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Intraoperative blood loss and gestational age at pregnancy termination
OTHER GYNECOLOGIC SURGERY of specimens with absent histopathology, decreasing from 6% in 1985 to 3% in 1995 (P 5 .013). This difference was explained by changes in the number of procedures performed on patients with private insurance and HMO reimbursement (P 5 .018). Conclusions: While the proportion of surgeries performed for specific indications did not change, the number of hysterectomies performed decreased, and there were fewer normal specimens.
Prediction of endometrial ablation success by preoperative findings William F. Ziegler, DO, Cynthia Sites, MD, Gary Badger, MS, Mousa Shamonki, BS Dept of OB/GYN and Biostatistics, University of Vermont College of Medicine, Burlington, Vermont Objective: To determine the influence of preoperative findings on the outcome of hysteroscopic endometrial ablation. Design: We performed a retrospective chart review of 80 women between the ages of 25 and 50 years who underwent an endometrial ablation for menorrhagia or menometrorrhagia from 1992 to 1996, through a university reproductive endocrinology clinic. Materials and Methods: All eligible patients had a detailed subjective history obtained for duration of dysmenorrhea (Dys) and menorrhagia or menometrorrhagia (Men). Each had a preoperative transvaginal pelvic ultrasound with documentation of the uterine cavity contour and if an intramural myoma was present. A gynecological examination was ascertained from the patients clinical record with regard to uterine size. A benign Papanicolaou smear within 1 year of surgery and a normal endometrial biopsy was required for inclusion. Those with evidence of carcinoma or menopausal symptoms were excluded. Each patient had endometrial preparation with either danazol, GnRHa, or progestin. All ablations were performed by the same surgeon with “rollerball” electrocautery. Those patients who required medical management or additional surgery to control their vaginal bleeding during follow-up were designated as ablation failures. The use of stepwise logistic regression with ablation outcome as the dependent measure was used along with univariate analyses via x2 and t test to compare successes and failures on specific characteristics. Results: The sample was divided into two groups, success (group 1) or failure (group 2), and were matched for gravity, parity, and uterine size. Between the two groups there were no significant differences in the duration of menorrhagia/ menometrorrhagia or dysmenorrhea. Additional therapy was required in 41% of the study group, designated as failures. The length of follow-up was 36 months for group 1 and 27.7 months for group 2. The results are summarized in the table below. 204
Group N Mean age (SD) Normal uterine cavity Intramural fibroid
1
2
P Value
47 (59%) 40 (65.23) 60% (28/47) 18% (8/44)
33 (41%) 41 (64.38) 39% (13/33) 34% (11/32)
.06 .07 .10
The difference in age between the two groups strongly suggests a tendency toward failure with increasing age (P 5 .06). The diagnosis of a normal uterine cavity preoperatively shows a trend for a successful outcome (P 5 .07) when compared with the presence of an intracavity lesion, fibroid, or polyp. Those patients with an intramural fibroid had a tendency toward a higher failure rate (P 5 .10). Comparing the medications used to prepare the endometrium, patients treated with danazol had a trend toward a higher success rate (P 5 .09) than GnRHa or progestins. Conclusion: Preoperative findings can provide additional information with regard to endometrial ablation success. It appears that the trend toward failure is increased in patients with increased age, the diagnosis of an abnormal uterine cavity by ultrasound, and the presence of an intramural fibroid. Danazol administration, to prepare the endometrium, appears to offer a lower failure rate compared to GnRH agonists or progestins. Patients at greater risk of endometrial ablation failure based on age $41 years, abnormal intrauterine cavity, or the presence of intramural fibroids should be counseled about the higher failure rate and consider an alternative procedure such as hysterectomy.
