The feasibility and efficacy of laparoscopic oophorectomy in the management of pelvic pain after hysterectomy

We aim to assess the feasibility and efficacy of laparoscopic oophorectomy in women with pelvic pain after hysterectomy in this retrospective review of 35 consecutive women presenting with pelvic pain who had had their ovaries conserved at the time of hysterectomy. Pain was attributed to the presence of these residual ovaries if there was an adnexal mass--or the pain improved following ovarian suppression with a GnRH analogue. The procedure was completed laparoscopically in 32 (91%) women. Overall, 27 (77%) women reported symptomatic relief following surgery. We conclude that laparoscopic oophorectomy is safe and provides symptomatic relief in this group of women.

A comparative study of glycodelin concentrations in uterine flushings in women with subseptate uteri, history of unexplained recurrent miscarriage and healthy controls

OBJECTIVE

To compare the concentration of glycodelin in uterine flushing at the implantation window obtained from women with subseptate uteri, women with a history of recurrent first trimester miscarriage and fertile controls.

STUDY DESIGN

Glycodelin concentration was assessed using Enzyme Linked Immunohistochemistry (ELISA) at The Early Pregnancy & Gynaecology Assessment Unit, King's College Hospital, London, England. Eight women with a subseptate uterus, 20 women with a history of unexplained recurrent first trimester miscarriage and 16 fertile controls had uterine cavity flushing, for glycodelin concentration, done 7 days after the luteinising hormone surge.

RESULTS

Glycodelin concentrations in uterine flushing obtained from women with subseptate uteri (n=8) (median 32.9 ng/ml, range 17.1-52.4 ng/ml) and recurrent miscarriage (n=20) (median 26.8 ng/ml, range 9.7-78.5 ng/ml) were significantly lower than in the control group (n=16) (median 67.7 ng/ml, range 59.0-77.6 ng/ml) (chi(2)=19.565, p<0.001).

CONCLUSION

Peri-implantation levels of glycodelin are lower in women at high risk of early pregnancy failure.

The value of ultrasound visualization of the ovaries during the routine 11–14 weeks nuchal translucency scan

OBJECTIVE

To investigate the feasibility and possible value of routine screening for ovarian pathology in asymptomatic pregnant women at 11-14 weeks' gestation.

STUDY DESIGN

A policy of routine ovarian visualization was implemented in 2925 pregnant women attending for a nuchal translucency scan at 11-14 weeks' gestation. In all cases, an attempt was made to visualize the ovaries on transabdominal ultrasound scan. Simple cysts were defined as unilocular cysts with regular internal walls and no solid components, which contained clear anechoic fluid. All other cysts were classified as complex. Simple cysts<5 cm in diameter were all managed expectantly with no further follow-up. All women with large simple cysts>or=5 cm in diameter or complex cysts had further detailed follow-up scans. Surgical intervention during pregnancy was offered to women with clinical symptoms suggestive of cyst complications or those with ultrasound features suggestive of malignancy. All other women were managed expectantly until after delivery.

RESULTS

Adnexal cysts were found in 728/2925 (24.9%) pregnant women. 400/728 (55%) women had simple cysts<5 cm in diameter, whilst 328/728 (45%) women had large simple or complex cysts requiring follow-up. On subsequent scans, cysts resolved spontaneously in 278/328 (84.8%) women. A total of 33/728 (4.5%) women with ultrasound evidence of adnexal cyst underwent surgery. In one woman the intervention was required because of pain, one woman had suspected cancer on ultrasound scan and the remaining 31/33 (94%) of operations were performed at patients' requests. All the cysts were found to be benign on histological examination. The overall intervention rate was 1.1/100 screened pregnant women or 4.5/100 cysts detected on ultrasound scan.

CONCLUSION

Asymptomatic adnexal cysts detected in the first trimester of pregnancy are unlikely to be malignant or to cause clinical symptoms antenatally. The policy of routine ultrasound visualization of the ovaries in pregnancy cannot be justified.

Reproducibility of the measurement of submucous fibroid protrusion into the uterine cavity using three-dimensional saline contrast sonohysterography

OBJECTIVE

To determine the intraobserver and interobserver reproducibility of measurement of the percentage of protrusion of submucous fibroids into the uterine cavity using three-dimensional saline contrast sonohysterography (3D-SCSH).

