The Effect of Maternal Lower Limb Compression on Amniotic Fluid Index, Uteroplacental Perfusion, and Fetal Blood Flow in Isolated Oligohydramnios.

INTRODUCTION: The aim of this study was to examine the efficacy of pneumatic compression of the maternal lower extremities in increasing the amniotic fluid index (AFI) in pregnancies complicated by isolated oligohydramnios. METHODS: Women with isolated oligohydramnios (AFI <5 cm) at 32-41 weeks of pregnancy were connected to a sequential compression device for 60 min. Prior and after the application, AFI and the pulsatility index (PI) of a number of arteries were measured. RESULTS: The median (interquartile range) maternal age of the 21 women included was 29 years (26.50-32.00), the median parity was 1 (1-2), and the median gestational age at intervention was 37.60 weeks (37.00-39.40). The median AFI increased after the application from 4.00 (3.62-4.50) to 6.08 cm (4.90-7.03) (p < 0.001). The median PI of the fetal renal artery decreased from 2.30 (2.01-2.88) to 2.26 (1.68-2.71) (p = 0.01). The hourly fetal urine production did not increase. Changes were not significant in the PI of the umbilical artery, the middle cerebral artery, and the bilateral uterine arteries. CONCLUSION: Short-term activation of pneumatic compression on maternal lower extremities could increase the AFI in women with isolated oligohydramnios.

Risk factors and prediction of ectopic pregnancy rupture following methotrexate treatment: A retrospective cohort study.

OBJECTIVE: Ectopic pregnancy (EP) rupture after methotrexate (MTX) treatment can have severe consequences. We examined clinical characteristics and beta-hCG trends that may predict EP rupture after MTX treatment. STUDY DESIGN: In this 10-year retrospective study of 277 women with an EP, we compared clinical, sonographic and beta-hCG trends, before and after MTX treatment, between those who did and did not have an EP rupture after MTX treatment. RESULTS: EP rupture was diagnosed in 41 women (15.1%) within 25 days of MTX treatment, and was correlated with higher parity and advanced pregnancy age: 2(0-5) vs. 1(0-6), P = 0.027 and 6.6(4.2-9.8) vs. 6.1(4-9.5), P = 0.045. EP rupture was also correlated with higher beta-hCG levels on days 0, 4 and 7 of MTX treatment: (2063 vs. 920 mIU/ml), (3221 vs. 921 mIU/ml) and (2368 vs. 703 mIU/ml), respectively, P < 0.001, for all. An increase of beta-hCG by>14% during days 0-4 showed a sensitivity of 71.4% CI 95% [55.4%-84.3%] and a specificity of 67.5% CI 95% [61.1%-73.6%] for predicting EP rupture after MTX treatment. Beta-hCG > 910 mIU/ml on day 0 showed a sensitivity of 80.9% CI 95% [66.7%-90.8%] and a specificity of 70.4% CI 95% [64.1%-76.3%] for predicting EP rupture after MTX treatment. A beta-hCG increase by>14% during days 0-4, and a beta-hCG value > 910 mUI/mL on day 0 were associated with increased risks of EP rupture after MTX treatment; the odds ratios were 6.4 and 10.5, respectively. Odds ratios were 8.06 [CI 95% (3.70-17.56)], P < 0.001 for every percent rise in beta-hCG during days 0-4; 1.37 [CI 95% (1.06-1.86)], P = 0.046 for every week change in gestational age; and 1.001 [CI 95% (1.000-1.001)], P < 0.001 for every unit rise in beta-hCG at day 0. CONCLUSION: Beta-hCG > 910 mIU/ml at day 0, a rise in beta-hCG by>14% during days 0-4, and more advanced gestational age were associated with EP rupture after MTX treatment.

Actinomyces in explanted transvaginal mesh: commensal or pathogen?

INTRODUCTION AND HYPOTHESIS: There is a paucity of information in the literature regarding the clinical impact and treatment of histologically positive actinomycosis explanted vaginal mesh. We aimed to report the prevalence and independent predicators of Actinomyces presence in explanted meshes on histology and to compare the clinical course in those with and without Actinomyces. Our hypothesis is that Actinomyces may act as a commensal rather than a pathogen when identified in extracted transvaginal meshes. METHODS: A single-center retrospective review of explanted vaginal mesh removed between 2013 and 2018 was undertaken and compared Actinomyces-positive and -negative cohorts on histology. Uni- and multivariate logistic regression analysis evaluated possible risk factors for positive Actinomyces including patient demographics, smoking, diabetes, hormone replacement therapy (vaginal/systemic), hysterectomy in primary surgery, rate and indication for prior mesh removal. The rate of symptom resolution or need for subsequent mesh excisions is compared between the two cohorts. RESULTS: Actinomycosis was identified in 11% (31/278) of explanted mesh. After multivariant analysis, only voiding dysfunction as an indication for mesh removal was statistically significantly associated with Actinomyces-negative histology (14 vs 0%, p < 0.001). At median review of 17 months, symptom resolution (87% vs 83% p = 0.68) and need for subsequent mesh removal (13% vs 19%, p = 0.37) following index mesh excision were similar between the groups. CONCLUSION: Actinomyces in explanted transvaginal mesh frequently acts as a commensal in those who are infection free. In this cohort, individualized care including conservative surveillance without antibiotics or full explantation is reasonable.

Single-port versus multi-port robotic sacrocervicopexy: Establishment of a learning curve and short-term outcomes.

