Novel modification of B-Lynch uterine compression sutures for management of atonic postpartum hemorrhage: VV uterine compression sutures

AIM

The aim of this study was to demonstrate a novel modification of uterine compression sutures for use in women with primary postpartum hemorrhage and to evaluate its effectiveness.

MATERIAL AND METHODS

This was a prospective observational study. Nineteen patients with atonic postpartum hemorrhage were subjected to the novel VV uterine compression sutures at the time of cesarean delivery.

RESULTS

The procedure was successful in 18 out of 19 women (94.7%) in controlling the bleeding and preserving the patient's uterus. Only one patient required supravaginal hysterectomy.

CONCLUSIONS

VV compression sutures comprise an easy, safe and effective procedure that can be applied in cases of atonic postpartum hemorrhage.

Agreement of histopathological findings of preoperative uterine curettage and hysterectomy specimens: impact of time factor and hormonal therapy

OBJECTIVES

To study the agreement of preoperative curettage and definitive histology after hysterectomy as well as the correlation of time factor and hormonal therapy to this agreement.

METHODS

This retrospective study was done in the Departments of Obstetrics and Gynecology and Pathology, Faculty of Medicine, Mansoura University, Egypt. Pathology reports of patients exposed to dilatation and curettage followed by hysterectomy during the period from May, 2004 to April, 2011 were reviewed.

RESULTS

We reviewed 83 cases who fulfilled the inclusion criteria. There were non-significant differences between findings of D&C and hysterectomy specimens (P = 0.42). The concordance rate between D&C and hysterectomy was 79.5%. One case of endometrial carcinoma (1.2%), one case of simple endometrial hyperplasia, one case of atrophic endometrium, and two cases of endometrial polyp were diagnosed only after hysterectomy (4.8%). Furthermore, histologic examination of hysterectomy specimens confirmed only 8 of 13 cases (61.5%) of endometrial hyperplasia with atypia. No significant correlation of time factor and hormonal therapy to the agreement between findings of D&C and hysterectomy specimens (P = 0.58 & 0.19 respectively).

CONCLUSION

There was no significant difference between preoperative endometrial histology and hysterectomy specimens (P = 0.41).This agreement had not been significantly affected by time interval and hormonal therapy. Future researches with larger number of cases are needed to confirm or disagree with our findings.

Immunohistochemical expression of cyclin A in testicular biopsies of fertile and infertile men: correlation with the morphometry of seminiferous tubules

Cyclin A is a member of the cyclin family of proteins, which are required for both the mitotic and meiotic divisions that characterise spermatogenesis in human and other mammalian species. The data on cyclin A expression in various human spermatogenic disorders and its relationship to the morphology of seminiferous tubules are not well clarified. This study aimed to evaluate the immunohistochemical expression of cyclin A in testicular biopsies of different spermatogenic disorders correlating with the morphology of seminiferous tubules using morphometry tools. Immunohistochemical evaluation of cyclin A was carried out on testicular biopsies obtained from 48 infertile males (nonobstructive azoospermia) and 15 normal subjects together with using semiautomatic morphometric analysis for evaluation of seminiferous tubules. Cyclin A is expressed in 100% of normal and hypospermatogenesis groups and in 80% of maturation arrest group, with complete absence in Sertoli cell only group. In positive cases, cyclin A stained the nuclei of spermatogonia and primary spermatocytes with a higher intensity of expression in normal cases compared with infertile group. Cyclin A expression was significantly associated with the different examined morphometric parameters. Cyclin A is involved in both mitosis and meiosis of human spermatogenesis as it is expressed in spermatogonia and primary spermatocytes. Morphometry of human testis is intimately correlated with the testicular histopathology.

Late post-cesarean surgical complication

AIM

The aim of the study was to clarify the incidence, indication, and management of late surgical intervention following cesarean section (CS) in a tertiary care university hospital.

METHODS

A cohort of 5981 women underwent CS from a group of 24,060 parturients in a retrospective study at a tertiary care university hospital. Surgical intervention after CS in the late postoperative period (after puerperium) was reviewed regarding clinical, operative, and pathological findings.

