Minimal impairment in pulmonary function following laparoscopic surgery.

BACKGROUND: Pulmonary function may be impaired in connection with laparoscopic surgery, especially in the head-down body position, but the clinical importance has not been assessed in detail. The aim of this study was to assess pulmonary function after laparoscopic hysterectomy and laparoscopic cholecystectomy. We hypothesised that arterial oxygenation would be more impaired after hysterectomy performed in the head-down position than after cholecystectomy in the head-up position. METHODS: We included 60 women in this prospective, observational study. The patients underwent elective laparoscopic cholecystectomy in the 20° head-up position or hysterectomy in the 30° head-down position. The primary outcome was the difference between arterial oxygenation (PaO2 ) 2 h postoperatively and the preoperative value. Two hours and 24 h after surgery, pulmonary shunt and ventilation-perfusion mismatch were assessed by use of an automatic lung parameter estimation system. RESULTS: Two hours after surgery, the mean change from baseline in PaO2 was -0.65 kPa [95% confidence interval (CI) -3.5 to 3.4, P = 0.14] in the hysterectomy group and -0.22 kPa [95% CI -3.4 to 2.0, P = 0.12] in the cholecystectomy group (P = 0.88). Shunt was significantly greater in the cholecystectomy group 24 h after surgery compared to the hysterectomy group [4%, 95% CI 0 to 9 vs. 0%, 95% CI 0 to 7, P = 0.02]. CONCLUSIONS: Minimal impairment in pulmonary gas exchange was found after laparoscopic surgery. Pulmonary shunt was larger after laparoscopic cholecystectomy, but no clinically significant differences in postoperative pulmonary gas exchange or spirometry were found between laparoscopic hysterectomy and laparoscopic cholecystectomy.

The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery.

OBJECTIVE: To investigate the prevalence and risk factors for urinary incontinence (UI) 20 years after one vaginal delivery or one caesarean section. DESIGN: Registry-based national cohort study. SETTING: Women who returned postal questionnaires (response rate 65.2%) in 2008. POPULATION: Singleton primiparae who delivered in the period 1985-1988 with no further births (n = 5236). METHODS: The Swedish Pregnancy, Obesity and Pelvic Floor (SWEPOP) study linked Medical Birth Register (MBR) data to a questionnaire about UI. MAIN OUTCOME MEASURES: Prevalence of UI and UI for more than 10 years (UI > 10 years) were assessed 20 years after childbirth. RESULTS: The prevalence of UI (40.3 versus 28.8%; OR 1.67; 95% CI 1.45-1.92) and UI > 10 years (10.1 versus 3.9%; OR 2.75; 95% CI 2.02-3.75) was higher in women after vaginal delivery than after caesarean section. There was no difference in the prevalence of UI or UI > 10 years after an acute caesarean section or an elective caesarean section. We found an 8% increased risk of UI per current body mass index (BMI) unit, and age at delivery increased the UI risk by 3% annually. CONCLUSIONS: Two decades after one birth, vaginal delivery was associated with a 67% increased risk of UI, and UI > 10 years increased by 275% compared with caesarean section. Our data indicate that it is necessary to perform eight or nine caesarean sections to avoid one case of UI. Weight control is an important prophylactic measure to reduce UI. Current BMI was the most important BMI-determinant for UI, which is important, as BMI is modifiable.

Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery.

