Thomas E. Nolan

Measurement of amniotic fluid volume: Accuracy of ultrasonography techniques

OBJECTIVE Our purpose was to determine amniotic fluid volume by the dye-dilution technique and compare it with the amniotic fluid index, largest vertical pocket, and two-diameter pocket (defined as vertical x horizontal of the largest vertical pocket). STUDY DESIGN This prospective study involved 40 women undergoing amniocentesis in late pregnancy to detect fetal lung maturity or evidence of chorioamnionitis. The amniotic fluid volume was quantified ultrasonographically by means of the amniotic fluid index, largest vertical pocket, and two-diameter pocket. During amniocentesis the fluid volume was calculated by the dye-dilution technique of Charles and Jacoby. RESULTS Ultrasonographic measurements by amniotic fluid index, largest vertical pocket, and two-diameter pocket correctly predicted normal amniotic fluid and hydramnios (74%). A new measurement, two-diameter pocket, gave a significantly more accurate estimate of oligohydramnios than did amniotic fluid index (p < 0.002) or largest vertical pocket (p < 0.0003). CONCLUSION All three indices are moderately accurate in identifying normal amniotic fluid volume and hydramnios. Two-diameter pocket is the most accurate test to predict oligohydramnios.

Urinary tract injury during hysterectomy based on universal cystoscopy.

OBJECTIVE: To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease. METHODS: This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease. RESULTS: Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation. CONCLUSION: Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury. LEVEL OF EVIDENCE: III

Morbidity and mortality rates of elective gynecologic surgery in the elderly woman

OBJECTIVE The purpose of this study was to report perioperative morbidity and mortality rates in elderly women who undergo gynecologic surgery. STUDY DESIGN The charts of 54 consecutive women ages 70 to 85 years who underwent major gynecologic surgery between June 1998 and November 2002 were reviewed retrospectively. RESULTS The mean age was 76.7 years. Fifty procedures (92.6%) were performed for pelvic organ prolapse and/or urinary incontinence. Forty-nine of the procedures were performed vaginally, and 27 of the procedures (50%) were performed with the use of general anesthesia. Postoperative cardiac complications occurred in five patients (10%), including three myocardial infarctions, two of which were fatal. Other complications included benign cardiac arrhythmias in two patients, slow return of gastrointestinal function in five patients (9.3%), and transient mental status changes in four patients (7.4%). The mean length of stay was 4 days. CONCLUSION Postoperative complications occurred infrequently among elderly women who underwent gynecologic surgery. Although age alone is not a contraindication to elective surgery, there may be increased risks for geriatric women.

Use of a subcutaneous closed drainage system and antibiotics in obese gynecologic patients

OBJECTIVE The purpose of this study was to evaluate the effect of subcutaneous closed drainage systems and prophylactic antibiotics on the wound breakdown rate in obese patients undergoing gynecologic surgery. STUDY DESIGN A prospective study was performed on 197 obese patients who were randomly selected to have a subcutaneous drain. Incision closure technique was standardized. Antibiotic usage was not randomized. Demographic data, perioperative data, and postoperative complications were noted and analyzed by X2 test and 2 x 2 contingency tables. RESULTS The overall complication rate was 25%, with 20% (22/109) among the group receiving a drain versus 31% (27/88) without a drain. Seventeen patients (8.6%) had wound breakdowns: 7 of 109 (6.4%) with drains and 10 of 88 (11.4%) without drains. Prophylactic antibiotics were given to 46% (50/109) in the drain group and 51% (45/88) without a drain. Fewer patients (2%) with a drain receiving antibiotics had wound breakdowns. The group with the most breakdowns had neither a drain nor antibiotics (14%). CONCLUSION We suggest the use of subcutaneous drains plus prophylactic antibiotics may decrease morbidity when operating on obese gynecologic patients.

Comparative efficacy of two sonographic measurements for the detection of aberrations in the amniotic fluid volume and the effect of amniotic fluid volume on pregnancy outcome.

Objective: To determine in pregnant women with preterm labor the relative efficacy of the amniotic fluid index (AFI) and the two‐diameter pocket to detect abnormalities in amniotic fluid volume (AFV), and to relate these findings to pregnancy outcome. Methods: Fifty‐seven healthy women with preterm labor underwent amniocentesis in the third trimester to detect subclinical chorioamnionitis and assess fetal lung maturity. The AFV was estimated by the AFI and two‐diameter‐pocket methods, then confirmed by a dye (aminohippurate sodium)‐dilution technique. Each labor was evaluated for severe variable decelerations requiring amnioinfusion, fetal distress resulting in cesarean delivery, and a 5‐minute Apgar score below 7. Results: Using fluid volume confirmed by dye dilution, the AFI correctly diagnosed AFV as low (less than 500 mL) in only two of 23 (8.7%) patients, compared to 14 of 23 (61%) for the two‐diameter pocket (P < .001). Fetal distress requiring cesarean delivery occurred significantly more often in the hydramnios group (three of six) compared to those with normal AFV (one of 23) (P < .03), and approached significance in the oligohydramnios group (two of 21) (P = .056). There were no significant differences among the three patient groups regarding the need for amnioinfusion for severe variable decelerations or the occurrence of 5‐minute Apgar scores below 7. Conclusions: Compared to the AFI, the two‐diameter pocket is a superior sonographic measurement for the detection of oligohydramnios. In an otherwise low‐risk pregnancy with preterm labor, oligohydramnios is associated with no greater risk for an adverse outcome than is a normal AFV. (Obstet Gynecol 1994;83:959‐62)

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair.

