Intra-obturator bupivacaine injection and post-operative pain following the trans-obturator tension-free vaginal tape procedure: randomized study.

PURPOSE: To assess the effectiveness of a long-acting anesthetic injection into the obturator membrane for pain relief in women undergoing trans-obturator tension-free vaginal tape. METHODS: A total of 22 women were randomized for the intra-operative injection of bupivacaine into one of their obturator membranes: the left or right side. All the participants were asked to define their groin pain on a visual analog scale (scored 0-10 cm) at 1, 6, 12, and 24 h post-operative. For each woman, pain scores were compared between the local anesthetic-injected side and the opposite side. RESULTS: Statistically significant differences were not observed in groin pain scores between the bupivacaine injection side and the no injection side at 1 h (p = 0.76), 6 h (p = 1), 12 h (p = 0.95), and 24 h (p = 0.82) post-operative. CONCLUSION: In women who undergo trans-obturator tension-free vaginal tape procedures, intra-operative intra-obturator injection of local anesthetics is not effective in alleviating the characteristic post-operative groin pain. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov (NCT03479996).

Acute Adnexal Torsion: Is Immediate Surgical Intervention Associated with a Better Outcome?

OBJECTIVES: We aimed to investigate whether surgery for adnexal detorsion within 6 h from admission to the hospital was associated with less adnexal ischemia. DESIGN: This is a retrospective cohort study. PARTICIPANTS/MATERIALS, SETTING, AND METHODS: This retrospective study was conducted at two university-affiliated medical centers and assessed women aged 18-45 years with adnexal torsion who were hospitalized within 12 h from the pain onset and underwent surgery for detorsion within 24 h. The study group was divided into 2 groups: early, surgical intervention within less than 6 h and late, surgical intervention between 6 and 24 h. The primary outcome was the rate of macroscopic appearance of ischemic adnexa. RESULTS: Two hundred and twenty women fulfilled the inclusion criteria. In 101 women, the adnexa with the torsion appeared macroscopically ischemic. There was no difference in ischemic adnexa between the early and late intervention groups (48% vs. 40%; p = 0.269). No significant association was found between the physical examination or ultrasonographic findings and the rate of ischemic adnexa within each group. LIMITATIONS: The main limitations of our study are its retrospective nature. Much of the clinical and ultrasonographic data are subjective and operator-dependent. The decision to operate may vary from one surgeon to another. CONCLUSION: Immediate surgical intervention in patients with adnexal torsion is not associated with a lower rate of adnexal ischemia. These findings suggest that in acute adnexal torsion, there is a wider time window for a thorough evaluation before surgery.

Routine ultrasonographic and hysteroscopic evaluations of women undergoing postpartum manual removal of placenta: a retrospective cohort study.

PURPOSE: This study aimed to assess the rates of retained products of conception (RPOC) after routine postpartum evaluation of patients who underwent post-delivery manual uterine revision due to retained placenta. METHODS: This is a retrospective cohort study of 599 consecutive women who underwent manual removal of placenta during 2010-2018. Group A comprised 465 women who underwent postpartum symptom-based evaluation (2010-2016). Group B comprised 134 women who were routinely evaluated by ultrasound and subsequently by hysteroscopic examination 6 weeks after delivery (2016-2018). RESULTS: The rates of abnormal postpartum bleeding were similar between groups A and B (12% and 13%, respectively, p = 0.72%). A significantly smaller proportion of women underwent hysteroscopy in group A than group B (12% vs. 37%, p < 0.05). The rate of persistent RPOC confirmed by hysteroscopy was significantly lower in group A than group B (9.7% vs. 23%, p < 0.05). CONCLUSION: Among patients who underwent post-delivery manual removal of placenta, a threefold higher rate of RPOC was discovered by routine elective evaluation than by evaluating only symptomatic patients. Future studies may show whether this approach translates to an effect on fertility.

Quantifying the effects of postcesarean adhesions on incision to delivery time.

