Comparison of transvaginal ultrasound, hysteroscopy, and dilatation and curettage in the diagnosis of abnormal vaginal bleeding and intrauterine pathology in perimenopausal and postmenopausal women.

STUDY OBJECTIVE: To compare transvaginal ultrasound, hysteroscopy, and dilation and curettage (D&C) in the evaluation of women with perimenopausal and postmenopausal bleeding. DESIGN: Descriptive study (Canadian Task Force classification II-1). SETTING: Seven outpatient clinics. PATIENTS: One thousand two hundred eighty-six women. INTERVENTION: Transvaginal ultrasound, hysteroscopy, and D&C. MEASUREMENTS AND MAIN RESULTS: Of our patient population, 29 (2.26%) had a histologic diagnosis of endometrial carcinoma; in 2 of them (7.14%) endometrial thickness was 5 mm or less. In 10 women (34.5%), endometrial carcinoma was missed by hysteroscopy (sensitivity 65.52%, specificity 99.92%). Complication rate of D&C was 1.4%. CONCLUSION: In women with perimenopausal and postmenopausal bleeding neither transvaginal ultrasound nor hysteroscopy as a single diagnostic tool is suitable to rule out endometrial cancer.

[Effectiveness and tolerance of depot leuprorelin acetate for preoperative endometrium flattening before endometrial ablation. German Leuprorelin Study Group]. / Wirksamkeit und Verträglichkeit von Leuprorelinacetat-Depot zur präoperativen Endometriumabflachung vor Endometriumablation. Deutsche Leuprorelinstudiengruppe.

OBJECTIVE: In order to assess the efficacy and tolerability of leuprorelin acetate depot in pre-operative flattening of the endometrium prior to hysteroscopic endometrial ablation, 94 patients from eight centres were included in the per protocol analysis. MATERIAL AND PATIENTS: The patients included were pre- or peri-menopausal, had completed their family planning and had intractable uterine bleeding. The primary target criterion was the reduction in maximum endometrial thickness after two injections of leuprorelin acetate depot with an interval of four weeks between injections. Surgery took place two weeks after the second injection. RESULTS: Sufficient pre-treatment was achieved in 91.5% of the patients with > 50% decrease and/or a type 1 endometrium according to sonographic and/or endometrial atrophy (Score 11) according to the central histological evaluation. The endometrium was flattened by a mean of 4.0 +/- 4.1 mm. In terms of clinical response, amenorrhoea, hypomenorrhoea or normal menstruation were achieved after endometrial ablation. Hence 91.5% of patients benefited from the overall treatment after six weeks and still 83% after six months. The trial medication was well tolerated overall. The most common side-effect described was hot flushes which could be attributed to the deliberate oestrogen withdrawal. CONCLUSION: In view of the good study results, hormone-suppressive pretreatment of the endometrium can be recommended prior to elective ablation. Surgery should take place during the oestrogen-suppressed phase.

Die hysteroskopische Endometriumablation--vom experimentellen Ansatz zu einer etablierten Methode.

A total of 94 pre- or peri-menopausal patients from eight centres with intractable uterine bleedings and completed family planning were assessed as part of a clinical trial on the use of leuprorelin acetate monthly depot prior to endometrial ablation. The primary target criterion was flattening of the endometrium after two injections of 3.75 mg leuprorelin acetate depot with an interval of one month between injections. Endometrial thickness before the first injection was compared with the thickness prior to surgery (two weeks after the second injection). Mean endometrial flattening of 4.0 +/- 4.1 mm was found. Sufficient pretreatment was achieved in 91.3% of the patients with > 50% decrease. In terms of clinical response, the development of amenorrhoea, hypomenorrhoea or normal menstruation was assessed six weeks and still 83% after six months. In view of the good study results, hormone-suppressive pretreatment can be recommended prior to hysteroscopic endometrial ablation. Surgery should then take place about two weeks after the second injection.

