Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2003
OBJECTIVE To review current knowledge about emergency contraception (EC), including available opt... more OBJECTIVE To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting. OPTIONS The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital copper intrauterine devices, are reviewed. OUTCOMES Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception. EVIDENCE MEDLINE and the Cochrane Database were searched for English-language articles published from January 1998 through March 2003, to update the previous SOGC guidelines published in 2000. Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. Key words used were: emergency contraception, post-coital contraception, emergency contraceptive pills, post...
Journal of The American Association of Gynecologic Laparoscopists, May 1, 1996
To evaluate the safety and clinical efficacy of a uterine thermal balloon endometrial ablation sy... more To evaluate the safety and clinical efficacy of a uterine thermal balloon endometrial ablation system for the treatment of menorrhagia. Prospective pilot study. University-affiliated teaching hospital. Thirty women with menorrhagia who met inclusion and exclusion criteria and signed informed consent. Under general (9 women) or neuroleptic (21) anesthesia and paracervical block, a 16-cm long, 3-mm diameter catheter with a latex balloon at its tip, housing a heating element, was inserted blindly transcervically into the uterus and filled with sterile 5% dextrose in water solution (range 2-21 ml, mean 9.2 ml). The catheter was connected to a control unit that maintained the temperature at 87 degrees C, monitored the pressure, and terminated the treatment after 8 minutes. There were no intraoperative or postoperative complications. At 6 months 25 patients (83%) reported significant improvement in menorrhagia (amenorrhea 1, staining 4, hypomenorrhea 13, moderate improvement 7). By 12 months 23 women (77%) reported significant improvement (amenorrhea 1, staining 4, hypomenorrhea 13, moderate improvement 5). Uterine balloon thermal therapy is a safe and effective option for women with menorrhagia. The procedure does not require additional training and expertise in operative hysteroscopy and the presently used energy sources. It requires no cervical dilatation (5 mm), is tolerated well under neuroleptic anesthesia, and potentially can be offered as an office procedure under local anesthesia.
Objective: To identify the indications for hysterectomy, preoperative assessment, and available a... more Objective: To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully. Options: The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners. Outcomes: Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits. Evidence: Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. Benefits, harms, and costs: Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery. Recommendations: Benign Disease 1. Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus. (I-A) 2. Abnormal uterine bleeding: Endometrial lesions must be excluded and medical alternatives should be considered as a first line of therapy. (III-B) 3. Endometriosis: Hysterectomy is often indicated in the presence of severe symptoms with failure of other treatments and when fertility is no longer desired. (1-B) 4. Pelvic relaxation: A surgical solution usually includes vaginal hysterectomy, but must include pelvic supporting procedures. (II-B) 5. Pelvic pain: A multidisciplinary approach is recommended, as there is little evidence that hysterectomy will cure chronic pelvic pain. When the pain is confined to dysmenorrhea or associated with significant pelvic disease, hysterectomy may offer relief. (II-C) Preinvasive Disease 1. Hysterectomy is usually indicated for endometrial hyperplasia with atypia. (I-A) 2. Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy. (I-B) 3. Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when invasive disease has been excluded. (I-B) Invasive Disease 1. Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma. (I-A) Acute Conditions 1. Hysterectomy is indicated for intractable postpartum hemorrhage when conservative therapy has failed to control bleeding. (II-B) 2. Tubo-ovarian abscesses that are ruptured or do not respond to antibiotics may be treated with hysterectomy and bilateral salpingo-oophorectomy in selected cases. (I-C) 3. Hysterectomy may be required for cases of acute menorrhagia refractory to medical or conservative surgical treatment. (II-C) Other Indications 1. Consultation with an oncologist or geneticist is recommended when considering hysterectomy and prophylactic oophorectomy for a familial history of ovarian cancer. (III-C) Surgical Approach 1. The vaginal route shoe should be considered as a first choice for all benign indications. The laparoscopic approach should be considered when it reduces the need for a laparotomy. (III-B) VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive. Sponsor: The Society of Obstetricians and Gynaecologists of Canada.
