Pub Date : 2023-10-01DOI: 10.1097/01.ogx.0000993684.04252.86
Gabriella M. Rustia, Michael G. Baracy, Emilee Khair, Karen H. Hagglund, Muhammad Faisal Aslam
ABSTRACT Pain after surgery may have different origins, such as incisions, affected viscera, surgical positioning, or peritoneal irritation from insufflation. Shoulder pain after gynecological laparoscopic surgery is a common concern thought to be associated with peritoneal irritation. Decreasing this pain is therefore a target for improvement of analgesic requirements and overall postoperative pain. This study aimed to determine changes in postoperative pain, surgical safety, and analgesic use via decreased insufflation pressures. The study was designed as a single-blinded, randomized clinical trial at a singular medical center within the United States where surgical treatment took place for pelvic organ prolapse via robotic-assisted sacrocolpopexy. Included were women 18 years or older who were able to complete the visual analog scale without assistance and who underwent scheduled robotic-assisted sacrocolpopexy. After inclusion, participants were randomized in a 1:1 ratio to undergo robotic-assisted sacrocolpopexy with peritoneal insufflation pressure at either 12 mm Hg (experimental) or 15 mm Hg (standard). Surgeries were performed by a single board-certified urogynecologist and resident assistant using a standard technique, the DaVinci Xi system, and an 8-mm AirSeal assist port. Surgeons and assisting OR professionals were not blinded to insufflation pressure. On the first postoperative day, all participants were asked to rate pain via a visual analog scale, as well as at 2 weeks postoperatively (with the addition of a PGI-I questionnaire). The 2-week surveys were collected by the principal investigator or primary surgeon (unblinded). A Likert scale of 0 to 10 was used to rate the highest preoperative and postoperative pain in the postanesthesia care unit. At the time of surgery, preoperative analgesia and opioid use were verified with active prescription records. After surgery, data were recorded for operative time, analgesic doses, conversion to laparotomy or increased insufflation pressure, additionally performed procedures, estimated blood loss, and length of stay. Enrollment occurred from April 27, 2021, to May 17, 2022, with final follow-up being completed on June 1, 2022. A total of 80 participants were enrolled, with 41 in the experimental insufflation group, and 39 in the standard insufflation group. Baseline differences did not exist between groups for prior abdominal surgeries, medical comorbidities, leading edge of prolapse, age, or body mass index. Although median preoperative pain was recorded as zero for both groups, the standard insufflation group did report a statistically higher pain level in the postoperative period. Furthermore, women in the experimental/lower insufflation group used statistically fewer morphine milliequivalents immediately after surgery as well as after discharge. There were no apparent operative problems significantly associated with lower insufflation pressures, as operative time, estimated blood loss,
{"title":"Pain With Differing Insufflation Pressures During Robotic Sacrocolpopexy: A Randomized Controlled Trial","authors":"Gabriella M. Rustia, Michael G. Baracy, Emilee Khair, Karen H. Hagglund, Muhammad Faisal Aslam","doi":"10.1097/01.ogx.0000993684.04252.86","DOIUrl":"https://doi.org/10.1097/01.ogx.0000993684.04252.86","url":null,"abstract":"ABSTRACT Pain after surgery may have different origins, such as incisions, affected viscera, surgical positioning, or peritoneal irritation from insufflation. Shoulder pain after gynecological laparoscopic surgery is a common concern thought to be associated with peritoneal irritation. Decreasing this pain is therefore a target for improvement of analgesic requirements and overall postoperative pain. This study aimed to determine changes in postoperative pain, surgical safety, and analgesic use via decreased insufflation pressures. The study was designed as a single-blinded, randomized clinical trial at a singular medical center within the United States where surgical treatment took place for pelvic organ prolapse via robotic-assisted sacrocolpopexy. Included were women 18 years or older who were able to complete the visual analog scale without assistance and who underwent scheduled robotic-assisted sacrocolpopexy. After inclusion, participants were randomized in a 1:1 ratio to undergo robotic-assisted sacrocolpopexy with peritoneal insufflation pressure at either 12 mm Hg (experimental) or 15 mm Hg (standard). Surgeries were performed by a single board-certified urogynecologist and resident assistant using a standard technique, the DaVinci Xi system, and an 8-mm AirSeal assist port. Surgeons and assisting OR professionals were not blinded to insufflation pressure. On the first postoperative day, all participants were asked to rate pain via a visual analog scale, as well as at 2 weeks postoperatively (with the addition of a PGI-I questionnaire). The 2-week surveys were collected by the principal investigator or primary surgeon (unblinded). A Likert scale of 0 to 10 was used to rate the highest preoperative and postoperative pain in the postanesthesia care unit. At the time of surgery, preoperative analgesia and opioid use were verified with active prescription records. After surgery, data were recorded for operative time, analgesic doses, conversion to laparotomy or increased insufflation pressure, additionally performed procedures, estimated blood loss, and length of stay. Enrollment occurred from April 27, 2021, to May 17, 2022, with final follow-up being completed on June 1, 2022. A total of 80 participants were enrolled, with 41 in the experimental insufflation group, and 39 in the standard insufflation group. Baseline differences did not exist between groups for prior abdominal surgeries, medical comorbidities, leading edge of prolapse, age, or body mass index. Although median preoperative pain was recorded as zero for both groups, the standard insufflation group did report a statistically higher pain level in the postoperative period. Furthermore, women in the experimental/lower insufflation group used statistically fewer morphine milliequivalents immediately after surgery as well as after discharge. There were no apparent operative problems significantly associated with lower insufflation pressures, as operative time, estimated blood loss,","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"50 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136010003","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/01.ogx.0000993692.30944.ce
William Burke, Joel Barkley, Emily Barrows, Rebecca Brooks, Kimberly Gecsi, Kathryn Huber-Keener, Myrlene Jeudy, Shirley Mei, Julia Sage O’Hara, David Chelmow
ABSTRACT Ovarian cancer has the 17th highest incidence among all cancers in the United States; however, it is the deadliest gynecologic cancer and the fifth most common cause of cancer-related death in women in the United States. The Centers for Disease Control and Prevention funded the American College of Obstetricians and Gynecologists (ACOG) to create educational materials for clinicians on the early diagnosis and prevention of gynecologic cancers. This article is an evidence summary based on ACOG's extensive literature review on the early diagnosis and prevention of ovarian cancer. An expert panel was recruited from the Society for Academic Specialists in General Obstetrics and Gynecology and the Society of Gynecologic Oncology to review and summarize evidence from articles published between January 2000 and October 2021. Topics used to frame the literature review included the epidemiology of ovarian cancer, risk factors, prevention and risk reduction, screening strategies and early detection, health disparities, diagnosis and care coordination by primary care providers, and special considerations. The Ovarian Cancer Evidence Review Conference occurred in February 2022 where the expert panel and stakeholder professional and patient advocacy organizations discussed their findings and drafted summaries to develop educational materials. Review of the epidemiology revealed that in 2022 there were 19,880 new cases of ovarian cancer, 12,810 women died of ovarian cancer, 5-year survival is 49.7% and correlates strongly with stage at diagnosis, and fewer than 10% of women with stage 1 disease will have recurrence. Risk factors for ovarian cancer include older age, inactivity, nulliparity, early menarche, late menopause, postmenopausal hormone therapy, genetic mutations such as BRCA1 and BRCA2 , and endometriosis. Risk-reducing bilateral salpingo-oophorectomy reduces incidence of ovarian cancer by 80% in BRCA1 and BRCA2 carriers (95% confidence interval, 0.12–0.39) and is recommended by ACOG for women at increased risk of ovarian cancer. Contraception, physical activity, and lactation may help reduce the risk of ovarian cancer. The most common methods studied for screening include transvaginal ultrasonography, bimanual palpation, and measuring tumor marker CA-125. The Risk of Ovarian Cancer Algorithm uses CA-125 and transvaginal ultrasound to estimate the risk of ovarian cancer based on age and change in CA-125; however, it is still being studied, and no established screening method exists for asymptomatic women. Several organizations including ACOG support identifying women at high risk and subsequent genetic counseling. Symptoms of ovarian cancer are nonspecific and include abdominal distention and pain, and while workup should include ultrasonography and CA-125 measurement, no high-quality studies have compared imaging, biomarkers, risk algorithms, or multimodal risk assessment tools for the primary evaluation of patients with high-risk symptoms. R
{"title":"Executive Summary of the Ovarian Cancer Evidence Review Conference","authors":"William Burke, Joel Barkley, Emily Barrows, Rebecca Brooks, Kimberly Gecsi, Kathryn Huber-Keener, Myrlene Jeudy, Shirley Mei, Julia Sage O’Hara, David Chelmow","doi":"10.1097/01.ogx.0000993692.30944.ce","DOIUrl":"https://doi.org/10.1097/01.ogx.0000993692.30944.ce","url":null,"abstract":"ABSTRACT Ovarian cancer has the 17th highest incidence among all cancers in the United States; however, it is the deadliest gynecologic cancer and the fifth most common cause of cancer-related death in women in the United States. The Centers for Disease Control and Prevention funded the American College of Obstetricians and Gynecologists (ACOG) to create educational materials for clinicians on the early diagnosis and prevention of gynecologic cancers. This article is an evidence summary based on ACOG's extensive literature review on the early diagnosis and prevention of ovarian cancer. An expert panel was recruited from the Society for Academic Specialists in General Obstetrics and Gynecology and the Society of Gynecologic Oncology to review and summarize evidence from articles published between January 2000 and October 2021. Topics used to frame the literature review included the epidemiology of ovarian cancer, risk factors, prevention and risk reduction, screening strategies and early detection, health disparities, diagnosis and care coordination by primary care providers, and special considerations. The Ovarian Cancer Evidence Review Conference occurred in February 2022 where the expert panel and stakeholder professional and patient advocacy organizations discussed their findings and drafted summaries to develop educational materials. Review of the epidemiology revealed that in 2022 there were 19,880 new cases of ovarian cancer, 12,810 women died of ovarian cancer, 5-year survival is 49.7% and correlates strongly with stage at diagnosis, and fewer than 10% of women with stage 1 disease will have recurrence. Risk factors for ovarian cancer include older age, inactivity, nulliparity, early menarche, late menopause, postmenopausal hormone therapy, genetic mutations such as BRCA1 and BRCA2 , and endometriosis. Risk-reducing bilateral salpingo-oophorectomy reduces incidence of ovarian cancer by 80% in BRCA1 and BRCA2 carriers (95% confidence interval, 0.12–0.39) and is recommended by ACOG for women at increased risk of ovarian cancer. Contraception, physical activity, and lactation may help reduce the risk of ovarian cancer. The most common methods studied for screening include transvaginal ultrasonography, bimanual palpation, and measuring tumor marker CA-125. The Risk of Ovarian Cancer Algorithm uses CA-125 and transvaginal ultrasound to estimate the risk of ovarian cancer based on age and change in CA-125; however, it is still being studied, and no established screening method exists for asymptomatic women. Several organizations including ACOG support identifying women at high risk and subsequent genetic counseling. Symptoms of ovarian cancer are nonspecific and include abdominal distention and pain, and while workup should include ultrasonography and CA-125 measurement, no high-quality studies have compared imaging, biomarkers, risk algorithms, or multimodal risk assessment tools for the primary evaluation of patients with high-risk symptoms. R","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"64 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136010152","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1097/01.ogx.0000979660.79986.29
Abdoulaye Ouattara, Noemie Resseguier, Aline Cano, Pascale de Lonlay, Jean-Baptiste Arnoux, Anais Brassier, Manuel Schiff, Samia Pichard, Alexandre Fabre, Celia Hoebeke, Nathalie Guffon, Alain Fouilhoux, Pierre Broué, Guy Touati, Dries Dobbelaere, Karine Mention, Francois Labarthe, Marine Tardieu, Loïc de Parscau, Francois Feillet, Chrystele Bonnemains, Alice Kuster, Philippe Labrune, Magalie Barth, Lena Damaj, Delphine Lamireau, Julie Berbis, Pascal Auquier, Brigitte Chabrol
ABSTRACT Inborn errors of metabolism (IEMs) requiring a restricted diet can have a significant impact on both children and their caregivers. Previous research has shown conflicting findings in the quality of life (QoL) of caregivers specifically, as many factors can influence daily interactions: home care demands, the potential for acute health crises and hospitalization, dietary constraints, medications, and others. Influencing factors have previously been reported to include emotional, adaptive, and socioeconomic factors, and previous research has varied greatly in sample characteristics, methods of collecting data and measuring QoL, and methods of analysis. This study was performed to clarify previous findings and provide a clearer picture of QoL in parents of children with IEMs requiring a restricted diet compared with the general population based on parent self-report. The final analysis included 785 parents of 578 children with IEMs requiring a restricted diet. Quality of life was assessed using the World Health Organization Quality of Life–BREF and was compared with age- and sex-matched control subjects from the general population. Parents of children with IEMs requiring a restricted diet in this study population experienced a significantly lower QoL in the areas of physical health (mean, −6.09 [SD, 15.01]) and social relationships (mean, −6.82 [SD, 17.71]), as well as a significantly higher QoL in psychological health (mean, +3.10 [SD, 14.25]). Multivariate models were examined to determine factors responsible for these differences in QoL; parental anxiety was negatively associated with all QoL domains. Other factors negatively associated with at least 1 domain included being a father (physical health and social relationships), older parent (physical and psychological health), having an education higher than high school (psychological health), and using more social support–seeking coping strategies (physical health and environment). Factors positively associated with at least 1 domain included having an education level higher than high school (environment), being a working parent (physical and psychological health, environment), and using more positive thinking coping strategies (psychological health). Child-related factors negatively associated with parental QoL included having at least 1 disease complication (social relationships and environment) and a higher number of hospital medical providers (physical health). A child being older positively impacted parental QoL in the environment domain. It is not uncommon for parents of children with chronic diseases or impairments to experience a lower QoL. In this study, some aspects of QoL were enhanced by the demands of caregiving, and some were negatively impacted. Discrepancies in previous literature may be partially attributed to varying tests, variable characteristics within a sample (eg, longer time since diagnosis), or differences in analysis methods. The results in this study indicate a
