Tapio Kurki

Major complications of laparoscopy: a follow-up Finnish study.

Abstract Objective: To examine recent figures on major laparoscopic complications in Finland. Methods: This was a nationwide record-linkage study from January 1995 through December 1996 including all Finnish hospitals performing gynecologic laparoscopies. Data files of the National Patient Insurance Association and the Finnish Hospital Discharge Register were used. Data were compared with previous results from 1990 to 1994. Results: Among 32,205 gynecologic laparoscopies, 130 major complications were noted. The total complication rate was 4.0 per 1000 procedures: 0.6 per 1000 in diagnostic laparoscopies, 0.5 per 1000 in sterilization, and 12.6 per 1000 in operative laparoscopies. Intestinal injuries were reported in 0.7 per 1000, incisional hernias in 0.3 per 1000, urinary tract injuries in 2.5 per 1000, major vascular injuries in 0.1 per 1000, and other injuries in 0.5 per 1000 gynecologic laparoscopic procedures. Seventy-five percent (88 of 118) of the major complications in operative laparoscopies occurred during hysterectomies. The total major complication rate decreased from 4.9% in 1993 to 2.3% in 1996 (χ 2 = 8.55, P = .003), but the incidence of ureteral injuries remained stable, at about 1% of laparoscopic hysterectomies. Ureteral injuries were most common in local hospitals (2.6%), followed by central (1.1%) and university hospitals (0.9%). From 1990 through 1996, the relative risk for ureteral injury in laparoscopic hysterectomies, compared with other operative laparoscopies was 29.0 (95% confidence interval [CI] 13.3, 63.0), for bladder injury 13.0 (95% CI 6.0, 28.2), for intestinal injury 1.3 (95% CI 0.6, 2.5), and for major vascular injury 0.4 (95% CI 0.1, 3.6). Compared with the figures for 1990–1994, all major complications in operative laparoscopies increased, from 0 per 1000 in 1990 to 14.0 per 1000 in 1996 (χ 2 = 20.28, P Conclusion: Laparoscopic hysterectomies are still associated with a stable 1% risk of ureteral injury, whereas other major complications were decreasing until 1996. Complications in other laparoscopic procedures generally are rare.

A randomised controlled trial of vaginal clindamycin for early pregnancy bacterial vaginosis

Objective To determine whether treatment of bacterial vaginosis (BV) with vaginal clindamycin affects pregnancy outcome.

RAPID EFFECT ON ENDEMIC MEASLES, MUMPS, AND RUBELLA OF NATIONWIDE VACCINATION PROGRAMME IN FINLAND

An immunisation programme to eliminate measles, mumps, and rubella from Finland within 10 years was started in November, 1982. A combined live vaccine is being given twice, at the ages of 14-18 months and 6 years, but at the beginning of the project children between these age limits are also being immunised. Because vaccinations are traditionally done by the public health nurses, special attention was paid to their motivation. 2.5 years after the launch of the project, 80.9% of the target children had been vaccinated. The incidence of measles has fallen by 93% and that of mumps by 87% compared with a normal prevaccination year (1982). A similar fall in incidence was seen for rubella, but only in the vaccinated age groups. Although elimination of measles, mumps, and rubella is not likely to be achieved with the present vaccination coverage, a drastic fall in the incidence of all three target diseases has occurred already. Every effort is being made to improve the coverage and thus to achieve the ultimate goal of the project.

Maternal origin of nucleated erythrocytes in peripheral venous blood of pregnant women

We studied the origin of nucleated red blood cells (NRBC) in peripheral venous blood samples from 40 pregnant women carrying a male fetus, using a technique that allows direct chromosomal analysis by in situ hybridisation on immunologically and morphologically classified cells. Samples from ten nulligravid women were studied as controls. NRBC were enriched by negative magnetic activated cell sorting (miniMACS) using anti-CD45 monoclonal antibody. NRBC were detected by alkaline phosphatase anti-alkaline phosphatase immunostaining using a monoclonal anti-glycophorin A antibody. The origin of the NRBC was determined by fluorescence in situ hybridisation using X and Y specific probes. NRBC were found in 37 of the 40 pregnant women at a range of 1 to 230 per 20 ml of venous blood and in 6 of the 10 controls at a range of 1 to 3 per 20 ml of venous blood. All NRBC detected in the pregnant women were evidently of maternal origin, and in the pregnant women the number of NRBC was significantly higher (P < 0.05) than in the controls. Pregnancy per se seems to induce the appearance of maternal NRBC in the circulation, and it cannot therefore be assumed that NRBC isolated from the maternal blood are of fetal origin on the basis of morphology alone. Discrimination of fetal NRBC must occur for prenatal diagnosis of fetal genetic disorders.

Increased incidence of bronchopulmonary dysplasia after antenatal administration of indomethacin to prevent preterm labor

The aim of this randomized study was to compare the neonatal outcome in infants who have been exposed in utero to indomethacin with that in infants exposed to a beta-adrenergic agonist, nylidrin hydrochloride. Eighty pregnant women threatened with preterm labor between 24 and 34 weeks of gestation were enrolled in the study. An intravenous infusion of nylidrin or enterally administered indomethacin was given for a maximum of 72 hours. If preterm labor recurred, all parturient patients were treated with nylidrin. Indomethacin prolonged gestation significantly more than the beta-adrenergic agonist (6.6 weeks vs 4.5 weeks; p = 0.04). Ten of the forty-two infants exposed to indomethacin and 2 of the 45 infants exposed to nylidrin had bronchopulmonary dysplasia (24% vs 5%; p = 0.02). Among the 28 infants delivered within 120 hours after the start of treatment, the incidences of respiratory distress syndrome (82% vs 29%; p = 0.02), bronchopulmonary dysplasia (73% vs 6%; p = 0.0006), and necrotizing enterocolitis or focal intestinal perforation (27% vs 0%; p = 0.03) were higher among those exposed to indomethacin than among those exposed to nylidrin. We infer that administration of indomethacin to pregnant women threatened with premature labor is associated with an increased risk of bronchopulmonary dysplasia in their infants if delivery occurs early.

Insulin-like growth factor-binding protein-1 in cervical secretion as a predictor of preterm delivery

Background. The aim of the study was to evaluate whether the phosphorylated isoforms of insulin‐like growth factor‐binding protein‐1 (IGFBP‐1), a protein produced by the decidua, can be detected in cervical secretions of pregnant women with preterm uterine contractions, and whether their presence predicts an increased risk of preterm delivery.

Portfolios as a learning tool in obstetrics and gynaecology undergraduate training.

We developed a structured portfolio for medical students to use during their obstetrics and gynaecology undergraduate training. The main objective was to support the learning process of the students. We also wanted feedback information to enhance teaching.

Incidence, treatment and outcome of peripartum sepsis

Background and methods.  Clinical and microbiological features of maternal sepsis in the peripartum period (7 days before to 7 days after delivery) were analyzed to determine possible risk factors, optimal treatment and outcome. In 43 483 deliveries during 1990–98, laboratory‐confirmed bacteremia was found in 41 (5.1%) out of 798 clinically suspected septic infections.

Insulin-like growth factor binding protein-1 in cervix as a marker of infectious complications in pregnant women with bacterial vaginosis

1 Kurki T, Sivonen A, Renkonen P-V, Savia E, Ylikorkala O. Bacterial vaginosis in early pregnancy and pregnancy outcome. Obstet Gynecol 1992; 80: 172–77. 2 Hay PE, Lamont RF, Taylor-Robinson D, Morgan J, Ison C, Person J. Abnormal bacterial colonisation of the genital tract and subsequent preterm delivery and late miscarriage. BMJ 1994; 308: 295–308. 3 Goldenberg RL, Thom E, Moawad AH, Johnson F, Roberts J, Caritis SN. The preterm prediction study: fetal fibronectin, bacterial vaginosis, and peripartum infection. Obstet Gynecol 1996; 87: 656–60. 4 Rutanen E-M, Karkkainen T, Lundqvist C, Pekonen F, Ritvos O, Tanner P, Welin M, Weber T. Monoclonal antibodies to the 27-34K insulin-like growth factor binding protein. Biochem Biophys Res Commun 1988; 152:208–15. 5 Martina NA, Kim E, Chitkara U, Wathen NC, Chard T, Giudice LC. Gestational age-dependent expression of insulin-like growth factor binding protein-1 (IGFBP-1) phosphoisoforms in human extraembryonic cavities, maternal serum, and decidua suggests decidua as the primary source of IGFBP-1 in these fluids during early pregnancy. J Clin Endocrinol Metab 1997; 82: 1894–98.

Safety aspects of laparoscopic hysterectomy

Hysterectomy is one of the most frequently performed of all surgical operations and approximately 10,000 hysterectomies are performed annually in Finland (1). A lifetime risk of a woman to undergo hysterectomy has been 30% in the United States (2), 20% in Finland (1) and in the United Kingdom (3), but only 10% in Sweden (4) and Denmark (5). Traditionally the uterus has been removed by an abdominal or vaginal route. In spite of the lower complication rate in vaginal hysterectomies (6), abdominal hysterectomy has been the main method of hysterectomy in most of the countries. More than ten years ago 90–95% of hysterectomies were performed abdominally in Finland (1) and in Sweden (7), 70–80% in the United States (8) and in the United Kingdom (3) but only 40% in Austria (9). The optimum approach to hysterectomy would retain the advantages of the abdominal route, which include clear visualization and ease of manipulation of the adnexal structures, and to combine these features with the principal advantage of vaginal hysterectomy, namely avoidance of a large abdominal incision. Laparoscopic hysterectomy tries to combine these techniques and it has already influenced approaches to hysterectomy, offering a short recovery for the patient (10). How-