Echogenicity of puborectalis muscle, cervix and vastus lateralis muscle in pregnancy in relation to mode of delivery

OBJECTIVES

To confirm our previous observation that levator hiatal dimensions and mean echogenicity of the puborectalis muscle (MEP) are significantly different at 12 weeks' gestation in women who delivered by Cesarean section due to failure to progress compared with those who delivered vaginally. The secondary objective was to assess the association between the echogenicity of the cervix and vastus lateralis muscle and mode of delivery.

METHODS

In this prospective multicenter study, 306 nulliparous women with a singleton pregnancy underwent ultrasound assessments of the pelvic floor at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, of the cervix and of the vastus lateralis muscle at 12 weeks' gestation. Dimensions of the levator hiatus, MEP and mean echogenicity of the cervix and vastus lateralis muscle were measured and compared according to mode of delivery.

RESULTS

Two hundred and forty-nine women were included in the analyses. We were unable to confirm our previous finding that MEP and levator hiatal transverse diameter and area at 12 weeks' gestation are associated significantly with mode of delivery. In addition, we could not demonstrate a significant association between echogenicity of the cervix or vastus lateralis muscle and mode of delivery. Overall, MEP was a mean of 20 points lower in women in the new database as compared with the previous study, despite the use of the same ultrasound equipment.

CONCLUSION

In a second, independent multicenter dataset, we were unable to confirm our previous finding that levator hiatal dimensions and MEP on pelvic floor muscle contraction are associated significantly with mode of delivery. We also found no association between echogenicity of the cervix or vastus lateralis and mode of delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Health-related quality of life after interval cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with stage III ovarian cancer

INTRODUCTION

The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) improves recurrence-free (RFS) and overall survival (OS) in patients with FIGO stage III ovarian cancer. We evaluated the effect of HIPEC on patient's health-related quality of life (HRQoL) in the OVHIPEC trial.

MATERIALS AND METHODS

OVHIPEC was a multicentre, open-label, randomized phase III trial for patients with stage III ovarian cancer. Patients were randomly assigned (1:1) to receive interval CRS with or without HIPEC with cisplatin. HRQoL was assessed using the EORTC QLQ-C30, and the ovarian (QLQ-OV28) and colorectal cancer (QLQ-CR38) modules. HRQoL questionnaires were administered at baseline, after surgery, after end of treatment, and every three months thereafter. HRQoL was a secondary endpoint, with the prespecified focus on the QLQ-C30 summary score and symptom scores on fatigue, neuropathy and gastro-intestinal symptoms. HRQoL was analysed using linear and non-linear mixed effect models.

RESULTS

In total, 245 patients were randomized. One-hundred-ninety-seven patients (80%) completed at least one questionnaire. No significant difference over time in the QLQ-C30 summary scores was observed between the study arms (p-values for linear and non-linear growth: p > 0.133). The pattern over time for fatigue, neuropathy and gastro-intestinal symptoms did not significantly differ between treatment arms.

CONCLUSION

The addition of HIPEC to interval CRS does not negatively impact HRQoL in patients with stage III ovarian cancer who are treated with interval CRS due to the extent of disease. These HRQoL results, together with the improvement in RFS and OS, support the viability of HIPEC as an important treatment option in this patient population. CLINICALTRIALS.

GOV NUMBER

NCT00426257.

EUDRACT NUMBER

2006-003466-34.

Paraneoplastic hypertrichosis lanuginosa acquisita: uncommon or overlooked?

Acquired hypertrichosis lanugo-type or hypertrichosis lanuginosa acquisita (HLA) is often associated with metabolic and endocrine disorders and use of certain drugs. The occurrence of HLA with malignancy was first noted in 1865, and it has since been described in 56 patients as a paraneoplastic syndrome both in women and in men. Sometimes HLA occurs concurrent with acanthosis nigricans, papillary hypertrophy of the tongue, and glossitis. The predominance of female cases is striking. Malignancy-associated HLA seems to occur especially in the age group 40-70 years. In women with HLA the most frequent malignancy is colorectal cancer, followed in order by lung cancer and breast cancer; in men lung cancer is the malignancy most frequently associated with HLA, followed by colorectal cancer. In 3 years we saw 10 patients with HLA, in whom the malignancy was usually metastasized. Only one patient had local disease; after removal of the primary tumour it took 2 years before the lanugo hair recurred. The aetiology of the syndrome is not clear: no specific hormonal or biochemical abnormalities have been identified as yet. The difference between hirsutism and lanugo-type hypertrichosis is discussed. It is stressed that the appearance of lanugo-type hypertrichosis in body areas previously perceived by patients as 'hairless' is highly indicative of internal malignancy.

