Michael S. Rogers

A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses.

OBJECTIVE Our purpose was to compare the results of laparoscopy with laparotomy in the management of ovarian masses not suspected to be malignant. STUDY DESIGN In a prospective randomized study 102 patients requiring surgical management of ovarian masses were randomly assigned to laparoscopy (52) or laparotomy (50) in a teaching hospital from July 1994 to September 1995. Inclusion criteria was tumor not suspected to be malignant with a diameter of < or = 10 cm as measured by ultrasonography. All operations were performed by trainees under the supervision of an experienced surgeon. Statistical analysis included t tests and chi2 tests. RESULTS There were no differences in demographic characteristics between the two groups nor any difference in the size of ovarian masses, adnexal adhesion score, or frequency of bilateral disease. All the ovarian masses were benign. Endometriotic cysts and dermoid cysts were the most common disorder in the two groups. Cystectomy was performed in > 70% of cases in each group. Operating time was not increased with the laparoscopic approach, and the frequency of inadvertent rupture of the ovarian masses was just as high as in laparotomy. The laparoscopic approach was associated with a significant reduction in operative morbidity (odds ratio 0.34, 95% confidence interval 0.13 to 0.88), postoperative pain and analgesic requirement, hospital stay, and recovery period. Patients in general were satisfied with the operation, but significantly more patients were satisfied with the laparoscopy scar. CONCLUSION Operative laparoscopy should replace laparotomy in the management of benign ovarian masses.

Reference intervals for thyroid hormones in pregnant Chinese women

Objective: To establish gestation-related reference intervals for thyroid hormones in a Chinese population. Materials and methods: A prospective study with 343 healthy pregnant women (5-41 weeks) and 63 non-pregnant controls. Thyroid stimulating hormone (TSH), free thyroxine (T4) and tri-iodothyronine (T3) (and human chorionic gonadotrophin) were measured by immunoassays. The median, 2·5th and 97·5th percentiles at 4-week intervals werecalculated. Data were also analysedfor significant trends using ANOVA. Results: Free T3 decreased during pregnancy, whereas free T4 initially increased, peaking between 9-13 weeks and then decreased, the decline becoming significant by week 21. TSH mirrored changes in free T4. Conclusion : The gestation-related reference intervals for thyroid hormones should alleviate the misinterpretation of thyroid function in pregnancy.

Glucose Intolerance and Cardiometabolic Risk in Children Exposed to Maternal Gestational Diabetes Mellitus in Utero

OBJECTIVE. The goal was to examine the carbohydrate tolerance and cardiometabolic risk among children exposed to maternal gestational diabetes mellitus in utero. METHODS. In this study, 164 Chinese children whose mothers had participated in a previous study on the screening and diagnosis of gestational diabetes mellitus (63 had gestational diabetes mellitus and 101 had normal glucose tolerance during the index pregnancies) underwent follow-up evaluations at a median age of 8 years (range: 7–10 years). Childrens weight, height, hip and waist circumferences, and blood pressure were measured, and weight-adjusted oral glucose tolerance tests were performed. RESULTS. Six children (3.7%) demonstrated impaired glucose regulation or diabetes mellitus at the follow-up evaluation. Children exposed to maternal gestational diabetes mellitus had significantly higher systolic (94 ± 1.2 vs 88 ± 0.9 mmHg) and diastolic (62 ± 0.8 vs 57 ± 0.6 mmHg) blood pressure values and lower high-density lipoprotein cholesterol (1.58 ± 0.04 vs 1.71 ± 0.03 mmol/L) levels, after adjustment for age and gender. A high (≥90th percentile) umbilical cord insulin level at birth was associated with abnormal glucose tolerance in the offspring. CONCLUSIONS. Maternal gestational diabetes mellitus increases the offsprings cardiometabolic risk, and in utero hyperinsulinemia is an independent predictor of abnormal glucose tolerance in childhood.

Pregnancy outcome after successful external cephalic version for breech presentation at term.

OBJECTIVE Our purpose was to review the outcome of pregnancies after external cephalic version at term, in particular the incidence and indications of intrapartum cesarean section after successful external cephalic version. STUDY DESIGN A prospective study was performed of 241 term pregnancies that had a total of 243 external cephalic versions. Each case with successful external cephalic version was matched to two control cases with cephalic presentation to compare pregnancy outcome. RESULTS External cephalic version was successful in 169 attempts (69.5%), of which 7 (4.1%) reverted to breech presentation. There was one case of abruptio placentae and eight cases (3.3%) of transient fetal bradycardia after the procedure. Among those who had a successful external cephalic version, the incidence of intrapartum cesarean section was 16.9%, which was 2.25 times higher than that of the control group (p < 0.005). This large number of abdominal deliveries was due to a significantly higher incidence of fetal distress and dystocic labor. The incidence of augmentation of labor was also significantly higher in the study group (37.7% vs 27.6%, p < 0.05). CONCLUSION Pregnancies after a successful external cephalic version at term are not the same as those with cephalic presentation. They are at higher risk of both dystocic labor and fetal distress and therefore require close intrapartum monitoring.

Lipid peroxidation in cord blood at birth: the effect of labour

Objective To determine the effect of labour on free oxygen radical activity in the fetus, as reflected by lipid peroxide levels in umbilical cord arterial blood.

Predictors of successful external cephalic version at term: a prospective study

Objective To investigate clinical and ultrasonographic predictors of outcome of external cephalic version at term.