Intraoperative blood loss and gestational age at pregnancy termination Dominic A. Marchiano, MD, Albert G. Thomas, MD, Robert Lapinski, PhD, Khousidai Balwan, BA, Jagruti Patel, BA Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Medical Center, New York, New York Objective: To establish the relationship of measured intraoperative blood loss to gestational age at pregnancy termination, and to determine which factors, if any, affect the risk of bleeding. Methods: A single-operator series of 363 consecutive women undergoing pregnancy termination between 5 and 24 weeks gestational age, as dated by ultrasound, was prospectively evaluated. All pregnancies under 13 weeks gestation were terminated by mechanical dilation and suction curettage without preoperative cervical ripening. All pregnancies between 13 and 24 weeks gestation were terminated by preoperative osmotic cervical dilation with laminaria tents and subsequent uterine evacuation by a combination of suction curettage, sharp curettage, and Bierer forceps extraction. All patients over 12 weeks gestation received a postoperative oxytocin infusion. Prim Care Update Ob/Gyns
OTHER GYNECOLOGIC SURGERY
Clinical outcomes of OPERA, Out-Patient Endometrial Resection/Ablation Arnold Kresch, MD Clinical Associate Professor, Stanford University School of Medicine, and Director, California Center of Pelvic Pain & Fertility, Palo Alto, California Objective: To evaluate the clinical outcomes of 18-month follow-up for OPERA, Out-Patient Endometrial Resection/ Ablation using the OPERAStar tissue aspirating resectoscope. Methods: Patients suffering from abnormal uterine bleeding (AUB) and/or submucosal fibroids who where indicated for surgical intervention underwent OPERA for treatment of their condition using the OPERAStar tissue aspirating resectoscope. This resectoscope contains a tissue aspiration and morcellation channel for continuous removal of tissue strips. Follow-up assessments were conducted at 1 month, 3 months, 6 months, 12 months, and 18 months to evaluate long-term clinical results of the procedure. Data collected include current level of bleeding, subsequent procedures to manage condition, and patient’s level of satisfaction.
Whenever possible, amniotic fluid and blood were collected and measured separately. Patients were excluded from the data analysis for pregnancy demise, PPROM, Potter’s syndrome, or inability to separate blood establish their relationship. After adjustment for gestational age, the results were analyzed to determine if blood loss was related to maternal age, smoking history, body habitus, or operative indication. Results: A curvilinear relationship between blood loss and gestational age was observed. Mean blood loss at 24 weeks exceeded 800 mL. After adjustment for gestational age, no factors significantly affected blood loss at dilation and aspiration of first trimester pregnancies. In those patients undergoing dilation and evacuation in the second trimester, both simple and stepwise regression analyses showed obesity (BMI $32.3) to be significantly associated with increased blood loss (P , .05). Neither age, parity, previous cesarean section, nor smoking history were significantly associated with increased blood loss at dilation and evacuation. Conclusions: With advancing gestational age, intraoperative blood loss increases in curvilinear fashion. Termination providers should be advised that, although blood loss is unaffected by many factors, obese patients are at risk for increased bleeding at dilation and evacuation of pregnancies beyond 12 weeks gestation.
Volume 5, Number 4, 1998
Results: A total of 33 patients presented with AUB requiring surgical intervention for relief of their symptoms. Uterine cavity averaged 10.7 cm (6 2.2), range 6.7–13.4 cm). Complete resection and ablation of the endometrium and submucosal fibroid(s) if present, was performed. Current 18-month follow-up data indicate that 21 (68%) patients achieved amenorrhea and 8 (26%) patients achieved hypomenorrhea. Two patients were lost to follow-up. Two patients underwent a subsequent procedure; one repeated OPERA and one hysterectomy for fibroids. Patient’s overall satisfaction rate with the results of their procedure was 97%. Conclusion: OPERA is an effective minimally invasive method for management of abnormal uterine bleeding. At 18 months, clinical outcomes of OPERA indicate an optimal level of patient satisfaction for management of their bleeding with 94% of patients achieving either amenorrhea or hypomenorrhea. Continuous aspiration and morcellation during resection keeps the operative field clear of debris and simplifies the procedure.
