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Assessment of Periodic Blood Loss: Inter- and Intraindividual Variations of Pictorial Blood Loss Assessment Chart Registrations
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Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S47–S70 Open Communications 6dReproductive Issues (11:54 AM d 11:59 AM)
Uterine Transplantation as a Clinical Application for the Treatment of Uterine Factor Infertility: 11 Years of Experimental Research Ramirez ER,1 Ramirez Nessetti DK,2 Nessetti MBR,3 Guido RS,4 AbuElmagd KM,5 Ramirez HA.6 1Obstetrics and Gynecology, St. Johns Regional Medical Center, Oxnard, California; 2Obstetrics and Gynecology, Nebraska Comprehensive Health Care/Nebraska Mental Health Centers, Lincoln, Nebraska; 3Family Medicine, Medical Psychology and Psychopharmacology, Nebraska Comprehensive Health Care/Nebraska Mental Health Centers, Lincoln, Nebraska; 4Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 5Director, Intestinal Rehabilitation & Transplantation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 6 Obstetrics and Gynecology, Universidad de La Sallle, Bogota, Santa Fe, Colombia Study Objective: The overall prevalence of uterine agenesis constitutes approximately 3-5% of the general population. Currently society has provided surrogacy and adoption as a temporary solution for absolute uterine factor infertiltiy. Unfortunately, these services may not be considered a valid option for a small group of patients due to cultural, demographic location or religious beliefs. This study is an overview of our 11 years of experience in the field of uterine transplantation. Design: Pilot Study Setting: University De La Salle Bogota’, Colombia; University of Pittsburgh Medical Center, Pennsylvania Patients: A total of 77 uterine allotransplants were performed in the pig, goat and sheep models. The non-human primate will serve as our primary model to confirm the feasibility of uterine allotransplantation. Intervention: All animals underwent uterine transplantation via a minilaparotomy incision using a Mobius retractor device. Measurements and Main Results: These animal models were preferred since their anatomical landmarks are comparable to the human female reproductive tract. In all animals, short-term effects of warm and cold ischemia were quantified and vascular patency assessed. After documenting vascular patency and uterine allograft viability, a modified uterine transplant procedure was established and pregnancy outcomes were ascertained. The ovine model was specifically evaluated for pregnancy, and embryos were transferred into each uterine allograft accordingly. Four months post-uterine allotransplantation, pregnancies were confirmed resulting in the delivery of a fully developed lamb via cesarean section. All animals were subjected to immunosuppressive therapy and discontinued after the completion of our study. The rhesus monkey is currently being evaluated as our final step in research, where we intend to demonstrate that a successful uterine transplant can be achieved in the non-human primate. Conclusion: The present study highlights the promising application of uterine transplantation for the treatment of absolute uterine factor infertility. Our goal is to provide a safe and effective procedure that may be suitable for human uterine transplants. 155
Open Communications 7dBasic Science (11:00 AM d 11:05 AM)
Does Surgical ‘‘Warming-Up’’ Improve Operative Performance? Kroft J,1 Arthur R,2 Pittini R.1 1Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; 2 Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada Study Objective: To determine if pre-operative warming-up, using a validated bench model for intra-corporeal suturing, improves efficiency, precision and quality of laparoscopic suturing. Design: Randomized cross-over trial. Patients: Fourteen obstetrics and gynecology residents were randomized (2 junior (year 2) and 12 senior (years 3-5) residents) and 13 completed the study. Intervention: Participants were randomized to warm-up or no warm-up, and then acted as their own controls at least two weeks later. Warm-up
consisted of the use of a laparoscopic bench model to practice intracorporeal suturing for 15 minutes. Measurements and Main Results: All participants performed a prevalidated intracorporeal suturing task (after either warm-up or no warmup), which was scored based on time, precision and knot strength. Each participant also completed a questionnaire anonymously to determine if they believed that warming-up improved their performance, regardless of the score received. There was no difference in score when warm-up was compared to no warm-up for the group as a whole. When the junior residents were excluded from the analysis, however, ANOVA showed a significant improvement in score only when a warm-up was completed in the second session (p = .022). The questionnaire revealed that 80% of participants felt warming-up subjectively improved their ability, independent of their actual score. Those participants who responded that the warm-up did not provide any benefit felt this was because the task itself was too difficult. Those who felt that warm-up was useful but whose scores did not reflect this felt it was because the first session provided ‘‘practice’’ which improved the second score regardless of warm-up. Conclusion: This study demonstrates that a pre-operative warm-up is beneficial. Neither warming-up nor practice improved scores independently, but the two in combination resulted in a significant improvement in performance. This demonstrates a novel approach to resident education for teaching advanced laparoscopic skills.