OBJECTIVE: To investigate prevalence and risk factors for symptomatic pelvic organ prolapse (sPOP) and sPOP concomitant with urinary incontinence (UI) in women 20 years after one vaginal delivery or one caesarean delivery. DESIGN: Registry-based national cohort study. SETTING: Women who returned a postal questionnaire in 2008 (response rate 65.2%). POPULATION: Singleton primiparae with a birth in 1985-88 and no further births (n = 5236). METHODS: The SWEPOP study used validated questionnaires about sPOP and UI. MAIN OUTCOME MEASURES: Prevalence rate and risk of sPOP with or without concomitant UI. RESULTS: Prevalence of sPOP was higher after vaginal delivery compared with caesarean section (14.6 versus 6.3%, odds ratio [OR] 2.55; 95% confidence interval [95% CI] 1.98-3.28) but was not increased after acute compared with elective caesarean section. Episiotomy, vacuum extraction and second-degree or more laceration were not associated with increased risk of sPOP compared with spontaneous vaginal delivery. Symptomatic POP increased 3% (OR 1.03; 95% CI 1.01-1.05) with each unit increase of current BMI and by 3% (OR 1.03; 95% CI 1.02-1.05) for each 100 g increase of infant birthweight. Mothers ≤ 160 cm who delivered a child with birthweight ≥ 4000 g had a doubled prevalence of sPOP compared with short mothers who delivered an infant weighing < 4000 g (24.2 versus 13.4%, OR 2.06; 95% CI 1.19-3.55). Women with sPOP had UI and UI > 10 years more often than women without prolapse. CONCLUSION: The prevalence of sPOP was doubled after vaginal delivery compared with caesarean section, two decades after one birth. Infant birthweight and current BMI were risk factors for sPOP after vaginal delivery.

A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women.

OBJECTIVE: To study the effect of one vaginal delivery (VD) compared with one caesarean section (CS) on the prevalence, severity and bothersomeness of urinary incontinence (UI) subtypes--stress (SUI), urge (UUI) and mixed (MUI)--20 years after delivery. DESIGN: Registry-based national cohort study. SETTING: Women who returned postal questionnaires (response rate 65.2%) in 2008. POPULATION: Primiparae with one birth in 1985-88 (n = 5236) and no further births. METHODS: Medical Birth Register data were linked to a questionnaire. Analysis of variance and multivariate analysis were used to obtain adjusted prevalences and odds ratios (adjOR). MAIN OUTCOME MEASURES: Prevalence, risk factors, severity, bothersomeness of UI subtypes. RESULTS: The prevalence of SUI, UUI and MUI was 15.3, 6.1, 14.4%, respectively, and was higher for all subtypes after VD versus CS. Moderate to severe incontinence was more prevalent after VD (21.3%) compared with CS (13.5%; adjOR 1.68, 95% confidence interval [95% CI] 1.40-2.03). Bothersome incontinence differed between MUI (38.9%), UUI (27.1%) and SUI (18.0%). The prevalence of bothersome UI was higher after VD compared with CS (11.2 versus 6.3%; adjOR 1.85, 95% CI 1.42-2.39) and consulting a doctor for UI was reported more often after VD than CS. Bothersome MUI occurred in 40.0% of incontinent women after VD compared with 29.9% after CS (adjOR 1.65, 95% CI 1.07-2.54). Symptomatic pelvic organ prolapse was an important modifier of UI with regard to its prevalence, duration, type and bothersomeness. CONCLUSION: The prevalence of SUI, UUI and MUI was higher and moderate to severe UI and bothersome UI were reported more often after VD than CS 20 years after one delivery.

The influence of smoking on bone loss and response to nasal estradiol.

OBJECTIVE: To investigate the influence of smoking on bone during therapy with nasally administrated estradiol in sequential combination with oral progesterone in early postmenopausal women. In addition, to observe the consequences of smoking on bone in untreated women. METHODS: Post-hoc exploratory analyses of data from 270 postmenopausal women randomized to 2 years' therapy with daily nasal administration of 17beta-estradiol or placebo sequentially combined with oral micronized progesterone in the active groups or placebo in the placebo group. RESULTS: During treatment with nasal estradiol, the bone mineral density (BMD) of the lumbar spine had increased less at 2 years in smokers as compared to non-smokers (2.6% vs. 3.9%, p = 0.03). Parallel changes were seen in the placebo group (-3.6% vs. -2.4%, p = 0.08). In the total hip BMD, there was no difference in the response to estradiol in smokers vs. non-smokers (1.4% vs. 1.4%, p = 0.89), whereas the change in the hip on the placebo was similar to that seen in the spine (-3.7% vs. -2.6%, p = 0.08). Supportive changes were seen in urinary CTX and in serum osteocalcin. CONCLUSIONS: These results indicate that cigarette smoking may reduce the efficacy of nasal estradiol to increase bone mass in early postmenopausal women. In addition, smoking may increase spontaneous bone loss in untreated women.