需要限制饮食的先天性代谢错误(IEMs)可能对儿童及其照顾者产生重大影响。先前的研究在护理人员的生活质量(QoL)方面显示了相互矛盾的发现，因为许多因素会影响日常互动:家庭护理需求，急性健康危机和住院治疗的可能性，饮食限制，药物治疗等。影响因素包括情绪、适应性和社会经济因素，以往的研究在样本特征、收集数据和测量生活质量的方法以及分析方法方面存在很大差异。本研究旨在澄清先前的研究结果，并根据父母的自我报告，对需要限制饮食的IEMs儿童的父母的生活质量与一般人群的生活质量提供更清晰的了解。最终的分析包括785名父母的578名需要限制饮食的IEMs儿童。使用世界卫生组织生活质量(Quality of life - bref)评估生活质量，并与来自一般人群的年龄和性别匹配的对照受试者进行比较。在本研究人群中，需要限制饮食的IEMs儿童的父母在身体健康(平均值，- 6.09 [SD, 15.01])和社会关系(平均值，- 6.82 [SD, 17.71])方面的生活质量显著较低，而在心理健康方面的生活质量显著较高(平均值，+3.10 [SD, 14.25])。我们检验了多变量模型，以确定造成这些生活质量差异的因素;父母焦虑与生活质量各域呈负相关。与至少1个领域负相关的其他因素包括:为人父亲(身体健康和社会关系)、父母年龄较大(身体和心理健康)、受教育程度高于高中(心理健康)以及使用更多寻求社会支持的应对策略(身体健康和环境)。与至少1个领域正相关的因素包括高中以上教育水平(环境)、有工作的父母(身心健康、环境)和使用更积极的思维应对策略(心理健康)。与儿童相关的因素与父母生活质量呈负相关，包括至少有一种疾病并发症(社会关系和环境)和更多的医院医疗服务提供者(身体健康)。孩子年龄的增大对父母的环境生活质量有积极影响。对于患有慢性疾病或损伤的儿童的父母来说，生活质量较低并不罕见。在本研究中，照顾需求对生活质量的某些方面有促进作用，而对某些方面则有负面影响。先前文献的差异可能部分归因于不同的测试，样本内的可变特征(例如，诊断后较长时间)或分析方法的差异。这项研究的结果表明，可能需要资源来支持需要限制饮食的iem儿童的父母。先前的文献显示，提供家庭医疗保健专业人员偶尔减轻父母的照顾责任，以及在类似情况下的父母支持团体的有效性。在所有领域中，父母焦虑都对生活质量产生负面影响，因此，针对减少父母焦虑的干预可能是改善生活质量的一种方法。父母对孩子的状况和照顾需求的适应可以解释生活质量与一般人群的某些方面的差异，但这些差异仍然需要解决，以提高生活质量。
{"title":"Individual and Family Determinants for Quality of Life in Parents of Children With Inborn Errors of Metabolism Requiring a Restricted Diet: A Multilevel Analysis Approach","authors":"Abdoulaye Ouattara, Noemie Resseguier, Aline Cano, Pascale de Lonlay, Jean-Baptiste Arnoux, Anais Brassier, Manuel Schiff, Samia Pichard, Alexandre Fabre, Celia Hoebeke, Nathalie Guffon, Alain Fouilhoux, Pierre Broué, Guy Touati, Dries Dobbelaere, Karine Mention, Francois Labarthe, Marine Tardieu, Loïc de Parscau, Francois Feillet, Chrystele Bonnemains, Alice Kuster, Philippe Labrune, Magalie Barth, Lena Damaj, Delphine Lamireau, Julie Berbis, Pascal Auquier, Brigitte Chabrol","doi":"10.1097/01.ogx.0000979660.79986.29","DOIUrl":"https://doi.org/10.1097/01.ogx.0000979660.79986.29","url":null,"abstract":"ABSTRACT Inborn errors of metabolism (IEMs) requiring a restricted diet can have a significant impact on both children and their caregivers. Previous research has shown conflicting findings in the quality of life (QoL) of caregivers specifically, as many factors can influence daily interactions: home care demands, the potential for acute health crises and hospitalization, dietary constraints, medications, and others. Influencing factors have previously been reported to include emotional, adaptive, and socioeconomic factors, and previous research has varied greatly in sample characteristics, methods of collecting data and measuring QoL, and methods of analysis. This study was performed to clarify previous findings and provide a clearer picture of QoL in parents of children with IEMs requiring a restricted diet compared with the general population based on parent self-report. The final analysis included 785 parents of 578 children with IEMs requiring a restricted diet. Quality of life was assessed using the World Health Organization Quality of Life–BREF and was compared with age- and sex-matched control subjects from the general population. Parents of children with IEMs requiring a restricted diet in this study population experienced a significantly lower QoL in the areas of physical health (mean, −6.09 [SD, 15.01]) and social relationships (mean, −6.82 [SD, 17.71]), as well as a significantly higher QoL in psychological health (mean, +3.10 [SD, 14.25]). Multivariate models were examined to determine factors responsible for these differences in QoL; parental anxiety was negatively associated with all QoL domains. Other factors negatively associated with at least 1 domain included being a father (physical health and social relationships), older parent (physical and psychological health), having an education higher than high school (psychological health), and using more social support–seeking coping strategies (physical health and environment). Factors positively associated with at least 1 domain included having an education level higher than high school (environment), being a working parent (physical and psychological health, environment), and using more positive thinking coping strategies (psychological health). Child-related factors negatively associated with parental QoL included having at least 1 disease complication (social relationships and environment) and a higher number of hospital medical providers (physical health). A child being older positively impacted parental QoL in the environment domain. It is not uncommon for parents of children with chronic diseases or impairments to experience a lower QoL. In this study, some aspects of QoL were enhanced by the demands of caregiving, and some were negatively impacted. Discrepancies in previous literature may be partially attributed to varying tests, variable characteristics within a sample (eg, longer time since diagnosis), or differences in analysis methods. The results in this study indicate a","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"54 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388490","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1097/ogx.0000000000001195
Hannah T. Ryles, Christopher X. Hong, Uduak U. Andy, Monique R. Farrow
ABSTRACT Ovarian torsion occurs when the ovary twists on its own supporting ligaments, resulting in ischemia and possible necrosis. This is a surgical emergency to restore adnexal perfusion, and even in the setting of a necrotic-appearing ovary, conservative management with detorsion alone does not increase postoperative complications compared with oophorectomy. Traditionally, oophorectomy was performed in these cases, and despite the new evidence supporting ovarian conservation, oophorectomy remains common. Despite updated guidelines by the American College of Obstetricians and Gynecologists (ACOG) in 2016, it is unclear to what extent practice patterns have changed in the years since. This retrospective cohort study aimed to describe the trend in surgical management of ovarian torsion between 2008 and 2020 and to describe the changes in management before and after the publication of the updated ACOG guidelines. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify women aged 18 to 50 years who underwent surgery for adnexal torsion between 2008 and 2020. Patients were classified as having undergone oophorectomy or ovarian conservation using ICD codes, and patients undergoing concurrent surgeries or procedures related to pregnancy or unrelated to adnexal torsion were excluded. Patients were then grouped into pre-ACOG guidelines (2008–2016) and post-ACOG guidelines (2017–2020). Patient demographics, clinical data, perioperative characteristics, and 30-day postoperative adverse events were queried and compared between year cohorts and surgical management groups. The primary outcome was proportion of oophorectomies, described as the number of oophorectomies over the total number of all torsion surgeries per year, with a 95% confidence interval (CI). Multivariable regression analysis was conducted to determine the odds of oophorectomy versus ovarian conservation between year cohorts while controlling for confounders. A total of 1791 patients were included in this study, with 402 (22.4%) in the 2008–2016 cohort and 1389 (77.6%) in the 2017–2020 cohort. Across both groups, 542 patients (30.3%) underwent ovarian conservation, and 1249 (69.7%) underwent oophorectomy. The overall proportion of oophorectomies was similar between the 2008–2016 and 2017–2020 cohorts (71.9% vs 69.1%; adjusted odds ratio, 0.94; 95% CI, 0.71–1.25). When evaluating the effects of time on odds of oophorectomy, a significant decrease in the odds of oophorectomy performed successively each year over the entire study period was found (average decrease, −1.6%/year; 95% CI, −3.0% to −0.22%), although the yearly successive decrease in the odds of oophorectomy remained similar before and after 2017. The median hospital length of stay was longer, and the hospital admission rates were high in the oophorectomy group compared with the ovarian conservation group. The results of this study demonstrate that 69.7% of surgeries for a
