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Preservation of ovarian tissue in adnexal torsion with fluorescein
Preservation of ovarian tissue in adnexal torsion with fluorescein Lynda L. Burt McHutchison, MD, Paul P. Koonings, MD, Charles A. Ballard, MD, and Gerrit d'Ablaing III, MD Los Angeles, California OBJECTIVE: Our purpose was to assess the ability of fluorescein to intraoperatively detect viable fallopian and ovarian tissues involved in adnexal torsion. STUDY DESIGN: This prospective study was performed at Los Angeles County + University of Southern California Women's Hospital. Participants were female patients 18 to 45 years old with adnexal torsion confirmed at exploratory celiotomy. Five milliliters of 10% fluorescein were injected intravenously, and the involved untwisted adnexa was observed under ultraviolet light. Nonfluorescent tissue was resected and histologically evaluated. RESULTS: Eleven patients were entered into the study. Mean age was 25 years (range 15 to 42). Eight patients (72%) had preservation of involved ovarian tissue. No complications were associated with this procedure. Only three patients (28%) underwent oophorectomy. CONCLUSION: The use of intravenous fluorescein appears to be a valuable adjunct in the management of adnexal torsion. Application of this technique in reproductive-aged patients resulted in a three-quarter reduction in oophorectomy procedures. (AM J OBSTET GYNECOL 1993;168:1386-8.)
Key words: Ovarian torsion, fluorescein
Delay in diagnosis, inability to distinguish strangulation from necrosis, and fear of embolus dislodgement have made adnexectomy the accepted method of management of adnexal torsion. I This condition occurs most commonly in the reproductive years, yet methods to preserve viable ovarian tissue have not been routinely used or evaluated. Fluorescein is a resorcinol compound that absorbs light in the ultraviolet spectrum. Traditionally, the presence of yellow-green fluorescence is equated with tissue perfusion. 2 Fluorescein has been used widely and was previously shown to be a safe, standard, and reliable measure of tissue viability in vascular, general, and gynecologic oncology surgery. 3. 4 By using fluorescein in the management of adnexal torsion, it may be possible to differentiate between viable and nonviable ovarian tissue in the compromised adnexa, allowing preservation of ovarian tissue that would have otherwise been removed. To address this issue we evaluated the use of fluorescein in patients with surgically confirmed adnexal torsion.
From the Departments of Obstetrics and Gynecology and Pathology, University of Southern California School of Medicine, Los Angeles County-University of Southern California Women's Hospital. Received for publication September 23, 1992; revised December 4, 1992; accepted December 16, 1992. Reprint requests: Paul P. Koonings, MD, 825 Fairfax Ave., Suite 337, Norfolk, VA 23507. COPYright © 1993 fry Mosfry- Year Book, Inc. 0002-9378193 $1.00 + .20 6/1/44967
1386
Material and methods This prospective study was conducted between June 1990 and October 1991. Eleven female patients with surgically confirmed adnexal torsion were enrolled in the study. All patients desired continued reproductive function. At surgery the involved adnexa was slowly untwisted. If an ovarian or paratubal cyst was encountered, cystectomy was performed. Then an intravenous test dose (l ml) of 10% fluorescein sodium was slowly injected, followed by a 4 ml bolus. The involved adnexal tissue was observed beneath an ultraviolet light. Nonfluorescent tissue was considered nonviable, removed, and examined histologically. The patient was then followed closely. Results The majority of patients were young, Hispanic and, oflow parity. The patients' mean age was 25 ± 7 (SD) years. The youngest patient was 15 years old and the oldest was 42. More than 90% of the patients were < 30 years old. Most patients were Hispanic (82%), 19% were Asian, and 14% were white. The median parity was o. Oophorectomy was performed in only three cases (28%). The entire ovary was preserved in a further four cases (36%), and the remaining four (36%) had a small ovarian wedge resection to facilitate cyst removal. Pathologic examination of removed tissue was benign in all cases. We were unable to demonstrate a statistical difference between those patients who underwent oophorectomy and those who did not, as far as age
McHutchison at al.
Volume 168. Number 5 Am J Obstet Gvnecol
1387
Table I. Postoperative patient characteristics Adnexa removed (n = 3)*
Adnexa retained (n = 8)
1 4 1
3
No. of patients with postoperative fever Days in hospital (mean) No. of patients requiring antibiotics
Significance
1
NS NS NS
1
NS, Not significant. *A wound seroma developed in one patient.
