Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions.

OBJECTIVE: To examine the risks of vaginal delivery after previous cesarean and to find criteria to help decide whether a trial of labor or an elective repeat cesarean should be preferred. METHODS: We evaluated 29,046 deliveries after previous cesarean registered in a pooled database of 457,825 deliveries used to assess quality control in gynecology and obstetrics departments in Switzerland. RESULTS: Among the 17,613 trial-of-labor cases logged (attempt rate 60.64%), the success rate was 73.73% (65.56% after inducing labor and 75.06% after the spontaneous onset of labor). The following complications were significantly more frequent in the previous-cesarean group: maternal febrile episodes (relative risk [RR] 2.77; 95% confidence interval [CI] 2.52, 3.05), thromboembolic events (RR 2.81; CI 2.23, 3.55), bleeding due to placenta previa during pregnancy (RR 2.06; CI 1.70, 2.49), uterine rupture (92 cases; RR 42.18; CI 31.09, 57.24), and perinatal mortality (118 cases, including six associated with uterine rupture; RR 1.33; CI 1.10, 1.62). The postcesarean group also showed a 0.28% rate of peripartum hysterectomy (81 cases; RR 6.07; CI 4.71, 7.83). There was one maternal death in the group, compared with 14 maternal deaths in the group without previous cesarean (no statistical significance). The risk of uterine rupture for patients with previous cesareans was elevated in the trial-of-labor group compared with the group without trial of labor (RR 2.07; CI 1.29, 3.30), but all other maternal risks, including peripartum hysterectomy (RR 0.36; CI 0.23, 0.56), were lower. When comparing the women having a trial of labor, the 70 with uterine rupture more often had induced labor (24.29% compared with 13.92% in the nonrupture group; P = .013), had epidural anesthesia (24.29% compared with 8.44%; P < .001), had an abnormal fetal heart rate tracing (32.86% compared with 8.53%; P < .001), and had failure to progress (21.43% compared with 7.98%; P = .001). CONCLUSION: A history of cesarean delivery significantly elevates the risks for mother and child in future deliveries. Nonetheless, a trial of labor after previous cesarean is safe. Induction of labor, epidural anesthesia, failure to progress, and abnormal fetal heart rate pattern are all associated with failure of a trial of labor and uterine rupture.

Axillary lymphadenectomy--just how radical should it be?

UNLABELLED: To determine whether local axillary recurrences correlate with the number of lymph nodes extirpated, 779 cases of breast cancer were analysed in retrospect. RESULTS: The number of lymph nodes extirpated varied between 1 and 42 per axilla. The axillary recurrence rate of 5.5% showed a minimal correlation between the frequency of these recurrences and the number of lymph nodes removed. There is an equally insignificant correlation between the percentage of positive histological findings and the number of lymph nodes extirpated: The trend analysis shows that with fewer than five lymph nodes extirpated, 40% of positive histological findings can be expected, whereas with over 20 lymph nodes extirpated the percentage is 45%. CONCLUSION: The number of lymph nodes extirpated is an unsuitable indicator as to how radical axillary clearance is. Surgeons should rely on anatomical boundaries rather than focusing on the number of lymph nodes removed.

A comparison between pregnancy-associated alpha 2-glycoprotein (alpha 2-PAG), carcino-embryonic antigen (CEA), CA-125, and CA-15-3 as tumor markers in breast cancer.

Pregnancy-associated alpha 2-glycoprotein (alpha 2-PAG) has been advocated as a good marker for various malignant diseases, in particular carcinoma of the breast. Re-evaluation of previously published results was required and in this study the correlation between alpha 2PAG and CEA, CA-125, and CA-15-3 was investigated and the monitoring efficiency determined in comparison to these above mentioned markers. Overall monitoring efficiency of alpha 2-PAG was in the same range as the corresponding parameters of CEA and CA-125; specificity was very high at the expense of sensitivity, resulting in a high positive predictive value. Monitoring of such patients by alpha 2-PAG as sole marker is not recommended.

Adenocarcinoma of the uterine cervix. An analysis of 84 cases between 1970 and 1988.

Of 1284 cases with cervical carcinoma of Stages 0-IV treated at the Gynaecological University Hospital CH-Zurich between 1970 and 1988, 84 (6.5%) were adenocarcinomas; whereas a previous study performed at our clinic between 1950 and 1970 had only revealed an incidence of 3.2%. Compared with the 1200 cases of squamous cell carcinoma during the period from 1970 to 1988 it is of interest that patients with adenocarcinomas are slightly older (median value: 48 years, squamous cell carcinoma: 44 years) and that there is a temporary postmenopausal decrease in incidence: whereas there were 29 cases in the 45- to 54-year age group and 12 in the 65- to 74-age group, only 3 cases occurred in the 55- to 64-age group. Of the 38 women undergoing radical hysterectomy, 9 (24%) showed metastases in the pelvic lymph nodes. Of 115 squamous cell carcinomas operated in the same way, 15 (13%) were metastatic, which corresponds to a value of 3.65 (p = 0.057) in the chi-square test and is just below significance different. No metastases could be evidenced in any of the 28 adnexa removed bilaterally. The general appearance of the adenocarcinoma largely corresponds to that of its squamous cell counterpart of the cervix, although there are certain indications, confirmed by some references, as to poorer prognosis, earlier formation of lymph node metastases and slightly reduced radio-sensitivity.

[Sonographic determination of residual urine]. / Sonographische Restharnbestimmung.

A method to determine residual urine volume by ultrasonotomography has been developed. In 206 patients the greatest horizontal and the greatest sagittal area of the urinary bladder were measured using a B-Mode real time scanner and the volume of the bladder was calculated from these two parameters. Then the bladder was emptied with a catheter and the determined volume was compared with the calculated volume. Applying the statistical method of multiple regression analysis a nomogram was computed for direct reading of the calculated residual urine volume. Using this ultrasonic method the bladder volume determination is highly reliable and due to its advantages (e.g. no risk of infection and urethral injury, quick, simple and inexpensive) it has replaced the catheter method for assessing residual urine volume at our institution.

[Laser conization and laser ablation of the transformation zone]. / Laserkonisationen und -vaporisationen der Portio.

OBJECTIVE: To evaluate postoperative courses and histological results after laser therapy of the transformation zone. METHOD: From 1993 to 1997, 136 laser interventions were performed (110 conizations and 26 vaporizations); 103 (76%) of these interventions were performed as outpatient procedures and 122 (89%) under local anesthesia. RESULTS: 94 (85%) of the 110 conizations showed tumor-free margins, whereas 12 (11%) had dysplastic changes in one or both margins. Follow-up of these 12 patients revealed 5 normal cytologic controls, 4 cases of hysterectomy without residual disease, 1 case of CIN III in the hysterectomy specimen, 1 case of CIN I in a radical hysterectomy (cervical cancer stage Ib in the histology of the conus), and 1 patient was lost to follow-up. In 4 cases (4%), there was only a suspicion of marginal involvement. These patients had either a normal cytologic control (n = 3) or no residual disease in the hysterectomy specimens (n = 1). There were eight bleedings that had to be treated with bicoagulation. CONCLUSIONS: Laser therapy offers the possibility of a very precise circumcision at the ectocervical site under colposcopic control. It can mostly be performed as an outpatient procedure under local anesthesia, and the frequency of postoperative complications compares to the other available methods. If the margins show dysplastic changes, follow-up rarely reveals recurrent disease. Expectative management with close cytologic follow-up is, therefore, justified in such cases, if fertility should be maintained.

[Postpartum footdrop due to compression of the lumbosacral trunk]. / Geburtstraumatische Fussheberpareseinfolge einer pelvinen Nervenschädigung.

We report on a rare peripartal neuropathy of the leg caused by pro longed difficult labor in which forceps were used or caesarean sec tion was performed. Immediately after delivery, the 2 patients corn plained of a unilateral footdrop and numbness in the leg. The foot drop was most likely due to a compression of the lumbosacral trunl exposed to the fetal head. This trunk contains fibres from the lumba roots L4 and L5 and connects the lumbar with the sacral plexus. The outcome was favourable in both patients. If subsequent pregnancies occur, caesarean section may be indicated.