{"title":"Changing Practices in the Surgical Management of Adnexal Torsion: An Analysis of the National Surgical Quality Improvement Program Database","authors":"Hannah T. Ryles, Christopher X. Hong, Uduak U. Andy, Monique R. Farrow","doi":"10.1097/ogx.0000000000001195","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001195","url":null,"abstract":"ABSTRACT Ovarian torsion occurs when the ovary twists on its own supporting ligaments, resulting in ischemia and possible necrosis. This is a surgical emergency to restore adnexal perfusion, and even in the setting of a necrotic-appearing ovary, conservative management with detorsion alone does not increase postoperative complications compared with oophorectomy. Traditionally, oophorectomy was performed in these cases, and despite the new evidence supporting ovarian conservation, oophorectomy remains common. Despite updated guidelines by the American College of Obstetricians and Gynecologists (ACOG) in 2016, it is unclear to what extent practice patterns have changed in the years since. This retrospective cohort study aimed to describe the trend in surgical management of ovarian torsion between 2008 and 2020 and to describe the changes in management before and after the publication of the updated ACOG guidelines. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify women aged 18 to 50 years who underwent surgery for adnexal torsion between 2008 and 2020. Patients were classified as having undergone oophorectomy or ovarian conservation using ICD codes, and patients undergoing concurrent surgeries or procedures related to pregnancy or unrelated to adnexal torsion were excluded. Patients were then grouped into pre-ACOG guidelines (2008–2016) and post-ACOG guidelines (2017–2020). Patient demographics, clinical data, perioperative characteristics, and 30-day postoperative adverse events were queried and compared between year cohorts and surgical management groups. The primary outcome was proportion of oophorectomies, described as the number of oophorectomies over the total number of all torsion surgeries per year, with a 95% confidence interval (CI). Multivariable regression analysis was conducted to determine the odds of oophorectomy versus ovarian conservation between year cohorts while controlling for confounders. A total of 1791 patients were included in this study, with 402 (22.4%) in the 2008–2016 cohort and 1389 (77.6%) in the 2017–2020 cohort. Across both groups, 542 patients (30.3%) underwent ovarian conservation, and 1249 (69.7%) underwent oophorectomy. The overall proportion of oophorectomies was similar between the 2008–2016 and 2017–2020 cohorts (71.9% vs 69.1%; adjusted odds ratio, 0.94; 95% CI, 0.71–1.25). When evaluating the effects of time on odds of oophorectomy, a significant decrease in the odds of oophorectomy performed successively each year over the entire study period was found (average decrease, −1.6%/year; 95% CI, −3.0% to −0.22%), although the yearly successive decrease in the odds of oophorectomy remained similar before and after 2017. The median hospital length of stay was longer, and the hospital admission rates were high in the oophorectomy group compared with the ovarian conservation group. The results of this study demonstrate that 69.7% of surgeries for a","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388492","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1097/ogx.0000000000001201
Abigail Davenport, Yi Li, Emily Melvin, Arthur Arcaz, Lucie Lefbom, Cheryl B. Iglesia, Alexis A. Dieter
ABSTRACT Common issues after pelvic reconstructive surgery are incomplete bladder emptying and urinary retention, often resulting in placement of an indwelling transurethral Foley catheter, which then remains until a patient returns to the office. Catheterization is significantly distressing for women undergoing these procedures and burdensome due to travel to the office during the postoperative period. In addition, in-office voiding trials add to the workload of health care professionals and staff. A potential alternative is at-home self-discontinuation of the Foley catheter. This study's primary aim was the comparison of the rates of health care utilization (calls, messages, office visits, and emergency department [ED] visits) and postoperative complications within 30 days of surgery among patients with voiding trials on the day of surgery, versus those with Foley placement and void trials on postoperative day 1. Secondary objectives included identifying risk factors for unsuccessful voiding trials and exploring any complications associated with catheter self-discontinuation. This study was designed as a prospective observational cohort study at 1 academic institution and included outpatient women undergoing outpatient urogynecologic or minimally invasive gynecological surgery for benign indications between August 2021 and January 2022. Qualifying patients included cisgendered English-speaking women of at least 18 years of age who exhibited postoperative urinary retention on the day of surgery. Excluded were patients with any preoperative degree of urinary retention (defined as any observation of a postvoid residual more than 200 mL), known upper motor neuron disease, and patients undergoing surgeries with concomitant extra pelvic procedures or minor procedures not requiring a postoperative voiding trial. Based on the exploratory nature of this study, primarily for determining safety and feasibility, the convenience sample size of 50 was set, and patients were recruited at the time of their unsuccessful voiding trials on the day of surgery. On the day of surgery, medical staff performed voiding trials in the postoperative anesthesia care unit, backfilling the bladder with 200 mL of sterile fluid. The void trial was successful if this was followed by a patient void of at least 150–200 mL, otherwise the voiding trial was marked as unsuccessful. Unsuccessful trials resulted in the insertion of an indwelling Foley catheter, followed by verbal and written instruction for performing a home-based, patient-led catheter self-discontinuation at 6:00 am on postoperative day 1. Instructions for catheter removal included pictures and written information. After removal, if the patient failed to void 150 mL within 6 hours, they were instructed to return to the office for additional care. Perioperative data collected from charts included age, parity, body mass index, self-reported race, surgical location, smoking status, periprocedural antibiotics, operative i