A randomized comparison of post-operative pain, quality of life, and physical performance during the first 6 weeks after abdominal or vaginal surgical correction of descensus uteri

AIMS

With respect to urogenital function, vaginal hysterectomy combined with anterior and/or posterior colporraphy has been shown to be superior to abdominal sacrocolpopexy with preservation of the uterus. We performed a randomized trial to compare the effects of both procedures on pain, quality of life and physical performance during the first six weeks after surgery.

METHODS

Eighty-two patients were randomized to have surgery either by vaginal or abdominal approach. All patients were asked to complete the RAND-36 before surgery and 6 weeks after surgery and to keep a diary for the first 6 weeks after surgery. This diary assessed the pain perception and use of pain medication, bother of limitations due to the surgery and performance of daily activities after surgery. These outcomes were compared.

RESULTS

All patients completed the RAND-36 and 68 patients completed the diary. Patients who had undergone abdominal surgery had a statistically lower score on the health change domain (56 vs 68), bodily pain domain (63 vs 80) and mental health domain (74 vs 81) of the RAND-36, as compared to patients who had undergone vaginal prolapse surgery. During hospital stay, the abdominal group experienced on average more days of pain (4.5 vs 3.0) and impaired mobility (3.7 vs 2.9) as compared to the vaginal group. Patients received more pain medication following abdominal surgery as compared to vaginal surgery.

CONCLUSIONS

The vaginal operation to correct a descensus uteri is associated with less pain, better quality of life and better mobility during the first 6 weeks of the recovery period as compared to the abdominal approach.

[Use of alcohol during conception, pregnancy and lactation]

Recently, the Dutch Health Council published a report on the risks of the use of alcohol during conception, pregnancy and lactation. Because the medical literature does not prove the safety of the use of small amounts of alcohol, the Health Council recommends using no alcohol whatsoever. One may wonder whether the advice of the Health Council is not too rigid. Since Karl Popper, it is evident that the truth of the hypothesis that the consumption of small amounts of alcohol is safe will never be verified. Because the medical literature also does not prove the harmfulness of the irregular use of small amounts of alcohol, it is not necessary to upset pregnant women who occasionally take an alcoholic beverage. It is preferable to use no alcohol; however, the rare consumption of a single glass does not seem to be harmful.

A randomised trial comparing low dose vaginal misoprostol and dinoprostone for labour induction

OBJECTIVE

To compare vaginal misoprostol with dinoprostone for induction of labour.

DESIGN

Randomised multicentre trial.

SETTING

Labour wards of one university hospital and two teaching hospitals.

POPULATION

Six hundred and eighty-one women with indication for labour induction at >or=36 weeks of gestation, singleton pregnancy and no previous ceasarean section.

METHODS

Misoprostol (25 mcg, hospital-prepared capsule) in the posterior vaginal fornix, every four hours, maximum three times daily or dinoprostone gel (1 mg) every four hours. Oxytocin was administered if necessary.

MAIN OUTCOME MEASURES

Primary: 'adverse neonatal outcome' (5-minute Apgar score <7 and/or umbilical cord pH <7.15). Secondary: labour duration, mode of delivery and patient satisfaction.

RESULTS

Three hundred and forty-one women received misoprostol and 340 dinoprostone. The median induction-delivery interval was longer in the misoprostol group compared with the dinoprostone group (25 versus 19 hours, P= 0.008). The caesarean section rate was lower in the misoprostol group: 16.1%versus 21%, but this difference was not statistically significant RR = 0.8 (95% CI 0.6-1.04). 'Adverse neonatal outcome' was found to be similar in both groups: 21% in the misoprostol and 23% in the dinoprostone groups. Significantly fewer neonates were admitted to NICU in the misoprostol group compared with dinoprostone 19%versus 26% (RR = 0.7, 95% CI 0.5-0.98).

CONCLUSIONS

Misoprostol in this dosing regimen is a safe method of labour induction. NICU admission rates were lower in the misoprostol group. No difference could be detected in patient satisfaction between groups.