Surveillance of health status on eight marine rainbow trout, Oncorhynchus mykiss (Walbaum), farms in Denmark in 2006.

The health status of eight marine rainbow trout farms was followed from mid-June to mid-September 2006 by sampling both dead and healthy fish approximately every 2 weeks for bacteriological and virological investigation. No fish pathogenic viruses were detected, but all farms experienced disease and mortality as a result of various bacterial infections. Yersinia ruckeri was found on four and Renibacterium salmoninarum on five of the farms, but only during the first part of the surveillance period. This indicates that the fish carried the infection from fresh water, and cleared the infection in salt water. Aeromonas salmonicida subsp. salmonicida caused mortality on five farms, but persisted throughout the sampling period. Although A. salmonicida was probably carried from fresh water, the fish were not able to clear the infection in the sea. Vibrio anguillarum caused mortality on six of the farms throughout the sampling period, O1 being the dominant serovar, and Photobacterium damselae subsp. damselae was found on seven farms as a cause of disease. During the period of highest water temperatures Vibrio parahaemolyticus and Vibrio vulnificus were detected in dead fish in five and two farms, respectively, although their significance as causative pathogens is questionable. Vibrio vulnificus has not previously been found in rainbow trout in Denmark. Both mortality and number of antimicrobial treatments during the period were considerably higher in unvaccinated compared with vaccinated fish. Resistance to commonly used antimicrobials was low or absent.

Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy.

STUDY DESIGN: In this prospective, consecutive, controlled cohort study, the authors analyzed the impact of a differentiated, individual-based treatment program on sick leave during pregnancy for women experiencing lumbar back or posterior pelvic pain during pregnancy. OBJECTIVE: To identify patients with pain early in pregnancy and, by means of individual information and differentiated physiotherapy, reduce sick leave during pregnancy. SUMMARY OF BACKGROUND DATA: Sick leave for back pain during pregnancy is common, and treatment programs have been aimed at reducing pain, for that reason. In Sweden, the average sick leave due to back pain during pregnancy is 7 weeks. METHODS: All pregnant women who attended a specific antenatal clinic and experienced lumbar back or posterior pelvic pain were included in an intervention group, and results were compared with women in a control group from another antenatal clinic. RESULTS: The intervention group comprised 54 women, compared with 81 women in the control group. Thirty-three women were on sick leave for an average of 30 days in the intervention group versus 45 women for an average of 54 days in the control group (P < 0.001). The reduction in sick leave reduced insurance costs by approximately $53,000 U.S. CONCLUSIONS: Sick leave for lumbar back and posterior pelvic pain in the intervention group was significantly reduced with the program, and the program was cost effective.

[Prognosis in familial adenomatous polyposis. Results from the Polyposis Registry]. / Prognosen ved familiaer adenomatøs polypose. Resultater fra polyposeregistret.

Regional and national polyposis registries have been established all over the world over last decades, with the aim to improve survival in patients with familial adenomatous polyposis (FAP). The Danish Polyposis Register was founded in 1971 and coordinates screening and prophylactic treatment. At the end of 1992 the register included 321 histologically verified FAP patients: 142/205 probands (69%) had colorectal cancer at the time of diagnosis of FAP versus only 2/116 call-up cases (2%). The 10-year cumulative crude survival was 94% among call-up cases versus only 41% among probands (p < 0.00001), and the survival increased significantly after establishment of the Polyposis Register in 1971. We conclude that centralized registration with identification and prophylactic examination of relatives at risk results in a substantial improvement of the prognosis.

Cesarean section: a controversial feature of modern obstetric practice.

Cesarean section (CS) has been an integral part of modern obstetrics during the last decades. As safety has increased, so too has the range of problems that CS is used to solve, to a degree that it must cause medical concern. There is a great danger in the blind faith that CS is the only way out in every difficult obstetric situation. The problem can always be easily solved by CS in an acute difficult obstetrical situation. However, CS is a major abdominal surgery and it may present any complication that besets major surgery including severe intraoperative and postoperative complications, a much greater risk for maternal death compared to vaginal delivery and also late complications, i.e. secondary involuntary infertility. Therefore, CS should never be undertaken lightly and without serious consideration of the justifications, preparations and all ancillary support.

