Ovarian response after laparoscopic ovarian cystectomy for endometriotic cysts in 132 monitored cycles.

OBJECTIVE: To investigate the follicular response of ovaries after laparoscopic ovarian cystectomy for endometriotic cysts. DESIGN: A retrospective, controlled study. SETTING: Obstetrics and Gynaecology Department of a university hospital. PATIENT(S): Patients with history of infertility who had laparoscopic ovarian cystectomy for endometriotic cysts. INTERVENTION(S): Laparoscopic ovarian cystectomy, transvaginal ultrasound monitoring of follicles in natural cycles, stimulated cycles using clomiphene citrate (CC), chronic low-dose FSH, and "flare down" regimen. MAIN OUTCOME MEASURE(S): Follicular response of postcystectomy and normal ovaries. RESULT(S): For women < 35 years of age, the mean follicular response of postcystectomy ovaries was reduced significantly when compared with normal ovaries in natural cycles (0.30 versus 1.00 follicle per cycle) and in CC-stimulated cycles (0.87 versus 1.27 follicles per cycle). The mean follicular response was not statistically significantly different when the ovaries were stimulated with chronic low-dose FSH or with the flare down regimen. For women > or = 35 years, postcystectomy ovaries responded with a comparable number of follicles as the normal ovaries in natural cycles and the three different ovarian stimulation regimens. CONCLUSION(S): Postcystectomy ovaries showed reduced follicular response in natural and CC-stimulated cycles for women < 35 years of age. Postcystectomy ovaries produced a comparable number of follicles as normal ovaries when stimulated with gonadotropins.

Effects of peritoneal macrophages from women with endometriosis on endometrial cellular proliferation in an in vitro coculture model.

OBJECTIVE: To study the effects of peritoneal macrophages on endometrial cellular proliferation in an in vitro coculture model and to compare the magnitude of these effects between macrophages from women with endometriosis and normal women. DESIGN: Controlled study of peritoneal macrophage function. SETTING: University hospital. PATIENT(S): Patients with a normal peritoneal cavity (n = 15) and with pelvic endometriosis (n = 20) undergoing laparoscopy. INTERVENTION(S): Peritoneal macrophages were cocultured with endometrial epithelial and stromal cells; endometrial cell cultures without macrophage coculture acted as controls. MAIN OUTCOME MEASURE(S): Endometrial cellular proliferation measured by 3H-thymidine incorporation. RESULT(S): Endometrial epithelial cells cocultured with peritoneal macrophages from women with endometriosis showed significantly increased proliferation compared with cocultures using macrophages from normal women when assessed at 24 hours (1.56 versus 1.03 times, respectively, over control) and at 72 hours (1.55 versus 1.10 times over control). Endometrial stromal cells cocultured with peritoneal macrophages from women with endometriosis similarly exhibited increased proliferation compared with cocultures using macrophages from normal women when assessed at 24 hours (1.65 versus 1.17 times over control) and at 72 hours (1.65 versus 1.21 times over control). CONCLUSION(S): Peritoneal macrophages of patients with endometriosis stimulate cellular proliferation of endometrial epithelial and stromal cells in vitro.

Laparoscopic hysterectomy versus abdominal hysterectomy: a controlled study of clinical and functional outcomes.

OBJECTIVE: To compare the clinical and functional outcomes of patients undergoing laparoscopic versus open hysterectomy for benign gynaecological pathology. SETTING: Gynaecological unit in a university hospital. METHODOLOGY: Forty consecutive cases of laparoscopic hysterectomy performed by the first author between June 1994 and December 1998 were reviewed. Their post-operative clinical and functional outcomes were compared with that of 40 patients with similar uterine size who had abdominal hysterectomy through a Pfannenstiel incision performed by consultant gynaecologists over the same time period. FINDINGS: Thirty-seven (92.5%) of the 40 patients had successful completion of laparoscopic hysterectomy. Of the patients who had successful laparoscopic hysterectomy, the duration of surgery was longer (mean duration: 159 vs 98 minutes), but they had a lower risk of complications (8.1% vs 20%), reduced analgesic requirement (mean pethidine dose: 93 vs 199 mg), and stayed for a shorter time in hospital (mean post-operation stay: 3.1 vs 4.9 days) when compared with patients who had abdominal hysterectomy. They were also able to return to full domestic function and sexual activity earlier. More patients in the laparoscopic hysterectomy group were happy with the appearance with the surgical scar, and the overall satisfaction with the surgery was also more positive than those who had abdominal hysterectomy. CONCLUSION: Laparoscopic hysterectomy is associated with improved clinical and functional outcomes when compared with open hysterectomy.

