Gary H. Lipscomb

Predictors of Success of Methotrexate Treatment in Women with Tubal Ectopic Pregnancies

BACKGROUND The use of methotrexate for the treatment of women with tubal ectopic pregnancies is now common practice. However, the clinical and hormonal determinants of the success of this treatment are not known. METHODS We studied 350 women with tubal ectopic pregnancies who were treated with methotrexate intramuscularly according to a single-dose protocol. Pretreatment serum concentrations of human chorionic gonadotropin and progesterone, the size and volume of the gestational mass, fetal cardiac activity, and the presence of fluid (presumably blood) in the peritoneal cavity were correlated with the efficacy of therapy, as defined by resolution of the ectopic pregnancy without the need for surgical intervention. RESULTS There was no relation between the womens age or parity, the size or volume of the conceptus, or the presence of fluid in the peritoneal cavity and the efficacy of treatment. Among the 320 women in whom treatment was successful (91 percent), the mean (+/-SD) serum chorionic gonadotropin and progesterone concentrations were 4019+/-6362 mIU per milliliter and 6.9+/-6.7 ng per milliliter (21.9+/-21.3 nmol per liter), respectively, as compared with 13,420+/-16,590 mIU per milliliter and 10.2+/-5.5 ng per milliliter (32.4+/-17.5 nmol per liter) (P<0.001 and P=0.02) in the 30 women in whom treatment was not successful. Fetal cardiac activity was present in 12 percent of the successfully treated cases and 30 percent of those in which treatment was not successful (P=0.01). Regression analysis revealed the pretreatment serum chorionic gonadotropin concentration to be the only factor that contributed to the failure rate. CONCLUSIONS Among women with tubal ectopic pregnancies, a high serum chorionic gonadotropin concentration is the most important factor associated with failure of treatment with a single-dose methotrexate protocol.

A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates.

Objective To compare intraoperative and postoperative outcomes between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy among patients who are not eligible for vaginal hysterectomy. Methods Study subjects were randomly assigned to undergo laparoscopically assisted vaginal hysterectomy or standard abdominal hysterectomy. Intraoperative and post-operative management was similar for each group. Surgical characteristics, complications, length of hospital stay, charges, and convalescence were analyzed. Results Sixty-five women at three institutions underwent laparoscopically assisted vaginal hysterectomy (n = 34) or abdominal hysterectomy (n = 31). Three patients in the laparoscopic group required conversion to abdominal hysterectomy. Mean operating time was significantly longer for laparoscopically assisted vaginal hysterectomy (179.8 versus 146.0 minutes). There were no differences in blood loss or incidence of intraoperative complications. There was a higher incidence of wound complications in the abdominal hysterectomy group, but no significant difference in the frequency of postoperative complications. Laparoscopically assisted vaginal hysterectomy required a significantly shorter mean hospital stay (2.1 days) and convalescence (28.0 days) than abdominal hysterectomy (4.1 days and 38.0 days, respectively). There were no significant differences in mean hospital charges between the study groups (laparoscopic

Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate☆☆☆★

8161, abdominal

A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery

6974). Conclusion Except for operating time, there are no differences between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy regarding intraoperative characteristics among abdominal hysterectomy candidates. Postoperatively, laparoscopically assisted vaginal hysterectomy requires a shorter hospital stay and convalescence. Hospital charges are similar between the procedures. A larger number of cases will help determine the indications for laparoscopically assisted vaginal hysterectomy.

A randomized comparison of the Pipelle, Accurette, and Explora endometrial sampling devices

OBJECTIVES The objective of this study was to review the largest single series of ectopic pregnancies treated with single-dose methotrexate reported to date. STUDY DESIGN A review of 315 patients with unruptured ectopic pregnancies treated with single-dose methotrexate 50 mg/m2 from March 21, 1990, to March 1, 1997, was performed. RESULTS Overall 287 patients were successfully treated with methotrexate for a success rate of 90.1%. Six patients electively withdrew and requested surgery within 1 week of starting therapy. Excluding withdrawals the overall success rate was 92.9%. Ten patients with an ectopic pregnancy > 3.5 cm but < or = 4 cm in size were treated for a 90% success rate. Forty-four patients with positive ectopic cardiac activity were treated with an 87.5% success rate. CONCLUSIONS This large series indicates that single-dose intramuscular methotrexate for treatment of ectopic pregnancy is associated with an excellent overall success rate.

Cefazolin versus cefazolin plus metronidazole for Antibiotic prophylaxis at cesarean section

OBJECTIVE The purpose of this study was to investigate the efficacy of continuous local anesthetic infusion system for pain control after cesarean delivery. STUDY DESIGN This was a randomized prospective double-blind study. Patients who underwent cesarean delivery had a pain system implanted subcutaneously after closure of the fascia. Patients were randomized to receive an infusion of either 0.25% bupivacaine (n = 20) or normal saline solution (n = 16) into the wound for 48 hours. Postoperative pain (determined with a visual analog scale) and postoperative morphine use were assessed at 12, 24, and 48 hours. RESULTS There were no significant differences in patient demographics or visual analog pain scores at any time interval between the bupivacaine versus the placebo group. However, narcotic requirements to produce this amount of pain relief were significantly less in patients who received bupivacaine infusion rather than normal saline solution at all time intervals. CONCLUSION The continuous local anesthetic infusion system appears to be effective in reducing postoperative morphine use after cesarean delivery.

Computer-assisted video evaluation of surgical skills

OBJECTIVES Our aim was to compare the Pipelle, Accurette, and Explora endometrial sampling devices. STUDY DESIGN Patients (n = 248) undergoing endometrial biopsy were randomized to one of the three sampling instruments. Diagnostic accuracy, ability to obtain sufficient tissue for histologic diagnosis, and patient discomfort during sampling of the three devices were compared. When available, endometrial biopsy specimens were compared with subsequent pathologic findings at hysterectomy. Statistical analysis was performed with one-way variance of the means, chi 2, and Kruskal-Wallis statistic. RESULTS In successful biopsies there was no statistical difference among groups in specimen adequacy and there was no discrepancy between endometrial biopsy and hysterectomy pathologic findings. However, 42% of Accurette biopsies either were failed attempts or obtained insufficient tissue (p < 0.01). Pain scores were similar among the groups. CONCLUSION The results with the Pipelle and Explora endometrial samplers appear to be comparable. However, given a 42% unusable specimen rate, the Accurette cannot be recommended for routine endometrial sampling.

Peritoneal closure at vaginal hysterectomy: a reassessment

Background Although prophylactic antibiotic medications have been shown to reduce the incidence of postoperative infectious morbidity after cesarean delivery, the most effective regimens have not been established. The purpose of this investigation was to compare the efficacy and costs of prophylaxis with cefazolin alone with cefazolin plus metronidazole. Methods Women undergoing cesarean delivery were randomized to prophylaxis with 2 g cefazolin (n = 81) or 1 g cefazolin plus 500 mg metronidazole (n = 79). Postoperative infectious morbidity and the duration of hospitalization in the two groups were compared. Results Thirty-seven (23%) of 160 patients developed endomyometritis. There was a significant reduction in the number of postoperative infections (14 versus 32%) and hospital days (3.12 versus 4.46) with cefazolin and metronidazole prophylaxis (P = 0.0064 versus P = 0.014) compared with cefazolin alone. The estimated antibiotic prophylaxis cost per person was less with cefazolin and metronidazole than with cefazolin alone (

The Effect of Nitrous Oxide and Carbon Dioxide Pneumoperitoneum on Operative and Postoperative Pain During Laparoscopic Sterilization Under Local Anesthesia

9.12 versus

Outpatient hysterectomy: Determinants of discharge and rehositalization in 133 patients

26.73). Conclusion Antibiotic prophylaxis with metronidazole and cefazolin results in fewer postoperative infections, decreased duration of hospitalization, and lower medication cost than cefazolin alone.