Ambulatory Gynecologic Surgery

A retrospective study evaluated the feasibility and safety of operative gynecologic procedures performed in an ambulatory surgical center. Between July 1993 and December 1995, 5766 women (mean age 36.9 yrs, range 13-95 yrs) who were referred to our center underwent surgery. The most common preoperative diagnoses were dysfunctional bleeding, missed abortion, postmenopausal bleeding, cervical dysplasia, mullerian duct malformation, infertility, endometriosis, adhesions, desire for sterilization, adnexal mass, lower abdominal pain, ectopic pregnancy, and fibroids. A total of 2351 laparoscopies, 2 laparotomies, and 3415 vaginal procedures were performed. The most common procedures were dilatation and curettage, 1455; hysteroscopy, 1051; adnexal surgery, 810; tubal ligation, 679; abdominal myomectomy, 186; operative hysteroscopy, 145; and cone biopsy, 118. The duration of surgery was 10 to 210 minutes. Most patients (99.51%) were discharged between 2 and 8 hours after surgery. Only 28 (0.49%) had to be admitted to the hospital; 18 women had preoperatively planned admissions and 10 were unexpectedly admitted postoperatively. The intraoperative and postoperative complication rate was 0.50% (29). We believe that ambulatory surgery is safe and efficient with proper patient selection and when the surgeon and the anesthetist have significant expertise.

Similarities and differences in couples' grief reactions following a miscarriage: results from a longitudinal study.

Recent studies have documented grief and depressive reactions in women after a miscarriage. However, the men's reactions to their partner's experience have been neglected. In a controlled follow-up study, 56 couples were studied shortly after the miscarriage, and 6 (N = 47) and 12 months later (N = 45). The participants completed standardized questionnaires for depression, physical complaints, anxiety, and grief. Contrary to commonly held beliefs, men do grieve, but less intensely and enduringly than their partners. The manner in which they experience their grief is similar to that of the women, except that the men cry less and feel less need to talk about it. Unlike the women they do not react with an increased depressive reaction (compared to age- and sex-matched community control groups). Giving up their personal expectations, hopes for, and fantasies about the unborn child is a major source of grieving for both. Some men feel burdened by their wives' grief or depressive reactions. Conflicting reactions may affect the couples' interactions and promote depressive reactions in the women.

Grief and depression after miscarriage: their separation, antecedents, and course.

Bereavement is a major risk factor for physical illness, grief, depression, and anxiety. In contrast to recent tendencies in the psychiatric literature to equate grief and depression, we propose that a careful discrimination between the two must be made for diagnostic, therapeutic, and investigative purposes. We report the results of a longitudinal study of a frequent but neglected event, miscarriage early in pregnancy, to make this point. Clinical criteria for differentiating grief and depressive reactions were developed based on phenomenological criteria and theoretical considerations. We hypothesized that the detrimental psychological and physical consequences occur only when the miscarriage was not mourned and resulted in a depressive reaction, but not in a grief reaction. In a controlled, representative study, 125 consecutive women were assessed shortly after their miscarriage (before the 20th week of gestation) and 6 months (N = 94) and 12 months (N = 90) later. Assessments included standardized questionnaires for life events, depression, physical complaints, anxiety, and a specific, multidimensional grief scale (Munich Grief Scale) that we had developed previously. Immediately after the miscarriage, the average anxiety and depression scores were elevated when compared with 80 pregnant and 125 age-matched community controls. Twenty percent of the patients who had miscarried showed a grief reaction, 12% showed a depressive reaction, and 20% responded with a combined depressive and grief reaction. The remaining women (48%) reported no changes in their emotional reactions. As predicted, longer-lasting psychological, social, and health status changes followed the initial depressive, but not the grief reactions. Depressive reactions were predicted by a history of previous depression, a lack of social resources, and an ambivalent attitude to the lost fetus. The grief measures were reliable and made it possible to discriminate between grief and depression.