The impact of minimal access surgery on gynaecological surgery in a university gynaecological unit over a 10-year period from 1991 to 2000.

OBJECTIVE: To assess the impact of minimal access surgery in replacing traditional open approach of surgery for benign gynaecological pathology. SETTING: Gynaecological unit in a university hospital. METHODOLOGY: All surgical procedures for the treatment of ectopic pregnancy, benign ovarian cyst, myomectomy, and hysterectomy for benign gynaecological pathology over a 10-year period (1991 to 2000) were studied. The percentages of procedures performed with the minimal access approach were compared with the traditional open approach over the study period. FINDINGS: The percentage of ectopic pregnancies treated laparoscopically has increased from a low of 27% in the initial two-year period of 1991-92 to stabilise at approximately 70% at the end of the decade. Laparoscopic approach for the treatment of benign ovarian cysts constituted just 31% of cases in the initial period (1991-92) and rose steadily to stabilise at approximately 50% of cases during the last four years of the decade. The proportion of advanced minimal access procedures such as myomectomy and hysterectomy increased at a more gradual pace during the decade. By 1999-2000, laparoscopic and hysteroscopic myomectomy constituted about 30% of all myomectomies but laparoscopic hysterectomy accounted for just about 5% of all hysterectomies performed. CONCLUSIONS: Minimal access surgery has largely replaced the open approach for the treatment of ectopic pregnancy and benign ovarian cysts. Advanced minimal access procedures such as myomectomy and hysterectomy showed a rising trend through the decade, but still accounted for a minority of procedures at the end of the decade.

Laparoscopic hysterectomy--a step forward?

Laparoscopic gynaecological surgery has made tremendous progress since the last decade and the introduction of laparoscopic hysterectomy has gained immense popularity amongst both gynaecologists and consumers alike in its short history of 5 years. This review surveys the literature available on this technique and critically evaluates the indications, limitations as well as the benefits and risks of this approach to hysterectomy. There is some evidence presently that laparoscopic hysterectomy may offer benefits to selected patients who otherwise have indications for an abdominal hysterectomy. Overall, the incidence of laparotomy for hysterectomy may be decreased by converting a portion of these patients to the laparoscopically-assisted vaginal approach.

Case report of ruptured endometriotic cyst in pregnancy treated by laparoscopic ovarian cystectomy.

Pregnancy is thought to have an ameliorating effect on endometriosis, inducing a state of quiescence. We report a case of ruptured endometriotic cyst in pregnancy successfully treated by laparoscopic ovarian cystectomy. Our patient subsequently progressed uneventfully to deliver a healthy baby girl at term. Laparoscopic ovarian cystectomy in pregnancy, even with ruptured cysts, appeared to be safe in trained hands with similar benefits of reduced post-operative morbidity.

Use of hormone replacement therapy in the asymptomatic postmenopausal woman: what is the current evidence?

