Five-year review of endometrial ablation with the SideFire laser fiber.

STUDY OBJECTIVE: To determine 5-year results of endometrial ablation with the SideFire laser fiber. DESIGN: All women seen in private office who were candidates for this procedure were followed over 5 years (Canadian Task Force classification II-2). SETTING: Patients were pretreated with depot leuprolide acetate in a private office. All procedures were done in an outpatient surgery center, and no patient was admitted to the hospital. PATIENTS: Eighty-six women with increased bleeding. INTERVENTION: Endometrial ablation with the SideFire laser fiber. MEASUREMENTS AND MAIN RESULTS: After follow-up of 12 to 72 months, 100% of patients had excellent results; 70 (82%) had total amenorrhea. Results were not less satisfactory in younger women. CONCLUSION: The SideFire laser fiber seems to be a good alternative that achieves improved outcomes compared with electrosurgery and balloon devices with hot fluid or electrodes. (J Am Assoc Gynecol Laparosc 6(1):65-69, 1999)

Endometrial ablation using SideFire laser fiber.

The first successful use of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser to control hypermenorrhea was reported in 1981. Variations on the technique were attempted to improve the amenorrhea rate. Using the Nd:YAG laser with the blanching or nontouch technique seems to result in a better outcome and higher rate of total amenorrhea than using the dragging technique. Unipolar coagulation attached to a rollerball or rollerbar was also introduced to improve treatment of the sidewalls of the uterus. The unpredictable nature of electrosurgery resulted in varying rates of amenorrhea from as low as 6% and in a subset of patients under 35 years old, to the 70% range in a nonage-adjusted patient population. Due to the report of improved rates of amenorrhea when using the blanching technique and the Nd:YAG laser, a fiber was developed to direct the laser energy at right angles to the axis of the fiber, therefore allowing a total treatment of the entire uterus in a perpendicular fashion. The theoretic benefit of this would be more complete and predictable destruction of the endometrial lining, avoiding fluid overload by coagulating and sealing the vessels and lymphatics. Results in 27 patients in this study seem to support that theory, since 23 patients (86%) experienced total amenorrhea. Mild spotting, requiring no more than a minipad for 3 days, occurred in the other four women. Fluid loss averaged 150 ml with a maximum of 500 ml; six patients had no measurable fluid loss. The age of the patient was not associated with any difference in the final result. The average time of the procedure was 46 minutes, with an average energy use of 89,670 joules. This seems to be a reasonable alternative that offers improved results compared with methods using electrosurgery or the Nd:YAG laser without the SideFire device.

Laparoscopic assisted vaginal hysterectomy: a report of 26 cases.

This study was undertaken to evaluate the feasibility and safety of laparoscopic assisted vaginal hysterectomy. We have retrospectively studied the first twenty-six cases. All cases were reviewed and included in this report. The complication rate is very minimal and well below that which would be expected from abdominal or vaginal hysterectomy approach. The operative time is approximately double that of a standard approach; however, the hospital stay is greatly decreased and the patient's return to normal activity has been considerably shortened when compared to the standard abdominal procedure. We conclude that the operation is not only feasible, but should be considered any time an abdominal approach to hysterectomy is being contemplated.

Effects of CO2 laser beam on cortical bone.

Sixteen bone blocks from two freshly amputated legs were used to study the effect of CO2 laser on cortical bone. They were divided into two groups. In Group I, the blocks were treated with CO2 laser using 1 mm spot (focused mode). In Group II, they were treated with CO2 laser using 3 mm spot (defocused mode). Two other variables were investigated: the power and time of exposure. Three histologic zones were observed: a superficial zone with black particle deposits (carbonization), an intermediate zone with fibrillations and enlarged empty lacunae, and a deep zone with normal appearing bone. The bony changes in the first two zones combined were superficial in all specimens and did not exceed 200 microns. Increased energy, a focused beam, and time of exposure were all associated with increased matrix changes. CO2 laser can be applied to cortical bone in vitro with minimal residual thermal damage.

Control of vascular reactivity in pregnancy.

Human pregnancy is characterized by a blunted pressor responsiveness to vasopressor substances. This was first reported by Dieckmann and Michel in 1937 in experiments in which they measured vascular reactivity to the pressor effects of a crude preparation of vasopressin. Recently, this has been reported to occur in response to epinephrine, norepinephrine (NE), and angiotensin II (AII). Gant and associates reported that the increasing vascular sensitivity to infused AII not only was characteristic of women who developed pregnancy-induced hypertension, but in fact preceded the development of pregnancy-induced hypertension. Although a variety of factors may mediate this blunted pressor responsiveness, the most likely candidate appears to be the localized production within endothelium and/or vascular smooth muscle of prostaglandins. Indeed, administration of indomethacin or aspirin results in an increased sensitivity to infused AII in normotensive previously AII-refractory women. Administration of the steroid hormone 5 alpha-dihydroprogesterone reverses this apparent prostaglandin-mediated response. In addition, administration of the phosphodiesterase inhibitor, theophylline, results in a restoration of vascular refractoriness to infused AII in women with pregnancy-induced hypertension or in women destined to develop pregnancy-induced hypertension. Although a variety of known and possibly unknown compounds might also effect the control of vascular reactivity during human pregnancy, the prostinoids appear to play a pivotal role in mediation of control of vascular reactivity during human pregnancy.

Pressor responsiveness to angiotensin II in hospitalized primigravid women with pregnancy-induced hypertension.

Hospitalization of women with pregnancy-induced hypertension is beneficial in improving pregnancy outcome, but how it affects this physiologic process is not clear. In the present investigation, we evaluated pressor responsiveness to angiotensin II in 62 hospitalized women with pregnancy-induced hypertension. Although each of the women became normotensive, at least transiently, all remained sensitive to the pressor effects of angiotensin II. Thus, the beneficial effect of hospitalization on women with pregnancy-induced hypertension cannot be attributed to a decrease in the responsiveness to the action of angiotensin II.

Hormone production during pregnancy in the primigravid patient. II. Plasma levels of deoxycorticosterone throughout pregnancy of normal women and women who developed pregnancy-induced hypertension.

The plasma concentration of deoxycorticosterone (DOC) was determined serially in a large group of primigravid women from 10 weeks' gestation to term. The plasma level of DOC in women whose pregnancies were uncomplicated (n = 44) was 234 +/- 33 pg/ml (mean +/- SE), at 10 to 14 weeks' gestation, a level two times that of nonpregnant subjects. The plasma level of DOC in these women rose to 778 +/- 65 pg/ml at 23 to 26 weeks' gestation, and at term (39 to 42 weeks) was 1,309 +/- 155 pg/ml. The plasma levels of DOC in women (n = 31) who eventually developed pregnancy-induced hypertension (PIH) were similar to those in the women who remained normal at all stages of pregnancy. We also found that, in women with normal pregnancies as well as in all stages of pregnancy. We also found that, in women with normal pregnancies as well as in women destined to develop PIH, the plasma concentration of DOC fluctuated in a manner parallel to that of progesterone throughout gestation; however, changes in the plasma level of DOC did not mirror those of cortisol. These data suggest that excessive plasma levels of DOC are not necessarily associated with the development of PIH. These data also support the view that, in pregnant women, a fraction of circulating DOC may arise via extra-adrenal 21-hydroxylation of progesterone rather than through adrenal secretion.

Control of vascular responsiveness during human pregnancy.

Normal human pregnancy is characterized by vascular refractoriness to AII. This pregnancy-induced vascular refractoriness appears to be mediated principally by decreased vascular smooth muscle responsiveness to AII rather than by alterations in blood volume or plasma concentrations of renin or AII. The mechanism that controls vascular refractoriness during normal pregnancy likely involves a localized prostaglandin or prostaglandin-like action mediated through cyclic nucleotides. The action of progesterone or one of its metabolites appears to mediate the synthesis or the catabolism of locally produced prostaglandins or prostaglandin-like agents.

Relationship of maternal placental blood flow to the placental clearance of maternal plasma dehydroisoandrosterone sulfate through placental estradiol formation.

