The role of the placenta in spontaneous preterm labor and delivery with intact membranes

OBJECTIVES

To determine whether placental vascular pathology and impaired placental exchange due to maturational defects are involved in the etiology of spontaneous preterm labor and delivery in cases without histologic acute chorioamnionitis.

METHODS

This was a retrospective, observational study. Cases included pregnancies that resulted in spontaneous preterm labor and delivery (<37 weeks), whereas uncomplicated pregnancies that delivered fetuses at term (≥37-42 weeks of gestation) were selected as controls. Placental histological diagnoses were classified into three groups: lesions of maternal vascular malperfusion, lesions of fetal vascular malperfusion, and placental microvasculopathy, and the frequency of each type of lesion in cases and controls was compared. Moreover, we specifically searched for villous maturational abnormalities in cases and controls. Doppler velocimetry of the umbilical and uterine arteries were performed in a subset of patients.

RESULTS

There were 184 cases and 2471 controls, of which 95 and 1178 had Doppler studies, respectively. The frequency of lesions of maternal vascular malperfusion was greater in the placentas of patients with preterm labor than in the control group [14.1% (26/184) vs. 8.8% (217/2471) (p=0.023)]. Disorders of villous maturation were more frequent in the group with preterm labor than in the control group: 41.1% (39/95) [delayed villous maturation in 31.6% (30/95) vs. 2.5% (13/519) in controls and accelerated villous maturation in 9.5% (9/95) vs. none in controls].

CONCLUSIONS

Maturational defects of placental villi were associated with approximately 41% of cases of unexplained spontaneous preterm labor and delivery without acute inflammatory lesions of the placenta and with delivery of appropriate-for-gestational-age fetuses.

Vindicating a traduced genius: Ignaz Philipp Semmelweis (1818-1865)

Anglophone narratives of Semmelweis's discovery of the cause and prophylaxis of childbed (puerperal) fever are based on a deficient historical record because important information about what happened to Semmelweis in Vienna, Austria, is contained in primary documents that had never been translated into English until very recently. The gaps in these narratives have been filled with invented facts and causal attributions that traduce Semmelweis by berating his character, education, and writing proficiency to hold him solely responsible for the rejection of his theory by most of his contemporaries and to explain the most puzzling aspect of his life: why he did not publish the results of his groundbreaking research in a medical journal for 11 years. This article presents the historical evidence contained in these primary documents that were missing from previous narratives and that provide very rational and understandable explanations for Semmelweis's actions. It also presents evidence that flatly contradicts the claims that have been made about Semmelweis's character, education, and writing skills and offers a more veridical portrayal of what happened to Semmelweis in Vienna that caused him to leave the city and delay publishing his results.

A Note on Semmelweis's Animal Experiments and Their Historical Significance

This article seeks to establish what animal experiments Semmelweis conducted, and when and why he conducted them, because the Semmelweis literature contains conflicting claims about these topics or has ignored them altogether. Semmelweis first conducted animal experiments between 22 March and 20 August 1849 with Rokitansky's assistant, Georg Maria Lautner, because his chief, Johann Klein, did not accept that by merely reducing the mortality rate from childbed fever with chlorine hand-disinfection, Semmelweis had proved his theory of the cause of childbed fever. However, Skoda concluded that the Lautner experiments did not resolve the doubts about Semmelweis's theory they were intended to resolve, and, therefore, asked the Academy of Sciences to award Semmelweis a grant to conduct further and more varied experiments with the physiologist, Ernst Ritter von Brücke. These additional experiments were conducted in the spring and summer of 1850, but yielded only ambiguous results, and led Brücke to conclude that questions about Semmelweis's theory could only be resolved by clinical observations, not animal experiments. This article discusses the reasoning behind these animal experiments, and Skoda's and Brücke's responses to them, and argues that their responses to the experiments caused Semmelweis to delay publishing his research until he had collected sufficient clinical evidence to prove his theory.

Why Semmelweis's doctrine was rejected: evidence from the first publication of his results by Friedrich Wieger, and an editorial commenting on the results

We present English translations of two French documents to show that the main reason for the rejection of Semmelweis's theory of the cause of childbed (puerperal) fever was because his proof relied on the post hoc ergo propter hoc fallacy, and not because Joseph Skoda referred only to cadaveric particles as the cause in his lecture to the Academy of Science on Semmelweis's discovery. Friedrich Wieger (1821-1890), an obstetrician from Strasbourg, published an accurate account of Semmelweis's theory six months before Skoda's lecture, and reported a case in which the causative agent originated from a source other than cadavers. Wieger also presented data showing that chlorine hand disinfection reduced the annual maternal mortality rate from childbed fever (MMR) from more than 7 per cent for the years 1840-1846 to 1.27 per cent in 1848, the first full year in which chlorine hand disinfection was practised. But an editorial in the Gazette médicale de Paris rejected the data as proof of the effectiveness of chlorine hand disinfection, stating that the fact that the MMR fell after chlorine hand disinfection was implemented did not mean that this innovation had caused the MMR to fall. This previously unrecognized objection to Semmelweis's proof was also the reason why Semmelweis's chief rejected Semmelweis's evidence.