156
Open Communications 7dBasic Science (11:06 AM d 11:11 AM)
Assessment of Periodic Blood Loss: Inter- and Intraindividual Variations of Pictorial Blood Loss Assessment Chart Registrations Hald K, Lieng M. Department of Gynecology, Oslo University Hospital, Oslo, Norway Study Objective: To explore the inter- and intraindividual variation of Pictorial Blood loss Assessment Chart (PBAC) registrations in women with subjective perception of both normal and heavy menstrual bleeding. Design: Prospective observational study. Setting: University tertiary referring centre in Oslo, Norway. Patients: 429 women that participated in three treatment trials for fibroids or endometrial polyps or in one cross sectional study of endometrial polyps. Intervention: Registration of PBAC, Hemoglobin and subjective assessment of periodic blood loss. Measurements and Main Results: A total of 1049 menstrual cycles were analysed. The median PBAC values in the three groups of women who assessed their bleeding as light, normal and heavy were 45.0, 116.0 and 254.5 (p\ 0.001) respectively. Calculation of sensivity and specificity for several cut-off points for PBAC above witch the women assessed their periodic blood loss as heavy showed at a maximum sensivity of 78.5 and specificity of 75.8 for a PBAC score of 160. At the same point the positive predictive value for the subjective assessment of heavy bleeding was 63.8 and the negative predictive value was 86.7. At PBAC values below 130, 90 % of the women claimed normal or light periodic blood loss and 91% had Hemoglobin values above 12.0 g/dL. The Intra Class Correlation for repeated PBAC measurements was 0.86 (95% CI 0.80, 0.90) for average measures. Conclusion: We found a significant difference in PBAC values between groups of patients that claimed to have light, normal and heavy periodic blood loss, however with relatively large overlaps of values within the groups. The consistency when a woman performed a second registration was high. The negative predictive value for both subjective assessment of heavy bleeding and Hemoglobin less than 12 g/dL was high for PBAC below 130. 157
Open Communications 7dBasic Science (11:12 AM d 11:17 AM)
Does a 24 Hour Call Impact OBGYN Attendings’ Laparoscopic Performance Post Call? Lyapis A, Fradinho M, Hacker M, Awtrey C. Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S47–S70 Open Communications 6dReproductive Issues (11:54 AM d 11:59 AM)
Uterine Transplantation as a Clinical Application for the Treatment of Uterine Factor Infertility: 11 Years of Experimental Research Ramirez ER,1 Ramirez Nessetti DK,2 Nessetti MBR,3 Guido RS,4 AbuElmagd KM,5 Ramirez HA.6 1Obstetrics and Gynecology, St. Johns Regional Medical Center, Oxnard, California; 2Obstetrics and Gynecology, Nebraska Comprehensive Health Care/Nebraska Mental Health Centers, Lincoln, Nebraska; 3Family Medicine, Medical Psychology and Psychopharmacology, Nebraska Comprehensive Health Care/Nebraska Mental Health Centers, Lincoln, Nebraska; 4Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 5Director, Intestinal Rehabilitation & Transplantation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 6 Obstetrics and Gynecology, Universidad de La Sallle, Bogota, Santa Fe, Colombia Study Objective: The overall prevalence of uterine agenesis constitutes approximately 3-5% of the general population. Currently society has provided surrogacy and adoption as a temporary solution for absolute uterine factor infertiltiy. Unfortunately, these services may not be considered a valid option for a small group of patients due to cultural, demographic location or religious beliefs. This study is an overview of our 11 years of experience in the field of uterine transplantation. Design: Pilot Study Setting: University De La Salle Bogota’, Colombia; University of Pittsburgh Medical Center, Pennsylvania Patients: A total of 77 uterine allotransplants were performed in the pig, goat and sheep models. The non-human primate will serve as our primary model to confirm the feasibility of uterine allotransplantation. Intervention: All animals underwent uterine transplantation via a minilaparotomy incision using a Mobius retractor device. Measurements and Main Results: These animal models were preferred since their anatomical landmarks are comparable to the human female reproductive tract. In all animals, short-term effects of warm and cold ischemia were quantified and vascular patency assessed. After documenting vascular patency and uterine allograft viability, a modified uterine transplant procedure was established and pregnancy outcomes were ascertained. The ovine model was specifically evaluated for pregnancy, and embryos were transferred into each uterine allograft accordingly. Four months post-uterine allotransplantation, pregnancies were confirmed resulting in the delivery of a fully developed lamb via cesarean section. All animals were subjected to immunosuppressive therapy and discontinued after the completion of our study. The rhesus monkey is currently being evaluated as our final step in research, where we intend to demonstrate that a successful uterine transplant can be achieved in the non-human primate. Conclusion: The present study highlights the promising application of uterine transplantation for the treatment of absolute uterine factor infertility. Our goal is to provide a safe and effective procedure that may be suitable for human uterine transplants. 155