Introduction and hypothesisThis study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP).MethodsThis is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh.ResultsMean postoperative value (±SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: −2.4 ± 1.1 (cm), −2.4 ± 0.9 (cm), and −7.7 ± 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05).ConclusionsConcurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.

The effects of standing, lifting and noise exposure on preterm birth, growth restriction, and perinatal death in healthy low-risk working military women

Objective. The effects of standing, lifting and noise in low-risk, healthy pregnant women are uncertain. In the past, the heterogeneity of the populations studied, the limitations of the designs of the retrospective and case control studies, and a failure of some of the larger investigations to evaluate all the potential confounding variables has hampered many studies. The purpose of this investigation was to evaluate, throughout pregnancy, the effects of standing, repetitive lifting, and noise in the workplace compared with no standing, lifting or noise exposure, on maternal and perinatal outcomes in a large prospective study of a low-risk healthy population of working women cared for by a single group of health providers. Methods. This prospective observational study used an extensive questionnaire to collect antepartum, intrapartum, and postpartum information. Information was collected on the initial visit, each subsequent visit, and immediately after delivery. The participating women were divided into groups based on the amount of time spent standing, the amount and extent of repetitive lifting, and noise exposure in the workplace. Results. Eight hundred and fourteen low-risk active duty women participated in this investigation over a 4-year period. Multivariate analysis with non-exposure compared with exposure reinforced the effect of standing on preterm labor (OR 1.80, 95% CI 1.05, 3.16) and preterm birth (OR 1.69, 95% CI 1.03, 2.80) and showed a trend toward an effect of noise exposure on preterm labor (OR 1.76, 95% CI 0.78, 3.39) after controlling for other exposures. Conclusions. This investigation suggests an association of occupational standing with preterm labor and preterm birth.

Venous thromboembolism during pregnancy: a current review of diagnosis and management.

Pregnancy is widely recognized to be a physiologic state with a markedly elevated risk for thromboembolic complications. The diagnosis and management of venous thromboembolic events during pregnancy, however, remains controversial because of the lack of prospective, randomized trials that have included pregnant women. Significant progress has been made in the last 10 years in the management of these conditions in the nonpregnant patient and strong clinical guidelines have been established recently. Obstetrician-gynecologists may modify these guidelines and apply them to the pregnant patient based on their knowledge of the physiologic changes in pregnancy. Objective diagnostic techniques should be used liberally when the diagnosis of deep vein thrombosis or pulmonary emboli is considered because early intervention may prevent serious maternal sequelae including death. Heparin remains the anticoagulant of choice during pregnancy because of its proven safety for both the patient and the fetus. It is likely that long-term anticoagulation is necessary when venous thromboembolism occurs antepartum, although the most efficacious regimen has yet to be established. There is some concern about the prolonged use of heparin during pregnancy, particularly regarding the risk of osteopenia.

Digital examination compared to trans-perineal ultrasound for the evaluation of anal sphincter repair

Objective: To assess the adequacy of a third‐ or a fourth‐degree laceration repair by comparing digital and trans‐perineal ultrasound measurements. Method: During a 4‐year period, 34 subjects without prior history of anal sphincter injury or fecal incontinence underwent ultrasound measurements of external anal sphincter muscle diameter and perineal length, which were compared to measurements obtained by digital examination. Results: Pearsons correlation coefficients for comparing the digital external sphincter examination to trans‐perineal ultrasonography, and the digital perineal examination to trans‐perineal ultrasonography were 0.88 and 0.40, respectively. Patients (n=4/34) whose external sphincter was identified as less than 1 cm by digital examination were found to have an external sphincter diameter of less than 1 cm by trans‐perineal ultrasound. Conclusion: The digital perineum examination is a reliable method of measuring the external sphincter thickness and perineal body length immediately after primary repair.

Symptomatic cecal perforation by an intrauterine device with appendectomy removal.

BACKGROUND: The intrauterine device is the most used contraceptive in the world, but it is not without risk of perforation of intra-abdominal organs. We report a perforation of the cecum and removal via appendectomy. CASE: A 23-year-old woman developed chronic abdominal pain after insertion of an intrauterine device 8 weeks postpartum. At laparoscopy, the device was found in the cecum and removed via appendectomy. CONCLUSION: Perforation is more common in the immediate postpartum state. An alternate method of removal via appendectomy proved useful.