Table II. Adnexal torsion studies demonstrating adnexal conservation rates
Author 5
Kelberg and Randa1l Peerman and Williams· McGowan 7 Lee and Welch 8 Lomano et al. 9 Hibbard' Current study
Year reported
Patients with adnexal torsion (No.)
1946 1954 1964 1967 1970 1985 1992
42 11 78 135 44 128 11
Adnexal torsion is an infrequent cause of abdominal and pelvic pain; however, it accounts for 3% of operative gynecology emergencies.' Extirpation of the involved adnexa is the most common procedure performed for this condition. Because adnexal torsion is most frequently identified in reproductive-aged patients, preservation of the involved tissue would seem to be advantageous in the majority of cases. Past reviews have demonstrated < 15% salvage rates (Table II). '. 5-9 Two explanations are usually given for this abysmal performance. First, the fear of embolus after untwisting of the involved adnexa is probably overestimated.' To our knowledge, no cases of pulmonary embolus directly attributable to the untwisting of an adnexal torsion have been reported. Until this complication is well established this rationale for adnexal removal does not seem justified in patients desiring future fertility. Second, there is the problem of identifYing viable tissue once the adnexa has been untwisted. This is probably the biggest barrier to adnexal preservation. Although WaylO reported the use of hot packs to determine tissue viability, this method is undesirable for use by reproductive surgeons because tissue damage may result. Recently Bider et al." reported an adnexal
Patients with adnexal conservation No.
1 0 11 7 6 7 8
I
% 2 0 14 5 13 7 72
salvage rate in over one half of their adnexal torsion cases. Observation was the method used to determine tissue viability. Unfortunately microscopic evaluation was performed in only 14% of patients, and postoperative morbidity was not addressed. In the current study the use of fluorescein was shown to be a reliable predictor of tissue viability. Nonfluorescent tissue was microscopically proven to be nonviable. Seventy-two percent of patients who otherwise may have lost their adnexa had preservation through the use of fluorescein. Fluorescein appears to be a valuable adjunct in the treatment of adnexal torsion in those patients desiring future fertility or ovarian preservation. Further prospective studies should be designed to confirm the capacity of fluorescein to alter current concepts of managing ovarian torsion.
REFERENCES 1. Hibbard LT. Adnexal torsion. AM] OBSTET GYNECOL 1985; 152:456-61. 2. Lange K, Boyd LJ. The use of fluorescein to determine the adequacy of the circulation. Med Clin North Am 1942; May:943-52. 3. Bulkley GB, Zuidema GD, Hamilton SR, O'Mara CS, Klacsmann PG, Horn SD. Intraoperative determination of small intestinal viability following ischemic injury. Ann Surg 1981;193:628-37. 4. Bongard FS, Elings VB, Markison RE. New uses of fluorescence in the surgical management of necrotizing soft tissue infection. Am] Surg 1985;150:281-3. 5. Kelberg MR, Randall ]H. Torsion of adnexal tumors and its relation to surgical emergency. AM] OBSTET GYNECOL 1946;52:464-8. 6. Peerman CG, Williams EL. Adnexal torsion. Obstet Gynecol 1954;3:523-6.
Wolman et al.
7. McGowan L. Torsion of cystic or diseased adnexal tissue. AM j OBSTET GVNECOL 1964;88: 135-6. 8. Lee RA, Welch jS. Torsion of the uterine adnexa. AM j OBSTET GYNECOL 1967;97:974-7. 9. LomanojM, TrelfordjD, Ullery jC. Torsion of the uterine adnexa causing an acute abdomen. Obstet Gynecol 1970; 35:221-5.
May 1993 Am J Obstet Gynecol
10. Way S. Ovarian cystectomy of twisted cysts. Lancet 1946; 2:46-7. 11. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 1991;173:363-6.