RESULTS

The CS rate was 24.86%. The incidence of late surgical intervention after CS was 0.40% (24/5981); of these 24 women, 10 (41.67%) were operated for skin lesions, two (8.3%) for urogenital fistula, three (12.5%) for gastrointestinal problems, three (12.5%) for omental masses and six (25%) for pelvic lesions.

CONCLUSION

Although the incidence of surgical intervention after CS in the late postoperative period is low and the outcome is favorable, several measures must be undertaken to reduce late surgical complications.

Is expectant management of early-onset severe preeclampsia worthwhile in low-resource settings?

OBJECTIVE

To evaluate the maternal and perinatal outcome following expectant management of early-onset severe preeclampsia (PE) at a tertiary hospital in Mansoura, Egypt.

METHODS

This prospective, observational study included 211 patients with severe PE, occurring between 24 and 34 weeks of gestation. They were classified according to gestational age on admission into three groups. Group 1 included 61 patients with gestational ages between 24 and 28 weeks. Group 2 (28 to <32 weeks) included 66 patients and group 3 (32-34 weeks) included 84 patients. Outcome measures included prolongation of gestation, and maternal and perinatal complications.

RESULTS

The median overall prolongation of gestation was 12 +/- 6 days. The rate of neonatal survival significantly increased (P < 0.001) from 12/61 (19.7%) in group 1 to 30/66 (45.5%) in group 2 and 67/84 (79.8%) in group 3. There were no maternal mortalities; however, 43 (20.4%) women developed significant morbidities. HELLP syndrome, renal impairment and placental abruption were the main complications.

CONCLUSION

In low-resource settings, expectant management of early-onset severe PE is associated with relatively higher rates of perinatal mortality and maternal morbidity and should be limited to gestational ages between 28 and 34 weeks of gestation.

Paraumbilical hernia repair during cesarean delivery

BACKGROUND AND OBJECTIVES

Pregnant women with paraumbilical hernia usually postpone hernia repair until after delivery, but some patients request that it be done during cesarean delivery. Therefore, we evaluated the outcome of combined cesarean delivery and paraumbilical hernia repair in a prospective study at a tertiary referral university hospital.

PATIENTS AND METHODS

In a prospective study, we compared the outcome of 48 patients undergoing cesarean delivery combined with paraumbilical hernia repair versus 100 low-risk patients undergoing cesarean delivery alone. The main outcome measures were operation time, blood loss, severity of pain, peripartum complications, hospital stay, hernia recurrence, and patient satisfaction.

RESULTS

The combined procedure took significantly longer than cesarean delivery alone (75.2 minutes versus 60.5 minutes, P<.001)). There were no major complications. Wound infection occurred in 6 patients (4.1%). Hospital stay did not differ significantly from those of controls. Pain at the hernia site repair occurred in two patients, and one hernia recurred in the hernia repair group during a mean follow-up period of 22 months (range, 6-36 months). All hernia patients reported that they preferred the combined operation.

CONCLUSIONS

Combined cesarean delivery and paraumbilical hernia repair had the advantage of a single incision, single anesthesia, and a single hospital stay while avoiding re-hospitalization for a separate hernia repair. Our results indicate that the combination approach is safe, effective, and well accepted.

Randomized controlled trial of three doses of letrozole for ovulation induction in patients with unexplained infertility

The aromatase inhibitor letrozole is a novel agent that can be used as an alternative to clomiphene citrate for ovulation induction in patients with unexplained infertility. The dose of letrozole used has varied between studies, and this study aimed to compare the three most commonly used doses: 2.5, 5 and 7.5 mg. A total of 179 patients were randomly recruited in this prospective study with 58, 61 and 60 patients in each dosage group respectively. This study reports a significantly higher (P < 0.05) number of follicles (total, > 14 mm and > or = 18 mm) on the day of administration of human chorionic gonadotrophin in the 7.5 mg group, associated with significantly fewer (P < 0.05) days of stimulation. However the pregnancy and miscarriage rates were similar in the three groups. In conclusion, it seems that the use of higher doses of letrozole offers no advantage in terms of pregnancy rates over the lower (2.5 mg) dose.

