Kielland's rotational forceps delivery: A comparison of maternal and neonatal outcomes with rotational ventouse or second stage caesarean section deliveries.

OBJECTIVES: The objective of our study was to derive accurate estimates of risks of maternal and neonatal complications associated with Kielland's rotational forceps delivery (KRFD) compared to rotational ventouse delivery (RVD) or 2nd stage caesarean section (CS). METHODS: This was a retrospective cohort study undertaken at a large tertiary maternity and neonatal unit in the United Kingdom between January 2010 and June 2018. Pregnancies with fetal demise, major fetal defects, those lost to follow-up, those delivering by elective or emergency CS in the first stage of labour and non-rotational instrumental deliveries were excluded. The study population included singleton pregnancies delivering by Kielland's forceps, rotational ventouse, 2nd stage CS or spontaneous unassisted cephalic vaginal delivery; the latter forming the control group. The maternal outcomes examined included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS). The neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores <7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. Absolute risks with 95 % confidence intervals (CI) were calculated in the study groups. Univariate and multivariate logistic regression analysis was carried out to estimate crude and adjusted odds ratio (OR) with 95 % CI. RESULTS: The study population of 23,786 pregnancies included: 491 (2.1 %) requiring KRFD, 344 (1.4 %) requiring RVD, 840 (3.5 %) that had a 2nd stage CS and 22,111 (93.0 %) spontaneous cephalic vaginal deliveries. With regard to maternal adverse outcomes, in pregnancies that had a KRFD compared to RVD, there was no significant difference in the incidence of OASIS (p = 0.599) or PPH (p = 0.982). In contrast, the risk of PPH was significantly higher in those delivering by a 2nd stage CS compared to KRFD (27.5 % vs. 12.4 %; p < 0.0001). With regard to neonatal adverse outcomes, in those delivering by KRFD compared to RVD and 2nd stage CS, there was no significant difference in the incidence of admission to NICU (p = 0.912; p = 0.746, respectively), 5-minute Apgar score<7 (p = 0.335; p = 0.150, respectively), jaundice (p = 0.810; p = 0.332, respectively), mild shoulder dystocia (p = 0.077), severe shoulder dystocia (p = 0.603) or birth trauma (p = 0.265; p = 0.323, respectively). The risk of maternal composite adverse outcome was highest after 2nd stage CS (OR 7.68; 95 %CI: 6.52-9.04) and lowest after KRFD (OR 3.82; 95 %CI: 2.98-4.91). The risk of composite neonatal adverse outcome was higher in those delivering by RVD (OR 2.87; 95 %CI: 2.10-3.91), compared to KRFD (OR 2.23; 95 %CI: 1.67-2.97) or 2nd stage CS (OR 2.02; 95 %CI: 1.60-2.54). CONCLUSION: Our study demonstrates that KRFD is a safer management option when compared to RVD or 2nd stage CS for the management of persistent fetal malposition in labour.

Risk of miscarriage following amniocentesis and chorionic villus sampling: a systematic review of the literature.

INTRODUCTION: The aim of this paper was to estimate the risk of miscarriage after amniocentesis or chorionic villus sampling (CVS) based on a systematic review of the literature. EVIDENCE ACQUISITION: A search of Medline, Embase, and The Cochrane Library (2000-2017) was carried out to identify studies reporting complications following CVS or amniocentesis. The inclusion criteria for the systematic review were studies reporting results from large controlled studies (N.≥1000 invasive procedures) and those reporting data for pregnancy loss prior to 24 weeks' gestation. Data for cases that had invasive procedure and controls were inputted in contingency tables and risk of miscarriage was estimated for each study. Summary statistics were calculated after taking into account the weighting for each study included in the systematic review. Procedure-related risk of miscarriage was estimated as a weighted risk difference from the summary statistics for cases and controls. EVIDENCE SNTHESIS: The electronic search from the databases yielded 2465 potential citations of which 2431 were excluded, leaving 34 studies for full-text review. The final review included 10 studies for amniocentesis and 6 studies for CVS, which were used to estimate risk of miscarriage in pregnancies that had an invasive procedure and the control pregnancies that did not. The procedure-related risk of miscarriage following amniocentesis was 0.35% (95% confidence interval [CI]: 0.07 to 0.63) and that following CVS was 0.35% (95% CI: -0.31 to 1.00). CONCLUSIONS: The procedure-related risks of miscarriage following amniocentesis and CVS are lower than currently quoted to women.