Laparoscopic Treatment of Benign Ovarian Dermoid Cysts

Forty-four women underwent laparoscopic surgery for treatment of 49 benign dermoid cysts in 1992 and 1993. Four patients presented with bilateral ovarian masses and one patient had two teratomas within one ovary. In the majority of cases (78.9%) the correct diagnosis was made preoperatively by pelvic examination and vaginal ultrasound. The average tumor size was 5.5 cm, ranging from 1 to 11 cm. Preservation of the ovary was achieved in most cases (40/81.6%). Uni- or bilateral adnexectomy was the treatment of choice in all postmenopausal women (5); in the remaining four patients salpingo-oophorectomy was performed due to torsion of a cyst (1), extensive adhesions (1) and large tumor size (2). CA 19-9 levels were elevated in 11 out of 20 patients, reaching a maximum value of 3,400 U/ml. No severe complications were encountered: two patients developed fever postoperatively, one of whom was suspected of having a chemical granulomatous peritonitis. We conclude that laparoscopic management of benign dermoid cysts is safe and effective and can therefore be highly recommended.

Comparison of minimally invasive surgery and laparotomy in the treatment of adnexal masses.

STUDY OBJECTIVE: To compare the outcome of laparoscopic treatment of adnexal masses with treatment by laparotomy. The procedures, their duration, and associated complications also were evaluated. DESIGN: Women were randomized to undergo either procedure based on the ward to which they were admitted. SETTING: A university teaching hospital. PATIENTS: The 192 patients were admitted with a preoperative diagnosis of adnexal mass. INTERVENTIONS: Surgical procedures were cystectomy, salpingectomy, oophorectomy, and unilateral or bilateral salpingo-oophorectomy. Organ-preserving techniques were used wherever possible. All tissue specimens were examined histologically. MEASUREMENTS AND MAIN RESULTS: The mean duration of surgery was statistically not significantly different between the groups, 96.8 minutes for minimally invasive surgery, and 116 minutes for laparotomy. Organ preservation did reach statistical significance at 65.7% and 17.2% respectively (p <0.001). Postoperative morbidity was statistically lower in patients undergoing minimally invasive procedures. Preoperative tumor marker levels did not correlate well with postoperative histology. One woman in the laparotomy group had histologically proved ovarian cancer. Minimally invasive surgery was converted to laparotomy in three patients in whom malignancy was suspected at the start of operation. CONCLUSIONS: Laparoscopic management of adnexal masses has definite advantages over laparotomy, for example, lower postoperative morbidity. In addition, intraoperative endoscopic diagnosis is highly accurate, and the frequency of unnecessary procedures is lower.

[Long-term psychological sequelae of spontaneous abortion: do medical management, recent pregnancy and delivery really help in coping with grief?]. / Psychische Langzeitfolgen nach Spontanabort: Helfen medizinische Betreuung, neuerliche Schwangerschaft und Entbindung wirklich bei der Trauerverarbeitung?

86 patients with spontaneous abortion were interviewed and followed up in a longitudinal study with an interview and standardised questionnaires shortly after the D&C at 7, 13 and 24 months later. Our results indicate profound and long-term adverse psychological sequelae. For most of the patients, a spontaneous abortion was considered to be of major importance. Without regard to the gestational age or ultrasonographic image, the embryo is represented early in fantasies and dreams as a child. The severity of grief reactions following abortion did not correlate well with gestational age or a new pregnancy. Mourning is still present 24 months after the abortion. While grief decreases continuously during the first 7 months following abortion, despair remains constant and self-reproachful coping shows even a statistically significant increase between months 13 and 24. The reason is, because 20% of patients develop a pathological grief reaction with an increase in depression, self-reproachful coping and physical complaints. This risk group of patients, who needs closer and more detailed observation and guidance, may be recognised as early as at the time of abortion.

[Ciprofloxacin/metronidazole vs. cefoxitin/doxycycline: comparison of two therapy schedules for treatment of acute pelvic infection]. / Ciprofloxacin/Metronidazol vs. Cefoxitin/Doxycyclin: Vergleich zweier Therapieschemata zur Behandlung der akuten pelvinen Infektion.

