David Rabinerson

Incisional hernias after laparoscopy.

Laparoscopy, using a two-puncture technique, has been used for a variety of gynecologic indications for more than two decades. The procedure is considered safe and effective, although rare complications, such as incisional hernias, have been reported. In this review, the issue of postlaparoscopic incisional hernias is discussed in terms of incidence, predisposing factors, time of appearance, and preventive measures. With the evolvement of operative laparoscopy, larger trocars and cannulas have been introduced, increasing the incidence of postlaparoscopic incisional hernias. Awareness of the possibility of this complication will lead to the use of proper surgical techniques, as suggested, while knowledge of the postoperative signs and symptoms will lead to early diagnosis and prevention of sequelae.

Thrombosis of the pelvic veins associated with a large myomatous uterus

Background Deep vein thrombosis is a rare indication for hysterectomy. Case A 45-year-old woman presented with a myomatous uterus of 20 gestational weeks size that was compressing the pelvic veins directly and causing thrombosis. After preparation of the patient with anticoagulants and installation of an umbrella device in the inferior vena cava, we performed an uneventful abdominal hysterectomy. Conclusion Pelvic deep vein thrombosis is a rarely reported complication of myomatous uterus. It can be managed successfully by anticoagulants, placement of an umbrella device in the inferior vena cava, and hysterectomy, as in our case.

Successful external version of B-twin after the birth of A-twin for vertex-non-vertex twins

OBJECTIVEnTo determine the optimal intrapartum management of twins, especially those in vertex--non-vertex presentation.nnnSTUDY DESIGNnThe study population consisted of 408 sets of twins delivered between 1988 and 1992, weighing at birth over 1500 g. According to our protocol, vaginal delivery was attempted in the vertex-vertex presentations. If non-vertex presentation was first, we performed cesarean section. In vertex--non-vertex cases, the first was delivered vaginally and external cephalic version or breech delivery was performed on the second. Apgar scores were compared according to presentation and delivery mode.nnnRESULTSnVaginal delivery was accomplished in 122 (73%) of 169 vertex--vertex presentations, 96 (68%) of 142 vertex--non-vertex presentations, and 4 (5%) of 99 non-vertex--other presentations. External cephalic version (ECV) of the second twin and subsequent vaginal delivery in vertex--non-vertex was successful in 75% of cases, and internal podalic version and assisted breech delivery were performed in 20 cases, and the remaining two were delivered by cesarean section. Apgar scores were not significantly different among the various groups, and no complications arose from external cephalic version performed on second non-vertex twins.nnnCONCLUSIONSnExternal cephalic version was found safe for delivering second non-vertex twins in cases where the first twin is in vertex presentation. In our opinion routine cesarean section is thus no longer justified in such cases.

Microalbuminuria following gestational diabetes

Background. Microalbuminuria (MA) precedes clinical nephropathy in patients with insulin‐dependent diabetes mellitus, and is associated with an increased mortality, mostly due to cardiovascular disease in patients with non‐insulin‐dependent diabetes mellitus. Microalbuminuria is rarely detected in patients with diabetes of less than five years duration. Our study was designed to determine whether MA and its sequelae also appear 5‐8 years after pregnancy complicated by gestational diabetes mellitus (GDM).

The missing forgotten intrauterine contraceptive device

Failure to locate the strings of an intrauterine contraceptive device may mean that the device is within the uterine cavity, was expelled or, worst of all, has perforated the uterine wall. We describe a 36-year-old woman complaining of infertility in whom two missing devices were found within the pelvis after having perforated the uterus. This report demonstrates the need to investigate every case of a missing intrauterine contraceptive device. An algorithm for the proper management of such cases is suggested.

Cervical polyp in the menopause and the need for fractional dilatation and curettage

OBJECTIVEnTo investigate the need for fractional dilatation and curettage following excision of symptomatic versus asymptomatic cervical polyps.nnnSTUDY DESIGNnA prospective study was carried out on 467 women who were referred for treatment of symptomatic (accompanied by vaginal bleeding or discharge) or asymptomatic cervical polyps, from January 1, 1990 to December 31, 1992. Of these, 204 were premenopausal and 263 postmenopausal. Every excision of a cervical polyp was followed by a dilatation and curettage. The histological data were evaluated statistically using the chi 2-test.nnnRESULTSnPostmenopausal women had more asymptomatic than symptomatic cervical polyps (P = 0.004). Cervical polyps were associated with more endometrial polyps in the postmenopausal than in the premenopausal women (P = 0.0009). Postmenopausal women with symptomatic cervical polyps had more endometrial abnormalities on histological examination than those with asymptomatic ones (P < 0.0001); this difference was not significant in the premenopausal group (P = 0.49).nnnCONCLUSIONSnWhile neither symptomatic nor asymptomatic cervical polyps are an indication for dilatation and curettage (following excision) in women in their reproductive years, and do not affect their management or prognosis, this is not the case in postmenopausal women. Symptomatic cervical polyps after the menopause must be excised and followed by mandatory fractional dilatation and curettage, because there is a marked incidence of associated severe pathological conditions in this age group.

Bacterial vaginosis: drugs versus alternative treatment.

Bacterial vaginosis is one of the most common infectious disorders affecting women. It is caused by several microorganisms, including Gardnerella vaginalis, Bacteroides, beta-streptococci and mobiluncus/falcivibrio sp. Bacterial vaginosis is thought to occur as a result of a change in vaginal pH mediated by the metabolic activity of anaerobic bacteria. This rise in vaginal pH interferes with the activity of vaginal lactobacilli which maintain vaginal acidity. Several types of antibiotics have been used to treat this condition. Although metronidazole was found to be the most effective, none was completely successful in either cure or prevention. Several attempts have recently been made to treat bacterial vaginosis using physiological or natural substances, such as lactate gel and commercial yoghurt, which is acidic and also contains lactobacillus strains. This kind of treatment looks promising and may have a place in certain clinical conditions, including pregnancy, in cases of recurrent inflammation, or as a prophylactic treatment before invasive gynecological procedures or abdominal surgery in patients known to be affected. This issue should be additionally studied and evaluated in light of the relatively little experience with this modality of treatment for bacterial vaginosis.

Membranous dysmenorrhea: The forgotten entity

Background Membranous dysmenorrhea involves the spontaneous slough of the endometrium in one cylindrical or membranous piece that retains the shape of the uterine cavity. Because this entity is rarely mentioned in the medical literature, the purpose of this report is to describe two such cases. Case An 18-year-old nullipara with regular menstrual cycles presented with membranous dysmenorrhea after taking the contraceptive Gynera (Gestodene 0.075 mg, ethinyl estradiol 0.030 mg). Symptoms disappeared when the medication was discontinued. The second patient, a 26-year-old woman, gravida 1, para 1, was on a 10-day monthly regimen of Provera (medroxyprogesterone acetate) 2.5 mg/ day for dysfunctional uterine bleeding. When the Provera dose was increased to 10 mg/day, the symptoms disappeared. Conclusion Membranous dysmenorrhea is “a disease of theories” with various recommended medications. When this condition is caused by iatrogenic treatment, the best approach is to discontinue the offending drug or change its dosage.

An isolated case of Q-fever during pregnancy

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Fetal middle-cerebral and umbilical artery flow assessments after glucose challenge test

Objective: To determine whether a change occurs in fetal middle‐cerebral and umbilical artery flow after glucose challenge testing. Method: Fetal middle‐cerebral and umbilical artery flow was assessed by Color Dopppler technology in 21 pregnant patients before and after the 50‐g glucose challenge test. The resistance index (IR) was evaluated separately for each vessel. Statistical significance was determined by Chi‐square test and repeated measurement analysis with two co‐variates. Results: After glucose ingestion the RI was significantly decreased in the middle‐cerebral artery, but not in the umbilical artery. A significant increase in RI was recorded in the umbilical artery when maternal plasma glucose level exceeded 102 mg%. Conclusion: Maternal ingestion of glucose significantly alters blood flow velocimetry in the fetal middle‐cerebral and umbilical arteries. These changes may lead to the misinterpretation of normal results. It is therefore recommended that sonographic flow velocimetry assessment not be performed early after concentrated glucose ingestion.