Mechanisms of death in structurally normal stillbirths

Objectives To investigate mechanisms of in utero death in normally formed fetuses by measuring amniotic fluid (AF) biomarkers for hypoxia (erythropoietin [EPO]), myocardial damage (cardiac troponin I [cTnI]) and brain injury (glial fibrillary acidic protein [GFAP]), correlated with risk factors for fetal death and placental histopathology. Methods This retrospective, observational cohort study included intrauterine deaths with transabdominal amniocentesis prior to induction of labor. Women with a normal pregnancy and an indicated amniocentesis at term were randomly selected as controls. AF was assayed for EPO, cTnI and GFAP using commercial immunoassays. Placental histopathology was reviewed, and CD15-immunohistochemistry was used. Analyte concentrations >90th centile for controls were considered "raised". Raised AF EPO, AF cTnI and AF GFAP concentrations were considered evidence of hypoxia, myocardial and brain injury, respectively. Results There were 60 cases and 60 controls. Hypoxia was present in 88% (53/60), myocardial damage in 70% (42/60) and brain injury in 45% (27/60) of fetal deaths. Hypoxic fetuses had evidence of myocardial injury, brain injury or both in 77% (41/53), 49% (26/53) and 13% (7/53) of cases, respectively. Histopathological evidence for placental dysfunction was found in 74% (43/58) of these cases. Conclusion Hypoxia, secondary to placental dysfunction, was found to be the mechanism of death in the majority of fetal deaths among structurally normal fetuses. Ninety-one percent of hypoxic fetal deaths sustained brain, myocardial or both brain and myocardial injuries in utero. Hypoxic myocardial injury was an attributable mechanism of death in 70% of the cases. Non-hypoxic cases may be caused by cardiac arrhythmia secondary to a cardiac conduction defect.

Rediscovering Ignaz Philipp Semmelweis (1818-1865)

Ignaz Philipp Semmelweis was a Hungarian obstetrician who discovered the cause of puerperal or childbed fever (CBF) in 1847 when he was a 29-year-old Chief Resident ("first assistant") in the first clinic of the lying-in division of the Vienna General Hospital. Childbed fever was then the leading cause of maternal mortality, and so ravaged lying-in hospitals that they often had to be closed. The maternal mortality rate (MMR) from CBF at the first clinic where Semmelweis worked, and where only medical students were taught, was 3 times greater than at the second clinic, where only midwives were taught, and Semmelweis was determined to find out why. Semmelweis concluded that none of the purported causes of CBF could explain the difference in MMR between the 2 clinics, as they all affected both clinics equally. The clue to the real cause came after Semmelweis' beloved professor, Jacob Kolletschka, died after a student accidentally pricked Kolletscka's finger during an autopsy. Semmelweis reviewed Kolletschka's autopsy report, and noted that the findings were identical to those in mothers dying of CBF. He then made 2 groundbreaking inferences: that Kolletschka must have died of the same disease as mothers dying of CBF, and that the cause of CBF must be the same as the cause of Kolletschka's death, because if the 2 diseases were the same, they must have the same cause. Semmelweis quickly realized why the MMR from CBF was higher on the first clinic: medical students, who assisted at autopsies, were transferring the causative agent from cadavers to the birth canal of mothers in labor with their hands, and he soon discovered that it could also be transferred from living persons with purulent infections. Bacteria had not yet been discovered to cause infections, and Semmelweis called the agent "decaying animal organic matter." He implemented chlorine hand disinfection to remove this organic matter from the hands of the attendants, as soap and water alone had been ineffective. Hand disinfection reduced the MMR from CBF 3- to 10-fold, yet most leading obstetricians rejected Semmelweis' doctrine because it conflicted with all extant theories of the cause of CBF. His work was also used in the fight raging over academic freedom in the University of Vienna Medical School, which turned Semmelweis chief against him, and forced Semmelweis to return to Budapest, where he was equally successful in reducing MMR from CBF. But Semmelweis never received the recognition that his groundbreaking work deserved, and died an ignominious death in 1865 at the age of 47 in an asylum, where he was beaten by his attendants and died of his injuries. Fifteen years later, his work was validated by the adoption of the germ theory, and honors were belatedly showered on Semmelweis from all over the world; but over the last 40 years, a myth has been created that has tarnished Semmelweis' reputation by blaming the rejection of his work on Semmelweis' character flaws. This myth is shown to be a genre of reality fiction that is inconsistent with historical facts.