{"title":"Assessing Health Care Utilization and Feasibility of Transurethral Catheter Self-Discontinuation","authors":"Abigail Davenport, Yi Li, Emily Melvin, Arthur Arcaz, Lucie Lefbom, Cheryl B. Iglesia, Alexis A. Dieter","doi":"10.1097/ogx.0000000000001201","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001201","url":null,"abstract":"ABSTRACT Common issues after pelvic reconstructive surgery are incomplete bladder emptying and urinary retention, often resulting in placement of an indwelling transurethral Foley catheter, which then remains until a patient returns to the office. Catheterization is significantly distressing for women undergoing these procedures and burdensome due to travel to the office during the postoperative period. In addition, in-office voiding trials add to the workload of health care professionals and staff. A potential alternative is at-home self-discontinuation of the Foley catheter. This study's primary aim was the comparison of the rates of health care utilization (calls, messages, office visits, and emergency department [ED] visits) and postoperative complications within 30 days of surgery among patients with voiding trials on the day of surgery, versus those with Foley placement and void trials on postoperative day 1. Secondary objectives included identifying risk factors for unsuccessful voiding trials and exploring any complications associated with catheter self-discontinuation. This study was designed as a prospective observational cohort study at 1 academic institution and included outpatient women undergoing outpatient urogynecologic or minimally invasive gynecological surgery for benign indications between August 2021 and January 2022. Qualifying patients included cisgendered English-speaking women of at least 18 years of age who exhibited postoperative urinary retention on the day of surgery. Excluded were patients with any preoperative degree of urinary retention (defined as any observation of a postvoid residual more than 200 mL), known upper motor neuron disease, and patients undergoing surgeries with concomitant extra pelvic procedures or minor procedures not requiring a postoperative voiding trial. Based on the exploratory nature of this study, primarily for determining safety and feasibility, the convenience sample size of 50 was set, and patients were recruited at the time of their unsuccessful voiding trials on the day of surgery. On the day of surgery, medical staff performed voiding trials in the postoperative anesthesia care unit, backfilling the bladder with 200 mL of sterile fluid. The void trial was successful if this was followed by a patient void of at least 150–200 mL, otherwise the voiding trial was marked as unsuccessful. Unsuccessful trials resulted in the insertion of an indwelling Foley catheter, followed by verbal and written instruction for performing a home-based, patient-led catheter self-discontinuation at 6:00 am on postoperative day 1. Instructions for catheter removal included pictures and written information. After removal, if the patient failed to void 150 mL within 6 hours, they were instructed to return to the office for additional care. Perioperative data collected from charts included age, parity, body mass index, self-reported race, surgical location, smoking status, periprocedural antibiotics, operative i","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"164 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1097/01.ogx.0000979652.08372.3b
Anna M. Frappaolo, Teresa C. Logue, Dena Goffman, Lisa M. Nathan, Jean-Ju Sheen, Maria Andrikopoulou, Timothy Wen, Mary E. D'Alton, Alexander M. Friedman
ABSTRACT Cesarean delivery is a method of improving outcomes for both mothers and neonates when there are medical complications to vaginal delivery. When used unnecessarily, however, it causes increased risks for adverse outcomes as a major surgery. Limited data and investigations have prevented some previous analyses of trends in cesarean deliveries, especially when classifying them as necessary or unnecessary. This study was designed to determine temporal trends in cesarean deliveries among low-risk patients over a 20-year period and to analyze trends in specific cesarean delivery indications. This study was designed as a repeated cross-sectional analysis among patients at low risk for cesarean delivery. The authors utilized the National Inpatient Sample data set, and then patients with conditions previously associated with an increased risk of cesarean delivery (eg, obesity) were excluded. Primary outcomes included temporal trends in the number of cesarean deliveries, as well as trends related to diagnoses of nonreassuring fetal status, labor arrest, or obstructed labor (including disproportion). Between 2000 and 2019, 40,517,867 eligible low-risk deliveries were identified. Of these, 4,885,716 were cesarean deliveries. The overall rate of cesarean delivery increased between 2000 and 2009 (from 9.7% to 13.9%) and then decreased between 2012 and 2019 (from 13% to 11.1%). The average annual percentage change (AAPC) from 2000 to 2005 was 6.4% (95% confidence interval [CI], 5.2%–7.6%), with a plateau from 2005 to 2009 (AAPC, 1.2%; 95% CI, −1.2% to 3.7%) and then a decrease from 2009 to 2019 (AAPC, −2.2%; 95% CI, −2.7% to −1.8%). Deliveries associated with the diagnosis of nonreassuring fetal status increased between 2000 and 2019 (AAPC, 2.1%; 95% CI, 1.7%–2.5%); those associated with labor arrest peaked in 2009 at 4.8% and then decreased to 2.7% in 2019 (AAPC 2009–2019, −5.6%; 95% CI, −6.6% to −4.6%). In contrast, cesarean deliveries due to obstructed labor continuously decreased from 2000 to 2019 (AAPC, −8.6%; 95% CI, −10.0% to −7.1%). After accounting for demographic and hospital characteristics, analysis showed that patients were at increased risk of cesarean delivery if they were between 35 and 39 years of age compared with the younger group of 25 to 29 years (adjusted odds ratio [aOR], 1.27; 95% CI, 1.25–1.28), if they delivered at a hospital in the South versus the Northeast (aOR, 1.11; 95% CI, 1.07–1.15), and if they were non-Hispanic Black versus non-Hispanic White (aOR, 1.23; 95% CI, 1.20–1.25). Overall trends showed increasing rates of cesarean delivery in the first 10 years of the study, but then decreasing rates for the final 10 years. Rates associated with diagnoses of nonreassuring fetal status increased over the study period, and those associated with labor arrest or obstruction decreased. The increase of cesarean delivery due to nonreassuring fetal status when compared with the overall trend of decreasing cesarean deliveries indica
{"title":"Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000–2019","authors":"Anna M. Frappaolo, Teresa C. Logue, Dena Goffman, Lisa M. Nathan, Jean-Ju Sheen, Maria Andrikopoulou, Timothy Wen, Mary E. D'Alton, Alexander M. Friedman","doi":"10.1097/01.ogx.0000979652.08372.3b","DOIUrl":"https://doi.org/10.1097/01.ogx.0000979652.08372.3b","url":null,"abstract":"ABSTRACT Cesarean delivery is a method of improving outcomes for both mothers and neonates when there are medical complications to vaginal delivery. When used unnecessarily, however, it causes increased risks for adverse outcomes as a major surgery. Limited data and investigations have prevented some previous analyses of trends in cesarean deliveries, especially when classifying them as necessary or unnecessary. This study was designed to determine temporal trends in cesarean deliveries among low-risk patients over a 20-year period and to analyze trends in specific cesarean delivery indications. This study was designed as a repeated cross-sectional analysis among patients at low risk for cesarean delivery. The authors utilized the National Inpatient Sample data set, and then patients with conditions previously associated with an increased risk of cesarean delivery (eg, obesity) were excluded. Primary outcomes included temporal trends in the number of cesarean deliveries, as well as trends related to diagnoses of nonreassuring fetal status, labor arrest, or obstructed labor (including disproportion). Between 2000 and 2019, 40,517,867 eligible low-risk deliveries were identified. Of these, 4,885,716 were cesarean deliveries. The overall rate of cesarean delivery increased between 2000 and 2009 (from 9.7% to 13.9%) and then decreased between 2012 