB, 4 of 54). Lymphatic-vascular space involvement was seen in three of these six patients, all of whom had horizontal tumor spread greater than 7 mm. Of the 297 stage IA1 patients, 5 (1.7 percent) had lymphatic-vascular space involvement, and confluent invasion was seen in 13 (4.4 percent). Of the 33 stage IA2 patients, 7 (21.2 percent) had lymphatic-vascular space involvement, and 12 ( 36.3 percent) had confluent invasion.In the entire group of 402 patients, there were four recurrences. One was in a stage IA2 patient who had a tumor that was 3.5 mm deep and 4.5 mm wide. Three occurred in patients with stage IB disease, whose tumors measured 1.5 × 7.3 mm, 3.5 × 8.0 mm, and 4.0 × 9.0 mm, respectively. The only patient who survived is the woman with 1.5-mm-deep tumor invasion. She was treated with radiation therapy for her recurrence and currently has no evidence of disease.Gynecol Oncol 1999;74:165–169

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

This study was conducted to evaluate the routine use of chemotherapy, with its attendant long-term effects, in children and adolescents after the surgical removal of ovarian immature teratoma. Forty-four girls who underwent laparotomy for complete removal of an ovarian tumor containing pure immature teratoma between 1995 and 1996 served as subjects. Patients were classified as having stage I cancer when disease was found in the ovary only with negative peritoneal washings. Among the patients who had adequate staging, no stage II disease was observed.Follow-up for the first 2 years included frequent measurements of serum levels of &agr;-fetoprotein (AFP) and diagnostic imaging studies of the chest and pelvis. Thereafter, patients returned annually for regular physical examinations.At diagnosis, the age range of the subjects was 1.5 to 20 years. Four girls were lost to follow-up, two shortly after surgery and two within 2 years. Nineteen patients were followed for more than 5 years, and four had undergone surgery less than 2 years earlier.Histologic examination found no embryonal carcinoma, choriocarcinoma, or germinoma. Fifteen patients were classified as having grade 1 tumors, 12 had grade 2 tumors, and 2 had grade 3 tumors. On central pathology review, 13 patients were found to have tumors containing microscopic foci of a yolk sac tumor that was previously undetected.Unilateral salpingo-oophorectomy was the treatment selected in 28 patients (64 percent). Only one hysterectomy was necessary. Lymph node samples, obtained from 16 patients, showed mature gliomatosis in three patients. Three subjects had positive peritoneal washings, all of which contained only mature teratomatous or immature glial cells.The 13 patients with ovarian immature teratoma plus yolk sac tumor were slightly older (median, 12 years) than those with pure teratoma (median, 10 years) and were more likely to have larger tumors. Fifty-five percent of the girls with immature teratoma had grade 1 disease, compared with only 8 percent of those whose teratoma contained a yolk sac tumor. Conversely, 46 percent of the children with immature teratoma plus yolk sac tumor were classified as having grade 3 disease, compared with 6 percent of those without yolk sac tumor. Ten of the 13 girls (80 percent) with yolk sac components had measurable levels of AFP, compared with only 10 of 31 of the girls (34 percent) with no yolk sac tumor elements. Furthermore, the median level of AFP was 252 among children with yolk sac tumor, compared with 25 among those without yolk sac tumor. Ovarian immature teratoma containing yolk sac tumor was less likely to rupture during removal than immature teratoma (8 vs. 32 percent).No patients died. There was one malignant recurrence in a 12-year-old girl who had a large ovarian immature teratoma with yolk sac tumor, an initial serum AFP level of 1045 ng/ml, and peritoneal washings and lymph nodes positive for gliomatosis. A sharp rise in her serum AFP level at 18 weeks signaled a recurrence. Two nodules containing grade 2 immature teratoma with yolk sac tumor were found in her liver. She was disease free 57 months after four courses of cisplatin, etoposide, and bleomycin therapy.Two other patients required additional surgical procedures. Both girls underwent exploratory laparotomy for a pelvic mass. One contained ovarian mature cystic teratoma and mature glial implants. The other was composed of multiple mature glial implants on the peritoneal surfaces and on the surface of the remaining ovary, which was removed. Both patients had normal serum AFP levels that did rise, and both continue to be well without additional symptoms. Normal adolescent follicular cysts were frequently observed among the entire study group.Am J Obstet Gynecol 1999;181:353–358

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Maternal smoking in pregnancy has been associated with both impaired fetal growth and perinatal deaths, suggesting abnormal placental function. The placenta, however, is disproportionately large in smokers at the time of delivery. It seemed possible that, because smoking reduces oxygen transport by increasing carboxyhemoglobin, placental enlargement might be a result of adaptive angiogenesis in the placental villi. The authors prepared plastic injection casts of the fetal capillaries within placental cotyledons, taking specimens from elective cesarean deliveries at 38 to 40 weeks’ gestation. Four women who had smoked more than one pack a day throughout pregnancy and four nonsmokers were included in the study.Low-power microscopic study of the casts suggested increased capillary density within the terminal capillary convolutes in women who smoked (Fig. 1). Higher magnification disclosed increased branching within the terminal capillary loops in specimens from smokers. Both elongated and compact types of angiogenesis were observed. These findings point to an adaptive response of the fetal capillary bed within the placental villi of smokers, a change that should increase the surface area for diffusional exchange and thereby offset the impaired oxygen transport caused by carbon monoxide displacing oxygen from hemoglobin in maternal and fetal blood.Fig. 1. Representative scanning electronmicrograph images of terminal villous capillaries from nonsmoking (A, ×4700) and smoking (B, ×3760;C, 4700) placentas. Branches (arrowheads) and sinusoidal dilations (stars) are indicated. Note dense capillary network (C) and a high degree of coiling (B).VC= venous capillary. Reproduced with permission of The Lancet Ltd.Stopping smoking may be an important way of preventing perinatal death in women who are otherwise at low risk. It possibly would help to use a visual approach when trying to persuade women of the dangers of smoking while pregnant. They could be shown how the placenta tries to maintain oxygen transfer to the developing fetus.Lancet 1999;354:303

