British journal of obstetrics and gynaecology最新文献

A variety of methods of management of the vaginal vault have been described, all of which maintain certain principles. In techniques that advocate closure of the vault, the peritoneum and vaginal epithelium are treated with separate sutures. This leaves a potential space above the vaginal closure. We describe a simple technique of mass closure which obliterates this space and incorporates the pedicles to provide support for the vault. This method may hold potential advantages in terms of haemostasis, risk of vault haematoma, and post-operative vaginal cuff infections.

Objective To determine whether there is an association between early recurrent miscarriage (before 10 weeks of pregnancy) and Factor V Leiden and G20210A prothrombin mutations.

Design A prospective study.

Setting Department of Gynaecology and Obstetrics, Saint Antoine Hospital, Paris, France.

Population Two groups of women: those with early unexplained recurrent miscarriage before 10 weeks of pregnancy (n=260) and control healthy women without a previous history of thromboembolism (n=240).

Methods Screening for defects in the protein C anticoagulant pathway was performed using the anticoagulant response to agkistrodon confortrix venom (ACV test). Protein C and Factor V Leiden mutation testing was performed for each low ACV level. Each sample was tested for the G20210A prothrombin mutation.

Results Factor V Leiden and G20210A mutations were found to be associated with early recurrent spontaneous miscarriage before 10 weeks of pregnancy, the odds ratios being 2.4 (95% CI 1–5) and 2.7 (95% CI 1–7), respectively. Similar results were found whether or not women had had a previous live birth.

Conclusions Early recurrent miscarriage before 10 weeks of pregnancy is significantly associated with Factor V or G20210A prothrombin mutations. These results indicate a possible role for anticoagulant prevention in these early miscarriages.

Objective To determine whether the insulin resistance syndrome and altered body composition are features of hypertensive pregnancy.

Design Women were recruited in the third trimester of pregnancy from the antenatal clinic, day assessment unit, and maternity ward of St George Hospital, Sydney.

Population Women with pre-eclampsia (n=12), gestational hypertension (n=12), essential hypertension in pregnancy (n=11), and normotensive pregnancy (n=10).

Methods Energy metabolism was assessed by indirect calorimetry to measure basal metabolic rate and diet-induced thermogenesis. Body composition was measured as lean body mass, total body water and fat mass by bio-electrical impedance. Blood was collected for measurement of glucose, insulin and lipid profiles. Insulin resistance was indirectly assessed by the insulin and glucose concentrations and diet-induced thermogenesis.

Results Women with essential hypertension and gestational hypertension were heavier than women with normotensive pregnancies both pre-pregnancy and in the third trimester, whereas women with pre-eclampsia were similar to those with normotensive pregnancy. Women with essential hypertension were otherwise similar to normotensive pregnancy but women with gestational hypertension had a reduced diet-induced thermogenesis and almost double insulin levels. Women with pre-eclampsia had a similar body composition and insulin levels but reduced basal metabolic rate, diet-induced thermogenesis and glucose levels compared with normotensive pregnancy.

Conclusions Women who develop gestational hypertension, but not pre-eclampsia, are more likely to be overweight. Women with essential hypertension are similar to women with normotensive pregnancy throughout pregnancy. Both gestational hypertension and pre-eclampsia appear to be associated with some degree of insulin resistance, greater than that occurring in normal pregnancy.

Objective To assess clinical status, changes in health related quality of life, and subsequent management five years after medical management or transcervical resection of the endometrium for treatment of heavy menstrual loss.

Design Five year follow up using postal questionnaires and operative databank review.

Setting Gynaecology department of a large UK teaching hospital.

Population Women referred to the gynaecologist for treatment of heavy menstrual loss.

Methods Eligible women, without a treatment preference, were randomised equally to either medical treatment or transcervical resection of the endometrium.

Main outcome measures Women's satisfaction with treatment, menstrual status, changes in health related quality of life, and additional treatments received at five years.

Results One hundred and forty-four patients completed questionnaires, achieving 77% follow up (medical n=71/94; transcervical resection of the endometrium n=73/93). At five-year follow up, 7/71 (10%) of those randomised to the medical arm still used medical treatment, while 72/94 (77%) had undergone surgical treatment and 17/94 (18%) a hysterectomy. Twenty-five (27%) women allocated to transcervical resection of the endometrium had undergone further surgery, 18/93 (19%) a hysterectomy. At five years women initially randomised to medical treatment were significantly less likely to be totally satisfied (P<0.01, difference 21%, 95% CI –37% to –4%), or to recommend their allocated treatment to a friend (P<0.001, difference 59%, 95% CI –73% to –45%). Bleeding and pain scores were similar in both groups and highly significantly reduced. Significantly more women in the transcervical resection of the endometrium arm had no bleeding or very light bleeding (P<0.02, difference -22%, CI –31% to –4%), and they had significantly less days heavy bleeding (P<0.02). Short Form 36 health survey scores were significantly improved from baseline for all eight health scales in the transcervical resection of the endometrium arm, and four in the medical arm.

Conclusions A policy of immediate transcervical resection of the endometrium for women referred to a gynaecologist for treatment of heavy menstrual loss achieves higher levels of satisfaction, better menstrual status, and greater improvements in health related quality of life than medical treatment. In addition, transcervical resection of the endometrium is safe and does not lead to an increase in the number of hysterectomies. An effective endometrial ablative technique should be offered to all eligible women seeking treatment of their heavy menses from a gynaecologist.