and 2019 (from 13% to 11.1%). The average annual percentage change (AAPC) from 2000 to 2005 was 6.4% (95% confidence interval [CI], 5.2%–7.6%), with a plateau from 2005 to 2009 (AAPC, 1.2%; 95% CI, −1.2% to 3.7%) and then a decrease from 2009 to 2019 (AAPC, −2.2%; 95% CI, −2.7% to −1.8%). Deliveries associated with the diagnosis of nonreassuring fetal status increased between 2000 and 2019 (AAPC, 2.1%; 95% CI, 1.7%–2.5%); those associated with labor arrest peaked in 2009 at 4.8% and then decreased to 2.7% in 2019 (AAPC 2009–2019, −5.6%; 95% CI, −6.6% to −4.6%). In contrast, cesarean deliveries due to obstructed labor continuously decreased from 2000 to 2019 (AAPC, −8.6%; 95% CI, −10.0% to −7.1%). After accounting for demographic and hospital characteristics, analysis showed that patients were at increased risk of cesarean delivery if they were between 35 and 39 years of age compared with the younger group of 25 to 29 years (adjusted odds ratio [aOR], 1.27; 95% CI, 1.25–1.28), if they delivered at a hospital in the South versus the Northeast (aOR, 1.11; 95% CI, 1.07–1.15), and if they were non-Hispanic Black versus non-Hispanic White (aOR, 1.23; 95% CI, 1.20–1.25). Overall trends showed increasing rates of cesarean delivery in the first 10 years of the study, but then decreasing rates for the final 10 years. Rates associated with diagnoses of nonreassuring fetal status increased over the study period, and those associated with labor arrest or obstruction decreased. The increase of cesarean delivery due to nonreassuring fetal status when compared with the overall trend of decreasing cesarean deliveries indica","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"2 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1097/ogx.0000000000001200
Katherine L. Woodburn, Angela S. Yuan, Michele Torosis, Kasey Roberts, Cecile A. Ferrando, Robert E. Gutman
ABSTRACT Although hysterectomy is traditionally performed at the time of pelvic organ prolapse repair for apical prolapse, women are increasingly interested in uterine preservation during pelvic organ prolapse surgical management. Approximately 36% to 60% of women indicate interest in uterine preservation, assuming equal efficacy. This has led to more uterus-preserving prolapse repairs (hysteropexy) being performed. After the removal of mesh products from the US market in 2019, transvaginal native tissue techniques are commonly used for hysteropexy. This study aimed to compare 6-week and 1-year anatomical failure rates between vaginal uterosacral ligament hysteropexy and sacrospinous ligament hysteropexy. Secondary outcomes included retreatment for prolapse, symptoms of recurrent prolapse, and perioperative adverse event rates in these 2 groups. This was a multicenter retrospective cohort study of patients undergoing vaginal uterosacral hysteropexy (USHP) or sacrospinous hysteropexy (SSHP) with a urogynecologist between January 1, 2015 and December 31, 2019. The pool of patient data was extrapolated from 4 geographically unique urban locations. Patient identification took place via querying the respective electronic medical records for the current procedural terminology codes of extraperitoneal colpopexy (57,282, SSHP) and intraperitoneal colpopexy (57,283, USHP). These operative reports underwent review in order to confirm that each patient had a uterus at time of surgery, underwent either USHP or SSHP, and did not undergo concurrent hysterectomy. Exclusion criteria included patients undergoing different types of uterine-preserving procedures or patients with less than 6 weeks of follow-up. The study included 147 patients undergoing SSHP and 114 having USHP over 5 years at the 4 clinical sites. The study population included mostly nonsmoking (179, 68.6%), White (224, 85.5%) patients with no history of pelvic surgery (142, 54.4%), and a mean Charleston Comorbidity Index score of 2. Overall, USHP patients exhibited a higher likelihood to undergo concurrent anterior repair, posterior repair, and incontinence procedures. The follow-up rate was 95% at 6 postoperative weeks with 4 anatomic failures. Not all patients had formal prolapse quantitation examinations recorded. However, only 32% (83/261) of patients were available for follow-up at 1 year after surgery when 10 patients met criteria for anatomic failure. Notably, although there was no statistically significant difference between failure rates for SSHP and USHP at either time point, there were roughly 3 times as many failures for USHP compared with SSHP, despite the SSHP representing a larger portion of the total cohort. At 1 year, however, 26 patients had undergone retreatment for prolapse, with 12 undergoing hysterectomy (11 due to prolapse, 1 due to colorectal cancer debulking). Of those undergoing hysterectomy, 10 were from the SSHP cohort, whereas 1 was from the USHP cohort. The 1 year ana
{"title":"Sacrospinous Fixation and Vaginal Uterosacral Suspension-Evaluation in Uterine Preservation Surgery","authors":"Katherine L. Woodburn, Angela S. Yuan, Michele Torosis, Kasey Roberts, Cecile A. Ferrando, Robert E. Gutman","doi":"10.1097/ogx.0000000000001200","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001200","url":null,"abstract":"ABSTRACT Although hysterectomy is traditionally performed at the time of pelvic organ prolapse repair for apical prolapse, women are increasingly interested in uterine preservation during pelvic organ prolapse surgical management. Approximately 36% to 60% of women indicate interest in uterine preservation, assuming equal efficacy. This has led to more uterus-preserving prolapse repairs (hysteropexy) being performed. After the removal of mesh products from the US market in 2019, transvaginal native tissue techniques are commonly used for hysteropexy. This study aimed to compare 6-week and 1-year anatomical failure rates between vaginal uterosacral ligament hysteropexy and sacrospinous ligament hysteropexy. Secondary outcomes included retreatment for prolapse, symptoms of recurrent prolapse, and perioperative adverse event rates in these 2 groups. This was a multicenter retrospective cohort study of patients undergoing vaginal uterosacral hysteropexy (USHP) or sacrospinous hysteropexy (SSHP) with a urogynecologist between January 1, 2015 and December 31, 2019. The pool of patient data was extrapolated from 4 geographically unique urban locations. Patient identification took place via querying the respective electronic medical records for the current procedural terminology codes of extraperitoneal colpopexy (57,282, SSHP) and intraperitoneal colpopexy (57,283, USHP). These operative reports underwent review in order to confirm that each patient had a uterus at time of surgery, underwent either USHP or SSHP, and did not undergo concurrent hysterectomy. Exclusion criteria included patients undergoing different types of uterine-preserving procedures or patients with less than 6 weeks of follow-up. The study included 147 patients undergoing SSHP and 114 having USHP over 5 years at the 4 clinical sites. The study population included mostly nonsmoking (179, 68.6%), White (224, 85.5%) patients with no history of pelvic surgery (142, 54.4%), and a mean Charleston Comorbidity Index score of 2. Overall, USHP patients exhibited a higher likelihood to undergo concurrent anterior repair, posterior repair, and incontinence procedures. The follow-up rate was 95% at 6 postoperative weeks with 4 anatomic failures. Not all patients had formal prolapse quantitation examinations recorded. However, only 32% (83/261) of patients were available for follow-up at 1 year after surgery when 10 patients met criteria for anatomic failure. Notably, although there was no statistically significant difference between failure rates for SSHP and USHP at either time point, there were roughly 3 times as many failures for USHP compared with SSHP, despite the SSHP representing a larger portion of the total cohort. At 1 year, however, 26 patients had undergone retreatment for prolapse, with 12 undergoing hysterectomy (11 due to prolapse, 1 due to colorectal cancer debulking). Of those undergoing hysterectomy, 10 were from the SSHP cohort, whereas 1 was from the USHP cohort. The 1 year ana","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388704","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
