Rose Kung

Predictors of women's physical health problems after childbirth.

The objectives of this study were to document the extent and the correlates of common physical health symptoms in women two months after childbirth. Of special interest was determining whether violence and depression histories increase the risk for experiencing these symptoms. Participants were recruited in six Toronto-area hospitals and were interviewed by telephone 8–10 weeks later. Two hundred of the 332 (60.2%) women who were approached completed the study. Most women (96%) reported at least one physical health symptom 2 months postnatally (Meanu200a=u200a3.4, SDu200a=u200a2.0). Stepwise logistic regression was conducted for each outcome. Antenatal depression was a significant predictor of excessive fatigue and bad headaches. Sick leave during pregnancy predicted postpartum backaches. Adult emotional abuse and household income were associated with bowel problems. Episiotomy, maternal complications, and planned pregnancy predicted perineal pain. Finally, being Canadian born and having an assisted vaginal delivery increased the risk for hemorrhoids while cesarean section decreased the risk. A high prevalence of physical symptoms was found in women after childbirth. History of depression and violence were implicated in the occurrence of some of these symptoms. Other important predictors included demographic, maternal, and delivery-related factors.

A New Bipolar System for Performing Operative Hysteroscopy in Normal Saline

We evaluated the efficacy and safety of the VersaPoint bipolar vaporization system during hysteroscopic treatment of 10 women with symptomatic submucous leiomyomata, endometrial polyps, uterine septa, and synechiae in a prospective, uncontrolled pilot study at two Canadian university-affiliated teaching hospitals. Patients were two women with recurrent pregnancy loss associated with a diagnosis of uterine septa, one with infertility, one with recurrent pregnancy loss and synechiae, and six with menorrhagia associated with either leiomyomata or endometrial polyps. Electrodes were inserted through a 5F operating channel of a 15F cystoscope, and a 17 or 21F hysteroscope. Three electrodes were used: ball, twizzle, and spring. Power settings ranged from 50 W (desiccation mode) to 200 W (vapor cut mode). Normal saline was used as the distention medium in all cases. Either general anesthesia or intravenous sedation with paracervical block was used. There were no major complications such as uterine perforation, excessive bleeding, fluid overload, or thermal injury. The amount of normal saline used varied considerably from 0.5 to 20 L. The maximum amount of saline absorbed was 900 ml in a case involving resection of 4.5- and 2.0-cm leiomyomata that lasted 115 minutes. Mild cramping, vaginal bleeding, and discharge in the first 2 to 3 days were relieved by nonsteroidal antiinflammatory agents. No patients were readmitted up to 6 weeks after the procedure. Preliminary results of this pilot study support the safety of the VersaPoint bipolar vaporization system, although its long-term efficacy remains to be determined. It appears to be well tolerated by some women using conscious sedation and paracervical block. Therefore, it can potentially be used in an office setting as well as in symptomatic patients who are at risk from a general anesthetic. (J Am Assoc Gynecol Laparosc 6(3):331-336, 1999)

Nitroglycerin as a uterine relaxant: a systematic review.

OBJECTIVEnTo evaluate the effectiveness of nitroglycerin as a uterine relaxant for preterm labour, fetal extraction at Caesarean section, external version, embryo transfer, cervical dilation for first trimester pregnancy termination, and primary dysmenorrhea.nnnDESIGNnA systematic review of randomized control trials (RCTs) of nitroglycerin in obstetrics and gynaecology.nnnMETHODSnWe searched PubMed (1966-2001), the Cochrane Controlled Trials Register, and the International Journal of Obstetric Anesthesia using text terms quot:nitroglycerin, glyceryl trinitrate, uterus, uterine, and relaxation. The last search was conducted in January 2001. References from review articles and abstracts from major scientific meetings (1997-2000) were reviewed for relevant publications. RCTs comparing nitroglycerin to either placebo or another therapeutic intervention (ritodrine, magnesium sulphate, and prostaglandin) and whose quality score was equal to or greater than 2 were included (Class I evidence as described in the Report of the Canadian Task Force on the Periodic Health Exam).nnnRESULTSnSixty articles were retrieved of which 13 were RCTs. Nitroglycerin was more effective for arresting preterm labour than placebo but not more effective when compared to ritodrine or magnesium. Nitroglycerin was not superior to placebo for uterine relaxation for either fetal extraction at Caesarean section or for external version. There were no differences in ease of embryo transfers when nitroglycerin spray was compared to placebo. In first trimester pregnancy terminations, less force was required to dilate the cervix when nitroglycerin was compared to no treatment. The incidence of preeclampsia was not reduced by nitroglycerin but fewer complications were noted when compared to the placebo group. In patients with primary dysmenorrhea, nitroglycerin significantly decreased pain.nnnCONCLUSIONnAlthough nitroglycerin is widely used, its superiority over currently used tocolytic agents is unproven. (Class C recommendation) Nitroglycerin has been demonstrated to decrease pain associated with dysmenorrhea. (Class A recommendation)