The publication of the Women's Health Initiative (WHI) Study results in July 2002 has changed the understanding of the use of hormone replacement therapy (HRT) in the postmenopausal woman, and challenged many of the accepted dogmas culled from decades of observational studies. The results of the WHI demonstrated a small but significant increased risk of coronary heart disease, strokes, pulmonary embolism and breast cancer amongst women who used continuous combined HRT. Conversely, there was a decreased risk of colonic cancer and osteoporotic fractures. However, the net balance of risk and benefit for long-term use of combined HRT has shifted towards the negative. In the light of the above findings, and together with the many associated studies that have since been published, the indications of HRT need to be reviewed. When the patient has disturbing vasomotor symptoms with compromised quality of life, HRT is clearly indicated for the relief of symptoms. As these symptoms are often transient, the period of therapy is usually short term. The situation is less clear among patients who do not have vasomotor symptoms, but nonetheless suffer from long-term degenerative changes of oestrogen deficiency. This article explores the implications for HRT in this post-WHI era, and seeks to define valid indications and conditions for its use.

Osteoporosis in relation to menopause.

With an ageing population in Singapore, it is anticipated that postmenopausal osteoporosis and related fractures will be an increasingly important health issue in the coming decades. Oestrogen replacement therapy has a long history of use to treat postmenopausal problems including osteoporosis. The availability of other potent agents such as bisphosphonates, calcitonin and selective oestrogen receptor modulators has enriched the therapeutic options. This article reviews the evidence for the choice of appropriate agents, and strategies to prevent and treat postmenopausal osteoporosis.

ECG waveform analysis in intrapartum fetal monitoring.

Intrapartum cardiotocography (CTG) has a high false positive rate and, in the absence of facilities for fetal scalp blood sampling, is associated with increased operative deliveries for 'fetal distress'. It is presently possible to obtain a representative fetal ECG signal using the fetal scalp electrode. There is renewed interest in fetal ECG waveform analysis in the hope that it will improve the specificity of detecting intrapartum fetal hypoxia when there is an abnormal fetal heart rate pattern. Two portions of the fetal ECG are potentially useful: the ST waveform (T/QRS ratio) and the PR interval correlated with the RR interval. Animal experiments suggest that changes in the ST waveform, increase in the T wave amplitude in particular, reflect myocardial anaerobic metabolism. Clinical studies have shown poor correlation between the T wave changes and fetal heart rate changes. There is also concern that the sensitivity of the ST waveform changes for fetal acidaemia may be poor. More information is required before its use is incorporated into routine clinical practice.

Maternal mortality: evolving trends.

Despite improvement in socioeconomic standards, good and accessible health care facilities the maternal mortality rate in Singapore is not declining. The maternal mortality rate in National University Hospital, Singapore, over a 7 year period 1986-1992 was 22.9 per 100,000 when direct and indirect causes were considered (34.4 per 100,000 when incidental deaths were included). However closer scrutiny reveals that most deaths were not due to the traditional direct causes of haemorrhage, sepsis, embolism or hypertensive disease. Most were due to medical disorders which in their own right carries a high risk to life even without a pregnancy.

PIP: Obstetrician-gynecologists reviewed patient records of women delivering during January 1986-December 1992 to determine the maternal mortality rate and trends and the causes of maternal deaths in the maternity ward at the National University of Singapore. There were 26,173 deliveries and 9 maternal deaths (a maternal mortality rate of 22.9/100,000). The causes of maternal deaths were pulmonary embolism (underlying condition, systemic lupus erythematosus [SLE]), hemorrhage from multiple sites (thrombotic thrombocytopenia), acute exacerbation of SLE with interstitial pneumonitis, pulmonary fibrosis (systemic sclerosis), fulminant hepatitis (prior hepatitis and liver disease), and cerebral embolism (rheumatic heart disease with mitral valve replacement). There were also three incidental maternal deaths bringing the maternal mortality rate up to 34.4/1000. The incidental causes of death included septicemia from perforated peptic ulcer (uncontrolled thyrotoxicosis), multiple metastases from lung cancer, and suicide (family dispute over adoption of newborn). A cesarean section preceded 4 (44%) of the 9 maternal deaths. Two of these deaths were incidental maternal deaths. Cesarean section was related to two of the remaining six (33%) deaths. These findings show that traditional direct causes of maternal death (hemorrhage, sepsis, embolism, or hypertension) were not responsible for the maternal deaths at this tertiary facility. Instead, the women tended to have medical conditions that placed them at high risk of death regardless of pregnancy status.