ABSTRACT A viable alternative to total abdominal hysterectomy is total laparoscopic hysterectomy (TLH), which offers abdominal route advantages for women in need of total hysterectomy for benign diseases. Fewer complications, faster recovery, and less pain are ensured by laparoscopy, although this method is not entirely devoid of pain. Reports from various authors indicate that up to 80% of laparoscopic surgery patients require opioid analgesia, which could increase hospital-stay duration and delay mobilization/recovery. Because of these statistics, opioid analgesic usages ought to be minimized, for the aforementioned reasons and also to prevent additional adverse effects. This study was performed to evaluate efficacy of reducing postoperative pain by infiltration of bupivacaine, a long-acting anesthetic agent, into the vaginal vault after TLH. This study was a randomized control trial designed as a 2-arm double-blinded study conducted at a North-Indian Apical Center in the Department of Obstetrics and Gynecology. After written informed consent from all patients, computer-generated randomization software placed them in 1 of 2 groups: group 1, the intervention group (received the infiltration of bupivacaine in the vaginal vault following TLH), or group 2 (the control group). The inclusion criteria were a uterine size of ≤12 weeks' pregnancy and patients requiring TLH with or without bilateral salpingo-oophorectomy for uterine size and benign conditions. Exclusion criteria were contraindication to any medication used by the study, presence of malignancy, history of multiple surgeries, and history of inflammatory disease. Postoperative pain outcome measured in both groups at 1, 3, 6, 12, and 24 hours via a visual analog score was the primary outcome. The secondary outcome was the need for rescue analgesia. A complete profile of each patient was created, using eligibility criteria, body mass index, and demographic profile, and a complete gynecological and physical examination was performed, along with preoperative investigations for fitness to general anesthesia. Per standard protocol, general anesthesia was administered for all surgeries. After vault closure, a fine-tipped aspiration needle was used to administer 10 mL of bupivacaine, which was infiltrated laparoscopically at 2 different locations, approximately 2–4 cm apart. The control group omitted this step. In the first 24 hours after operation, pain was treated using 1 g intravenous paracetamol every 6 hours. For the next 5 days, patients were given nonsteroidal anti-inflammatory drugs (diclofenac) 3 times daily for 5 days. Participants scaled their pain using the visual analog scale (VAS) score at the 1, 2, 6, 12, and 24 hours intervals postsurgery. Scores greater than 4 initiated the distribution of tramadol 50 mg intramuscular. Also recorded were the uterine weight, the operative time, complications, and the amount of operative bleeding. Group 1 patients exhibited VAS scores of less than 4
{"title":"Vaginal Vault Infiltration With Bupivacaine for Postoperative Pain Control After Total Laparoscopic Hysterectomy: A Randomized Control Trial","authors":"Kallol Kumar Roy, Poojitha Kalyani Kanikaram, Nilanchali Singh, Vimi Riwari, Rinchen Zangmo, Jyoti Meena, Anamika Das, Deepika Kashyap, Archana Minz","doi":"10.1097/ogx.0000000000001194","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001194","url":null,"abstract":"ABSTRACT A viable alternative to total abdominal hysterectomy is total laparoscopic hysterectomy (TLH), which offers abdominal route advantages for women in need of total hysterectomy for benign diseases. Fewer complications, faster recovery, and less pain are ensured by laparoscopy, although this method is not entirely devoid of pain. Reports from various authors indicate that up to 80% of laparoscopic surgery patients require opioid analgesia, which could increase hospital-stay duration and delay mobilization/recovery. Because of these statistics, opioid analgesic usages ought to be minimized, for the aforementioned reasons and also to prevent additional adverse effects. This study was performed to evaluate efficacy of reducing postoperative pain by infiltration of bupivacaine, a long-acting anesthetic agent, into the vaginal vault after TLH. This study was a randomized control trial designed as a 2-arm double-blinded study conducted at a North-Indian Apical Center in the Department of Obstetrics and Gynecology. After written informed consent from all patients, computer-generated randomization software placed them in 1 of 2 groups: group 1, the intervention group (received the infiltration of bupivacaine in the vaginal vault following TLH), or group 2 (the control group). The inclusion criteria were a uterine size of ≤12 weeks' pregnancy and patients requiring TLH with or without bilateral salpingo-oophorectomy for uterine size and benign conditions. Exclusion criteria were contraindication to any medication used by the study, presence of malignancy, history of multiple surgeries, and history of inflammatory disease. Postoperative pain outcome measured in both groups at 1, 3, 6, 12, and 24 hours via a visual analog score was the primary outcome. The secondary outcome was the need for rescue analgesia. A complete profile of each patient was created, using eligibility criteria, body mass index, and demographic profile, and a complete gynecological and physical examination was performed, along with preoperative investigations for fitness to general anesthesia. Per standard protocol, general anesthesia was administered for all surgeries. After vault closure, a fine-tipped aspiration needle was used to administer 10 mL of bupivacaine, which was infiltrated laparoscopically at 2 different locations, approximately 2–4 cm apart. The control group omitted this step. In the first 24 hours after operation, pain was treated using 1 g intravenous paracetamol every 6 hours. For the next 5 days, patients were given nonsteroidal anti-inflammatory drugs (diclofenac) 3 times daily for 5 days. Participants scaled their pain using the visual analog scale (VAS) score at the 1, 2, 6, 12, and 24 hours intervals postsurgery. Scores greater than 4 initiated the distribution of tramadol 50 mg intramuscular. Also recorded were the uterine weight, the operative time, complications, and the amount of operative bleeding. Group 1 patients exhibited VAS scores of less than 4 ","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"16 10 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1097/01.ogx.0000979668.10711.82
Melissa L. Acreman, Sofia Bussolaro, Yvette C. Raymond, Ilaria Fantasia, Daniel L. Rolnik, Fabricio Da Silva Costa