The efficacy and safety of two antibiotic regimens for the treatment of acute pelvic inflammatory disease (PID) was compared in a prospective and randomised study. 57 patients received either 0.2 gms ciprofloxacin intravenously b.i.d. in combination with 0.5 g metronidazole intravenously t.i.d. (n = 26), or alternatively 2 g cefoxitin intravenously t.i.d. in combination with doxycycline 0.1 g b.i.d. (n = 31). After commencing therapy intravenously, medication with ciprofloxacin, metronidazole and doxycycline was continued orally after two or three days. In the ciprofloxacin/metronidazole group, PID was found to be severe in 7, moderate in 12 and mild in 7 patients. The numbers in the cefoxitin/doxycycline group were 8, 20 and 3 respectively. The clinical result after treatment with ciprofloxacin/metronidazole was resolution of all symptoms in 24 patients and improvement in 2 others. In the cefoxitin/doxycycline treated group, resolution was found in 27 patients, improvement in 2 others. Failure occurred in 2 patients. 53 different microorganisms as the suspected cause of PID were isolated in the ciprofloxacin/metronidazole group and 56 in the cefoxitin/doxycycline group. According to our clinical and bacteriological criteria, treatment for PID was successful in 97% of the ciprofloxacin/metronidazole group and in 87% of the cefoxitin/doxycycline group. Adverse reactions were found in 4 patients in the ciprofloxacin/metronidazole treated group. Therapy had to be terminated in 3 of these patients. In the cefoxitin/doxycycline group 2 patients had adverse reactions, and therapy had to be terminated in one of these patients. According to our results, both antibiotic regimens can be recommended for the treatment of PID.

[Chronic grief after spontaneous abortion: results of a longitudinal study after 13 months]. / Chronische Trauer nach einem Spontanabort: Ergebnisse einer Längsschnittstudie nach 13 Monaten.

Presented are follow-up results on coping with spontaneous abortion. Although the majority of women feel that this is a significant negative life event, their grief gradually decreases within 7 to 13 months. Compared to population standards they are neither depressed nor do they suffer from increased physical complaints. A subgroup of women is identified with chronic ("pathological") grief based on increased or rising levels of grief (PGS), depression (SCL-90) and physical complaints (BL). Independently from a following pregnancy these women (about 20%) report a high importance of their abortion, painful feelings in seeing pregnant women and babies and fears of another abortion even after 13 months. Scores immediately after the abortion permit a good discrimination of patients with chronic grief and uncomplicated course: Patients who later develop chronic grief report a high level of negative feelings during the pregnancy leading to the loss, extensive preparations for the expected baby, an unsettled vocational and family situation and intensive strains and despair immediately thereafter. Conditions and ways of grieving with this specific loss are discussed.

Laparoscopic therapy for tubal pregnancy using prostaglandins.

Nineteen patients with confirmed tubal pregnancy and constant or rising plasma beta-human chorionic gonadotropin (beta-hCG) levels were treated with laparoscopically guided injection of prostaglandin F2 alpha into the oviduct. Fifteen patients received additional prostaglandin E2 during three consecutive postoperative days. One patient was excluded from the study. The treatment was defined as successful when plasma beta-hCG levels declined below the lower detection limit and no further intervention other than prostaglandin application was required. The treatment was successful in 12 patients (66.7%). Given a beta-hCG level greater than 2,500 mU/mL as an exclusion criterion for treatment with prostaglandin, the success rate was 84.6%. Six patients underwent salpingotomy because of rising beta-hCG levels following treatment. The outcome was not related to the postoperative treatment with prostaglandin E2. None of the treated patients displayed any adverse reactions following prostaglandin F2 alpha application. Postoperative hysterosalpingography was performed on six successfully treated patients, demonstrating bilaterally patent fallopian tubes in all of them. Prostaglandin therapy in tubal pregnancy has been proven effective in selected cases.