Journal of Minimally Invasive Gynecology, May 1, 2012
Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly inte... more Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly interpreted and classified as benign or malignant. Because their behavior and clinical prognosis is also uncertain, the World Health Organization has termed these "smooth muscle tumors of uncertain malignant potential" (STUMP). Herein we describe 2 cases, present a review of the literature, and highlight the diagnostic challenges and therapeutic dilemmas associated with uterine STUMP in myomectomy specimens from women who wish to maintain or enhance their fertility. The clinical course of residual STUMP remains speculative.
Abstract Objectives: to determine the reproductive outcome and estimate the cost for a Jive birth... more Abstract Objectives: to determine the reproductive outcome and estimate the cost for a Jive birth after a single IVF-ET cycle and neosalpingostomy via laparotomy or laparoscopy in patients with bilateral tubal obstruction. Design: retrospective review of medical records. Setting: tertiary reproductive medicine university institute. Patients: three cohorts of infertility patients, treated for bilateral tubal obstruction were compared. Thirty-seven patients with bilateral distal tubal obstruction were treated between July 1990 and July 1994 with laparoscopic bilateral neosalpingostomy using a Coherent ultra-pulse CO 2 laser. Seventy-two patients with bilateral distal tubal obstruction had undergone neosalpingostomy prior to July 1990 by laparotomy, using the CO 2 laser and microsurgical techniques. One hundred and twenty-seven patients with all forms of bilateral tubal obstruction were treated with a single cycle of IVF-ET in the same institute between July 1990 and December 1994. The three groups were comparable in female age and length of infertility. Results: the live birth rate was 19 percent (14 of 72), 22 percent (8 of 37) and 19 percent (24 of 127), and the ectopic pregnancy rate was seven percent (5 of 72), eight percent (3 of 37) and three percent (4 of 127) for the laparotomy, laparoscopy and IVF-ET cycle groups, respectively. The estimated cost for alive birth was $10,497 following laparoscopy, while it was $29,532 and $28,300 following laparotomy and IVF-ET, respectively. Conclusions: the reproductive performance following bilateral laparoscopic neosalpingostomy is at least equal to the pregnancy rate following neosalpingostomy via laparotomy and a single IVF-ET cycle. The least expensive live birth is associated with laparoscopic neosalpingostomy.
Morphological, biophysical, and biochemical parameters of lung growth were studied at autopsy on ... more Morphological, biophysical, and biochemical parameters of lung growth were studied at autopsy on a male infant with hypophosphatasia who died with asphyxia immediately after birth. The lungs were hypoplastic because of a marked decrease in airspace formation but lung maturation was normal for gestational age by all the parameters used. Diaphragmatic development, assessed by weight and fiber measurement, was in keeping with the decreased chest size. The proposed mechanism for this late onset type of pulmonary hypoplasia, attributed to decreased thoracic volume, is correlated with antenatal ultrasonographic observations of normal fetal breathing movements in the affected infant.