Cumulative summation test for learning curve (LC-CUSUM) in outpatient hysteroscopy.

OBJECTIVES: Outpatient hysteroscopy has become an integral part of postgraduate training in gynecology. It is an operator-dependent procedure, however there are no recommendations regarding total number of performed procedures to reach proficiency. MATERIAL AND METHODS: This study aimed to assess the learning curve (LC) using cumulative summation test for learning curve (LC-CUSUM). RESULTS: A success rate of 97% a failure rate ≥ 10% were established to denote an adequate and an inadequate performance. A third-year trainee needed 56 procedures to reach the predefined level of performance. CONCLUSIONS: As the length of the LC for outpatient hysteroscopy seems highly variable, it is reasonable to provide tailored monitoring while training.

Efficacy and tolerability of intravenous morphine patient-controlled analgesia (PCA) in women undergoing cesarean delivery.

OBJECTIVES: The aim of the study was to evaluate analgesic efficacy and tolerability of patient-controlled analgesia (PCA) with intravenous morphine. MATERIAL AND METHODS: Our observational study included 50 women who underwent a Misgav-Ladach or modified Misgav-Ladach cesarean section. Automated PCA infusion device (Medima S-PCA Syringe Pump, Medima, Krakow, Poland) was used for postoperative pain control. Time of morphine administration or initiation of intravenous patient-controlled analgesia (IV PCA) with morphine was recorded, as well as post-operative pain at rest assessed by a visual analogue scale (VAS). All patients were followed up for 24 hours after discharge from the operating room, taking into account patient records, worst pain score at rest, number of IV PCA attempts, and drug consumption. RESULTS: Median of total morphine doses used during the postoperative period was 42.9mg (IQR 35.6-48.5), with median infusion time of 687.0 min. (IQR 531.0-757.5). Pain severity and total drug consumption improved after the first 3 hours following cesarean delivery (p < 0.01). Mean number of PCA attempts per patient was 33 (IQR: 24-37), with median of 11 placebo attempts (IQR: 3-27). CONCLUSIONS: Patient-controlled analgesia with morphine is an efficient and acceptable analgesic method in women undergoing cesarean section.

A randomized, single blind, placebo-controlled trial for the pain reduction during the outpatient hysteroscopy after ketoprofen or intravaginal misoprostol.

STUDY OBJECTIVE: To assess the efficacy of ketoprofen vs intravaginal misoprostol for pain relief during outpatient hysteroscopy. DESIGN: Prospective, randomized, single-blind, placebo-controlled clinical trial (Canadian Task Force classification I). SETTING: Tertiary medical center. PATIENTS: One hundred fifty women referred for hysteroscopy between January and October 2013. INTERVENTIONS: Women were randomized to receive vaginal misoprostol, 400 µg, with 100 mL of 5% intravenous glucose (misoprostol arm); intravenous ketoprofen, 50 mg/mL, in 100 mL 5% glucose with intravaginal placebo (ketoprofen arm); or vaginal placebo tablets, 100 mL 5% intravenous glucose (placebo arm) before outpatient hysteroscopy. MEASUREMENTS AND MAIN RESULTS: A visual analog scale (VAS) was used for 1-dimensional pain assessment. Patients were asked to mark a VAS score before, during, and at 5 and 15 minutes after the procedure. Median VAS scores during and directly after the anesthesia-free hysteroscopy were significantly lower in the misoprostol group than in the ketoprofen (p = .02) or placebo (p = .006) groups. There were no statistical differences between the 3 arms in median VAS score assessed at 15 minutes after the procedure (p = .16). There were no differences in procedure time between groups (p = .16). CONCLUSION: When administrated 4 hours before the procedure, 400 µg vaginal misoprostol seems to reduce the pain during and immediately after hysteroscopy. The effect does not depend on patient age, hormone status, parity, or type of outpatient hysteroscopy (operative or diagnostic).

