Colin A. Walsh

Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis.

Hysterectomy is a very common gynaecological procedure. The vaginal route is considered preferable for hysterectomy, although the ideal route for women unsuitable for the vaginal approach remains unclear. We performed a meta-analysis of published randomised controlled trials to compare outcomes in total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy (TLH) for benign disease. Pooled odds ratios (OR) were calculated for categorical variables using random effects models as per Der Simonian and Laird. Continuous variables were compared by means of weighted mean differences (WMD). TLH is associated with reduced overall peri-operative complications (pooled OR 0.19; 95% CI 0.07-0.50) and reduced estimated blood loss (WMD -183ml; 95% CI -346ml to -21ml; p=0.03). Additionally, there are trends towards shorter hospital stay (WMD -2.5 days; 95% CI -5.1 days to 0.01 days; p=0.05) and post-operative haematoma formation (pooled OR 0.17; 95% CI 0.03-1.01) compared to TAH. The only trade-off appears to be a longer operating time in the TLH group (WMD 22min; 95% CI 5-39min; p=0.01). Rates of major complication were not statistically different (pooled OR 1.35; 95% CI 0.32-5.73) though this analysis is likely underpowered to detect many major complications. As such, TLH appears to offer benefits to women requiring total hysterectomy for benign indications compared to TAH, particularly regarding minor complications, blood loss and hospital stay. However, larger studies are needed to assess the impact on major intra-operative complications and long-term clinical outcomes, particularly pelvic organ prolapse.

Rupture of the primigravid uterus: a review of the literature.

Uterine rupture is a catastrophic obstetric complication, associated with high rates of perinatal morbidity and mortality. The most common risk factor is previous uterine surgery, and most cases of uterine rupture occur in women with a previous cesarean delivery. Traditionally, the primigravid uterus has been considered almost immune to spontaneous rupture. In fact, although spontaneous rupture of the primigravid uterus is indeed a very rare event, a number of such cases have been reported recently. Prompt recognition of uterine rupture and expeditious recourse to laparotomy are critical in influencing perinatal and maternal morbidity. Not all uterine ruptures present with the typical clinical picture of abdominal pain, hypovolemia, vaginal bleeding, and fetal compromise. Therefore, it is important to maintain a high index of suspicion for uterine rupture in women presenting with some, or all, of these features, regardless of parity. Here we provide a systematic review of cases of spontaneous uterine rupture in primigravid women reported in the literature to date. Clinical presentation, differential diagnosis, common etiological factors, complication rates, and appropriate management of this rare obstetric event are discussed. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that uterine rupture in a primigravida is a rare event, without typical signs and symptoms, and explain that the morbidity and mortality of the mother and child is directly related to a high index of suspicion and prompt treatment by the clinician.

Laparoscopic versus open appendicectomy in pregnancy: a systematic review.

BACKGROUND Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnant women. The benefits of a laparoscopic over an open approach to appendicectomy are well established in the non-pregnant population. Data on the optimal surgical approach to acute appendicitis in pregnant women are conflicting. METHODS A systematic review of reported cases of laparoscopic appendicectomy (LA) in pregnancy over the period 1990 to 2007. Twenty-eight articles documenting 637 cases of LA in pregnancy were included. Data on pregnancy outcome, patient characteristics, operative technique and peri-operative complications were analysed. RESULTS The rate of fetal loss following LA in pregnancy approaches 6% and is significantly higher than that following open appendicectomy. Fetal loss was highest in cases of complicated appendicitis. Incidence of preterm delivery appears lower in the LA group although this complication is likely to be under-reported in a significant proportion of cases. Trimester at the time of LA does not appear to influence complication rates. The negative appendicectomy rate in this series was 27%, which is higher than in the non-pregnant population. Complication rates following LA with negative appendicitis are as high as with simple appendicitis. Rates of entry-related complications were 2.8% in the Veress needle group and 0% in the Hasson open entry group. The overall rate of conversion to laparotomy was 1%. No difference was found in the preterm delivery rate between women who received prophylactic tocolysis and those who were not tocolysed. CONCLUSIONS Laparoscopic appendicectomy in pregnancy is associated with a low rate of intra-operative complications in all trimesters. However, LA in pregnancy is associated with a significantly higher rate of fetal loss compared to open appendicectomy. Rates of preterm delivery appear similar or slightly better following a laparoscopic approach. Open appendicectomy would appear to be the safer option for pregnant women for whom surgical intervention is indicated.

Staples vs subcuticular sutures for skin closure at cesarean delivery: a metaanalysis of randomized controlled trials.

Recently published randomized trials examining skin closure technique on postcesarean wound complications have produced conflicting results. We performed a metaanalysis of trials comparing staples and subcuticular sutures for skin closure at cesarean section (CS). Pooled outcome measures were calculated using random effects models. Primary outcomes were rates of wound dehiscence (separation) and a composite wound complication rate. Secondary outcomes were patient satisfaction, operating time, and postoperative pain. A total of 877 women from 5 trials were included. Both wound separation (pooled odds ratio, 4.01; P < .0001) and composite wound complication (pooled odds ratio, 2.11; P = .003) rates were higher with staples. The use of staples reduced operating time (weighted mean difference, -5.05 minutes; P = .021). Data on postoperative pain and patient satisfaction were insufficient for metaanalysis. Our findings suggest a possible benefit with subcuticular sutures compared to skin staples for skin closure at CS. However, the optimal skin closure technique at CS demands further study.

Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials.

OBJECTIVE Recent randomized trials comparing total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH) have produced conflicting results. The role of TLH in women suitable for VH remains uncertain. STUDY DESIGN This study was a metaanalysis of randomized studies comparing TLH and VH for benign disease. Pooled outcome measures (odds ratio [OR] and weighted mean difference [WMD]) were calculated using random-effects models. RESULTS No differences in perioperative complications, either total (pooled odds ratio, 0.87; P = .74) or by grade of severity, were demonstrated. TLH was associated with reduced postoperative pain scores (WMD -2.1; P = .03) and reduced hospital stay (WMD -0.62 days; P < .0001) but took longer to perform (WMD 29.3 minutes; P = .003). No differences in blood loss, rate of conversion to laparotomy, or urinary tract injury were identified. CONCLUSION TLH may offer benefits compared with VH for benign disease, although this analysis is likely underpowered for rare complications. Further studies of long-term outcomes, including prolapse, urinary incontinence, and sexual function, are required.

Unexplained prelabor uterine rupture in a term primigravida.

BACKGROUND: Uterine rupture is a catastrophic obstetric complication. The main risk factor is a scarred uterus, usually secondary to a previous cesarean delivery. Uterine rupture in a primigravid woman is a very rare event. CASE: A 33-year-old primigravida presented at term with severe abdominal pain, signs of hemodynamic instability, and fetal bradycardia. She was not in labor, and the fetal heart tones disappeared before a cesarean could be performed. After a failed attempt at induction, exploratory laparotomy was performed for worsening maternal hemodynamic status. A complete rupture of the posterior uterine wall was found with a well-grown fetus free in the abdominal cavity. The uterus was repaired in two layers, and the patient did well postoperatively. CONCLUSION: We report the rare occurrence of a spontaneous uterine rupture in a nonlaboring primigravid with no known risk factors. The differential diagnosis of this presentation includes concealed placental abruption, subhepatic hematoma with or without liver rupture, splenic rupture, rupture of the broad ligament, and rupture of a uterine vein. Although uterine rupture occurs more commonly in the multiparous population, it cannot be assumed that the primigravid uterus is immune to rupture.

Outcome of second delivery after prior macrosomic infant in women with normal glucose tolerance

OBJECTIVE: Our aim was to estimate the obstetric outcome of second delivery in women with normal glucose tolerance whose first fetus was macrosomic (fetal weight ≥ 4,500 g). METHODS: Primiparas delivering a macrosomic infant during the years 1997–2000 were identified from a hospital computer database, and the obstetric outcome of a second delivery was analyzed up until June 2003. A control group (birth weight 3,000–3,500 g) served for comparison. RESULTS: Among 13,020 first pregnancies, 301 (2.3%) were macrosomic. A similar proportion in the macrosomic group, 156 of 301 (52%), and control group, 171 of 300 (57%), returned for second delivery (P = .252). Compared with controls, first macrosomic deliveries were characterized by higher rates of operative delivery, anal sphincter injury, and shoulder dystocia. At second delivery, 32% of neonates in the macrosomic group and 0.3% in the control group weighed 4,500 g or more (P < .001). More prelabor cesareans were performed in the macrosomic group compared with controls (27 of 156, 17.3%, compared with 8 of 171, 4.7%; P < .001). Among 104 women in the macrosomic group who labored after first vaginal delivery, 99% (103 of 104) delivered vaginally again compared with 44% (11 of 25) who labored after primiparous cesarean delivery (P < .001), which compares with 97% (146 of 150) and 77% (10 of 13), respectively, in the control group. CONCLUSION: Despite a one-third recurrence of macrosomia, first vaginal delivery of a macrosomic infant was associated with a high incidence of second vaginal delivery. Conversely, primiparous macrosomic cesarean delivery conveyed a high risk (56%) for repeat intrapartum cesarean whether macrosomia recurred or not. LEVEL OF EVIDENCE: II-2

Mode of delivery at term and adverse neonatal outcomes.

OBJECTIVE: To determine the relationship between mode of delivery and serious adverse neonatal outcomes in term, singleton, cephalic neonates. METHODS: A 10-year study of 64,555 term neonates reaching the second stage of labor in a single tertiary obstetric unit from 2000 to 2009. Multiple pregnancies, preterm deliveries (before 37 weeks of gestation), and lethal congenital anomalies were excluded. The primary outcome was the rate of peripartum death by mode of delivery. Secondary outcomes were rates of neonatal encephalopathy, intracranial hemorrhage-related mortality, and the relationship between instrument choice and adverse outcomes. Categorical data were compared using the &khgr;2 test, with odds ratios (ORs) and 95% confidence intervals included when appropriate. RESULTS: Compared with neonates delivered by second-stage cesarean, there were no differences in the rates of either peripartum neonatal death (OR 0.42; P=.37) or neonatal encephalopathy (OR 1.07; P>.99) after operative vaginal delivery. The rates of neonatal encephalopathy associated with operative vaginal and second-stage cesarean delivery were 4.2 and 3.9 per 1,000 term neonates, respectively. No significant differences in adverse neonatal outcomes were demonstrated between vacuum-assisted and forceps-assisted deliveries, although subanalysis is limited by the small numbers of serious adverse outcomes. The absolute risk of neonatal death secondary to intracranial hemorrhage is 3–4 per 10,000 operative vaginal deliveries for both instruments. CONCLUSIONS: Operative vaginal delivery is associated with similar rates of serious neonatal complications compared with cesarean delivery at full dilatation. LEVEL OF EVIDENCE: II

Does Adenosine Triphosphate Released Into Voided Urodynamic Fluid Contribute to Urgency Signaling in Women With Bladder Dysfunction

PURPOSE Adenosine triphosphate released from urothelium during stretch stimulates afferent nerves and conveys information on bladder fullness. We measured adenosine triphosphate released during cystometric bladder filling in women with idiopathic detrusor overactivity and stress incontinence (controls), and assessed whether the level of released adenosine triphosphate is related to cystometric parameters. MATERIALS AND METHODS Routine cystometry was done in 51 controls and 48 women with detrusor overactivity who were 28 to 87 years old. Voided urodynamic fluid was collected and stored at -30 C. Adenosine triphosphate was measured by a bioluminescence assay. RESULTS Adenosine triphosphate levels were similar in voided urodynamic fluid of controls and patients with detrusor overactivity (p = 0.79). A significant inverse correlation was seen between adenosine triphosphate and maximal cystometric capacity in controls (p = 0.013), and between voided volume and adenosine triphosphate in controls (p = 0.015) and detrusor overactivity cases (p = 0.019). A significant correlation between first desire to void and adenosine triphosphate was also noted in detrusor overactivity cases (p = 0.033) but not in controls (p = 0.58). No correlation was seen between adenosine triphosphate and detrusor pressure during filling or voiding. CONCLUSIONS Adenosine triphosphate measurement in voided urodynamic fluid is a novel approach to understanding signals that may contribute to the urgency sensation (a sudden compelling desire to pass urine). The inverse correlation between adenosine triphosphate in voided urodynamic fluid and first desire to void suggests that adenosine triphosphate has a role in modulating the early filling sensation in patients with detrusor overactivity.

Probiotics in pregnancy and maternal outcomes: a systematic review

Abstract Objectives: To systematically review the literature on the use of probiotics in pregnancy and their impact on maternal outcomes. Methods: Online databases were searched in April 2012 using the following terms to identify eligible studies: “probiotics”, “pregnancy”, “maternal outcomes” and “metabolism”. Primary outcomes of selected studies were maternal fasting glucose during pregnancy and rates of gestational diabetes mellitus (GDM). Secondary outcomes were rates of pre-eclampsia, maternal inflammatory markers and lipid profiles and gestational weight gain. Studies whose primary outcomes were bacterial vaginosis, pre-term delivery and infant atopy were excluded. Only English-language articles were included. The limited number of eligible studies and varying outcomes precluded formal meta-analysis of these data. Results: Initially, 189 articles were identified and screened. Seven articles met inclusion criteria and are included in the present review. Results demonstrated that probiotic use in pregnancy could significantly reduce maternal fasting glucose, incidence of GDM and pre-eclampsia rates and levels of C-reactive protein. Conclusions: Probiotics hold potential as a safe therapeutic tool for the prevention of pregnancy complications and adverse outcomes related to maternal metabolism. Further randomised controlled trials are urgently required, particularly among those at high risk of metabolic disorders, such as overweight and obese pregnant women.