Cesarean section and intraoperative surgical complications.

The incidence of surgical complications associated with cesarean section (CS) was studied prospectively in 1319 patients undergoing CS during the years 1978, 1979 and 1980 (18% of all deliveries). The overall complication rate was 11.6% (9.5% patients with minor complications and 2.1% with major complications). The complication rate for emergency operations was 18.9% and for elective CS, 4.2%--a highly significant difference. (p less than 0.001). Six risk factors were associated with the occurrence of surgical complications in emergency cases: Station of the presenting part of the fetus in relation to the spinal plane (p less than 0.001), labor prior to surgery (p less than 0.001), low gestational age (less than 32 weeks) (p less than 0.001), rupture of fetal membranes (with labor) prior to surgery (p less than 0.01), previous CS (p less than 0.01), and skill of the operator (p less than 0.05). However, no such risk factors were found in the elective group. The clinical relevance of these findings is summarized in two conclusions. Firstly, the proportion of emergency operations needs to be reduced, either in favor of elective procedures, or by allowing more patients to give birth by the vaginal route. Secondly, emergency CS requires great skill on the part of the surgeon, and should therefore not be entrusted to young, inexperienced obstetricians.

The incidence of acute neonatal respiratory disorders in relation to mode of delivery.

Over a 3-year period all infants (n = 7401) born at the Department of Obstetrics and Gynecology, Central Hospital, Borås Sweden, were studied for signs of respiratory disease. For all infants who developed signs of respiratory disorders the mode of delivery and the type of anesthesia used in cesarean section (CS) were analysed. The incidence of respiratory disorders in the whole material was 3.0% (n = 220) and the mortality rate for these disorders was 0.24%. There was a significantly higher incidence (p less than 0.001) of respiratory disorders in infants weighing greater than or equal to 2500 g born by CS vis-à-vis infants born by the vaginal route. The group born by elective CS under maternal general anesthesia had a higher (p less than 0.05) rate of respiratory disorders than those born by elective CS under maternal epidural anesthesia. It is concluded that the risk of respiratory disorders in infants delivered by CS is related to the mode of delivery per se. Consequently, a reduction in the proportion of such interventions ought to reduce the overall number of infants developing respiratory disease, as indicated in the present study.

The course of subsequent pregnancies after previous cesarean section.

The course of pregnancies subsequent to cesarean section (CS) was studied. During the years 1970-72, 543 women were delivered by CS at Borås Central Hospital. A questionnaire was sent to all 543 during the autumn of 1976 and the spring of 1977. The questions concerned further conceptions and the outcome of all subsequent pregnancies after CS. Of the 440 (81%) women who answered the questionnaire, 244 (55.5%) became pregnant, the total number of subsequent pregnancies being 306. The incidence of spontaneous abortion, extra-uterine pregnancy and legal abortion was not significantly higher than the corresponding rate for the total material for our department during the same period. Among the 215 women who completed a new pregnancy, an elective CS was performed in 81 cases (38%). Trial of labor occurred in 143 patients, 91 of whom (68%) gave birth per vaginam , while 43 (32%) were delivered by acute CS. In nearly half of the acute CS cases the indication was a narrow pelvis not detected until labor had started. This indicates that roentgenologic pelvimetry should be considered in certain cases, when planning delivery after a previous CS.

Postoperative cesarean section morbidity: a prospective study.

During a 3-year period, 1,319 women delivered of their infants by cesarean section were prospectively studied to determine the type and rate of postcesarean complications and to identify risk factors which predispose to postoperative morbidity. The overall complication rate was 14.5% and the most common complication was infection (13.3%), in particular, endometritis (6.6%), urinary tract infection (3.1%), and wound infection (1.6%). A lower complication rate was seen in elective operations (4.7%) compared with emergency operations (24.2%). Four significant factors that predispose to postoperative morbidity were identified: duration of ruptured membranes prior to operation (p less than 0.001), duration of labor prior to operation (p less than 0.001), anemia (p less than 0.01), and obesity (p less than 0.01). Patients with a combination of risk factors had an increased complication rate, in some cases as high as 91%. The clinical relevance of these findings in trying to decide possible ways to reduce the complication rate by changing the delivery routines is discussed.