Peer review of medical practices: missed opportunities to learn

Appropriately conducted peer review of medical practices provides the greatest opportunity for health care professionals to learn from their mistakes and improve the quality and safety of health care. But in practice, peer review has not been an effective learning tool because it is subjective and irreproducible. Physicians reviewing the same cases disagree over the cause(s) of adverse outcomes and the quality and appropriateness of care, and agreement is not improved by training, use of objective review criteria, or having the reviewers discuss the cases. The underlying reason is a general lack of understanding and an oversimplified view of the causes of medical errors in complex, high-risk organization and a preoccupation with attributing medical errors to particular individuals. This approach leads to judgments, not understanding, and creates a culture of blame that stops learning and undermines the potential for improvement. For peer review to have an impact on the quality of care and patient safety, it must be standardized to remove cognitive biases and subjectivity from the process.

The diagnostic performance of the Mass Restricted (MR) score in the identification of microbial invasion of the amniotic cavity or intra-amniotic inflammation is not superior to amniotic fluid interleukin-6

OBJECTIVE

Intra-amniotic infection/inflammation are major causes of spontaneous preterm labor and delivery. However, diagnosis of intra-amniotic infection is challenging because most are subclinical and amniotic fluid (AF) cultures take several days before results are available. Several tests have been proposed for the rapid diagnosis of microbial invasion of the amniotic cavity (MIAC) or intra-amniotic inflammation. The aim of this study was to examine the diagnostic performance of the AF Mass Restricted (MR) score in comparison with interleukin-6 (IL-6) and matrix metalloproteinase-8 (MMP-8) for the identification of MIAC or inflammation.

METHODS

AF samples were collected from patients with singleton gestations and symptoms of preterm labor (n = 100). Intra-amniotic inflammation was defined as >100 white blood cells/mm(3) (WBCs) in AF; MIAC was defined as a positive AF culture. AF IL-6 and MMP-8 were determined using ELISA. The MR score was obtained using the Surface-Enhanced Laser Desorption Ionization Time of Flight (SELDI-TOF) mass spectrometry. Sensitivity and specificity were calculated and logistic regression models were fit to construct receiver-operating characteristic (ROC) curves for the identification of each outcome. The McNemar's test and paired sample non-parametric statistical techniques were used to test for differences in diagnostic performance metrics.

RESULTS

(1) The prevalence of MIAC and intra-amniotic inflammation was 34% (34/100) and 40% (40/100), respectively; (2) there were no significant differences in sensitivity of the three tests under study (MR score, IL-6 or MMP-8) in the identification of either MIAC or intra-amniotic inflammation (using the following cutoffs: MR score >2, IL-6 >11.4 ng/mL, and MMP-8 >23 ng/mL); (3) there was no significant difference in the sensitivity among the three tests for the same outcomes when the false positive rate was fixed at 15%; (4) the specificity for IL-6 was not significantly different from that of the MR score in identifying either MIAC or intra-amniotic inflammation when using previously reported thresholds; and (5) there were no significant differences in the area under the ROC curve when comparing the MR score, IL-6 or MMP-8 in the identification of these outcomes.

CONCLUSIONS

IL-6 and the MR score have equivalent diagnostic performance in the identification of MIAC or intra-amniotic inflammation. Selection from among these three tests (MR score, IL-6 and MMP-8) for diagnostic purposes should be based on factors such as availability, reproducibility, and cost. The MR score requires a protein chip and a SELDI-TOF instrument which are not widely available or considered "state of the art". In contrast, immunoassays for IL-6 can be performed in the majority of clinical laboratories.

Systemic bias in peer review: suggested causes, potential remedies

OBJECTIVE

The aim of this study was to determine if peer review conducted under real-world conditions is systematically biased.

STUDY DESIGN

A repeated-measures design was effectively created when two board-certified obstetrician-gynecologists reviewed the same 26 medical records of patients treated by the same physician, and provided written evaluations of each case and a summary of their criticisms. The reviews were conducted independently for two different, unaffiliated hospitals. Neither reviewer was aware of the other's review, and neither was affiliated with either hospital or knew the physician under review. This study reports the degree of agreement between the two reviewers over the care rendered to these 26 patients.

RESULTS

Three of the 26 cases reviewed had complications. Both reviewers criticized these cases, but criticized 2 of them for different reasons. At least one of the reviewers criticized 14 (61%) of the 23 uncomplicated cases, about which no quality concerns had been raised prior to the review. With one exception, they criticized completely different cases and criticized this 1 case for different reasons. Thus, only 4 of the 17 cases criticized by at least one of the reviewers were criticized by both of them, and only 1 of the 4 cases were criticized for the same reason. The Kappa statistic was -0.024, indicating no agreement between the reviewers (P = 0.98).

CONCLUSIONS

As presently conducted, peer review can be systematically biased even when conducted independently by external reviewers. Dual-process theory of reasoning can account for the bias and predicts how the bias may potentially be eliminated or reduced.

Maternal death following cardiopulmonary collapse after delivery: amniotic fluid embolism or septic shock due to intrauterine infection?

PROBLEM

The amniotic fluid embolism (AFE) syndrome is a catastrophic complication of pregnancy frequently associated with maternal death. The causes and mechanisms of disease responsible for this syndrome remain elusive.