Clinical experience with the OPERA StarSL using saline irrigation fluid for OPERA Joseph R. Feste, MD, Eberhard C. Lotze, MD Clinical Associate Professor, Department of Obstetrics & Gynecology, Baylor College of Medicine, University of Texas Health Science Center Objective: To present clinical results using a new hysteroscopic resectoscope, the OPERAStarSL with PEARL technology, which cuts and coagulates uterine tissue in a physiologic, conductive fluid environment in order to perform OPERA, Out-Patient Endometrial Resection/Ablation. Use of physiologic normal saline in resectoscopy has not previously been 205
Prediction of endometrial ablation success by preoperative findings William F. Ziegler, DO, Cynthia Sites, MD, Gary Badger, MS, Mousa Shamonki, BS Dept of OB/GYN and Biostatistics, University of Vermont College of Medicine, Burlington, Vermont Objective: To determine the influence of preoperative findings on the outcome of hysteroscopic endometrial ablation. Design: We performed a retrospective chart review of 80 women between the ages of 25 and 50 years who underwent an endometrial ablation for menorrhagia or menometrorrhagia from 1992 to 1996, through a university reproductive endocrinology clinic. Materials and Methods: All eligible patients had a detailed subjective history obtained for duration of dysmenorrhea (Dys) and menorrhagia or menometrorrhagia (Men). Each had a preoperative transvaginal pelvic ultrasound with documentation of the uterine cavity contour and if an intramural myoma was present. A gynecological examination was ascertained from the patients clinical record with regard to uterine size. A benign Papanicolaou smear within 1 year of surgery and a normal endometrial biopsy was required for inclusion. Those with evidence of carcinoma or menopausal symptoms were excluded. Each patient had endometrial preparation with either danazol, GnRHa, or progestin. All ablations were performed by the same surgeon with “rollerball” electrocautery. Those patients who required medical management or additional surgery to control their vaginal bleeding during follow-up were designated as ablation failures. The use of stepwise logistic regression with ablation outcome as the dependent measure was used along with univariate analyses via x2 and t test to compare successes and failures on specific characteristics. Results: The sample was divided into two groups, success (group 1) or failure (group 2), and were matched for gravity, parity, and uterine size. Between the two groups there were no significant differences in the duration of menorrhagia/ menometrorrhagia or dysmenorrhea. Additional therapy was required in 41% of the study group, designated as failures. The length of follow-up was 36 months for group 1 and 27.7 months for group 2. The results are summarized in the table below. 204
Group N Mean age (SD) Normal uterine cavity Intramural fibroid
1
2
P Value
47 (59%) 40 (65.23) 60% (28/47) 18% (8/44)
33 (41%) 41 (64.38) 39% (13/33) 34% (11/32)
.06 .07 .10
The difference in age between the two groups strongly suggests a tendency toward failure with increasing age (P 5 .06). The diagnosis of a normal uterine cavity preoperatively shows a trend for a successful outcome (P 5 .07) when compared with the presence of an intracavity lesion, fibroid, or polyp. Those patients with an intramural fibroid had a tendency toward a higher failure rate (P 5 .10). Comparing the medications used to prepare the endometrium, patients treated with danazol had a trend toward a higher success rate (P 5 .09) than GnRHa or progestins. Conclusion: Preoperative findings can provide additional information with regard to endometrial ablation success. It appears that the trend toward failure is increased in patients with increased age, the diagnosis of an abnormal uterine cavity by ultrasound, and the presence of an intramural fibroid. Danazol administration, to prepare the endometrium, appears to offer a lower failure rate compared to GnRH agonists or progestins. Patients at greater risk of endometrial ablation failure based on age $41 years, abnormal intrauterine cavity, or the presence of intramural fibroids should be counseled about the higher failure rate and consider an alternative procedure such as hysterectomy.
