Unplanned Cesarean delivery is associated with risk for postpartum depressive symptoms in the immediate postpartum period.

PURPOSE: Postpartum depression (PPD) is a common pregnancy complication. The association between cesarean delivery (CD) and PPD has shown conflicting results in prior studies, although emergent CD appears to be a clear risk factor. Establishing PPD risk is critical and may, however, be related to the unplanned nature of the CD, rather than the surgery itself. Our objective was to determine whether women who underwent unplanned CD were more likely than those with vaginal delivery to have higher depressive symptoms and thus screen positive for PPD risk in the immediate postpartum period. MATERIALS AND METHODS: This cohort study was conducted at a community medical center using data for deliveries between 8/2015-1/2016. Women were screened in the hospital for depressive symptoms (PPD risk) using the Edinburgh Postnatal Depression Scale (EPDS) within 4 days post-delivery. Logistic regression, adjusting for maternal race/ethnicity and parity, was performed to evaluate the association between delivery route (vaginal vs planned vs unplanned CD) and PPD risk (EPDS ≥ 10). RESULTS: A total of 2094 women had complete data for analysis. Overall, 44 women (2.1%) screened positive for PPD risk. Logistic regression results showed that unplanned CD was significantly associated with PPD risk (OR = 2.28, 95% CI 1.13-4.57, p = .022), after adjusting for parity and race/ethnicity. Planned CD was not associated with PPD risk. CONCLUSION: Unplanned CD may be an independent risk factor for PPD risk in the immediate postpartum period. This finding might explain why some previous studies have demonstrated different results with regards to risk of CD where the unplanned nature of the delivery was not accounted for.

Gasless versus conventional laparoscopy.

The objective of our study was to evaluate the technical advantages of using the Laparolift device and examine the clinical benefits of gynecologic laparoscopy without pneumoperitoneum. A randomized single-blinded clinical trial was performed employing a sample of 30 consecutive patients undergoing laparoscopic gynecologic surgery with a primary outcome measure of visualization. Visualization was found to be inferior in gasless patients. The conclusion was that conventional laparoscopy employing pneumoperitoneum provides surgical exposure superior to that offered by the Laparolift device.

Gallstones implanting in the ovary. A complication of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the treatment of choice for most patients with cholelithiasis. The spillage and loss of gallstones into the peritoneal cavity is a relatively common event occurring during these procedures and has generally been thought to be of little consequence. Although in many cases this does appear to be true, there are uncommon but nevertheless noteworthy sequelae being described. Complications reported have included intraperitoneal abscesses; foreign body granuloma formation; and, more rarely, cholelithiasis of the ovary. We present the case of a 30-year-old woman, who underwent diagnostic laparoscopy for infertility 20 months following a laparoscopic cholecystectomy. Gross findings showed tissue deposits that suggested a malignant tumor. Microscopic findings revealed gallstones embedded in the ovaries and the pelvic peritoneum. To our knowledge, this is the longest reported persistence of gallstones involving the ovary. A full case report is presented, and the possible complications of lost laparoscopic gallstones are reviewed.

The role of endoscopy in the management of the infertile patient.

As newer technologies are incorporated into the field of gynecologic surgery, we must know their limitations, and be able to ascertain their true efficacy with certainty. This is especially important when we make decisions with and for our patients, which may affect their future fertility. This review was written with this important goal in mind.

Preoperative and postoperative treatment of the gynecologic patient.

The gynecologic practice has seen an increasing expansion into the field of endoscopy, with a marked decrease in postoperative complications. Patients are having surgery on an outpatient basis with small incisions, decreased medication requirements, and rapid ambulation. However, we must still be prepared to treat patients for whom this newer technology is not indicated. With our increasing longevity will come an increase in the population of patients who will be at increased operative risk. Many recent reports have centered on the need for careful patient selection and education, preoperative laboratory and radiologic evaluation, and medical prophylaxis. The surgeon must be sure that reasonable low-risk evaluation and care has been taken preoperatively to avoid intraoperative and postoperative morbidity and mortality.