Appendicitis in pregnancy: diagnosis, management and complications.

BACKGROUND: Acute appendicitis is the most common surgical emergency in pregnancy. The purpose of this study is to investigate the clinical presentation, management and outcome in patients who underwent appendectomy during pregnancy. MATERIAL AND METHODS: The case records of 56 women who underwent appendectomy during pregnancy between January 1985 and December 1997 were reviewed and analyzed. RESULTS: The incidence of appendicitis in pregnancy was one in 766 births. The preoperative diagnosis was correct in 75% of the cases. Uterine contractions and a history of diffuse or periumbilical pain migrating to the right lower abdominal quadrant were significantly more frequent among women with appendicitis compared to those patients where the appendectomy revealed a normal appendices. Abdominal pain, nausea, vomiting, leukocyte count, CRP and body temperature were not helpful in establishing the correct diagnosis. There was no maternal morbidity related to the appendectomy. Pregnancy complications were found to be considerable: 4/12 (33%) who underwent appendectomy for appendicitis during the first trimester aborted spontaneously. Second trimester appendectomy for appendicitis was followed by premature delivery in 4/28 (14%). However, no pregnancy complications were observed following third trimester appendectomy for appendicitis. We found no increase in pregnancy complications in cases with perforated appendicitis. CONCLUSION: Appendicitis in pregnancy should be suspected when a pregnant woman complains of new abdominal pain. No laboratory finding was found to be diagnostic for acute appendicitis during pregnancy. Considerable fetal loss was found after appendectomy during pregnancy in the first and second trimester. No increase in pregnancy complications in cases with perforated appendicitis was observed. The combination of symptoms and clinical judgement is still vital in deciding which patient needs surgical treatment. Based on the results in the present study we recommend prophylactic antibiotic treatment in all laparotomies during pregnancy when appendicitis is suspected.

Rupture and dehiscence of cesarean section scar during pregnancy and delivery.

A prospective study was undertaken to evaluate the risk of uterine rupture or dehiscence after cesarean section. During the 10 years of the study, 24,644 patients were delivered of infants. Of these women, 2036 (8.3%) had previously undergone cesarean section. A trial of labor was allowed in 1008 of these patients, and 92.2% were delivered vaginally. The incidence of uterine rupture in this trial of labor group was 0.6%, compared with 0.4% in the total group. Cesarean section scar rupture caused no serious complications in either the mothers or the offspring in the trial of labor group. Uterine rupture in this group was not associated with use of oxytocin or epidural analgesia. Patients with lower-segment scar rupture had no history of puerperal pyrexia. The incidence of uterine dehiscence was 4%. In summary, the risk of uterine rupture in patients who have previously undergone cesarean section but are allowed a trial of labor is low and not associated with serious complications. Vaginal delivery is therefore considered the safest route of delivery in these patients.

Cesarean section and maternal mortality in Sweden 1973-1979.

During the years 1973-79, 704732 births took place in Sweden and 63 075 cesarean sections (CS) were performed. Within the study period there were 20 maternal deaths associated with delivery or puerperium. Thirteen of these patients were delivered by CS and 7 by the vaginal route. The hospital records of the 13 deaths associated with CS were closely analysed and it was found that 5 of the patients were critically ill before the beginning of surgery, and the CS per se was not responsible for these deaths. The 8 remaining maternal deaths gave a corrected (cesarean-attributed) maternal mortality rate of 12.7/100 000 cesarean deliveries. For vaginal deliveries the mortality rate was 1.1/100 000 deliveries. Thus, the risk of maternal death from CS in Sweden was twelve times as high as that from vaginal parturition. All maternal deaths except one, associated with CS, occurred after emergency operation. No deaths were ascribable to anesthesia complications. The most common causes of death after CS were pulmonary embolism, amniotic fluid embolism, coagulopathy and peritonitis. Time trends in the causes of maternal death in Sweden are discussed.