WEDNESDAY, SEPTEMBER 6 1 INVITED PRESENTATIONS EN3.01 MICROENDOSCOPY EN3.01.01 USE OF MICROLAPAROSCOPY A. J.M. Audebert , IGFI, Bordeaux, France The terminology "microlaparoscopy" was firstly used in the early 90’s and is, presently, defined as the use of a scope of 2 mm, or less, of diameter. The advances of technology have allowed to develop small scopes with good quality of visualization, as demonstrated by several comparative studies. Many advantages of microlaparoscopy have been claimed: easier use under local anesthesia, lesser risks of complication, better cosmetic outcome with, indeed, better acceptability by the patients. Some of them need, however, to be further properly evaluated. Microlaparoscopy is used preferentially in three various main groups of indications: 1- Diagnostic under local anesthesia (mainly for infertility, chronic pelvic pain, acute pain, second look and emergency cases); the reduced pneumoperitoneum requires a good experience in laparoscopy. The reported failure rates vary from 1 to 12 %. A variant is the so called "Pain mapping", performed for chronic pelvic pain in patients under conscious sedation. 2- Diagnostic and operative under general anesthesia, especially in young children. If the strict definition is respected, the procedures thus performed are limited and dependant on the available instrumentation. 3- As an initial procedure for safer wall entry for patients with previous laparotomy. These patients have been shown to be at higher risk of complication during the installation phase of laparoscopy; a microlparoscopy is initially performed at the Palmer’s point to assess the internal umbilical area and insert under visual control the main ombilical trocar. The specific technical aspects and the assessent, based upon the latest reports, of each major indication will be presented. EN3.01.02 TRANSVAGINAL HYDROLAPAROSCOPY (THL) IN THE SUBFERTILE PATIENT S. Gordts , R. Campo, I. Brosens, Leuven Institute for Fertility and Embryology, Leuven, Belgium. Objective: To evaluate the possibilities for the exploration of the pelvis by a vaginal access and using prewarmed saline as distentionmedium. Materials and methods: The procedure is performed on an ambulatory basis with the patient in a horizontal decubitus position. After infiltration with a local anaesthetic of the posterior fornix, a specially developed Veress needle trocar system (Circon, USA) is introduced into the pouch of Douglas. A 30º angled 2.7 mm endoscope with a wide angle of 105º (Circon, USA) is used for the exploration. We now performed the procedure in 157 patients referred for primary or secundairy infertility and after informed consent. All patients had normal vaginal examination and normal ultrasound. Results: Access was obtained and 149 patients (95%). In 6 patients the technique failed due to tenting of the peritomeum, mostly during our first experiences, or due to obesity. In 2 patients the procedure was aborted due to complications˚: one rectumperforation, treated conservatively with antibiotics during 6 days and one hematoma formation of the broad ligament also conservatively treated with expectant management. The findings were normal in 58.5%; endometriosis was diagnosed in 16.5% and adhesions in 17.5% of the patients; 7.5% other pathology was found. On a linear painscale from 0 (no pain) to 100 (unbearable pain) 68% of the patients reported the pain to be lower than 30 and 24% between 30 and 50. Asked if they would have any objections to repeat the procedure under the same circumstances, 96% didn’t object. Conclusions: In our experience THL proved to be an accurate procedure in the exploration of the subfertile patient. In contrast to standard laparoscopy it is less invasive as it can be performed under local anesthesia. Furtermore it allows the inspection of the tubo-ovarian structures in their natural position without a need for supplementary manipulation. EN3.02 SECOND GENERATION ENDOMETRIAL ABLATION EN3.02.01 ENDOMETRIAL ABLATION VIA THERMACHOICE BALLOON THERAPY CE Miller, MD , Department OB/GYN, University of Illinois, Chicago, IL, USA Of the 600,000 hysterectomies performed in the United States each year, 120,000 are performed for abnormal uterine bleeding with no evidence of uterine fibroids. Unfortunately, the majority of hysterectomies performed are still via an open abdominal route. Moreover, hysterectomy carries with it increased morbidity and even mortality. Endometrial ablation or endometrial resection performed via the hysteroscope has enabled successful treatment of menometrorrhagia without hysterectomy. Electrosurgical instrumentation, utilizing the rollerball, and the bare fiber Nd:YAG laser can be used to ablate the endometrium, while the monopolar resectoscope can resect endometrium. Unfortunately, these techniques are limited by physician expertise. Moreover, risks include uterine perforation, fluid overload, and inadvertent bowel burn. Because of the morbidity related to the invasiveness of hysterectomy as well as secondary to the expertise required to perform endometrial ablation or resection via the hysteroscope, other techniques of endometrial ablation have come to the forefront. Originally introduced as a latex balloon, the ThermaChoice Balloon Ablation system is now a latex free silicone balloon. The balloon, fills with or D5W check with Mary normal saline and expands against and covers the endometrium. This fluid is then heated to 87 degrees centigrade to destroy the lining of the uterus. Studies in the United States as well as abroad reveal amenorrhea rates slightly less than 20% with significant reduction of blood flow and patient acceptance on par with roller ball endometrial ablation techniques. The ThermaChoice Balloon is easy to use and has been proven to be cost effective and safe. EN3.02.02 SECOND GENERATION ENDOMETRIAL ABLATION: PHOTODYNAMIC THERAPY R. L. Reid , Dept. OB/GYN, Queen’s University, Kingston, ON, Canada Endometrial ablation, at outpatient, day surgery procedure has broadened the indications for surgical intervention for abnormal uterine bleeding. A range of therapeutic options now exist including laser, electrosurgery, radiofrequency, microwave, and thermal ablation (both hot and cold). All of these techniques share the potential for inadvertent uterine perforation and damage to adjacent structures. Recently a technique that selectively destroys the endometrium and adjacent myometrial layers without danger to surrounding structures had been developed in the animal model. Exposure of the monkey uterus to a natural precursor (5-amino-levulinic acid {ALA}) in the heme biosynthetic pathway, resulted in endometrial accumulation of the potent photosensitizer, Protoporphyrin IX. Subsequent exposure 3-4 hr later of the endometrial cavity to activating fiberoptic light (635nm @ 300 mW) resulted in highly selective full thickness endometrial destruction. The requirement for both photosensitized tissue and exposure to activating light offers tissue selectivity and adds an additional margin of safety. Simplification of EA techniques may broaden the indications, however, failure rates with inadvertent pregnancies or the need for hysterectomy, and counselling re the need for combined hormone replacement therapy remain important issues that require monitoring. EN3.02.03 MICROWAVE ENDOMETRIAL ABLATION Togas Tulandi , McGill University, Royal Victoria Hospital, Women`s Pavilion, Montréal, Québec, Canada Hysteroscopic endometrial ablation has become an accepted alternative to hysterectomy in the treatment of dysfunctional uterine bleeding. The possible complications of hysteroscopic endometrial ablation are fluid overload, electrolytes imbalance and rarely injury to internal organs. In order to find a simpler and safer technique, non-hysteroscopic
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WEDNESDAY, SEPTEMBER 6 1
INVITED PRESENTATIONS
EN3.01 MICROENDOSCOPY
EN3.01.01USE OF MICROLAPAROSCOPYA. J.M. Audebert , IGFI, Bordeaux, France
The terminology "microlaparoscopy" was firstly used in the early 90’sand is, presently, defined as the use of a scope of 2 mm, or less, ofdiameter. The advances of technology have allowed to develop smallscopes with good quality of visualization, as demonstrated by severalcomparative studies.Many advantages of microlaparoscopy have been claimed: easier useunder local anesthesia, lesser risks of complication, better cosmeticoutcome with, indeed, better acceptability by the patients.Some of them need, however, to be further properly evaluated.Microlaparoscopy is used preferentially in three various main groups ofindications:1- Diagnostic under local anesthesia (mainly for infertility, chronicpelvic pain, acute pain, second look and emergency cases); the reducedpneumoperitoneum requires a good experience in laparoscopy. Thereported failure rates vary from 1 to 12 %. A variant is the so called"Pain mapping", performed for chronic pelvic pain in patients underconscious sedation.2- Diagnostic and operative under general anesthesia, especially inyoung children. If the strict definition is respected, the procedures thusperformed are limited and dependant on the available instrumentation.3- As an initial procedure for safer wall entry for patients with previouslaparotomy. These patients have been shown to be at higher risk ofcomplication during the installation phase of laparoscopy; amicrolparoscopy is initially performed at the Palmer’s point to assess theinternal umbilical area and insert under visual control the main ombilicaltrocar. The specific technical aspects and the assessent, based upon thelatest reports, of each major indication will be presented.
EN3.01.02TRANSVAGINAL HYDROLAPAROSCOPY (THL) IN THESUBFERTILE PATIENTS. Gordts , R. Campo, I. Brosens, Leuven Institute for Fertility andEmbryology, Leuven, Belgium.
Objective: To evaluate the possibilities for the exploration of the pelvisby a vaginal access and using prewarmed saline as distentionmedium.Materials and methods: The procedure is performed on an ambulatorybasis with the patient in a horizontal decubitus position. After infiltrationwith a local anaesthetic of the posterior fornix, a specially developedVeress needle trocar system (Circon, USA) is introduced into the pouchof Douglas. A 30º angled 2.7 mm endoscope with a wide angle of 105º(Circon, USA) is used for the exploration.We now performed the procedure in 157 patients referred for primary orsecundairy infertility and after informed consent. All patients hadnormal vaginal examination and normal ultrasound.Results: Access was obtained and 149 patients (95%). In 6 patients thetechnique failed due to tenting of the peritomeum, mostly during ourfirst experiences, or due to obesity. In 2 patients the procedure wasaborted due to complications : one rectumperforation, treatedconservatively with antibiotics during 6 days and one hematomaformation of the broad ligament also conservatively treated withexpectant management. The findings were normal in 58.5%;endometriosis was diagnosed in 16.5% and adhesions in 17.5% of thepatients; 7.5% other pathology was found. On a linear painscale from 0(no pain) to 100 (unbearable pain) 68% of the patients reported the painto be lower than 30 and 24% between 30 and 50. Asked if they wouldhave any objections to repeat the procedure under the samecircumstances, 96% didn’t object.Conclusions: In our experience THL proved to be an accurate procedurein the exploration of the subfertile patient. In contrast to standardlaparoscopy it is less invasive as it can be performed under localanesthesia. Furtermore it allows the inspection of the tubo-ovarianstructures in their natural position without a need for supplementarymanipulation.
EN3.02 SECOND GENERATION ENDOMETRIAL ABLATION
EN3.02.01ENDOMETRIAL ABLATION VIA THERMACHOICE BALLOONTHERAPYCE Miller, MD , Department OB/GYN, University of Illinois, Chicago,IL, USA
Of the 600,000 hysterectomies performed in the United States each year,120,000 are performed for abnormal uterine bleeding with no evidenceof uterine fibroids. Unfortunately, the majority of hysterectomiesperformed are still via an open abdominal route. Moreover,hysterectomy carries with it increased morbidity and even mortality.Endometrial ablation or endometrial resection performed via thehysteroscope has enabled successful treatment of menometrorrhagiawithout hysterectomy. Electrosurgical instrumentation, utilizing therollerball, and the bare fiber Nd:YAG laser can be used to ablate theendometrium, while the monopolar resectoscope can resectendometrium. Unfortunately, these techniques are limited by physicianexpertise. Moreover, risks include uterine perforation, fluid overload,and inadvertent bowel burn.Because of the morbidity related to the invasiveness of hysterectomy aswell as secondary to the expertise required to perform endometrialablation or resection via the hysteroscope, other techniques ofendometrial ablation have come to the forefront. Originally introducedas a latex balloon, the ThermaChoice Balloon Ablation system is now alatex free silicone balloon. The balloon, fills with or D5W check withMary normal saline and expands against and covers the endometrium.This fluid is then heated to 87 degrees centigrade to destroy the lining ofthe uterus.Studies in the United States as well as abroad reveal amenorrhea ratesslightly less than 20% with significant reduction of blood flow andpatient acceptance on par with roller ball endometrial ablationtechniques. The ThermaChoice Balloon is easy to use and has beenproven to be cost effective and safe.
EN3.02.02SECOND GENERATION ENDOMETRIAL ABLATION:PHOTODYNAMIC THERAPYR. L. Reid , Dept. OB/GYN, Queen’s University, Kingston, ON, Canada
Endometrial ablation, at outpatient, day surgery procedure hasbroadened the indications for surgical intervention for abnormal uterinebleeding. A range of therapeutic options now exist including laser,electrosurgery, radiofrequency, microwave, and thermal ablation (bothhot and cold). All of these techniques share the potential for inadvertentuterine perforation and damage to adjacent structures. Recently atechnique that selectively destroys the endometrium and adjacentmyometrial layers without danger to surrounding structures had beendeveloped in the animal model. Exposure of the monkey uterus to anatural precursor (5-amino-levulinic acid {ALA}) in the hemebiosynthetic pathway, resulted in endometrial accumulation of the potentphotosensitizer, Protoporphyrin IX. Subsequent exposure 3-4 hr later ofthe endometrial cavity to activating fiberoptic light (635nm @ 300 mW)resulted in highly selective full thickness endometrial destruction.The requirement for both photosensitized tissue and exposure toactivating light offers tissue selectivity and adds an additional margin ofsafety.Simplification of EA techniques may broaden the indications, however,failure rates with inadvertent pregnancies or the need for hysterectomy,and counselling re the need for combined hormone replacement therapyremain important issues that require monitoring.
EN3.02.03MICROWAVE ENDOMETRIAL ABLATIONTogas Tulandi , McGill University, Royal Victoria Hospital, Women`sPavilion, Montréal, Québec, Canada
Hysteroscopic endometrial ablation has become an accepted alternativeto hysterectomy in the treatment of dysfunctional uterine bleeding. Thepossible complications of hysteroscopic endometrial ablation are fluidoverload, electrolytes imbalance and rarely injury to internal organs. Inorder to find a simpler and safer technique, non-hysteroscopic
WEDNESDAY, SEPTEMBER 62
techniques including the used of thermal balloon and microwave energyhave been employed.In microwave endometrial ablation (MEA), the energy is delivered intothe endometrium by an applicator where it is radiated in a hemisphericalpattern. Domestic microwave ovens use a frequency of 2-3 GHz. Byincreasing the frequency to 9.2 GHz, the penetrating ability of themicrowaves is dramatically reduced to 6 mm. The procedure is firstdone by dilating the cervix. The microwave applicator is then insertedinto the uterine cavity. During the procedure, the surgeon views a real-time computer display that shows the temperature at the tip of theapplicator. With the tip of the applicator at the fundus, the power isswitched on and heating is allowed until approximately 75oC. Theapplicator is moved slowly from side to side until the entire fundal areahas reached the therapeutic temperature. The applicator is then graduallywithdrawn continuing the side to side movement until the internalcervical os is reached.A recent randomized study demonstrates that MEA is as effective as thestandard endometrial resection. The satisfaction rate (amenorrhea orminimal bleeding) after the procedure was >80%. The duration oftreatment with microwaves; analgesic requirements and postoperativemorbidity were significantly less than endometrial resection. It istechnically very simple and the average duration of the procedure isabout 3-5 minutes. MEA is a promising non-hysteroscopic technique fordysfunctional uterine bleeding.
FM3.01 MATERNAL DISEASE AND PREGNANCY
FM3.01.01ANAEMIAS. Gopalan , Postgraduate Institute of Medical Education and Research,Chandigarh, India
Anaemia is one of the leading causes of maternal mortality indeveloping countries like India and contributes to 20% of maternaldeaths. If all maternal deaths are analysed, 64% have associated anaemiairrespective of the primary cause.Commonest cause of anaemia in pregnancy is still iron deficiency aloneor in combination with folic acid deficiency. In spite of government ofIndia’s iron supplementation’s programme, prevalence is as high as62.3%. This could be due to a) reduced bioavailability of iron because ofdietary habits b) iron deficiency anaemia antedating pregnancy c) lack ofiron intake due to lack of antenatal supervision and advice. Preexistinganaemia is due to poor spacing between pregnancies, parasiticinfestations such as hookworm etc.In pregnancy, treatment of anaemia includes confirmation of the type ofanaemia, ascertaining the etiology and instituting appropriate therapeuticmeasures.Management of anaemia complicating pregnancy would depend onseverity and gestation at diagnosis. In first and second trimesters ofpregnancy blood transfusion may be necessary in women with severeanaemia. Majority of women will respond to oral or intramuscular irontherapy.Difficulty arises in management of women admitted in labour withsevere anaemia. Cardiac output increases during labour and immediatelyafter delivery precipitating cardiac failure. Around 30 to 40% percent areadmitted in failure. Partial exchange transfusion is helpful in suchinstances. At term pregnancy when not in labour, packed cell transfusionunder close monitoring is beneficial. Delivery should always beconducted at a hospital with adequate facilities to manage thecomplications since maternal mortality is highest after delivery.Prevention of anaemia would depend on creating awareness amongstwomen regarding importance of iron supplementation and achieving aneffective programme of screening for anaemia as well as correction atthe primary health care facility.
FM3.02 INDUCTION OF LABOR
FM3.02.01INDUCTION OF LABOUR – OVERVIEW OF METHODOLOGYAndrew Calder , Obstetrics and Gynaecology, University of EdinburghCentre for Reproductive Biology, Edinburgh, U.K.
The clinician’s capability to interrupt pregnancy to the perceivedadvantage of the mother, her offspring or both remains one of the
cornerstones of obstetric care. Two options only are available – deliveryby caesarean section or the artificial induction of labour.The rates of caesarean deliveries continue to rise all around the worldcausing widespread concern. It is self evident that, where clinicalcircumstances call for delivery, if there is a safe and reliable alternativeto caesarean section this should be preferred.It may be fanciful, at least for the present, to expect that we might devisemethods of induction the results of which were labours which wereshorter, easier, more efficient and altogether safer than the bestspontaneous labours but we should at least strive towards such anobjective. Such a goal must depend on exploiting our current state ofknowledge of the physiological control of parturition and exploring newavenues as our understanding of that most complex of processes furtherdevelops.The secret of success lies in bringing about the two essential componentsof labour – myometrial contractions and cervical connective tissuemodification – in a co-ordinated fashion. Without the latter, the formermay be not only futile but dangerous. Methods of ripening the cervix asa prelude to myometrial contractility have paid dividends and there isstill scope for further improvements.The influence of such agents as antiprogestogens, relaxin, nitric oxide,and several cytokines and chemokines (interleukin-8, monocytechemotactic peptide-1) on the myometrium and cervix are currently thesubject of keen investigation. Some or all of these may find their wayinto clinical practice to add to the options provided by the three maintools currently at our disposal – amniotomy, oxytocin andprostaglandins. For the present however we need to improve the way inwhich we use these existing tools to maximum clinical benefit.
FM3.02.02MANAGEMENT OF POSTTERM PREGNANCYMary E Hannah , Department of Obstetrics and Gynaecology,Sunnybrook and Women’s College Health Sciences Centre, Universityof Toronto, Ontario, Canada
Approximately 6% of women will reach or go beyond 42 weeks’gestation, unless labour is induced electively prior to this time. The risksof stillbirth, serious neonatal morbidity, and Caesarean section areincreased for postterm, compared to term, pregnancies. Routine earlypregnancy ultrasound reduces the number of women who requireinduction of labour for postterm pregnancy.When to induce labour? Randomized controlled trials (RCTs) and meta-analyses of RCTs suggest that the risk of perinatal death will be lower iflabour is induced, than if the pregnancy is managed expectantly, oncethe pregnancy reaches 41 to 42 weeks’ gestation. A policy of inductionof labour at 41-42 weeks’ will not increase the risk of Caesarean section,regardless of parity or the state of the cervix, and may actually lower thisrisk. If labour is to be induced, the ripeness of the cervix should dictatethe method to be used. Unless a contraindication to prostaglandinsexists, cervical ripening agents (vaginal or intracervical prostaglandins,vaginal or oral misoprostol) should be considered.What is happening in Canada? The rates of induction of labour forpostterm pregnancy have increased steadily over the past 15 years inmost parts of Canada. The likelihood of a woman delivering at 41 0/7 –41 6/7 weeks gestation has increased from 11.9% (1980) to 16.3%(1995), and a similar decline has occurred in the proportion of birthsdelivering at ³42 weeks’ gestation: 7.1% (1980), 2.9% (1995). Alongwith these changes in timing of delivery, the stillbirth rate amongpregnancies delivering at ³41 weeks’ gestation has decreased. Thusthere is an association between increasing rates of induction of labour at41 weeks’ gestation and decreasing stillbirth rates. There is no evidencethat the increasing use of induction of labour at 41 weeks’ gestation hasincreased the rate of Caesarean section for women giving birth at ³41weeks’ gestation.References:1. Hannah ME, Hannah WJ, Hellmann J. et al. Induction of labor ascompared with serial antenatal monitoring in postterm pregnancy. Arandomized controlled trial. N Engl J Med 1992;326:1587-92.2. Crowley P. Interventions for preventing or improving the outcome ofdelivery at or beyond term. In: The Cochrane Library; Issue 4, 1999.Oxford: Update Software.3. Sue-A-Quan AK, Hannah ME, Cohen MM et al. Effect of Inductionof labour on stillbirth and Caesarean section rates for posttermpregnancy. CMAJ 1999;160:1145-9.
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FM3.02.03INDUCTION AFTER CESAREAN SECTIONTae-Bok Song , Department of Obstetrics and Gynecology, ChonnamUniversity Medical School, Kwangju, Korea
Spontaneous labor may be preferable in a woman who has previouslyundergone cesarean delivery. However, there are many cases which needinduction or augmentation of labor. If oxytocin is not used selectively, asignificant number of VBAC-TOL (vaginal birth after cesarean – trial oflabor) will end up as repeat cesarean procedures.Initial concern that oxytocin usage would significantly increase the riskof uterine rupture/dehiscence has not been confirmed. Meta-analysis ofselected studies indicates that the use of oxytocin during VBAC-TOLdoes not appear to influence the risk of a dehiscence or rupture, nor doesit increase perinatal mortality rates. However, a case-control study foundthat excessive oxytocin infusion increased the risk for rupture ordehiscence. In 1995 the ACOG Practice Patterns Committee concludedthat oxytocin use for induction or augmentation of labor was notcontraindicated. Then in 1998 the ACOG advised that the use ofoxytocin or PGE2 gel for VBAC “requires close patient monitoring”.The College also noted that this recommendation was based on“....limited or inconsistent scientific evidence,” which suggests thatfurther research in this area was needed.Although the use of prostaglandin E2 gel for cervical ripening isextensive and is likely to have been employed in many prior VBACcandidates and its use appears justified at this point, reported data arelimited. There are several reports about using misoprostol for inductionwith risk of uterine rupture. Unfortunately, available reports involveinsufficient numbers to draw a definite conclusion.The role of labor induction during VBAC-TOL is still controversial andthe impact of labor induction should be studied further, controlling formultiple variables.