METHODS

Women diagnosed with submucous uterine fibroids on B-mode two-dimensional (2D) ultrasound scan were invited to join the study and 3D-SCSH was carried out. 3D volume datasets were stored digitally and were examined later using the technique of planar reformatted sections. The reproducibilities of the measurement of fibroid diameter and protrusion ratio into the uterine cavity (ratio of the size of the segment of the fibroid protruding into the cavity to the total diameter of the fibroid) were examined by two independent observers who were unaware of the initial 2D scan findings. Interobserver reproducibility was assessed by calculating the difference between measurements taken by the two operators (limits of agreement) and interclass correlation coefficient. Intraobserver repeatability was assessed by calculating the difference between two measurements for each variable (limits of agreement) and further expressed as an intraclass correlation coefficient.

RESULTS

Thirty-three 3D ultrasound volumes were examined. There was a good agreement between the observers in classifying the fibroids as greater or less than 50% confined to the myometrium (Cohen's kappa 0.81). There was no bias in measurements for both variables either between observers or with repeated measurements by each observer. For fibroid diameter and protrusion ratio the inter- and intraclass correlation coefficients were high (0.984-0.995), with narrow limits of agreement.

CONCLUSION

3D-SCSH is a reproducible method for the quantification of the percentage of a submucous fibroid protruding into the uterine cavity.

Expectant management of miscarriage—prediction of outcome using ultrasound and novel biochemical markers

BACKGROUND

The aim of this study was to examine the value of various ultrasound and biochemical parameters for the prediction of successful expectant management of miscarriage.

METHODS

This was a prospective observational study. Clinically stable women with an ultrasound diagnosis of miscarriage were offered expectant management. In all cases, gestational age, size of retained products of conception, serum HCG, progesterone, 17-hydroxyprogesterone, insulin growth factor-binding protein 1 (IGFBP-1), inhibin A and inhibin pro alpha-C RI levels were recorded. Follow-up continued until resolution of the pregnancy. Clinical data, ultrasound findings and biochemical markers were analysed using univariate analysis and decision tree analysis.

RESULTS

Fifty-four women underwent expectant management of miscarriage. Thirty-seven (69%) had successful expectant management and 17 (31%) required surgery. The size of retained products, serum HCG, progesterone, inhibin A and inhibin pro alpha-C RI were all significantly different in those pregnancies that resolved spontaneously (P<0.05). Serum inhibin A was the best predictor of a complete miscarriage.

CONCLUSION

This study shows that novel biochemical markers may be used to predict the likelihood of successful expectant management of miscarriage.

A comparative study of three-dimensional saline infusion sonohysterography and diagnostic hysteroscopy for the classification of submucous fibroids

BACKGROUND

The purpose of this study was to compare three-dimensional saline infusion sonohysterography (3D SIS) and diagnostic hysteroscopy for the diagnosis and classification of submucous uterine fibroids.

METHODS

This was a prospective double-blind study of 49 women who presented with a history of menorrhagia, diagnosed on non-enhanced two-dimensional ultrasonography with submucous fibroids. Fibroids were classified on 3D SIS according to the proportion of fibroid contained within the endometrial cavity, using the European Society of Hysteroscopy Classification of Submucous Fibroids. These results were then compared with the findings at diagnostic hysteroscopy.

RESULTS

A total of 61 submucous fibroids was identified in 49 symptomatic women. Diagnostic hysteroscopy confirmed these findings in all cases. There was agreement between the two methods in 11/12 cases of Type 0 fibroids (92%), 34/37 (92%) of Type I fibroids and 9/12 (75%) of Type II fibroids. The overall level of agreement was good with a kappa value of 0.80.

CONCLUSIONS

There is a good overall agreement between 3D SIS and diagnostic hysteroscopy in classification of submucous fibroids. Agreement is better in cases where a greater proportion of the fibroid is contained within the uterine cavity.

Expectant management of tubal ectopic pregnancy: prediction of successful outcome using decision tree analysis

OBJECTIVE

To establish whether a decision tree based on a combination of clinical, morphological and biochemical parameters could be constructed to help in the selection of women with tubal ectopic pregnancies for expectant management.

