Preventing hyponatremic encephalopathy: comparison of serum sodium and osmolality during operative hysteroscopy with 5.0% mannitol and 1.5% glycine distention media.

STUDY OBJECTIVE: To determine whether isotonic 5.0% mannitol is superior to 1.5% glycine in preventing development of hyponatremic encephalopathy. DESIGN: Prospective, comparative study (Canadian Task Force classification II=2). SETTING: Gynecology department of a community hospital. PATIENTS: One hundred twenty-two women undergoing operative hysteroscopy. INTERVENTIONS: Eighteen blood serum chemical indicators analyzed preoperatively and postoperatively in 61 women undergoing operative hysteroscopy with 1. 5% glycine (group 1) were compared with those of 61 women having similar surgery with 5.0% mannitol (group 2). Fluid deficit (difference between input and output volume of distention fluid) was recorded, and differences between presurgical and postsurgical indicators of the two groups (mean difference score) were compared. MEASUREMENTS AND MAIN RESULTS: Mean +/- SEM sodium difference scores of groups 1 and 2 were -1.73 +/- 0.42 mEq/L (range -7.00 to 2.00 mEq/L) and -5.04 +/- 1.07 mEq/L (range -36.00 to 3.00 mEq/L), respectively (p <0.01). Serum osmolality difference scores were -6. 88 +/- 1.36 mmol/L (range -13.00 to -1.00 mmol/L) and -1.87 +/- 0.35 mmol/L (range -3 to 15 mmol/L), respectively (p <0.01). Distention fluid deficits were 0.435 +/- 0.071 L (range 0-2.448 L) and 0.473 +/- 0.084 L (range 0-3.640 L), respectively (p = 0.862). Two women (3.4%) in group 1 and five (8.2%) in group 2 developed postoperative asymptomatic dilutional hyponatremia (p = 0.211), which was the only complication. Two of the five women in group 2 developed severe dilutional hyponatremia. CONCLUSION: We found that 5.0% mannitol distention fluid produces greater postoperative dilutional hyponatremia than 1.5% glycine, but hypo-osmolality does not occur with mannitol. Its use should lessen the risk of hyponatremic encephalopathy.

Experience with laparoscopic leiomyoma coagulation and concomitant operative hysteroscopy.

STUDY OBJECTIVES: To evaluate the experiences of women who underwent laparoscopic leiomyoma coagulation (myolysis) alone and those who had myolysis in conjunction with transcervical endomyometrial resection (TEMR), transcervical electrosurgical resection of submucous leiomyomas (TSR), or both. DESIGN: Continuing, prospective observational study with mean (+/- SEM) follow-up of 36.0 +/- 1.2 months (range 18-54 mo). SETTING: Gynecology department of community and teaching hospitals. PATIENTS: One hundred sixty-seven women with symptomatic leiomyomata. INTERVENTIONS: Women complaining of pressure, pain, or both underwent only myolysis. Those with the additional symptom of chronic menorrhagia underwent TEMR, TSR, or both. Nineteen (11.4%) of the 167 women had elective second-look laparoscopy 6.0 +/- 0.3 months (range 6-8 mo) later to evaluate possible adhesion formation. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were control of symptoms, numbers and types of concomitant and subsequent procedures, changes in uterine and leiomyomata volumes, and number of successful pregnancies. Mean total uterine volume of the 167 women decreased from 620 +/- 28.4 cm3 before leuprolide treatment to 131 +/- 7.2 cm3 by 7 to 12 months postoperatively (p <0.0001). Five (3.6%) women had hysterectomies for persistent or recurrent menorrhagia, pain, pressure, or a combination of symptoms (p = 0.01). Pathologic evaluation revealed adenomyosis, leiomyomata, or both. Of 52 women with chronic menorrhagia, 33 (63.5%) developed amenorrhea and 17 (32.7%) developed hypomenorrhea or eumenorrhea; 2 (3.8%) required repeat TEMR. The two women who desired to retain fertility had uncomplicated full-term pregnancies and uneventful vaginal deliveries. CONCLUSIONS: Myolysis alone or in conjunction with TEMR, TSR, or both obviated the need for major surgery in 162 (97.0%) women. Until further studies are concluded, myolysis should be performed selectively in women contemplating pregnancy.

The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial.

