Arthur Zaltz

A New Bipolar System for Performing Operative Hysteroscopy in Normal Saline

We evaluated the efficacy and safety of the VersaPoint bipolar vaporization system during hysteroscopic treatment of 10 women with symptomatic submucous leiomyomata, endometrial polyps, uterine septa, and synechiae in a prospective, uncontrolled pilot study at two Canadian university-affiliated teaching hospitals. Patients were two women with recurrent pregnancy loss associated with a diagnosis of uterine septa, one with infertility, one with recurrent pregnancy loss and synechiae, and six with menorrhagia associated with either leiomyomata or endometrial polyps. Electrodes were inserted through a 5F operating channel of a 15F cystoscope, and a 17 or 21F hysteroscope. Three electrodes were used: ball, twizzle, and spring. Power settings ranged from 50 W (desiccation mode) to 200 W (vapor cut mode). Normal saline was used as the distention medium in all cases. Either general anesthesia or intravenous sedation with paracervical block was used. There were no major complications such as uterine perforation, excessive bleeding, fluid overload, or thermal injury. The amount of normal saline used varied considerably from 0.5 to 20 L. The maximum amount of saline absorbed was 900 ml in a case involving resection of 4.5- and 2.0-cm leiomyomata that lasted 115 minutes. Mild cramping, vaginal bleeding, and discharge in the first 2 to 3 days were relieved by nonsteroidal antiinflammatory agents. No patients were readmitted up to 6 weeks after the procedure. Preliminary results of this pilot study support the safety of the VersaPoint bipolar vaporization system, although its long-term efficacy remains to be determined. It appears to be well tolerated by some women using conscious sedation and paracervical block. Therefore, it can potentially be used in an office setting as well as in symptomatic patients who are at risk from a general anesthetic. (J Am Assoc Gynecol Laparosc 6(3):331-336, 1999)

Neonatal Outcomes of Low-Risk, Late-Preterm Twins Compared With Late-Preterm Singletons

OBJECTIVE To test the hypothesis that the risk of neonatal morbidity among late-preterm twins is similar to that of late-preterm singletons. METHODS We conducted a retrospective cohort study of all women with twin or singleton pregnancy who gave birth during the late-preterm period in a single tertiary center between 2008 and 2015. Neonatal outcomes of low-risk, late-preterm twins were compared with those of low-risk, late-preterm singletons. The primary outcome was the same primary composite respiratory morbidity variable that was used in the randomized controlled trial of Gyamfi-Bannerman et al on the administration of antenatal corticosteroids during the late-preterm period. RESULTS A total of 922 singleton and 721 twin late-preterm neonates met the inclusion criteria. The rates of composite respiratory morbidity and severe composite respiratory morbidity were similar for twins and singletons (8.3% compared with 7.4%, P=.5 and 6.8% compared with 6.0%, P=.5, respectively), but were lower than the rates of the same composite respiratory morbidity variable in the randomized controlled study described previously. The odds for respiratory morbidity were similar for twins and singletons for both composite respiratory morbidity (adjusted odds ratio [OR] 0.73, 95% CI 0.48-1.12) and severe composite respiratory morbidity (adjusted OR 0.79, 95% CI 0.50-1.24). CONCLUSION The risk of respiratory morbidity among late-preterm twins is similar to that of late-preterm singletons. Still, the low absolute rates of the composite respiratory morbidity in our population suggest that administration of antenatal corticosteroids may be mostly justified among neonates born closer to 34 weeks of gestation.

Omega-3 Supplements in Pregnancy: Are We Too Late to Identify the Possible Benefits?

OBJECTIVE Postpartum depression (PPD) is a common and recurring illness. Most women who experience PPD do not seek professional help; for those who do, the available treatment options are not supported by extensive research evidence. Several lines of research have linked omega-3 fatty acids (omega-3) supplementation with a reduced risk of PPD. Although it has been suggested that women in the perinatal period consume sufficient omega-3 to potentially prevent PPD, there is a lack of definitive research evidence. This pilot study surveyed pregnant womens current use of omega-3, multivitamin, and other supplements, as well as their attitudes toward omega-3 research during pregnancy, to assess the feasibility of pregnant womens participation in a large randomized controlled trial evaluating omega-3 supplementation. METHODS Women attending prenatal clinics over a three-week period were invited to participate in a survey. The survey contained an information letter that was followed by a brief questionnaire assessing the use of nutritional supplements and opinions regarding the likelihood of participating in a clinical trial during pregnancy. RESULTS Of the 176 women who completed the survey, six women were in the first trimester of pregnancy, 82 were in the second trimester, and 87 were in the third trimester. One hundred fifty-nine respondents (90.3%) reported taking a multivitamin supplement but none were taking a supplement that contained omega-3; only 20 (11.4%) were taking omega-3. Seventy-eight women (44.4%) responded that they would participate in a clinical study evaluating the effects of fish oil on their health. CONCLUSION The results of our study indicate that many pregnant women take prenatal multivitamins and nutritional supplements, that there are currently few pregnant women attending clinics at our hospitals who are supplementing with omega-3, and that pregnant women would be willing to participate in a clinical trial evaluating the effects of omega-3.

A Rare Congenital Anomaly: Double Bladders on 2- and 3-Dimensional Ultrasound Imaging: Clinical Letter

A 37-year-old woman was referred to our imaging clinic for a second-trimester anatomic pregnancy ultrasound (US) examination and to delineate the anatomy related to the patient’s double bladder. The patient was born in Hong Kong and had a diagnosis of a vestibular ectopic anus as well as complete duplication of the urinary bladder and urethra. She also had a capillary hemangioma in the left labium majus, which spontaneously involuted. In the neonatal period, the patient underwent a right transverse colostomy followed by perineal proctoplasty at 9 months of age to manage the ectopic anus. She also underwent extensive testing of her urinary system. A voiding cystogram confirmed the duplication of the bladder and urethra. However, on 2 separate cystoscopies, only a single urethra was found leading into the bigger bladder, which only had a single ureteric orifice. As a child, the patient did have some intermittent urinary incontinence. Her medical history was also notable for a sacral intradural lipoma with a tethered spinal cord. This anomaly was detected when the patient had progressive wasting of the left leg at the age of 9 years. She underwent successful surgery to remove the lipoma. As an adult, the patient was reassessed by urology and denied any urinary symptoms. On presentation to our clinic, an US examination was performed with 2-dimensional and 3-dimensional (3D) imaging using a Voluson E8 US machine (GE Healthcare, Milwaukee, WI) with 3D as well as color and power Doppler capabilities. The transducer used for the transperineal images was a 3D transvaginal C5-9 transducer. Because it has a smaller footprint than a 3D curvilinear abdominal transducer, manipulation of the transvaginal transducer is much more comfortable for the patient due its smaller size. In addition, the higherfrequency endoluminal transducer, although having a smaller field of view, is compensated for by improved detail and image resolution. Two bladders were clearly identified on a vesical as well as transvaginal US evaluation. Transperineal US was able to show the presence of 2 urethras (Figure 1, A and B) for the first time in imaging this patient. Three-dimensional imaging clearly outlined the urethral course and relationship with the bladder, vagina, and rectum (Figure 1, C and D). No notable maternal renal

Beware selection bias

As experienced front-line obstetricians with leadership responsibilities, we have concerns with the conclusions and implications of the article by Muraca and colleagues on operative delivery in the second stage of labour.[1][1] Although an important strength is the size of this population-based