FM3.03 ECTOPIC PREGNANCY
FM3.03.01MATERNAL MORTALITY OF ECTOPIC PREGNANCIESHein Odendaal , Dept OB/GYN, University of Stellenbosch,Stellenbosch, South Africa
Ruptured tubal ectopic pregnancy is an important cause of maternalmortality. In the USA it has a mortality rate of 38/100,000 events and isone of the major causes of maternal mortality. In Hong Kong it wasfound to have caused 13.7% of maternal deaths, the third most commoncause after haemorrhage and pre-eclampsia. However, in the UK,according to the latest report, it caused only 4.2% of deaths, with a deathrate of 0.3 per 1000 ectopic pregnancies. It is substantially moredangerous than either childbirth or legal termination of pregnancy. Incertain countries the incidence of ectopic pregnancy is rising. It is alsoconcerning that ectopic pregnancy is increasing as a cause of death inthe haemorrhage group of causes. The direct cause of death is mostcommonly haemorrhage from a tubal rupture which occurs in about 25%of ectopic pregnancies.In developing countries the situation is much worse. In Jamaica ectopicpregnancy has been found the third most common cause of maternaldeath, after hypertensive diseases and obstetric haemorrhage. It is thefourth most common cause of maternal death in Zambia. An incidenceof 1.1% with a mortality rate of 2% was found in the Transkei, SouthAfrica. About 71% of cases had tubal rupture and two thirds of patientswere in shock or severely anaemic in arrival.Tubal rupture cannot be predicted. A high index of suspicion shouldtherefore be maintained, particularly in women with risk factors forectopic pregnancy. Early diagnosis followed by prompt resuscitation andefficient transfer or immediate surgery are essential to reduce maternaldeaths.As salpingitis is one of the very few preventable causes of ectopicpregnancy, early treatment is mandatory. However, it remains to be seenwhether the syndromic approach to the treatment of pelvic inflammatorydisease will reduce the incidence of ectopic pregnancy.
FM3.03.02PHARMACOLOGICAL MANAGEMENTJohn Tzafettas , University of Thessaloniki, Thessaloniki, Greece
The medical management of unruptured EP, after adequate patientselectiion, in the majority of cases renders any surgical interventionunnecessary and preserves fertility potential. In both, the conservativemanagement with MTX and the salpingostomy techniques, tubal patencyand future fertility performance, seem to be similar.Repeated administration of MTX leads to regression of the EP in up to95% of the treated cases. However, not rarely (@20%) this isaccompanied by unpleasant side effects, due to systemic distribution ofthe drug, which can be avoided with a single dose. This is even moreadvantageous when the drug can be administered intra-amniotically,under ultrasound guidance.Medical management of EP, has very rarely been employed, when thegestational mass was beyond 35 mm, and/or the cardiac activity visible.In the limited number of cases that this was reported, the success ratewas low and this could be attributed to the inadequate amount of MTXgiven (£ 50mg).The above, generally accepted limitations of this treatment, have beenbased mostly on «logical» assumptions and hence, they are ratherarbitrary. We found that, in the unruptured early ET (<56 days from theLMP), the local administration of 100mg MTX, under laparoscopic orsonographic guidance, seems to be effective, regardless of thepretreatment _- HCG levels, the size of the gestational sac or thepresence of cardiac activity, and with no significant side effects. In viewof the high initial dose(100mg), repeat MTX is not recommended.Instead, cases with persistently high _-hCG levels, should be managedby laparoscopic salpingostomy or, if the fetal heart activity is visible, by«intracardiac» injection of 10% KCL or other embryotoxic agent.Although in the laparoscopic linear salpingostomy, the resolution periodis more predictable and shorter , local injection of MTX could be thefirst choice in unruptured EP, avoiding a comparatively prolonged andmore complicated laparoscopic salpingostomy. Hence, the recentlyreported view that operative laparoscopy should remain the «goldstandard» for treating early EP, does not seem justified, however itmight be appreciated that «the technique chosen , often depends on theskills of the gynaecologist».
FM3.03.03LAPAROSCOPIC MANAGEMENT OF ECTOPIC PREGNANCY.Per Lundorff , Viborg-Kjellerup Sygehus, Viborg, Germany
The benefits of laparoscopic surgery were evaluated in a randomizedtrial and compared with atraumatic surgical treatment by laparotomy.Consecutive analysis of human chorionic gonadotropin (hCG) in serumwas used for prediction and detection of persistent trophoblast. Thepelvic status could be evaluated both at EP surgery and at second-looklaparoscopy. Impairments or improvements of adhesions betweenlaparotomy and laparoscopy were evaluated. Fertility outcome wasassessed by questionnaires to all patients, and the impact of adhesionformation and adhesiolysis was rated with respect to the fertilityoutcome.Results: For the laparoscopy group the mean postoperative stay athospital was 2.2 days and 5.4 days for the laparotomy group. The meansick leave for the laparoscopy group was 10.9 days and 24.1 days forthe laparotomy group. Thirteen patients (12%) developed complicationsbecause of persistent trophoblastic activity. There was no statisticalsignificans between the groups. After the laparoscopic approach, theimpairment of the adhesion status was considerably less than afterlaparotomy. HCG levels of 3000 IU/L was a valuable limit for detectingpersistent trophoblast. Yet, intrauterine pregnancy rate after laparoscopicsurgery did not differ from the laparotomy group.Conclusions: Pre and postoperative hCG determinations are valuable forthe prediction and detection of subsequent complications. The fertilityoutcome of patients treated by laparoscopy or laparotomy is equal,although adhesion formation is more extensive after laparotomy.
WEDNESDAY, SEPTEMBER 64
ON3.01 GYNECOLOGICAL PATHOLOGY: UTERUS
ON3.01.01HOW DOES THE PATHOLOGY OF ENDOMETRIAL CARCINOMAINFLUENCE CLINICAL MANAGEMENT?M. Quinn , Oncology/Dysplasia Unit, The Royal Women’s Hospital,Melbourne, Victoria, Australia.
The pathologist is a key member of the multidisciplinary teamresponsible for the care of women with gynaecological malignancies.For endometrial cancer, macroscopic and microscopic findings are thecornerstone of therapy, and ultimately are the most important influenceon the outcome of our patients.When a pelvic clearance is performed in patients with endometrialcancer, then evaluation of lymph node status is critical, particularly anynodes that are enlarged. Frozen section of such nodes will not onlydirect any further surgery, but also will allow a rational basis foradjuvant radiation and/or cytotoxic treatment.On opening the uterus, the size and type of the tumour can usually beeasily evaluated – the presence of a type 1 tumour, which is usuallyexophytic and non-infiltrative with a good prognosis, can usually behandled conservatively, whereas those type 2 tumours which are usuallyendophytic and invasive, will need a more aggressive surgical approach.Tumours which extend down to the cervix or involve the tubes andovaries will also require a thorough surgical assessment. Myometrialinvasion can usually be evaluated with about 90% accuracy.Histopathological assessment should include the type of tumour, thegrade, taking into account nuclear atypia, the site of the tumour, the size,the depth of invasion and total myometrial thickness, presence orabsence of lymph vascular space involvement, involvement of adjacentorgans and metastases, including lymph nodes, and whether peritonealcytology is positive or negative. On this basis tumours can usually beclearly divided into high risk and low risk with an “intermediate risk”being slightly more difficult to define.Currently, there is no place for measurement of hormone receptorsroutinely since although they do provide some prognostic information,treatment strategies are not changed on their presence or absence.
Despite excellent studies into ploidy status over the last 15 years,particularly from Europe, these have not found their way into the routinearmamentarium of the multidisciplinary team.Likewise, recent advances in molecular biology have clearly shown alink between such tumour suppressor genes as P53 in endometrialcancers, but we are a long way from molecular biological estimationsreplacing the gold standard of histopathology.
ON3.01.03TAMOXIFEN AND ITS ROLE IN ENDOMETRIAL CANCERDr. Patrick Neven , Algemene Kliniek St.-Jan, Brussels, Belgium
Tamoxifen is the most important anti-breast cancer drug in clinical useand has the potential as a chemopreventive breast cancer agent. Theeffects of tamoxifen on the endometrium have caused concern since thelate 1980s, and clear evidence of endometrial changes has emerged fromour department using outpatient hysteroscopy. Based on 2 case controland 2 cohort follow-up studies, we were able to demonstrate that 50% ofwomen receiving long term tamoxifen experienced some sort of adverseendometrial effects. Although many women retain an atrophicendometrial layer, tamoxifen intake can lead to extensive senile cysticatrophia of the human endometrium, to endometrial hyperplasia and toendometrial polyp formation. Based on three studies, one case-controlstudy of breast cancer patients and two randomised controlled trials, onein women with early breast cancer and one in healthy women with afamily history of the disease and based on a critical review of theliterature, we have shown that tamoxifen doubles the risk for developingendometrial cancer in postmenopausal women, although this increasedrisk may be higher and is duration (i.e. time of use)-dependent.Although screening for endometrial abnormalities is feasible and mayincrease drug compliance it may not be cost-beneficial. However,uterine safety becomes important when only a small benefit of thetreatment is to be expected as in the use of tamoxifen in healthy womenfor breast cancer prevention.Those who advocate screening should start with pretreatment uterineassessment using transvaginal ultrasonography or outpatienthysteroscopy. Symptom-free women with a normal pretreatment uterine
cavity can be screened annually with transvaginal sonography from 2 to3 years after the start of tamoxifen. Hysteroscopy or saline infusionsonography will be required if there is endometrial thickening becausethe only value of transvaginal ultrasonography is a normal finding beinga thin rectilinear endometrium.In summary, postmenopausal women on tamoxifen have an increasedrisk for developing endometrial cancer.
ON3.02 VULVAR DISORDERS
ON3.02.01MANAGEMENT OF VULVAR INTRAEPITHELIAL NEOPLASIAL. Micheletti , M. Preti, F. Bogliatto, M. Massobrio Department ofGynecology and Obstetrics, University of Torino, Torino, Italy.
Objectives: The aim of the study is to present the outcome of vulvarintraepithelial neoplasia (VIN) treated or followed without treatment atthe Vulvar Clinic of the Department of Gynecology and Obstetrics of theUniversity of Torino.Study Methods: From June 1981 to December 1999 114 VIN werehistologically diagnosed: 27 VIN I, 15 VIN II and 72 VIN III. For thepurpose of the study the retrospective recruitment of the cases wasstopped in December 1998 and the patients were followed untilDecember 1999.Results: The follow up (median 3.6 years, range 1- 14.9) is available in64 patients surgically treated: 12 VIN I, 9 VIN II and 43 VIN III. Themedian age of the patients was respectively 51.1, 31.5 and 53.7 years. In6% (2 VIN I, 1 VIN II and 1 VIN III) of the 64 patients a spontaneousregression was observed and the median age of these patients was 44years. Recovery at the first treatment was obtain in 49/60 patients(82%): 8 VIN I, 6 VIN II and 35 VIN III. Recurrence was observed in6% of the patients (1 VIN I and 3 VIN III), median age 66 years, andprogression in 11% (1 VIN I, 2 VIN II and 4 VIN III), median age 58years: all patients except one were cured after further treatment. Amongthe progressed group, five patients developed an invasive carcinoma andin three of them, median age 70 years (mean 66), a lichen planus wasoriginally associated.Conclusions: According to our experience, despite VIN grade,excisional versus destructive approach should be preferred since aninvasive neoplasia could arise both in patients with low and high-gradeVIN. Therefore observation could be done for low grade VIN arising inwomen under 45 years or pregnant or reliable for strict follow up
ON3.02.03THE MANAGEMENT OF VULVODYNIAPh.Weijenborg , Dept Psychosom Gyn & Sexology Leiden UniversityMedical Center, Leiden, The Netherlands.
Vulvodynia is defined as chronic vulvar discomfort, especiallycharacterized by the patient’s complaint of burning, stinging, irritationand/or rawness (1). It is important to recognize the different subsets ofvulvodynia, since treatment options differ (2). There has been muchcontroversy about the etiology, diagnosis and management of one ofthese subsets: the vulvar vestibulitis syndrome (3 ). The syndrome(VVS) is characterized by the complaint of dyspareunia, tenderness ofthe vestibule to cotton-swab palpation and vestibular erythema (4). Stillthe ideal approach is not determined.Some basic ideas on the management of VVS will be considered,referring to a model for this pain problem. Somatic as well aspsychological aspects are discussed.1.Burning Vulvar Syndrome: Report of the ISSVD. J Reprod Med1984;29:457.2.Wesselmann U, Burnett AL, Heinberg LJ. The Urogenital and RectalPain Syndromes. Pain 1997;73:269-94.3.Bergeron S, Binik YM, Khalifé S, Pagidas K. Vulvar VestibulitisSyndrome: A Critical Review. Clin J Pain 1997;13:27-42.4.Friedrich EG. The vulvar Vestibulitis Syndrome. J Reprod Med1987;32:110-4.
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RM3.01 ENDOSCOPIC MANAGEMENT OF ENDOMETRIOSIS
RM3.01.02EXCISION OF PELVIC ENDOMETRIOSISDavid B. Redwine , Endometriosis Institute Of Oregon, Bend, OR,United States
No medicine eradicates endometriosis, and medicine treats only thesymptoms, not the disease. For these reasons, surgery is the treatment ofchoice. Because endometriosis can invade beneath the visible pelvicsurface to varying degrees, thermal ablation with laser vaporization orelectrocoagulation may leave disease incompletely treated. Excision ofendometriosis gives the surgeon a better chance of completely removingall disease, including deeply invasive disease. Mature excisionaltechniques have been described and evaluated for endometriosis of anylocation and any depth of invasion. Excision can be performed withsharp scissors, monopolar or bipolar electrosurgery, or laser. Monopolarelectrosurgical excision is the most versatile technique, since the scissorscan be used to palpate, grasp and rearrange tissue, cut sharply, cut withelectrosurgery, coagulate bleeders, blunt dissect, and retract. Thiseliminates most instrument changes and speeds surgery along. Excisionresults histologic confirmation of endometriosis which enhances thescientific process, since the visual identification of endometriosis is notalways correct. The technique of monopolar electroexcision ofendometriosis is simple in concept. Abnormal peritoneum is grasped andelevated away from underlying vital structures. 90 watts of pure cuttingcurrent passed down 3 mm scissors is used to incise normal peritoneumaround the lesion of interest. Retroperitoneal blunt dissection is used toseparate fibrosis associated with endometriosis from vital structures.Remaining tendrils of connective tissue held on stretch can then bequickly cut with electrosurgery. Parenchymal disease, such as of theuterosacral ligaments, can be quickly resected using 50 watts ofcoagulation current, which has a higher voltage and therefore a morepowerful cut. Recurrent disease after complete excision is uncommon,calling into question Sampson’s theory of origin of endometriosis.Symptom relief is excellent and fertility is not compromised by excision.
RM3.01.03THE ENDOMETRIOTIC DISEASE THEORYP.R. Koninckx , University Hospital Gasthuisberg, DepartmentObstetrics-Gynaecology, Division Endoscopic Surgery, CatholicUniversity of Leuven, Leuven, Belgium
The Sampson and metaplasia theories consider endometriosis as normalglands and stroma outside the uterus. The key phenomenon is theimplantation/metaplasia, whereas the subsequent growth anddevelopment is considered inevitable, albeit modulated by peritoneal andimmune factors. The disease therefore is considered progressive andrecurrent.EDT considers retrograde menstruation of viable endometrial cells andoccasional implantation of these cells a normal physiologicphenomenon. These nonimplanted or implanted cells are normallyremoved by the defence mechanisms of the body, such as macrophages.Attachment and implantation is favoured when the mesothelial layer isdamaged by trauma, infection, or even by low-grade inflammation (e.g.irritation caused by CO2 pneumoperitoneum) or by abundant retrogrademenstruation. It seems logical to postulate that by mere statisticalmechanisms, attachment and implantation must occur more frequentlywhen more viable cells are present in peritoneal fluid. Although thesecells can temporarily grow and develop depending upon theenvironment, their ultimate fate when left alone will be a spontaneousregression. This can be complete disappearance/removal or this canresult in some fibrotic or scar tissue as the remnant of localinflammation, containing eventually some endometrial cells, shieldedfrom the bloodstream and from immunocompetent cells, comparable tothe bacteria in an abscess.ED is caused by a cellular modification, e.g. a genetic mutation, asobserved in many benign tumours. This cellular accident will happenmore frequently in genetically predisposed persons, and will be favouredby other factors such as total body irradiation, or chemical pollutantssuch as dioxins. It seems logical that the probability of such a cellularaccident increases when more cells are present. The type of cellularmodification, together with local factors such as the peritoneal fluidmicroenvironment or the intra-ovarian milieu, will determine whetherthey will develop into typical lesions, deep endometriosis or cysticovarian endometriosis, and whether the morphologic characteristics will
be chocolate cysts, endometrial glands and stroma, or adenomyosisexterna. Typical lesions are considered either as the remnant of a normalphysiologic condition, or as a benign tumour with such a lowinvasiveness and growth potential that the lesions remain inactive overlonger periods.The EDT has the following clinical implications. According to theimplantation theory endometriosis is a recurrent disease and women inwhom the diagnosis of (minimal) endometriosis is made are considered atrisk for developing severe endometriosis later in life. According to theEDT, minimal endometriosis, especially subtle or nonpigmented lesions,are no longer considered a pathologic condition and these women shouldnot be considered as having an increased risk to develop severeendometriosis. Since the EDT considers endometriotic disease as a benigntumour, complete surgical excision would eradicate the disease with no riskof recurrence. The actual data showing low recurrence rates after excisionof severe and cystic ovarian endometriosis are consistent with this view.According to the EDT the increase with age and heriditary aspects can beinterpreted as the probability for a cellular incident to happen.The importance of the EDT as opposed to the Sampson and metaplasiatheories, is that implantation is viewed as relatively unimportant,whereas the driving motor become the cellular changes. This obviouslyis crucial for research and treatment which should reorient frompreventing implantation to understanding, preventing or treating cellulardamage or the consequences. According to the EDT endometriosis isentering the era of tumour biology.
RM3.02 NEW METHODS OF CONTRACEPTION
RM3.02.01NESTORONE ROD: A SECOND GENERATION SUBDERMALIMPLANTR. Massai 1, Moo-Young A2, 1Instituto Chileno de Medicina Reproductiva (ICMER), Santiago, Chile. 2The Population Council, NewYork, USA.
The Nestorone (NES) implant is a second generation implant for femalecontraception. It is easy to insert and remove and very efficacious andsafe. Its adverse effects are minimal. This implant contains NES, apotent 19 Nor-progesterone derivative, which does not affectlipoproteins and does not bind to SHBG. The steroid is not biologicallyactive when administered by the oral route due to its rapidbiotransformation by first-pass hepatic metabolism. Thus NES is ideallysuited for breastfeeding and non-breastfeeding women.In previous dose-finding studies in non-breastfeeding women, only onepregnancy was reported, and it occurred in the 24th month of use of asingle implant (100 mg/d). Experience with this implant in 3576 woman-months of use demonstrated high contraceptive efficacy for nearly twoyears (Pearl Index: 0.34). The mode of action is primarily ovulationinhibition and secondarily, increased viscosity of the cervical mucus.The contraceptive effectiveness of the implant was also assessed inbreastfeeding women during lactation and after weaning, for up to twoyears. In 2195 woman-months of use, there were no pregnancies and noadverse effects on breastfeeding or infant growth and health.In order to provide a greater margin of safety beyond two years, thisimplant was reformulated to deliver a higher dose of NES (125 mg/d) fora longer time. This reformulated version is currently being tested in amulticenter Phase II clinical study designed to measure its contraceptiveefficacy beyond two years.
RM3.02.02IMPLANON – A SINGLE ROD SUBDERMAL IMPLANTJ. Newton , Birmingham University/Birmingham Women`s Hospital,Birmingham, United Kingdom.