An animal study of different treatments to prevent postoperative pelvic adhesions.

A study was designed to test various high-molecular-weight solutions in the prevention of postoperative intraabdominal adhesions. The bicornuate rat uterus was used as the surgical model, and 80 mature white female rats underwent surgical injury of the right uterine horn. The rats were randomly divided into 5 groups: groups A, B, and C received 5 ml intraperitoneally of chondroitin sulfate, sodium carboxymethylcellulose, and 32% dextran 70, respectively; group D was treated with microsurgical repair; and group E, the control, received no therapy. The animals were killed postoperatively, and the adhesions were scored. Significantly better results in adhesion prevention were demonstrated in the sodium carboxymethylcellulose group vs. the other groups, except in group A where the difference was not significant.

Hysteroscopic management of mullerian fusion defects.

Operative hysteroscopy for mullerian fusion defects in properly selected cases and in experienced hands is a safe and effective method of management of uterine septal defects associated with recurrent pregnancy losses. For the patient, it is a more acceptable alternative because it avoids laparotomy, a lengthy hospital stay, and blood transfusions. Medical costs are reduced compared with more traditional approaches. While providing the same level of success, this technique makes a vaginal delivery possible.

Chondroitin sulphate. A new intraperitoneal treatment for postoperative adhesion prevention in the rabbit.

A study was designed to test chondroitin sulphate and other high-molecular-weight solutions, using the rabbit uterus as the surgical model, in the prevention of postoperative adhesions. Eighty-five mature white female New Zealand rabbits underwent surgical injury of each uterine horn, with surgical repair of the left horn only in all animals using 9-0 nylon. The rabbits were randomly divided into five groups: groups A, B and C received 25 mL of chondroitin sulphate, sodium carboxymethylcellulose or 32% dextran 70, respectively. The remaining two groups received either 50 mL of normal saline (D) or no solution (E). Postoperatively the animals were killed, and the adhesions were carefully scored. The results clearly demonstrated the superiority of chondroitin sulphate as an intraperitoneal treatment for the prevention of postoperative adhesions (P less than .001 vs. carboxymethyl cellulose, dextran, saline and control).

Adhesion formation to the uterine horn of the rat in response to nylon and a new absorbable clip.

We have evaluated the tissue reactivity as manifested by adhesion formation to the uterine horn of the rat in response to a new absorbable surgical clip. A standard lesion on the uterine horn was created and repaired with either nylon sutures or an absorbable clip. Adhesion formation to the operative site was evaluated using a point based grading system, seven, 21 and 120 days postoperatively. A statistically significant increase in adhesion formation and their severity was seen on the uterine horns repaired with the surgical clips. The adhesions did not improve with time. In two instances, abscesses were formed around the clips. The use of the surgical clips in the peritoneal cavity needs to be investigated further. Their use in women in the reproductive age group who wish to preserve their reproductive potential is discouraged.

Resectoscopic management of müllerian fusion defects.

Of the 103 patients taken to the operating room for hysteroscopic resection of a septum, 72 underwent successful resection of the septum. The initial hysterogram can identify those patients who may benefit from the procedure but cannot discriminate between bicornuate and septate uteri. Knowledge of the size and contour of the uterus is essential to the final decision to proceed transcervically, opposed to transabdominally. In the transcervical repair group, at the time this article was written, there were 58 term deliveries and 5 ongoing pregnancies greater than 30 weeks (1 had a spontaneous abortion after surgery and subsequently conceived a term pregnancy), for a successful pregnancy rate of 86%. This correlated well with the pregnancy rates observed after metroplasty. Therefore, hysteroscopic resection constitutes a valuable alternative to the classical transabdominal approach.

A comparison of three techniques for ovarian reconstruction.

