Analgesic efficacy of continuous wound infiltration compared with continuous intravenous fentanyl after gynaecological surgery: a non-inferiority, randomised controlled trial

OBJECTIVE

The present trial aimed to prove the non-inferiority of the analgesic efficacy of continuous wound infiltration (CWI) to that of continuous intravenous fentanyl (IV) and to compare the safety of the two methods.

METHODS

This trial was a prospective, single-centre, two-arm, non-inferiority, randomised controlled trial. Patients participating in the trial were randomised to a CWI group or an IV group. The VAS (visual analogue scale), additional analgesic usage and side effects were then compared between the groups.

RESULTS

In total, 61 patients were enrolled; two in CWI were excluded, leaving 59 (30 in the CWI group and 29 in the IV group) for analysis. The difference in the VAS score at 24 h (CWI group - IV group) was -3.2 (95% confidence interval [CI] -14.7 to 8.2), which was less than the non-inferiority margin of 15. The mean amount of total fentanyl use at postoperative hour 48 was 1395 (95% CI 886-1903) µg in the CWI group and 3186 (95% CI 2716-3658) µg in the IV group. The amount of other analgesics and the incidence of adverse effects did not differ significantly between the groups.

CONCLUSION

CWI was non-inferior to IV in terms of its analgesic effect, and has an opioid sparing effect in open gynaecological surgery.

Longitudinal assessment of anti-Müllerian hormone after cesarean section and influence of bilateral salpingectomy on ovarian reserve

OBJECTIVE

This study aimed to compare longitudinal changes in ovarian reserve markers after cesarean section (CS) with and without bilateral salpingectomy (BS).

STUDY DESIGN

We prospectively enrolled women >35 weeks' gestation scheduled for CS alone or CS + BS and obtained blood samples for anti-Müllerian hormone prior to surgery and at 3 and 6 months after surgery. At the 3-month visit, we similarly performed transvaginal ultrasound for antral follicle count.

RESULTS

We enrolled 50 women; 30 underwent CS only and 20 underwent CS + BS. Although anti-Müllerian hormone level increased over 6 months of follow-up in both groups, no clinically important differences in the geometric mean (interquartile range) (ng/mL) were observed at any timepoint (baseline [0.69 {0.36-1.21} {CS only} vs 0.49 {0.32-2.10} {CS + BS}, p = 0.64]; 3 months [1.35 {0.58-3.13} vs 1.45 {1.04-2.25}, p = 0.79]; and 6 months [1.74 {0.93-4.45} vs 2.60 {1.41-5.10}, p =0.27]). Similarly, we detected no difference in antral follicle count.

CONCLUSION

BS at the time of CS does not have a negative impact on ovarian reserve 6 months after surgery.

IMPLICATION

While our results provide reassuring data that bilateral salpingectomy for permanent contraception at the time of cesarean section does not impact ovarian reserve, longer adequately powered studies are needed.

Patients' need for information on permanent contraception during a cesarean section: A cross-sectional questionnaire survey

AIM

The present study aimed to explore the need for information about permanent contraception in Japanese women with repeated cesarean sections (CS).

METHODS

The present, cross-sectional survey used a self-administered questionnaire mailed to women with a second or later CS at Tokyo Metropolitan Tama Medical Center between March 2010 and December 2017. Those who were pregnant, had given birth less than 1 year before the survey or had an hysterectomy were excluded.

RESULTS

The present study analyzed 284 patients (60 with permanent contraception, 224 without permanent contraception). Forty-eight (80%) of women with permanent contraception, and 135 (60%) of women without permanent contraception believed that information on permanent contraception was needed before CS. Among women without permanent contraception, significantly fewer women obtained adequate information of permanent contraception from their healthcare workers before a CS compared with women with permanent contraception (8% vs. 71%, p < 0.001). A higher rate of unreliable contraceptive use (41%) and unintended pregnancies (4%) after the latest CS were found among the women without permanent contraception.

CONCLUSIONS

A large portion of the study cohort wished they had received information on permanent contraception before CS; however, the patients without permanent contraception had limited access to this information. Adequate information about permanent contraception should be provided to women planning a CS to enable them to make an informed decision with respect to the treatment.

Relationship between the precursors of high grade serous ovarian cancer and patient characteristics: decreased incidence of the p53 signature in pregnant women

Objective

To investigate the relationship between the precursors of high grade serous ovarian cancer (HGSOC) and the characteristics of patients with a low HGSOC risk in terms of the effects of pregnancy.

Methods

We prospectively examined consecutive cases in which the bilateral fallopian tubes were removed during benign gynecological or obstetric surgery and assessed the relationship between the patient characteristics, including parity and pregnancy, and the incidence of HGSOC precursors. All the fallopian tubes were examined by applying the Sectioning and Extensively Examining the Fimbriated End (SEE-FIM) Protocol.