Implanon is a single rod subdermal implant containing 68mgEtonogestrel. It lasts for at least 3 years and should only be beadministered by those familiar with the insertion technique.In our centre, we have been working with this implant for the last 10years and have published the results of the Pase 2 clinical studies of thepharmacodynamics of leeched implant system, the endometrial responsein Implanon users, ultrasound and endocrine parameters, and thebleeding patterns associated with Implanon use. In addition, weparticipated in the multi-centre clinical tudy of Implanon use and thecomparative study of Implanon versus the 6 rod Norplant system. This
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new subdermal device has proved to be highly effective with nopregnancies being reported after more than 70,000 cycles of use.The single rod implant is 4cm in length and 2mm in diameter. TheEtonogestrel is contained within a flexible EVA membrane. The initialrelcase rate of hormone is 67mg per day. Each Implanon rod comesindividually packed within the needle of a sterile disposable speciallydesigned inserter. Within one day after insertion, serum blood levels aregreater than 90pg/ml of Etonogestrel, which is the critical serum levelrequired to inhibit ovulation. These levels are maintained for at least 3years in a controlled release. Within one week of removing the singlerod, serum blood levels are below the sensitivity of the assay and morethan 90% of women ovulate within 30 days of removal. There appears tobe no effect of patient weight on the serum level, even those weighingmore than 70Kg also have levels of Etonogestrel which inhibitovulation. Its primary effect is of ovulation inhibition, but it hassecondary effects on cervical mucus and the endometrium. In clinicalstudies, both FSH and LH, ultrasound follicle monitoring and serumprogesterone levels confirm these statements. In 2,362 women, over73,429 cycles, no pregnancies were seen.Using a 90 day WHO reference period analysis, the main difference withImplanon is the increased incidence of amenorrhoea, which may beperceived as an advantage rather than frequent and prolonged bleedingepisodes. Compared to studies of Implanon versus a multi-implantdevice, there was an increased incidence of amenorrhoea with Implanoncompared to the other device. Despite the menstrual change,discontinuation rates are low if effective pre-insertion counselling hastaken place, with more than 80% of women remaining on Implanon atthe staart of the third year. Adverse experiences in the multi-centre studycompared with a multi-implant device show no major differences and alow overall incidence of adverse experience. Weight change isunremarkable. Effects on acne and dysmenorrhoea will be presented.One of the key features of Implanon in addition to its high efficacy andcurrent absence of pregnancy, is the difference in insertion and removaltime compared with a multi-rod system. With Implanon the mean timeto eject the subdermal implant is 1.1 minute compared with a mean timeof 4.3 minutes for the multi-implant system. Removal times show asimilar, highly significant difference, 2.6 minutes being the meanremoval for Implanon, with 10.2 minutes being the mean removal timefor multi-rod implants.Counselling is essential and must include contraindications toprogestogens and local anaesthetics, a medical and family history,advantages and limitations of hormone implants, correct timing forinjection and removal techniques, effect on menstruation and theincidence of other adverse effects is also important to stress the rapidreturn to reproductive function after removal of the implant, themaximum period of use, i.e. 3 years, at the present time, and its overallsafety.
UR3.01 STRESS URINARY INCONTINENCE
UR3.01.01DIAGNOSTIC PROCEDURES IN STRESS URINARYINCONTINENCE – THE ROLE OF URODYNAMICS ANDULTRASOUND IN UROGYNECOLOGYHeinz Koelbl, Martin Luther University, Halle-Wittenberg, Halle/Saale,Germany
Introduction: Since 50 years urodynamics and ultrasound havecontributed a lot to our clinical knowledge in urogynecology includinglower urinary tract and pelvic floor dysfunction. With the time theimportance of various diagnostic techniques has changed, especially inregard to their clinical relevance. The euphoric phase of urodynamicswas replaced by the increasing number of reports about the „necessity“of ultrasound. Generally, we have to differentiate between diagnosticprocedures found in clinical routine and procedures important forurogynecologic reasearch.In genuine stress incontinence (GSI) urodynamics is helpful to excludeother forms or to identify mixed forms of urinary incontinence byapplication of filling cystometry. The value of uroflowmetry to assessdetrusor function in the emptying phase of the bladder should not beunderestimated in regard to the increasing number of older women withimpaired detrusor function especially when undergoing stressincontinence surgery with the potential risk of postoperative impairedvoiding funciton. The urethral pressure profile at rest helps to identifythe, hypotonic urethra“, a term defined as a maximum urethral pressrue
of less than 20 cm H2O, and urethral length. Patients with hyptonocurethras have an increased risk to develop recurrent GSI, which at leastshould be included in preperative information of the patient. Thereurethral pressure profile during stress is irrelevant in clinical practice toassess GSI, due to it´s lack of sufficient sensitivity and specificity.Sonographic imaging of the lower urinary tract has replacedconventional radiology in many institutions. In regard tourethrocystography quantitative and qualitative assessment has beeenshown to help the investigator to identify urethrovesical morphology andit´s surrounding structures in patients with GSI and / or pelvic floorrelaxation. The techniques can be combined with urodynamicscomparable to conventional videourodynamics. Three-dimensionalultrasound and endosonographic techniques are still a matter of scientificdiscussion, but have enlarged the knowledge about the functionalanatomy of the urethra and the periurethral structures. Comparativestudies of MRI and ultrasound are able to identify site-specific lesion inpatients with GSI and pelvic floor disorders. Meanwhile, identificitaionof middle and posterior compartemental defects of the pelvic floor is notrestricted to radiological and clinical examination techniques.Urodynamics and sonographic techniques are not conclusive methods toidentify patients with GSI. They complement each other in conjunctionwith patient history, symptoms, quality of life, and last but not leastclinical findings. Both techniques earn their merits in the broad field ofurogynecology including the pelvic floor.
UR3.01.03NEW DEVELOPMENTS IN THE TREATMENT OF STRESSURINARY INCONTINENCE – THE TVT PROCEDURE.C. G. Nilsson , Dept. of Obstetrics & Gynecology, Helsinki UniversityCentral Hospital, Helsinki, Finland
Surgical Treatment of female stress urinary incontinence has focused onthe hypermobility and anatomical changes of the bladder neck and theproximal urethra. The majority of our traditional incontinence operationsare thought to cure urinary leakage by restoring pressure transmissionconditions at the bladder neck (1). A new integral theory has beenpresented, according to which the main closure mechanism of theurethra is situated at the mid-urethra (2). Anatomical structures such asthe pubo-urethral ligaments, the anterioir part of the pubococcygealmuscle and fibrous tissue elements within the anterioir vaginal wall, areall situated at the mid-urethra. The operation is performed in localanesthesia. Through three 1-1.5cm long incisions a Proleneâ tape isbrought under the mid-urethra and paraurethrally on both sides of theurethra, in close contact with pubic bone, by a specially designed device.The tape is intended to support the mid-urethra and strengthen the pubo-urethral ligaments. Clinical experience with this new method areencouraging. Cure rates of 85-95% have been reported (3). Intra-andpostoperative complications are minor and few. The method is suitablefor primary as well as recurrent cases of stress incontinence. Theoperation can be performed as a day surgical procedure and there seemsto be one decline in cure rate by time.1) Enhöming, Acta Chir Scand Suppl. 19612) Petros & Ulmsten, Scand J Urol Nephrol 19933) Ulmsten et al. Int Urogynecol J 1998
SS3.01 COLLECTION AND CLASSIFICATION OFPERINATAL DATA
SS3.01.01CURRENT PROBLEMS IN GLOBAL PERINATAL DATAMANAGEMENTJelka Zupan , World Health Organization, CH-1211 Geneve 27,Switzerland
Current data are critical in the goal of international health efforts toimprove the global health of mothers and infants. Perinatal mortality isan important health indicator often used as evidence of the effect ofprenatal and obstetric care. For international use and comparison theindicator has little meaning unless standard definitions are used, thereporting is consistent and sufficient attention is given to data quality.International surveillance is conducted through vital national registrationsystems, population based surveys, hospital discharge data systems,disease reporting and other sources.
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Around 150 countries have a system of civil registration and statistics,and half of them are considered to be complete. They are an importantsource of population based data for critical outcomes, however, theyprovide inadequate measures for service programs and no data onmorbidity.Hospital discharge data systems routinely provide estimates of causes ofmajor morbidity and mortality in the population, however, theseestimates are not representative of the population. Early postnatal stayalso limits the completeness of data particularly where most babies areborn and die at home.Population based surveys give important data on health and use ofservices despite their limitations such as small sample size for rareevents and recall bias.The role of computer and communication technology should bring hugechanges to surveillance of perinatal events and enable expandingsurveillance efforts in less developed settings.
SS3.01.03INNOVATIVE TOOLS FOR PROCESSING PERINATAL DATA.JM Belizán and G Lindmark, FIGO Committee of Perinatal Health,.Latin American Center for Perinatology (PAHO/WHO), Montevideo,Uruguay and Uppsala University, Uppsala, Sweden
A crucial element to improve health care is the knowledge and analysisof information. When countries and hospitals lack an evaluation of thecharacteristics of the population assisted, the care provided and theoutcomes of such care are blinded and consequently have no orientationto guide their practice and their resources. All of those providing healthcare should be aware of the relevance of the data they are collecting andtranslating into records. Each data collected and then analyzed should befully justified about its usefulness. Quality is more important thanquantity. FIGO Committee on Perinatal Health estimated than with only15 indicators it is feasible to have a good diagnosis of the characteristicsof the population, the care provided and the results obtained. The LatinAmerican Center for Perinatology (PAHO/WHO) is developing a tool toanalyze perinatal data that will provide to the user a friendly output withvital statistics, trends of indicators and risks. This system will be linkedto the Epi-Info statistical package and consequently worldwideavailable. The Minimal Perinatal Data Set proposed by FIGO as well asany data set could use this analytic system to obtain useful outputs toorient care.
SS3.01.04SIMPLIFIED ICD CODING MANUAL FOR PERINATAL HEALTHP. Lumbiganon , Dept. OB/GYN, Faculty of Medicine, Khon KaenUniversity, Khon Kaen, Thailand
Objectives: To develop a simplified ICD 10 coding manual to be usedby Perinatal health personnel.Methods: The first step involved communications with all nationalsocieties affiliated with FIGO, to review existing systems used for thecollection of perinatal data and obtain comment on the existing ICD 10classification. The provincisional simplified version of the ICD 10classification related to Pregnancy, Childbirth and the Puerperium wasdeveloped using a manual developed by the Swedish Association of Ob& Gyn as a model. The WHO committee on ICD 10 classification wasalso contacted for comment and suggestion. This draft manual wascirculated to relevant FIGO Advisory Expert Panel members and someselected delegates in different regions of the world with a request to testit in the actual clinical settings for a one-month period or a minimum of100 deliveries.Results: Eleven countries requested to take part in the field testcompleted the trial. Their response in general terms were positive. Allcomments arising from the field testing were carefully reviewed byFIGO Committee on Perinatal Health and a final draft of the simplifiedversion is to be planned in conjuction with WHO-ICD office.Conclusions: A simplified ICD-10 coding manual for perinatal healthwill be developed in the form of pocket size list which is handy forclinical use.
SS3.02 MICROINVASIVE LESIONS OF BREAST CANCERSPANISH LANGUAGE SESION
SS3.02.02CONSERVATIVE TREATMENT OF MICROINVASIVE BREASTCARCINOMA.AJ. Herruzo . Facultad de Medicina. Basque Country University. Bilbao.Spain
Microinvasive breast carcinoma (MIC) is a controversial lesion, and thenatural history of patients with intraductal carcinoma (DCIS) andmicroinvasion is poorly defined. Microinvasive breast carcinoma (MIC)has a good prognosis.Microinvasion is defined as a single focus of invasive carcinoma < or =2 mm or up to 3 foci of invasion, each < or =1 mm in greatestdimension. The extent of DCIS did not correlate with the number of fociof microinvasion. It has a different biology than T1 invasive carcinomawith > or =90% DCIS, which may progress and cause death. Largetumors with multiple foci of microinvasion may have metastaticpotential. and the clinical management of these patients, with particularreference to management of the axilla, has been controversial.Breast-conserving surgery and definitive irradiation should beconsidered the alternative to mastectomy and the correct treatment forappropriately selected and staged patients with microinvasive ductalcarcinoma of the breast.The size (extensive intraductal component -EIC- ) and margin status ofDCIS each are found to be independent predictors of residual disease.The cases of microinvasive carcinoma not associated with axillarylymph node metastases and appeared to be associated with an excellentprognosis.Further study is indicated to determine the appropriate management andlong term prognosis of patients with this lesion.
SS3.02.04CELLULAR MARKERSJordi XERCAVINS , Sabina SALICRÚ, Mª Dolors SABADELL,Unidad de Patología Mamaria,. Hospitals Vall d’Hebron,. Barcelona.,Cátedra de Obstetricia y Ginecología,. Universidad Autónoma deBarcelona.
El carcinoma ductal “in situ” es la proliferación de células epitelialesmalignas dentro del sistema galactofórico de la mama sin evidencia deinvasión del estroma subyacente a través de la membrana basal en laobservación al microscopio óptico. Existen diversas clasificaciones demicroinvasión aunque la más aceptada es la que se refiere a focos decancer invasivo con un diámetro máximo de 1mm. La predisposiciónhereditaria al cancer de mama y la progresión de la enfermedad desdelesiones benignas hasta la malignidad tienen su base en alteracionesgenéticas diversas como en los genes que regulan el crecimiento celular(oncogenes), la supresión tumoral o la apoptosis pero teniendo en cuentaque es un proceso multisecuencial.Se han utilizado multiples gradaciones de los marcadores celulares conel objetivo de establecer el pronóstico para cada lesión siendo los de másinterés:- tipo y grado histológico- marcadores del fenotipo de la neoplasia: índice de proliferación,
morfología nuclear, angiogénesis.- receptores hormonales, receptores nucleares de retinoides, BCAR1- marcadores indicativos de integridad de respuesta: receptores de
progesterona- oncogenes de supresión tumoral- marcadores de inestabilidad genética- ciclinaEl uso de biomarcadores para cuantificar la variabilidad interindividualen la respuesta a la exposición a carcinógenos tiene implicacionessignificativas para el consejo sobre el riesgo carcinogénico y paraplantear estrategias de quimioprevención. Del mismo modo podemosestablecer índices pronósticos basándose en estos marcadores y a otrosfactores importantes como el índice pronóstico de Van Nuys.
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FM3.04 FETAL ORIGINS OF ADULT DISEASE
FM3.04.01OVERVIEWF. André Van Assche , University Hospital Gasthuisberg, Leuven,Belgium
There is evidence that an abnormal intra-uterine environment has longlasting consequences in adult life.However, when we published in 1979 for the first time in theinternational litterature that an abnormal intra-uterine environment couldinduce consequences in later life, we felt major septicism at that time.At this moment, epidemiologic data show that intra-uterine growthrestriction is related with insulin resistance in adult life expressed asvascular diseases and type II diabetes. Asymetric fetal macrosomia maybe responsible for reduced insulin secretion in adult life.Animal experiments may explain some of the working mechanisms.Severe diabetes or malnutrition during pregnancy in the rat induces fetalgrowth restriction; at adulthood these offspring show insulin resistanceand vascular dysfunction. We suggest that an underdevelopment duringfetal life of insulin receptors may be operational. There is also evidencethat oxidative stress is involved.Mild diabetes in the rat induces fetal macrosomia, in adult life there is areduced insulin secretion.It is clear that the maternally derived changes in fetal plasmacomposition (glucose, amino-acids, fatty-acids) certainly influence thedevelopment and function of the fetal endocrine pancreas, but they affectother organs and functions as well (kidney, hypothalamus, endothelium,etc).The consequences are mostly seen at older age, since the vitality of theorganism is reduced and can not more compensate for these alterations.
FM3.04.02PLACENTAL GLUCOCORTICOID METABOLISM: ANENDOCRINE LINK WITH THE «BARKER HYPOTHESIS»M. D. Kilby , Birmingham Women’s Hospital, Birmingham, UnitedKingdom
Babies who are born small at birth and continue to be small duringinfancy are known to be at increased risk of developing cardiovasculardisease in adult life. It is thought that these adult diseases are«programmed» by an inadequate supply of nutrients or oxygen in-utero.As well as birthwieght, placental weight has also been correlated withadult cardiovascular disease, independently of birthweight. Babies witha placenta that is disproportionately large (in relation to theirbirthweights), are at increased risk of cardiovascular disease also.In animals, fetal hypercortisolaemia is associated with impaired fetalgrowth. The placenta is the site of production of a unique enzyme whichmetabolises cortisol to relatively inactive, cortisone, called 11bhydroxysteroid dehydrogenase 2. We have demonstrated that placentalweight is directly proportional to the activity of this enzyme in theplacenta and that in severely growth restricted babies, the 11b HSD2expression is significantly reduced, especially if associated withplacental vascular disease.Also, in «uncomplicated» pregnancies in which amniocentesis has beenperformed and fetal size estimated using ultrasound, there appears to bean inverse relationship between amniotic fluid cortisol concentration andfetal size (independent of gestational age). This provides furtherevidence of an association between placental/fetal weight ratio and fetalcortisol metabolism in-utero.Such evidence, indicates that the placenta is more than a «transportsystem» for nutrients and oxygen. It has the ability to at as an endocrineorgan and data presented in this presentation further expands on thishypothesis.
FM3.04.03PERINATAL OUTCOME AND THE PLACENTAT T Lao , Department of Obstetrics & Gynaecology, The University ofHong Kong, Queen Mary Hospital, Hong Kong SAR, China.
There is now evidence of an association between an increased placentalweight to birthweight ratio (placental ratio) with cardiovascularcomplications and diabetes mellitus in adulthood. Yet there is scantyinformation on the relationship between the placental size or pathology
with the perinatal outcome, despite that fact that the placenta has beenreferred to as the “diary of the pregnancy”. Placental infarction andchronic villitis has been associated with fetal growth restriction inpreterm and term infants. In the preterm infant, the presence of chorionicand umbilical vasculitis, which are thought to represent pre-existinginfection, are associated with increased risk of intraventricularhaemorrhage independent of confounders. While the placental weight iscorrelated with infant birthweight, a disproportionately heavier placenta,as reflected by an increased placental ratio, can be found with the small-for-gestational age (SGA) newborns, as well as maternal anaemia andgestational diabetes mellitus. An “overweight” placenta is associatedwith evidence of acute or subacute antenatal hypoxia, including lowApgar scores, respiratory distress, neurological abnormalities, andneonatal death, especially in infants born before 35 weeks. Some of theneurological abnormalities persisted into childhood. Most recently, it hasbeen shown that in SGA infants without major anomalies, a highplacental ratio was due to increased placental weight and decreasedbirthweight in the absence of any difference in maternal characteristicsor antenatal complications. Furthermore, the infants with a highplacental ratio had increased incidence of meconium stained liquor,hypocalcaemia, hypomagnesaemia, phototherapy for neonatal jaundice,and sepsis. While histological examination of the placenta may not befeasible as a routine in many centres, the placental weight is usuallyavailable soon after childbirth. Further studies are warranted todetermine whether this information may help to identify not onlysubjects who are at risk of diseases in adulthood, but also newborns whomay have increased morbidity in infancy and childhood.
FM3.04.04FETAL CARDIOVASCULAR PROGRAMMINGK. Marsal, H. Gardiner, J. Brodszki, Department of Obstetrics andGynecology, University Hospital, Lund, Sweden
The reactive fetus responds to severe uteroplacental insufficiency byreducing flow to non-essential organs, and increasing flow to thecerebral circulation, heart and adrenal glands. Obstructed areas withinthe placenta result in increased impedance and may even cause reversalof flow back into the fetal arterial circulation at end-diastole thusincreasing the ventricular afterload and compromising fetalcardiovascular function.We have studied the hypothesis that abnormal arterial flow patterns inSGA fetuses program early vascular development which, by a process ofamplification, may result in adult onset hypertension. Fetalcardiovascular function was examined using ultrasound. Pulse waveformand pulse wave velocity in the thoracic descending aorta wasinvestigated using a phase-locked echo-tracking system. Spectral pulsedDoppler ultrasound was used for examination of aortic, middle cerebralarterial and intracardiac blood flow velocities and the velocity waveformwas evaluated.The dimensions of the descending aorta in growth restricted fetuses wereequivalent to younger, normally grown fetuses of similar mean fetalweight. SGA fetuses had lower ventricular diastolic filling than normalfetuses and did not show gestational increase in fractional shortening.The maximal velocity through the aortic valve was less in growthrestricted fetuses, but there were no significant differences in thepulmonary artery maximal velocity. The pulse wave characteristics ofthe descending aorta differed in SGA fetuses (lower late decrementalvelocity and reduced relative pulse amplitude).The differences in the vascular biophysical properties observed ingrowth restricted fetuses support the hypothesis that vascularremodelling occurs and attempts to maintain stable arterial wall stress.However, whilst fetal adaptive mechanisms may aid survival they mayresult in cerebral, and vascular abnormalities.
ON3.03.01OVERVIEW OF CERVICAL SCREENING WORLDWIDESaloney Nazeer , Clinique de Stérilité et d`EndocrinologieGynécologique, Geneva, Switzerland
Cervical cancer is perhaps the most preventable major form of cancer todate, yet 450 000 women develop invasive disease which causes morethan 200 000 deaths each year, globally.Developing countries account for 80% of the cervical cancer diseaseburden but only 5% of the global resources for cancer control. In these
WEDNESDAY, SEPTEMBER 6 9
countries incidence often equates to mortality because of unawareness,poverty, lack of or in adequate screening programmes with limitedtechnical and fiscal resources. In the face of the above Pap-smear, whichcontinues to be the initial screening test for cervical cancer, will not beavailable in most settings for several decades. It has been estimated that40-50% women in developed countries have had a Pap-smear in the lastfive years compared to 5% in the developing countries. Consequentlythe disease burden is increasing in these countries with 80-85% casesseen at late, incurable stages (III & IV) making incidence equivalent tomortality.Studies conducted worldwide, to evaluate alternative feasible techniquesfor cervical cancer screening in comparison to Pap-smear were reviewedat the Consensus Conference on Cervical Cancer Screening &Management, Tunis 1999. Data from initial studies shows ‘VisualInspection with Acetic Acid' and 'HPV detection' to be the mostpromising methods with high sensitivity. The issues regarding practicalimplementation of these research findings in actual screeningprogrammes is being addressed through Regional technical workshopsunder the umbrella project of the International Network on Control ofGynaecological Cancers (INCGC).It is now established that 95% of cervical cancer cases are associatedwith oncogenic types of Human Papilloma Virus. Clinical trials onpreventive and therapeutic vaccines are underway. The vital questionhowever, prevails as to what will come first - an effective screening toolor a preventive vaccine? It then leads to the question, whether theavailability of vaccine will obviate the need for screening?
ON3.03.02THE ROLE OF HUMAN PAPILLOMAVIRUS TESTING INCERVICAL SCREENINGJ. Cuzick , Imperial Cancer Research Cancer Fund, Department ofMathematics, Statistics & Epidemiology, London, United Kingdom
The human papilloma virus is now established as the primary cause inover 95% of all cervix cancers world-wide. It is readily detectable inmaterial collected in a smear, and is an obvious candidate for screening.Thee are three potential roles for the test –
i. Improving management in women with borderline or midlydyskaryotic smears
ii. Post-treatment surveillanc to detect incomplete excision of CIN iii. As a primary screening test
HPV has better sensitivity for CIN 2/3 than cytology, and thus argues forits use in the first two situations. There are number of possible ways inwhich HPV testing could be employed as a primary screening test –either alone, in conjunction with cytology or only where cytology isequivocal. In addition, self-sampling is a possbility.The high sensitivity of HPV makes it a good candidate for primaryscreening, but issues of specificity are likely to determine its ultimaterole. Results from currently available trials on HPV screening will bepresented as well as the status of ongoing studies.
ON3.03.03PROSPECTS FOR CERVICAL SCREENING IN DEVELOPINGCOUNTRIESL.Denny (1) , L.Kuhn (2), T.C.Wright Jr. (2), (1) Groote SchuurHospital, University of Cape Town, Cape Town, Western Cape, SouthAfrica, (2) Columbia University, New York City, NY, United States.
Objectives:To evaluate alternative methods to cytology for theprevention of cervical cancer in developing countries.Methods: A volunteer sample of 2944 previously unscreened womenrecruited from a squatter camp outside Cape Town, were screened using1] Pap smear 2] HPV DNA detection using HC 1 and HC 11,with probesfor oncogenic types HPV 3] Direct Visual Inspection of the cervix (DVI)after 5% acetic acid and 4] Cervicography. Women who were positiveon any of the screening tests were referred for on-site colposcopy andhistological sampling. In Phase 2 of the study an additional 3000 womenwere screened and tested for HIV, chlamydia and gonococcus infectionof the cervix.Results:Of the initial 2944 women screened, there were 95 (3.5%) casesof LSIL, 74 (2.4%) of HSIL and 12 (0.4%) of cases of cancer. DVI andHPV DNA testing using HC 1 at the standard cut-off for a positive testidentified 18 and 16% of women as positive and detected 67% and 73%of the cases of HSIL and cancer. Using HC 2, HPV DNA testing
identified 88% of the cases of HSIL and cancer. Cytology was positivein 8% of women and identified only marginally more cases of HSIL andcancer at 78%. While the sensitivity of DVI and HPV testing werealmost equivalent to cytology, the specificity was lower. Data fromphase 2 is in process of being analysed and will be presented at theconference.Conclusion: Both DVI and HPV testing have equivalent or bettersensitivity to expert cytology, although both tests lack specificity whichwould result in large numbers of women being overtreated were womento be treated in a 'screen and treat' protocol. HPV testing hasconsiderable potential as a screening test, as it also identifies women atgreatest risk of developing HSIL in the future allowing resources to betargeted to this group of women. Methods of improving specificity ofDVI and HPV testing will be discussed as well as the expected outcomeof different screening protocols based on the performance of thescreening tests.
ON3.03.04HEALTH ECONOMIC CONSIDERATIONS IN CERVICALSCREENINGK. L. Noller , University of Massachusetts Memorial Healthcare,Department of Obstetrics & Gynecology, Worcester, MA, USA
During the past several years chages in the preparation and laboratoryinterpretation of cervical cytologic specimens have been developed.Based on publications to date, these techniques generaly produce modestincreases in the accuracy of cervical cytologic sampling.Unfortunately, all of the proposed techiniques result in increased cost. Inmany cases, it is unclear whether the expense of such systems isjustified. However, because pap smear screening varies greatly indifferent parts of the world, no one statement concerning the costefficiency of these new techniques is appropriate.For example, at one end of the spectrum there are countries where manywomen, most of whom are at low risk for cervical cancer, have annualcervical cytologic screening. For these women (who do not need yearlyscreening in the first place) the increased cost of the new technologies isprobably not warranted. At the other end of the spectrum are thosewomen, a screening method that i most likely to detect disease wouldalmost certainly be cost effective.Health care resources are not unlimited anywhere in the world. Thejudicious use of new technology requires a careful assessment of theneeds of the population and the financial support available.
RM3.03 POLYCYSTIC OVARIAN DISEASE
RM3.03.01WHAT IS PCO?Z.M. van der Spuy , Dept. OB/GYN, University of Cape TownFaculty of Health Sciences, Cape Town, South Africa
The polycystic ovary syndrome is arguably the most commonendocrinopathy of women. Ultrasound assessment of ovarianmorphology is the gold standard for the diagnosis of polycystic ovaries(PCO). The typical ultrasound features include increased stroma andmultiple discreet follicles (at least 8 of <10mm in diameter) oftenarranged peripherally. The polycystic ovary syndrome (PCOS) isdiagnosed when PCO occurs in the presence of clinical symptoms suchas menstrual dysfunction, hirsutism or infertility. It is an heterogenouscondition with variable clinical and endocrine features. Presentation isinfluenced by a variety of extra-ovarian factors. Hyperinsulinaemia in afeature in many women with PCOS and appears to be the “trigger” forclinical expression of this condition. It is a major determinant ofexcessive androgen secretion and is implicated in other aspects of PCOSincluding anovulation and dyslipidaemia. Obesity is a common featureand has an independent effect on the endocrine profile.Polycystic ovaries are an inherited phenotype and have been found inabout 20% of healthy volunteers. In contrast they are present in over90% of women with hirsutism and in about 75% of patients withanovulatory infertility. Hypertension, diabetes mellitus anddyslipidaemia occur more frequently in women with PCOS whencompared with control subjects.It has become evident that PCOS is more than an ovarian disturbanceand the metabolic disorders may have long-term consequences both interms of reproductive function and of general health
WEDNESDAY, SEPTEMBER 610
RM3.03.02GENETICS OF POLYCYSTIC OVARY SYNDROMEStephen Franks , Imperial College School of Medicine, St Mary'sHospital, London W2 1PG
Polycystic ovary syndrome (PCOS) is one of the most common cause ofanovulatory infertility. It is now recognised that, in addition to thereproductive implications, PCOS is associated with a characteristicmetabolic disturbance of which hyperinsulinaemia and insulin resistanceare the central features. This is in turn related to an increase in the risk oftype 2 diabetes in later life. Despite the clinical significance of PCOS, itsaetiology remains uncertain but the high prevalence of cases within thefamilies of affected cases suggests that there is a major genetic cause.Most of the clinical genetic studies published to date, including our own,have concluded that the most likely mode of inheritance is autosomaldominant but recent studies at our centre suggest that PCOS mayrepresent a complex trait involving the interaction of a small number ofgenes with environmental - principally nutritional - factors (Franks et al,Hum Reprod 1997;12:2641-8). We have evidence that polymorphism ofthe insulin gene (INS) variable number tandem repeat (VNTR) is a majorsusceptibility locus for PCOS. The INS-VNTR is in the 5' regulatoryregion of the gene; it has been shown to be involved in insulin secretionand has been implicated in the aetiology of type 2 diabetes.Abnormalities in the regulation of key genes in the androgenbiosynthetic pathway have also been uncovered. In particular, alleles ofCYP11a (coding for P450 cholesterol side chain cleavage) are associatedwith PCOS and there is also evidence for linkage at this locus. Recently,genes implicated in ovarian follicular development have been suggestedto have a role in the aetiology of PCOS, as demonstrated by the recentidentification of the follistatin gene as a potential disease locus (Urbaneket al, Proc Natl Acad Sci 1999; 96: 8573-8578). It seems unlikely thatPCOS can be explained on the basis of a single gene disorder although,in a given family, one gene may have a predominant effect. Anoligogenic model seems the most appropriate basis on which tounderstand the genetic origins of PCOS.
RM3.04 FEMALE STERILIZATION
RM3.04.01CREST STUDY: HOW EFFECTIVE IS TUBAL STERILIZATION?H. B. Peterson , World Health Organization, Geneva, Switzerland
A 1997 report from the U.S. Collaborative Review of Sterilizationevaluated prospectively a total of 10,865 women who underwent tubalsterilization in medical centers in nine U.S. cities in 1978 to 1987.Women enrolled earliest in the study were eligible for up to 14 years offollow-up. A total of 143 true sterilization failures were identified.Conclusions include� Tubal sterilization is highly effective but pregnancies may be more
common than previously thought; the risk appears to vary bymethod of occlusion and technique.
� In general, the risk of pregnancy is greater for women sterilized atearlier ages.
� Pregnancy can occur for many years after sterilization and the moreremote from sterilization it occurs, the more likely it is to be ectopic.
� The risk of ectopic pregnancy likewise persists and varies by ageand method of occlusion; there were ectopic pregnancies identifiedin the 10th year of follow-up after all four methods of laparoscopicsterilization.
Does Tubal Sterilization Cause Menstrual Abnormalities?A preliminary analysis found no menstrual changes attributable tosterilization within the first year or two after the procedure. Findings ofchanges at five years after the procedure could be attributable to ageing.A report based on an analysis of the final data set is pending. Availableevidence argues against the existence of a post-tubal sterilizationsyndrome.Does Tubal Sterilization Increase the Risk of Hysterectomy?Although women undergoing sterilization were approximately fourtimes more likely than their nonsterilized counterparts to undergohysterectomy at 5 years after the procedure, the increase is likely to beattributable to non-biologic factors.What is the likelihood of Regret after Sterilization?The prevalence of regret increased with time since sterilization and washighest among women who were young at the time of the procedure.
RM3.04.02US FDA PIVOTAL STUDIES WITH THE FILSHIE CLIPGilbert Marcus Filshie , University Hospital of Nottingham, QueensMedical Centre, Nottingham, United Kingdom
The Filshie clip was developed in conjunction with Mr D Casey with thesupport of the Simon Population Trust between 1974 and 1982. Duringthis time over 12,000 prototype clips had been tested. The final modelbecame available in 1982. Preparations for the FDA approval wassubsequently sought and the final approval (PMA) was granted in 1996.The clip is made of titanium (ASTM Grades I and II) and silicone rubber(a medical grade silicone rubber). Both these materials have beenextensively used clinically. Non-clinical laboratory studies included:microbiology, toxicology, minology, bi-compatability, stress, wear, shelflife and radio active effects on the silastic elastima. A review of theliterature was also conducted. There were no significant adversebiological responses noted in the literature or on tests. Carcinogenicstudies were conducted in 200 rats and 200 mice following theapplication of mini-Filshie clips. The results showed no evidence ofcarcinogenic activity resulting from the occlusion of the uterine horns inthe animals. Eleven clinical investigations were conducted todemonstrate the safety and efficacy of the Filshie clip system. Four ofthese studies were pivotal ie they were large, multi-centre, prospectiverandomised, comparative trials involving the Filshie clip versus the Wolf(Hulka) clip, the tubal ring, applied laparoscopically (2 studies) andmini-laparotomy (2 studies). There were seven non-pivotal studies. Sixthousand, one hundred and two women received the Filshie clip either asan interval procedure or in the puerperium and 3,095 of these were partof the pivotal studies. A summary of the pivotal studies is shown inTable I. 0.1% of women are reported to have a clip migration from theapplication site and of this total three women experienced expulsion ofthe clip but did not appear to have experienced any serious sequalae. Iwould like to acknowledge Professor Theodore King, Family HealthInternational and Femcare Ltd for supporting these studies as well as the40 investigators who contributed so diligently.Table I: Summary Data of all Clinical Studies Pivotal
Study1
Number Design2
Control
Group Approach
Treated Population
Filshie Control
Months of
follow up
No. of
Centres
Treated Population Overall3
Pregnancy Rates + SE
_______________________
Filshie Control
Statistically
Significant
Outcome
Measures
6267
6267 ext
6266
6265
6265 ext
6264
PRC
PRC
PRC
PRC
PRC
PRC
Wolf Clip
Wolf Clip
Wolf Clip
Tubal Ring
Tubal Ring
Tubal Ring
Laparoscopy
Laparoscopy
Minilaparotomy
Laparoscopy
Laparoscopy
Minilaparotomy
622
298
441
916
356
462
625
301
437
909
347
446
12
24
12
12
24
12
4
2
5
7
4
5
0.002 + 0.002
0.010 + 0.007
0.000 + 0.000
0.002 + 0.002
0.007 + 0.005
No pregnancies
0.010 + 0.004
0.028 + 0.012
0.003 + 0.003
0.002 + 0.002
0.003 + 0.003
None
None
None
Filshie group
less likely to
have surgical
injury and less
likely to have
pain during
recovery
None
None
1ext = extended protocol. The protocol was extended to 24 months for a subset of women
2PRC = prospective, randomised and controlled
3Gross cumulative life-table pregnancy rates + standard error through study protocol designated follow up period
RM3.04.03FEMALE STERILIZATION FAILURER. J. Stock , Portsmouth Naval Medical Center, Protsmouth, VA, UnitedStates
There are more than 100 procedures described for female tubalsterilization. All the procedures are designed to permanently obstruct the
WEDNESDAY, SEPTEMBER 6 11
Fallopian tubes. They also all have related complications and reportedfailures. Sterilization failures may be categorized into 4 groups: 1)conception occuring prior to the surgical procedure; 2) the surgicalprocedure performed on a tubular structure other than the Fallopian tube;3) and improperly performed surgical procedure on the Fallopian tube;or 4) the occurrence of tubo-peritoneal fistula formation or spontaneousanastomosis as a consequence of natural healing following a propelyperformed procedyre. The focus of this presentation will be on the latter3 possibilities.Associated tubular structures are rarely mistaken for Fallopian tubes andare the result of incomplete operative exposure.Improperly performed procedures are most commonly associated withclip, ring of electrocoagulation techniques. These procedures involvespecific knowledge and use of equipment, approach to the tube, andapplication to the appropriate section of the Fallopian tube. The failuresin these cases are the results of incomplete obstruction/destruction of thetube.Segmental destruction of the tube by whatever means will result in ahealing process that will tend to maintain a patent lumen. Usually theresult will be a tubo-peritoneal fistula. However, if the two ends are inclose proximity then spontaneous anastomosis may occur.The most successful sterilization procedures are those in which thesegmental obstruction leads to fibrosis without separation, or tubaldivision with the uterine end of the tube buried beneath the peritoneum.
RM3.04.04FEMALE STERILIZATION – STERILIZATION REVERSALS. Nair , Mount Elizabeth Hospital, Singapore
Tubal sterilization has evolved over the years into minimally invasivelaparoscopic approaches with less traumatic and tube preserving devicesof tubal interruption (clips;rings). Due to the very small lumen size ofthe fallopian tube (500, um), the concept of microsurgery was initiatedby Swolin (1967) who proposed the use of magnification and delicateinstrumentation. Gomel (1977) and Winston (1977) independentlyproved the feasibility microsurgical sterilization reversal with resulltssuperior to macrosurgery. Pregnancy rates of 80% to 90% are achievableusing microsurgical technique (Kim etal 1997). Most pregnancies occurwithin the first year (80%). The main prognostic factor for pregnancy isthe age of the patient.The type of anastomosis and whether it is unilateral or bilateral has nostatistically significant effect on fetrility results (Glock 1996). Acommonly held niew is that the best fertility results after sterilizationreversal when clips are used for tubal sterilization. Sieler (1983)however, reported that the type of sterilization procedure did not affectprognosis. The final length of the reanastomosed tube is an importantprognistic factor (Silber & Cohen 1984; Kim etal 1997). The pregnancyrate was dismal in patients with a tubal length of less than 4 cm.Yet another revolution in microsurgery is the laparoscopic approachwhich provides a «closed» environment and utilizes patient positioningand pneumoperitoneum to obtain exposure without retractors / packinghence potentially reducing de novo adhesion formation. The advent ofnew « ultra-micro » laparoscopic instruments and the 3 chip CCDcamera has enabled traditional microsurgery to be performedlaparoscopically (Koh 1996).
UR3.02 INTERNATIONAL UROGYNECOLOGYASSOCIATION SYMPOSIUM: INCONTINENCE
UR3.02.01QUALITY OF LIFEL Cardozo, King’s College Hospital, London, UK
Urinary incontinence is a distressing condition which has been shown toadversely affect all aspects of the quality of life of those women whosuffer from it. Various studies have been undertaken to try to measurethe impact that incontinence has on normal daily living but the generichealthy questionnaires which are in current use are not specific enoughto for this purpose. In recent years several new disease (incontinence)specific questionnaires have been developed which provide a moresensitive tool with which to evaluate the psychosocial impact of urinarydisorders in women.The International Continence Society has recommended that quality oflife be included as an outcome measure in all clinical trials of new
interventions aimed to treat urinary incontinence. Before such measuresare introduced it is important that they are adequately tested for validityand reproducibility and it is important to recognise that such instrumentscannot be used in isolation but must be included as part of an overallassessment, including subjective and objective parameters.
UR3.02.02DEVICES AND BEHAVIOURAL TECHNIQUESG. Willy Davila, Cleveland Clinic Florida Fort Lauderdale, FL, UnitedStates
Treatment of urinary incontinence utilizing pelvic neuromuscularrehabilitative techniques makes rational sense, as the pathophysiologicbasis for most types of incontinence and voiding dysfunction is based onneuromuscular dysfunction. Timed voiding and bladder drills have beendemonstrated to be very effective as first line therapy for incontinentwomen, especially those with urge incontinence. Pelvic floor exercisesby themselves are typically not effective due to the difficulty inidentifying the levator musculature. Biofeedback-guided exercises havebeen demonstrated to be effective, especially in a motivated patient whoperforms exercises on a long-term basis.Functional electrical stimulation, initially thought to be a means ofenhancing pelvic floor contraction strength, is primarily effective inwomen with urge incontinence. Multiple variables can be adjusted toindividualize the utility of electrical stimulation for specific incontinencetypes.Devices used for the treatment of incontinence function by a variety ofmethods; external urethral obstruction, bladder neck elevation, andintraurethral valvular effect. Of those, intra-vaginal devices designed toelevate the bladder neck in a manner similar to anti-incontinence surgeryhave the highest degree of acceptance and usage. These are particularlyuseful in women who do not wish surgical therapy, or those in whomsurgery may not be appropriate.Numerous effective non-surgical treatment options are available forwomen who suffer from urinary incontinence. Individualization oftherapy is key to successful modality selection.
UR3.02.03TREATMENT OF GENUINE STRESS INCONTINENCE: MININVASIVESURGERYMauro Cervigni , "S. Carlo di Nancy" Hospital, Roma, Italy
Type 1 and Type 2 Stress Urinary Incontinence (SUI) is defined as a urineleakage under stress associated with an urethral and bladder neckhypermobility. The actual world-wide concept is to create a support over along period on which the hypermobile urethra can be compressed duringabdominal straining. Up to now the gold standard for the treatment of SUI isthe Burch procedure. Nevertheless its reliability and long-term efficacy (81%after 5 y. F-U), the modern trend of surgery is to obtain the same results of thetraditional techniques with mini-invasive and day-surgery procedure. Needlesuspensions were the first attempt of a less traumatic and mini-invasiveapproach. But recent papers on long-term discouraging resultsi (Kelly andKirshbaum ’91) suggested to find new techniques. Recently some groups haveintroduced the laparoscopy in the treatment of SUI. But, the sparse reports inthe Literature, the short follow-up, the lack of a specific definition of the termscure and improve and the complication rate raise some doubts on theadvantages of these techniques on transvaginal techniques.. In 1982 Ulmstenpostulated the hypothesis that the principal mechanism for urinary continencewas related not only to the bladder neck, but also and mainly at the middlethird of the urethra, were there is the location of the maximum intraurethralpressure. According to this hypothesis he proposed an ambulatory surgicalprocedure: Tension free Vaginal Tape (TVT), in which a Prolene mesh tape ispositioned in local anesthesia below the middle third of the urethra. Theadvantages are numerous:1. the patient awake has an intact pelvic floor reflex during cough maneuvers(extremely important for the evaluation of the degree of the tape tension).2. The tape is positioned “tension free”, only loosely placed, without vaginalor bladder neck elevation,3. this position create an “urethral kinking” only during stress, allowing anormal funneling of the bladder neck during. voiding with a positive effect onthe onset of micturition.. The new technologies (Bone Anchors) combinedwith new concepts on physiopathology of continence (TVT.) are dramaticallychanging the surgical treatment of SUI. The near future might confirm theseexpectancies.
WEDNESDAY, SEPTEMBER 612
UR3.02.04THE SURGICAL MANAGEMENT OF RECURRENT STRESSURINARY INCONTINENCEJ. A. Schulz, H. P. Drutz , Mount Sinai Hospital, Toronto, ON, Canada
Recurrent stress urinary incontinence is a distressing problem. It scausesare multifactorial and the literatire continually provides suggestions forchanges to the surgical approach. Over 200 surgical procedures exist forthe treatment of stress urinary incontinence, and this leaves thepractising surgeon with an overwhelming range of choice. This articlewill review current available techniques for the surgical treatment ofrecurrent stress urinary incontinence.
SS3.03 SAFE MOTHERHOOD: ENSURING SKILLEDATTENDANCE AT BIRTH
SS3.03.01SETTING MIDWIFERY STANDARDS: A MULTI-COUNTRYEXPERIENCED. Sungkhobol , World Health Organization, Regional Office for South-East Asia, New Delhi, India.
Maternal mortality and morbidity are a major public health concern inmany countries of the World Health Organization South-East AsiaRegion, and the Region still accounts for 40 per cent of the world’smaternal deaths. Statistics reveal that more than 50 per cent of deliveriesin the Region occur at home and are mostly assisted by unskilledattendants. Maternal health services in many countries in the Region areparticularly inadequate.In response to the needs expressed by Member States, the RegionalOffice has developed Standards of Midwifery Practice for SafeMotherhood. The standards, which include management of selectedobstetric complications and emergencies, were developed specificallyfor use in countries of the Region with their active involvement. Theysupport evidence-based care and are intended to be “prototype”standards for adaptation according to countries’ needs.These standards were field tested in four countries of the Region wheremidwifery services are at different stages of development. The field testhas demonstrated that by implementing the standards the quality ofmidwifery services has improved, client satisfaction has increased, andthe competence and self-confidence of midwifery-trained personnel havebeen enhanced. The lessons learnt during this process were used infinalizing the standards.Several countries in the Region have now set their own midwiferystandards by adapting the “prototype” standards. The use of thesestandards will assist countries in ensuring and enhancing the quality ofmidwifery services in order to address the problems of high maternalmortality and morbidity.