Metabolic and inflammatory responses after laparoscopic and abdominal hysterectomy

OBJECTIVE Our purpose was to quantify and compare the metabolic and inflammatory changes after laparoscopic and abdominal hysterectomy. STUDY DESIGN Forty-four patients with no major medical disease requiring abdominal hysterectomy for benign disorders were randomly assigned to have laparoscopic hysterectomy (n = 20) and abdominal hysterectomy (n = 24). Venous blood and 24-hour urine samples were collected the day before and for each of the first 3 postoperative days. RESULTS No differences were present in demographic characteristics, operating time, and uterine weight between the two groups. No major complications were encountered. The laparoscopic hysterectomy group had a significantly lower postoperative morphine consumption (median 5.5 vs 14 mg, P < .05), lower febrile morbidity rate (15% vs 45.8%, P < .05), and shorter hospital stay (median 4 vs 6 days, P < .001) and demonstrated a less intense stress response in terms of serum interleukin-6 (median 50.6 vs 73.9 pg/mL x hour x 10, P = .01), C-reactive protein (median 28.1 vs 44.7 mg/L x hour x 10(2), P = .005), cortisol (median 23.4 vs 27.2 mg/mL x hour x 10(3), P = .04), white blood cell count (median 59.5 vs 69.8 10(9)/L x hour x 10, P = .009), 24-hour urinary excretion of cortisol (median 34.8 vs 44.2 nmol/L x hour x 10(3), P = .02), and norepinephrine (median 80.8 vs 132.4 nmol/L x hour x 10(2), P = .001). No significant difference was detected in plasma glucose (median 41.5 vs 45.6 mmol/L x hour x 10, P = 6) and 24-hour urinary excretion of epinephrine (median 32.2 vs 34.1 nmol/L x hour x 10(2), P = .3). CONCLUSION Laparoscopic hysterectomy is associated with a lower morbidity and a less intense stress response than abdominal hysterectomy for benign diseases.

Anti-angiogenic effects of green tea catechin on an experimental endometriosis mouse model

BACKGROUND The development of new blood vessels plays an essential role in growth and survival of endometriosis. Epigallocatechin gallate (EGCG) from green tea has powerful anti-angiogenic properties and our aim was to evaluate these properties in experimental endometriosis. METHODS AND RESULTS Eutopic endometrium from endometriosis patients was transplanted s.c. to severely compromised immunodeficient mice, randomly treated i.p. with EGCG (anti-angiogenic and -oxidant), Vitamin E (a non-angiogenic antioxidant) or saline for 2 weeks. The endometrial implant, including adjacent host outer skin and subcutaneous layers plus inner abdominal muscle and peritoneum, was collected. New microvessels were determined by species-specific immunohistochemistry. Angiogenic factors in lesions and abdominal muscle were detected by quantitative real-time PCR. Apoptosis was studied by terminal deoxynucleotidyltransferase-mediated dUTP nick-end labelling and quantitative real-time PCR. In saline control, endometrial implants developed new blood vessels with proliferating glandular epithelium and were tightly adhered to host subcutaneous and abdominal muscle layers. After EGCG, endometriotic lesions were smaller than control (P < 0.05), and glandular epithelium was smaller and eccentrically distributed. Angiogenesis in lesions from the implant and adjacent tissues was under-developed, and microvessel size and density were lower (both P < 0.01) than control. mRNA for angiogenic vascular endothelial growth factor A, but not hypoxia inducible factor 1, alpha subunit, was significantly down-regulated in lesions after EGCG (P < 0.05). In addition, apoptosis in the lesions was more obvious, and nuclear factor kappa B and mitogen activated protein kinase 1 mRNA levels were up-regulated (P < 0.05) after EGCG treatment. No differences were observed with Vitamin E treatment. CONCLUSIONS EGCG significantly inhibits the development of experimental endometriosis through anti-angiogenic effects.

Comparison of peritoneal oxidative stress during laparoscopy and laparotomy

STUDY OBJECTIVE To identify oxidative stress in peritoneum during laparoscopic and open surgery by measuring products of lipid peroxidation, and to determine whether surgical approach influences the type of oxidative metabolite synthesized. DESIGN Retrospective analysis (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Twenty-eight consecutive women with uterine myomas or ovarian cysts. INTERVENTION Laparoscopic or open surgery (14 patients each). MEASUREMENTS AND MAIN RESULTS We obtained 1 x 1-cm squares of peritoneum at the beginning and end of surgical procedures away from sites of surgery. 8-Isoprostaglandin F(2alpha), hydroxyeicosatetranoic acids (HETEs), and malondyaldehyde (MDA) were measured by enzyme-immunoassay, high-performance liquid chromatography, and thiobarbituric acid adduction method, respectively. Comparisons showed significant increases in 5-HETE and 8-prostane in the laparoscopy group, which were correlated with duration of pneumoperitoneum and volume of carbon dioxide (CO(2)) insufflated, respectively. In the laparotomy group only MDA rose significantly related to duration of surgery. CONCLUSIONS Lipid peroxidation was observed in peripheral peritoneum during laparoscopic surgery, mediated through noncyclooxygenase and lipoxygenase pathways, and appears to be due to effects of CO(2) pneumoperitoneum. Biochemical reactions were also observed in the laparotomy group, but are thought to be related to mechanisms other than lipid peroxidation.

Lipid peroxidation in cord blood at birth

OBJECTIVE The purpose of this study was to determine oxygen free radical activity in the neonate at birth and relate it to umbilical cord blood acid-base status. STUDY DESIGN A series of 110 singleton deliveries had determination of two lipoperoxides in umbilical cord blood: malondialdehyde and organic hydroperoxide. Umbilical pH, PO2, PCO2, bicarbonate, and base excess were also measured. RESULTS There was a significant association between lipoperoxides and cord blood pH and base excess. A significant difference existed in the levels of umbilical artery lipoperoxides between nonacidemic and acidemic fetus, as defined by an umbilical arterial pH < 7.20. CONCLUSION There is a positive association between lipoperoxide production and acid-base balance at delivery.