British journal of obstetrics and gynaecology最新文献

Objective To investigate whether hypertriglyceridemic dyslipidemia is a risk factor for either early or late onset pre-eclampsia.

Design Prospective cohort study and nested case–control study.

Setting Aker Hospital: a university hospital with all levels of obstetric care.

Participants 2157 Caucasian pregnant women.

Methods Blood samples were obtained from non-fasting subjects at 18 weeks of gestation. All samples were analysed for triglycerides, total-cholesterol, high density lipoproteins cholesterol and non-high density lipoproteins cholesterol. ApoB-100 were analysed in pre-eclamptic women and in 3:1 matched controls. The cohort data were analysed by multiple logistic regression and the case–control data by conditional logistic regression.

Main outcome measures Adjusted odds ratios of early and late onset pre-eclampsia according to early second trimester serum concentration levels of lipids and ApoB-100.

Results Eighteen women developed early onset pre-eclampsia and 53 women developed late onset pre-eclampsia. In the cohort model, women with triglycerides above 2.4mmol/L had increased risk (OR 5.1; 95% CI 1.1–23.1) of early onset pre-eclampsia compared with those with triglycerides levels ≤ 1.5mmol/L. For women with high triglycerides: non-high density lipoproteins cholesterol ratios (>90 centile) the OR (95% CI) for early onset pre-eclampsia was 7.1 (2.3–22.0) compared with those with low ratios (≤ 50 centile). Similar associations were found in the case control model. We found no associations between plasma lipids and risk of late onset pre-eclampsia.

Conclusions Hypertriglyceridemic dyslipidemia before 20 weeks of gestation is associated with the risk of developing early but not late onset pre-eclampsia, giving support to the contention that these two variants of the disease are at least partly pathogenically different.

Objectives To determine whether trainees in obstetrics and gynaecology tie adequate surgical knots and to assess whether formal training improves knot tying skills.

Design A comparative study assessing surgical knots before and after tuition.

Population Fourteen trainees in a single obstetrics and gynaecology department.

Setting A basic surgical skills workshop based in a London teaching hospital.

Methods Trainees tied surgical knots around a 120mm jig using 2/0 glycan polymer. Each trainee tied 11 knots before and after a two and a half hour teaching session. Knots were tested using a mechanical testing machine.

Outcome measures Knot strength (N); proportion of knots that were ‘secure’ (defined as those that eventually failed on the testing device by breakage rather than slippage); proportion of knots that were ‘dangerous’ (defined as those with a tensile strength of < 5 N).

Results After tuition, the median knot strength of the whole group was 5.7 N stronger than before instruction (95% CI 4.6–12.3 N). Prior to tuition 13.5% (20/148) knots tied had a tensile strength of < 5 N. This was compared with 3.4% (5/148) after tuition (OR = 0.2, 95% CI 0.1–0.6). Before instruction 55.4% (82/148) of the knots were secure compared with 66.9% (99/148) after tuition (OR = 1.6, 95% CI 1.0–2.7).

Conclusion Knot tying workshops can improve the ability of trainees in obstetrics and gynaecology to tie reef knots.

Objective To design and validate a condition-specific health-related quality of life questionnaire for the assessment of women with anal incontinence.

Design A psychometric study by postal survey.

Setting South Manchester University Hospital, UK.

Sample Two hundred and twenty women with known anal incontinence.

Method The questionnaire was adapted from the King's Health Questionnaire, a condition-specific health-related quality of life questionnaire for the assessment of women with urinary incontinence. The questionnaire was then tested for acceptability, reliability and validity by postal survey.

Results The Manchester Health Questionnaire was found to be highly acceptable to women and showed excellent internal consistency, test–retest reliability, criterion and construct validity.

Conclusion The questionnaire is both a valid and reliable instrument for the assessment of health-related quality of life among women with anal incontinence. It will be useful in many different clinical settings and be of practical use in the evaluation of women after childbirth. As the good response rates show it could be a successful part of a postal survey.

Current treatments for twin reversed arterial perfusion sequence are associated with significant morbidity and most are not feasible in early gestation. We report the use of an interstitial laser in two pregnancies complicated by this sequence at 14 and 15 weeks, respectively. A 600μm laser fibre was introduced via a 17 gauge needle into the abdomen of the perfused twin close to the vitelline artery and umbilical vein, which were occluded by neodymium:yttrium aluminium garnet (Nd:YAG) laser. Both pregnancies continued uneventfully and each resulted in the birth of a healthy baby at term.