SS3.03.02IMPROVING LIFE SAVING SKILLSJoseph Taylor , Sandra Buffington, Diana Beck, Deborah Armbruster,Central Hospital, Koforidua, Ghana
The Life Saving Skills (LSS) program was developed to meet specificneeds identified in the field and is based on real-life experience of healthcare providers, particularly midwives and physicians. LSS responds tothe needs of many countries by proving a practical, hands-on andsystematic way to reduce maternal mortality and morbidity by trainingmidwives, and other health care providers, to provide women withemergency obstetric services.The Life - Saving Skills Performance Improvement ApproachIt is critical for the improvement of the LSS program that a PerformanceImprovement Approach (PIA) to training be taken. A PIA implies notonly the systematic development of a quality training program includingpreparation, competency-based training and follow-up, but also thedevelopment of a number of interlinking systems that support each otherto produce an overall Training and Continuing Education System. Thisapproach requires an investment of human resources during the set-upphase and the ongoing monitoring and support.By following this LSS Performance Improvement Approach to training,an in-service training and continuing education system can be designedthat is focused on provider and community needs and reflects agreedupon clinical protocols.
Follow-up of trainees with supportive supervision and a continuingeducation structure supports what has been taught. Supportivesupervision provides feedback to the midwife or provider and thesupervisor on performance of the midwife as well as retention of skillsand knowledge.When problems with performance are identified, this information is fedinto the continuing education component and contributes to the overallsustainability of the system.Conclusion: Begining in 1987, the Safe Motherhood initiative broughtthe magnitude and tragedy of women and infants dying in childbirth tothe world's attention. The Life-Saving Skills program is one of theprograms developed to decrease maternal and infant mortality andserious morbidity.
SS3.03.03COMMUNITY MIDWIFES - HOW EFFECTIVE ARE THEY?Ms.Yanne Annas , IBI, Jakarta, Indonesia
One alternative solution decided by The Government of Indonesia tomeet the high maternal mortality in the country was accelerate themidwifery training programme. Between 1989-1996 there are 3midwifery programmes two basic midwifery programmes (Types A &C) and one post basic programme for instructors (type B).The quality of the graduates depended on many factors, among others,local situations, existing teachers & facilities and availability of clinicalpractice (in hospital & community).Focus of the midwifery programme at that time was more on quantityrather that on quality of the graduates. The government was in a hurry toplace one midwife in each village ( + 65.000 villages).Several continuing education programme have been conducted toupgrade and improve the knowledge and skills of these midwives(community/village midwives).Many studies have been conducted on the community midwives, on theirperformances, their workload and also on their competence in technicalskills. Even so, many community midwives are doing well in theirrespective village and they are integrated in the everyday life of thevillage.The main problem now, is that most of them are only on a 3 yearscontract with the government to work in the village (the government isnot able to employ them on full-time basis as government employee).After 3 years they may extend their contract to three more years.But some also left the village after their contract expired and to findwork else where. Data on how many of them are still working as amidwife or doing some other work, no accurate data is available yet.
SS3.03.04THE ROLE OF NATIONAL PROFESSIONAL ORGANISATIONSChristine Achurobwe , Uganda Private Midwives Association, Kampala,Uganda
Objectives: The aim of the study was to:· Identify roles and responsabilities for National Professional
organisations.· Encourage formation of National profesional organisations.· Formulate National/Regional collaboration between organisations.Study Methods: Fifty percent (50%) questionnaires were distributed tomembers of two National Professional organisations to find out the roleof their organisation: how they have assisted the country. Also how theyhave collaborated with other organisation outside the country.Results: Eighty percent (80%) of questionnaires were received back withwhat they thought was the roles or how they collaborated with otheroutside organisations.Conclusions: National Professional organisations are available resourceswhich can be uterized and supported to expand National Programmesmore especialy in community. My presentation will elaborate on whatUganda Women Medical doctors have done. The preservation will alsoindicate the need for National and regional National Organisationcollaboration where we can build our roles and responsabilities by usingNational/Regional Experienced personnel to provide knowledge & skillsto other organisations.
WEDNESDAY, SEPTEMBER 6 13
SS3.04 GERMAN SOCIETY SESSION
SS3.04.02HEMATOPOIETIC TRANSPLANT POTENTIAL OF UNRELATEDAND RELATED CORD BLOOD: EXPERIENCE OF THEEUROCORD/NETCORD BANK DÜSSELDORFT. Somville 1, H. Rüttgers2, W. Meier3, O. Bellmann4, A. Ring5, HG. Schnürch6, H. Streng7, H. Lehnen8, M. Kusche9, U. Rosseck10,G. Kögler11 and P. Wernet11.1Dept. of Gynecol. and Obstetrics H.-Heine-University Düsseldorf,2St.Antonius Wuppertal, 3EVK Düsseldorf, 4Florence Nightingale,Düsseldorf, 5AKH Viersen, 6 Lukashospital Neuss, 7Josefinum,Augsburg, 8Elisabeth Hospital Rheydt, 9Marienhospital Aachen, 10Dept.of Gynecology and Obstetrics Neuwerk, 11Institute for TransplantDiagnostics and Cell Therapeutics, H.-Heine-University Düsseldorf.
To date, hematopoietic stem cells from cord blood (CB) have beenemployed in over 1500 allogeneic (sibling and unrelated matched andmismatched transplantation’s worldwide. The examination andstandardization of unrelated and related cord blood derived stem cellpreparations and banking as well as their biological characterization wasinitiated in Düsseldorf already in 1993. Hitherto a total of 4615 CBsamples (4513 unrelated, 132 for directed donations within the family;mean volume 90+25 ml, total nucleated cells (NC) 10 + 5x108) from cordblood have been defined by hematological, immunological andmicrobiological criteria. These CB samples were collected from theumbilical cord vein immediately after vaginal full term delivery orcesarean section and stored frozen in liquid nitrogen.Only 5.0 ml of a CB sample is required for routine laboratory testing asthere are HLA-class I typing, HLA-class II typing by sequence-specificoligonucleotide probes (PCR-SSOP), ABO typing, sterility control,assessment of progenitor- and stem cells by colony forming- assays, andCD34+ status as well as for CMV, Hepatitis B, C, HIV, Parvo B19before releasing the CB unit for transplantation. With regard to viralinfections maternal sera were tested for HBsAg , anti-HBc, anti-HCV,-HIV-1-2, -HTLVI-II, -CMV and Syphilis. Within the last four years atotal of 7400 preliminary searches, 920 extended unit reports weresubmitted to the CB bank Düsseldorf by fax or World Wide Web.Thusfar 102 unrelated and 3 related CB units were transplanted in over40 different transplant centers world-wide.The median patient age was 6 years (range 0.3-48), the median weight21kg (range 4-70kg). The majority of the patient suffered from ALL(n=36), JCML (n=1) AML (n=13), CML (n=8) and Lymphoma (n= 5),MDS (n=6), AA (n=5), FA (n=2); 29 patients had genetic and acquireddiseases. All CB samples as well as the patients blood samples weretyped in Duesseldorf for HLA-class I by serology confirmed by PCR-SSP and by high resolution DNA typing for HLA-DRB1 and HLA-DQB1 alleles. 94% of the 105 patients receiving unrelated CB weremismatched at one or more HLA-loci. Until now 41 patientstransplanted with unrelated CB from Düsseldorf were evaluable forengraftment with an overall engraftment rate of 84% with a median timeof 23days (range 10-57 days). 49% of the transplanted patients are alivewith a median follow-up of 320 days.
SS3.04.03NEW THERAPEUTIC APPROACHES IN CERVICAL CANCERPATIENTSA. Schneider and M. Possover, Dept. Gyn., University of Jena,University Hospital, Jena, Germany
Objectives: The aim of the study was to investigate the effect of nervesparing laparoscopic assisted radical vaginal hysterectomy (LARVH)type 3 for preservation of bladder function.Study Methods: 66 patients with cervical cancer FIGO Stage 1b1, 1b2,2a, and 2b underwent LARVH type 3. In 38 patients only the vascularpart of the cardinal ligament was transected at the pelvic side wall andthe neural part was preserved. In 28 patients the conventional type 3procedure with complete transection of the vascular and neural part ofthe cardinal ligament and at the pelvic side wall had been done.Results: There was no difference in peri- and post- operativecomplications between both groups. Bladder training by suprapubiccatheter was stopped at postoperative day 11.2 in the patients treated bythe nerve sparing techniques compared to 21.4 days in patients treatedby the conventional technique (p=0.0007). Length of the parametriummeasured on the fresh specimen was 6.8 cm for both groups.
Conclusions: Nerve sparing LARVH type 3 allows preservation of themotoric function of the bladder without imparing radicalness ofresection of the parametrium.
SS3.04.05FRONTIERS IN GYNECOLOGICAL ENDOCRINOLOGYThomas Rabe , University Women’s Hospital; Heidelberg, Germany
Selectic topics - based on clinical trials mainly performed in Europe:Hyperandrogenism: workup according clinical feature; in cases withmoderate and severe androgenisation an androgen producing tumor mustbe ruled out by serum testosterone (>1,5 ng/ml) and DHEAS (> 7mg/ml); in infertility patients a 21-hydroxylase-deficiency must besuspected by 17-OH-progesterone > 4 ng/ml after ACTH stimulation test(25 IU i.m.) and verified by a gene sequenzing; if positive a screening ofthe partner and a dexamethasone therapy in early pregnancy untilgenetic diagnosis is recommended. Treatment option in non-infertilitypatients range from spironolactone, low dose OCs to OCs containingcyproterone acetate*), chlormadinone acetate*), dienogest*) ornorgestimate (* not on the US market).Thrombophilia: increased risk for thrombosis by use of OC (up to 50-200fold in patients with homocygous factor-V-Leiden mutation) as wellas in HRT takers (2-3fold) (controls: 1/10 000). Family risk (history) forcardiovascular disease must be considered and if positive a screening isrecommended for antithrombin III, protein-C, -S and APC-resistancy,exclusion of Factor-V-Leiden, and optional: homocysteine, lipids orcarbohydrates. No differences in thrombophilia due to differentprogestagens used for OC and HRT.Contraception: New progestogens for oral hormonal contraception are orwill be soon available: medrogestone (Wyeth), drospirenone (Schering).Progestogens with low androgenicity should be preferred. New 24-day-regimen with gestodene; clinical trials with Ocs containing naturalestrogens. New ethinyl estradiol free oral hormonal contraceptives. Thelevonorgestrel releasing system (Mirena/Schering) has been accepted bymore than 1.5 million users in Europe. Further innovations: vaginalrings, hormonal patches, implants and once-a-month injectable.HRT: 70 innovations (35 patches) are in clinical trials. Continuous,cyclic or intermittend use of progestogens might be selected forendometrial protection as well as a small levonorgestrel releasing IUS.Primary prevention of cardiovascular disease and Alzheimer must beprooven for ERT/HRT as well as their use following gynecologicalcancers. Breast cancer: HRT increases the chance the breast cancerdiagnosis leading to a favorable prognosis and lower mortality whencompared to non-HRT users.
SS3.04.06NEW PROCEDURES OF OVARIAN STIMULATION.Klaus Diedrich , Michael Ludwig, Department of Gynecology andObstetrics, Medical University of Lübeck, Lübeck, Germany
Ovarian stimulation is an essential part of each treatment cycle inassisted reproductive technology (ART). However, especially in IVFthese ovarian stimulation procedures have different problems like therisk of ovarian hyperstimulation syndrome (OHSS), patients discomfortdue to the length of the procedure, hormonal withdrawal symptoms orcyst formation. Using the new drug class of LHRH antagonists, some ofthese problems can be avoided or significantly reduced in theirincidence. Ovarian stimulation can be integrated in a spontaneousmenstrual cycle. With Cetrorelix (Cetrotide, ASTA Medica AG,Frankfurt, Germany & Serono International S.A., Geneva, Switzerland)the first antagonist was available. It could be shown in a prospective,randomized study, that the risk of OHSS was significantly reduced withCetrotide compared to the long protocol. Prospective, randomizedstudies using Cetrotide as well as prospective studies using theantagonist Ganirelix (Orgalutran, Organon GmbH, Oss, TheNetherlands) showed, that antagonists can be used with either urinarygonadotrophins or recombinant FSH with the same success rates. Thereis an ongoing debate, whether antagonist protocols might lead to lowerpregnancy rates compared to agonist protocols in ovarian stimulation.Until now, no prospective randomized study could show a significantdifference in pregnancy rates. A tendency towards lower pregnancy ratesin antagonist protocols might be due to a bias in the studies and to alearning curve, which is necessary to yield optimal results with this newdrugs. An open worldwide observational study using Cetrotide showed
WEDNESDAY, SEPTEMBER 614
pregnancy rates in daily practice, which are in the range of the longprotocol. In experienced centers no disadvantages for the patients couldbe seen, when Cetrotide was used instead of the long protocol.
SS3.05 INTERACTIVE SESSION
SS3.05SOLVING THE DILEMMAS, AN OBSTETRICAL ISSUE (I AND II)Ernesto Castelazo-Morales , Instituto Nacional de Perinatología, MexicoCty, Mexico
Preterm labor remains as a worldwide public health problem; lack ofevidence and consensus over diagnostic and therapeutic issues stillgenerate an enormous amount of controversy. This course is designed toreview the way to approach this problem, confront different ways tohandle it, hear the experts opinion and take a look at the evidence in aninteractive session which includes case presentations. Main objects areto review etiology and epidemiology, identify risk, approach prevention,discuss management, anticipate potential complications, improve fetaloutcome and consider delivery options. The course will start with a briefreview lecture based on evidence followed by several short controversialcase presentations covering different aspects of the topic; by electronicmeans the audience will have the opportunity to test its skills, compareand discuss them with the rest of the participants.
PS3.01 PRESIDENT’S SESSION
PS3.01.03PARTNERSHIPS FOR SAFE MOTHERHOOD: HOW MUCH IS AMOTHER WORTH?J. E. Thompson , University of Pennsylvania, Philadelphia, PA, UnitedStates
This paper will address the power of partnerships in promoting SafeMotherhood globally and locally. Particular attention will be given to therole of the International Confederation of Midwives (ICM), FIGO, andWHO as partners in promoting the health of women and childbearingfamilies throughout the world, including their participation with otherson the Interagency Group on Safe Motherhood (IAG). Examples of theseimportant partnerships will be drawn from joint efforts in upgrading theknowledge and skills of midwives through pre-Congress workshops, thepromotion of Life Saving Skills in the developing world, and the settingof international competencies and standards for all those with“midwifery skills” who are vital in any effort to reduce maternalmorbidity and mortality throughout the world. Skilled attendance at birthis one of the lessons learned from over 10 years of the global SafeMotherhood Initiative, and will be used as one example of the power ofpartnerships that promote the health of women.The discussion of the collaborative relationships between midwives andobstetricians at local, national, regional and global levels will focus onthose aspects of this inter-professional relationship that promote thehealth of women with seamless, high quality, evidenced-basedchildbearing care from village through hospital, as needed. Discussionwill highlight some of the inter-professional conflicts during the pastdecades as well as successes based on mutual respect, trust, andappropriate use of the unique competencies of both obstetricians andmidwives in the care of women during their childbearing years.Examples from developed and developing nations will be used to answerthe question, “How much is a mother worth?”The summary of this paper will focus on the values and ethics of SafeMotherhood, and the basic human rights that are needed by women inorder to survive one of their most important roles in any society – that ofbearing and caring for the world’s children. Midwives and obstetriciansworking together can make a difference in lives of all the world’swomen and families.
PS3.02.02CONTRACEPTION IN 2050Professor R V Short , Department of Obstetrics & Gynecology, RoyalWomen’s Hospital, University of Melbourne, Australia
By 2050, the population of the world will be around 10 billion. Manydeveloped countries will have falling populations, as the increasing costs
of educating children make childbearing prohibitively expensive, and aswomen choose to postpone marriage and childbearing for the sake oftheir careers. Improved sex education in school, and free availability ofcondoms, the oral contraceptive pill and emergency contraception willhopefully reduce the current high rates of teenage pregnancy andabortion. After achieving their desired family size, women willincreasingly opt for forms of contraception like gestagen-releasingintrauterine devices that reduce menstrual blood loss, thereby avoidingthe need for a hysterectomy as the menopause approaches. It seemsunlikely that we will develop an effective hormonal or immunologicalcontraceptive for men. The rising divorce rate is likely to make male andfemale sterilization less popular options.The situation in developing countries, where most of the populationgrowth will be taking place, will be very different. The inexorablespread of HIV infection form Africa to Asia, with India as its newepicentre, will drastically reduce life expectancies, with earlychildbearing as the probable response. The condom is likely to remainthe only contraceptive that offers protection against the rising tide ofsexually transmitted diseases. Massive educational efforts will be neededamong adolescents to increase condom acceptability and use. Loosefitting, re-usable plastic condoms might be more “sensational” and costeffective than the current latex varieties. They would also be morecompatible with a range of new topical microbicides and HIV receptorblockers that should afford additional protection to men and womenagainst sexually transmitted diseases. As abortion becomes legal in moreand more developing countries, maternal mortality rates should fall.Cheap non-surgical means of female sterilization will also have animportant role to play as desired family size continues to decline.
WEDNESDAY, SEPTEMBER 6 15
FREE COMMUNICATIONS
FC3.01 ASSISTED RERODUCTION
FC3.01.01BIRTH AFTER INJECTION OF SPERM AND THE CYTOPLASMOF TRIPRONUCLEATE ZYGOTES INTO METAPHASE IIOOCYTES IN PATIENTS WITH REPEATED IMPLANTATIONFAILURE AFTER ASSISTED FERTILIZATION PROCEDURESM-S Lee (1), C-C Huang (2), T-C Cheng (2), C-I Chen (1)(1) Dept. OB/GYN, Chung-Shan Medical and Dental College
Hospital, Taichung, Taiwan.(2) Dept. Infertility, Lee Women’s Hospital, Taichung, Taiwan.Objectives: To assess the technique of injecting a single sperm andcytoplasm obtained from tripronucleate zygotes into metaphase IIoocytes for the treatment of patients with repeated implantation failureafter ISCI or IVF.Study Methods: We studied patients with repeated implantation failureafter ICSI or IVF. The metaphase II oocyte of recipients was injectedwith their husbands’ spermatozoa and cytoplasm aspirated from thetripronucleate zygotes of donors.Results: In total, 62 metaphase II oocytes from nine recipients wereinjected. Of the 62 injected oocytes, 3 (5%) degenerated and 43 (69%)had two pronuclei 18 hours after injection. Embryo development ratewas 90.6% (39/43). All cleaved embryos were transferred into theuteruses of recipients. Four clinical pregnancies occurred in fourrecipients. Five healthy infants were born.Conclusion: Injection of the cytoplasm of tripronucleate zygotes mayenhance the clinical pregnancy rate in patients with repeatedimplantation failure after ICSI or IVF.
FC3.01.02IVF SUCCESS RATE FOLLOWING TUBAL STERILIZATIONJ. Horovitz , D. Sitko, M. Commenges, P. Rolland, A. Papaxanthos,D. Dallay. Maternity B-C, Hôpital Pellegrin, Bordeaux, France
Objective: Evaluate the success rate of vitro fertilization and embryotransfer (IVF-ET) in women who have undergone tubal sterilization forpersonal reasons but again desire pregnancy because of a change in theirlife, and compare the success rate for this group to that of a controlgroup.Study Methods: Two groups of patients were studied, between March1990 and October 1998, in the Maternity of the Teaching Hospital ofBordeaux. Group I consists of 37 couples where the wife underwenttubal sterilization mainly for personal reasons. This group had 56 IVF-ET. Group II is the control group and is composed of 237 couples wherethe wife is infertile because of tubal pathology only. This group had 404IVF-ET. The following parameters were studied: age, previous fertility,number of ampullae of HMG, number of oocytes retrieved, number andquality of embryos, number of ongoing pregnancies (>= 12wg).Results: The statistical analysis of IVF-ET data was done using students’t test and x2 test.
Tubal ligation Tubal pathologies P value
Years 34.5 31.7 p = 0.000 /s
Total number of ampullae 30.7 40.9 p = 0.0025 /s
Number of oocytes 5.5 6.7 p = 0.0230 /s
Total number of embryos 3.5 4.2 p = 0.0821 /ns
Number of embryos C1 D1 1.44 1.65 p = 0.95701 /ns
Number of embryos transferred 2.44 2.45 p = 0.9570 /ns
Ongoing pregnancies 16.7% (6) 17.7% (66) p = 0.875 /ns
Conclusion: Despite a past fertility rate of 89%, the patients of group Ido not have a higher success rate than patients of group II (past fertilityrate of 23%). The IVF-ET procedure success rate is not related to pastfertility but rather to the age of the patient at the time of the procedure.
FC3.01.03INTRAUTERINE INSEMINATION (IUI) IN UNEXPLAINEDINFERTILITY IN RURAL SET-UPD. Satish , D. Sunetra, Doshi Ultrisound Clinic, Akluj, India
Objectives: The aim of the study was to know the percentage ofconception by IUI method, which is non-invasive & economic methodfor unexplained infertility in rural set-up
Study Methods: This Study was conducted in my private nursing homewhich is situated in rural area like Akluj, having population of 40 000.50 cases have been selected for IUI in last year i.e. from 1st January 1997to 1st January 1998. In all cases, basic workup was found to be negative.Follicular study was done by Transvaginal sonography & when folliclereaches to 19-20 mm, Inj. HCG 5000 I.U. given I.M. & IUI done.Results: Out of 50 cases, 12 patients conceived (24%). Out of 12 cases,5 conceived at 3rd cycle (41.66%). Out of 12 cases, 2 premature delivery,6 full term normal delivery, 2 lower segment caesarean section, 2abortion at 2 months.Conclusions: Fifty cases were selected for IUI. In all above cases, basicworkup was found to be negative. Follicular study was done by TVprobe. Ovulation induction done by Clomiphane citrate in every case.When follicle reaches to 19-20 mm, semen sample prepared by HAM F-10 media (0.5ml) injected in the uterine cavity by IUI canula. Patientwas kept for 20 minutes in head low position.Out of 50 cases, 12 patients conceived (24% conception rate). This IUIis one of the best, non-invasive & economic method for unexplainedinfertility in rural set-up.
FC3.01.04MECHANICAL OR LASER HATCHING?J. Konc , K. Kanyó: Infertility and IVF Unit, St. John Hospital, Budapest,Hungary.