ABSTRACT Noninvasive prenatal testing has been a reliable method for prenatal screening for the common autosomal trisomies for the last decade. It has been analyzed in many prospective studies for accuracy in screening for the most common trisomies—13, 18, and 21—and the technology has continued to progress. With high accuracy for common trisomies, advances are attempting to expand noninvasive prenatal testing for identifying rare autosomal trisomies, such as trisomies 7, 15, 16, and 22; sex chromosome aneuploidies; and segmental copy number variants. Although cell-free DNA (cfDNA) technology is now available to screen for these abnormalities, accuracy and detection rates have not been well studied. This systematic review analyzes and reports the diagnostic accuracy of cfDNA screening for the rare autosomal trisomies. This review included case series with 10 or more cases that reported on the accuracy of cfDNA in reporting rare autosomal trisomies that were confirmed by diagnostic results or postnatal genetic testing; the final review included 31 studies. Methodological analysis found the risk of bias to be high in most studies, with only 5 rated as high quality and low risk in all domains. All studies included in the final analyses were published between 2017 and 2022, and study populations ranged from 14 to 153,575 patients. Indications for screening and characteristics of the patients varied from study to study, with 12 studies in high-risk women, 10 studies in the general obstetric population, and 9 studies without inclusion of underlying risk factors and indications. Whole-genome sequencing was used in all studies as testing methodology. Testing timing varied and was performed anywhere from gestational week 8 to week 39. In the 3 studies that analyzed sensitivity and specificity of cfDNA testing, sensitivity ranged from 87.2% to 100%, and specificity ranged from 90.7% to 99.9%. In all 3 of these studies, there were significant limitations that led authors to acknowledge the difficulty of drawing clear conclusions about sensitivity and specificity from their data. Meta-analysis performed for positive predictive value (PPV) provided a pooled estimate of 11.46% (95% confidence interval [CI], 7.80%–15.65%). Sensitivity analysis including only studies at low risk of bias gave a PPV of 9.13% (95% CI, 2.49%–18.76%). Analysis was performed again with groups divided into high or low background risk, with a slightly higher PPV in the higher background risk group, but no significant difference between these groups ( P = 0.595). Statistical heterogeneity was not explained by year of publication or baseline risk of participants but could be largely explained by rate of diagnostic follow-up. Studies with a follow-up rate of less than 50% showed a PPV of 23.69% (95% CI, 9.21%–41.94%), whereas studies with a follow-up rate greater than 50% reported a PPV of 8.80% (95% CI, 6.08%–11.90%). Based on the results of this systematic review and meta-analysis, it is
{"title":"The Predictive Value of Prenatal Cell-Free DNA Testing for Rare Autosomal Trisomies: A Systematic Review and Meta-analysis","authors":"Melissa L. Acreman, Sofia Bussolaro, Yvette C. Raymond, Ilaria Fantasia, Daniel L. Rolnik, Fabricio Da Silva Costa","doi":"10.1097/01.ogx.0000979668.10711.82","DOIUrl":"https://doi.org/10.1097/01.ogx.0000979668.10711.82","url":null,"abstract":"ABSTRACT Noninvasive prenatal testing has been a reliable method for prenatal screening for the common autosomal trisomies for the last decade. It has been analyzed in many prospective studies for accuracy in screening for the most common trisomies—13, 18, and 21—and the technology has continued to progress. With high accuracy for common trisomies, advances are attempting to expand noninvasive prenatal testing for identifying rare autosomal trisomies, such as trisomies 7, 15, 16, and 22; sex chromosome aneuploidies; and segmental copy number variants. Although cell-free DNA (cfDNA) technology is now available to screen for these abnormalities, accuracy and detection rates have not been well studied. This systematic review analyzes and reports the diagnostic accuracy of cfDNA screening for the rare autosomal trisomies. This review included case series with 10 or more cases that reported on the accuracy of cfDNA in reporting rare autosomal trisomies that were confirmed by diagnostic results or postnatal genetic testing; the final review included 31 studies. Methodological analysis found the risk of bias to be high in most studies, with only 5 rated as high quality and low risk in all domains. All studies included in the final analyses were published between 2017 and 2022, and study populations ranged from 14 to 153,575 patients. Indications for screening and characteristics of the patients varied from study to study, with 12 studies in high-risk women, 10 studies in the general obstetric population, and 9 studies without inclusion of underlying risk factors and indications. Whole-genome sequencing was used in all studies as testing methodology. Testing timing varied and was performed anywhere from gestational week 8 to week 39. In the 3 studies that analyzed sensitivity and specificity of cfDNA testing, sensitivity ranged from 87.2% to 100%, and specificity ranged from 90.7% to 99.9%. In all 3 of these studies, there were significant limitations that led authors to acknowledge the difficulty of drawing clear conclusions about sensitivity and specificity from their data. Meta-analysis performed for positive predictive value (PPV) provided a pooled estimate of 11.46% (95% confidence interval [CI], 7.80%–15.65%). Sensitivity analysis including only studies at low risk of bias gave a PPV of 9.13% (95% CI, 2.49%–18.76%). Analysis was performed again with groups divided into high or low background risk, with a slightly higher PPV in the higher background risk group, but no significant difference between these groups ( P = 0.595). Statistical heterogeneity was not explained by year of publication or baseline risk of participants but could be largely explained by rate of diagnostic follow-up. Studies with a follow-up rate of less than 50% showed a PPV of 23.69% (95% CI, 9.21%–41.94%), whereas studies with a follow-up rate greater than 50% reported a PPV of 8.80% (95% CI, 6.08%–11.90%). Based on the results of this systematic review and meta-analysis, it is","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388703","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1097/ogx.0000000000001182
Sonia Giouleka, Eirini Boureka, Ioannis Tsakiridis, Antonios Siargkas, Apostolos Mamopoulos, Ioannis Kalogiannidis, Apostolos Athanasiadis, Themistoklis Dagklis
Importance Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus contributing in the reduction of neonatal morbidity and mortality rates. Objective The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques, and timing of placing and removal of CC. Evidence Acquisition A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) on CC was carried out. Results There is a consensus among the reviewed guidelines regarding the recommended techniques, the indications for rescue CC, the contraindications, as well as the optimal timing of CC placement and removal. All medical societies also agree that ultrasound-indicated CC is justified in women with history of prior spontaneous PTD or mid-trimester miscarriage and a short cervical length detected on ultrasound. In addition, after CC, serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are unanimously discouraged. In case of established preterm labor, CC should be removed, according to ACOG, RCOG, and SOGC. Furthermore, RCOG and SOGC agree on the prerequisites that should be met before attempting CC. These 2 guidelines along with FIGO recommend history-indicated CC for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages, whereas the ACOG suggests the use of CC in singleton pregnancies with 1 or more previous second trimester miscarriages related to painless cervical dilation or prior CC due to painless cervical dilation in the second trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue CC remains a matter of debate. Conclusions Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm delivery in women considered as high-risk for these common pregnancy complications. The development of universal international practice protocols for the placement of CC seems of paramount importance and will hopefully improve the outcomes of such pregnancies. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After participating in this activity, the learner should be able to identify the indications and contraindications of cervical cerclage; evaluate the prerequisites before cervical cerclage placement; and explain the strategies for perioperative and postoperative care after cervical cerclage placement.
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