[Prognosis of local-regional recurrence in breast carcinoma]. / Die Prognose des lokoregionären Rezidivs beim Mammakarzinom.

992 primary breast cancers were treated at the Gynaecological Department of the University Hospital of Zürich between 1971 and 1988. Local recurrence (LR) has occurred in 131 patients up to now after a median follow-up of 5.1 years. 75% of the LR manifested the first three years after operation. Especially the locoregional (axillary) recurrences occurred early. The frequency of LR was independent of the menopausal status and the steroid receptors, but was dependent on the initial axillary nodal status and the tumor size. Patients with nodal involvement had recurrences significantly more often (74 of 372 = 20%) than those without (34 of 469 = 7%). LR of patients with tumors smaller than or equal to 2 cm occurred in 7%, in patients with tumors greater than 2 cm in 17%. The 5-year survival of all patients and the patients with a LR was 80% and 57% respectively. The longer the disease-free interval, the better the prognosis of survival. The findings suggest, that especially an early LR can not be looked at as merely a local problem but rather as a signal of a systemic manifestation of the disease.

[Major gynecologic surgery in the geriatric patient]. / Grössere gynäkologische Operationen bei der geriatrischen Patientin.

A retrospective analysis of 256 important interventions in geriatric gynecologic patients (over 70 years of age) was carried out. There were 77 vaginal, 86 abdominal, 9 combined abdomino-vaginal and 82 breast operations. Minor (131) and major (31) complications are described in detail. Two postoperative deaths accounted for a mortality rate of 0.8% in these patients. It is emphasized, that on the premises of a thorough evaluation of the possible treatments, a modern anesthesiologic technique, a well devised operative strategy and the modern postoperative care we can nowadays justify extensive surgery even in the very old gynecologic patient.

[Risk factors: assessment at the initial examination]. / Risikofaktoren: Erfassung bei der Erstuntersuchung.

Risk factors can be characterized as anamnestic or prospective (important regarding the outcome). The relative risk rises with the number of ovulatory menstrual cycles. Contraceptive pills and combined estrogen-gestagen therapy do not rise the relative risk. Irradiation of the breast leads to a higher risk depending on the applicated dose and the age of the irradiated subject. It is though important to state that the irradiation in mammographic examination of the breast is so minimal that it can be neglected and that no increased risk for the contralateral breast after irradiation for breast cancer could be documented.

[Statistical models with reference to their value for medical process quality assurance]. / Statistische Modelle im Hinblick auf ihre Aussage für eine medizinische Prozess-Qualitätssicherung.

Since the revision of the KVG (Art. 58) (Health Insurance Law) in 1995, systematic scientific monitoring is laid down by statute in order to ensure quality (Health Insurance Regulations; KVV Art. 77). In addition, the statistics law of 1992 prescribes the BFS statistics (with ICD coding) (model 1). Since 1983 the "Arbeitsgemeinschaft Schweizerischer Frauenkliniken" (ASF) (The Swiss Working Group of Obstetrical and Gynecological Institutions) has been maintaining a common set of statistics which amongst other things also serves for quality assurance purposes (model 2). In 1995 a number of surgical hospitals joined together under the title "Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie" (AQC) (Swiss Surgical Quality Assurance Working Group) and now also maintain similar common statistics (model 3). In this paper the three above-mentioned models are described with regard to their suitability for process quality assurance. Whilst the BFS statistics are unsuitable for this purpose, the two other methods of data collection largely fulfil the requirements for process quality assurance by using statistical models. The largest deficiency in the ASF and AQC statistics is the lack of comprehensive geographical coverage which in contrast is provided by the BFS statistics thanks to statutory requirements. However, all three models are unsuitable for the areas of structure and outcome quality assurance. Therefore other solutions must be sought for these purposes.

[Measuring patient satisfaction in inpatient gynecology: significant quality improvements]. / Patientenzufriedenheits-Messungen im stationären, gynäkologischen Bereich: Signifikante Qualitätsverbesserungen.