METHODS

This was a prospective observational study in a tertiary referral early pregnancy unit in an inner city teaching hospital. The study group consisted of 179 women with ultrasound diagnosis of ectopic pregnancy. Demographic, clinical and ultrasound data were recorded in each case at the initial visit. In addition all women had a blood sample taken for the measurements of serum beta-human chorionic gonadotropin (beta-hCG) and progesterone. Clinically stable women with non-viable pregnancies and no signs of hematoperitoneum were managed expectantly on an outpatient basis until their serum beta-hCG declined to <20 IU/L. Women who developed pelvic pain during follow-up and those with non-declining serum beta-hCG were offered surgery.

RESULTS

A total of 107/179 (59.8%) tubal ectopics were considered suitable for expectant management. Ectopic pregnancy resolved spontaneously in 75/107 (70%) women, which was 41.9% of the total number of tubal ectopics. Maternal age, initial serum beta-hCG and progesterone were all significantly different in pregnancies that resolved spontaneously compared to those requiring surgery (P < 0.05). Initial serum beta-hCG level was the best predictor of the outcome of expectant management. These differences enabled a construction of a four-level decision tree to estimate the likelihood of successful expectant management.

CONCLUSIONS

There are significant differences in demographic, ultrasound and biochemical findings between spontaneously resolving ectopics and those requiring treatment. Decision tree analysis may be used as a guide to estimate the probability of successful expectant management in individual cases.

Assessing congenital uterine anomalies: the role of three-dimensional ultrasonography

Congenital uterine anomalies are associated with a range of adverse reproductive outcomes but may also be found incidentally. Their significance in women with normal reproductive histories, who do not have a history of recurrent miscarriage or infertility, has been uncertain. The absence of these data has made it difficult to understand the true significance of congenital uterine anomalies found in women with adverse pregnancy outcomes. The advent of transvaginal three-dimensional ultrasonography has enabled the accurate, non-invasive, outpatient diagnosis of congenital uterine anomalies. It has enabled large-scale screening and morphological analysis of congenital uterine anomalies.

The value of detection of normal ovarian tissue (the 'ovarian crescent sign') in the differential diagnosis of adnexal masses

OBJECTIVE

The aim of the study was to evaluate whether the presence of normal ovarian tissue adjacent to an adnexal tumor (the 'ovarian crescent sign') could assist in the preoperative differential diagnosis of adnexal lesions.

METHODS

This was a prospective observational study including 100 women with a preoperative diagnosis of an adnexal mass. Demographic and biochemical data were collected and all women underwent a detailed transvaginal ultrasound scan. Tumor volume, morphological characteristics and Doppler features were recorded in each case. In addition, the tissue adjacent to the cyst was systematically examined for the presence of normal ovarian tissue. All the findings were compared to the final histological diagnosis.

RESULTS

Sixty-seven (67%) of the cysts removed were benign, nine (9%) were borderline and 24 (24%) women had invasive malignant lesions. Normal ovarian tissue was seen in 58/76 (76%) women with non-invasive lesions, and in one woman (4%) with an invasive malignancy. In the absence of normal ovarian tissue, ovarian cancer was diagnosed with a sensitivity of 96% and specificity of 76%.

CONCLUSION

The presence of normal ovarian tissue adjacent to an ovarian cyst is a useful morphological feature that may be used to help exclude an invasive ovarian malignancy in women with adnexal masses detected on ultrasound scan.

Reproducibility of three-dimensional ultrasound diagnosis of congenital uterine anomalies

OBJECTIVE

To examine the reproducibility of the diagnosis of congenital uterine anomalies and the repeatability of measurements of uterine cavity dimensions using three-dimensional (3D) ultrasound.

METHODS

The reproducibility of diagnosis of congenital uterine anomalies was examined by re-slicing stored 3D ultrasound volumes. Each data set was evaluated by two independent observers. Assessment of uterine morphology was performed in a standardized plane, with the interstitial portions of the Fallopian tubes used as reference points. Additionally, in 35 cases of congenital uterine anomalies the width of the uterine cavity (W), fundal distortion (F) and the length of unaffected uterine cavity (C) were measured. Intraobserver and interobserver variabilities were evaluated by each observer performing all three measurements twice.