Postpartum depression and companionship in the clinical birth environment: A randomized, controlled study Wendy-Lynne Wolman, PhD," Beverley Chalmers, PhD," G. Justus Hofmeyr,b and V. Cheryl Nikodem, BA, RNb
Johannesburg, South Africa OBJECTIVE: Postpartum depression is a common feature of childbearing and is the cause of considerable morbidity. We have explored the possibility that clinically oriented care during labor may contribute to its occurrence. STUDY DESIGN: Of 189 nulliparous women laboring in a familiar community hospital, 92 were allocated by randomized, sealed envelopes to receive additional companionship from one of three volunteer labor companions recruited from the community. RESULTS: The group receiving support attained higher self-esteem scores and lower postpartum depression and anxiety ratings 6 weeks after delivery. CONCLUSION: In the clinical labor environment companionship modifies factors that contribute to the development of postnatal depression. We emphasize the importance of paying attention to the psychosocial environment in which labor takes place, to facilitate adaptation to parenthood. (AM J QBSTET GVNECOL 1993;168:1388-93.)
Key words: Companionship in labor, postpartum depression Of the various psychologic consequences of childbirth postpartum depression is regarded by many researchers and clinicians as the most clinically important. I,4 With greater clinical significance than transient postpartum "blues"5 and considerably more common than overt postpartum psychoses,6, 7 postpartum depression comprises a group of poorly defined, depressive-type symptoms that have their onset in the early postpartum weeks or months and can persist for more than a
From the Departments of Psychologya and Obstetrics and Gynaecology/ Coronation Hospital, University of the Witwatersrand. Supported by the South African Medical Research Council, the Human Sciences Research Council, the Iris Ellen Hodges Fund of the University of the Witwatersrand, and the Association for Childbirth and Parenthood of Southern Africa. Received for publication May 7, 1992; revised September 16, 1992; accepted December 16, 1992. Reprint requests: B.E. Chalmers, PhD, 1212 Old Post Dr., Oakville, Ontario, Canada L6M lA6. Copyright © 1993 by Mosby-Year Book, Inc. 0002-9378193 $1,00 + ,20 6!1!45010
1388
year.S,IO The reported incidence ranges from 3% to 34%.11 The clinical symptoms of postpartum depression are extensive and sometimes conflicting. Depression itself is not necessarily one of the leading symptoms, I, 2 although it is usually evident. 3 Oppenheim5 mentions exhaustion, irritability, and weepiness as women's main complaints, whereas Pitt'° describes retardation of energy and motivation levels. Feelings of helplessness and hopelessness prevail,9 and anxiety is common. I, 2, 10 Vegetative symptoms such as loss of libido, I, 10, 12 appetite disturbance,5 and sleep disturbance are usually present. 5 Psychosomatic SYII1ptoms such as headache, asthma, backache, vaginal discharge, and abdominal pain may be reported." \3 Cognitive symptoms, which may be more difficult to detect, may include obsessional thinking, fear of harming the baby or self,4 suicidal thoughts,14 and depersonalization. lo Overt rejection of the baby may be an extreme reaction. I With early diagnosis and treatment the prognosis is good, and over two thirds of patients recover within a
Key words: Ovarian torsion, fluorescein
Delay in diagnosis, inability to distinguish strangulation from necrosis, and fear of embolus dislodgement have made adnexectomy the accepted method of management of adnexal torsion. I This condition occurs most commonly in the reproductive years, yet methods to preserve viable ovarian tissue have not been routinely used or evaluated. Fluorescein is a resorcinol compound that absorbs light in the ultraviolet spectrum. Traditionally, the presence of yellow-green fluorescence is equated with tissue perfusion. 2 Fluorescein has been used widely and was previously shown to be a safe, standard, and reliable measure of tissue viability in vascular, general, and gynecologic oncology surgery. 3. 4 By using fluorescein in the management of adnexal torsion, it may be possible to differentiate between viable and nonviable ovarian tissue in the compromised adnexa, allowing preservation of ovarian tissue that would have otherwise been removed. To address this issue we evaluated the use of fluorescein in patients with surgically confirmed adnexal torsion.
From the Departments of Obstetrics and Gynecology and Pathology, University of Southern California School of Medicine, Los Angeles County-University of Southern California Women's Hospital. Received for publication September 23, 1992; revised December 4, 1992; accepted December 16, 1992. Reprint requests: Paul P. Koonings, MD, 825 Fairfax Ave., Suite 337, Norfolk, VA 23507. COPYright © 1993 fry Mosfry- Year Book, Inc. 0002-9378193 $1.00 + .20 6/1/44967
1386
Material and methods This prospective study was conducted between June 1990 and October 1991. Eleven female patients with surgically confirmed adnexal torsion were enrolled in the study. All patients desired continued reproductive function. At surgery the involved adnexa was slowly untwisted. If an ovarian or paratubal cyst was encountered, cystectomy was performed. Then an intravenous test dose (l ml) of 10% fluorescein sodium was slowly injected, followed by a 4 ml bolus. The involved adnexal tissue was observed beneath an ultraviolet light. Nonfluorescent tissue was considered nonviable, removed, and examined histologically. The patient was then followed closely. Results The majority of patients were young, Hispanic and, oflow parity. The patients' mean age was 25 ± 7 (SD) years. The youngest patient was 15 years old and the oldest was 42. More than 90% of the patients were < 30 years old. Most patients were Hispanic (82%), 19% were Asian, and 14% were white. The median parity was o. Oophorectomy was performed in only three cases (28%). The entire ovary was preserved in a further four cases (36%), and the remaining four (36%) had a small ovarian wedge resection to facilitate cyst removal. Pathologic examination of removed tissue was benign in all cases. We were unable to demonstrate a statistical difference between those patients who underwent oophorectomy and those who did not, as far as age
McHutchison at al.
Volume 168. Number 5 Am J Obstet Gvnecol
1387
Table I. Postoperative patient characteristics Adnexa removed (n = 3)*
Adnexa retained (n = 8)
1 4 1
3
No. of patients with postoperative fever Days in hospital (mean) No. of patients requiring antibiotics
Significance
1
NS NS NS
1
NS, Not significant. *A wound seroma developed in one patient.
Table II. Adnexal torsion studies demonstrating adnexal conservation rates
Author 5
Kelberg and Randa1l Peerman and Williams· McGowan 7 Lee and Welch 8 Lomano et al. 9 Hibbard' Current study
Year reported
Patients with adnexal torsion (No.)
1946 1954 1964 1967 1970 1985 1992
42 11 78 135 44 128 11
Adnexal torsion is an infrequent cause of abdominal and pelvic pain; however, it accounts for 3% of operative gynecology emergencies.' Extirpation of the involved adnexa is the most common procedure performed for this condition. Because adnexal torsion is most frequently identified in reproductive-aged patients, preservation of the involved tissue would seem to be advantageous in the majority of cases. Past reviews have demonstrated < 15% salvage rates (Table II). '. 5-9 Two explanations are usually given for this abysmal performance. First, the fear of embolus after untwisting of the involved adnexa is probably overestimated.' To our knowledge, no cases of pulmonary embolus directly attributable to the untwisting of an adnexal torsion have been reported. Until this complication is well established this rationale for adnexal removal does not seem justified in patients desiring future fertility. Second, there is the problem of identifYing viable tissue once the adnexa has been untwisted. This is probably the biggest barrier to adnexal preservation. Although WaylO reported the use of hot packs to determine tissue viability, this method is undesirable for use by reproductive surgeons because tissue damage may result. Recently Bider et al." reported an adnexal
Patients with adnexal conservation No.
1 0 11 7 6 7 8
I
% 2 0 14 5 13 7 72
salvage rate in over one half of their adnexal torsion cases. Observation was the method used to determine tissue viability. Unfortunately microscopic evaluation was performed in only 14% of patients, and postoperative morbidity was not addressed. In the current study the use of fluorescein was shown to be a reliable predictor of tissue viability. Nonfluorescent tissue was microscopically proven to be nonviable. Seventy-two percent of patients who otherwise may have lost their adnexa had preservation through the use of fluorescein. Fluorescein appears to be a valuable adjunct in the treatment of adnexal torsion in those patients desiring future fertility or ovarian preservation. Further prospective studies should be designed to confirm the capacity of fluorescein to alter current concepts of managing ovarian torsion.
REFERENCES 1. Hibbard LT. Adnexal torsion. AM] OBSTET GYNECOL 1985; 152:456-61. 2. Lange K, Boyd LJ. The use of fluorescein to determine the adequacy of the circulation. Med Clin North Am 1942; May:943-52. 3. Bulkley GB, Zuidema GD, Hamilton SR, O'Mara CS, Klacsmann PG, Horn SD. Intraoperative determination of small intestinal viability following ischemic injury. Ann Surg 1981;193:628-37. 4. Bongard FS, Elings VB, Markison RE. New uses of fluorescence in the surgical management of necrotizing soft tissue infection. Am] Surg 1985;150:281-3. 5. Kelberg MR, Randall ]H. Torsion of adnexal tumors and its relation to surgical emergency. AM] OBSTET GYNECOL 1946;52:464-8. 6. Peerman CG, Williams EL. Adnexal torsion. Obstet Gynecol 1954;3:523-6.
Wolman et al.
7. McGowan L. Torsion of cystic or diseased adnexal tissue. AM j OBSTET GVNECOL 1964;88: 135-6. 8. Lee RA, Welch jS. Torsion of the uterine adnexa. AM j OBSTET GYNECOL 1967;97:974-7. 9. LomanojM, TrelfordjD, Ullery jC. Torsion of the uterine adnexa causing an acute abdomen. Obstet Gynecol 1970; 35:221-5.
May 1993 Am J Obstet Gynecol
10. Way S. Ovarian cystectomy of twisted cysts. Lancet 1946; 2:46-7. 11. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 1991;173:363-6.
Postpartum depression and companionship in the clinical birth environment: A randomized, controlled study Wendy-Lynne Wolman, PhD," Beverley Chalmers, PhD," G. Justus Hofmeyr,b and V. Cheryl Nikodem, BA, RNb
Johannesburg, South Africa OBJECTIVE: Postpartum depression is a common feature of childbearing and is the cause of considerable morbidity. We have explored the possibility that clinically oriented care during labor may contribute to its occurrence. STUDY DESIGN: Of 189 nulliparous women laboring in a familiar community hospital, 92 were allocated by randomized, sealed envelopes to receive additional companionship from one of three volunteer labor companions recruited from the community. RESULTS: The group receiving support attained higher self-esteem scores and lower postpartum depression and anxiety ratings 6 weeks after delivery. CONCLUSION: In the clinical labor environment companionship modifies factors that contribute to the development of postnatal depression. We emphasize the importance of paying attention to the psychosocial environment in which labor takes place, to facilitate adaptation to parenthood. (AM J QBSTET GVNECOL 1993;168:1388-93.)
Key words: Companionship in labor, postpartum depression Of the various psychologic consequences of childbirth postpartum depression is regarded by many researchers and clinicians as the most clinically important. I,4 With greater clinical significance than transient postpartum "blues"5 and considerably more common than overt postpartum psychoses,6, 7 postpartum depression comprises a group of poorly defined, depressive-type symptoms that have their onset in the early postpartum weeks or months and can persist for more than a
From the Departments of Psychologya and Obstetrics and Gynaecology/ Coronation Hospital, University of the Witwatersrand. Supported by the South African Medical Research Council, the Human Sciences Research Council, the Iris Ellen Hodges Fund of the University of the Witwatersrand, and the Association for Childbirth and Parenthood of Southern Africa. Received for publication May 7, 1992; revised September 16, 1992; accepted December 16, 1992. Reprint requests: B.E. Chalmers, PhD, 1212 Old Post Dr., Oakville, Ontario, Canada L6M lA6. Copyright © 1993 by Mosby-Year Book, Inc. 0002-9378193 $1,00 + ,20 6!1!45010
1388
year.S,IO The reported incidence ranges from 3% to 34%.11 The clinical symptoms of postpartum depression are extensive and sometimes conflicting. Depression itself is not necessarily one of the leading symptoms, I, 2 although it is usually evident. 3 Oppenheim5 mentions exhaustion, irritability, and weepiness as women's main complaints, whereas Pitt'° describes retardation of energy and motivation levels. Feelings of helplessness and hopelessness prevail,9 and anxiety is common. I, 2, 10 Vegetative symptoms such as loss of libido, I, 10, 12 appetite disturbance,5 and sleep disturbance are usually present. 5 Psychosomatic SYII1ptoms such as headache, asthma, backache, vaginal discharge, and abdominal pain may be reported." \3 Cognitive symptoms, which may be more difficult to detect, may include obsessional thinking, fear of harming the baby or self,4 suicidal thoughts,14 and depersonalization. lo Overt rejection of the baby may be an extreme reaction. I With early diagnosis and treatment the prognosis is good, and over two thirds of patients recover within a