Objectives: In the past few years two different trends spred worlwide athathing to improve the implantation and pregnancy rates. The firstmethod was mechanical hatching (AH) and later was used laser one(LAH). We use non-contact laser, the source of laser bbeam touches thezona pellucida tangentially only. The authors used the mechanicalhatching and the non contact laser hatching too and they compared theefficience and safety of both methods.Study methods: From February 1998 to November 1999 the authorsparalelly used both hatching methods. The authors used an infrared1,48um diode laser (Fertilase, MTM, Montreux, Switzerland).Indications for LAH or AH were he age of 35 or above, and/orpreviously three times performed unsuccesful embryo transfer. At allwomen above 35 years LAH or AH was performed. Under the age 35three or more unsuccesful embryo transfer gave indication for theseinterventions.The randomisation of the patients for using laser or mechanical hatchingmethode happened according to our two embriologists duty service,because one of our embriologists performed only mechanical and theother used only laser hatching. The study patients were divided in twogroups according to the randomisation of our embriologists duty service.The Group 1 (LAH) consisted 330 patients, the Group 2 (AH) consisted114 patients. The control Group 3 consisted 450 patients withouthatching.Results: In Group 1 (LAH) the clinical pregnancy rate was 35,15%(116/330). In Group 2 (AH) clinical pregnancy rate was 25,4% (29/114)In the control Group 3 the pregnancy rate was 36,9% (166/450). The rateof major malformation was the same in the three groups. The rate ofmissed abortion in these groups was not different.Conclusions: By the help of non-contact laser hatching or with themechanical hatching we were able to reach good clinical pregnancy rate.But there are some adventages of non-contact laser. The administrationof non-contact laser hatching is quicker, simplier and easier. A diodelaser will have adventages of giving reproducible result with a hole ofdefined diameter. The laser hatching method is also cheaper, and itspares the working time of the embriologists.
FC3.01.05THE REALITIES OF SETTING UP AN ASSISTED CONCEPTIONTREATMENT PROGRAMME IN A DEVELOPING COUNTRY LIKENIGERIA.R A Ajayi 1, V N Bolton2 and J H Parsons2. 1The Bridge Clinic Limited, P O Box 70294 Victoria Island, Lagos, Nigeria. 2The AssistedConception Unit, Kings College Hospital, Denmark Hill, Camberwell,London, United Kingdom, SE5 9RS.
Objective: To outline the problems overcome in the establishment of anassisted conception programme in Nigeria.Design: A descriptive, longitudinal study.
WEDNESDAY, SEPTEMBER 616
Setting: The Bridge Clinic Assisted Conception Unit, Victoria Island,Lagos, Nigeria.Patients: Couples attending the Bridge Clinic Limited who requireconventional in vitro fertilisation (IVF) and intra- cytoplasmic sperminjection (ICSI).Main interventions: A technology transfer IVF programme with a teamfrom the Assisted Conception Unit of Kings College Hospital, London.Main Outcome measures. The number of treatment cycles carried out inthe first operational year, the results of treatment and the problems thatwere successfully overcome in the setting up of the programme.Results: 81 ICSI treatment cycles and 26 IVF treatment cycles werecarried out in the first year. 81 of these 107 treatment cycles hadembryos transferred and there were 14 ongoing pregnancies, whichinclude the first ICSI pregnancies in Nigeria. The ICSI programme hadto be set up early because 75% of those requesting treatment requiredICSI. The problems overcome include the high cost of treatment,infrastructural difficulties like power generation, difficulties in gettingsupplies and the social and cultural difficulties of accepting assistedconception treatment in a country with mass illiteracy.Conclusion: The difficulties of setting up an assisted conceptionprogramme in a developing country can be overcome with carefulplanning.
FC3.01.06ANALYSIS OF FETAL GROWTH, INFANT BIRTH WEIGHT AND24 HOUR PHYSIOLOGICAL FUNCTION IN ASSISTEDPREGNANCY (AP) VERSUS NON INTERVENTION PREGNANCY(NIP)M. A Omamo-Nyamogo , Dept. OB/GYN, Nyanza Provincial TeachingHospital, Kisumu, Kenya
Objectives: Demonstrate or exclude difference(s) in fetal growth andinfant physiological fitness and birth in assisted pregnancy as comparedto pregnancy without any from of therapeutic intervention.Study Methods: This was a case-control study in which 200 women withassisted pregnancy and 200 women who conceived and went throughterm pregnancy without any from of therapeutic intervention wererecruited at 10 weeks and followed up to 24 hours after deliveryfollowing spontaneous labor at term.Results: The mean fetal weight during pregnancy and birth weight of 3500g in AP were significantly higher than corresponding values in NIP.Caesarean section (c/s) rate was higher (9%) in AP than (7%) in NIP. Inboth groups, the leading indication for c/s was feto maternaldisproportion. 24 hours physiological fitness assessed by respiratoryfunction and reflex activity was similar in both groups. There was nodifference in congenital malformationsConclusions: AP may be associated with slightly larger than averagebabies. The slight increase in c/s rate is statistically insignificant andfetal well being is preserved.Recommendation: Clients be cancelled appropriately and hospital staffinstructed on meticulous monitoring of AP parturients.
FC3.01.07PROSPECTIVE CONTROLLED STUDY OF THE EFFECT OFUTERINE FIBROIDS ON THE OUTCOME OF ASSISTEDCONCEPTION TREATMENTY. Khalaf , R. Hart, C.T. Yeong, H. Bickerstaff, R. Lawson, A. Taylor,P. Braude, Assisted Conception Unit, Guy’s and St. Thomas’ HospitalsTrust, London, UK.
Introduction: The effect of uterine fibroids on the outcome of assistedconception has been the subject of recent debate. We set out toprospectively evaluate IVF&ICSI cycles in the presence of uterinefibroids.Materials & Methods: All patients from 1st of August 1999 to date wereincluded in the study. Prior to embarking on a cycle of assistedconception all patients underwent a pelvic ultrasound scan. If asubmucosal fibroid was suspected hydrosonography was performed andthe fibroid resected if appropriate. The outcome of the subsequentassisted conception cycle was then analyzed. Multifollicular stimulationwas carried out using either urinary or recombinant FSH. Buserelinacetate was used for down regulation in the long protocol. The studyevaluated number of days of FSH stimulation, total amount of FSH usedper cycle, cycle cancellation rates, number of preovulatory follicles,
number oocytes obtained, normal fertilization rates, number of embryosavailable for replacement, those replaced, implantation and pregnancyrates.Results: We have identified 105 patients who have uterine fibroids andare embarking on assisted conception treatment of which 59 patients todate have been treated. The control groups are those patients withoutfibroids who are treated during the same time interval. Both study andcontrol groups are matched in age, duration of infertility, and basalserum FSH levels. The two groups are comparable in their response tostimulation with identical cancellation rates (10%). The mean number ofoocytes obtained was 10.5 and 10.1 in the study and controlled groupsrespectively. The overall pregnancy and implantation rates were 11.1%and 8.9% in the study patients compared to 28.0% and 13.0% in thecontrol group respectively (p=0.02 for pregnancy rate).Conclusion: Our study suggests that uterine fibroids are associated withlower implantation and pregnancy rates in assisted conception treatment.With more patients, we may be able to ascertain any differential effect ofsite and size of fibroids on the outcome of assisted conception.
FC3.01.08ROLE OF PROLACTIN IN HUMAN REPRODUCTIONK. Kaur , M. Singh, Dept. OB/GYN, Bombay Infertility ResearchCentre, Jalandhar, Punjab, India.
Objectives: Prolactin may play a role in ovarian steroidogenesis andcircumstantial evidence suggests that hyperprolactinaemia in womeninterferes with ovarian function, however the precise role of Prolactin inthe selection and maturation of dominant follicle during ovulation isunclear. The present study was undertaken in an attempt to define thisrole.Study Methods: 150 infertile women with HSG evidence of bilateralpatent tubes were divided into 2 study groups. In the 1st group of 100patients controlled ovarian hyperstimulation (C.O.H.) was done withClomiphene citrate and IUI was done. In the second group of 50 patientsIVF was done and C.O.H. was achieved by use of Buserelin & MetrodinHP injection i.e. the standard long protocol. Serum Prolactin andProgesterone were checked on day 2 as well as 36 hrs after induction ofovulation with HCG in both groups of patients, while follicular fluidProlactin and Progesterone were assayed in all the 50 patientsundergoing IVF.Results: In the 1st group comprising of C.O.H. with C.C. + IUI, baselineProlactin on day 2 was mostly found within normal limits while 36 hrsafter HCG serum Prolactin was found equivalent to or less than that atthe initiation of menstruation. While in the 2nd group (IVF group), whereGnRH down regulation was done using Buserelin and then Metrodin HPwas used as a full long protocol for induction of ovulation, there wereparadoxical results, i.e. serum Prolactin on 34 hrs after induction ofovulation with HCG was much higher as compared to baseline andfollicular fluid Progesterone 34 hrs after HCG was also considerablyhigher as compared to what one expects in preovulatory follicular fluidwith respect to serum progesterone.Discussion: The paradoxical mid cycle rise of serum Prolactin and highfollicular fluid progesterone suggest that exogenous GnRH andanalogues cause Prolactin release from the Pituitary. Moreover,synchronized pulsatile release of Prolactin and LH has been observedwhen endogenous GnRH is increased as in postmenopausal women andin mid Luteal phase in response to Naloxone. The detailed mechanismby which Prolactin affects ovum maturation and has an effect onprogesterone production is discussed.
FC3.01.09PREMATURE LUTEINIZATION: DOES IT OR DOES IT NOTADVERSELY AFFECT CLINICAL OUTCOME IN IVF-ETCYCLES?J.S. Younis , M. Matilsky, O. Radin, S. Bar-Ami, M. Ben-Ami.Reproductive Medicine Unit, Dept. OB/GYN, Poriya Hospital, Tiberias,Israel
The etiology, pathogeneis, and effect on clinical outcome of prematureluteinization (PL), in long GnRH-a IVF-ET cycles, is stronglycontroversial.Objectives: To examine whether PL, developing in long GnRH-a IVF-ET cycles, has any adverse effect on clinical outcome, and to studywhether this phenomenon could be related to ovarian reserve.
WEDNESDAY, SEPTEMBER 6 17
Study Methods: 76 consecutively seen women employing the longGnRH-a & hMG protocol for IVF-ET were prospectively evaluated.Basal hormonal ovarian studies were assessed in al women one monthbefore starting the treatment. Patients were evaluated in their first cycleof treatment and were divided into those with (study group) and otherswithout (control group) premature luteinization. Premature luteinizationwas defined as P/E2 ratio of more than 1 on hCG day*.Results: 21 (41%) of the women in the study population demonstratedPL (study group). Patients characteristics were similar in the 2 groups.Day 3 FSH levels were significantly higher in the study a compared tothe control group, 9.3±3.1 and 6.7±1.9 mlU/ml, respectively. P levels onhCG day were significantly lower in the study compared to the controlgroup, 1.9±0.7 and 1.2±0.6 ng/ml, respectively. Inversely, maximal E2
levels on hCG day were significantly lower in the study compared to thecontrol group, 971±566 and 2541±921 pg/ml, respectively. In addition,the total amount of hMG dosage was significantly higher in the studycompared to the control. Moreover, the number of follicles (³14mm),oocytes and embryos achieved, were significantly lower in the study incontrast with the control group. Likewise, the clinical pregnancy ratewas significantly lower in the PL group as opposed to controls, 13% and42% respectively.Conclusions: Premature luteinization developing in the long GnRH-acycles seems to adversely affect IVF-ET clinical outcome. Our resultssupports the notion that PL in this setting is related to low ovarianreserve.*Younis et al. Fertil Steril 1998:69;461-5
FC3.02 BACTERIAL VAGINOSIS
FC3.02.01RELATIONSHIP OF LACTOBACILLI TO GENITAL MICROFLORARESPONSIBLE FOR BACTERIAL VAGINOSIS.A. Aroutcheva , J.Simoes, S.Faro, Rush-Presbyterian-St. Luke's MedicalCenter, Chicago, IL, United States.
Normal vaginal microflora is predominantly presented by Lactobacillusspecies that have the ability to regulate the growth of other vaginal floraby forming antibacterial products including lactic acid, H2O2 andbacteriocins.The clinical condition that is characterized by replacing Lactobacilliwith Gardnerella vaginalis (Gv) and anaerobes is Bacterial vaginosis(BV). The purpose of the study was to determine the associationbetween Lactobacilli and genital microorganisms detected in BV (Gvand anaerobes).Lactobacillus species were obtained from 35 gynecology patients. Thelactic acid produced was tested biochemically and H2O2 formation wasdetermined in MRS agar with horseradish peroxide. Bacteriocin activitywere investigated in multilayer agar plate using indicator strains: Gv (20isolates), Prevotella bivia, Bacteroides fragilis and Peptostreptococcusanaerobius (3 isolates of each).Lactic acid production ranged from 0.68-2.5mg/ml. H202 was positivein 82.8% of the organisms, but there was no correlation found betweenthese parameters (P=0.992).The bacteriocin activity study demonstrated that 29 lactobacilli isolatesinhibited the growth of 15 strains of Gv. Six strains of lactobacillidemonstrated zero activity, while five strains of Gv were not inhibitedwith Lactobacillus species. Only two Lactobacilli were inactive againstall anaerobes.No statistical correlation between bacteriocin production, formation oflactic acid and H2O2 was found (P=0.33). Six H2O2-producer strains,were not able to inhibit growth of Gv. However, strains with a lowproduction of lactic acid were found to be active against indicatorstrains.These findings conclude that Lactobacillus species differ from eachother in their ability to produce defense factors, but each make acontribution to maintain normal vaginal balance.
FC3.02.02ROLE OF UROGENITAL MYCOPLASMA INFECTION INIMMINENT ABORTIONJ. Peterek , Dept. OB/GYN, University Teaching Hospital, Warsaw,Poland.
Objectives: The aim of the study was to determine the incidence andimportance of infections with M.hominis (M.h.) and U.urealyticum(U.u) in pregnant women with imminent abortion.Study Method: One hundred and four women, aged 18 – 30 years (meanage 24 years), in 7th – 13th week of pregnancy with imminent abortionwere divided into two groups: Group A – 56 women with the firstpregnancy, Group B – 48 pregnant women in whom the previouspregnancy resulted in miscarriage or preterm labor. The diagnosis ofinfection by U.u. and M.h. was performed using Mycofast Evaluation 2(International Microbio) test, based on hydrolysis of urea by U.u. andhydrolysis of arginine to ornitine by M.h.. The material for the studieswas taken from the cervical canal. The results were analyzed statisticallyby chi2 test with Yates correction.Results: In Group A, U.u. infection was detected in 21.4% of cases. InGroup B, U.u. infection was detected in 41.6% of cases and M.h. in4.2% of studied subjects. In none of the studied patients, infection withboth species of U.u. and M.h. was found. The difference of detectedinfections varied significantly in both groups (p<0.001). In 87 out of thegroup of 104 studied women, progressing pregnancy was observed andin 17 (16.3%) of cases, the pregnancy was ended in miscarriage whichwas dependent on the detected infections (p<0.002).Conclusions: Among the causes of imminent abortion, infections withU.u. and M.h. should be taken into consideration.Prophylactic examinations of pregnant women contribute to thedetection of frequently asymptomatic or oligosymptomatic STD andmake possible avoidance of pregnancy complications.
FC3.02.03DOES BACTERIAL VAGINOSIS CAUSE CERVICALINTRAEPITHELIAL NEOPLASIA?D.Boyle (1) , S.Barton (2), J.Pollock (3), J.R.Smith (2), (1) ImperialCollege School of Medicine, Fulham Road, London, England, UnitedKingdom, (2) Chelsea and Westminster Hospital, London, England, UK,(3) Pollock and Pool Laboratories Ltd., Reading, Berkshire, UK.
Previous research examining the relationship between bacterialvaginosis (BV) and cervical intraepithelelial neoplasia (CIN )hasproduced conflicting results, often failing to control for importantconfounding variables such as the presence of human papilloma virus(HPV). If BV produces carcinogenic nitrosamines, these might actindependently on the cervix or, more likely, synergistically withoncogenic HPV.Women were recruited from two London hospitals. All underwentscreening for sexually transmitted diseases, had cervical cytologyperformed and cervical cells saved for HPV testing. A subgroup hadvaginal washings taken for analysis of nitrosamine content. BV wasdiagnosed by standard methods.379 women were eligible for analysis:123 with BV and 276 without.Cervical cytology results showed that 12/123 women with BV had CINwhereas 20/256 women without BV had CIN. Specimens suitable forHPV testing were available for 285/379 women and were analysed byhybrid capture for the presence of high and low risk types of HPV.Nitrosamine analysis was performed on a total of 122 specimens: 36 BVpositive and 84 BV negative.There was no causal relationship between BV and CIN even when highrisk HPV was controlled for. Nitrosamine analysis showed nostatistically significant difference between BV positive and negativespecimens.This study did not demonstrate a causal relationship between BV andCIN or that BV organisms produce greater quantities of nitrosaminesthan normal vaginal flora.
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FC3.02.04COITUS- RELATED VARIATIONS IN VAGINAL MICROBIALFLORAA.S.Palakathodi AS (1) , P.Thorsen (1), S.H.Ebrahim (2), D.Schendel(2), J.A.McGregor (1), G.J.Westergraad (1), (1) Odense UniversityHospital, Odense, Denmark, (2) C.D.C., Atlanta, GA, United States.
Objective: To assess the association between coital frequency andvaginal microbial flora.Methods: The prevalence of microorganisms among pregnant women(Odense University Hospital, Denmark) who reported frequent coitus(³7 episodes/ 4 weeks) were compared with that among who reportedinfrequent coitus (£3 episodes/ 4weeks) at initial prenatal visit.Results: Of a total 2,927 pregnant women, the majority reported havingcoitus (any coitus: 89.2%; frequent: 22.8%; daily: 2.9%) and not usingcondoms (96.9%) in the 4 weeks before enrollment. Among those whoreported no condom use, the prevalence of vaginal microorganisms wassignificantly high among women who had frequent coitus than womenwho had infrequent coitus for 8 of the 18 microorganisms (Bacteriodesspecies, Group B Streptococcus, Mycoplasma hominis, Ureaplasmaurealyticum, Candida albicans, nospecific Candidas, Gardnerllavaginalis, nonspecific anerobic bacteria). The prevalence of Chlamydiatrachomatis, Trichomonas vaginalis and Enterococcus faecalis amongwomen who had frequent coitus was slightly higher than those who hadinfrequent coitus.Conclusion: Frequent unprotected coitus increases vaginal colonizationby microorganisms leading to altered vaginal ecology, and, thereby, mayfacilitate transmission of some infections.
FC3.02.05VAGINAL CLINDAMYCIN IS INEFFECTIVE IN PREVENTINGPRETERM BIRTH AND PERIPARTUM INFECTIONS IN A LOWRISK POPULAITON WITH BACTERIAL VAGINOSIS: A DOUBLE-BLIND PLACEBO-CONTROLLED MULTICENTER TRIALM Kekki , T Kurki, J Pelkonen, M Kurkinen-Räty, B Cacciatore,J Paavonen. Dept. of Ob/Gyn, Univ. Hospital, Helsinki, Dept. ofOb/Gyn, Univ. Hospital, Oulu, Vihti Health Center, and Helsinki CityHealth Department, Finland.
Objectives We wanted to study whether treatment of BV in earlypregnancy decreases the risk of preterm delivery and peripartuminfectious morbidity.Study Methods In this multicenter, randomized, double-blind, placebo-controlled intervention study, screening for BV was performed byvaginal Gram-stain from 5432 healthy women with singletonpregnancies during the first antenatal clinic visit at 10-17 weeks ofgestation. Women with a history of preterm birth were excluded. BV-positive women were randomized to treatment with either vaginalclindamycin cream or identical placebo cream for seven days. RepeatGram-stains were taken one week after the treatment and at 30-36 weeksof gestation.Preterm birth was defined as delivery before 37 gestational weeks.Peripartum infectious morbidity was defined as postpartum endometritis,postpartum sepsis, post-caesarean section wound infection or episiotomywound infection, based on clinical examination and necessitatingantimicrobial therapy.Results The prevalence of BV was 10% (565 of 5432). Of the BV-positive women 380 (67%) were randomized to the treatment arms. Theprimary cure rate was 63% (119 of 189) in the clindamycin group and35% (64 of 184) in the placebo group (OR 1.8, 95% confidence interval1.3-2.6). The overall rate of preterm deliveries was 5% (10/189) in theclindamycin group and 4% (7/191) in the placebo group (OR 1.4, 95%CI 0.5-3.9). The rate of peripartum infectious morbidity was 12%(22/189) in the clindamycin group and 18% (34/191) in the placebogroup (OR 1.5, 95% CI 0.9-2.7). BV recurred in 11% (26/246) ofwomen who completed all follow-up visits. The rate of pretermdeliveries was 15% (4 of 26) in this subgroup compared with 2% (2 of121) among women who remained BV-negative after the treatment (OR9.3, 95% CI 1.6-53.5). The rate of peripartum infectious morbidity washighest (15 of 57, 26%) among women with persistent BV after thetreatment and lowest (10 of 121, 8%) in women who remained BV-negative (OR 3.2, 95% CI 1.4-7.5).Conclusions Vaginal clindamycin did not decrease the rate of pretermdeliveries or peripartum infections among women with BV. Recurrent
and persistent BV increased the risk for preterm deliveries or peripartuminfections.
