Lucia Haakova

A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease

OBJECTIVESnTo compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).nnnSTUDY DESIGNnA prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.nnnRESULTSnVaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.nnnCONCLUSIONSnBased on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.

Prenatally Diagnosable Differences in the Cellular Immunity of Fetuses with Down’s and Edwards’ Syndrome

Introduction: Lymphocyte subpopulations are identified by the uniform CD classification (Cluster of Differentiation) and can be accurately differentiated with monoclonal antibodies using the method of flow cytometry. With the aid of cordocentesis it is possible to perform studies on the status and development of cellular immunity as early as in the second trimester of pregnancy. Objective: To compare lymphocyte subpopulations present in fetuses with chromosomal abnormalities (Down’s syndrome (DS), Edwards’ syndrome (ES)) and fetuses with normal karyotype. Study Design: Prospective observational study. Methods: We examined a total of 61 pregnant women with an average age of 31.5 years (20– 46 years). Results: In fetuses with DS we found a significant decrease in B lymphocytes (CD19),a decrease in the subpopulations of multi-reactive B-cells (CD5+CD19+, B-CLL),and a decrease in the index of CD4/CD8 and class II HLA-DR. In contrast, the representation of NK cells expressing /CD3-CD (16 + 56)+/ was greatly increased. In ES we found a decrease in T lymphocytes (CD3), a decrease in T-helper lymphocytes (monocytes CD4), a decreased index of CD4/CD8 and a greater representation of NK cells /CD3-CD (16 + 56)+/. Conclusion: We determined the normal values of lymphocyte subpopulations in physiological fetuses. We demonstrated that the immunological defect of the affected fetuses is already present antenatally, and can be reliably diagnosed in the second trimester of pregnancy.

ABO fetomaternal compatibility poses a risk for massive fetomaternal transplacental hemorrhage

Objective. Severe fetomaternal transplacental hemorrhage increases the risk of fetal anemia. In the third trimester, the syncytiotrophoblast becomes thinner, especially in areas where it comes into intimate contact with villous capillaries, and forms a vasculosyncytial membrane. Our aim was to determine whether ABO compatibility puts the fetus at a greater risk of severe fetomaternal hemorrhage. Design. Case study. Setting. A tertiary care center. Sample and methods. Between 2003 and 2007, we evaluated eight cases of severe fetomaternal transfusion. The Kleihauer‐Betke test was used for diagnosis of fetomaternal hemorrhage. We evaluated blood group compatibility between the mother and fetus and assessed the perinatal outcome. The Fischers factorial test was used for testing a hypothesis. Results. The incidence of adverse outcomes following transplacental hemorrhage was 75% (six of eight). There were two perinatal deaths and four infants were affected by post‐hypoxic damage of varying severity. Fetomaternal ABO compatibility was present in seven of the eight cases. The risk of severe fetomaternal hemorrhage was significantly increased when there was ABO compatibility between the mother and fetus. This was associated with a very poor perinatal outcome. Conclusion. We recommend that resuscitation in utero by intrauterine transfusion should be considered before the 33rd week of gestation in cases of severe fetal anemia. In later gestation, urgent cesarean section is required with adequate resuscitation of the newborn.

P17.11: Vein of Galen aneurysm: prenatal diagnosis and management

Fetal ventriculomegaly is a common finding on obstetrical ultrasound examination. It is a congenital defect caused by excess of cerebral fluid in the lateral ventricles of the cerebrum and can result in neurological impairment. Ventriculomegaly is considered mild (the atrial diameter of the lateral ventricle is 10–12 mm), moderate (12.1–15 mm) and severe (≥ 15.1 mm). Ventriculomegaly can be associated with other congenital malformations such as agenesis of the corpus callosum, spina bifida and heart defects. In 50% of the cases it is isolated. It is always connected with an increased risk of chromosomal abnormality. A 25-year old primipara was hospitalized twice at the Obstetrics and Gynecology Department of the Institute of Mother and Child in Warsaw. Ultrasound examination performed in south Poland ambulatory center at 18 weeks of gestation revealed severe fetal ventriculomegaly (Evans ratio 85%) and termination of pregnancy was proposed but the patient refused. The first admission to our Department was at 32 weeks of gestation for prenatal diagnostics. During hospitalization ultrasound examination revealed regression of this state. Atrial diameter of the right lateral ventricle was 14 mm and of the left 12 mm. Fetal MRI was performed confirming the asymmetrical moderate fetal venriculomegaly. Fetal echo revealed congenital fetal heart defect (VSD). At 40 weeks of gestation cesarean section was performed because of imminent intrauterine infection -female newborn 3460 grams/10 Apgar points. The child is actually an out -patient of the Children and Adolescents Surgery Department of the Institute of Mother and Child. TORCH tests are correct. Progression of the asymmetrical moderate ventriculomegaly is observed in consequent ultrasound examinations of the CNS. MRI performed at 2 – months of age revealed hydrocephalus, Evans ratio 47% and hypoplasia of the corpus callosum. Neurological examination reveals no motor or neurological impairment.

P27.15: Inadvertent intra‐arterial administration during intraumbilical transfusion as a cause of severe bradycardia and fetal hypoxia

We performed an arterial embolization at 29 weeks. We observed the disappearing of vascular flow inside the tumor, without any modification on placenta flow. Delivery at 41 weeks gestation: normal newborn (3250 g). We consider that the procedure could be less iatrogenic than others. We could be more selective than laser and less toxic than alcohol. We didn’t observe any bleeding after needle removal. The procedure could be performed after a complete vascular cartography (contribution of the 3D Doppler imaging), a perfect preparation of Histoacryluf6da and be careful not to create a venous embolization. We suggest to do an prospective study, to have an answer about the timing of the procedure, to evaluate the risk and the advantages.

OP16.01: Trauma after instrumental delivery—the use of 3D/4D ultrasound in the evaluation of levator ani muscle

Case 2 presented at 8 weeks with a live pregnancy situated in the Cesarean scar, bulging into the urinary bladder. Color Doppler showed prominent vascularity. Initial βhCG was 55419IU/l and methotrexate was given (day 1). On day 6 βhCG had fallen and a second dose of methotrexate was given. On day 10 the fetal heartbeat was absent and by day 12 the vascularity had reduced significantly. ERPC was then carried out on day 14. By day 31, the βhCG was 32IU/l. The use of B-mode and Doppler ultrasound with βhCG to guide timing of evacuation has not been described before. In our cases it was effective and safe, with fertility preserved, no significant blood loss at any stage and no long term follow up was needed. More cases are required to confirm effectiveness and safety of this new strategy.

Prenatal treatment of severe congenital erythropoetic porphyria (CEP) – a case report

Introduction:u2002 Less than 3% of porhpyhia cases affect children and CEP is the most severe.