Ting-Chung Pun

Tranexamic acid-associated necrosis and intralesional thrombosis of uterine leiomyomas: A clinicopathologic study of 147 cases emphasizing the importance of drug-induced necrosis and early infarcts in leiomyomas

IntroductionWomen with menorrhagia have increased levels of plasminogen activators in the endometrium. Tranexamic acid (cyklokapron), an antifibrinolytic agent, is commonly prescribed worldwide to women with menorrhagia, including those with fibroids. Necrosis in uterine leiomyomas may be associated with pregnancy, and progestogen or oral contraceptive use but its association with tranexamic acid has not been investigated. Four hundred ninety patients with uterine leiomyomas in 2004 and 2005 were reviewed. Their ages ranged from 22 to 86 (mean 47.2). One hundred forty-seven (30%) were treated with tranexamic acid. ResultsInfarct-type necrosis was observed in the leiomyomas of 38 patients, 22 of whom had tranexamic acid (15%) whereas the remaining 16 had no drug exposure (4.7%) (odds ratio=3.60; 95% confidence interval: 1.83-6.07; P=0.0003). Two patients who took the drug less than 2 weeks before surgery had early infarcts with appearance resembled coagulative type necrosis. Eleven of the 22 cases of drug-induced necrotic leiomyoma (50%) also showed intralesional thrombus formation, and 4 showed organization of the thrombi. ConclusionsInfarct-type necrosis and thrombosis of leiomyoma was more commonly observed in patients treated with tranexamic acid. Although the drug is effective for menorrhagia, clinicians should be aware of the possible complications associated with leiomyoma necrosis such as pain and fever. Distinguishing between types of necrosis may not always be straightforward particularly in early infarcts when the reparative connective tissue reaction between the viable and necrotic cells is not well-developed, resulting in an appearance similar to coagulative necrosis. When the overall gross and microscopic features of a leiomyoma with coagulative necrosis favor a benign lesion, the drug history should be reviewed so that this type of early and healing infarct-type necrosis is considered as the underlying cause of the apparent coagulative necrosis. This may otherwise result in a diagnosis of smooth muscle tumor of uncertain malignant potential, leading to prolonged follow-up and unnecessary further surgical intervention.

Fetal cerebral doppler studies as a predictor of perinatal outcome and subsequent neurologic handicap

Objective To study the use of middle cerebral arterial Doppler findings in a group of high-risk fetuses as a predictor of adverse perinatal outcome, including subsequent neurologic handicap. Methods A group of very high-risk fetuses was recruited over a 2-year period for study. Weekly fetal biometries and Doppler studies of the umbilical artery and middle cerebral arteries were carried out until delivery. Main outcome indices analyzed included birth weight ratio (ratio of observed birth weight to mean birth weight for gestation), days of ventilator requirement, neonatal intracranial hemorrhage or periventricular leukomalacia, necrotizing enterocolitis, and follow-up data on major neurologic handicap and death. Results Seventy-four patients were recruited. One hundred thirty-four sets of examinations were made and prospective follow-up data were available for up to 2 years. The ratio of the umbilical and middle cerebral arterial resistance index was found to be inversely proportional to the birth weight ratio. Fetuses who had a high prenatal umbilical-cerebral Doppler ratio had significantly lower birth weight ratios than those with normal findings (0.72 versus 0.92; P < .001). The ratio was a more sensitive marker for growth restriction (sensitivity 78%) than conventional fetal biometry and umbilical arterial systolic-diastolic ratio. However, fetuses with high ratios did not have higher incidences of perinatal complications or subsequent neurologic handicap. Conclusion Prenatal cerebral vasodilation is a sensitive marker for growth restriction and it seems to be a physiologic response to hypoxia. Fetuses with intrauterine cerebral vasodilation do not have increased risk for subsequent gross neurologic damage.

Anaemia in pregnancy--is the current definition meaningful?

OBJECTIVE To determine if the current definition of antenatal anaemia (haemoglobin < 10 g/dl) has any clinical significance. STUDY DESIGN A retrospective study on all singleton deliveries over a 3-year period in two teaching hospitals under one university department was conducted by the extraction of data from a computer database. The major pregnancy complications and perinatal outcome were compared between mothers with and without anaemia and adjusted for parity. RESULTS The incidence of multiparity was significantly higher in the 817 anaemia patients compared to the 10125 non-anaemia patients, but there was no difference in the incidence of other major antenatal complications, type of labour or mode of delivery, incidence of preterm delivery, or perinatal mortality or morbidity, after adjusting for parity. Among the anaemia patients, those with thalassaemia trait (54.8%) had a significantly higher incidence of gestational glucose intolerance but the incidences of other complications and the perinatal outcome were similar to the iron deficiency patients. CONCLUSION Antenatal anaemia, defined as a maternal haemoglobin of < 10 g/dl, does not adversely affect pregnancy outcome. This raises the question of whether the diagnosis of anaemia should be redefined.

Successful conservative management of placenta previa accreta during cesarean section

A 39-year-old G5P3 woman with two previous lower segment cesarean deliveries was diagnosed with anterior placenta previa accreta. Ultrasound examination showed the absence of a normal subplacental sonolucent layer and the anterior lower uterine wall was deeply invaded by the placenta. Abnormal blood vessels connecting from placenta to the serosa were seen on color Doppler imaging (Fig. 1). Because of her strong desire to retain the uterus, an anecdotal approach was decided. The placenta was left in-situ with the cord tied close to its insertion during emergency lower segment cesarean section at 36 weeks, and a 2.9 kg healthy baby was delivered. She was given three units of blood and prophylactic broad-spectrum antibiotics. MRI scan on Day 10 showed that the accreta involved also part of posterior myometrium (Fig. 2). Follow-up scans showed gradual shrinkage of the placenta with reduced vascularity and a piece of grayish-white tissue was passed out together with fresh vaginal bleeding on day 56. Her menstruation returned 5 months after delivery. A scan at 6 months showed complete involution of the uterus with echogenic foci in the myometrium suggestive of calcified placental remnant (Fig. 3).

Umbilical artery doppler velocimetry compared with fetal heart rate monitoring as a labor admission test

A total of 155 patients admitted in early labor to the delivery unit of the University of Hong Kong were recruited into a study comparing the value of umbilical artery Doppler velocimetry and fetal heart rate (FHR) monitoring in early labor as an admission test. FHR monitoring for 30 min was recorded on admission, and umbilical A/B ratio was simultaneously performed. The FHR tracing was scored according to the Lyons score by a third independent observer after delivery. Outcome variables studied included small for gestational age (SGA), intrapartum FHR abnormalities, operative deliveries for fetal distress, umbilical cord pH, Apgar scores, admission into the special care baby unit, and a combination of the variables. It was found that at cut-off values of Lyons score < 7 and umbilical A/B ratio > 2.6 at term, about 19% of cases were abnormal for either tests, with only a few cases of overlap. Umbilical A/B ratio was found to be significantly correlated with SGA. The sensitivity and positive predictive values were, however, low. Both tests were relatively poor predictors for most of the outcome variables studied. Interestingly, FHR monitoring did not seem to have any advantage over Doppler velocimetry as a labor admission test. Further larger scale studies to evaluate their usefulness in medium and low risk populations are indicated.

A prospective randomized trial to compare immediate and 24‐hour delayed catheter removal following total abdominal hysterectomy

Objective. To assess whether early or immediate removal of a 12F in‐dwelling Foley catheter after total abdominal hysterectomy affects the level of subjective pain assessment postoperatively. Design. Randomized controlled trial. Setting. University Hospital. Population. Seventy women underwent total abdominal hysterectomies for various benign gynecological diseases. Methods. Women were randomized to have the urinary catheter removed in the operating room after the surgical procedure or to have it removed on postoperative day 1. Main outcome measures. The primary outcome was patients’ pain assessment and the secondary outcomes were rate of re‐catheterization and symptomatic urinary tract infection. Results. There was no difference in the pain assessment between the two groups. A significantly higher number of urinary retention episodes requiring re‐catheterization were found in the immediate removal group compared with the delayed removal group (20 vs. 0%; p= 0.011). The incidence of symptomatic urinary tract infection did not differ between the two groups. Conclusions. There are pros and cons regarding the policy of one‐day in‐dwelling catheterization compared to immediate catheter removal.

Left upper quadrant approach in gynecologic laparoscopic surgery

Objective. To review the use of the left upper quadrant approach in benign gynecologic laparoscopic surgery over a nine‐year period. Design. Retrospective review. Setting. University‐affiliated hospital. Population. Women who underwent laparoscopic gynecologic surgery the upper quadrant approach between January 2002 and December 2010. Methods. Medical records were reviewed. Main outcome measures. Demographic data, past surgical histories, indications for surgery and the use of the left upper quadrant approach, intraoperative findings, diagnosis and any complications. Results. 143 patients were identified, accounting for 4.9% of all gynecologic laparoscopic surgery. The indications for using the left upper quadrant approach were: previous open abdominal surgery (113, 79.0%), surgery in the second trimester of pregnancy (16, 11.1%), presence of large pelvic mass (9, 6.2%), previous transverse rectus abdominis myocutaneous flap for breast reconstruction (3, 2.0%), previous periumbilical hernia repair (1, 0.6%) and previous laparoscopic umbilical wound dehiscence (1, 0.6%). In women with previous abdominal surgery, the overall incidence of adhesions between omentum and/or bowel to the anterior abdominal wall in the umbilical region was 58.4%. Twelve (8.3%) patients required conversion to laparotomy. One patient had subcutaneous surgical emphysema over the left upper quadrant entry site. Conclusions. The left upper quadrant approach is an effective, safe and easy technique for peritoneal cavity access in women undergoing laparoscopic gynecologic surgery and should be considered in women with risk factors of periumbilical adhesions and in the presence of a large pelvic mass.

Continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries after the study period: Was this the Hawthorne effect?

BACKGROUND The incidence of birth trauma and birth asphyxia related to instrumental deliveries in our obstetric unit was high (2.8%) in 1998-1999. A study was performed in 2000 to identify the risk factors. Unexpectedly, the incidence (0.6%) was reduced significantly during the study period. We attributed this phenomenon to the famous Hawthorne effect (tendency to improve performance because of awareness of being studied). OBJECTIVES The objectives were to study whether there is a continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period (2001-2003) and to investigate the presence of underlying confounding factors apart from the Hawthorne effect. METHOD To compare the hospital obstetric statistics among the pre-study period (1998-1999), the study period (2000) and the post-study period (2001-2003), in particular the incidence of birth trauma and birth asphyxia related to instrumental deliveries, the instrumental delivery rate, the overall Caesarean section rate, the Caesarean section rate for no progress of labour, the incidence of failed instrumental delivery, the incidence of attempted instrumental delivery in the operating theatre, and incidence of direct second-stage Caesarean sections. RESULTS The incidence of birth trauma and birth asphyxia related to instrumental deliveries (0.6%) during the study period (2000) was significantly lower than that (2.8%) during the pre-study period (1998-1999; RR 0.27, 95% CI 0.11-0.70). This phenomenon continued into the post-study period (2001-2003) when the incidence of 1.0% was similarly lower than that in the pre-study period (RR 0.35, 95% CI 0.20-0.64). The instrumental delivery rate decreased further in the post-study period (13.5%) compared with those in the study (16.6%) and pre-study (19.5%) periods (RR 0.81, 95% CI 0.75-0.89 and RR 0.69, 95% CI 0.65-0.74, respectively). There was a marked increase in the direct second-stage Caesarean section rate in the post-study period (7.1%) compared to those in the study (0.4%) and pre-study (0.7%) periods (RR 15.9, 95% CI 5.05-49.73 and RR 9.77, 95% CI 5.28-18.08, respectively). CONCLUSION A change in obstetric practice was identified that may explain the continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period.

Surgical Management of Adnexal Masses in Pregnancy

Surgical management of adnexal masses during pregnancy appears to have favorable outcomes for both mother and fetus.

Positive predictive value of endometrial polyps in Pipelle aspiration sampling: a histopathological study of 195 cases.

OBJECTIVE To estimate the positive predictive value of Pipelle endometrial sampling in detecting the presence of an underlying endometrial polyp. The secondary objective is to examine the histologic features that can predict the presence of endometrial polyps. STUDY DESIGN This is a retrospective case review study. 195 women who had undergone diagnostic hysteroscopy and/or polypectomy were identified in a University teaching hospital. All patients had a prior polyp diagnosis in the Pipelle endometrial sample. The histology of these samples were compared and analyzed with subsequent DH findings and final hysteroscopic biopsies. Slides were reviewed by 2 gynaecological pathologists. RESULTS 162 women were premenopausal (mean age 46.1, SD=4.6) and 33 were postmenopausal (mean age 57.2, SD=8.1). The commonest indication for a Pipelle endometrial sampling was abnormal uterine bleeding. Presence of polyp was confirmed by DH in 56.3% (111/195) cases. Of these, 81.1% (90/111) were confirmed histologically. The positive predictive value of detection of polyps in Pipelle endometrial samples for premenopausal and postmenopausal women was 53.7% and 72.7%, respectively (p=.05). The most reliable histologic features that can predict the presence of an underlying polyp was fibrous stroma (p=.01) and focal glandular clustering (p=.03). The prevalence of endometrial hyperplasia and carcinoma in women who was confirmed to have polyp was 11.7% (13/111). CONCLUSION The positive predictive value of Pipelle endometrial samples in detecting endometrial polyps was 56.3%. It was higher in the postmenopausal women (72.7%) compared to premenopausal women (53.7%). The prevalence of endometrial hyperplasia and carcinoma in women who was confirmed to have polyp was consistent with the rate reported in the literature. Using ultrasonography as an adjunct maybe helpful in diagnosing endometrial polyps.