Is laparoscopic hysterectomy a waste of time?

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Citations from the literature/International Journal of Gynecology & Obstetrics SO (1995) 315-323

were not detected in any of the samples, indicating that there was no biochemical evidence of a risk of toxicity. Indeed, vitamin A correlated significantly with birthweight, head circumference, length, and gestation period. There was also a significant positive relationship between zinc and birthweight. In contrast, copper showed a negative correlation with birthweight and head circumference. Vitamin E and magnesium were not associated with any of the anthropometric measurements, although magnesium showed an increasing trend with birthweight. The data suggestthat most of the mothers of the subjectsstudied may have been marginal with respect to vitamins A and E and zinc. In those with low birthweight babies, a higher intake would have improved their nutritional status and possibly the outcome of their pregnancy. For these low-income mothers, liver and liver products are the cheapest and the best source of vitamins A and E, heme iron, B vitamins and several other essential nutrients; hence the advice of the Department of Health may have been misplaced. A Iongitwdinal study of Imete& vaginosis during pregmmcy

Hay P.E.; Morgan D.J.; Ison C.A.; Bhide S.A.; Romney M.; McKenzie P.; Pearson J.; Lamont R.F.; Taylor-Robinson D. GBR BR J OBSTET GYNAECOL 1994 101112(1048-1053) Objective: To determine the longitudinal changesin the incidence of bacterial vaginosis in pregnancy. Design: A prospective study of women during pregnancy. Setting: A District General Hospital in North-West London. Subjects: Seven hundred and eighteen pregnant women attending antenatal clinics. At their first attendance and subsequently, Gram-stained vaginal smearswere examined and Mycoplasma hominis and Gardnerella vaginalis were sought by culture. Results: Initially, 87 (12%) women had bacterial vaginosis diagnosed on Gramstained reading of the vaginal smears. Examination of further smears, obtained from 176 women at 36 weeks of gestation, showedthat those whosevaginal flora was normal initially, and who went to term, rarely developed vaginosis (three of 127, 2.4%). Samples were obtained at 36 weeks gestation from 32 women who had bacterial vaginosis initially, and went to term. In almost 50% (15 of 32) of these a normal lactobacillusdominated flora had regenerated. Thirty-five women (5%) had initial vaginal smearsgraded as intermediate. From this group, six of the 17 (35%) women from whom samples were obtained at 36 weeks gestation still had flora of an intermediate pattern, 10 (59%) now had normal flora and only one (6%) had developed bacterial vaginosis. Women with bacterial vaginosis were more likely to be culture-positive for M hominis than those with normal flora (34/78vs. 10/563,odds ratio 42.73 (18.9 to 102.3)P < O.OOl),or to be culture-positive for G. vaginalis than those with normal flora (35/78 vs. 211563,odds ratio 21.0 (10.75 to 41.2) P < 0.001). Conclusion: Pregnant women do not commonly develop bacterial vaginosis after 16 weeks gestation, and if present, it remits spontaneously in approximately half of those who reach term. As bacterial vaginosis is associated with increased rates of second trimester miscarriage and preterm delivery, any treatment aimed at its eradication in pregnancy should be given no later than the beginning of the second trimester of pregnancy.

clinical significanec of absent or reversed end diastolic velocity waveforms in umbilical artery

Karsdorp V.H.M.; Van Vugt J.M.G.; Van Geijn H.P.; Kostense P.J.; Arduini D.; Montenegro N.; Todros R. NLD LANCET 1994344/8938(1664-1668) Doppler ultrasound provides a non-invasive method to assessfetal hemodynamics. We looked at the outcome of dop pier velocimetry of the umbilical artery In three groups of pregnancies: those with positive end diastolic velocities (PED; R = 214), absent end diastolic velocities (AED, n = 178) and reversed end diastolic velocities (RED, n = 67). We collected our data from 9 European centres. Logistic regression showed that compared with pregnancies with hypertension only, pregnancies complicated by intra uterine growth retardation (IUGR) had a higher risk of developing absent or reyersedend diastolic velocity waveforms (ARED) flow. ARED flow in the umbilical artery (odds ratio: OR = 3.1). Pregnancies complicated by both IUGR and hypertension had an even higher risk (OR = 7.4). Maternal age and smoking habits did not influence the risk of developing ARED flow. The overall perinatal mortality rate was 28%. Significantly more neonates in the ARED flow group needed admittance to the neonatal intensive care unit (PED group 60%, AED group 96%, RED group 98%). The OR for perinatal mortality in pregnancies complicated by AED flow was 4.0 and in RED flow was 10.6, compared with PED flow, even after adjustment for menstrual age. ARED flow in the umbilical artery did not influence the risk of respiratory distress syndrome or necrotising enterocolitis of the neonate, but ARED flow significantly influenced the risk of cerebral hemorrhage, anemia, or hypoglycemia. We advise that pregnancies complicated by IUGR and/or hypertension should be followed up with doppler velocimetry to trace utero-placental problems as early as possible. A cesareansection is recommendedin all pregnanciescomplicated by ARED flow if the gestational age and predicted neonatal weight can be handled by the local neonatal intensive care unit.

LAPAROSCOPIC

SURGERY

Is Iaparoscopic hysterectomy a waste of time? Richardson R.E.; Boumas N.; Magos A.L. GBR LANCET 1995 345/8941(36-41) Laparoscopic hysterectomy (LH) is a way to avoid laparotomy. However, there is evidence that most women treated by abdominal hysterectomy are suitable for vaginal surgery. TO test this hypothesis, and to determine the relative merits of lap aroscopic and vaginal hysterectomy (VH) and the best technique for LH, we prospectively studied 98 women who had relative contraindications for vaginal surgery by traditional criteria. 75 underwent LH and 23 VH. The LH group included 22 women who had been assignedto this route of surgery as part of a prospective randomized controlled comparison with VH (23 women). Surgery was completed with the intended technique in 93.9% of cases.5 women in the LH group (6.7%) and

Citations from the literature/International

Journal of Gynecology & Obstetrics SO (199s) 315-323

2 in the VH group required laparotomy or additional procedures. In the prospective randomized study LH took longer than VH (mean duration 131 vs. 77 mitt). VH was the faster procedure, irrespective of uterine size and need for oophorectomy. With LH, the operative time increased as more of the hysterectomy was carried out with laparoscopic rather than vaginal dissection. Complication rates, blood loss, analgesia requirements, and recovery were similar for the two techniques. Our study confirms that most hysterectomiescould be performed vaginally, and that LH is a much slower procedure. If LH is done, it should be converted to a vaginal procedure as early as possible to reduce the overall operating time. LH does seem to be a waste of time for most patients. Ultrswnd-guided injection of metbotrexate versusIaparoscopic salphtgotomy in ectopic pqpwcy

Femandez H.; Pauthier S.; Doumerc S.; La: :dier C.; Olivennes F.; Ville Y.; Frydman R. FRA

FERTIL STERIL 1995 63/l (25-29) Objective: To compare local injection of methotrexate (MTX) under sonographic control to laparoscopic salpingotomy for conservative management of ectopic pregnancy (EP). Design: Prospective randomized study. Patients: Forty patients were randomized into two groups using a random number table. Inclusion criteria were an EP visualized by ultrasound with a pretherapeutic score s 13 as assessedby six criteria graded from 1 to 3: gestational age, hCG level, P level, abdominal pain, volume of the hemoperitoneum, and diameter of the hematosalpinx. Interventions: Group 1 patients injected transvaginally with 1 mgikg MTX into the EP without anesthesia versus group 2 patients undergoing laparoscopic salpingotomy. Main Outcome Measures: Postoperative hospital stay, decreaseof hCG levels, successrate. Results: The success rates, defined by hCG levels returned to normal (< 10 mIU/ml [conversion factor to SI units, l&O]), were 19 of 20 in both groups. Medical treatment was associated significantly with shorter postoperative stay (24 versus 46 h) and a higher initial hCG level. Human chorionic gonadotropin returned to normal more quickly after laparoscopic treatment (14 versus 28 days). Conclusions: In selected cases of EP with a pretherapeutic score s 13, MTX treatment appeared to be as safe and efficient as was conservative treatment by laparoscopy. A randomized pmpective study of laparoscopic vaginal hysterectomy veraus rhdondnal hystemetomy each nith bilateral =lPk-tomY