METHOD OF STUDY

We report two cases of maternal deaths attributed to AFE: (1) one woman presented with spontaneous labor at term, developed intrapartum fever, and after delivery had sudden cardiovascular collapse and disseminated intravascular coagulation (DIC), leading to death; (2) another woman presented with preterm labor and foul-smelling amniotic fluid, underwent a Cesarean section for fetal distress, and also had postpartum cardiovascular collapse and DIC, leading to death.

RESULTS

Of major importance is that in both cases, the maternal plasma concentration of tumor necrosis factor-alpha at the time of admission to the hospital and when patients had no clinical evidence of infection was in the lethal range (a lethal range is considered to be above 0.1 ng/mL).

CONCLUSION

We propose that subclinical intraamniotic infection may be a cause of postpartum cardiovascular collapse and DIC and resemble AFE. Thus, some patients with the clinical diagnosis of AFE may have infection/systemic inflammation as a mechanism of disease. These observations have implications for the understanding of the mechanisms of disease of patients who develop cardiovascular collapse and DIC, frequently attributed to AFE. It may be possible to identify a subset of patients who have biochemical and immunological evidence of systemic inflammation at the time of admission, and before a catastrophic event occurs.

Funisitis and chorionic vasculitis: the histological counterpart of the fetal inflammatory response syndrome

OBJECTIVE

To determine whether there is a relationship between the presence of histological signs of inflammation in the extraplacental membranes and umbilical cord and the concentrations of fetal plasma interleukin-6 (IL-6).

METHODS

The study examined a cohort of patients who were admitted with preterm labor or preterm premature rupture of the membranes (PROM) and who underwent cordocentesis. Inclusion criteria included fetal plasma available for IL-6 determination, histological examination of the umbilical cord and placenta, and delivery within 48 h of the procedure. This last criterion was used to preserve a meaningful temporal relationship between fetal plasma IL-6 and the results of histological examination of the placenta. Fetal plasma IL-6 was determined by a high sensitivity ELISA. Forty-five patients were available for study: 18 patients had preterm labor with intact membranes and 27 had preterm PROM.

RESULTS

The incidence of funisitis was 44.4% (20/45): 27.8% (5/18) in patients with preterm labor and intact membranes and 55.6% (15/27) in patients with preterm PROM. The median values of fetal plasma IL-6 in patients with funisitis, chorioamnionitis without funisitis, and non-inflamed membranes were 51.4, 18.4 and 5.2 pg/ml, respectively. After log transformation of the fetal plasma IL-6 concentration, the means differed significantly from each other (ANOVA, p < 0.02). There was no difference in log fetal plasma IL-6 concentration between patients with funisitis and those with chorioamnionitis without funisitis. The difference in mean concentration of log fetal plasma IL-6 between patients with funisitis or chorionic vasculitis and those without inflammation was highly significant (post-hoc test, p = 0.01 and p < 0.01, respectively). Fetuses with fetal plasma IL-6 > 11 pg/ml had a significantly higher rate of histological signs of inflammation in the extra-placental membranes and umbilical cord than those with fetal plasma IL-6 < 11 pg/ml (funisitis: 55.6% (15/27) vs. 27.8% (5/18), p < 0.05; chorionic vasculitis: 55.6% (15/27) vs. 12.5% (2/16), p < 0.01; chorioamnionitis only: 25.9% (7/27) vs. 16.7% (3/18), p < 0.05; no inflammation: 18.5% (5/27) vs. 55.6% (10/18), p < 0.05, respectively). Fetuses with funisitis had significantly higher rates of clinical and histological chorioamnionitis, and neonatal infectious morbidity (proven + suspected sepsis) than fetuses without funisitis (40% (8/20) vs. 8% (2/25), 90% (18/20) vs. 36% (9/25), and 40% (8/20) vs. 4% (1/25), respectively; p < 0.01 for each). Fetuses with chorionic vasculitis had significantly higher rates of clinical and histological chorioamnionitis as well as neonatal infectious morbidity (proven + suspected sepsis) than fetuses without chorionic vasculitis (100% (17/17) vs. 42.3% (11/26), p < 0.01; 82.4% (14/17) vs. 50.0% (13/26), p = 0.05; and 41.2% (7/17) vs. 7.7% (2/26), p = 0.01).

CONCLUSION

Fetal plasma IL-6 concentration is significantly associated with the presence of inflammatory lesions in the extraplacental membranes and umbilical cord. Fetuses with fetal plasma IL-6 > 11 pg/ml had a significantly higher rate of funisitis and/or chorionic vasculitis than fetuses with fetal plasma IL-6 < 11 pg/ml. These findings suggest that funisitis/chorionic vasculitis is the histological manifestation of the fetal inflammatory response syndrome.

Port-site recurrences following laparoscopic operations for gynaecological malignancies

OBJECTIVE

To determine the frequency of port-site recurrences following laparoscopic surgical treatment of gynaecological malignancies metastatic at the time of surgery.