We compared three methods of ovarian reconstruction in 23 mature female New Zealand White rabbits. Each animal was its own control. The right ovary in each rabbit was incised and repaired by placing three 8-0 nylon sutures through and through the base of the defect (method A). The left ovary was repaired without these through-and-through sutures. In 16, hemostasis was achieved by microbipolar cautery (method B); in seven, hemostasis was achieved with three sutures placed entirely inside the defect (method B1). The cortex of each ovary was repaired identically by continuous 8-0 nylon suture. Outcome was evaluated by laparoscopy 14 days after mating. Through-and-through sutures (right ovary) caused a significant increase in adhesion formation and decrease in nidation index. When these animals were put to death 14 weeks later, the right ovaries were significantly smaller. On the left, there was no difference in any outcome variable between methods B and B1. This study clearly shows the detrimental effect of through-and-through sutures for ovarian reconstruction.

The day of initiation of human menopausal gonadotropin stimulation affects follicular growth in in vitro fertilization cycles.

The attainment of synchronous follicular development in human menopausal gonadotropin/human chorionic gonadotropin-stimulated cycles for in vitro fertilization (IVF) continues to be a perplexing problem. Two regimens of follicle stimulation for IVF cycles were, therefore, compared. Twenty-nine patients commenced human menopausal gonadotropin (hMG) therapy on day 1 of the menstrual cycle (Group I), while 30 women received hMG from the third day of the cycle (Group II). The hMG therapy was tailored to the individual patients's response, based on ultrasonographic measurements of follicular size and serum estradiol (E2) levels. Both groups of patients received a mean of 19.6 +/- 1.4 ampules of hMG over a mean of 6.1 +/- 0.2 days. The pattern of serum E2 and progesterone levels in the periovulatory and luteal phase was not affected by the day of initiation of hMG therapy, although Group I patients demonstrated lower (P less than 0.05) E2 levels on the 2 days prior to human chorionic gonadotropin (hCG) administration. In terms of follicle growth, Group II follicles consistently demonstrated a significantly (P less than 0.01, chi 2 test) larger proportion of medium- and large-sized follicles compared to Group I follicles on almost all of the days when ultrasonographic measurements were taken. In addition, Group II follicles demonstrated an earlier shift (day-1) to the larger follicles than Group I follicles (day 0). Significantly (P less than 0.001) more oocytes were recovered per aspirated follicle in Group II patients, but the fertilization rate per oocyte was greater (P less than 0.003) for Group I oocytes. Nevertheless, pregnancy rates did not differ between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Delaying human chorionic gonadotropin administration in human menopausal gonadotropin-induced cycles decreases successful in vitro fertilization of human oocytes.

Correct timing of human chorionic gonadotropin (hCG) administration in induced cycles for in vitro fertilization is of crucial importance to oocyte maturation and normal luteal function. The purpose of this work was to compare the effect of hCG timing on follicular development, oocyte maturation, and fertilization in vitro, as well as on the pattern of luteal phase hormone secretion. Ovulation was induced in 32 normally cycling women by human menopausal gonadotropin (hMG)/hCG administration. In the first group (17 women) 10,000 IU hCG was administered 24 hours after the last injection of hMG and in the second group (15 women) 48 to 72 hours after the last hMG injection. Serum estradiol levels prior to oocyte aspiration were similar in both groups, as were the numbers of large follicles on the day of hCG administration (4.5 +/- 2.3 versus 4.1 +/- 1.9 follicles/woman, respectively). The distribution of oocyte-corona-cumulus complexes was similar in both groups and was comprised of 11% immature, 43% intermediate, and 45% mature complexes. The fertilization rate, however, was significantly (P less than 0.001) reduced in the group treated by delayed hCG injection (57% versus 84%), and the percentage of degenerated oocytes was increased (9% versus 1%). Luteal phase length as well as progesterone and estradiol levels were comparable in both groups. It is concluded that an interval longer than 24 hours between the last injection of hMG and the administration of an ovulatory dose of hCG does not affect follicular and luteal phase serum steroid patterns but may result in a decreased oocyte fertilization rate, possibly due to atretic changes in the follicles.