Raju K.S.; Auld B.J. GBR

BR J OBSTET GYNAECOL 1994 101112(1068-1071) Objective: To identify differences in the peri-operative outcome of women undergoing hysterectomy with bilateral salpingo-oophorectomy performed either by abdominal hysterectomy and bilateral salpingo-oophorectomy or by laparoscopic-assisted salpingo-oophorectomy and vaginal hysterectomy. To identify any potential management implications, including financial differences, between these two forms

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of operations. Subjects and methods: Eighty women undergoing hysterectomy and bilateral salpingo-oophorectomy for benign gynecological conditions were prospectively randomixed to have the procedure by laparoscopic-assistedbilateral salpingo-oophorectomy and vaginal hysterectomy or total abdominal hysterectomy and bilateral salpingo-oophorectomy. The peri-operative and post-operative courses of both groups were compared. Results: Although laparoscopic-assisted bilateral salpingo-oophorectomy and vaginal hysterectomy took longer (100(S.D. 5.6) versus 57 (S.D.4.7) min, P < O.OOOl),the women undergoing this procedure had a shorter time in hospital (3.5 vs. six days, P c 0.0081)quicker recovery (three versus six weeks, P < 0.0001) and returned to work earlier. There were minimal complications in both groups and they were not significantly different. The cost of the laparoscopic-assisted procedure was greater during the operation with longer operating time and cost of disposable instruments. However, the total cost of treatment was less in this group because of shortened post-operative stay. Conclusion: The study shows laparoscopic-assisted bilateral salpingo-oophorectomy and vaginal hysterectomy is a safe and cost-effective procedure for women requiring a hysterectomy and bilateral salpingooophorectomy.

EXPERIMENTAL MEDICINE Reduced thromboxane receptor affinity and vasocodrictor rapomea in placentae from diabetic pregmnries Wilkes B.M.; Mento P.F.; Hollander A.M.

USA PLACENTA 1994 1518(845-855) Thromboxane has been implicated in the pathogenesis of maternal hypertension in high-risk pregnancies, but potential abnormalities in thromboxane-mediated constriction of fetoplacental vesselshas not been examined. Using the isolated perfused fetoplacental cotyledon, we compared the vasoconstrictor responsesto a thromboxane mimetic, U46619, in placentae from normal women and women with diabetes mellitus (classesC, D and R). Increases in perfusion pressure in response to bolus injections of U46619 were used to construct dose-responsecurves. The threshold dose of U46619 to causea pressor responsewas similar in placentae from normal and diabetic pregnancies, but the slope of the dose-response curve was decreasedby 39% in placentae from diabetic pregnancies compared with normal controls (P < 0.01). To examine the potential contribution of altered thromboxane receptors, equilibrium binding studies were performed using the thromboxane antagonist [3H]-SQ29548to a 44 000 g fraction of placental homogenate. The affinity of thromboxane receptors was significantly decreasedin placentae from diabetic pregnancies compared with normal controls [K(d) = 41.9 f 7.9, (a = 6) versuscontrol, 21.4 f 1.3nM (n = 26), P c O.OOl]. In contrast, the density of thromboxane receptor sites was not significantly changed (diabetes, 176.0 + 6.2 vs. control, 150.3f 6.5 fmol/mg, P = not significant). Placental production of thromboxane and prostacyclin were measuredby the in-