FC3.02.06SCREENING AND TREATMENT OF BACTERIAL VAGINOSIS INPREGNANCY TO PREVENT PERINATAL COMPLICATIONSR.P.S. Camargo , J.A. Simoes, J.G. Cecatti, Dept OB/GYN, School ofMedical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil
Objectives: To investigate the impact of a new intervention withscreening diagnosis and treatment of bacterial vaginosis in a low riskpregnant women population to prevent perinatal complications.Study Methods: This was an operational research study performed at aBrazilian university hospital in Campinas, Brazil, between January 1997and March 1999. The women were divided in two groups: 71 womenwith diagnosis but without treatment of bacteria vaginosis (beforeintervention) and 134 women with diagnosis and treatment of bacterialvaginosis during pregnancy (after intervention). Univariate analysis wasperformed with Qui square, Fisher and variance tests. Risk ratios with95% confidence interval were calculated for the main dependentvariables. Multiple regression analysis was used to compare the groups.Results: There was no difference between the groups except for thehistory of a treated urinary tract infection, higher for the group withouttreatment. The risk ratios of no treatment were significantly higher, 7.5,4.3, 6.0 and 4.2 for preterm premature rupture of the membranes,preterm labor, prematurity and low birth weight, respectively.Prematurity occurred in 22.5% of the group without treatment and in3.7% of the group with treatment. Preterm premature rupture of themembranes and preterm labor were associated with prematurity inmultiple regression analysis. In the group without treatment, puerperalinfection and neonatal morbidity were significantly higher.Conclusions: For bacterial vaginosis during pregnancy the treatmentseems to decrease perinatal complications.
FC3.02.07PREVALENCE OF BACTERIAL VAGINOSIS IN A CHILEANPOPULATIONE. Castro , M. Domínguez, P. Navarrete, C. Plaza, M. Quintana, M.Cisterna, L. Cifuentes, R. Zemelman R. Depto. Obstetricia yPuericultura, Facultad de Medicina y Depto. Microbiología, Universidadde Concepción, Concepción, Chile.
Objetives: The aim of the study was to evaluate the prevalence ofbacterial vaginosis (BV) in women attending at health centers in theConcepción Talcahuano area, Chile.Study Methods: Six hundred fifteen women were included in the study.Women were randomly selected between April 1997 and April 1999,among those gave consent. The population was composed of 352 womenusing contraceptives, 140 pregnant women, 80 sex workers, 43 womenattending in gynecologic clinics. A routine gynecologic speculumexamination was performed on each patient. One sample was obtainedfrom the lateral walls of the vagina with cotton swab. BV was diagnosedusing the Nugent criteria.Results: It was found 31.3% (110/352) women using contraceptives withBV. No statistical difference was found between the occurrence of BVand the use of oral contraceptive or intrauterine device. It was found19.3% (27/110) pregnant women; 37.5% (30/80) sex workers and 23.3%(10/43) women attending in gynecologic clinics with the syndrome.Conclusions: The prevalence of BV encountered deserves future studiesrelated to prevention and treatment of this syndrome considering itscomplications.This investigation was supported by the Grant Dirección deInvestigación Nº 96.848.004-1.1, Universidad de Concepción, Chile.
FC3.02.08THE TREATMENT OF BACTERIAL VAGINOSIS WITH‘POVIDONE-IODINE’ IN THE 1ST TRIMESTER OF PREGNANCYT.A. Starostina , H.M. Demidova, A.S. Ancirskaya, O.Yu. Azarova,Clinic of Obstetrics and Gynecology, Moscow Medical SechenovAcademy, Moscow, Russia.
Recent investigations suggest the actuality of bacterial vaginosistreatment during pregnancy because this disease increases the risk of
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pregnancy failure, premature membrane rupture, chorionamnionitis andpostpartum complications.Objective: To evaluate the efficacy of the bacterial vaginosis treatmentby “Povidone-iodine” (EGIS) vaginal suppositoria in pregnant females.Study Methods: The study population consisted of 40 1st trimester (7-14weeks of gestation) in patients with diagnosed bacterial vaginosis.Bacterial vaginosis was verified based on clinical picture, Gram stainedmicroscopy and cultural investigation of vaginal smears. Patients weretreated by “Povidone-iodine” (1 suppositorium per vaginum for thenight) during the 7 days. 3 females were excluded from the studybecause of iodine allergy.Results: Of 37 cases, clinical recovery was detected in 31 (83.7%), withnormal samples in 78.4% (29/37) 7-10 days after the finished treatment.Microbiological features of bacterial vaginosis remained in 21.6% (8) ofcases. Candidosis vulvovaginitis complicated the treatment in 2 cases.Bacterial vaginosis relapsed in 6.8% of patients between the 29th and32nd weeks of gestation and in 17.2% (5) of females 6 months afterdelivery.Conclusions: Our data suggest that bacterial “Povidone-iodine” is ahighly efficient, well tolerated and easily applied drug without seriousside effects. It allows us to recommend it for bacterial vaginosistreatment. Although the lack of experience of “Povidone-iodine”application, its use is promising for prevention of miscarriage andintrauterine fetal infection in female with bacterial vaginosis during the1st trimester of pregnancy when the drug choice is restricted byteratogeneous effects opportunity.
FC3.02.09TANTUM ROSA IN THE TREATMENT OF BACTERIALVAGINOSIS DURING PREGNANCYTioutiounnik V.L., Efimov B.A. Research Centre of Obstetrics,Gynecology & Perinatology, Moscow, Russia
Objectives: Treatment of bacterial vaginosis (BV) during pregnancy is avery complicated problem, due to probably negative influence of mostmedicines on fetus. The aim of this investigation is the study of theefficacy of Tantum Rosa in pregnant patients with BV in second & thirdtrimesters of pregnancy.Methods: 49 pregnants were observed. Diagnosis of BV was based onclinical, microbiological, microscopia data, and results of amine test andvaginal pH.Results: The warm solution (vaginal douche one-time bottle with 140 mlof solution - 140 mg of active substance), have been used two times aday - 10 days. 4 patients, beside BV, have had vaginal candidosis. Weincluded in the treatment dafnegin vaginal suppositories, containing 100mg of active substance) - 1 suppositoria for 6 days. Clinical recoveryand normalization of laboratory data were noted in 46 (93.7 %) patients.The second part of treatment was appointment of eubiotics for 10 days(acilact, bifidum or lactobacterin, bifidin) - the medicines that restore thenormal correlation of lactobacillus in vagina.Conclusions: Tantum Rosa is very efficacious for treatment BV duringpregnancy.
FC3.03 CERVICAL CARCINOMA: SURGERY ANDPROGNOSTIC FACTORS
FC3.03.01RADICAL TRACHELECTOMY IN EARLY STAGE CARCINOMAOF THE CERVIX: OUTCOME AS JUDGED BY RECURRENCEAND FERTILITY RATEST. Mould, J.H. Shepherd , D. Oram, Dept. OB/GYN, St. Bartholemew’sHospital, London, UK.
Objective: To assess the recurrence and fertility rates in women withearly stage invasive cancer of the cervix treated by radicaltrachelectomy.Study Method: Review of on-going research program and direct contactwith all women to confirm pregnancies and outcome.Results: 27 women had been treated by trachelectomy. There were norecurrences, and the mean follow-up was 23 months (range 6 – 60months). Of 13 women trying to have a baby, 8 had conceived with atotal of fourteen pregnancies and 6 live births. 2 were still trying and 3were experiencing sub-fertility. There were five premature deliveriesand one late miscarriage. Four of the preterm births and the late
miscarriage were associated with prelabor spontaneous rupture ofmembranes.Conclusions: This conservative, yet locally radical procedure for ahighly selected and counseled group of women who wish to preservetheir fertility appears to offer a safe alternative to traditional radicalhysterectomy in early invasive cervical cancer.
FC3.03.02INVASIVE CARCINOMA (CA) OF THE CERVIX: IMPACT OFRACE, COMORBID DISEASE ON PROCEDURE TYPE, COST ANDLENGTH OF STAY (LOS)S.E.Brooks , A. Ghosh, J. Gardner, C.R. Baquet, T. Chen, University ofMaryland Medical Systems, 405 W. Redwood Street, Baltimore, MD,United State, 21071.
Objective: To examine the association of comorbid illness, race andinsurance status on resource utilization and procedure type duringadmission for invasive ca of the cervix (ICD-9 180.0-180.9) in astatewide population based discharge database.Methods: Hospitalizations were classified into relatively homogeneoussub-groups based on diagnoses indicating a primary or secondarydiagnosis of invasive cervical ca. Procedures during admission,oncologic sequelae and comorbid diseases were evaluated. Multivariatetechniques controlled for age, race, insurance status, comorbid illnessand oncologic sequelae.Result: The mean age was 49.5. Sixty per cent (606/1009) were white,354/1009 (35 %) African American, 5% other. Alcohol and drug relateddisorders, hypertension and circulatory system disease were associatedwith up to 60% of admissions for surgical procedures. AfricanAmericans were 1.6 times more likely to undergo urgent/emergentadmission (95% confidence limit 1.2,2.2), to have comorbid illness,p<0.01 and were more likely to undergo admission for radiation therapyrather than surgery p=0.001. The factors associated with the highest costand length of stay were emergency admissions, oncologic emergencies,and circulatory system disorders but race was not a significant factorinfluencing these outcomes.Conclusions: Although there were racial differences in the types ofprocedures occurring during hospitalizations, there were no significantracial differences in cost of admission, or length of stay whenmultivariate analysis adjusted for age,insurance status and comorbidillness. The influence of comorbid illnesses, particularly alcohol anddrug disorders, hypertension and heart disease on outcome warrantsfurther study and intervention.
FC3.03.03LAPAROSCOPIC COMMON ILIAC AND PARAORTICLYMPHADENECTOMYH. Al Sultan , Dept. OB/GYN, Aleppo Hospital University, Aleppo,Syria.
Objectives: Pretreatment evaluation of common iliac and paraorticlymphnodes status for appropriate cervical cancer staging and realizingcorrect treatment with exact prognostic.Study Methods: A total number of 10 patients were studied between1997-99, stage IIB, IIA, IB. All patients underwent firstly laparoscopiccommon iliac lymphadenectomy with frozen section.If lymphnodes were negative, we selected appropriate radicalhysterectomy or radio therapy, but when lymphnodes were positive, wecontinued to make subinferiormesentric paraortic lymphadenectomyfollowing appropriate treatment.Results: Five patients with FIGO stage IIB cervical cancer provide fourfrom the same staging and one patient with common iliac and paraorticlymphnodes metastasis, another three patients with FIGO stage IIAprovide common iliac lymphnodes negative adding another one patientwith FIGO stage IB had also common iliac lymphnodes negative. Allpatients tolerated the procedures smoothly except one operation for stageIIB cancelled due to anesthetic problems. Main time of operation was 60minutes.Conclusion: Laparoscopic common iliac and paraorticlymphadenectomy was feasible and effective surgical staging procedurein pretreatment evaluation of cervical cancer and elaborate suitabletreatment.
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FC3.03.04THE FIRST TWO CASES OF ABDOMINAL RADICALTRACHELECTOMY EFFECT ON MENSTRUATION, OVULATIONAND FERTILITYM.Al-Kurdi , Dep. Ob/Gyn, M.Harris, Dep.Pathology,Hinchingbrooke Hospital, Huntingdon, Cambridgeshire, UK.
Objectives: The aim of this case report is to assess feasibility to carry outsuccessfully the procedure, effectiveness and its effect on myometrium,endometrium, menstruation, ovulation and fertility.Study Methods: Case report on two abdominal radical trachelectomieswere performed on two women at age 36 and 34 respectively.Results: Both women had stage Ib2, poorly and moderatelydifferentiated squamous cell carcinoma of their cervix respectively. Thewomen wanted to preserve their fertility.At 34 and 23 months respectively the two women are well and diseasefree.Conclusions: Abdominal radical trachelectomy is a possible andeffective alternative treatment for cervical carcinoma stage Ib2. Theeffects of the procedure on the myometrium, endometrium,menstruation, ovulation and fertility are discussed.
FC3.03.05RESULT OF THE TREATMENT OF STAGE IA CERVICALCARCINOMA BY COLD KNIFE CONISATIONA.Basta , K.Pitynski, M.Strama, A. Szczudrawa, Jagiellonian University,Kopernika 23, Krakow, Malopolska, Poland, 31-501.
Objectives: Minimal invasive surgery begin more and more popular ingynecological oncology. The aim of the study was evaluation oftreatment results of stage Ia cervical carcinoma with the use of coldknife conisation.Study methods: The study group included 54 women aged 25 – 41 yearswith stage Ia it is 48 women with stage Ia1 and 6 women with stage Ia2who were diagnosed and treated in our Department in the years 1982 –1994. Stage of cervical carcinoma was settled in colposcopy evaluationand histological examination of colposcopy directed biopsy specimens.Treatment and follow up results were analyzed.Results: Specimens without involvement of any margins were obtainedin 45 (93,8%) patients with stage Ia1, and 5 (83,3%) women with stageIa2 cervical cancer. Absence of neoplastic cells involvement intovascular space was found in all patients with stage Ia1 and in 4 (78,6%)cases of stage Ia2. Out of the 3 patients with stage Ia1 and involvedmargins in 2 cases subsequent hysterectomy and in one case reconisationwere performed. In one patient residual disease and in one womencarcinoma in situ were revealed. In 2 cases of stage Ia2 with vascularspace involvement subsequent radical hysterectomy and pelviclymphadenectomy were performed. Non of that patients had lymph nodemetastases. One of them had residual disease.Conclusions: Cold knife conisation gives satisfactory results in treatmentof cervical cancer in Ia1 stage. In selected cases can be also practical atyoung women in stadium Ia2.
FC3.03.06DETECTION OF OCCULT TUMOR CELL DEPOSITS INLIPOSUCTION ASSISTED RADICAL HYSTERECTOMY INCERVICAL CANCER: FIRST RESULTSU. Fischer , Dept. OB/GYN, L.-C. Horn, Institute of Pathology, J.Einenkel, M. Höckel, Dept. OB/GYN University of Leipzig, FRG
Objectives: Recently, Höckel et al. (AJOG 1998;178:971-6) have beendescribed a modification of Wertheim-Meigs operation, termedliposuction-assisted nerve-sparing extended radical hysterectomy(LANS-RH) to improve radicality accompanied by preservation ofpelvic splanchnic nerves. The aim of this study was to identify occulttumor cell deposits (OTCD) in additional resected pelvic tissue.Study Methods: The liposuction specimens of 20 patients, treated byLANS-RH, were step sectioned, H&E-stained and investigatedimmunohistochemically, using the cytokeratine antobodies MNF 116(DAKO, Hamburg, FRG) and AE1/AE3 (Boehringer, Mannheim, FRG).For visualisation the AEC-method was performed.Results: In 6 patients the liposuction material represented small lymphnodes on H&-E-stained slides. In one of these cases OTCD were seen in
a subcapsular lymphatic vessel. Two cases showed OTCD in liposuctedfatty tissue and in a small vessel on immunohistochemistry, respectively.Conclusions: In accordance to earlier reports of breast cancer patients,the detection of OTCD can be improved by immunohistochemistry.Additionally, the LANS-RH, as a modification of classic Wertheim-Meigs procedure, is capable to remove tumor burden pelvic tissue andmay be reduce risk of recurrence. Probably post-operative adjuvanttherapy can be omitted in patients treated by LANS-RH. But, actuallythe follow up times of these cases is to short to draw any conclusions.
FC3.03.07IMPROVEMENT OF HPV DETECTION RATE ON CYTOLOGICALSMEARS BY PCR IN SITU HYBRIDIZATIONY.H. Xiao , S. Sato, Y. Yokoyama, Y. Saito, Dept. OB/GYN, HirosakiUniversity School of Medicine, Aomori, Japan
Objectives: To assess the HPV detection value of PCR in situhybridization (PISH) in cytological uterine cervical smears bycomparison with florescence in situ hybridization (FISH) andimmunohistochemical staining (HIS).Study Methods: From 1985 to 1995, a total of 162 archivalPapanicolaous smears of uterine cervices were available from 54 womenbefore they were histologically confirmed as cervical severe displasia(SD) (n=17), microinvasive cervical cancer (Ic) and cervical carcinomain situ (CIS) (n=37). Three smears of each patient were selected andrandomized into three groups for HPV detection by means of FISH(Ns=54), PISH (Ns=54) and IHS (Ns=54), respectively. We analyze theHPV detection rates in the groups of various histological lesions and thetotal HPV detection rates by three methods.Results: In SD group, PISH showed 58.8% positive incidence, whichwas significantly higher than FISH (23.5%) (P < 0.05), but was nodifferent with IHS (47.1%). In Ic and CIS group, PISH showed 73.0%positive incidence, which was significantly higher than FISH (43.2%) (P< 0.01), while IHS showed 67.6% positive incidence, which was alsosignificantly higher than FISH ( P < 0.05). About the total detection rate,PISH (68.5%) and IHS (61.1%) were all significantly higher than FISH(37.0%) (P < 0.01 and < 0.05), but were not different from each other.Conclusions: PISH can improve the HPV detection rate inmorphologically intact cells on uterine cervical cytological smearscomparing to FISH and IHS. The PISH technique, possessing highsensitivity and specificity, will become a practical method to perform insitu analyses of nucleic acid molecules and cytological screeningsimultaneously.
FC3.03.08IMPACT OF TUMOR LOAD IN SURGICALLY TREATEDHISTOLOGICALLY STAGED EARLY CERVICAL CANCER:MULTIVARIATE ANALYSIS OF 568 PATIENTSL.-C. Horn , G. Raptis, Inst. of Pathology, University of Leipzig,Germany, U. Fischer, K. Bilek, Dept. OB/GYN University of Leipzig,Germany.
Objectives: The purpose of the study was to evaluate the prognosticimpact of tumor load and histology in pT1b cervical cancer (CC).Study Methods: 568 patients with histologically staged operative treatedCC were cured in a period of 17 years. All cases with pelvine lymphnode metastases (LNM) received postoperative radiation. Morphologicparameters, like tumor size ( < /> 4cm), intratumoral LVSI, grading,relative depth of invasion (RDI), peritumoral inflammatory response(PIR), patients age and histologic type were correlated to prognosis,using Chi2- and Cox-regression-analysis.Results: The 5-year-suvival-rate (5-YSR) of pT1b1 tumors with a RDIof >66% of the cervical wall declined from 86.9 to 79.3 (p=.0093). InpT1b2-CC RDI showed no prognostic impact. The recurrence rate in thelatter tumors with LVSI was significant higher (p=.012). All poorlydifferentiated (G3) pT1b-CC in general and those with pelvine LNMhave had a poor prognosis, but not in cases without LNM. T1b-tumorswith large tumorload (>4cm) showed a poor prognosis, even when LNMwere recognised (5-YSR: pT1b1: 87.8%, pN0 90.8%, pN1 70.9; pT1b2:64.7%, pN0 85.2, pN1 37.4%; p=.0009). In multivariate analysis pelvineLNM, tumor size, LVSI and tumor grading reached statistic significane(p<.01) regarding overall survival, but the tumor type, RDI, PIR andpatients age showed no prognostic impact. In cases without LNM only
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LVSI reached prognostic significance. In cases with pelvine LNM tumorsize and grading (p<.03) were prognostic indicators.Conclusions: High tumor load in operative treated pT1b-CC represents astrong prognostic factor, even in separate analysis of node negative andpositive patients. Large tumors, especiallly cases with pelvine LNMrepresent a high risk group and may represent candidates for (neo-)adjuvant multimodal therapy.
FC3.03.09MODIFIED TECHNIQUE OF RADICAL SURGERY FORCARCINOMA CERVIX — FIFTEEN YEARS EXPERIENCEC.N. Purandare , N. Gada, L. Bhosle., J.A. Lopez. Grant MedicalCollege, Mumbai, India.
Objectives:1. To present our experience with modified technique of radical surgeryfor carcinoma cervix in 140 patients using Purandare's modified vagino-abdominal approach.2. To study the 5 year survival rates and complicaton rates of surgery.Study Methods: The technique was carried out in 140 cases who weresuffering from carcinoma cervix upto stage IIa and early stage IIb.Surgical technique included:1. Vaginal dissection of the cuff of vagina of 1cm wide margin withgrowth free area.2. Distal cuff closed by nonabsorbable suture and remaining vaginapacked and closed by absorbable suture.3. Abdominal dissection carried out consisting of Radical Werthiem'sHysterectomy with transperitoneal lymphadenectomy with bilateralInternal iliac artery ligation.Results1. None of the patients had wound infection, pelvic infection, abscessformation, vaginal cuff cellulitis or thromboembolic phenomenon.2. Overall early morbidity rate was 7.6%,3. Incidence of urinary fistula was nil,4. The recurrence rate was 5%,5. The 5 year survival rate was 92%.Conclusion: We find this technique extremely useful in that thepostoperative complications are infrequent and relatively minor, whileclinical control of the tumor appears excellent.
FC3.04 CONTRACEPTION
FC3.04.01FEMCAP, A NEW BIRTH CONTROL METHODA. Shihata , Scripps Instittution of Med. & Science, 14058 Mira MontanaDr., Del Mar, California, United States, 92014.
Objective: To develop a safe, effective and acceptable woman-controlledbarrier contraceptive device that minimize the transmission of STDs.Study methods: Silicone rubber was chosen because it is hypo-allergenic, inert, durable, and easy to clean. The FemCap was designedto fit the anatomy of the cervix and vagina. It is shaped like a sailor hat.While its dome covers the cervix, its rim fits into the vaginal fornicesand covers the vaginal vault, and its brim conforms to the vaginal walls.A unique groove, facing the vaginal opening was designed to storemicrobicidal spermicide that trap and kill the sperm and STD organisms.Result: A new contraceptive barrier device is developed that is safe,effective, acceptable, and may minimize the transmission of STDs.Conclusion: The FemCap could fulfill the primary objective ofdeveloping a woman-controlled barrier contraceptive device. TheFemCap will be used in conjunction with microbicidal spermicide,hence may fulfill the secondary objective of reducing the risk oftransmission of STDs.
FC3.04.02ADVERSE EFFECTS ON THE REPRODUCTIVE HEALTH OFWOMENS. Mukherjee , Dept. OB/GYN, L.H.M.C. & S.S.K. Hospital, New Delhi,India
Objectives: As the next millennium approaches, the current worldpopulation of 5.9 billion will continue to increase by 81 million per year-93% of which will come from the developing countries. In developing
countries each year, more than half a million women die from maternalcauses. Most of these deaths could be prevented not only by providingappropriate medical care immediately, but also by offering familyplanning counseling and services which could prevent many futureunintended of family planning information; services and appropriatecounseling are well known factors for offering effective and safecontraceptive methods.Study Methods: This is a retrospective study of women who receivedfamily planning services at Lade Hardinge Medical College & S.S.K.Hospital from 1/8/1998 to 31/7/99.Results: 2 269 cases underwent operative family planning procedures,out of which 1 745 were the total number of sterilization (76.7%). Thepre operative complication rate was 0.9% and the postoperativecomplication rate was 4.9%. The sterilization failure rate was 1.1%.Conclusions: As population scientist and healthcare provider, we mustredouble efforts to eliminate or significantly reduce barriers tocontraceptive use in developing countries and promote an integratedhealthcare service which is accessible, acceptable and can easily bemolded to suit different social, cultural and religious settings.