Objective To investigate insulin-mediated vasorelaxation in pregnancy, and the role of nitric oxide in this response.

Design In vitro study of isolated subcutaneous resistance arteries from pregnant and non-pregnant women.

Methods Small arteries (mean vessel diameter <300μm) were isolated from biopsies of subcutaneous fat from 14 pregnant and seven non-pregnant women. Insulin-mediated attenuation of the vasoconstriction response to noradrenaline, before and after nitric oxide synthase inhibition, was studied in isolated arteries using wire myography. Vessel responses to noradrenaline following incubation with insulin were also tested after endothelial denudation. Maximum responses were compared using one-way ANOVA and Bonferroni's post hoc test for multiple comparisons.

Results In pregnancy, the maximum vasoconstriction produced by noradrenaline was increased (P<0.01). Insulin significantly reduced this response in pregnant women (P<0.01), while inhibition of nitric oxide synthase with N^ω-nitro-L-arginine methyl ester (L-NAME) resulted in potentiation (P<0.05). Following inhibition of nitric oxide synthase with L-NAME, addition of the insulin was still able to produce a significant attenuation in maximum vasoconstriction to noradrenaline in pregnant women (P<0.01). Furthermore, the absence of functioning endothelium did not abolish the attenuating effect of the insulin on noradrenaline-induced vasoconstriction in pregnant women (P<0.01).

Conclusions The vasodilatory effect of insulin is not diminished in pregnancy, despite the development of insulin resistance. Furthermore, the attenuation of vasoconstrictor tone is via an endothelium-independent mechanism. This suggests that the vascular dysfunction associated with diabetes mellitus does not occur with physiological insulin resistance.

Objectives To assess the long term outcome of laparoscopic supracervical hysterectomy.

Design Retrospective study.

Setting Minimal Access Surgical Unit, Department of Gynaecology, Royal Surrey County Hospital, Surrey.

Methods Analysis of patient case records.

Population Seventy consecutive women who had a laparoscopic supracervical hysterectomy.

Outcome measures Symptoms related to the cervical stump and the need for further surgery.

Results The mean time of patient follow up was 66 months (range 52–84). The mean time from initial procedure to second treatment was 14 months (range 3–53). Seventeen women (24.3%) reported symptoms related to the cervical stump, and all required further surgery. The cervical stump was removed in 16 (22.8%). One patient had laparoscopic adhesiolysis only and two had a laparotomy and trachelectomy because the bowel was adherent to the cervical stump. Nine had a laparoscopically assisted cervical trachelectomy as the sole procedure. Five had laser treatment to endometriotic deposits, and laparoscopically assisted cervical trachelectomy. Histological analysis showed normal cervical tissue in six (35.3%). Endometriosis was detected in four cervical stumps (23.5 %), residual endometrium in another four (23.5 %) cases, and chronic cervicitis, mild CIN and a mucocoele in a further three patients. Of the 17 women who reported cervical stump symptoms, 14 (82.3%) had been treated for endometriosis in the past, compared with 17/53 (32%) who did not have symptoms (P<0.0002, χ² test).

Conclusions Symptoms related to the cervical stump requiring further surgery frequently occur following a laparoscopic supracervical hysterectomy.

Objective To investigate whether deeply infiltrating endometriosis occurs with equal frequency between left and right uterosacral ligaments.

Design Retrospective analysis of consecutive cases.

Setting Department of gynaecological surgery in a tertiary care university hospital in Paris, France.

Population One hundred and thirty consecutive women with laparoscopic resection of histologically proven deep endometriosis infiltrating the uterosacral ligaments.

Methods Laterality, intraoperative aspect of the uterosacral ligaments, and associated endometriosis were recorded during laparoscopy. Deep endometriosis infiltrating the uterosacral ligaments was considered as histologically proven in the presence of endometrial glands and stroma.

Main outcome measure Frequency of left- and right-sided deep endometriosis infiltrating the uterosacral ligaments.

Results The left uterosacral ligament alone was involved in 69 cases; the right uterosacral ligament alone was involved in 38 cases; both were involved in 23 cases. For patients with unilateral deep endometriosis infiltrating the uterosacral ligaments the observed proportion of endometriosis involving the left uterosacral ligament (69/107, 64.5%) was significantly different from the expected proportion of 50% (χ²=8.98; P < 0.01).

Conclusion Anatomical differences between left and right hemipelvis and differences in the frequency of ovulation between right and left ovary could explain these results.