Gender and unwanted pregnancy: a community-based study in rural Ghana

This study investigates attitudes concerning unwanted pregnancies in a rural district of western Ghana. Structured questionnaires were used to interview men and women between 15 and 49 years of age (n = 2179) to measure the prevalence of unwanted pregnancy, how often it led to induced abortion and to establish the reasons why a pregnancy was considered unwanted. At some time in their life at least one unwanted pregnancy was experienced by 41% of men and 43.6% of women. Men and women reported a similar proportion of pregnancies (17.3% and 16.1%, respectively) as unwanted. The proportion of unwanted pregnancies terminated by induced abortion varied with the reason why the pregnancy was undesirable. Among both men and women socio-economic problems were most commonly cited with unwanted pregnancies. Pregnancies perceived by women as unwanted ended more often in an induced abortion than those unwanted by men. Reproductive health programs need to make contraceptives available, accessible and acceptable for both women and men. More research is needed to facilitate a clear understanding of the impact of gender on unwanted pregnancy and its prevention.

Infertility in rural Ghana

OBJECTIVES

This study measured the prevalence of self-reported infertility, as well as the level of knowledge of causes of infertility. Infertility was defined as failure to achieve conception after a minimum of 12 months of exposure.

METHODS

Prevalence and knowledge of infertility were assessed in a representative community-based survey using a structured questionnaire in a rural district in Ghana among a random sample of 2,179 men and women from 15 to 49 years.

RESULTS

The prevalence of infertility was 11.8% among women and 15.8% among men. The knowledge of causes of infertility was limited; only 46.5% of the respondents reported any cause. Most respondents failed to identify reproductive tract infections as causes of infertility.

CONCLUSIONS

Infertility in Ghana and other sub-Saharan countries deserves more recognition as a public health problem. Prevention and treatment of infertility should be incorporated in reproductive health programs, while male participation in reproductive health programs and research needs to be encouraged. Public education about the causes of infertility is recommended.

Abdominal versus vaginal approach for the management of genital prolapse and coexisting stress incontinence

Patients who undergo surgery because of genital prolapse and coexisting stress incontinence can be treated by a combination of surgical procedures via a unified route. We performed a retrospective study among 47 patients to compare micturition, defecation and prolapse symptoms after surgery, as well as duration of hospital stay and complication rate between patients who underwent a unified vaginal or abdominal surgical correction. All patients were treated between January 1995 and December 1997 in the University Medical Center Utrecht or St Antonius Hospital Nieuwegein, The Netherlands. Abdominal surgery was associated with a higher prevalence of difficulty in bladder emptying (relative risk (RR) 2.3 (95% CI 1.4-8.4)), fecal incontinence (RR 3.4, CI 1.1-10.7) and soiling (OR 2.8, CI 1.2-6.2), as well as with a longer postoperative hospital stay (8.6 vs 7.3 days) and a higher complication rate (25.0% vs. 11.4%) than vaginal surgery. These results suggest that a unified vaginal surgical correction of genital prolapse and coexisting stress incontinence appears to be preferable to a unified abdominal surgical correction.

Contraception and induced abortion in rural Ghana

This article describes the results of a community-based survey on birth control in a rural district in western Ghana. Structured interviews with 2179 women and men aged 15-49 years were used to study the prevalence of contraceptive methods and induced abortion. In addition, the influence of induced abortion on reported fertility in relation to residence and education was analysed. The results show that 59.8% had used a contraceptive method at some time in life, while use of induced abortion was reported by 22.6% of respondents. Prevalence of ever-use of any method to avoid childbirth, contraception and/or induced abortion was 67.1%. Urban residence and higher education were associated with more induced abortions and higher use of contraceptive methods. Differences in use of induced abortion were partly responsible for the education and residence-related changes in fertility. Induced abortion needs to be considered when discussing methods in use to avoid childbirth in developing countries.

Malaria prophylaxis and the reduction of anemia at childbirth

OBJECTIVES

To assess the effect of introducing chloroquine prophylaxis during pregnancy on prevalence of anemia (<10.9 g/dl) at childbirth and perinatal outcome.

METHODS

Observational study in a rural district hospital in Ghana, which compared 2803 women who received chloroquine prophylaxis during pregnancy with 3084 historical controls, who had not received prophylaxis during pregnancy. Main outcome measures were hemoglobin level at childbirth, perinatal mortality and birth weight.

RESULTS

Mean hemoglobin level before childbirth increased from 10.7 g/dl (S.D.=1.0 g/dl) to 11.0 g/dl (S.D.=0.9 g/dl). Prevalence of anemia decreased from 29.4 to 13.3% (OR=0.4 and 95% CI=0.3-0.4). Prevalence of moderately severe anemia (<9.0 g/dl) decreased from 4.4 to 3.3% (OR=0.7, 95% CI=0.6-0.97). Perinatal mortality and low birth weight (<2500 g) remained unchanged.