RESULTS

Eighty-three 3D ultrasound volumes were examined. Both operators classified 27 uteri as normal, 33 as arcuate, 19 as subseptate and three as unicornuate. A single case of uterine anomaly was described as arcuate uterus by one operator and subseptate by another (kappa 0.97). The intraobserver variability for each of the three measurements (W, F and C) was satisfactory with limits of agreement ranging from +/-1.43 to +/-2.51 mm. The examination of the interobserver variability showed no significant differences between the two observers (F = 0.484, P > 0.05).

CONCLUSION

3D ultrasound is a reproducible method for the diagnosis of congenital uterine anomalies and for the measurement of uterine cavity dimensions.

First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar

OBJECTIVE

To describe first-trimester ultrasound diagnosis and management of pregnancies implanted into uterine Cesarean section scars.

METHODS

All women referred for an ultrasound scan because of suspected early pregnancy complications were screened for pregnancies implanted into a previous Cesarean section scar. The management of Cesarean section scar pregnancies included transvaginal surgical evacuation, medical treatment with local injection of 25 mg methotrexate into the exocelomic cavity and expectant management.

RESULTS

Eighteen Cesarean section scar pregnancies were diagnosed in a 4-year period. The prevalence in the local population was 1 : 1800 pregnancies. Surgical treatment was used in eight women and it was successful in all cases. The respective success rates of medical treatment and expectant management were 5/7 (71%) and 1/3 (33%). Five women (28%) required blood transfusion and one woman (6%) had a hysterectomy.

CONCLUSIONS

Cesarean section scar pregnancies are more common than previously thought. When the diagnosis is made in the first trimester the prognosis is good and the risk of hysterectomy is relatively low.

A comparative study of the morphology of congenital uterine anomalies in women with and without a history of recurrent first trimester miscarriage

BACKGROUND

The true impact of congenital uterine anomalies on reproductive outcomes is unknown. The aim of this study was to examine differences in the morphology of uterine anomalies found in women with and without a history of recurrent miscarriage.

METHODS

A total of 509 women with a history of unexplained recurrent miscarriage and 1976 low risk women were examined for the presence of congenital uterine anomalies by three-dimensional ultrasound. The anomalies were classified according to the American Fertility Society classification. In addition, the size of fundal distortion (F) and the length of the remaining uterine cavity (C) were measured to calculate a distortion ratio (F/F+C). The findings were compared with the measurements obtained in low risk women with an incidental finding of uterine anomaly.

RESULTS

In all, 121 anomalies were detected in the recurrent miscarriage group and 105 in low risk women. There was no significant difference in relative frequency of various anomalies or depth of fundal distortion between the two groups. However, with both arcuate and subseptate uteri, the length of remaining uterine cavity was significantly shorter (P < 0.01) and the distortion ratio was significantly higher (P < 0.01) in the recurrent miscarriage group.

CONCLUSION

The distortion of uterine anatomy is more severe in congenital anomalies, which are found in women with a history of recurrent first trimester miscarriage.

Prediction of early pregnancy viability in the absence of an ultrasonically detectable embryo

OBJECTIVE

To identify clinical, ultrasound and biochemical parameters that may allow prediction of pregnancy viability in women without a detectable embryo on ultrasound examination.

METHODS

This was a prospective observational study of pregnant women with an ultrasound finding of a gestational sac measuring < 20 mm mean diameter without a visible embryo. Women's age, menstrual dates, clinical symptoms (pain and bleeding), mean gestational sac diameter and measurements of serum beta-human chorionic gonadotropin and progesterone were recorded in all cases. All women were managed expectantly until the pregnancy viability was established conclusively based on clinical and ultrasound findings. All parameters were tested by univariate analysis and then analyzed in a stepwise procedure to form a logistic regression model for predicting pregnancy viability.

RESULTS

One hundred and eighteen (59%) women had a normal intrauterine pregnancy and 82 (41%) had a miscarriage. Stepwise analysis showed that three diagnostic parameters (maternal age, gestational sac diameter and serum progesterone) contributed significantly to the predictive power of the logistic model. With this model, at a cut-off value of 10% probability, the diagnosis of viable pregnancy was made with a sensitivity of 99.2% (95% CI, 95.8-99.97) and specificity of 70.7% (95% CI, 61.3-78.9).