DESIGN

Retrospective review of metastatic primary and recurrent gynaecological malignancies.

RESULTS

Twenty-five women were studied. Twenty-four had metastatic disease at the time of laparoscopic surgery, 22 in association with a primary malignancy (cervix: n = 12, ovary: n = 7, endometrium: n = 3), and two in association with recurrent ovarian cancer; all received pelvic or extended field radiation or chemotherapy after surgery. One woman with Stage IIIC ovarian cancer, disease-free at the completion of neoadjuvant chemotherapy following laparotomy by a general surgeon, was included; she developed scalene node metastases 18 months after definitive laparoscopic surgery. Seventy-one 5 mm trocars and fifty 10 mm trocars (total n = 121) were used for surgery; thirty-one 10 mm trocar sites and forty-four 5 mm sites (total n = 75) received post-operative treatment with chemotherapy (n = 49) or radiation (n = 26). Four women (16%) developed recurrences in association with endometrial (n = 2) and cervical (n = 2) cancer at six trocar sites. All recurrences were associated with abdominopelvic and/or distant metastases, and all occurred at untreated 5 mm trocar sites. The difference in recurrence rates between 5 mm and 10 mm trocar sites (chi(2) = 6; P < 0.025), and between treated and untreated trocars (chi(2) = 5; P < 0.05) were both statistically significant (McNemar's test), but the effects of treatment and trocar size on the port-site recurrence rate were confounded.

CONCLUSIONS

Port-site recurrences are local manifestations of disseminated disease that result from the enhancement of tumour growth characteristic of healing tissues and can be prevented by appropriate post-operative therapy.

Preliminary prospective observations on the laparoscopic management of endometrial carcinoma using the two-stage approach to aortic lymphadenectomy

STUDY OBJECTIVE

To determine the value of a two-stage approach to laparoscopic aortic lymphadenectomy (ALN) in women with endometrial cancer.

DESIGN

Prospective case series.

PATIENTS

Twenty-three consecutive, unselected women with endometrial cancer were managed prospectively according to a previously defined protocol. All had laparoscopic hysterectomy, ten required pelvic and one had an aortic lymphadenectomy (ALN). Pelvic lymph node metastases (PLNM) were present in two (20%) and aortic lymph node metastases in one (10%) patient. Mean age was 60; three women were over 80 years old, and two were 78 years old. Mean weight and body mass index were 192 and 33.5, respectively; two women weighed over 300 pounds and another two weighed over 250 pounds. Mean anesthetic time was 3.2 hours, mean blood loss 469 ccs, and mean drop in hemoglobin 2.5 g/dl. One patient was transfused. Median hospital stay was 2 days. One patient had a questionable ileus post-operatively, and another was hospitalized for 10 days to control her diabetes and blood pressure.

CONCLUSIONS

By predicating ALN on the presence of PLNM in endometrial cancer, the number of ALN can be reduced without reducing the number of aortic lymph node metastases detected, and laparoscopic management can be extended to morbidly obese women.

Laparoscopic management of gynecological malignancies

The primary surgical management of endometrial and cervical carcinoma requires four operations: simple and radical hysterectomy, and pelvic and aortic lymphadenectomy. All these four operations can now be carried out laparoscopically with significant reduction in morbidity and among the patient population that develops these malignancies, namely, the elderly and the obese. Moreover, as judged by the number of nodes harvested and the proportion of positive nodes, the radicality of laparoscopic lymphadenectomy is equivalent to its 'open' counterpart. Thus, laparoscopic management is feasible in almost every patient who has carcinoma of the endometrium or cervix. Experience with the laparoscopic management of ovarian cancer is more limited. There has been concern that the increased frequency of cyst rupture makes laparoscopic management inappropriate, but cyst rupture per se does not impair survival provided patients are managed appropriately with adjuvant chemotherapy, and all but stage I, grade I ovarian cancer is treated with neoadjuvant chemotherapy. Many patients who have stage II-IV disease can be satisfactorily 'debulked' laparoscopically, and a significant proportion of those who cannot be debulked primarily can be debulked laparoscopically after neoadjuvant chemotherapy. The laparoscopic management of ovarian cancer promises to be the most active area of advance over the next few years.

A new technique of primary trocar insertion for laparoscopy

A new method of primary trocar insertion exploits the anatomy of the anterior abdominal wall at the umbilicus. The point of fusion between the skin, fascia, and peritoneum is identified, and a tiny incision is made precisely over this point, enabling a small clamp to be introduced directly into the peritoneal cavity. After stretching the opening with this clamp, a 5-mm trocar is introduced into the peritoneal cavity over a blunt probe, and the abdomen is insufflated. The opening is stretched further with a Kelly clamp, and a 10-mm trocar is introduced over a blunt probe. The technique was used in 54 consecutive patients, 20 of whom had prior low vertical incisions. Ten women had very dense periumbilical adhesions, placing at least four at extremely high risk of bowel injury from blind entry. There were no injuries, and the technique is so quick and effective that it is now the author's routine method of trocar insertion for laparoscopy.