Risk factors for cesarean section after using the Foley catheter for labor induction.

OBJECTIVE: The aim of the study was to investigate the value of the Bishop score and ultrasound examination of the cervix in predicting the success of labor induction with the use of the Foley catheter determined by the mode of delivery MATERIAL AND METHODS: Foley catheter induction of labor was performed in 135 pregnancies between 38 to 42 weeks gestation. The study group was divided into two groups, depending of the mode of delivery: vaginal vs. cesarean. RESULTS: The Bishop score was significantly higher in the vaginal delivery group when compared to the caesarean section group (5.2; 95%CI: 4.4 - 6.2 vs. 3.9; 95%CI: 2.8-4.9). Cervical length was not statistically significantly different between the two groups. Multivariate logistic regression showed that patient-specific risk for caesarean section decreases with increasing maternal age and the Bishop score (Detection Rate [DR] of 52% at fixed False Positive Rate [FPR] of 10%). CONCLUSIONS: Failure of labor induction with the use of the Foley catheter can be predicted by maternal age and pre-induction Bishop score.

Early spontaneous preterm deliveries before 34 weeks' gestation in a tertiary care centre: analysis of maternal factors and obstetric history.

OBJECTIVE: The aim of this study is to investigate risk factors associated with spontaneous early preterm delivery. METHODS: The study included 1865 singleton pregnancies with 31 spontaneous deliveries between 23 and 35 weeks' gestation compared to 1834 deliveries at the term analysed between 2008 and 2009. Both groups were 100% Caucasian. RESULTS: Spontaneous early delivery occurred in 31(1.2%) of the 2528 pregnancies. In the preterm delivery group, compared with unaffected pregnancies, there was an increased incidence of maternal anaemia (OR 2.8, 95%CI: 1.8-4.5; p < 0.001). Previous preterm delivery between 23 and 34 weeks' gestation (OR 10.7, 95%CI: 5.2-21.7; p < 0.001) as well as vaginal bleeding beyond the first trimester (OR 3.8, 95%CI: 1.2-12.1; p = 0.039), assisted conception (4.1, 95%CI: 2.0-8.4; p = 0.001) and fetal loss before 16 weeks' gestation (OR 4.2, 95%CI: 2.5-7.1; p < 0.001) are strongly associated with spontaneous preterm delivery. CONCLUSIONS: Previous preterm delivery as well as fetal loss before 16 weeks' gestation, assisted conception, vaginal bleeding beyond the first trimester and maternal anaemia are strongly associated with an increased risk for spontaneous early preterm delivery.

HE4 protein and SMRP: Potential novel biomarkers in ovarian cancer detection.

Epithelial ovarian cancer has the highest mortality of all gynecological cancers, and its progression is often without symptoms. Clinical outcome and survival may be improved if the disease is identified in the early stages. The objective of the study was to evaluate the utility of the serum biomarkers human epididymis protein 4 (HE4), soluble mesothelin-related protein (SMRP) and CA125 in the detection of ovarian cancer. In this retrospective study, the serum concentrations of CA125, HE4 protein and SMRP were measured in a cohort of 70 patients with epithelial ovarian cancer (EOC) compared with 78 healthy controls. Median serum levels of CA125 for ovarian cancer cases were 503.55±560.7 U/ml vs. 9.28±14.47 U/ml in the control group (p<0.001); for SMRP 5.13±7.64 nM vs. 1.02±0.89 nM (p<0.01); and for HE4 597.95±934.59 pM vs. 56.75±43.79 pM (p<0.001), respectively. Positive correlations between the clinical stage of EOC and CA125, HE4 and SMRP serum concentrations were found [(R=0.83; p<0.001); (R=0.64; p<0.001); (R=0.45; p<0.001), respectively]. Data analysis for the whole study group also revealed a significant correlation between plasma concentrations of CA125 and HE4 (R=0.45; p<0.001), between CA125 and SMRP (R=0.38; p<0.001) as well as HE4 and SMRP (R=0.51; p<0.001). Similar significant correlations between serum biomarker concentrations were also found in the ovarian cancer group [CA125 and HE4 (R=0.31; p<0.01); CA125 and SMRP (R=0.25; p<0.05); HE4 and SMRP (R=0.44, p<0.001), respectively]. A significant correlation was observed between the serous histological type of EOC and serum concentration of HE4 in the study group compared with other non-serous types of ovarian cancer (p<0.01). In conclusion, measuring CA125 in combination with new biomarkers such as SMRP and HE4 may improve the accuracy of ovarian cancer diagnosis, particularly in early detection of the disease.

