Compressive uterine sutures to treat postpartum bleeding secondary to uterine atony.

OBJECTIVE: To demonstrate the usefulness of a new method of applying compressive sutures to treat postpartum bleeding secondary to uterine atony. METHODS: Multiple sutures were applied longitudinally and transversally around the uterus of 7 women with postpartum uterine atony and postpartum bleeding. RESULTS: The procedure was successful in all cases. CONCLUSION: Compressive sutures of the uterus were effective in treating uterine atony with postpartum bleeding. LEVEL OF EVIDENCE: III.

[Hysteroscopic diagnostic accuracy in post-menopausal bleeding]. / Eficácia diagnóstica da histeroscopia nas metrorragias pós-menopausa.

OBJECTIVE: To evaluate the diagnostic accuracy of hysteroscopy at our unit for postmenopausal bleeding, specially concerning proliferative lesions. METHODS: We analyzed the results of 335 hysteroscopies that were done during the last 8 years in our hysteroscopic unit and we compared the hysteroscopic diagnosis with the biopsy result done during the procedure. Data were group according to pathologic findings in three groups normal, proliferative lesions and benign lesions. Data were analyzed by direct comparison. Sensitivity and specificity were calculated, Kappa index was used to access the inter-rater reliability, and likelihood ratio and the post test probability were used to analyze the true value of hysteroscopy. RESULTS: Women were aged between 36 and 88 years, with an average of 61,5. Histological diagnosis was atrophy in 42,1% patients, polyps in 43,3%, sub-mucous fibromioma in 5%, hyperplasic lesions in 9,6%, half of them being carcinomas. Overall Kappa index for the 3 groups was 0,831 which is in line with excellent agreement. Concerning proliferative lesions (hyperplasia + carcinoma vs carcinoma alone) and comparing to histology, sensitivity was 78,1% vs 81,3%; specificity 95,7% vs 98,7%. The positive likelihood ratio was 18,2 vs 64,8 and the negative likelihood ratio was 0,23 vs 0,19. The probability post positive test was 66% vs 76% and the probability post negative test was 2,4% vs 0,95%. No cases of carcinoma were identified among the 129 women diagnosed as having atrophy. However 3,9% of all the lesions regarded as being polyps at the hysteroscopy proved to be proliferative lesions at hysteroscopy. CONCLUSION: Hysteroscopy at our unit is a highly accurate procedure concerning post menopausal endometrial bleeding, with its results being in line with the literature. Diagnosing atrophy or excluding a proliferative lesion by the observer was highly predictive of a negative carcinoma in the histology. Using this argument whenever a proliferative lesion was excluded, only 1 in 302 hysteroscopies hid a carcinoma. Polyps should be regarded as possible proliferative lesions. Despite this result we believe a biopsy should always be undertaken no matter the observer's diagnosis.

Cystocele - vaginal approach to repairing paravaginal fascial defects.

The objective of this study is to determine the efficacy and safety of vaginal approach to repair paravaginal defects in patients with symptomatic cystocele. This was a retrospective study of 66 women with a diagnosis of symptomatic cystocele grade 2 to 4, referred to our unit between January 2002 and March 2005. A clinical evaluation was carried out using the Baden-Walker classification before and after the surgery. The same surgical team performed every surgery. The repair of paravaginal fascial defects was carried out through a vaginal approach, exposing the arcus tendineus. The paravaginal fascial defects were corrected through suspension of vesicovaginal fascia to the arcus tendineus with nonreabsorbable Ethibond 0 sutures. Women were seen for follow-up at 3, 6, and 12 months. The presence of well-demarcated vaginal lateral sulci at grade 0, firmly apposed to the lateral pelvic sidewalls and no anterior relaxation with Valsalva maneuver, were used as criteria for cure. Grade 2 cystocele was diagnosed preoperatively in most women. The mean duration of complaints due to prolapse was 64.6 months. There were no major intraoperative complications. Mean time of inpatient stay was of 4.9 days. The cure rate at 12 months was 91.6%. There were five cases of recurrence of cystocele 6 months after surgery. Surgical repair of symptomatic cystocele through a paravaginal approach is a safe and efficacious technique. Vaginal approach to repair paravaginal fascia defects had a low postoperative morbidity and high cure rate at 12 months (91.6%).

[Pregnancy and delivery outcomes in women with previous cervical conization]. / Desfecho da gravidez e do parto em mulheres submetidas a conização cervical.

OBJECTIVE: The purpose of this study was to assess the effect of cervical conization on subsequent pregnancy and delivery outcomes. METHOD/STUDY DESIGN: We used a retrospective design that included the records of all women who had conization of the cervix in our department between March 1st 1993 and September 1st 2001. Loop electrosurgical excision procedure (LEEP) was performed in every woman. From the totality of records we selected the ones who subsequently got pregnant (20 patients) and determined the pregnancy and delivery events. RESULTS: 113 women in the reproductive years underwent cervical conization during this period; 45 (39.8%) were lost to follow up, 48 (42.5%) didn't get pregnant and 20 (11.7%) women achieved 21 pregnancies. Among these 21 pregnancies there were 2 (9.5%) spontaneous abortions, 2 (9.5%) voluntary terminations of pregnancies, 1 (4.8%) elective termination of pregnancy, 1 (4.8%) ectopic pregnancy, 1 (4.8%) pregnancy evolving in the first trimester at the time of the study and 14 (66.7%) term deliveries. This last group was studied with more detail. Half of the women were nulliparous and half were multiparous. There were 2 cases of threatened preterm labour, 2 gestation diabetes, 1 pregnancy induced hypertension, 1 intrauterine growth restriction, 1 macrosomic foetus, 1 premature rupture of membranes and in three cases the labour was induced. The mean time between conization and delivery was 35.75 months. All deliveries occurred between 37 and 40 weeks of gestation; 11 (78.6%) women delivered vaginally and 3 (21.4%) had caesarean section. Only one newborn weighted less than 2500 g. The mean duration of labour (active phase of the first stage and 2nd stage) was 130.92 minutes (95 minutes for multiparous and 157.5 minutes for nulliparous women). CONCLUSION: Despite the small number of cases, pregnant patients who previously underwent LEEP don't seem to be at increased risk of adverse pregnancy outcome, preterm delivery, caesarean delivery or low birth weight. There was, however, a tendency to short duration of labour.

[Thrombasthenia of Glanzmann. Vaginal hysterectomy treated with recombinant factor VIIa]. / Trombastenia de Glanzmann. Histerectomia vaginal de urgência tratada com factor VIIa recombinante.

In the present article, regarding a clinical case of Thrombasthenia of Glanzmann with severe anaemia by menometrorrhagia, the authors propose the vaginal hysterectomy and the administration of the recombinant factor VIIa on the immediate pre and postoperative as effective therapeutical alternatives.