OBJECTIVE: To quantify the effects of postcesarean section adhesions severity on the incision to delivery time. METHODS: Secondary analysis of data of a prospective randomized controlled trial of women undergoing first repeat cesarean section. The presence and severity of adhesions were reported by surgeons postoperatively and accrued into an adhesion severity score. The primary outcome measure was the correlation between adhesion severity score and incision to delivery time. RESULTS: Of the 97 women analyzed, 47 (48.5%) had an urgent cesarean delivery. Forty-four patients (45.4%) had adhesions. Adhesion score correlated with incision to delivery time (R = .38, p < .01). Patients with adhesions had a significantly longer incision to delivery time (10.3 + 5.9 versus 8.2 = 3.7 minutes, respectively; p = .04). In the Kaplan-Meier analysis, more patients with adhesions remained undelivered at any time point after incision (p = .036). The mean delivery time of patients with adhesion score three was significantly longer in comparison with women with no adhesions (13.0 versus 8.2 minutes, respectively; p = .002). CONCLUSIONS: Post cesarean adhesions delay delivery of the newborn. There is a linear correlation between adhesion severity and the incision to delivery interval.

Is intrauterine device a risk factor for failure of conservative management in patients with tubo-ovarian abscess? An observational retrospective study.

PURPOSE: Tubo-ovarian abscess (TOA) is a serious and potentially life-threatening complication of pelvic inflammatory disease (PID). TOA formation may be an uncommon, but serious complication associated with the use of an intrauterine device (IUD). While the majority of TOA respond to antibiotic therapy, in approximately 25% of cases surgery or drainage is indicated. In the present study, we compared the failure rate of conservative management in patients with and without IUD, who were admitted with a diagnosis of TOA. METHODS: In this retrospective case-control study, 78 women were diagnosed with TOA. All patients were treated initially by broad-spectrum intravenous antibiotics. The failure of conservative management after 72 h was followed by surgical intervention. RESULTS: The patients were divided into two groups: 24 patients were IUD-carriers, and 54 did not use IUD. There was no significant difference in surgical intervention rate between IUD group (50%) and no-IUD group (43%), p = 0.32. The WBC count was significantly higher in IUD-carriers diagnosed with TOA than in patients without IUD (16.5 ± 6.6 vs. 13.1 ± 4.6, p = 0.001). The patients with IUD had significantly larger abscesses as revealed by ultrasound than patients without IUD (61.6 ± 21.4 vs. 49.6 ± 20.6 mm, p = 0.02). CONCLUSION: The surgical intervention rate in TOA patients with and without IUD was similar.

Are Ultrasonographic Findings Suggestive of Ovarian Stromal Edema Associated with Ischemic Adnexal Torsion?

OBJECTIVE: To study whether sonographic findings suggestive of ovarian stromal edema are associated with tissue ischemia in patients with adnexal torsion. METHODS: A study of 79 patients with adnexal torsion was performed. Patients were divided into an ischemic group, in which the twisted adnexa were seen as blue or black, and a non-ischemic group, in which the adnexa retained normal color and appeared viable. Clinical and ultrasonographic findings, specifically the presence of ultrasonographic signs suggestive of ovarian stromal edema, were compared between the two groups. RESULTS: Of the 79 patients with torsion, in 44 (55.7%) the adnexa appeared ischemic at surgery. The presence of ischemia was not associated with age, pregnancy, duration of pain, vomiting or findings at physical examination. There was no significant difference between the ischemic and the non-ischemic group in the proportion of patients with signs of ovarian stromal edema (59 vs. 40%, p = 0.11), in the proportion of patients with absent/diminished stromal Doppler flow (36 vs. 28%, p = 0.12%) or in the proportion of patients with both signs of stroma edema and absent/diminished stromal Doppler flow (20 vs. 12%, p = 0.36). CONCLUSION: Ultrasonographic signs of ovarian stromal edema do not assist in differentiating between ischemic and non-ischemic adnexal torsion.

Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study.

OBJECTIVE: We sought to determine the effect of nonclosure of the visceral and parietal peritoneum during cesarean section on the formation of adhesions. STUDY DESIGN: This was a prospective randomized trial of 533 women undergoing primary cesarean section; in 256 the peritoneum was left open and in 277 it was closed. Fifty women in the nonclosure group and 47 women in the closure group were subsequently evaluated intraoperatively at a repeat cesarean. The presence of adhesions and their severity were evaluated at several sites. RESULTS: The nonclosure and closure groups were comparable with regard to the proportion of patients with adhesions at any site (60% vs 51%, respectively; P = .31). Time from incision to delivery was comparable in the nonclosure and closure groups (8.98 ± 4.7 vs 9.32 ± 5.2 minutes, respectively; P = .84). CONCLUSION: Closure or nonclosure of the peritoneum at cesarean section did not lead to large differences in the adhesion rate.