In the present study a validated questionnaire was used to measure patient satisfaction in a clinic of gynecology in a regional hospital. The goal was to assess problems, to solve them, and to increase patient satisfaction. A 50-item questionnaire was applied to assess satisfaction scores of 60 gynecology patients in 1996, and of 185 patients in 1998/99. The overall degree of patient satisfaction amounted to 74.2 +/- 22.7% increasing two years later to 78.0 +/- 25.8%. This represents a significant improvement and can be considered as success to improve quality. A significant increase of the satisfaction scores was obtained in four domains: 1. Information about the planned intervention, 2. courtesy and willingness to explain the procedures of the anesthesiologists, 3. cleanliness and 4. comfort of room. The present study confirms that validated assessment of patient satisfaction allows to identify problems and to solve them with appropriate corrective measures. This results in an increase of patient satisfaction.

[Vasectomy for contraception]. / Vasektomie zur Empfängnisverhütung.

In order to obtain more information about possible sequelae of vasectomy, a follow-up examination was conducted in 247 men who had been vasectomized between one and ten years previously. A high degree of satisfaction with this method of family planning was found, and negative reactions were few. The relatively wide indication adopted at the University Hospital in Basel for vasectomy as a method of preventing pregnancy is therefore confirmed. Lack of objective information about possible physical or psychosexual reactions appears to be the most important reason why this method of contraception has not yet received due recognition.

Ultrasonic assessment of residual urine volume.

A new method to assess residual urine volume using ultrasound has been developed. By measuring the areas of the bladder in both longitudinal and transverse directions the amount of residual urine volume can be estimated with a degree of accuracy comparable to the catheterisation method. A nomogram containing relevant urine volume determinations has been computed by applying the statistical method of multiple regression analysis in more than 200 cases studied. We find this nomogram to be easy to work with, and due to the advantages of ultrasonic assessment (e.g., there is no risk of infection, it is atraumatic, and it is quick), this approach may be recommended as a suitable method for routine practice in lieu of the catheterisation method.

[The contribution of ultrasound in urologic diagnosis]. / Der Beitrag der Sonographie zur urologischen Diagnostik.

Urological diagnosis is considerably improved by the application of sonography. The best results are undoubtedly obtained if the investigations are carried out by an appropriately trained urologist familiar with clinical differential diagnosis. Various sonographic techniques which have proved helpful in this field are discussed, and a novel method for assessing the residual urinary volume is described.

Premature contractions: possible influence of sonographic measurement of cervical length on clinical management.

In a retrospective case control study with historical controls, the influence of the introduction of vaginal sonographic cervical length measurement on the utilization of hospital services and pregnancy outcome of gravid women at risk of preterm delivery was examined. Prior to the introduction of vaginal ultrasonography to measure cervical length, we registered 76 hospitalizations totalling 1827 hospitalization days due to premature cervical ripening and/or premature labor in 1991 and 1992. In 1994 and 1995, after vaginal ultrasonography was introduced and intravenous tocolysis was limited to cases with cervical shortening to less than 3 cm, there were 64 admissions resulting in just 869 hospitalization days. Long-term hospitalizations (over 10 days) were reduced from 55 to 25 cases (p < 0.0001) and the median length of hospital stay decreased from 18 to 8 days (p < 0.0001). The number of preterm births (< or = 37 weeks) remained stable: 12 cases in 1991-1992 and 13 cases in 1994-1995. In conclusion, vaginal sonographic measurement of cervical length provides an objective criterion for cervical shortening with premature labor. The method could therefore be a suitable means of reducing unnecessary therapeutic interventions in gravid women with premature contractions and/or cervical dilatation. A prospective randomized trial to confirm these findings is suggested.

[Diagnostic and therapeutic problems in angiolipoleiomyoma]. / Diagnostische und therapeutische Probleme beim Angiolipoleiomyom.

6 cases of angiolipoleiomyoma of the kidney operated in the last 10 years are discussed. New diagnostic possibilities and also, the problems of providing an accurate preoperative diagnosis are mentioned. Usually therapeutic steps depend on whether the tumor ist presenting in combination with tuberous sclerosis or wether it is isolated. Radical surgery is more frequent and justifiable when the tumor is isolated, than in patients with tuberous sclerosis, where the therapy should be more conservative.