OBJECTIVES: The purpose of this study was to compare the learning curves, surgical outcomes and complications of multi-port access robotic-assisted laparoscopic sacrocervicopexy (MP-RSC) to single-port robotic access (SP-RSC) for vaginal apex prolapse. METHODS: A retrospective study of the first 52 MP-RSC procedures compared with the first 52 SP-RSC procedures performed at one medical center. Primary outcomes were intraoperative bleeding, operative time, and hospitalization. Secondary outcomes were surgical complications. RESULTS: There was a statistically significant difference in mean operative times between the MP-RSC and SP-RSC procedures: 206.5 ±â€¯39.4 and 187.8 ±â€¯46.2, respectively, P = 0.028. The mean estimated intraoperative blood loss was 35 [20-87.5] ml and 20 [10-47.5] ml, respectively, P = 0.008. Respective mean operative times decreased from the first 15 to the subsequent 15 cases: in the MP-RSC group from 224.2 ±â€¯43.2 to 198.4 ±â€¯36.3 min, P = 0.088, and in the SP-RSC group from 222.4 ±â€¯53.1 to 161.3 ±â€¯28.2 min, P < 0.001. The subsequent 22 cases showed different trends. Hospitalization (days) and level of pain at 24 h postoperative, according to a 1-10 point visual analogue scale, did not differ. Adverse events were rare in both groups. CONCLUSIONS: MP-RSC and SP-RSC are feasible and the short term outcomes and learning curves for both procedures are comparable.

Comparison between Lornoxicam and Paracetamol for Pain Management after Dilation and Curettage for Abortion.

BACKGROUND: Management of postoperative pain has become a growing concern, even for minor gynecological procedures. Proper postoperative pain management has been shown to lead to earlier mobilization, shortened hospital stay, and increased patient satisfaction. The optimal means of reducing the pain of pregnancy termination has not yet been determined. OBJECTIVES: To compare the efficiency in pain management of two drugs, lornoxicam and paracetamol, given intravenously postoperatively to women who underwent abortion with dilation and curettage. METHODS: The cohort comprised 80 women scheduled for dilation and curettage for pregnancy termination at 6-12 gestational weeks. The anesthesiologist gave 1000 mg paracetamol or 20 mg lornoxicam soon after starting the procedure, according to a randomization table. The medical staff and the patients were blinded to the drug that was administered. Pain levels were evaluated by a 10 cm visual analogue scale (VAS) at 15, 30, 60, 90, and 120 minutes following arrival at the postoperative care unit. RESULTS: Mean levels of pain decreased from 60 minutes postoperative until the end of recording, reaching minimum levels at 120 minutes: 0.8 ± 0.19 and 1.5 ± 0.28, for lornoxicam and paracetamol, respectively. The differences between the groups were statistically significant (P < 0.05 from 60 minutes after the procedure until the time of discharge. CONCLUSIONS: Compared to women who received paracetamol, women who received lornoxicam after dilation and curettage for termination of pregnancy reported lower levels of pain, from 30 minutes postoperative until the time of discharge following the procedure.

Single Port Robotic Assisted Sacrocolpopexy: Our Experience With the First 25 Cases.

OBJECTIVES: In single-port surgery, the surgeon operates almost exclusively through a single entry point, typically the patient's navel, leaving only a single small scar. The aims of this study were to share some tips and tricks of single-port robotic-assisted sacrocolpopexy and to evaluate the learning curve of mastering the skills to operate this procedure. METHODS: This is a retrospective study of the first 25 single-port; robotic-assisted sacrocolpopexy surgeries performed during July to December 2015 at Rambam Health Care Campus by a single surgeon.Primary points of interest included intraoperative bleeding, length of surgery, length of hospitalization, and surgical complications. RESULTS: The median age was 59 years (range, 35-74); the median "pelvic organ prolapse quantification" stage was 3 (range, 2-4). The median total operative time was 190 minutes (range, 114-308), and console time was 130 minutes (85-261). Comparisons between the first 15 cases and the following 10 cases demonstrated significant decreases in median total operative and console times: 226 minutes (range, 142-308) versus 156 minutes (range, 114-180), and 170 minutes (range, 85-261) versus 115 minutes (range, 90-270), respectively (P < 0.008). There were no intraoperative adverse events. Postoperative adverse events were also rare, including 1 case of small bowel adhesions that required a second laparoscopic surgery for adhesiolysis. After this incident, we peritonalized the mesh in all 13 successive cases; median time was 8 minutes (range, 5-15 minutes). CONCLUSIONS: Single-port robotic-assisted sacrocolpopexy is a feasible procedure with low complication rates, minimal blood loss and postsurgical pain, fast recovery, short hospitalization, and virtually scar-free results. Outcomes of long-term follow-up should be investigated.

The effect of pelvic organ prolapse repair on vaginal sensation.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate vaginal and clitoral sensation before and after robotic sacrocolpopexy for the repair of pelvic organ prolapse. METHODS: Twenty-two women, mean age 63 years (range 41-77), were admitted for robotic sacrocolpopexy repair of pelvic organ prolapse; 4 were lost to follow-up. Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina (anterior and posterior areas) and clitoris 1 day before and a mean of 12 ± 4 months following surgery. Student's paired t test was used to compare sensory thresholds before and after surgery. RESULTS: For the 18 women who completed follow-up, sensitivity was significantly higher after surgery (sensory threshold decreased) at the clitoral and vaginal regions, to cold and warm stimuli. In contrast, the vaginal and clitoral vibratory sensory thresholds did not change significantly following surgery. CONCLUSION: The repair of pelvic organ prolapse by robotic sacrocolpopexy could potentially play a role in restoring clitoral and vaginal wall sensation. The effects of these sensory changes on sexual function and the quality of sexual life need further investigation.