Value of estimating intraocular antibody production in diagnosis of typical and atypical lesions of ocular toxoplasmosis

Serum and aqueous humor (AH) samples were collected from 45 patients: 20 with typically active or reactivated retinal lesions of Toxoplasma (Group I), 16 with atypical lesions (Group II) and 9 with old quiescent scars (Group III). Also, serum and AH samples were collected from 10 patients with chronic toxoplasmosis without any ocular manifestation (Group IV). T. gondii specific IgG, IgA and IgM antibodies were measured by ELISA in AH and serum and the intraocular (local) antibody production was determined by calculating Goldman-Witmer coefficient (G.W.C.). IgG antibodies were the only class detected in all sera of patients with ocular and nonocular toxoplasmosis. An intraocular IgG antibody synthesis was confirmed in 95% and 37.5% of patients with typical (Group I) and atypical (Group II) posterior uveitis respectively and in none of either patients with quiescent scars (Group III) or the ophthalmologically free patients (Group IV). As regard the typical active lesions, the sensitivity of the IgG assay (95%) was higher than that of IgA (60%) and IgM (5%) assays. Beside the conclusion that AH analysis to detect local antibody production is more reliable than the estimating of serum antibodies for the diagnosis of ocular toxoplasmosis, the detection of AH specific antibodies in 6 atypical cases, who were treated successfully by antitoxoplasmic therapy, represent a help to increase the number of uveitis cases in which specific treatment can be established.

Day 5 inhibin B levels in a treatment cycle are predictive of IVF outcome

BACKGROUND

Day 5 serum inhibin B during IVF treatment has been investigated as a predictor of outcome.

METHODS

A total of 54 women (< or = 39 years, normal menses and endocrine profiles) were treated with urinary gonadotrophins or recombinant FSH following pituitary down-regulation. Serum day 3 FSH in a preceding cycle was <8.5 IU/l. Plasma inhibin B, inhibin A and estradiol were determined after 4 days of gonadotrophin administration (day 5).

RESULTS

Day 5 inhibin B was the most highly correlated with the number of mature follicles (>14 mm), oocytes retrieved and fertilized. Receiver operating characteristic analysis gave high accuracy for day 5 inhibin B in predicting ovarian response and indicated that a threshold of 400 pg/ml may be helpful in the decision as to whether to continue treatment. Women with <400 pg/ml (n = 16) had lower numbers of follicles, mature follicles, oocytes retrieved, fertilized and cleaved compared with those >400 pg/ml (n = 36) and this threshold gave a positive likelihood ratio of 30, 92.9% sensitivity, 95.0% specificity and 86.7% positive predictive value to detect poor ovarian response. Day 5 inhibin B was the best predictor of pregnancy (no live births and four cycles cancelled, low inhibin group; nine live births and no cancelled cycles, high inhibin group).

CONCLUSIONS

Normogonadotrophic, normogonadal women with day 5 inhibin B <400 pg/ml in down-regulated cycles have a poor response to ovarian stimulation and are less likely to conceive compared with women with higher day 5 inhibin B.

Becoming a doctor

Medical training cannot be equated with merely studying for a degree. It encompasses much more, challenging one's values, self perception and perspective on life itself. During five years at medical school, the individual irreversibly alters to become "a medic", not just "a student of medicine", no matter how much detachment from the course and its associated lifestyle the individual has endeavoured to preserve. In the following article, we intend to explore the different stages of training and discuss how each shapes the student. "Becoming a medic" intellectually, emotionally and spiritually is the inevitable consequence of spending five years at medical school, and the assumption of this role is indeed crucial to survival in medical practice. The importance of bringing our own individual qualities to the profession must, however, not be overlooked. Personal flair and abilities should be nurtured, not suppressed during medical school. A diversity of interests serves both to ease the pressures laid upon us at medical school, and to broaden our characters and deepen our understanding of humanity. Medical students, while necessarily adapting to the role of a doctor, should emerge from their training not as narrow "medics" but as enthusiastic, compassionate people equipped to treat patients to the best of their ability.