Laparoscopic anatomy and dissection of the pelvis

All anatomically important pelvic structures lie embedded in the fatty-fibrous connective tissue of the retroperitoneum from which they can be freed by blunt dissection in the correct tissue planes. By relying on fixed laparoscopic landmarks, the correct surgical planes of dissection can be found, and all vital structures freed and identified by a systematic dissection consisting of a precise sequence of operative steps. Once the retroperitoneal dissection has been completed and all vital structures identified, most gynaecological operations can be carried out safely and without much difficulty laparoscopically. A non-anatomical approach to laparoscopic pelvic surgery may be easier to learn, but it is neither very versatile nor very safe except in the simplest of cases.

Surgical anatomy and dissection techniques for laparoscopic surgery

All anatomically important pelvic structures lie embedded in the fatty-fibrous connective tissue of the retroperitoneum from which they may be freed by blunt dissection in the correct tissue planes. By relying on fixed laparoscopic landmarks, the correct surgical planes of dissection can be found, and all vital structures freed and identified by a systematic dissection consisting of a precise sequence of operative steps. Once the retroperitoneal dissection has been completed and all vital structures identified, most gynecologic operations can be carried out safely and without much difficulty laparoscopically. A nonanatomical approach to laparoscopic pelvic surgery may be easier to learn, but it is neither very versatile nor very safe except in the simplest of cases.

Extraperitoneal Laparoscopic Hysterectomy for Fibroid Uteri

The feasibility of dividing the uterine arteries laparoscopically using the extraperitoneal technique for laparoscopic hysterectomy to remove large (&gte;500 g) fibroid uteri was assessed in a retrospective review. Over 9 months, 24 women underwent extraperitoneal laparoscopic hysterectomy for a fibroid uterus. Additional procedures were performed in five patients: one colposuspension, one pelvic lymphadenectomy, and three pelvic and aortic lymphadenectomies. In 14 cases the uterus weighed 500 g or more (mean 847 g), 5 weighed 0.7 to 1.0 kg, and 3 weighed 1 kg or more. One patient had pelvic and another had pelvic plus aortic lymphadenectomy in addition to hysterectomy. Two (14%) women required transfusion. Twenty-five (89%) of 28 uterine arteries were divided laparoscopically; both arteries in 12 patients, one artery in 1 patient, and neither artery in 1. None of the women in whom both uterine arteries were divided required transfusion, whereas both in whom one or both arteries were divided vaginally did. In most patients undergoing a laparoscopic hysterectomy by the extraperitoneal technique, both uterine arteries can be divided laparoscopically, and the procedure seems to reduce blood loss.

Laparoscopic pelvic and aortic lymphadenectomy

A systematic approach to the laparoscopic management of gynaecological malignancies began about 5 years ago more or less simultaneously in a few centres in France and the USA. Mature data and long-term follow-up are not yet available. Despite the absence of comparative studies, evidence is, in this author's opinion, now compelling that pelvic and aortic lymphadenectomy can be carried out just as effectively laparoscopically as via a laparotomy. This conclusion is based on traditional surgical, anatomical and pathological considerations such as the way in which the operation is executed, photodocumentation of the extensiveness of the dissection, the lymph node harvest and the proportion of positive lymph nodes recovered. The benefits of a laparoscopic approach have yet to be demonstrated in comparative studies, but compared with historical controls, the reduction in morbidity is so dramatic as to leave little doubt that patients benefit from laparoscopic treatment in experienced hands.

Possible metaplastic origin of lymph node "metastases" in serous ovarian tumor of low malignant potential (borderline serous tumor)

A patient with a stage III serous ovarian carcinoma of low malignant potential (borderline serous tumor) is described who had extensive involvement of the pelvic and para-aortic lymph nodes by both borderline tumor and endosalpingiosis. Transition from endosalpingiosis to papillary serous borderline tumor was demonstrable in multiple intranodal sites, and in fully developed lesions, areas of metaplastic growth acquired a desmoplastic stroma. This finding suggests that the lymph node "metastases" may have arisen de novo by neoplastic transformation of preexistent metaplastic tubal-type epithelium (endosalpingiosis), and would lend further credence to the metaplastic (rather than metastatic) origin or extraovarian implants in serous ovarian carcinoma of low malignant potential.

Laparoscopic pelvic lymphadenectomy in obese women with gynecologic malignancies

Laparoscopic pelvic lymphadenectomy was performed successfully in 10 women weighing over 180 pounds (mean 212 lbs) in conjunction with simple (7) or radical (3) hysterectomy for carcinoma of the endometrium or cervix. Four patients had extensive lysis of adhesions in addition, and one had a myomectomy to allow access to the cul-de-sac. Mean operating time was approximately 4 hours (range 2.5-7 hrs), mean blood loss 1030 ml (range 300-2000 ml), and median hospital stay 3.5 days. The average number of lymph nodes recovered was 33 (range 11-49 nodes). It is concluded that obesity, even in the presence of other pelvic pathology, does not significantly limit the feasibility of pelvic lymphadenectomy. This finding is important to the laparoscopic management of women with endometrial carcinoma.