OBJECTIVE: To assess the force needed to mechanically dilate the cervix of a nonpregnant woman after intracervically injecting dilute (0.05 U/mL) vasopressin solution. METHODS: In a randomized, double-blind study, equal amounts of either a dilute vasopressin solution or placebo (normal saline) were injected into the intracervical stroma at 4- and 8-o'clock positions, just beneath the mucosal surface, in 52 women immediately before cervical dilatation in preparation for operative hysteroscopy. When vasopressin solution was used, 20 mL of a dilute solution (4 U of 0.05 U/mL of vasopressin in 80 mL of normal saline) was injected. An electronic strain gauge and load cell were used to measure the peak linear force needed to dilate the cervix from 3 mm to 11 mm, using half-size metal dilators. RESULTS: The mean (+/- standard error of the mean) total peak linear force needed to dilate the cervix from 3 to 11 mm in the treated (vasopressin) and control (placebo) groups was 20.29 +/- 1.22 lb (range 5.54-40.82) and 37.05 +/- 2.55 lb (range 6.11-52.2), respectively, a statistically significant difference. The mean total peak linear force needed to dilate the cervix in the treated group and in the control group in 0.5-mm increments from 3 to 11 mm was 1.14 +/- 0.07 lb (range 0.81-1.69) and 2.08 +/- 0.07 lb (range 1.64-2.43), respectively, also a statistically significant difference. With increasing parity, significantly less force was needed to dilate the cervix from 3 to 11 mm in the treated group than in the control group (P < .001). CONCLUSIONS: Administration of dilute vasopressin solution (0.05 U/mL) to the cervical stroma significantly reduces the force needed to dilate the cervix.

Relationship of endometrial thickness with the menstrual timing of leuprolide acetate administration for preoperative preparation for hysteroscopic surgery.

STUDY OBJECTIVES: To assess the relationship of menstrual timing of administration of gonadotropin-releasing hormone (GnRH) agonist on the effectiveness of endometrial thinning and unwanted uterine bleeding. DESIGN: Prospective observational study. SETTING: Gynecology department of a community hospital. PATIENTS: One hundred consecutive women in a private practice, without submucous myomas, scheduled for transcervical endomyometrial resection or ablation. INTERVENTIONS: A GnRH agonist was administered at an unspecified time of the menstrual cycle. Transcervical hysteroscopic endomyometrial resection or ablation was performed 1 month later. MEASUREMENTS AND MAIN RESULTS: No significant statistical differences were seen in either the effectiveness of endometrial thinning or the occurrence or severity of unwanted uterine bleeding. CONCLUSIONS: A GnRH agonist as pretreatment for endomyometrial resection or ablation can be administered at any time during the menstrual cycle with similar efficacy. Timing of surgery can be at the mutual convenience of patient and physician.

The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: a randomized controlled trial.

OBJECTIVE: To assess the effect of intracervical injection of dilute (0.05 U/mL) vasopressin solution on blood loss during operative hysteroscopy. METHODS: In a randomized, double-blind study, dilute vasopressin solution or placebo (normal saline) was injected into the cervical stroma of 106 women before dilation of the cervix in preparation for operative hysteroscopy. Intraoperative bleeding was calculated by dividing the number of red blood cells per milliliter of outflow distention fluid by the number of red blood cells per milliliter of the woman's blood immediately before the procedure and multiplying this quotient by the total amount of outflow fluid collected. Pressures were kept constant with a hysteroscopic infusion pump. RESULTS: The mean (+/-standard error of the mean) intraoperative blood loss of the treated (vasopressin) and control (placebo) groups was 20.3 +/- 4.1 mL (range 0-135) and 33.4 +/- 5.4 mL (range 0-290), respectively. The volume of distention fluid intravasation in the treated and control groups was 448.5 +/- 47.0 mL (range 30-1410) and 819.1 +/- 79.7 mL (range 20-1977), respectively. The operating time in the treated and control groups was 31.1 +/- 1.2 minutes (range 18-52) and 34.1 +/- 1.3 minutes (range 19-65), respectively. For all three outcome measures, the differences between the two groups were statistically significant, but for visual clarity of the uterine cavity during surgery, the difference was not significant. CONCLUSION: Administration of dilute vasopressin solution (0.05 U/mL) to the cervical stroma significantly reduces blood loss, distention fluid intravasation, and operative time during hysteroscopy. Further evaluation is required to determine the optimum dosage.

