Elective versus emergency cesarean hysterectomy on a teaching service--1981 to 1991.

We compared the differences in morbidity of elective and emergency cesarean hysterectomy (CH) in a training program. Records of patients who had elective or emergency CH were reviewed for information reflecting perioperative morbidity and fetal outcome. Eighty-eight CHs were elective and 18 were emergencies. Compared to emergency CHs, operative time for elective CHs was 30 minutes less, intraoperative blood loss was 700 mL lower, less postoperative blood replacement was needed, and hospital stay was 3.5 days shorter. Emergency CH had nearly twice the frequency of postoperative febrile morbidity and a three-times-higher rate of morbidity due to other causes. CHs were done at a gestational age of 36 or more weeks in 81.6% of elective cases, compared to only 50% of emergency cases. Mean birth weight of newborns delivered electively was 900 g higher, and Apgar scores were better. These data show that CHs done by house staff in training have a significantly lower complication rate when the operations are elective rather than emergent.

Episiotomy repair: chromic versus polyglycolic acid suture.

The use of an episiotomy for vaginal delivery is a controversial topic in modern obstetrics. If one is done, however, correct technique and appropriate suture material are important. On the LSU Obstetrics Service, the usual midline episiotomy has traditionally been closed with 2-0 chromic suture. Theoretically, the use of a less reactive material, eg, polyglycolic acid (Dexon), may be beneficial in terms of acute postpartum discomfort and healing. As a comparison of healing and patient comfort parameters between 2-0 chromic and 2-0 polyglycolic acid suture used for episiotomy repair after delivery, two consecutive months' worth of parturients at Medical Center of Louisiana/Charity Hospital had episiotomy repair, with either chromic or polyglycolic acid suture, by junior house officers routinely attending delivery. Patients had follow-up during hospital stay, and when examined at 6 weeks for evidence of suture line healing, they were also asked about comfort and resumption of sexual activity. Of 48 patients who had repair with 2-0 chromic suture, 6 were lost to follow-up. Of 44 gravidas who had repair with 2-0 polyglycolic acid suture, 7 were lost to follow-up. At the 6-week postpartum examination, patients with polyglycolic acid sutures had significantly better healing. A noticeable scar was present in 42 of 42 patients with chromic sutures versus 21 of 37 in the polyglycolic acid group, a scar with granulation tissue in 16 of 42 versus 3 of 37, and a gaping scar in 9 of 42 and 0 of 37, respectively. Recovery of function, measured by resumption of sexual activity by 6 weeks, was demonstrated in 1 of 42 patients who had chromic sutures versus 19 of 37 patients who had polyglycolic acid sutures. Episiotomy repair with 2-0 polyglycolic acid (Dexon) offers significant advantages over traditional 2-0 chromic suture, both in terms of wound healing and resumption of normal patient activity, including sexual activity.

Comparison of morbidity in cesarean section hysterectomy versus cesarean section tubal ligation.

This study was undertaken to compare the morbidity of cesarean section hysterectomy (C-HYST) and cesarean section bilateral tubal ligation (C-BTL) in a nonemergency or elective environment. Charts were reviewed for patients who underwent elective C-HYST or elective C-BTL before the onset of labor, without the use of antibiotics. Demographics, maternal morbidity, operative difficulties and postoperative complications were compared. Statistically significant differences in patient demographics include a higher maternal age in the C-HYST group than for those in the C-BTL group (31.0 +/- 5.8 versus 27.7 +/- 5.4 years; p = 0.002). C-BTL patients had higher gestational ages (39.4 +/- 1.6 versus 38.7 +/- 1.3 years; p = 0.0017). The C-HYST group had a higher estimated blood loss (1,201 +/- 472 versus 718 +/- 364 milliliters; p = 0.001), change in hematocrit level (6.0 +/- 4.4 percent versus 4.5 +/- 3.4 percent; p = 0.013) and operating time (115 +/- 37 versus 74 +/- 26 minutes; p = 0.0001). Blood transfusion was similar in both groups. Febrile morbidity was higher in the C-BTL group (68.0 percent versus 50.0 percent; p = 0.01). Endometritis was the significant determinant of febrile morbidity for the C-BTL group (41.7%) and cuff cellulitis in the C-HYST group (25.6 percent). Intraoperative and postoperative complications between the two groups were rare and not statistically different. Clinical morbidity for C-HYST is not significantly different than C-BTL. Elective C-HYST may be used in place of C-BTL when indications for hysterectomy are present.

Production of a phosphatidylglycerol-like substance by genital flora bacteria.

Bacteria contaminating amniotic fluid have anecdotally been shown to produce a phosphatidylglycerol-like substance, thus giving false positive tests for phosphatidylglycerol in vaginal pool fluid from patients with premature rupture of the membranes. Isolates of Escherichia coli, Proteus mirabilis, Acinetobacter calcoaceticus, Klebsiella pneumoniae, Staphylococcus aureus, coagulase-negative Staphylococcus, Streptococcus faecalis, and Streptococcus agalactiae (group B streptococcus) were grown in broth and analyzed for the presence of phosphatidylglycerol-like material by one-dimensional thin-layer chromatography and also by a polyclonal, immunologic slide agglutination test (Amniostat-FLM). All species demonstrated a positive test result for phosphatidylglycerol by either thin-layer chromatography, slide agglutination, or both. The material migrated separately from cardiolipin and phosphatidylethanolamine as determined by chromatography, but identically with the phosphatidylglycerol control. Gram-negative species were more strongly positive than gram-positive organisms. Colony counts on the order of 10(8) colony-forming units per milliliter were necessary to give positive test results for phosphatidylglycerol. The possible clinical implications of these findings are discussed.