Percutaneous endoscopic gastroscopy tube migration: a rare cause of a common surgical problem

Percutaneous endoscopic gastroscopy (PEG) is now the preferred method for long-term enteral nutrition for patients with inadequate oral intake. It is usually replaced by a Foley catheter when it becomes non-functional because of blockage or wear and tear. PEG tube migration is an unusual complication which may not be noticed by the patient or the medical staff and may present as delayed small bowel obstruction. We report on a patient who developed such a complication and the missing PEG tube was replaced by a Foley catheter when it was thought the original tube had fallen out. The use of catheters with an external stop device is recommended to prevent this rare complication.

The effect of gonadotrophins with differing LH/FSH ratios on the secretion of the various species of inhibin in women receiving IVF

We have measured secretory patterns of inhibin A, B, total alpha inhibin, pro-alphaC inhibin and oestradiol in women following pituitary suppression who were randomised into two groups to receive either urinary gonadotrophin (25:75 IU/ampoule of luteinizing hormone (LH) and follicle stimulating hormone (FSH; Normegon; n = 11) or recombinant (r)FSH (75 IU/ampoule of FSH alone, n = 16). The women were of similar age (approximately 33 years) and length of infertility (approximately 4 years) and had a normal endocrine evaluation. Plasma FSH, LH, oestradiol, inhibin A, B, pro-alphaC and total alpha inhibin were measured by immunoassay prior to and following gonadotrophin stimulation. Immunoactive FSH, LH and oestradiol blood concentrations following pituitary down regulation were similar in the two groups being <2.0, <3.6 IU/l and <82 pmol/l respectively. The units of FSH given (2230 versus 2764 IU; Normegon versus rFSH), duration of treatment (9.1 versus 9.4 days) and number of follicles of > or =14mm on the day of human chorionic gonadotrophin (HCG) administration (17 versus 14) were also similar. Inhibin A or B concentrations rose similarly during Normegon or rFSH administration, peaking at days 9-11. Total alpha and pro-alphaC inhibin concentrations were lower (P < 0.05) in the rFSH group during days 10 and 11 of treatment being 18.9 +/- 15.9 ng/ml (Normegon) and 4.6 +/- 2.8 ng/ml (rFSH) for total alpha inhibin and 8.5 +/- 6.8 ng/ml (Normegon) and 2.8 +/- 1.6 ng/ml (rFSH) for pro-alphaC inhibin on day 10. Overall, higher total alpha inhibin concentrations were associated with more mature follicles and oocytes, greater fertilization rates and better quality embryos. We conclude that inhibin A and B secretion was similar in both groups and is primarily controlled by FSH, whereas total alpha inhibin and pro-alphaC increased preferentially in the Normegon group over the rFSH group, indicating that they are, in part, stimulated by LH.

A randomized prospective assessor-blind evaluation of luteinizing hormone dosage and in vitro fertilization outcome

OBJECTIVE

To determine the effect of exogenous LH dosage on IVF outcome.

DESIGN

Single-blinded (assessor-blinded) study with random assignment of treatment groups.

SETTING

Human Assisted Reproduction Unit, Rotunda Hospital, Dublin, Ireland.

PATIENT(S)

Infertile normogonadotropic women undergoing their first cycle of IVF were studied.

INTERVENTION(S)

Patients were randomized to gonadotropin drugs with varying doses of LH per ampule: recombinant FSH containing no LH (group 0, n = 39), urinary FSH containing <1 IU of LH per ampule (group 1, n = 30), hMG containing 25 IU of LH per ampule (group 25, n = 30), and hMG containing 75 IU of LH per ampule (group 75, n = 29). The FSH dose was kept constant at 75 IU per ampule. A long-protocol GnRH-analog regimen was used.

MAIN OUTCOME MEASURE(S)

Dose and duration of gonadotropin stimulation, follicle and oocyte numbers, implantation rate, and pregnancy rate.