CONCLUSION

The use of a logistic regression model allows prediction of pregnancy viability when an embryo cannot be visualized on ultrasound scan.

Chronic lymphocytic leukaemia developing in the course of chronic myeloid leukaemia

Both chronic myeloid leukaemia (CML) and chronic lymphocytic leukaemia (CLL) are rare illnesses. Their co-existence has been previously reported, typically with CML following CLL. We report to our knowledge the first case of CLL developing some years after initial diagnosis of Philadelphia (Ph) chromosome positive CML. We provide molecular evidence that CLL arose in a Ph negative clone. The implications of the findings are discussed.

Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening

OBJECTIVE

To determine reproductive outcomes in women with congenital uterine anomalies detected incidentally by three-dimensional ultrasound.

METHODS

We studied 1089 women with no history of infertility or recurrent miscarriage who were seen for a transvaginal ultrasound scan. They were screened for uterine abnormalities using three-dimensional ultrasound. We determined prevalence of miscarriage and preterm labor in women with normal and abnormal uterine morphology.

RESULTS

We found that 983 women had a normally shaped uterine cavity, 72 an arcuate, 29 a subseptate, and five a bicornuate uterus. Women with a subseptate uterus had a significantly higher proportion of first-trimester loss (Zeta = 4.68, P <.01) compared with women with a normal uterus. Women with an arcuate uterus had a significantly greater proportion of second-trimester loss (Zeta = 5.76, P <.01) and preterm labor (Zeta = 4.1, P <.01). There were no other significant differences in pregnancy outcomes between women with normal and abnormal uterine morphology.

CONCLUSION

This study shows the potential value of three-dimensional ultrasound and confirmed that women with congenital uterine anomalies were more likely to have adverse pregnancy outcomes than women with a normal uterus.

Concentrations of heavy metals in roadside soils, plants, and landsnails from the West Bank, Palestine

Concentrations of Cu, Cd, Pb and Zn were determined in roadside soil, plant and landsnail samples along Nablus-Ramallah main road in the West Bank. Average concentrations (microgram.g-1, dry weight) of the four metals in soil samples were, Cu: 23.8, Zn: 128.3, Cd: 0.45 and Pb: 149.9. These values were higher than those found in soil samples collected from control sites. Metals in roadside plant samples were within normal levels although plants from control sites were found to have slightly less metals. Different parts of a plant (roots, stem & leaves) were found to accumulate metals in different concentrations. The average concentration (microgram.g-1) of metals in different plant parts were: Cu: < 5.2, Cd: < 1.0, Pb: < 2.19 and Zn: < 5.18. Average concentrations (microgram.g-1) of metals in the three roadside snails were ranging between 121-132 for Cu, 18-27 for Cd, 21-24 for Pb and 43-69 for Zn. Snails were found to magnify Cd to serious levels (> 30-50 times higher than in plants and soils). Lead in snails was about 10 times higher than that in plant leaves and much less than that in roadside soils. Other metals in snails did not show abnormal concentrations.

Levels of trace metals and effect of body size on metal content of the landsnail Levantina hierosylima from the West Bank-Palestine

Levels of four trace metals (Cu, Zn, Cd and Pb) were determined in the landsnail Levantina hierosylima from four locations in the West Bank. Average concentration of the metals was 126.9, 42, 20.2 and 19.4 ppm for Cu, Zn, Pb and Cd, respectively. Significant differences in metal concentrations were observed between snails from the four sampling sites (Jerusalem, Abu-Dies, Qarawa, and Taibeh). Differences are most probably due to atmospheric fallout of metals from traffic roads and industrial facilities. Effect of snail size (weight and shell width) on metal content was investigated for the four metals. Plotting metal content against soft tissue weight resulted in significant relationships. Small snails were found to be richer in Zn, Cd and Pb than larger ones. Regression coefficients for the relationships were 0.75, 0.76 and 0.81 for Pb, Cd and Zn, respectively. Copper content was directly related to body weight (regression coefficient = 0.96) indicating that Cu concentration is independent of body weight. Plotting metal content against shell width indicated similar results but with less strong correlation coefficients. L. hierosylima is a promising bioindicator for metal pollution and further laboratory investigations are needed in order to know more about the uptake and release of metals by this organism.