Laparoscopic bipolar coagulation for the conservative treatment of adenomyomata.

STUDY OBJECTIVE: To assess the effectiveness of treating adenomyomata with laparoscopic bipolar coagulation. DESIGN: Prospective, observational study. Setting. The gynecology department of a community hospital. PATIENTS: Ten women, each with severe dysmenorrhea, chronic menorrhagia, and adenomyomata diagnosed by magnetic resonance imaging. INTERVENTIONS: Laparoscopic bipolar coagulation of adenomyomata. MEASUREMENTS AND MAIN RESULTS: The mean (+/- SEM) total adenomyoma volume before leuprolide acetate administration was 119 +/- 16 cm3 (range 6-190 cm3); after 3 months of therapy this was reduced to 86 +/- 8 cm3 (range 6-162 cm3, p <0. 0001) a 27.7% reduction. Further reduction occurred 7 to 12 months postoperatively to 31 +/- 3.4 cm3 (range 3-155 cm3, p <0.0001), a 73.9% reduction from baseline. Twelve months postoperatively, seven (70.0%, p <0.05) women had continued resolution or significant reduction of dysmenorrhea and resolution of menorrhagia. One woman (10.0%) with unresolved dysmenorrhea and menorrhagia required hysterectomy, and two (20.0%) with recurrent menorrhagia required resection of the endomyometrium; one continued to have menorrhagia but refused further surgical or medical treatment. CONCLUSIONS: Conservative treatment obviated the need for major surgery in 90% of women with adenomyomata, but further evaluation of this technique is necessary to determine its definitive role.

Magnetic resonance imaging for diagnosing adenomyomata.

STUDY OBJECTIVES: To evaluate the accuracy of magnetic resonance imaging (MRI) for diagnosing nodular adenomyosis by percutaneous myometrial biopsies. DESIGN: Prospective observational study. SETTING: Gynecology department of community hospitals. PATIENTS: Twenty women with severe dysmenorrhea, chronic menorrhagia, and an MRI diagnosis of adenomyomata. INTERVENTIONS: Several laparoscopically guided, percutaneous myometrial biopsy specimens were taken in an attempt to confirm histologically an MRI diagnosis of adenomyoma; and resectoscopic endomyometrial biopsy specimens were taken in an attempt to confirm an MRI diagnosis of adenomyosis. MEASUREMENTS AND MAIN RESULTS: Eighteen (90%) of the 20 women had an MRI diagnosis of adenomyosis histologically confirmed by myometrial biopsy. The remaining two (20.0%) had an MRI diagnosis of adenomyosis histologically confirmed by endomyometrial biopsy. CONCLUSIONS: An MRl diagnosis of adenomyoma was confirmed by transabdominal uterine biopsy in most patients. These results, when combined with those obtained by resectoscopic endomyometrial biopsy, established a diagnosis of adenomyosis in all patients.

100 laparoscopic hysterectomies in private practice and visiting professorship programs.

STUDY OBJECTIVE: To evaluate 100 laparoscopic hysterectomies and their variations in private practice and visiting professorship programs. DESIGN: A prospective observational study. SETTING: Gynecology departments of 17 teaching, community, and proprietary hospitals in the northeastern United States. PATIENTS: One hundred women who successfully underwent laparoscopic hysterectomy, 91 of whom were followed for 6 months. INTERVENTIONS: From July 1990 to August 1994, 108 women (mean age 41.6 yrs, range 38-68 yrs) for whom a vaginal hysterectomy was relatively contraindicated underwent a hysterectomy attempted by the laparoscopic route. The most common indications for hysterectomy were pelvic pain, chronic menorrhagia, and uterine leiomyomas. The women were classified according to hysterectomy, with groups comparable in age, weight, uterine size and weight, concomitant surgery performed, uterine and coexisting pathology, and history of pelvic surgery. Of the 108 women, 35 had laparoscopic hysterectomies (LH), 56 had laparoscopic-assisted vaginal hysterectomies (LAVH), and 9 had subtotal laparoscopic hysterectomies (SLH). Eight procedures were converted to laparotomy, two attempted LHs and six attempted LAVHs. In 22 cases, bipolar coagulation of vascular pedicles was done exclusively, in 58 the Endo GIA 30 stapler was used exclusively, and in 20 a combination of both modalities was used. Bilateral ureteral catheters were inserted 49 times. MEASUREMENTS AND MAIN RESULTS: There were eight complications (8.0%): two blood transfusions, two cases of transient, asymptomatic pyrexia, two abdominal wall hematomas, one Richter hernia, and one urinary tract infection. The hernia repair was the only delayed laparotomy. The mean (+/-SEM) surgical time was 123 +/- 8 minutes (range 45-235 min), and the mean hospital stay was 1.48 days +/- 0.4 (range 1-5 days). Ninety-five of the 100 women who successfully underwent a laparoscopic procedure returned to work within 2 weeks (range 4-14 days, range 15-53 days for the remaining 5). CONCLUSION: Hysterectomy performed or aided by the laparoscope, whether LH, LAVH, or SLH, is effective and safe as long as at least one member of the surgical team is an experienced and appropriately trained laparoscopic surgeon. Further studies are necessary to determine if the credentialing process for advanced laparoscopic surgery would be facilitated by a visiting professorship program.

