Deborah Penava

Perioperative Complication Rates of Primary and Repeat Hysteroscopic Endometrial Ablations

STUDY OBJECTIVE To determine perioperative complication rates at primary and repeat endometrial ablations. DESIGN Prospective cohort study (Canadian Task Force classification II-2). SETTING Tertiary care teaching hospital. PATIENTS Seventy-five women who underwent a repeat ablation and 800 who had a primary ablation by the same surgeon (GAV) between 1990 and 2000 for a diagnosis of menorrhagia and/or dysmenorrhea. INTERVENTIONS Hysteroscopic ablation involving coagulation or resection of endometrium, and second ablation after failure of the first. MEASUREMENTS AND MAIN RESULTS Serious perioperative complications were uterine perforation, hemorrhage, excess fluid absorption, and genital tract burns. They occurred in 9.3% of repeat ablations compared with 2.05% of primary ablations (p = 0.006). CONCLUSION Repeat endometrial ablation has a significantly higher rate of perioperative complications than primary ablation.

Neonatal outcomes are associated with latency after preterm premature rupture of membranes

Objective:To determine factors associated with latency time to birth after preterm premature rupture of membranes (PPROM) and the impact on neonatal outcomes.Study Design:Data on singleton pregnancies with PPROM (n=1535 infants) were prospectively collected in a computerized perinatal/neonatal database at a tertiary care perinatal center. Latency was characterized as ⩽72h versus >72 h after PPROM.Result:The percentage of women with latency to birth >72 h decreased from 67% in very preterm (gestational age (GA) 25 to 28 weeks) to 10% in late preterm women (GA 33 to 36 weeks). PPROM women with latency ⩽72 h were more likely to have pregnancy-induced hypertension and birth weight <3%; PPROM women with latency >72 h were more likely to have received steroids and develop clinical chorioamnionitis. PPROM <32 weeks GA with latency ⩽72 h was associated with a two-fold higher incidence of severe neonatal morbidity, while PPROM between 29 to 34 weeks GA and latency ⩽72 h was associated with a higher incidence of moderate neonatal morbidity.Conclusion:A latency period >72 h was associated with a decreased incidence of adverse neonatal outcomes up to 32 weeks GA for severe and 34 weeks GA for moderate morbidity indices.

Laparoscopic Mobilization of the Rectosigmoid and Excision of the Obliterated Cul-de-sac

STUDY OBJECTIVE To evaluate the feasibility and surgical and clinical outcomes of laparoscopic excision of anterior recto-sigmoid wall endometriosis and en bloc dissection of the obliterated cul-de-sac. DESIGN Retrospective cohort (Canadian Task Force classification II-2). SETTING University-affiliated teaching hospital. PATIENTS Eighty-one women with infertility and/or chronic pelvic pain. Intervention. Laparoscopic excision of all endometrial implants and uterosacral ligaments, and dissection of the cul-de-sac using a horseshoe-shaped approach to mobilize, but not resect, the rectosigmoid. MEASUREMENTS AND MAIN OUTCOMES Eleven women (24%) had endometriomas. Cumulative pregnancy rates in 34 women with primary infertility and 12 with secondary infertility were 62% and 42%, respectively. Eighty-eight percent of 61 women with pain reported significant improvement of symptoms. CONCLUSION Laparoscopic excision of cul-de-sac and rectovaginal endometriosis by this approach is feasible and safe when performed by an experienced surgeon, and results in high rates of cumulative pregnancy and relief of pain. Some patient variables may give higher rates of success for pregnancy than others.

Factors that influence excessive gestational weight gain: moving beyond assessment and counselling.

Abstract One in four Canadian adults is obese, and more women are entering pregnancy with a higher body mass index (BMI) than in the past. Pregnant women who are overweight or obese have a higher risk of pregnancy-related complications than women of normal weight. Gestational weight gain (GWG) is also associated with childhood obesity. Although the factors influencing weight gain during pregnancy are multifaceted, little is known about the social inequality of GWG. This review will address some of the socioeconomic factors and maternal characteristics influencing weight gain and the impact that excessive GWG has on health outcomes such as post-partum weight retention. The effects of an overweight or obese pre-pregnancy BMI on GWG and neonatal outcomes will also be addressed. The timing of weight gain is also important, as recommendations now include trimester-specific guidelines. While not conclusive, preliminary evidence suggests that excessive weight gain during the first trimester is most detrimental.

Laparoscopic Bowel Injuries: A Review

Abstract Laparoscope has evolved from a diagnostic procedure to the principal method of tubal ligation, and now replaces many of the traditional gynaecological surgical approaches. Access to the abdominal cavity is achieved by CO2 insufflation, then primary trocar insertion, direct trocar insertion, or by the open technique. Bowel injuries occur regardless of the access method. The frequency is estimated to be in the range of 0.5 to 1.8/1,000 procedures, with many occurring during the initial access step, indicating that such injuries are unpredictable and virtually unavoidable. The principles involved in the management of intra-operative bowel injury include: 1) having increased awareness of potential injuries and taking all known precautions necessary to ensure safety; 2) recognition of the extent of the injury and 3) repair of the injury, taking into account its extent and location, blood supply and degree of faecal contamination. The decision to proceed with laparoscopic management over repair by laparotomy and whether to repair the injury primarily or perform a colostomy with delayed repair is dependent upon the experience and the skill of the surgeons involved.

Measuring fetal adipose tissue using 3D water-fat magnetic resonance imaging: a feasibility study

Abstract Purpose: Analysis of fetal adipose tissue volumes may provide useful insight towards assessment of overall fetal health, especially in cases with abnormal fetal growth. Here, we assess whether fetal adipose tissue volume can be reliably measured using 3D water-fat MRI, using a quantitative assessment of the lipid content of tissues. Materials and methods: Seventeen women with singleton pregnancies underwent a fetal MRI and water-only and fat-only images were acquired (modified 2-point Dixon technique). Water and fat images were used to generate a fat signal fraction (fat/(water + fat)) from which subcutaneous adipose tissue was segmented along the fetal trunk. Inter-rater (three readers) and intrarater reliability was assessed using intraclass-correlation coefficients (ICC) for 10 image sets. Relationships between adipose tissue measurements and gestational age and estimated fetal weight percentiles were examined. Results: The ICC of the inter-rater reliability was 0.936 (p < .001), and the ICC of the intrarater reliability was 0.992 (p < .001). Strong positive correlations were found between adipose tissue measurements (lipid volume, lipid volume/total fetal volume, mean fat signal fraction) and gestational age. Conclusions: 3D water-fat MRI can reliably measure volume and quantify lipid content of fetal subcutaneous adipose tissues.

Management of Laparoscopic Trocar Injuries to Anterior Abdominal Wall Blood Vessels

Abstract the incidence of trocar injuries of vessels at the anterior abdominal wall has been reported to be approximately two percent. Knowledge of the anatomy, landmarks, and intra-operative laparoscopic identification may assist in avoidance of these injuries. Prior to the withdrawal of the laparoscope, removing all trocars under direct vision and slowly decreasing the intra-abdominal pressure by allowing gradual escape of the carbon dioxide will allow the surgeon to identify any trickling of blood from trocar sites. Mechanical tamponade with a Foley catheter through the trocar site, electrocoagulation, or direct ligation of the bleeding vessel using a variety of techniques will ensure that the patient will not be exposed to increased associated morbidity from a laparoscopic procedure.

Nine Cases of Bowel Injury during 3,472 Laparoscopies

Astract The incidence and consequences of bowel injuries during laparoscopies, including the potential need for laparotomy and possible ileostomy, must be understood by both the surgeon and patient before embarking upon any surgical procedure. The risk of bowel injury has been reported to be between 0.5 and 1.8/1,000 laparoscopies; those injuries that require laparotomy have had a risk of 0.88 to 1.09/1,000 cited. Incidences may be dependent upon the practice of the surgeons involved. A review of the practice of a single gynaecologist, performing mostly advanced laparoscopic procedures in a tertiary level centre, was undertaken. All the cases over a 13-year period were reviewed and are reported. The incidence of bowel injury was 2.6/1,000 cases (0.3%), including Veress needle and trocar injuries. Repairs requiring laparotomy had an incidence of 1.4/1,000 cases. These rates may reflect the specialized referral practice of the surgeon involved and the number of advanced laparoscopic cases performed, but it also may reflect the reality of the practice of gynaecological laparoscopy over the past 13 years.