Results

Of the 113 patients enrolled, 67 were gynecological and 46 were obstetric. The p53 signature was identified in 21 patients. No other precursors were identified. In a comparison of the p53 signature-positive and negative groups, parous women and pregnant women were significantly fewer in the p53 signature-positive group (53% vs. 86%, p=0.002, 10% vs. 47%, p=0.001, respectively). Current pregnancy was also associated with a significantly lower incidence of the p53 signature after multivariate adjustment (odds ratio [OR]=0.112; 95% confidence interval [95% CI]=0.017–0.731; p=0.022). Among gynecological patients, parous women were fewer in the p53 signature-positive group on univariate (47% vs. 73%, p=0.047) and multivariate analysis (OR=0.252; 95% CI=0.069–0.911; p=0.036). No other characteristics were associated with p53 signature positivity.

Conclusions

The incidence of the p53 signature was significantly lower in parous women and pregnant women. This decreased incidence of early phase serous carcinogenesis may be one of the possible mechanisms underlying HGSOC risk reduction among parous women.

Management of labor and delivery in myasthenia gravis: A new protocol

AIM

Pregnancy with myasthenia gravis (MG) is known to be associated with an increased cesarean section rate, presumably due to maternal fatigue during labor. Although epidural labor analgesia (ELA) appears to be a good option for circumventing maternal fatigue, a protocol for managing MG deliveries has not been established. This study, based on a review of our case series, aimed to evaluate the validity of our management protocol for maternal MG, in which ELA is used depending on MG severity.

METHODS

Parturients with systemic muscle weakness or worsening symptoms were classified as Category A (A), and those without symptoms were classified as Category B (B). In A, ELA was given at the onset of labor. Immediate vacuum delivery was done once the fetal head descended to station +2. For B, spontaneous vaginal delivery was chosen. The duration, blood loss, fetal weight, Apgar score and MG symptoms on post-partum day (PPD) 1, 14 and 30 were recorded.

RESULTS

Six patients were enrolled. Four were classified in A, and two were classified in B. No adverse events occurred during labor. Transvaginal delivery was successfully achieved in all the patients. Symptoms of MG were well-controlled. MG symptoms were stable on PPD 1 in all the patients although two patients complained of worsening symptoms after PPD 14.

CONCLUSION

Women with MG can safely undergo spontaneous or operative vaginal delivery. ELA is a good option for circumventing the effects of maternal fatigue on delivery. Our protocol may lower the cesarean section rate in maternal MG.

Surgical removal of an isolated femoral metastasis of uterine cervical squamous cell carcinoma: a case report and review of the literature

A bone metastasis from uterine cervical cancer normally indicates short life expectancy. Resection of the lesion is therefore palliative. The authors consider herein whether surgical resection can promote disease control while improving quality of life. A 33-year-old woman -presenting FIGO Stage IB 1 uterine cervical squamous cell carcinoma underwent a radical hysterectomy and pelvic irradiation. Twenty-two-months later, a solitary femoral metastasis was detected. Given the pain, imminent bone fracture, the patient's relative youth, absence of other metastases, and complete control of the primary lesion, wide excision of the lesion, and reconstruction were performed. Sixteen months later, she was disease-free and ambulatory using a cane. The findings of both the present case and the review showed that patients were disease-free for over one year after surgery, suggesting that resection may assist disease control as well as improve patients' quality of life.

Adnexal torsion of mature cystic teratoma with hemorrhagic infarction: helpful findings on successive plain abdominal radiographs

Adnexal torsion is a relatively rare cause of lower abdominal pain in women, but in many cases it leads to a serious condition. We present a case of adnexal torsion of a mature cystic teratoma in which hemorrhagic infarction was reflected by progressive enlargement and wall thickening on successive plain abdominal radiographs. There has been no other report describing such changes of adnexal torsion on plain abdominal radiographs.

3D analysis of cracking behaviour under indentation in ion-irradiated beta-SiC

To provide a microstructural basis for evaluating fracture toughness by an indentation test, a new method to analyse three-dimensional (3D) cracking behaviour in beta-SiC is developed. As an example, the effect of ion irradiation on crack propagation was studied. The sequential cutting-out of thinned sections by focused ion beam (FIB) processing around an indentation impression enabled the reconstruction of the 3D behaviour of cracking near the indentation impression. The FIB processing has an advantage in making finely polished thin sections for scanning electron microscopy (SEM)/transmission electron microscopy without damaging the structure near cracks. In the present work, the procedure of cross-sectioning and the results of crack propagation analysis in beta-SiC by SEM inspection are described.

Microstructural analysis of the deformation range under nano-indentation in beta-SiC

As a powerful tool to analyse microstructural evolution under irradiation and the interaction of moving dislocations with radiation-induced defects, a focused ion beam (FIB) method was applied to ion-irradiated SiC followed by the nano-indentation test. An FIB method has excellent capability to prepare thin foils from the area of interest with a high accuracy of location and wide flexibility in the sampling direction. These advantages are demonstrated in the application to Si ion-irradiated SiC by transmission electron microscope observation.

Application of FIB with micro pick-up to microstructural study of irradiated SiC/SiC composites

The combination of focused ion beam (FIB) micro-processing and the lift-out technique using the micro pick-up system was applied to the preparation of TEM specimens of irradiated SiC/SiC composites. The deformation caused by microstructural evolution was observed in the pyrolitic carbon interphase, and several helium bubbles and cavities were detected in the CVI matrix.