RESULT(S)

The median duration of ovarian stimulation; median number of gonadotropin ampules used; serum E2 levels; and numbers of follicles, oocytes, and embryos were similar among the four groups. Median LH levels on the day of hCG administration, however, differed significantly. Live birth rates per cycle differed markedly, but statistical significance was not achieved (23%, 7%, 20%, and 31% for groups 0, 1, 25, and 75, respectively). A significant trend in implantation rates was noted with increasing LH dosage of the urinary preparations (19%, 10%, 18%, and 28% for groups 0, 1, 25, and 75, respectively).

CONCLUSION(S)

In the present study, although the residual endogenous LH after down-regulation was adequate for ovarian response and E2 synthesis, the addition of exogenous LH improved implantation. An FSH/LH ratio of 75/75 IU per ampule appeared to be the optimum dose.

Hepatocellular carcinoma in Mansoura-Egypt: experience of 385 patients at a single center

BACKGROUND/AIMS

Hepatocellular carcinoma is one of the commonest malignancies in the world. The two main etiological factors for hepatocellular carcinoma are cirrhosis and viral hepatitis. Although the first choice of treatment for hepatocellular carcinoma is surgical resection, most of them are unresectable at the time of diagnosis.

METHODOLOGY

From January 1994 to June 1999, 385 patients with hepatocellular carcinoma were presented to the Gastroenterology surgical center, Mansoura University, Egypt and subjected to similar diagnostic process. Forty-five (11.6%) of these patients (34 males and 13 females) with a mean age of 50.9 years (+/- 7.53 years) were subjected to different types of hepatic resection.

RESULTS

The underlying liver pathology was cirrhosis in 85%. Positive virology was found in 82.5% (HCV 61%, HBV 14.5% and combined 7%). The main presentation were asymptomatic in 144 (37.4%) patients, abdominal pain in 92 (23.9%) patients, ascites in 95 (24.6%) patients, jaundice in 53 (14%) patients and upper gastrointestinal hemorrhage in 26 (6.75%) patients. Only 45 (11.6%) were resectable, they were subjected to hepatic resection with operative mortality in 2 cases (4.4%) and with overall mortality in 29 (64.4%) cases after 48 months (32.8 +/- 19 months) of follow-up. The main causes of late mortality were recurrence in 14 (31.1%) cases, hepatic cell failure in 7 (15.5%) cases and other causes in 6 (13.3%).

CONCLUSIONS

Hepatocellular carcinoma is now a common malignancy in Egypt, which usually develops on top of cirrhosis of viral origin in 82%. Hepatic resection is the only method of treatment with a low resectability rate.

Transplacental transmission of hepatitis C virus in HIV-negative mothers

The aim of this work was to evaluate transplacental transmission of hepatitis C virus (HCV) in HIV-negative pregnant women who were HCV-PCR-positive, and also to determine the serotypes of the virus in these cases. Therefore, 767 pregnant women were screened for anti-HCV antibodies, hepatitis B surface antigen (HBsAg) and anti-HIV antibodies. HCV PCR was performed for HCV-positive women. Those who were PCR-positive were tested for anti-HCV IgM. Neonates of PCR-positive mothers were tested for virus transmission by the PCR test. Virus serotyping was done for mothers and neonates. Anti-HCV antibodies were detected in 105 out of 767 (13.7%) pregnant women. PCR was positive in 18 out of 67 HCV-positive women (26.9%). Transplacental transmission occurred in 11.1% of HIV-negative pregnant women. HCV type 4 predominates in Egypt (83.3%). Mothers who are PCR-positive and have high aspartate aminotransferase and positive anti-HCV IgM are most likely to transmit HCV to their babies.

Essential pre-conceptual measures for the female partner before commencing an in vitro fertilisation programme

Two hundred and eighty-one women were checked for the presence of specific pre-conceptual data and their medico-legal implications prior to commencing an in vitro fertilisation (IVF) programme. In only 9.6 per cent were the results of a recent rubella test available in the patients referral notes. Fifty-four per cent were then tested in the unit. Two per cent were found to be not immune. Thirty-six per cent of women needed a cervical smear prior to commencing therapy. No such test had been undertaken previously in 6.7 per cent and 12.7 per cent had abnormal test results. Pre-conceptual intake of folic acid is considered an important preventative measure. The patient uptake rose from 15 per cent to 97 per cent following specific advice.