Background: Resectoscopic injuries to bowel and/or vessels, although rare, can be catastrophic, r... more Background: Resectoscopic injuries to bowel and/or vessels, although rare, can be catastrophic, resulting in significant patient harm including death and can provoke medicolegal litigation. Objective: To examine indications, preoperative risk factors, perioperative findings and intervention, and clinical outcomes of resectoscopic injuries. Materials and methods: Eleven cases of resectoscopic complications were reviewed by one author (G.A.V.) for medicolegal purposes. After grouping of the complications, one case for each complication was selected, edited and reconstructed to reflect and highlight all potential complications associated with monopolar resectoscopes (26F, 9-mm) and nonconductive distending medium. Although these cases are reconstructed from actual complications, they do not reflect specific cases of medicolegal opinions and outcomes. Indications for resectoscopic surgery included abnormal uterine bleeding and/or infertility in premenopausal women. Results: Injuries were associated with uterine perforation resulting in hemorrhage or bowel injury; urinary bladder injury without uterine perforation; and thermal injuries to lower genital tract and dispersive electrode site. Conclusions: Resectoscopic complications are associated with any one or a combination of trauma during uterine access or intra-operatively, excessive fluid intravasation of distending medium or thermal injuries from applied energy. Uterine perforation in the presence of distorted anatomy (e.g. uterine fibroids) may be considered as a known and accepted complication. Lower genital tract and dispersive electrode site burn occur due to inherent design of monopolar resectoscopes. Appropriate intra- and post-operative intervention minimizes adverse clinical and medicolegal outcomes. Lack of post-operative vigilance and inappropriate delay in investigation and intervention is associated with adverse clinical and, potentially, unfavourable legal outcomes. What is new?: Reviewing resectoscopic complications raises awareness; provides insight for avoidance, recognition and timely intervention to minimise adverse clinical and medicolegal outcomes.
A cross sectional retrospective study of 400 cases of amniocentesis was performed to evaluate the... more A cross sectional retrospective study of 400 cases of amniocentesis was performed to evaluate the reliability of using fetal fat staining cells as a method for assessment of fetal age and maturity. A sharp rise in the percentage of these cells in amniotic fluid occurred after 37 weeks of gestation and a level of 20 per cent or more indicated fetal age of 38 weeks or more, corresponding to maturity by our definition. The false positive and negative rates were 3.5 per cent and 14 per cent respectively. The pre-eclamptics, diabetics and Rh sensitized groups fell within the distribution of the normal population. The dysmature group, however, showed an earlier rise (20% at 36 weeks). The origin of the fetal fat staining cells and the reasons for the early rise in dysmaturity are discussed. Estimation of fetal fat staining cells in the amniotic fluids using the 20 per cent level is a reliable test for maturity in normal and some abnormal pregnancies, excluding dysmaturity.
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2003
OBJECTIVE To review current knowledge about emergency contraception (EC), including available opt... more OBJECTIVE To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting. OPTIONS The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital copper intrauterine devices, are reviewed. OUTCOMES Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception. EVIDENCE MEDLINE and the Cochrane Database were searched for English-language articles published from January 1998 through March 2003, to update the previous SOGC guidelines published in 2000. Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. Key words used were: emergency contraception, post-coital contraception, emergency contraceptive pills, post...
Journal of The American Association of Gynecologic Laparoscopists, May 1, 1996
To evaluate the safety and clinical efficacy of a uterine thermal balloon endometrial ablation sy... more To evaluate the safety and clinical efficacy of a uterine thermal balloon endometrial ablation system for the treatment of menorrhagia. Prospective pilot study. University-affiliated teaching hospital. Thirty women with menorrhagia who met inclusion and exclusion criteria and signed informed consent. Under general (9 women) or neuroleptic (21) anesthesia and paracervical block, a 16-cm long, 3-mm diameter catheter with a latex balloon at its tip, housing a heating element, was inserted blindly transcervically into the uterus and filled with sterile 5% dextrose in water solution (range 2-21 ml, mean 9.2 ml). The catheter was connected to a control unit that maintained the temperature at 87 degrees C, monitored the pressure, and terminated the treatment after 8 minutes. There were no intraoperative or postoperative complications. At 6 months 25 patients (83%) reported significant improvement in menorrhagia (amenorrhea 1, staining 4, hypomenorrhea 13, moderate improvement 7). By 12 months 23 women (77%) reported significant improvement (amenorrhea 1, staining 4, hypomenorrhea 13, moderate improvement 5). Uterine balloon thermal therapy is a safe and effective option for women with menorrhagia. The procedure does not require additional training and expertise in operative hysteroscopy and the presently used energy sources. It requires no cervical dilatation (5 mm), is tolerated well under neuroleptic anesthesia, and potentially can be offered as an office procedure under local anesthesia.