Open Communications 7dBasic Science (11:00 AM d 11:05 AM)
Does Surgical ‘‘Warming-Up’’ Improve Operative Performance? Kroft J,1 Arthur R,2 Pittini R.1 1Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; 2 Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada Study Objective: To determine if pre-operative warming-up, using a validated bench model for intra-corporeal suturing, improves efficiency, precision and quality of laparoscopic suturing. Design: Randomized cross-over trial. Patients: Fourteen obstetrics and gynecology residents were randomized (2 junior (year 2) and 12 senior (years 3-5) residents) and 13 completed the study. Intervention: Participants were randomized to warm-up or no warm-up, and then acted as their own controls at least two weeks later. Warm-up
consisted of the use of a laparoscopic bench model to practice intracorporeal suturing for 15 minutes. Measurements and Main Results: All participants performed a prevalidated intracorporeal suturing task (after either warm-up or no warmup), which was scored based on time, precision and knot strength. Each participant also completed a questionnaire anonymously to determine if they believed that warming-up improved their performance, regardless of the score received. There was no difference in score when warm-up was compared to no warm-up for the group as a whole. When the junior residents were excluded from the analysis, however, ANOVA showed a significant improvement in score only when a warm-up was completed in the second session (p = .022). The questionnaire revealed that 80% of participants felt warming-up subjectively improved their ability, independent of their actual score. Those participants who responded that the warm-up did not provide any benefit felt this was because the task itself was too difficult. Those who felt that warm-up was useful but whose scores did not reflect this felt it was because the first session provided ‘‘practice’’ which improved the second score regardless of warm-up. Conclusion: This study demonstrates that a pre-operative warm-up is beneficial. Neither warming-up nor practice improved scores independently, but the two in combination resulted in a significant improvement in performance. This demonstrates a novel approach to resident education for teaching advanced laparoscopic skills.
156
Open Communications 7dBasic Science (11:06 AM d 11:11 AM)
Assessment of Periodic Blood Loss: Inter- and Intraindividual Variations of Pictorial Blood Loss Assessment Chart Registrations Hald K, Lieng M. Department of Gynecology, Oslo University Hospital, Oslo, Norway Study Objective: To explore the inter- and intraindividual variation of Pictorial Blood loss Assessment Chart (PBAC) registrations in women with subjective perception of both normal and heavy menstrual bleeding. Design: Prospective observational study. Setting: University tertiary referring centre in Oslo, Norway. Patients: 429 women that participated in three treatment trials for fibroids or endometrial polyps or in one cross sectional study of endometrial polyps. Intervention: Registration of PBAC, Hemoglobin and subjective assessment of periodic blood loss. Measurements and Main Results: A total of 1049 menstrual cycles were analysed. The median PBAC values in the three groups of women who assessed their bleeding as light, normal and heavy were 45.0, 116.0 and 254.5 (p\ 0.001) respectively. Calculation of sensivity and specificity for several cut-off points for PBAC above witch the women assessed their periodic blood loss as heavy showed at a maximum sensivity of 78.5 and specificity of 75.8 for a PBAC score of 160. At the same point the positive predictive value for the subjective assessment of heavy bleeding was 63.8 and the negative predictive value was 86.7. At PBAC values below 130, 90 % of the women claimed normal or light periodic blood loss and 91% had Hemoglobin values above 12.0 g/dL. The Intra Class Correlation for repeated PBAC measurements was 0.86 (95% CI 0.80, 0.90) for average measures. Conclusion: We found a significant difference in PBAC values between groups of patients that claimed to have light, normal and heavy periodic blood loss, however with relatively large overlaps of values within the groups. The consistency when a woman performed a second registration was high. The negative predictive value for both subjective assessment of heavy bleeding and Hemoglobin less than 12 g/dL was high for PBAC below 130. 157
Open Communications 7dBasic Science (11:12 AM d 11:17 AM)
Does a 24 Hour Call Impact OBGYN Attendings’ Laparoscopic Performance Post Call? Lyapis A, Fradinho M, Hacker M, Awtrey C. Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts