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Serum screening for down's syndrome
FRIDAY,
SEPTEMBER
8
1
INVITED EN5.01 TECHNIQUES
OF HYSTERECTOMY
- WHICH ONE?
EN5.01.02
LAPAROSCOPIC HYSTERECTOMY Minna Kauko, North Karelian Central Hospital, Finland Still more than ten years after the first laparoscopic hysterectomy, the laparoscopic approach is struggling to find its place among abdominal and vaginal hysterectomies. Although, about 95% of hysterectomies with benign indications could be managed either laparoscopically or vaginally, the abdominal route remains to predominate in many countries, e.g. the USA, UK, Scandinavian countries. The costeffectiveness of laparoscopic approach against open abdominal has been proven, the low penetration rate reflects the lack of training possibilities, low surgical skills, fear of complications and complexity of laparoscopic techniques. The variety of techniques include the use of all possible laparoscopic hemostatic methods for sealing the uterine blood flow. Electrosurgery -weather mono- or bipolar- has brought about complications due to electric current. Mechanical hemostatic methods e.g. clips and linear staplers have their advocates, but may be complex to use and expensive. Ultrasound energy as a hemostatic and cutting method has shown to be an effective and safe alternative. It simplifies the procedure and potentially makes it easier to adopt. The general belief of laparoscopic approach for hysterectomy being time consuming in comparison to other routes has been proven wrong. Every laparoscopic technique by itself has its learning curve. Only after completion of ones learning curve, fair comparisons to older methods can be done. The use of ultrasound energy decreases the operation time due to simplicity and multifunctionality of the instrumentation.
EN5.01.03 VAGINAL HYSTERECTOMY S S. Sheth, Sheth Nursing Home, Mumbai,
India
With the introduction of laparoscopic surgery for hysterectomy, a clear picture is emerging for the choice of the technique of hysterectomy-its route, indications and limitations. Backed by experience of 5500+ vaginal hysterectomies done, the author is convinced that vaginal is preferred route to the abdominal because of its advantages. Only when the vaginal route is contraindicated or risky, does the need to resort to the alternate, abdominal route, recommended. LAVH is preferred to abdominal hysterectomy, but involves knowledge of laparoscopic surgery as well as vaginal hysterectomy. There is sufficient evidence to suggest that, if VH can be done, it is preferred to LAVH. However, there are definite situations where laparoscopic assistance either in the form of evaluatory or operative role is required to perform VH. Indications and contraindications for the techniques and limitations of gynaecologist for each technique are getting crystallised. Thus, vaginal surgeons are gradually learning laparoscopic surgery to convert abdominal hysterectomy to LAVH and gynec laparoscopists are learning VH to perform more LAVH and eventually VH. 70%.80% of hysterectomies should be possible vaginally and the remaining need laparoscopic assistance or laparotomy, but in reality at most centres practice this in reverse. If hysterectomy is possible by all three approaches, in the best interest of the patient, the order of preference would be vaginal, LAVH and abdominal, in that order. Oophorectomy, adnexectomy for benign pathology and debulking can change the practice in favour of VH. Above matter is presented and highlighted through scientific data.
FM5.01 SCREENING
FOR FETAL ABNORMALITIES
FM5.01.01 SERUM SCREENING FOR DOWN’S SYNDROME M. Academic Department of Obstetrics and Gynecology,
University
of Birmingham,
Birmingham,
United Kingdom
Serum screening for Down’s Syndrome was first announced in the late 1980’s. Initial studies indicated that the introduction of a serum test comprising AFP and HCG undertaken at 15-16 weeks would identify about 60% of Down’s syndrome pregnancies for a 5% false positive
rate. Maternal age was of course another factor in the calculation but the false-positive rate was very sensitive to the mother’s age. Subsequently other analytes were added in an attempt to improve the sensitivity and false-positive rate and probably the best combination in the quadruple test. All the initial work with serum testing concentrated on the second trimester, but more recently interest has been shown in the first trimester serum screening using HCG and/or PAPP-A. Some first trimester work would suggest that the use of serum testing at this time is probably as effective as second trimester testing, although calculations are always complicated by the fact that there is a high spontaneous loss rate of Down’s syndrome babies between the first and second trimester. The talk will address the various analytes that have been used and their likely efficacy.
FM5.01.02 FIRST TRIMESTER ULTRASOUND Jo-Ann University of Toronto, Toronto,
Canada
Gestational age of ultrasound examination < 10 weeks = sonoembryology lo-14 weeks Advantages and disadvantages The lo-14 week scan Increased nuchal translucency and chromosome defects Structural anomalies with increased nuchal translucency karyotype ??
??
??
??
??
and normal
CNS Anomalies Acrania Encephalocele Holoprosencephaly Spina bifida Venticulomegaly Cardiac Anomalies Four chamber view Outflow tracts Arrythmias Structural defects Gastrointestinal defects Abdominal wall defects Diaphragmatic hernia Urinary Tract Defects Renal agenesis Polycystic kidney disease Dysplastic kidneys Megacytsis Skeletal dysplasias Summaries Summaries
and limb defects
of studies in low risk populations. of studies in high risk populations
Protocol for ultrasound weeks gestation.
examination
to detect fetal anomalites
at lo-14
References: Achiron et al. First trimester diagnosis of fetal congenital heart disease by tramvaginal ultrasonography. Obstetrics and Gynecology 1994, 84: 69-72. Blaas HG. The examination of the embryo and early fetus: how and by whom. Ultrasound in Obstetrics and Gynecology. 1999, 14:153-158. Hernadi Let al. Screening for fetal anomalites in the 12’h week of pregnancy by trans.vaginal sonography on a non-selected population. Prenatal Diagnosis 1997, 17: 753-759. Hyett et al. Using fetal nuchal translucency to screen for major congenital heart defects at lo-14 weeks of gestation. BMJ 1999, 318: 81-85. Johnson SP et al. Ultrasound screening for anencephaly at lo-14 weeks of gestation. Ultrasound in Obstetrics and Gynecology. 1997, 9:14-16. Nicolaides KH, Azar G, Snijders RJM, Gosden CM. Fetal nuchal oedema:associated malformations and chromosomal defects. Fetal Diagn Ther1992;7:123-131. Nicolaides KH, Brizot ML, Snijders RJM. Fetal nuchal translucency thickness: ultrasound screening for fetal trisomy in the first trimester of
SEPTEMBER
8
1
INVITED EN5.01 TECHNIQUES
OF HYSTERECTOMY
- WHICH ONE?
EN5.01.02
LAPAROSCOPIC HYSTERECTOMY Minna Kauko, North Karelian Central Hospital, Finland Still more than ten years after the first laparoscopic hysterectomy, the laparoscopic approach is struggling to find its place among abdominal and vaginal hysterectomies. Although, about 95% of hysterectomies with benign indications could be managed either laparoscopically or vaginally, the abdominal route remains to predominate in many countries, e.g. the USA, UK, Scandinavian countries. The costeffectiveness of laparoscopic approach against open abdominal has been proven, the low penetration rate reflects the lack of training possibilities, low surgical skills, fear of complications and complexity of laparoscopic techniques. The variety of techniques include the use of all possible laparoscopic hemostatic methods for sealing the uterine blood flow. Electrosurgery -weather mono- or bipolar- has brought about complications due to electric current. Mechanical hemostatic methods e.g. clips and linear staplers have their advocates, but may be complex to use and expensive. Ultrasound energy as a hemostatic and cutting method has shown to be an effective and safe alternative. It simplifies the procedure and potentially makes it easier to adopt. The general belief of laparoscopic approach for hysterectomy being time consuming in comparison to other routes has been proven wrong. Every laparoscopic technique by itself has its learning curve. Only after completion of ones learning curve, fair comparisons to older methods can be done. The use of ultrasound energy decreases the operation time due to simplicity and multifunctionality of the instrumentation.
EN5.01.03 VAGINAL HYSTERECTOMY S S. Sheth, Sheth Nursing Home, Mumbai,
India
With the introduction of laparoscopic surgery for hysterectomy, a clear picture is emerging for the choice of the technique of hysterectomy-its route, indications and limitations. Backed by experience of 5500+ vaginal hysterectomies done, the author is convinced that vaginal is preferred route to the abdominal because of its advantages. Only when the vaginal route is contraindicated or risky, does the need to resort to the alternate, abdominal route, recommended. LAVH is preferred to abdominal hysterectomy, but involves knowledge of laparoscopic surgery as well as vaginal hysterectomy. There is sufficient evidence to suggest that, if VH can be done, it is preferred to LAVH. However, there are definite situations where laparoscopic assistance either in the form of evaluatory or operative role is required to perform VH. Indications and contraindications for the techniques and limitations of gynaecologist for each technique are getting crystallised. Thus, vaginal surgeons are gradually learning laparoscopic surgery to convert abdominal hysterectomy to LAVH and gynec laparoscopists are learning VH to perform more LAVH and eventually VH. 70%.80% of hysterectomies should be possible vaginally and the remaining need laparoscopic assistance or laparotomy, but in reality at most centres practice this in reverse. If hysterectomy is possible by all three approaches, in the best interest of the patient, the order of preference would be vaginal, LAVH and abdominal, in that order. Oophorectomy, adnexectomy for benign pathology and debulking can change the practice in favour of VH. Above matter is presented and highlighted through scientific data.
FM5.01 SCREENING
FOR FETAL ABNORMALITIES
FM5.01.01 SERUM SCREENING FOR DOWN’S SYNDROME M. Academic Department of Obstetrics and Gynecology,
University
of Birmingham,
Birmingham,
United Kingdom
Serum screening for Down’s Syndrome was first announced in the late 1980’s. Initial studies indicated that the introduction of a serum test comprising AFP and HCG undertaken at 15-16 weeks would identify about 60% of Down’s syndrome pregnancies for a 5% false positive
rate. Maternal age was of course another factor in the calculation but the false-positive rate was very sensitive to the mother’s age. Subsequently other analytes were added in an attempt to improve the sensitivity and false-positive rate and probably the best combination in the quadruple test. All the initial work with serum testing concentrated on the second trimester, but more recently interest has been shown in the first trimester serum screening using HCG and/or PAPP-A. Some first trimester work would suggest that the use of serum testing at this time is probably as effective as second trimester testing, although calculations are always complicated by the fact that there is a high spontaneous loss rate of Down’s syndrome babies between the first and second trimester. The talk will address the various analytes that have been used and their likely efficacy.
FM5.01.02 FIRST TRIMESTER ULTRASOUND Jo-Ann University of Toronto, Toronto,
Canada
Gestational age of ultrasound examination < 10 weeks = sonoembryology lo-14 weeks Advantages and disadvantages The lo-14 week scan Increased nuchal translucency and chromosome defects Structural anomalies with increased nuchal translucency karyotype ??
??
??
??
??
and normal
CNS Anomalies Acrania Encephalocele Holoprosencephaly Spina bifida Venticulomegaly Cardiac Anomalies Four chamber view Outflow tracts Arrythmias Structural defects Gastrointestinal defects Abdominal wall defects Diaphragmatic hernia Urinary Tract Defects Renal agenesis Polycystic kidney disease Dysplastic kidneys Megacytsis Skeletal dysplasias Summaries Summaries
and limb defects
of studies in low risk populations. of studies in high risk populations
Protocol for ultrasound weeks gestation.
examination
to detect fetal anomalites
at lo-14
References: Achiron et al. First trimester diagnosis of fetal congenital heart disease by tramvaginal ultrasonography. Obstetrics and Gynecology 1994, 84: 69-72. Blaas HG. The examination of the embryo and early fetus: how and by whom. Ultrasound in Obstetrics and Gynecology. 1999, 14:153-158. Hernadi Let al. Screening for fetal anomalites in the 12’h week of pregnancy by trans.vaginal sonography on a non-selected population. Prenatal Diagnosis 1997, 17: 753-759. Hyett et al. Using fetal nuchal translucency to screen for major congenital heart defects at lo-14 weeks of gestation. BMJ 1999, 318: 81-85. Johnson SP et al. Ultrasound screening for anencephaly at lo-14 weeks of gestation. Ultrasound in Obstetrics and Gynecology. 1997, 9:14-16. Nicolaides KH, Azar G, Snijders RJM, Gosden CM. Fetal nuchal oedema:associated malformations and chromosomal defects. Fetal Diagn Ther1992;7:123-131. Nicolaides KH, Brizot ML, Snijders RJM. Fetal nuchal translucency thickness: ultrasound screening for fetal trisomy in the first trimester of