Laparoscopic Two-Team Slings for Women with Stress Urinary Incontinence

STUDY OBJECTIVEnTo review long-term success and complication rates of laparoscopic two-team sling procedures in women with stress urinary incontinence or mixed incontinence confirmed by urodynamic testing and cystoscopy.nnnDESIGNnProspective study (Canadian Task Force classification II-2).nnnSETTINGnTertiary urogynecology unit at a university-affiliated teaching hospital.nnnPATIENTSnOne hundred seventy-five women.nnnINTERVENTIONSnLaparoscopic two-team sling procedure.nnnMEASUREMENTS AND MAIN RESULTSnThe extraperitoneal approach to the space of Retzius was accomplished using a balloon device, and the intraperitoneal approach involved a transverse incision through the anterior parietal peritoneum 6 cm above the symphysis. A 1.5- to 2.0-cm wide strip of polypropylene mesh was inserted through a vertical incision along the anterior vaginal wall, perforating the urogenital diaphragm under laparoscopic guidance. The mesh was sutured to Coopers ligaments bilaterally with 0 polypropylene sutures. Mean operating time was 80.1 +/- 30.0 minutes, mean estimated blood loss was 160 +/- 146 ml, and mean hospital stay was 2.4 +/- 1.2 days. Patients were followed at 6 weeks, 6 months, 1 year, and yearly (mean 17.8 mo, range 1-5 yrs).nnnCONCLUSIONnLaparoscopic two-team sling procedures can be performed safely in women with recurrent stress incontinence and those with risk factors for failure of retropubic urethropexy. Long-term success rates are excellent (91.1%) with few complications.

Laparoscopic two-team sling for stress urinary incontinence

The two-team sling procedure is recommended for women with recurrent stress urinary incontinence (SUI), particularly those with low urethral pressures. These procedures have been performed for 20 years using a combined abdominovaginal approach and Marlex mesh. From July 1993 to February 1996, 100 cases of laparoscopic two-team procedures were performed using both extraperitoneal and intraperitoneal approaches. An overall success rate of 95% was achieved with a mean follow-up of 1.5 years (range 6 mo-3 yrs). Complications were small bowel perforation (1%) from the umbilical cannula requiring laparotomy and small bowel resection, inadvertent cystotomy (3%), voiding dysfunction (3%), and mesh erosion (3%). The mean operating time was 70 minutes and average length of hospital stay was 1.5 days. The laparascopic two-team sling is a suitable surgical alternative for women with recurrent SUI.

Incidentally found hyperreactio luteinalis in pregnancy

Hyperreactio luteinalis (HL) is a rare pregnancy-related condition in which the ovaries become massively enlarged bilaterally, occupied by multiple benign theca lutein cysts, secondary to increased ovarian stimulation by beta-human chorionic gonadotropin (B-hCG). HL should resolve spontaneously postpartum, however, their occurrence has led some physicians unfamiliar with the natural history of the condition to perform unnecessary ovarian cystectomies or oophorectomies. A healthy 32-year-old woman was incidentally found to have new onset multicystic ovaries on ultrasound at 31u202f+u202f3 weeks gestational age, which continued to enlarge, with a maximum volume of ∼448.0 cm3 and ∼323.5 cm3 in right and left ovaries, respectively. She also developed signs and symptoms of hyperandrogenism, and later abdominal pain which ultimately expedited delivery. This paper demonstrates that familiarity with HL as a clinical entity, its typical presentation and natural history, and targeting conservative management is paramount in minimizing iatrogenic harm by obstetricians given the increased use of ultrasound in pregnancy. Patients presenting after the first trimester with bilateral multicystic ovaries with a spoke wheel appearance on ultrasound, hyperandrogenism, abnormally elevated B-hCG, or symptoms consistent with elevated B-hCG should prompt a possible diagnosis.