CONCLUSIONS

Routine chloroquine prophylaxis in pregnancy is useful in reducing anemia at childbirth in malaria-endemic regions. Fetal outcome did not improve with chloroquine prophylaxis in this study.

The effect of immersion on haemodynamic and fetal measures in uncomplicated pregnancies of nulliparous women

OBJECTIVE

To evaluate the effect of immersion in water on maternal haemodynamic measures and fetal heart rate patterns in healthy nulliparous women.

DESIGN

A randomised cross-over study.

PARTICIPANTS

Twenty pregnant women were studied between 26-29 weeks and between 34-37 weeks of gestation.

METHODS

The women were either immersed in water for 35 minutes or rested on a bed for a similar period of time. Maternal blood pressure, thoracic electrical bioimpedance, urine and blood samples, and fetal heart rate patterns were obtained before and after immersion or bedrest.

RESULTS

Compared with bedrest and pre-immersion values, immersion resulted in a significant decrease in blood pressure, which returned to baseline values within 1.5 hour. Urine production increased for a short period after immersion, but 24 hour samples showed no difference compared with bedrest. Sodium, potassium and creatinine levels in urine remained constant. No significant changes were found for the other haemodynamic measures. There were no effects on fetal heart rate nor on its variation.

CONCLUSION

In healthy pregnant women immersion for 35 minutes has a clear effect on blood pressure and urine production. However, these effects are short lasting.

A simple strategy to detect significant premenstrual changes

The prevalence of the ten most prominent premenstrual symptoms (top-ten) was calculated in Dutch women (n = 202), who considered themselves to suffer from complaints related to menstruation. Premenstrual syndrome was diagnosed where the scores of 5 or more of the top-ten symptoms showed an increase of at least 2 points (on a visual analog scale rated from 1 to 10) from day 12 to day 26 during two consecutive cycles. This diagnosis was confirmed in almost all subjects using a 'gold standard' criterion of an increase of at least 30% in complaints from the follicular phase to the luteal phase. In contrast to the latter strategy the 'top-ten' method successfully excluded women who felt free from premenstrual complaints. It is concluded that the 'top-ten' method is a simple and valid strategy to detect significant premenstrual changes.

Is premenstrual syndrome an endocrine disorder?

To both patients and physicians it seems natural to attribute adverse premenstrual phenomena to cyclic fluctuations of hormones produced by the ovary. This seems so plausible that, although the endocrine mechanism that causes premenstrual syndrome remains unknown, the condition itself is often treated with hormonal substances. Psychosocial factors are thus considered to be of only secondary importance. They may play a role as a contributing factor, to the 'real' cause of premenstrual syndrome they are not an essential ingredient. The aim of this review article is to examine how strong the evidence is for the possible existence of an endocrine factor as the causative agent in premenstrual syndrome. Using an epidemiological approach we conclude that the continuing search for the responsible mechanism that causes premenstrual syndrome may very well be an endocrine 'Holy Grail'. Human behavior cannot be understood within a single (hormonal) frame of reference. Cyclical ovarian activity is only one of the etiological factors in premenstrual syndrome. Unravelling the pathogenesis of premenstrual syndrome requires a multidisciplinary approach.

Recurrent abortion and the diagnosis of Wilson disease

We describe the first patient with Wilson disease and recurrent abortion who was effectively treated with oral zinc for both conditions. Between the ages of 21-26, this patient experienced seven successive unexplained abortions. At age 27, neurologic signs and liver function disturbances appeared. Wilson disease was diagnosed when Kayser-Fleischer rings were detected in the cornea. Decoppering therapy was instituted with zinc sulfate per os. By the age of 31, hepatic and neurologic signs had vanished. The patient conceived, and after an uncomplicated eighth pregnancy she delivered her first healthy child. Two years later, a ninth pregnancy was equally successful. The chance that Wilson disease may be the cause of recurrent abortion is small. However, because the disease is fatal if left untreated and because it is an underdiagnosed disease, we recommend screening for Wilson disease in cases of unexplained recurrent abortion when family history demonstrates consanguinity or neurologic, psychiatric, and/or liver disorders. A strategy to this end is proposed.

Sigmoid volvulus in a West African population

The incidence, clinical presentation, etiology, and treatment of sigmoid volvulus in a West African population are described. This retrospective study, based on 146 cases in eight years, shows that the incidence of the disorder of 12 new cases per 100,000 population per year is extremely high in the area described. It also shows that good results can be obtained in the treatment of sigmoid volvulus even in suboptimal conditions in rural hospitals when adhering to sound surgical principles.