[Grief, depression and anxiety after spontaneous abortion--a study of systematic evaluation and factors of influence]. / Trauer, Depressivität und Angst nach einem Spontanabort--Eine Studie über systematische Erfassung und Einflussfaktoren.

Recent studies demonstrate profound and long-lasting adverse psychological and family sequelae of a spontaneous abortion. However, decisive issues of quality, course and determinants cannot be answered sufficiently due to shortcomings of research (e.g. lack of representative samples and adequate measures, reliance on cross-sectional study designs). Grief reactions and their determinants are differentiated in relation to depressiveness and anxiety in 86 patients from a longitudinal study, employing the Perinatal Grief Scale (Thoedter et al. 1988) and standardized symptom checklists. For the majority of the women, around the 10th week of gestation, the embryo is psychologically represented in fantasies, dreams and concrete arrangements in reality. Immediately after the abortion, these women react with painful feelings of "active grief" and "despair". Additional stresses in the pregnancy and lack of social support predict "self-reproachful coping". Women with recurrent abortions who have no children show depressive reactions. Retrospectively, these also present more anxiety and depressive moods during pregnancy. Results support reliability and validity of the grief scale. Implications for counselling and psychotherapy of women after a spontaneous abortion are discussed with respect to these risk constellations.

[Doppler flow changes in maternal and fetal blood vessels before and during peridural anesthesia]. / Dopplerflussverhalten in mütterlichen und fetalen Gefässen vor und während Periduralanästhesie.

26 women with an uneventful singleton pregnancy near term underwent scheduled Caesarean section with lumbar epidural anaesthesia (PDA). Doppler-flow measurements of the foetal umbilical artery and the maternal hypogastric artery were taken before and after sympathicolysis was established. The mean arterial blood pressure was maintained unchanged between the measurements. Both measurements were performed by the same examiner. Three patients received additional general anaesthesia during the operation because of inadequate analgesia. The resistance index (RI) with PDA decreased significantly in 23 patients by a mean of 7.6% (p less than 0.05). The RI in those patients (n = 3) with inadequate analgesia increased by a mean of 27%. The physiologically reversed diastolic flow in the maternal hypogastric artery was mathematically taken into consideration by applying the quotient of the systolic flow and the diastolic reversed flow (V/R-quotient). The V/R-quotient increased with established sympathicolysis by more than 180% in all but one patient. The neonates' mean umbilical artery pH was 7.32 (7.27 to 7.41), the mean five minute Apgar score was 10 (8 to 10).

The implication of upright posture on pregnancy.

Pregnant women spend more than half of the day in an upright position. The physiological effects of this posture on the mother and the fetus are evaluated. Changes in vascular autoregulation and anatomy lead to maternal fainting in about 8% of women during early pregnancy. The immediate effects of such episodes on the fetus are unknown. There is a positive correlation of orthostatic dysregulations and abortions. In late pregnancy we found a significant increase in functional residual capacity in the upright posture. Minute volume and oxygen consumption were also significantly increase (p less than 0.001). Regarding the cardiovascular changes we detected a rhythmic change of the maternal heart rate with the change to upright position, which had not been published before. Change from the left lateral position to unsupported standing increased maternal heart rate by a mean of 27 beats per minute and a mean duration of 105 seconds in two thirds of the women. This was accompanied by a decreased cardiac output, systolic blood pressure and an increased oxygen consumption. The gravid uterus is responsible for these changes. During the upright position, the venous flow to the right ventricle is inhibited by the relaxed uterus. Contractions, leaning forward and the muscle pump improve the venous return. The phenomenon reached its maximum during the 38th week, where 71% of pregnant women displayed a cyclic change in heart rate. The fetal heart rate baseline is significantly increased in the upright position with a significantly reduced acceleration frequency (p less than 0.001). Combined with the data from epidemiologic studies, prolonged standing during late pregnancy may signal potential risks for the fetus such as low birth weight, prematurity and stillbirths because of an 'uterovascular syndrome'. Maternal standing possibly may be used as a physiological fetal stress test.