Objective: To identify the indications for hysterectomy, preoperative assessment, and available a... more Objective: To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully. Options: The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners. Outcomes: Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits. Evidence: Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. Benefits, harms, and costs: Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery. Recommendations: Benign Disease 1. Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus. (I-A) 2. Abnormal uterine bleeding: Endometrial lesions must be excluded and medical alternatives should be considered as a first line of therapy. (III-B) 3. Endometriosis: Hysterectomy is often indicated in the presence of severe symptoms with failure of other treatments and when fertility is no longer desired. (1-B) 4. Pelvic relaxation: A surgical solution usually includes vaginal hysterectomy, but must include pelvic supporting procedures. (II-B) 5. Pelvic pain: A multidisciplinary approach is recommended, as there is little evidence that hysterectomy will cure chronic pelvic pain. When the pain is confined to dysmenorrhea or associated with significant pelvic disease, hysterectomy may offer relief. (II-C) Preinvasive Disease 1. Hysterectomy is usually indicated for endometrial hyperplasia with atypia. (I-A) 2. Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy. (I-B) 3. Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when invasive disease has been excluded. (I-B) Invasive Disease 1. Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma. (I-A) Acute Conditions 1. Hysterectomy is indicated for intractable postpartum hemorrhage when conservative therapy has failed to control bleeding. (II-B) 2. Tubo-ovarian abscesses that are ruptured or do not respond to antibiotics may be treated with hysterectomy and bilateral salpingo-oophorectomy in selected cases. (I-C) 3. Hysterectomy may be required for cases of acute menorrhagia refractory to medical or conservative surgical treatment. (II-C) Other Indications 1. Consultation with an oncologist or geneticist is recommended when considering hysterectomy and prophylactic oophorectomy for a familial history of ovarian cancer. (III-C) Surgical Approach 1. The vaginal route shoe should be considered as a first choice for all benign indications. The laparoscopic approach should be considered when it reduces the need for a laparotomy. (III-B) VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive. Sponsor: The Society of Obstetricians and Gynaecologists of Canada.
Journal of Minimally Invasive Gynecology, May 1, 2012
Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly inte... more Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly interpreted and classified as benign or malignant. Because their behavior and clinical prognosis is also uncertain, the World Health Organization has termed these "smooth muscle tumors of uncertain malignant potential" (STUMP). Herein we describe 2 cases, present a review of the literature, and highlight the diagnostic challenges and therapeutic dilemmas associated with uterine STUMP in myomectomy specimens from women who wish to maintain or enhance their fertility. The clinical course of residual STUMP remains speculative.
Abstract Objectives: to determine the reproductive outcome and estimate the cost for a Jive birth... more Abstract Objectives: to determine the reproductive outcome and estimate the cost for a Jive birth after a single IVF-ET cycle and neosalpingostomy via laparotomy or laparoscopy in patients with bilateral tubal obstruction. Design: retrospective review of medical records. Setting: tertiary reproductive medicine university institute. Patients: three cohorts of infertility patients, treated for bilateral tubal obstruction were compared. Thirty-seven patients with bilateral distal tubal obstruction were treated between July 1990 and July 1994 with laparoscopic bilateral neosalpingostomy using a Coherent ultra-pulse CO 2 laser. Seventy-two patients with bilateral distal tubal obstruction had undergone neosalpingostomy prior to July 1990 by laparotomy, using the CO 2 laser and microsurgical techniques. One hundred and twenty-seven patients with all forms of bilateral tubal obstruction were treated with a single cycle of IVF-ET in the same institute between July 1990 and December 1994. The three groups were comparable in female age and length of infertility. Results: the live birth rate was 19 percent (14 of 72), 22 percent (8 of 37) and 19 percent (24 of 127), and the ectopic pregnancy rate was seven percent (5 of 72), eight percent (3 of 37) and three percent (4 of 127) for the laparotomy, laparoscopy and IVF-ET cycle groups, respectively. The estimated cost for alive birth was $10,497 following laparoscopy, while it was $29,532 and $28,300 following laparotomy and IVF-ET, respectively. Conclusions: the reproductive performance following bilateral laparoscopic neosalpingostomy is at least equal to the pregnancy rate following neosalpingostomy via laparotomy and a single IVF-ET cycle. The least expensive live birth is associated with laparoscopic neosalpingostomy.
Morphological, biophysical, and biochemical parameters of lung growth were studied at autopsy on ... more Morphological, biophysical, and biochemical parameters of lung growth were studied at autopsy on a male infant with hypophosphatasia who died with asphyxia immediately after birth. The lungs were hypoplastic because of a marked decrease in airspace formation but lung maturation was normal for gestational age by all the parameters used. Diaphragmatic development, assessed by weight and fiber measurement, was in keeping with the decreased chest size. The proposed mechanism for this late onset type of pulmonary hypoplasia, attributed to decreased thoracic volume, is correlated with antenatal ultrasonographic observations of normal fetal breathing movements in the affected infant.
Background: Resectoscopic injuries to bowel and/or vessels, although rare, can be catastrophic, r... more Background: Resectoscopic injuries to bowel and/or vessels, although rare, can be catastrophic, resulting in significant patient harm including death and can provoke medicolegal litigation. Objective: To examine indications, preoperative risk factors, perioperative findings and intervention, and clinical outcomes of resectoscopic injuries. Materials and methods: Eleven cases of resectoscopic complications were reviewed by one author (G.A.V.) for medicolegal purposes. After grouping of the complications, one case for each complication was selected, edited and reconstructed to reflect and highlight all potential complications associated with monopolar resectoscopes (26F, 9-mm) and nonconductive distending medium. Although these cases are reconstructed from actual complications, they do not reflect specific cases of medicolegal opinions and outcomes. Indications for resectoscopic surgery included abnormal uterine bleeding and/or infertility in premenopausal women. Results: Injuries were associated with uterine perforation resulting in hemorrhage or bowel injury; urinary bladder injury without uterine perforation; and thermal injuries to lower genital tract and dispersive electrode site. Conclusions: Resectoscopic complications are associated with any one or a combination of trauma during uterine access or intra-operatively, excessive fluid intravasation of distending medium or thermal injuries from applied energy. Uterine perforation in the presence of distorted anatomy (e.g. uterine fibroids) may be considered as a known and accepted complication. Lower genital tract and dispersive electrode site burn occur due to inherent design of monopolar resectoscopes. Appropriate intra- and post-operative intervention minimizes adverse clinical and medicolegal outcomes. Lack of post-operative vigilance and inappropriate delay in investigation and intervention is associated with adverse clinical and, potentially, unfavourable legal outcomes. What is new?: Reviewing resectoscopic complications raises awareness; provides insight for avoidance, recognition and timely intervention to minimise adverse clinical and medicolegal outcomes.
A cross sectional retrospective study of 400 cases of amniocentesis was performed to evaluate the... more A cross sectional retrospective study of 400 cases of amniocentesis was performed to evaluate the reliability of using fetal fat staining cells as a method for assessment of fetal age and maturity. A sharp rise in the percentage of these cells in amniotic fluid occurred after 37 weeks of gestation and a level of 20 per cent or more indicated fetal age of 38 weeks or more, corresponding to maturity by our definition. The false positive and negative rates were 3.5 per cent and 14 per cent respectively. The pre-eclamptics, diabetics and Rh sensitized groups fell within the distribution of the normal population. The dysmature group, however, showed an earlier rise (20% at 36 weeks). The origin of the fetal fat staining cells and the reasons for the early rise in dysmaturity are discussed. Estimation of fetal fat staining cells in the amniotic fluids using the 20 per cent level is a reliable test for maturity in normal and some abnormal pregnancies, excluding dysmaturity.
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