Objective To quantify the impact of publication criteria on differences in published national perinatal mortality rates among Western European countries.

Design Descriptive study of perinatal mortality rates in Western European countries with adjustments for international differences in publication data.

Population All live births and perinatal deaths in 1994 in Western European countries.

Methods The 1994 perinatal mortality rates were obtained from national and Eurostat publications for Belgium, Denmark, Finland, France, Germany, Greece, The Netherlands, Norway, Portugal, Spain, Sweden, United Kingdom (England, Wales, Scotland, Northern Ireland). Two methods, one direct and one indirect, were used for adjusting these officially published rates for differences in registration laws or publication practices. For the indirect method adjustment factors were derived from an analysis of a large Finnish database using different cutoff points for gestational age and birthweight. For the direct method a common cutoff point was imposed for birthweight (1000g) and gestational age (28 completed weeks) on national perinatal mortality data, obtained from civil registration or hospital/obstetrics databases in each country.

Results The published perinatal mortality rates ranged from 5.4 per 1000 total births in Sweden and Finland to 9.7 in Greece and Northern Ireland. The indirect adjustment method showed that some countries apply cutoff points for registration or publication of perinatal mortality which may raise the perinatal mortality rate by up to 17% above the most commonly used threshold for including live and stillbirths. The direct adjustment method showed that a common lower limit of 1000g for birthweight or 28 weeks for gestational age would reduce the perinatal mortality rate, but by a differing extent ranging from 14% to 40%. Both adjustment methods reduced the contrast between the countries’ perinatal mortality rates, and changed their rank order.

Conclusion These quantitative results confirm that international differences in countries’ published perinatal mortality rates partly reflect differences between countries’ criteria for registration and publication of perinatal deaths.

Objective To assess the effectiveness of a dual head coincidence gamma camera in identifying ovarian cancer as a less expensive alternative to the traditional 2-[¹⁸F] fluoro-2-deoxy-D-glucose (¹⁸FDG) system using positron emission tomography.

Design Prospective study.

Population Twenty consecutive women suspected of having ovarian carcinoma. Inclusion was based on abnormal serum CA125 (reference range is 0–35 units/L), ultrasound, computerised tomography or clinical findings.

Methods Women underwent assessment before staging laparotomy. Two nuclear medicine physicians, who were blinded to the pre-operative assessment, reported on ¹⁸FDG- dual head coincidence gamma camera imaging.

Main outcome measures The histology and operative staging were compared with the ¹⁸FDG- dual head coincidence gamma camera findings.

Results Twelve women had pelvic malignancies (nine primary and three recurrences), seven women had benign pathology and one patient had a borderline malignancy. We were able to image accurately all malignant pelvic masses with dual head coincidence gamma camera, as well as accurately demonstrate disease spread. Two of the benign pelvic masses localised ¹⁸FDG. The positive predictive value for detecting malignancy was 86%.

Conclusions Dual head coincidence gamma camera offers accurate and affordable imaging in suspected ovarian masses, with improved specificity over CA125, ultrasound and computerised tomography. These results are similar to those obtained on more expensive dedicated PET systems. We report on a series of patients believed to have primary or recurrent carcinoma and recognise the need to include patients more likely to have benign lesions to assess false positive results. However, we believe that dual head coincidence gamma camera is useful in the pre-operative assessment of women with suspected ovarian cancer.

Objective To examine the postnatal development of a group of children born after in utero laser ablation therapy for severe twin-to-twin transfusion syndrome.

Design Retrospective cohort outcome study involving assessment of neurodevelopment and physical well being.

Setting Harris Birthright Centre, King’s College Hospital, London.

Participants Twins and singleton survivors treated via laser ablation therapy for twin-to-twin transfusion syndrome over a four-year period.

Methods Of 54 families contacted to participate in the study, who had been treated for twin-to-twin transfusion syndrome during a four-year period, 24 families attended for paediatric assessment; 12 pairs of twins and 12 singleton survivors were assessed for perinatal, neurological and neurodevelopmental outcome using the Griffiths scales of mental development. A further 20 families were assessed via a proforma after contact with their general practitioner. A comparison of these groups showed no significant differences in sociodemographic factors or severity of disease between responders (44 families, 81.5%) and non-responders (10 families).

Results The group of children assessed by a paediatrician had low birthweight (1619g donor, 1814g recipient, 1877g singleton) and had been born preterm (33 weeks twins, 31.2 weeks singleton) with attendant increased resuscitation, neonatal unit admission (mean 40 days) and instrumental delivery. Mean Griffiths scores were within the normal range of ability (91.2 donor vs 97.7 recipient and 101.6 singletons) with the only significant difference being in the locomotor subscale where donor (82.6) and recipient (85.3) were less than singletons: -99.1 (P<0.05). There was no cerebral palsy in the singleton survivors, but there were five cases in the twin group. All except one affected child (with quadriplegia) had mean Griffiths scores in the normal range. In the GP proforma group there was one case, in a twin, of cerebral palsy.

Conclusion The overall cerebral palsy rate was 9%: 0% in the singleton survivors group and 13.3% in the twin survivors group. This pilot data highlights the need for careful long term follow up of children affected by twin-to-twin transfusion syndrome.