[Burch laparoscopic procedure for repairing proven stress incontinence--report of 32 cases]

There are more than 200 procedures for repairing stress urinary incontinence. We evaluated the safety and efficiency of the Burch laparoscopic procedure in 32 women with urodynamically proven genuine stress incontinence. Mean operating time was 40 minutes and mean hospitalization time after the procedure was 30 hours. The cure rate was 97%, similar to that reported in other studies (80-95%). The major complications were 2 cases (6.2%) of unintended bladder injury, diagnosed and repaired laparoscopically. Although follow-up has only been for 3-42 months, the high cure rate and safety and advantages of laparoscopy over laparotomy, make laparoscopic Burch colposuspension the procedure of choice for repairing stress incontinence.

Human otoacariasis

Accidental entry of insects and other arthropods is a common aetiology of aural foreign bodies (FB) presenting to accident and emergency departments. A retrospective study revealed that the FB in almost half (148) of 348 cases of aural FB investigated at the Universiti Sains Malaysia Hospital was an arthropod. The most common arthropod encountered was the cockroach, followed by a cattle tick. The high prevalence of tick infestation of the human ear canal (i.e. human otoacariasis) currently appears to be unique to the Malaysian state of Kelantan. The presentation of patients with intra-aural ticks, the methods used to remove the ticks, the complications encountered, and recommendations for an appropriate course of action in such cases are discussed.

Natural occurrence of Nocardia in soil of Tucumán: physiological characteristics

This is the first study initiated in Argentina to establish the presence of species of Nocardia from soil samples. These samples were gathered in different areas of Tucumán. Thirty three pathogenic strains of Nocardia were isolated by the paraffin bait method. Out of them, 28 were N. brasiliensis, 3 N. asteroides and 2 N. caviae. N. brasiliensis was widely distributed in the soil of the areas tested. It is proved that N. caviae, so rarely found in other regions of the world, occurs in Tucumán. A detailed study of the morphological and physiological characteristics for identification is discussed.

Relationships between the physiological characteristics and pathogenicity of Nocardia brasiliensis

The analysis of 19 physiological properties of 28 strains of Nocardia brasiliensis isolated from soil reveal differences which could be of great value in distinguishing pathogenic from nonpathogenic strains.

In vivo determination of phagocytic indices and candidacidal activities of Candida species by rat peritoneal macrophages

A possible correlation between pathogenesis and phagocytosis is established through comparison of the kinetics of the ingestion of nine Candida species by rat peritoneal macrophages in the early stages of infection. After 3 h of intraperitoneal injection of 6.10(8) yeasts to Sprague-Dawley rats, the phagocytic indices, candidacidal activity and the fate of the yeasts are assayed. Phagocytic indices allow separation of the species into four groups. Candidacidal activity and phagocytic indices are coincidently smaller in the more pathogenic species. Common events occur with the species assayed. All the yeasts can be isolated from blood, spleen and kidneys from the first h, whilst invasion to liver occurs from the second h post-infection.

In vitro determination of phagocytic indices of Candida berkhout species by rat peritoneal macrophages

The aims of this investigation were to study and describe the behaviour of 13 different species of Candida, as compared with C. albicans, by means of phagocytosis assays in vitro. Tests were carried out with rat peritoneal macrophages in contact with quantified suspensions of live yeasts. Phagocytic indices, candidacidal activity and filamentation rat were tested microscopically after 3 h incubation at 37 degrees C. The phagocytic indices obtained allowed us to separate the fungi into four groups. Candida albicans and tropicalis belong to Group I; diddensii and shehatae, among others, belong to Group II; sake, krusei, viswanathii, etc., Group III; and C. glaebosa and haploid strains of Pichia ohmeri (C. guilliermondii var. membranaefaciens), Group IV. These data would suggest a possible correlation between pathogenesis and phagocytic indices. There were no evidences of any phagocytes ability to kill yeasts. Candidacidal activity was absent in the species assayed. Yeast lysis may have been observed if our assays would have taken longer than 3 h.