Rare case of uterine PEC-oma (perivascular epithelioid cell tumor) recurrence. Case report and literature review.

Perivascular epithelioid cell tumor (PEC-oma) is a rare mesenchymal neoplasm. Literature reports more than 100 cases of PEC-oma, a third of which is of uterine or uterine retroperitoneum origin. The case of a 59-year-old woman presented here is, to the best of our knowledge, the first described fast uterine PEC-oma recurrence of the tumor of the gastrointestinal tract origin. In this text the authors also present literature review concerning this rare female tumor

[Predictive value of CA 125 in detection of ovarian cancer in pre- and postmenopausal patients]. / Wartosc predykcyjna stezenia CA 125 w diagnostyce raka jajmnika u kobiet przed i po menopauzie.

AIM: The aim of the study was to evaluate the usefulness of CA125 measurements in ovarian cancer diagnostics in pre- versus postmenopausal women. MATERIAL AND METHODS: The study group consisted of 99 serum specimens of women diagnosed with ovarian cancer (28 pre- and 71 postmenopausal). The control group consisted of 86 specimens collected from women without any ovarian pathology (34 pre- and 52 postmenopausal). CA 125 measurements were performed with Zymed Laboratories CA 125 ELISA Kit. Descriptive statistics, including mean values, standard deviation (SD) and 95CI of CA 125 among pre- and postmenopausal women, were calculated. The usefulness of CA 125 measurements in ovarian cancer diagnostics was assessed by calculating specificity sensitivity positive and negative predictive rates among pre- versus postmenopausal women. Statistical calculation was preformed with the use of STATISTICA 6.0 StatSoft Inc. (2001) software (wwwstatsoft. com). RESULTS: Higher CA 125 concentrations were observed in controls among pre- versus postmenopausal women (10.01 +/- 15.41; 95% CI: 4.63-15.39 IU/ml vs. 8.88 +/- 13.74; 95% CI: 5.06-12.71/U/ml, respectively NS). In contrary among women with ovarian cancer CA 125 levels were higher in postmenopausal women when compared to premenopausal (352.11 +/- 432.07; 95% CI: 184.57-519.65 vs. 541.59 +/- 547.98 95% CI: 411.89-671.29, respectively p < 0.05). In premenopausal group the CA 125 sensitivity was calculated at 64% whereas specificity 94.12% (FPR 5.9%; OR: 10.9), positive predictive value 90% and negative predictive value 94.12%. Among postmenopausal women results were as follows: sensitivity 88.73%, specificity 98.07% (FPR 1.9%, OR: 46.7), positive predictive value 98.44% and negative predictive value 86.44%. CONCLUSIONS: CA 125 measurements were more useful in the postmenopausal group. Higher CA 125 levels were observed in women with ovarian cancer diagnosis when compared to controls, in which lower CA 125 were observed. Higher sensitivity specificity and positive predictive values were observed in the postmenopausal group.

[Dysfunctional uterine bleeding--diagnostics and treatment]. / Czynnosciowe krwawienia maciczne--diagnostyka i leczenie.

Dysfunctional uterine bleeding (DUB) occurs frequently in women at the reproductive age and is unrelated to structural uterine abnormalities. It significantly impairs the quality of life for many otherwise healthy women. Evaluation of patients with abnormal uterine bleeding and identification of those with DUB is based on medical records, physical examination, laboratory tests, uterine imaging and endometrial sampling. Surgical treatment options include hysterectomy and conservative surgery (endometrial resection or ablation). Medical therapy, with the avoidance of possibly unnecessary surgery, is an attractive treatment option. However, there is considerable variation in practice and lack of consensus regarding the most effective therapy.