Dissecting the pelvic retroperitoneum and identifying the ureters. A laparoscopic technique

A technique for dissecting the pelvic retroperitoneum and identifying the ureters and uterine arteries is described that makes use of the obliterated hypogastric arteries. The obliterated arteries are readily identified laparoscopically and, as relatively fixed structures, are easily dissected free of the bladder and surrounding areolar tissues. Once freed by blunt dissection, they are traced proximally to where they are joined by the uterine arteries to form the internal iliac arteries. Blunt dissection just proximal and medial to the uterine artery will open the pararectal space, the medial border of which is bounded by the ureter. The uterine arteries are then traced to where they cross the ureters and are freed from them by blunt dissection. The site at which the uterine arteries are divided and the extent to which the extraperitoneal spaces are developed and ureters mobilized off the medial leaf of the broad ligament are tailored to the operation performed.

Prognostic factors in surgical stage III and IV carcinoma of the endometrium

OBJECTIVE

To identify prognostic factors in surgical stage III and IV endometrial carcinoma.

METHODS

We performed a retrospective analysis of 58 cases of stage III and IV endometrial cancer using the Cox proportional hazards model.

RESULTS

Extrapelvic peritoneal metastases and positive peritoneal cytology greatly affected survival. If either of these factors was present, the 2-year survival rate was only 25%, whereas if they were absent, it was 82%. All patients with extrapelvic metastases died of their disease despite systemic therapy, as did ten of 13 patients with positive peritoneal cytology. Although postoperative therapy in these patients varied, it had no obvious effect on survival or on the site of recurrence. In the absence of abdominal disease or positive peritoneal cytology, survival was not influenced significantly by the presence or absence of lymph node metastases. The difference in survival between women with aortic and pelvic lymph node metastases (24% at 5 years) was not significant, but the power to detect this difference was low (35%). Stage affected survival significantly (P < .05), but a two-category variable, indexing patients as having either positive peritoneal cytology or abdominal disease, provided a much better fit and a more parsimonious model for the data.

CONCLUSION

Five-year survival rates exceeding 70% can be achieved in endometrial carcinoma even if extrauterine disease is present, provided that peritoneal cytology is negative and abdominal metastases are absent.

Laparoscopic-Vaginal Radical Hysterectomy

Eleven patients with stage IA2-IIA carcinoma of the cervix have been treated by combined laparoscopic-vaginal radical hysterectomy and bilateral pelvic lymphadenectomy (3-Stage IA2, 5-stage IB, 3-Stage IIA). The patients were unselected. Three patients had bulky (&gte; 5 cms) tumors, one of whom weighed 239 lbs; one had prior anterior-posterior repair, was apareunic and had significant vaginal narrowing; two patients had extensive pelvic adhesions, one of whom also had a 480 gram uterus. Pelvic lymph node metastases were present in one patient and paracervical lymph node metastases in one. The technique used has undergone significant modification. The laparoscopic phase of the procedure contributes much more to the operation than the lymphadenectomy for it allows a symbiotic partitioning of the operation into the laparoscopic and vaginal components. Only those steps of the operation are carried out vaginally that are easier to perform from below (division of the uterosacral and cardinal ligaments, unroofing of the ureter), and they are made much easier by the preceding laparoscopic phase of the operation. Laparoscopic development of the para-vesical and para-rectal spaces makes vaginal entry into these spaces very straightforward, and laparoscopic division of the uterine artery facilitates vaginal unroofing of the ureter. By allowing the proximal ureter to be freed from the medial leaf of the broad ligament, and the proximal attachments and blood supply of the uterus to be divided, the laparoscopic phase of the operation also permits the cervical ligaments to be divided before the ureters are freed from the vesico-cervical ligament, which helps to avoid a Schuchardt incision in most patients.

Laparoscopically assisted hysterectomy for uteri weighing 500 g or more

We attempted to determine the feasibility and results of laparoscopically assisted vaginal hysterectomy (LAVH) for removing symptomatic fibroid uteri not suitable for vaginal hysterectomy. We retrospectively reviewed cases in which the uterus weighed 500 g or more and was considered not suitable for traditional vaginal hysterectomy after examination under anesthesia. Laparoscopically assisted hysterectomy with or without unilateral or bilateral adnexectomy was successfully completed in 20 (91%) of 22 cases. Thirteen patients had concurrent laparoscopic lysis of adhesions, and one a laparoscopic bladder neck suspension. Mean uterine weight was 837 g, mean operating time 167 +/- 42 minutes, mean blood loss 390 +/- 107 ml, and mean hospital stay 2.6 days. No febrile morbidity or surgical complications occurred among these patients. The only significant intraoperative complication was bleeding requiring blood transfusions, which occurred in one of the two women who required abdominal hysterectomy. Our results suggest that LAVH is a safe and effective alternative to total abdominal hysterectomy of the very large fibroid uterus, and that conversion to total abdominal hysterectomy could be expected to occur in less than 10% of cases.

An operative technique for laparoscopic hysterectomy using a retroperitoneal approach

The technique used for abdominal hysterectomy does not lend itself well to a laparoscopic approach because vital structures will be difficult to visualize and retroperitoneal spaces difficult to open. An entirely different approach is required. An operative technique for laparoscopic hysterectomy is based on a systematic dissection of the retroperitoneum in a very precise sequence of operative steps. It provides complete control of the operative field and allows visualization of all important retroperitoneal structures. The technique is simple to learn, and requires no special surgical skills beyond what is necessary for routine laparoscopic gynecologic procedures.

The discriminatory human chorionic gonadotropin zone for endovaginal sonography: a prospective, randomized study

OBJECTIVE

To determine the probability of detecting the gestational sac of a normal intrauterine pregnancy by vaginal ultrasound at different gestational ages and serum hCG concentrations.

DESIGN

Prospective, randomized study.

SETTING

Pregnant human volunteers in a university-based clinical research environment.

PATIENTS

Women with viable pregnancies who conceived spontaneously or after ovulation induction.

INTERVENTIONS

Vaginal ultrasound and serum hCG determinations were performed between 20 and 30 days after conception. The timing of the tests was determined randomly.

MAIN OUTCOME MEASURE

Detection of gestational sac.

RESULTS

The probability of detecting a gestational sac increased significantly with both gestational age and serum hCG concentration, but the regression on gestational age fitted the data much better than the regression on loge (hCG). The probability of detecting a sac was similar in multiple and singleton pregnancies of the same gestational age but, for a given hCG concentration, the probability of detecting a sac was lower for multiple than for singleton pregnancies because multiple gestations were associated with higher serum hCG concentrations than singleton pregnancies of the same gestational age.

CONCLUSION

If it is known, gestational age rather than the serum hCG concentration should be used to determine whether the gestational sac of an intrauterine pregnancy should be detectable by vaginal ultrasound. Failure to image a gestational sac > or = 24 days after conception is presumptive evidence of an ectopic pregnancy. Reliance on serum hCG rather than gestational age may lead to an erroneous diagnosis of ectopic pregnancy in women with multiple pregnancies.

Urinary tract injuries during laparoscopically assisted hysterectomy: causes and prevention

Two patients who had urinary fistulas after laparoscopic hysterectomy are described. In both cases the ureters were dissected free and the uterus was freed laparoscopically. Injury to the urinary tract occurred during transvaginal closure of the vaginal cuff. Preventative strategies are discussed.

The electronic video operative laparoscope

A new 14-mm electronic video operative laparoscope accommodates a 5-mm operative channel. The video image sensor is located at the distal end of the laparoscope. The image quality is far superior to that of the standard video camera systems that attach to rigid endoscopes. Additional advantages are improved maneuverability, elimination of focusing, superior illumination system, and the capability to interchange with conventional video equipment. This instrument marks the next generation of laparoscopes.

Steroid receptor concentrations in endometrial carcinoma: effect on survival in surgically staged patients

Estrogen and progesterone receptor concentrations were measured in the primary tumors of 137 surgically staged women with clinical stages I and II endometrial carcinoma. For each steroid, increasing receptor concentrations were associated with a decrease in hazard (increase in survival) and the effect was linear for each receptor. When expressed dichotomously, steroid receptor status was also significantly associated with a number of known risk factors, and the significance of the association was influenced by the receptor concentration used as the criterion for receptor positivity. In a multivariate analysis, only progesterone receptor concentration affected survival independently, but the effect disappeared when the analysis was restricted to women with disease confined to the uterus. We conclude that the estrogen and progesterone receptor status of the primary tumor is of limited prognostic significance in endometrial carcinoma unless extrauterine disease is present.

A prospective, randomized study of the chorionic gonadotropin-time relationship in early gestation: clinical implications

OBJECTIVE

To investigate the hCG-time relationship in early pregnancy.

DESIGN

Prospective, randomized study.

SETTING

Pregnant human volunteers in a university-based clinical research environment.

PATIENTS

Normal pregnant women with viable singleton pregnancies, conceived spontaneously or after ovulation induction.

INTERVENTIONS

Vaginal ultrasound was performed, and blood samples were obtained for hormone parameters between 20 and 30 days after conception. The timing of the tests was determined by random assignment using sealed envelopes.

MAIN OUTCOME MEASURE

Serum hCG.

RESULTS

The log hCG-time relationship was linear, both during the first 20 days and between 20 and 30 days after conception. The inclusion of a quadratic term in either regression was not statistically significant. The slopes of the two regression lines were also not statistically different.

CONCLUSION

For practical purposes, the hCG-time relationship in early pregnancy can be treated as log-linear, but short sampling intervals should be used if doubling times are to be calculated from paired samples.