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Many hyperprolactinemic patients do not tolerate bromocriptine or other dopamine agonists and, even if they do, often must take them two or three times each day. Cabergoline is a long-lasting dopamine agonist whose action lasts up to 2 weeks after a single dose so that it may be taken once or twice a week. This study evaluated cabergoline in 353 women and 102 men with pathologic hyperprolactinemia. Roughly 40 percent of the group had a microadenoma, and the same proportion had a macroadenoma. No cause was evident in 16 percent of cases. Of 292 patients who previously had received bromocriptine, 140 were intolerant and 58 were resistant to the drug. The median baseline serum prolactin was 124 &mgr;g/liter. Cabergoline therapy usually began at a dose of 0.25 or 0.5 mg twice weekly, and the dose was adjusted at 2- to 3-month intervals as needed to consistently reduce the prolactin level. Patients then were followed up every 4 to 6 months.Menstrual function became normal during cabergoline therapy in 89 percent of the women evaluated, several of whom became pregnant and delivered healthy children. The visual fields became normal in 70 percent of 47 patients. Migraine symptoms lessened significantly in 72 percent of 71 patients. Prolactin levels became normal in 86 percent of all patients and decreased by 75 percent or more in more than half of the others. The median lowest serum prolactin level, achieved in 8 months on average, was 5.6 &mgr;g/liter. The tumor shrank to some degree in two thirds of patients. At the end of follow-up, the median dose of cabergoline was 0.5 mg/week. Minor side effects were reported by 8.5 percent of patients, and major or persistent symptoms were reported by 4 percent. Headache and postural hypotension were the most common adverse effects. Of the 14 patients who withdrew because of intolerance, 12 had also failed to tolerate bromocriptine. Only 9 percent of bromocriptine-intolerant patients were also intolerant of cabergoline. Patients harboring a microprolactinoma required lower doses and were more likely than those with macroadenomas to achieve a normal serum prolactin level. The baseline and lowest serum prolactin levels correlated weakly but significantly. In more than two thirds of patients who had been resistant to bromocriptine, control was achieved with cabergoline. This large-scale study affirms the effectiveness and tolerance of cabergoline when used to treat pathologic hyperprolactinemia.J Clin Endocrinol Metab 1999;84:2518–2522

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The most commonly defined cause of spermatogenic failure in male-factor infertility is a deletion of theAZFcregion of the Y chromosome, a finding reported in 2 to 21 percent of men with nonobstructive azoospermia or severe oligospermia. The most frequent management is intracytoplasmic sperm injection (ICSI), but there is concern that infertility might be transmitted to sons in this way. This study focused on three unrelated men from couples who had been primarily infertile for 2 to 3 years. All the men had nonobstructive azoospermia with maturation arrest; there were normal-appearing spermatogonia and spermatocytes but virtually no spermatids.All three men were found on polymerase chain reaction testing to lack theDAZgene cluster and other markers of theAZFcregion in the Y chromosome. All four sons born as a result of ICSI had inherited the Y deletions. The Y chromosome appeared to be intact in the paternal grandfathers, suggesting ade novodeletion in the infertile fathers. The deletions could have arisen either in germ cells of the paternal grandfathers or zygotically or postzygotically in the ICSI fathers. These findings provide a rationale for alerting couples to the likelihood that a Y chromosome deletion conferring male infertility will be transmitted to male offspring by ICSI.Hum Reprod 1999;14:1722–1726

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Tibolone is a synthetic steroid having weak estrogenic, androgenic, and progestational activity. Administered orally, it has been shown to be an effective and safe treatment for climacteric symptoms and does not stimulate the endometrium. Tibolone also inhibits enzymes involved in estradiol synthesis in human breast cancer cells. Its effects on bone have now been examined in a 2-year randomized trial of 47 healthy postmenopausal women aged 50 to 57 years who entered an osteoporosis screening study. All had bone mineral density (BMD) above the 25th centile for the normal population in the lumbar spine and femur. None of the subjects had used hormone replacement therapy for at least 6 months. Participants received either 2.5 mg of tibolone daily or no treatment and were reviewed at 12-week intervals for 8 years. BMD was estimated by dual-energy x-ray absorptiometry.Tibolone-treated patients had significantly increased BMD from 6 months onward in the lumbar spine (Fig. 1) and from 72 weeks onward in the trochanter (Fig. 2). Untreated women had no significant changes in BMD at the trochanter site, but bone density declined significantly in the lumbar spine, femoral neck, and Ward’s triangle. Significant differences between the tibolone-treated and control women began emerging at week 72. Six women withdrew from tibolone therapy, and three in the untreated group dropped out of the study. No tibolone-related side effects were regarded as severe; only one woman withdrew because of vaginal bleeding. Most often vaginal spotting ceased within the first 6 months of treatment.Fig. 1. Median percentage change in lumbar spine bone mineral density (interquartile range).Fig. 2. Median percentage change in femoral neck bone mineral density (interquartile range).Tibolone may be an effective means of forestalling bone loss in postmenopausal women and seems to be well tolerated. One qualification is that this study failed to demonstrate increased bone density at the femoral neck and Ward’s triangle, both clinically important sites.Br J Obstet Gynaecol 1999;106:678–683

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID