Heleen J. van Beekhuizen

Complications of obstructed labour: pressure necrosis of neonatal scalp and vesicovaginal fistula

In August 2004 a 16-year-old primigravida was referred to our regional hospital from a health centre with prolonged obstructed labour. She had been in labour with ruptured membranes for 3 days. The patient could not be transferred earlier because no transport was available. On admission she had fever (temperature 40°C) and foul-smelling meconium-stained discharge; the fetus was tachycardic. The cervix was fully dilated and the caput succedaneum was visible in the vulva. No signs of female genital cutting were present. Vacuum extraction with a 5 cm Malmstrom metal cup failed and after initiation of broad-spectrum antibiotics a caesarean section was done successfully. Mother and baby received prophylactic antibiotic treatment for 8 days. The baby boy did not show lacerations from the vacuum cup which had been normally positioned over the posterior fontanelle. The mothers urinary catheter was left in situ for 2 weeks for vesicovaginal fistula prophylaxis. (excerpt)

Lymph node count at inguinofemoral lymphadenectomy and groin recurrences in vulvar cancer

Objective The objective of the study is to determine the risk factors for groin recurrence (GR) in patients with primary vulvar squamous cell carcinoma (SCC) after inguinofemoral lymphadenectomy (IFL) without lymph node metastases and/or adjuvant chemoradiotherapy. Methods The study is a multicenter retrospective review of clinical and histopathological data of patients with lymph node–negative vulvar SCC who underwent an IFL. Patients with and without GRs were compared to identify risk factors. Results In 134 patients, 252 groins were eligible for the analyses—16 patients underwent ipsilateral IFL and 118 patients underwent bilateral IFL. Groin recurrences occurred in 4 (1.6%) of the 252 dissected groins. Besides, 1 patient who underwent ipsilateral IFL had a recurrence in the nonoperated contralateral groin; this groin was left out of analysis. The median number of dissected nodes per groin was 9.8 (range, 1–38) in all patients and 6.5 (range, 5–8) in patients with GR. Multivariate analyses showed that GR was related to poor differentiation (P = 0.04), and node count less than 9 (P = 0.04), no association with age, tumor localization, tumor diameter, focality, invasion depth, or stage was found. Nineteen patients with both low node count and poor differentiation had 19% GRs. Survival analyses showed less favorable survival in patients with poor differentiation. Conclusions The overall risk of developing GR after negative IFL in patients with vulvar SCC is low (1.6% per groin) but significantly higher in patients with tumors with a poor differentiation and lymph node count less than 9 at IFL. A large well-designed prospective study is needed to evaluate closer surveillance in patients at risk.

Single‐dose compared with multiple day antibiotic prophylaxis for cesarean section in low‐resource settings, a randomized controlled, noninferiority trial

To investigate the efficacy of a single prophylactic dose of ampicillin combined with metronidazole to prevent postcesarean section infections compared with a multiple day regimen in low‐resource settings.

Repeat sentinel lymph node procedure in patients with recurrent vulvar squamous cell carcinoma is feasible

OBJECTIVE Standard treatment of primary T1 squamous cell carcinoma (SCC) of the vulva <4cm consists of wide local excision (WLE) and sentinel lymph node (SLN) procedure of the groin(s). In case of a local recurrence WLE and inguino femoral lymphadenectomy (IFL) is generally recommended. In this study we assessed the feasibility of repeat SLN procedure in patients with recurrent vulvar SCC who were not able or willing to undergo IFL. METHODS A retrospective study was performed in consecutive patients with recurrent vulvar SCC who underwent a repeat SLN procedure between 2006 and 2014. We present the clinical and pathological outcomes. The study conforms to the STROBE guidelines. RESULTS A total number of 27 patients aged 35-87years at first diagnosis of SCC of the vulva were identified. Median follow-up after 2nd surgery was 27.4 (range 2-96) months. In 78% of patients and in 84% of the groins the repeat SLN procedure was successful. No structured questionnaires were used to describe details on the repeat SLN procedures but in general the gynecologic oncologists experienced repeat SLN procedures more challenging compared to primary procedures. There were no groin recurrences documented. CONCLUSIONS Our findings suggest that it is feasible to perform a repeat SLN procedure in recurrent vulvar SCC, but the procedure appears technically more challenging compared to primary setting, resulting in a lower SLN identification rate.

A randomized controlled trial on the value of misoprostol for the treatment of retained placenta in a low-resource setting

To evaluate the efficacy and safety of misoprostol among patients with retained placenta in a low‐resource setting.

Treatment of retained placenta with misoprostol: a randomised controlled trial in a low-resource setting (Tanzania)

BackgroundRetained placenta is one of the common causes of maternal mortality in developing countries where access to appropriate obstetrical care is limited. Current treatment of retained placenta is manual removal of the placenta under anaesthesia, which can only take place in larger health care facilities. Medical treatment of retained placenta with prostaglandins E1 (misoprostol) could be cost-effective and easy-to-use and could be a life-saving option in many low-resource settings. The aim of this study is to assess the efficacy and safety of sublingually administered misoprostol in women with retained placenta in a low resource setting.MethodsDesign: Multicentered randomised, double-blind, placebo-controlled trial, to be conducted in 5 hospitals in Tanzania, Africa.Inclusion criteria: Women with retained placenta, at a gestational age of 28 weeks or more and blood loss less than 750 ml, 30 minutes after delivery of the newborn despite active management of third stage of labour.Trial Entry & Randomisation & Study Medication: After obtaining informed consent, eligible women will be allocated randomly to the treatment groups using numbered envelopes that will be randomized in variable blocks containing identical capsules with either 800 microgram of misoprostol or placebo. The drugs will be given sublingually. The women, maternal care providers and researchers will be blinded to treatment allocation.Sample Size: 117 women, to show a 40% reduction in manual removals of the placenta (p = 0.05, 80% power). The randomization will be misoprostol: placebo = 2:1Primary Study Outcome: Expulsion of the placenta without manual removal. Secondary outcome is the number of blood transfusions.DiscussionThis is a protocol for a randomized trial in a low resource setting to assess if medical treatment of women with retained placenta with misoprostol reduces the incidence of manual removal of the placenta.Clinical Trial RegistrationCurrent Controlled Trials ISRCTN16104753

Generalized unprovoked vulvodynia; A retrospective study on the efficacy of treatment with amitriptyline, gabapentin or pregabalin

OBJECTIVE To describe patient characteristics of women diagnosed with generalized unprovoked vulvodynia (GUV) and to estimate efficacy and tolerability of treatment. MATERIAL AND METHODS Retrospective observational study in 241 women who presented with GUV at three vulvar disease clinics in Rotterdam, The Netherlands during 1996-2013. Main outcome was efficacy of amitriptyline, gabapentin or pregabalin treatment. RESULTS The median duration of symptoms was 24 months and median age 62 years (range 36-89). Most of the patients reported a burning sensation, often worsened by sitting, urinating or having intercourse. Treatment with either amitriptyline, gabapentin or pregabalin produced long lasting pain relief in 60% and temporary pain relief in 10%, while treatment was not successful in 30% of the patients. Around 30% of the patients had to stop their medication due to side effects. In 44 of the 241 (18%) women signs of vulvar dermatoses were present that could not explain the symptoms. These women experienced the same therapeutic efficacy as those without any visible abnormalities (chi-square goodness of fit p=0.49). CONCLUSIONS Amitriptyline, gabapentin and pregabalin produced long lasting pain relief in most of the women with GUV. The 2015 International Society for the Study of Vulvovaginal Disease nomenclature acknowledges the concomitant presence of vulvar dermatoses and vulvodynia. This enables treatment of both conditions simultaneously, a situation that occurs regularly according to our study. We advocate that women with symptoms of GUV, with or without the presence of vulvar dermatoses, receive a therapeutic trial with drugs such as amitriptyline.

Comment on: Does the number of nodes removed impact survival in vulvar cancer patients with node-negative disease? Madeleine Courtney-Brooks, Paniti Sukumvanich, Sushil Beriwal, Kristin K. Zorn, Scott D. Richard, Thomas C. Krivak. Gynecological Oncology 117 (2010) 308–311

We read the study of Courtney-Brooks et al. with great interest. They concluded that removal of greater than 10 lymph nodes was associated with a significant improvement in DSS in patients with stage III node-negative vulvar carcinoma. The extent of the removal of lymph nodes in vulvar cancer remains controversial, and many countries have conflicting guidelines. The strength of the study of Courtney-Brooks et al. is that they include more than 1000 patients. However, some issues need clarification: