Alloimmunisation during pregnancy in Greece: need for nationwide HDFN prevention programme.

AIM/OBJECTIVES: To access the incidence and specificity of maternal red blood cells alloimmunisation and its relevant clinical impact in Greece. BACKGROUND: The rate of alloimmunisation in pregnant women in Greece is unknown. MATERIALS/METHODS: We performed a 4-year study in two tertiary hospitals in Greece. Demographics, transfusion and obstetric history were analysed. Maternal alloimmunisation was detected with indirect anti-globulin test. RESULTS: We investigated 4368 pregnant women. Of which 3292 (75·37%) were Greek and 1076 (24·63%) were migrants. In 39 alloimmunised women, 41 alloantibodies were detected (0·89%). The incidence of alloimmunisation was 0·66% (22/3292) in Greeks and 1·76% (17/1076) in migrants (P = 0·01). Anti-D was the most frequent alloantibody (0·18%). Anti-D was more frequent in migrants; 5·76% compared to 0·56% in Greek RhD negative women (P = 0·002). Other antibody specificities in declining frequency rank were anti-K, anti-E, anti-Lea, anti-M, anti-c, anti-Ce, anti-Jka, anti-Jkb and anti-C. Primiparae vs para >2 and past history of blood transfusion were significantly associated with alloimmunisation during pregnancy (P = 0·0088, P < 0·0001, respectively). CONCLUSIONS: Our results depict differences in the delivery of health care between migrants and Greek women, as well as the heterogeneity in practices for the prevention of haemolytic disease of foetus and newborn in Greece and highlight the need for the implementation of nationwide guidelines.

Multiple dermoid cysts within the same ovary: our experience of a rare case with review of the literature.

OBJECTIVE: Ovarian dermoid cysts are relatively frequent ovarian lesions that can be easily diagnosed by transvaginal ultrasonography. However, the recognition of multiple dermoid cysts, separated by normal ovarian tissue, within a single ovary is rare. CASE: We present a case with bilateral dermoid cysts, four dermoid cysts within the right ovary and one in the contralateral ovary. Transvaginal ultrasonography showed hyperechogenic areas in the right ovary with a hypoechogenic area in front of them; the hyperechogenic areas were separated by areas with the echogenicity of normal ovarian tissue and indentation, suggesting the presence of multiple dermoid cysts within the same ovary. CONCLUSION: Preoperative ultrasonographic suspicion of multiple dermoid cysts within the same ovary might contribute to a better decision about the surgical approach.

How to increase the proportion of hysterectomies performed vaginally.

OBJECTIVES: The main purpose of our study was to identify the patient characteristics of women undergoing hysterectomy and to estimate the proportion of hysterectomies that could be done vaginally by recognized surgical techniques. STUDY DESIGN: The records of 500 women who underwent hysterectomy were reviewed. The characteristics of patients without an absolute contraindication to vaginal hysterectomy were analyzed. RESULTS: Overall, 96 (19.2%) of our study group underwent vaginal hysterectomy. A total of 382 (76.4%) women were judged not to have an absolute contraindication to this route. The most frequent characteristics of this group were lack of uterine prolapse (76.4%), a myomatous uterus (44.5%), and a need for oophorectomy (43.2%). We did not exclude women who did not have significant uterine prolapse or a history of pelvic surgery or pelvic tenderness and we included those requiring oophorectomy or with a uterine size up to that of 14 weeks' gestation; with these criteria more than two thirds of the entire study population could undergo vaginal surgery. CONCLUSIONS: To maximize the proportion of hysterectomies performed vaginally, gynecologists need to be familiar with surgical techniques for dealing with nonprolapsed uteri, uterine leiomyomas, and vaginal oophorectomy.

Vaginal hysterectomy for the large uterus.

OBJECTIVE: To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size. DESIGN: A prospective observational study. SETTING: The Royal Free Hospital, London. PARTICIPANTS: Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size. INTERVENTIONS: Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy. MAIN OUTCOME MEASURES: Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra- and post-operative complications, duration of hospitalisation. RESULTS: The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n = 6) and superficial vaginal grazes (n = 5). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days). CONCLUSION: Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.

Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy.

OBJECTIVE: To evaluate patient acceptance and the clinical feasibility of carbon dioxide compared with normal saline for uterine distension in outpatient hysteroscopy. DESIGN: Prospective, randomized clinical trial. SETTING: Outpatient hysteroscopy clinic in a university hospital. PATIENTS: One hundred fifty-seven patients undergoing outpatient hysteroscopy. INTERVENTIONS: Outpatient hysteroscopy was performed with carbon dioxide or normal saline with endometrial biopsy when indicated. MAIN OUTCOME MEASURES: Need for local anesthesia, cervical dilatation, view of uterine cavity, need to change from carbon dioxide to normal saline distension, procedure time, patient discomfort (lower abdominal pain, shoulder tip pain, nausea) and complications. RESULTS: Carbon dioxide was used for uterine distension in 79 women and normal saline was used in 78. Cervical dilatation was required more often with carbon dioxide hysteroscopy, although there was no increased requirement for local anesthesia. Hysteroscopic vision was similar between the two media, but eight carbon dioxide cases had to be converted to liquid distension. Procedure times were significantly longer for carbon dioxide hysteroscopy as was the occurrence of bubbles during the procedure. Lower abdominal pain and shoulder tip pain were significantly worse with carbon dioxide distension. Although the incidence of nausea and vomiting was higher with the use of carbon dioxide, the differences did not achieve statistical significance. CONCLUSION: The use of normal saline for uterine distension had no adverse affects on the hysteroscopic view. It provided a shorter operating time and was well accepted by patients. Because of its easy availability and low cost, normal saline is an excellent alternative to carbon dioxide in women undergoing outpatient hysteroscopy.

Is laparoscopic hysterectomy a waste of time?

Laparoscopic hysterectomy (LH) is a way to avoid laparotomy. However, there is evidence that most women treated by abdominal hysterectomy are suitable for vaginal surgery. To test this hypothesis, and to determine the relative merits of laparoscopic and vaginal hysterectomy (VH) and the best technique for LH, we prospectively studied 98 women who had relative contraindications for vaginal surgery by traditional criteria. 75 underwent LH and 23 VH. The LH group included 22 women who had been assigned to this route of surgery as part of a prospective randomised controlled comparison with VH (23 women). Surgery was completed with the intended technique in 93.9% of cases. 5 women in the LH group (6.7%) and 2 in the VH group required laparotomy or additional procedures. In the prospective randomised study LH took longer than VH (mean duration 131 vs 77 min). VH was the faster procedure, irrespective of uterine size and need for oophorectomy. With LH, the operative time increased as more of the hysterectomy was carried out with laparoscopic rather than vaginal dissection. Complication rates, blood loss, analgesia requirements, and recovery were similar for the two techniques. Our study confirms that most hysterectomies could be performed vaginally, and that LH is a much slower procedure. If LH is done, it should be converted to a vaginal procedure as early as possible to reduce the overall operating time. LH does seem to be a waste of time for most patients.

Transvaginal endoscopic oophorectomy.

Four women underwent transvaginal endoscopic oophorectomy during vaginal hysterectomy. The adnexa were visualized with a laparoscope inserted into the upper vagina. Bilateral salpingo-oophorectomy or oophorectomy was carried out with standard laparoscopic instruments introduced through the vagina without a pneumoperitoneum; Endoloop sutures and bipolar electrocoagulation were used for hemostasis.

Ethanol and breast cancer: an association that may be both confounded and causal.

We have examined the association of alcohol intake during various life periods, by beverage category, with breast cancer risk in Greece. A hospital-based case-control study was performed in Athens, involving 820 women with breast cancer as well as 795 orthopedic patients and 753 healthy visitor controls. Relative risk patterns were very similar with either control series, which were therefore combined to increase precision of the estimates. Drinkers of beer were at significantly elevated risk for breast cancer [odds ratio (OR), 1.34 (95% confidence interval, 1.05-1.71)]. However, drinkers of other alcoholic beverages were not at increased risk. Among beer drinkers there was no dose-response, and drinkers of both beer and other beverages had a lower OR compared to drinkers of beer only. By contrast, drinkers of 3 or more glasses of alcohol per day, mostly of spirits, were at elevated risk for breast cancer [OR for 3 - < 4 glasses per day, 3.01 (1.14-7.95); OR for 4 or more glasses per day, 3.79 (1.05-13.71)]. Reported frequency of consumption was a stronger predictor of breast cancer risk than either duration-weighted total consumption or consumption before the age of 30 years. There were no coherent patterns for interaction with menopausal status, obesity or use of menopausal estrogens. The association of very low levels of alcohol intake with breast cancer risk may be due to confounding, whereas drinking 3 or more glasses of alcoholic beverages daily appears to genuinely increase breast cancer risk, perhaps by acting as a late-stage growth enhancing factor. However, the data also are compatible with a linear relationship that has no threshold.