Intraoperative blood loss and gestational age at pregnancy termination Dominic A. Marchiano, MD, Albert G. Thomas, MD, Robert Lapinski, PhD, Khousidai Balwan, BA, Jagruti Patel, BA Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Medical Center, New York, New York Objective: To establish the relationship of measured intraoperative blood loss to gestational age at pregnancy termination, and to determine which factors, if any, affect the risk of bleeding. Methods: A single-operator series of 363 consecutive women undergoing pregnancy termination between 5 and 24 weeks gestational age, as dated by ultrasound, was prospectively evaluated. All pregnancies under 13 weeks gestation were terminated by mechanical dilation and suction curettage without preoperative cervical ripening. All pregnancies between 13 and 24 weeks gestation were terminated by preoperative osmotic cervical dilation with laminaria tents and subsequent uterine evacuation by a combination of suction curettage, sharp curettage, and Bierer forceps extraction. All patients over 12 weeks gestation received a postoperative oxytocin infusion. Prim Care Update Ob/Gyns
OTHER GYNECOLOGIC SURGERY
Clinical outcomes of OPERA, Out-Patient Endometrial Resection/Ablation Arnold Kresch, MD Clinical Associate Professor, Stanford University School of Medicine, and Director, California Center of Pelvic Pain & Fertility, Palo Alto, California Objective: To evaluate the clinical outcomes of 18-month follow-up for OPERA, Out-Patient Endometrial Resection/ Ablation using the OPERAStar tissue aspirating resectoscope. Methods: Patients suffering from abnormal uterine bleeding (AUB) and/or submucosal fibroids who where indicated for surgical intervention underwent OPERA for treatment of their condition using the OPERAStar tissue aspirating resectoscope. This resectoscope contains a tissue aspiration and morcellation channel for continuous removal of tissue strips. Follow-up assessments were conducted at 1 month, 3 months, 6 months, 12 months, and 18 months to evaluate long-term clinical results of the procedure. Data collected include current level of bleeding, subsequent procedures to manage condition, and patient’s level of satisfaction.
Whenever possible, amniotic fluid and blood were collected and measured separately. Patients were excluded from the data analysis for pregnancy demise, PPROM, Potter’s syndrome, or inability to separate blood establish their relationship. After adjustment for gestational age, the results were analyzed to determine if blood loss was related to maternal age, smoking history, body habitus, or operative indication. Results: A curvilinear relationship between blood loss and gestational age was observed. Mean blood loss at 24 weeks exceeded 800 mL. After adjustment for gestational age, no factors significantly affected blood loss at dilation and aspiration of first trimester pregnancies. In those patients undergoing dilation and evacuation in the second trimester, both simple and stepwise regression analyses showed obesity (BMI $32.3) to be significantly associated with increased blood loss (P , .05). Neither age, parity, previous cesarean section, nor smoking history were significantly associated with increased blood loss at dilation and evacuation. Conclusions: With advancing gestational age, intraoperative blood loss increases in curvilinear fashion. Termination providers should be advised that, although blood loss is unaffected by many factors, obese patients are at risk for increased bleeding at dilation and evacuation of pregnancies beyond 12 weeks gestation.
Volume 5, Number 4, 1998
Results: A total of 33 patients presented with AUB requiring surgical intervention for relief of their symptoms. Uterine cavity averaged 10.7 cm (6 2.2), range 6.7–13.4 cm). Complete resection and ablation of the endometrium and submucosal fibroid(s) if present, was performed. Current 18-month follow-up data indicate that 21 (68%) patients achieved amenorrhea and 8 (26%) patients achieved hypomenorrhea. Two patients were lost to follow-up. Two patients underwent a subsequent procedure; one repeated OPERA and one hysterectomy for fibroids. Patient’s overall satisfaction rate with the results of their procedure was 97%. Conclusion: OPERA is an effective minimally invasive method for management of abnormal uterine bleeding. At 18 months, clinical outcomes of OPERA indicate an optimal level of patient satisfaction for management of their bleeding with 94% of patients achieving either amenorrhea or hypomenorrhea. Continuous aspiration and morcellation during resection keeps the operative field clear of debris and simplifies the procedure.
Clinical experience with the OPERA StarSL using saline irrigation fluid for OPERA Joseph R. Feste, MD, Eberhard C. Lotze, MD Clinical Associate Professor, Department of Obstetrics & Gynecology, Baylor College of Medicine, University of Texas Health Science Center Objective: To present clinical results using a new hysteroscopic resectoscope, the OPERAStarSL with PEARL technology, which cuts and coagulates uterine tissue in a physiologic, conductive fluid environment in order to perform OPERA, Out-Patient Endometrial Resection/Ablation. Use of physiologic normal saline in resectoscopy has not previously been 205