Evaluation of surgical condition during laparoscopic gynaecological surgery in patients with moderate vs. deep neuromuscular block in low-pressure pneumoperitoneum.

INTRODUCTION: The significant effect of deep neuromuscular block (NMB) in laparoscopic surgery is still controversial, especially in lower-pressure pneumoperitoneum. This study investigates the effect of deep neuromuscular block on intraabdominal pressure (IAP), surgical space quality, post-operative abdominal pain, and shoulder tip pain in laparoscopic gynaecological surgery. MATERIAL AND METHODS: This is a randomised, double-blinded control trial which randomised samples to moderate NMB (train-of-four count [TOF] of 1 or 2) or deep NMB (post-tetanic count [PTC] of 1 or 2). Surgery began with IAP 8 mmHg but was allowed to increase the pressure if the surgical condition was unfavourable. The surgical condition was rated on a 4-point scale. Post-operative abdominal pain and shoulder tip pain was assessed using a numerical rating scale for pain, with 0 defined as no pain and 10 severe pain at recovery area (time 0), 30 minutes, and 24 hours post-operation. RESULTS: Seventy patients completed the study. The rate of increasing IAP between the 2 groups ( P = 0.172) is not significant, but deep NMB requires less pressure - mean highest IAP of 10.31 (± 1.39) mmHg, moderate NMB 11.54 (± 1.69) mmHg. The mean surgical space condition score was significantly better in the deep NMB group at 2.4 (± 0.7) compared to moderate NMB at 3.2 (± 0.66), P < 0.005. There was a significantly lower post-operative abdominal pain score in deep NMB but no significant difference in shoulder tip pain score between the 2 groups. CONCLUSIONS: Deep NMB enables the usage of lower IAP in laparoscopic surgery without interfering with surgical space condition, and it reduces the post-operative abdominal pain score in 24 hours compared to moderate NMB.

Comparison between hCG and GnRH Agonist for Ovulation Trigger in GnRH Antagonist In-Vitro Fertilization Cycles in a Tertiary Hospital in Malaysia: An observational study.

OBJECTIVE: hCG is commonly used as an ovulation trigger in IVF. Its usage is associated with OHSS. GnRH agonist is an alternative to hCG and is associated with reduced incidence of OHSS. This study compared the cycle outcomes of GnRH agonists with hCG as an ovulation trigger in IVF cycles. METHODS: The medical notes of 209 IVF cycles receiving GnRH agonist and hCG as ovulation trigger over 18 months were reviewed in this retrospective study. The number and quality of mature oocytes, the number and quality of embryos, pregnancy rates, and outcomes were compared using Independent T-test or One-way ANOVA for normal distribution. The Mann-Whitney test or Kruskal-Wallis test was used for not normally distributed. p<0.05 was considered statistically significant. RESULTS: The cycle outcomes of 107 GnRH agonist-trigger and 102 hCG-trigger were compared. The MII oocytes retrieved and 2PN count was significantly higher in the GnRH agonist trigger group (p<0.001). Clinical pregnancy rate and ongoing pregnancy were higher in the GnRH agonist trigger group but were not statistically significant. The GnRH agonist trigger group was associated with low OHSS than the hCG trigger group (n=2(1.9%) and n=12(11.8%) respectively, p=0.004). CONCLUSION: GnRH agonist trigger is an option as a final maturation trigger in high-responder women undergoing IVF or ICSI cycles.

A rare cause of acute abdomen in a paediatric patient: A case report of a twisted ovarian cyst.

Ovarian cysts are rare in children. Their common presentation is acute abdomen, which can be a life-threatening event that needs emergent investigation and intervention. Herein, we report a gynaecological case of a twisted ovarian cyst in an 11-year-old girl who presented to the emergency department with sudden-onset generalised abdominal pain. Multiple strong analgesics were prescribed, and pain-controlled analgesia was then started. Abdominal ultrasound revealed a left adnexal mass, and abdominal computed tomography showed a non-enhancing soft tissue tumour with multiple cystic components in the pouch of Douglas. The patient underwent emergency laparotomy, which revealed a gangrenous left ovarian mass measuring 9x5 cm that was twisted five times. Histopathology showed extensive haemorrhagic infarction with no remnant of viable tissue, consistent with a twisted ovary. It was challenging to determine the origin of the pain in this patient, as thorough examination could not be performed because she was in severe pain. Abdominal ultrasound helps guide diagnosis, as a gynaecological cause is rare in premenarchal children. A vigilant assessment is important to avoid delays in diagnosis and emergency intervention.

A 10-Year Review of Methotrexate Treatment for Ectopic Pregnancy in a Malaysian Tertiary Referral Hospital.

Background Ectopic pregnancy was recorded as the fourth principal cause of maternal death in Malaysia in 2019. Early diagnosis and use of methotrexate treatment proved to be safe and effective alternatives to surgical treatment. This study investigates the success rate of methotrexate treatment for ectopic pregnancy in a tertiary hospital in Malaysia. Methods This was a retrospective review of 73 patients with ectopic pregnancies treated with methotrexate according to a single-dose protocol from January 2009 until November 2019. The diagnosis of ectopic pregnancy was made using a combination of transvaginal scan and serial serum ß-hCG levels. Their clinical and demographic data were reviewed. Serum ß-hCG levels were measured at pre- and post-treatment to determine the rate of successful resolution. Results The overall success rate was 87.7% (64/73 patients) with methotrexate treatment. Fifty-six patients (76.7%) were successfully treated with a single dose of methotrexate, and eight patients (11.0%) required a second dose of methotrexate. There was no relation between socio-demographic, pre-treatment ß-hCG levels, ectopic mass size, and treatment efficacy. Smaller size of ectopic pregnancy (adjusted OR=29.23; 95% CI: 2.69, 317.90; P=0.006) and absence of free fluid at the pouch of Douglas (POD) (adjusted OR=27.31; 95% CI: 2.84, 262.32; P=0.004) was found to increase the likelihood of overall treatment success. Absence of fetal cardiac activities was found to increase the likelihood of first-dose methotrexate treatment success (OR=10.20; 95% CI: 1.93, 53.79; P=0.006). Conclusions Early diagnosis of ectopic pregnancy may reduce morbidity and mortality. In carefully selected cases, methotrexate treatment has been proven to be cost-effective and avoided risks associated with surgery and anaesthesia.