Transcervical electrosurgical resection of submucous leiomyomas for chronic menorrhagia.

STUDY OBJECTIVE: To evaluate the effectiveness and safety of transcervical electrosurgical resection (TSR) of submucous leiomyomas with or without concomitant transcervical endomyometrial resection (TEMR) for chronic menorrhagia. DESIGN: Prospective observational study, with 6-month follow-up of all 208 women and up to 6-year follow-up of 185 (88.9%). SETTING: Gynecology departments of teaching, community, and proprietary hospitals. PATIENTS: Two hundred eight women with submucous leiomyoma requiring surgical treatment of menorrhagia between March 1988 and March 1994. INTERVENTIONS: All 208 women (age range 32-63 yrs) underwent TSR with a continuous-flow gynecologic resectoscope. In 88 of these women who had no desire to preserve fertility, concomitant TEMR was performed. MEASUREMENTS AND MAIN RESULTS: Six months postoperatively 113 (94.2%) of the 120 women who underwent only TSR reported normal menses and 85 (96.6%) had satisfactory results; 62 (70.5%) who had both TSR and TEMR were amenorrheic. Eleven (73%) of the 15 women who had TSR and wanted to conceive subsequently became pregnant. One hundred eighty-five (88.9%) of the 208 patients have been followed for as long as 6 years. Ninety (84.1%) of the 107 women who had only the initial TSR and 69 (88.5%) of the 78 who had initial TSR and TEMR had satisfactory results. Only five women (2.7%) required major abdominal surgery. Among those undergoing TSR and TEMR, 49 (62.8%) were amenorrheic for as long as 6 years after TSR and one or two TEMRs. Eight (3.8%) of the 208 women had perioperative complications: 6 (2.9%) had fluid overload, 1 (0.5%) had dilutional hyponatremia, and 1 (0.5%) had excessive postoperative bleeding requiring tamponade. CONCLUSIONS: We believe that TSR with or without concomitant TEMR is an effective and safe treatment for women with submucous leiomyomas suffering from chronic menorrhagia.

Paracervical block with 2-chloroprocaine.

Thirty healthy term gravidas in active labor received a paracervical block (PCB) with the ester-type local anesthetic, 2-chloroprocaine (2CP). Good to excellent pain relief resulted in all but 1 case. The duration of action was short (mean 38.9 min), requiring repeat blocks in 6/30 cases. Fetal heart rate and uterine contractions were electronically monitored, and fetal acid-base status was periodically checked by fetal scalp pH measurements. PCB-related fetal bradycardia was observed in 3 cases, but in only 1 case was PCB the only cause for the bradycardia. Fetal acidosis was not observed. No instance of neonatal depression or acidosis as expressed by the 1- and 5-minute Apgar scores and cord blood acid-base evaluation was observed. No maternal complications were observed. It is concluded that paracervical block using 2CP is an effective though short-acting method of pain relief which, when properly monitored, is safe for both mother and fetus.

Interlocking twins. Experience with four cases and suggested management.

Experience with the management of 4 pairs of locked twins is described and analyzed. In view of the high morbidity figures a proposed preemptive management is suggested.