We have suggested that the placental clearance of maternal plasma dehydroisoandrosterone sulfate (DS) through estradiol (E2) formation (PC-DSE2) is reflective of uteroplacental blood flow (F). Clewell and Meschia13 suggested that PC-DSE2 is related to F as follows: Cobs = F(1-e-C/F), where Cobs = PC-DSE2 and C = total placental clearance of maternal plasma DS. This equation contains two unknown quantities, F and C. To solve the equation, Clewell and Meschia assumed that C was constant. Using 19.7 ml/min for C, they allowed PC-DSE2 to vary widely and computed F. Upon finding that F was unrealistically low for some values of PC-DSE2, they concluded that reductions in PC-DSE2 do not reflect alterations in uteroplacental blood flow. In the analysis of the relationship of F to PC-DSE2, it is important to know the value of C. Since the direct measurement of C is not possible at this time, we have evaluated C by measuring the difference between the metabolic clearance rate of DS (MCR-DS) prior to and immediately following delivery. Any change in MCR-DS before and after delivery should be a reflection of the amount of maternal plasma DS cleared by the placenta through all metabolic routes including PC-DSE2, providing nonplacental clearances of maternal plasma DS before and immediately after delivery are the same. We measured MCR-DS and PC-DSE2 in 15 pregnant women within 5 days before delivery and repeated the MCR-DS measurement in these women beginning 90 minutes after delivery. Among these 15 women, C ranged from a low of 4.7 ml/min in a woman with severe pre-eclampsia to a high of 28.5 ml/min in a woman with twins. In addition to the finding that C varied widely, it was also ascertained that PC-DSE2 was positively correlated with C (r = 0.908; p less than 0.001). The finding that low or high values for PC-DSE2, observed in complicated pregnancies, were associated with similar changes in C is suggestive that a change in PC-DSE2 is reflective of a change in uteroplacental blood flow.

Hormone production during pregnancy in the primigravid patient. I. Plasma levels of progesterone and 5-alpha-pregnane-3,20-dione throughout pregnancy of normal women and women who developed pregnancy-induced hypertension.

The plasma concentrations of progesterone and 5-alpha-pregnane-3,20-dione (5-alpha-dihydroprogesterone) were measured from as early as 12 weeks through 41 weeks of gestation in primigravid women. Two groups of primigravid women were assessed, those with uncomplicated pregnancies and those who developed pregnancy-induced hypertension. Plasma levels of progesterone and 5-alpha-dihydroprogesterone rose progressively throughout gestation in both groups of women. The ratio of the level of progesterone to that of 5-alpha-dihydroprogesterone in individual plasma samples of women with uncomplicated pregnancies was 7.0 from 12 to 15 weeks' gestation while at 35 to 41 weeks' gestation the ratio had declined to 4.6. Similar results were obtained in plasma samples of women who ultimately developed pregnancy-induced hypertension. Since no differences in plasma levels of progesterone or 5-alpha-dihydroprogesterone were detected between primigravid women with uncomplicated pregnancies and those who developed pregnancy-induced hypertension, we conclude that neither progesterone nor 5-alpha-dihydroprogesterone concentrations in plasma are of value in identifying women at risk of developing pregnancy-induced hypertension.

Oral administration of theophylline to modify pressor responsiveness to angiotensin II in women with pregnancy-induced hypertension.

Normally, women become refractory to the pressor effects of infused angiotensin-II (A-II) early in pregnancy. Gravid women destined to develop pregnancy-induced hypertension (PIH) lose this refractoriness to A-II several weeks prior to the detection of hypertension. Normal pregnant women also lose their A-II refractoriness after treatment with prostaglandin synthetase inhibitors and, in this regard become similar to gravid women who are destined to develop PIH. From this observation, we have concluded that a prostaglandin(s) or a prostaglandin-related substance(s) is likely involved in the mediation of vascular reactivity to A-II during pregnancy. The present study was conducted to ascertain if control of vascular reactivity during pregnancy also involves the cyclic nucleotides. Since theophylline is known to inhibit the action of phosphodiesterase, an action that results in increased cellular levels of cyclic 3',5'-adenosine monophosphate (cAMP), we evaluated the effective pressor dose of A-II before and after the administration of theophylline to women with mild PIH who were beyond the 28th week of gestation. The effective pressor dose of A-II in these women with PIH before theophylline treatment was 7.3 +/- 1.4 ng. times kg.(-1) times min.(-1) (mean and standard error). Following treatment of these women with the equivalent of 500 mg. of theophylline daily for four days, the effective pressor dose of A-II was 16.7 +/- 3.8 ng. times kg.(-1) times min.(-1) (p less than 0.025). These findings are consistent with the view that a prostaglandin(s) synthesized in the arteriole may modulate the vascular refractoriness to A-II by altering the intracellular level of cAMP in vascular tissues.

Effect of prostaglandin synthetase inhibitors on pressor response to angiotensin II in human pregnancy.

Pregnant women destined to develop pregnancy-induced hypertension (PIH) lose refractoriness to the pressor effects of infused angiotensin II (A-II) several weeks before the onset of hypertension. This loss of refractoriness to A-II is unrelated to plasma renin activity or circulating levels of A-II. In animal studies it has been shown that the prostaglandins are important mediators of vascular reactivity. Specifically, the uterine blood flow appears to vary directly with prostaglandin E concentrations in uterine venous effluent. The present study was designed to evaluate the effects of prostaglandin synthetase inhibitors on the pressor effects of A-II in human pregnancy. The "effective A-II pressor dose" (nanograms of A-II X kg-1 X min-1 necessary to cause a 20 mm Hg rise in diastolic pressure) was determined in 14 pregnant women before and after treatment with either 25 mg indomethacin or 600 mg aspirin given twice, 6 h apart. The effective pressor dose required before treatment [22.7 +/- 3.4 ng X kg-1 X min-1 (mean +/- SE)] was significantly greater than that after treatment [8.7 +/- 1.2 ng X kg-1 X min-1 (P less than 0.001)]. The refractoriness to A-II observed in normal human pregnancy may be mediated in part by the action of prostaglandins or related substances produced in the arteriole.

Modification of vascular responsiveness to angiotensin II in pregnant women by intravenously infused 5alpha-dihydroprogesterone.

In gravid women who are destined to develop pregnancy-induced hypertension (PIH), normal pregnancy-associated refractoriness to the pressor effects of administered angiotensin II (A-II) is lost several weeks before the onset of hypertension. From a study of the determinants of A-II pressor responsiveness in normal gravid women, it appears likely that the loss of resistance to A-II is principally unrelated to plasma renin activity or to plasma A-II levels. However, it recently has been shown that the vascular refractoriness to A-II in normal women can be reduced significantly by the administration of the prostaglandin synthetase inhibitors, indomethacin or aspirin. In seven women who had developed PIH and who had lost their refractoriness to A-II, the infusion of 5alpha-pregnan-3,20-dione (5alpha-DHP) was associated with restoration of refractoriness to the pressor effects of A-II. Moreover, in five normotensive gravid women beyond 28 weeks' gestation in whom the refractoriness to A-II was reduced by the administration of indomethacin, the intravenous infusion of 5alpha-DPH was associated with restoration of refractoriness to the pressor effects of A-II. These observations are consistent with the view that a progesterone metabolite(s) may be important in the maintenance of normal blood pressure during human pregnancy.

The rape victim: a review of 117 consecutive cases.

The case records of 117 women examined at University Hospital for the complaint of alleged rape have been reviewed. The usual victim was white, single, under the age of 25 years, and attacked by a single assailant. Fifteen patients sustained serious physical injury, and 60 received minor injuries. Six children required hospitalization for reparative surgery. One patient required hospitalization for 9 days secondary to severe emotional stress. The number of attacks was lowest in the daytime and highest from midnight to 6:00 AM. Cultures from the endocervix were positive for gonorrhea in 12% of rape victims. Unfortunately, it would appear from public records that there is little hope of the attackers being convicted.