FC3.04.03BARRIERS TO CONTRACEPTIVE UPTAKE IN THE STATE OFORISSA (EASTERN INDIA)S.Kar , Obs&Gyn, Kar Clinic, A-32, Unit 4, Bhubaneswar, Orissa, India-751001
Objectives: Aim of the study was to a)identify the factors that limituptake of contraceptives amongt couples in urban and peri-urban areasof Orissa.b)role of providers in giving family planning advice and theirlevel of knowledge.Study Methods: The study covered 4800 respondents, of which 2302were relevant to the objectives of this study. 1532 were women, 366were men. Following methods of investigations were used: structuredand un-structured interview, depth interview, focus group discussion,observation and dummy client. Medical, paramedical practitioners andmedical retail outlets were randomly selected for observation. Threestudy teams of four investigators each carried out field work for 10weeks. Detailed computer analysis of data was carried out. 'Ethnograph'a package for qualitative analysis of computer data was used. This studywas carried out with funds from the British Department For InternationalDevelopement (DFID)Results: 40-50% of women had not heard of the condom or IUCD. Morethan 50% of men had'nt heard of the IUCD. Most had heard of theOCpill, but majority did not know anything else about it. Level ofknowledge about characteristics of contraceptives was very low.Providers were substantially responsible for miscomunication. Mostwomen have little or no opportunity to seek information or adviceregarding contraception.Conclusions: Poor uptake and utilisation of modern methods ofcontraception is mainly responsible for the uncontrolled rise inpopulation of developing countries.There is a large potential demand forspacing methods and lack of knowledge is a more important barrier toadoption than hostile views to specific methods. Efforts on a massivescale are needed to promote awareness, availability and utilisation ofmodern methods of reversible contraceptives.
FC3.04.04ACCEPTABILITY OF POSTPARTUM IUD (PPIUD)H. T. Salem , M. A. Kamel, S. A. Mohamed & O. M. Shaaban,Dept. OB/GYN, Faculty of Medicine, Assiut University, Assiut, Egypt
Objectives: To study the factors affecting the acceptability andperformance of 3 groups of postpartum IUD insertion (postplacental,predischarge and trans-cesarean).Study Methods: A total of 1880 and 1661 women were counseledantenatally and postpartum for PPIU insertion. According to womenacceptance IUD (CuT 380) were inserted postplacental (within 10minutes after placental deliver) in 60 women, predischarge (within 48hours after delivery) in 74 women, trans-cesarean (before closure of theuterine incision) in 54 women and interval (after the end of purperium)55 women. All the subjects were followed up monthly for careful pelvicexamination and ultrasonographic scanning.Results: Out of 3541 women counseled, 1024 (28.9%) accepted the ideaof PPIUD. Only 264 (7.5%) accepted the immediate postpartum
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insertion. The mean age and parity of the acceptors were 33 years and4.3. The net cumulative continuation rates were 69, 72, 84 and 80 per100 women for the post placental predischarge, trans-cesarean andinterval IUD insertions respectively. Complete or partial expulsion wasthe main cause of discontinuation (8.4%). No perforation or pregnancyoccurred in this study.Conclusion: With proper counseling and training immediate postpartumIUD insertion can be valid option in postpartum family planning. It issafe, effective and with minimal side affects.
FC3.04.05ATTITUDES TOWARDS CONTRACEPTION IN PAKISTANF. Maqsood , R. Sohail, F. Zaman, Dept. OB/GYN, PostgraduateMedical Institute/Services Hospital, Lahore, Pakistan.
Objectives: To assess awareness of women regarding contraception,available facilities and contraceptive practices. To analyze the influenceof social, religious and cultural beliefs affecting attitudes.Study Methods: 1000 married women, aged 15-45, attending theantenatal and gynecological clinics were interviewed, a questionnairewas filled out and the data was analyzed.Results: 80% of the women attending the antenatal and gynecologicalclinics were in favor of using contraceptive methods to limit their familysize, however, 70.4% of the women interviewed were not using anyform of contraception. Those not practicing contraception had parityabove 4. 48% had knowledge about contraceptive methods and theiravailability, 34% had no knowledge and awareness regarding them,while 15%, despite having knowledge, were not aware of theiravailability. 60% were using barrier method. Religion, considered to bea major factor, influenced only 30% of the women, who believed thatcontraception is prohibited in Islam.Conclusion: Contraceptive prevalence rate is very low and religious,social and cultural beliefs are important operative factors. Desire formale offspring plays a significant role in increased family size. There isneed for greater efforts by family planning services to enhanceawareness and ensure availability of facilities.
FC3.04.06NEW METHOD OF PUERPERAL TUBAL STERILIZATION INDEVELOPING COUNTRIES.B.Dhorepatil , Shree Maternity Home, Siddharth Mansion, Nagar Road,Pune 411 006, Maharashtra, India, 411006.
Objective: To improve the acceptence of post-partum tubal sterilizationin private practicing gynecologist in developing countries.Study Methods: The present methods of post-partum sterilization used indeveloping countries ie.India is open tubal ligation.The approach oflaparoscopy for tubal sterilization (bipolar cauterization & cutting thetube at isthmic region) in immediate post-partum period is used in thisstudy to improve the acceptence for permanent contraception which isthe need in developing country like India. In this study 50 cases wereincluded for a period of one year. The proper consent was taken &procedure explained.Results: The procedure was well accepted by all the patients.No extrahospitlization required.There were no significant complicationsoccured.There were no failures in this study though the period is short.Conclusions:This has improved the acceptence of purperal sterilizationin private practice.
FC3.04.07KNOWLEDGE AND PRACTICE OF CONTRACEPTION AMONGUNITED ARAB EMIRATES WOMEN.S.Ghazal-Aswad , D.Rizk, S.Al-Khoori, H.Shaheen, Faculty of Medicine& Health Sciences, UAE University, PO Box 17666, Al-Ain, UnitedArab Emirates.
Objectives: To determine the knowledge and practice of contraceptionamong United Arab Emirates [UAE] women.Methods: UAE women at risk of pregnancy defined as married, aged 15-44 years and had previously born children, were randomly selected fromthe community (n=200) and health care centers (n=200). Subjects wereinterviewed about their contraceptive practice using a structuredquestionnaire.
Results: 166 participants (41.5%) were using contraception. All usednatural methods in addition to other methods. The association betweenusing birth control and each of old age, high level of education and lowfamily income was significant. Religious beliefs and low expectation ofsuccess of birth control were the reasons given by non-users. 85% ofsubjects did not accept sterilization without medical indications norcontraception before the first pregnancy. 26% of women believed thatcontraceptive methods could be purchased over the counter and 78%were unaware that they could be used for treatment of gynecologicdiseases. 42.5 % of women thought that the age limit for usingcontraception in women was 40 years. 48.7 % of users had menstrualdisturbances and all were most bothered by the inability to pray.Conclusion: Contraception is not commonly used by UAE womenbecause of social traditions, religious beliefs and lack of information.
FC3.04.08NORPLANT CONTRACEPTIVE SUBDERMAL IMPLANTS: FIVEYEARS EXPERIENCE IN ANKARA, TURKEYHale Aktun , Hakan R. Yalcin, Perran Moroy, Oya GokmenZekai Tahir Burak Women’s Health Education and Research Hospital,Family Planning Clinic, Ankara, Turkey
Objective: To assess the efficacy, safety and acceptability of norplantimplants.Study design: A prospective study conducted in the family planningclinic, Zekai Tahir Burak Women’s Health Education and ResearchHospital, Ankara, Turkey from 1994 to 1999. Norplant is one such,based on the use levonorgestrel capsules which inroduced into women’sarms, produce a daily secretions of hormones and have from two to fiveyears’ effect.Results: This report summarized five years’ experience with thesubdermal levonorgestrel implants in 711 women. The mean age of thepatients was 21.2±2.4. Menstruel disturbances ranging from amenorrheato menorrhagia, were the majör side effects and were present 327(45.9%) of women during the five years. These disturbances resulted in15 removals, medical complications, including headache, desire forpregnancy etc. were the principal reasons for another 39 removals.Conclusion: The efficacy, safety and acceptability of the implantsuggests that norplant is one of the most effective and practical forms ofcontraception for any women who wants long term, continuous yetreversible contraceptive options.
FC3.04.09THE DETERMINANTS OF THE CHOICE AND USE OF FERTILITYREGULATING METHODS IN GEORGIAK. Kuparadze, L. Baramidze, Zhordania Institute of HumanReproduction, Tbilisi, Georgia.
Objectives: The aim of the study was to assess the characteristics ofwomen who do not use modern contraception (abortion clients) versususers of modern contraceptive methods (age, religion, education,profession, income, medical and reproductive history, smoking, pastexperience with abortion and contraception, future plans and etc.)Study Methods: Data were collected using semi-structured interviewswith clients and providers, using pretested questionnaires. One hundredninety women for contraception (C) and 194 women coming forabortion (A) included in this study.Results: Most of the patients are 25-34 years old. The average age of thepatients is 27.In group A, considerable number of patients 43percent, 8 were with higheducation. At the moment of survey 27% of patients have no childrenyet, 20% comes on school children/students. In this group, 39.3% preferto use condom, 36.3-IUD. 63.4% had the induced abortion before but forgroup C (96.6%) was using contraceptive after abortion.For group C, majority of patients were using contraceptive pills 80% and8.9% condom.Most of women in group A (75.9%) have not felt any discomfort usingmodern methods of contraception. Mostly is concern pills 69.2%, thencondom 30.8% and IUD 15.4%.Conclusions: Education level and life conditions in both groups aresimilar, which manifests lack of information (mass media, gynecologist,sex education) for those who prefers abortion to contraception.
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FC3.05 EFFECTS OF HRT
FC3.05.01ENDOMETRIAL HYPERPLASIA WITH TIBOLONE (LIVIAL®)L. Schmaltz , M. Albernaz, E. Souza, Dept. OB/GYN, Hospital MaternoInfantil de Goiânia, Goiània, Brazil.
Objectives: To question the endometrial security after long termTibolone use.Study Methods: Case report of 3 cases of endometrial hyperplasia duringTibolone medication.Results: The first placebo controlled trials suggested almost anendometrial protection, showing no stimulation and bleeding not greaterthan placebo. Most studies had only one year follow-up and there arevery few described cases of Tibolone associated hyperplasia, until now.We describe 3 cases of private office, that developed endometrialhyperplasia, tow of them with focal atipias, after on year or more ofTibolone. The patients were ³ 54 years old, more than 1 yearmenopause, weren’t obese, had normal exams, except for a type IIcontrolled diabetes and had £ 5 mm endometrium before and HRT(Hormone Replacement Therapy). Case 1 had only one month ofcombined estrogen during HRT, and two of them had used oral or localestrogen before Tibolone, but all had endometrium less than 6 mm andstayed amenorrheic for more than 1 year before bleeding and hyperplasydiagnosed by transvaginal sonography, hysteroscopy and biopsy.Conclusion: We need more studies with long-term follow-up andTibolone interaction to confirm it is safe to the endometrium. Until then,doctors must control endometrial stimulation with Tibolone like anyother HRT.
FC3.05.02SUBCUTANEOUS EXTRADIOL IMPLANT AS A REGIMEN FORHRT IN MENOPAUSAL ESTROGEN DEFICIENCYS. Suhonen(1) , L. Anttila(2), R. Punnonen(3), E. Varila (3), I. Rauramo(4), T. Salmi(2)(1) Dept OB/GYN, Helsinki City Maternity Hospital, Helsinki, Finland.(2) Turku University Central Hospital, Turku, Finland.(3) Tampere University Hospital, Tampere, Finland.(4) Leiras Oy, Helsinki, Finland
Objectives: To investigate the efficacy and safety of the subcutaneousestradiol implant (E2) treatment for menopausal estrogen deficiency.Study Methods: This was an open, non-comparative, multi-center studyin 37 peri- and 61 postmenopausal women. Two implants, eachcontaining 70 mg E2, were inserted at study entry under local anesthesiain the subjects’ upper arm and the treatment was used for 24 months.Oral MPA (10mg) for 10 days/month was used to oppose endometrialstimulation. S-E2 concentrations were measured and the relief ofclimacteric symptoms was evaluated by using Kupperman index.Results: The treatment compliance was high: 85 (86.7%) out of 98subjects completed the 24 months follow-up. The steady state E2
concentration (192.0 pmol/l) was reached in 7 days remaining at anacceptable level for up to 24 months. Relief of menopausal symptomswas successful: the median Kupperman index declined from entry tothree months by 64% and 80% and to 24 months by 100% and 90% inthe peri- and postmenopausal groups. The most common adverse eventswere headache and breast tenderness. 10 out of 13 discontinuations weredue to adverse events.Conclusions: Subcutaneous E2 implant is an effective and safe long-termtreatment method for HRT in menopausal estrogen deficiency. Patientcompliance is high since daily or weekly administration is not needed.
FC3.05.03EFFICACY AND SAFETY OF A COMBINATION OF 2 MGESTRADIOL VALERATE PLUS 2 MG DIENOGEST INPOSTMENOPAUSAL WOMENT. Graser (1), T. Romer (2), F. Walter (1), M. Oettel (1)Medical Research Dept. Jenapharm GmbH & Go. KG, Germany.Jena and Clinic OB/GYN, University of Cologne, Germany.
Objectives: To evaluate the efficacy, safety and tolerability ofcontinuous combined hormone replacement therapy (HRT) with 132valerate plus 2 mg dienogest).
Study Methods: In an open, multinational, multicenter, non-controlledphase III study, 1501 women aged 52-65 years with postmenopausalsymptoms were treated with KlimodienÒ for 12 treatment cycles (48weeks), with assessments of efficacy, safety, tolerability (adverseevents) at 8, 24 and 48 weeks. Efficacy was assessed using theKupperman Index. Safety assessment included transvaginal sonography,endometrial biopsy, mammography, physical and gynecologicalexamination, vital signs, prothrombotic factors and routine laboratorysafety parameters.Results: Kupperman Index improved with increasing duration oftreatment, accompanied by improvement of self-reported well being.Individual climacteric symptoms, such as hot flushes and pychonervousdisorders, also improved. The most pronounced improvement was seenin HRT-naïve patients. The incidence of breakthrough bleeding declinedover time, resulting in complete amenorrhea in 86.2% of the patientsafter 12 cycles of treatment. Furthermore, total and LDL cholesterollevels decreased and HDL cholesterol levels increased. Decreases inalkaline phosphatase, pyridinoline, and desoxypyridinoline demonstratedthat dienogest did not affect the inhibitory action of extradiol on boneresorption. Endometrial thickness remained almost constant and theincidence of serious endometrial findings was similar to that of untreatedwomen.Conclusions: Continuous combined substitution with KlimodienÒ iseffective, safe and well tolerated in postmenopausal women. The hybridprogestin dienogest does not abolish the estrogen benefits ofKlimodienÒ.
FC3.05.04WHAT IS COMING AFTER HORMONE REPLACEMENT INWOMEN AND MEN? CONSIDERATIONS FROM THEENDOCRINOLOGIC AND PHARMACOLOGIC POINTS OF VIEWREGARDING HORMONE DISPLACEMENTM. Oettel (1), W. Elger (1), M. Obendorf (1), V. Patchev (1), U.Schumacher (1), B. Winkelmann (2)(1) Dept. Research and Development, Jenapharm GmbH & Co. KG,
Jena, Germany.(2) Herzzentrum Ludwigshafen Medizinische Klinik B, Ludwigshafen,
Germany.
The near future of hormone replacement in women is stronglyinfluenced by the development of selective estrogen receptormodulators, estrogen sulfamates, and selective progesterone receptormodulators. New developments for hormone replacement in men refer totissue specific androgens (selective androgen receptor modulators) andnon-feminizing estrogens.A new approach could be hormone displacement. On the basis of ourown epidemiologic data the age-related reductions of the secretion ofestrogens, androgens, DHEAS and their clinical consequences will bediscussed. The secretion of cortisol and progesterone (at least in men) isnot age related. Therefore, a relative hypercortisolism and aprogesterone/testosterone imbalance occurs. The potential therapeuticvalue of selective antiglucocorticoids will be presented as well as thedifferent approaches to the modulation of non-classical progesteroneaction.
FC3.05.05COMPARATIVE BIOAVAILABILITY OF TWO TRANSDERMALDEVICES OF 17-b- (ESTRADIOL TD760 AND OESCLIMÒ50) INPOST-MENOPAUSAL VOLUNTEERSD. Deprez (1), G. Blanchot (1), A. Renoux (2), D. Chassard (2)(1) Institut de Recherche Pierre Fabre, Boulogne, France.(2) Groupe CEPHAC-ASTER, Paris, France.
Objective: To compare the pharmacokinetic profiles and the relativebioavailability of estradiol and estrone after a 2-week application ofTD760 applied once weekly versus OesclimÒ50 applied twice weekly.Study Methods: Single center, open labelled, randomized, two 14 dayperiod cross-over study in 36 healthy post-menopausal women with FSH³ 40 IU/I and plasma estradiol < 45 pg/ml. A wash-out period of oneweek was observed between the two treatment periods. Blood sampleswere collected for each treatment period before patch application (TO)and every 12/24 hours from D8 to D15 as well as 1, 2, 4 and 12 hoursafter last patch removal on D15. Plasma estradiol (E2) and estrone (E1)were assayed by GC/MS. Cmax Tmax, Cmin, AUC168-336h, Cav, PTF and E2/E1
WEDNESDAY, SEPTEMBER 624
ratio for Cav were calculated. Local and general tolerability was assessedthroughout the study.Results: TD760 provided stable plasma concentrations of E2 and E1fluctuating around a mean Cav of 52.1 pg.ml-1 (range: 16.2 – 144.4). Thesignificantly higher Cav observed with OesclimÒ50 (83.9 pg.ml-1, range:28.5 – 312.8, CI 90% of [0.66; 0.73]) resulted from higher peaksreached twice a week and were associated with slightly more estrogen-related AEs. E2/E1 Cav ratios were close to the physiologicalpremenopausal ratio for both devices. Tolerability was good; the mostfrequent adverse events (AEs) were mainly observed with OesclimÒ50(12 AEs reported by 7 subjects vs. 8 AEs reported by 5 subjects) andwere estrogen-related (breast pain, pelvic inflammation). The samenumber of subjects presented with pruritus for TD760 and OesclimÒ50(4 per group).Conclusions: Application over a week of matricial TD760 led to plasmaconcentrations of estradiol and estrone fluctuating within thephysiological range of concentrations observed in pre-menopausalwomen.
FC3.05.07THE EFFECT OF TWO DIFFERENT HORMONE REPLACEMENTTHERAPY REGIMENS ON POSTMENOPAUSAL SYMPTOMSA. Elfituri (1) , M.S.Elmahaishi (2), H.Chrystyn (1), (1) University ofBradford, School of Pharmacy, # 22, Quayside Lodge, London, England,United Kingdom, SW6 2UZ, (2) Misurata Teaching Hospital, MainStreet, Misurata, Libya.
Objectives: To evaluate the effects of two different HormoneReplacement Therapy (HRT) regimens, a sequential regimen of 17-Bestradiol with dydrogesterone, and a continuous regimen of tibilone.Study methods: 80 healthy women with postmenopausal symptoms, 12-24 months since their last menstrual period, were enrolled in a 6-monthprospective study. Participants were randomly prescribed two differentpreparations: the first group (n=30) received a monthly-bleed HRT; 17-B estradiol 2 mg tablets sequentially combined in one tablet withdydrogesterone 10 mg for 14 days of each cycle (Femoston, SolvayPharma). The second group (n=50) received a bleed-free HRT; tibilone2.5 mg tablets once daily (Livial, Organon). The presence and severityof short and intermediate-term postmenopausal symptoms were reportedat baseline and after 3 and 6 months of treatment. Observed side effects,if any, and patient compliance were recorded.Results: A total of 53 women completed the 6-month study period, 22 ofthe first group and 31 of the second group. Participants, in both groups,experienced a significant improvement after the third month oftreatment. The observed symptoms were relived by the end of the studyperiod, with no significant differences between the groups. Women whocompleted the study period showed their satisfaction and compliance tothe used medications. No significant side effects were recorded.Conclusions: Tibilone, without the need for withdrawal bleeding, similarto 17-B estradiol, relieves short and intermediate-term postmenopausalcomplaints.
FC3.05.08SULPHATASE INHIBITION BY TIBOLONE PREVENTSSTIMULATION OF BREAST AND ENDOMETRIUMH.J.Kloosterboer and M.E.de Gooyer, N.V. Organon, Oss, TheNetherlands
Objectives: Tibolone is a tissue specific agent due to tissue selectivemetabolism of the compound. Estrogenic metabolites of tibolone areformed in the liver and intestine and are responsible for the effects onbone whereas formation of the delta-4 isomer, a progestagenicmetabolite, in the endometrium opposes the estrogenic action on thistissue. The majority of the estrogenic metabolites is in the inactivesulphated form. Previous studies have shown that tibolone diminishestumor growth in the DMBA model. This effect may be due to a loweringof estrogenic compounds by sulphatase inhibition. Such an inhibitionmay not occur in bone, because it would lower the estogenic response onbone. This means that tibolone or its metabolites must show tissueselective inhibition. In order to test this hypothesis the effect of tiboloneand its metabolites on sulphatase activity in breast cells (T47D) andosteoblast-like cells (MG63; HOS TE 85) were tested.Study Methods: Cells were incubated with estrone sulphate and theamount of intracellular estrone plus estradiol was assessed using HPLC.
In these studies EMATE was used as a positive control. In addition theeffect on sulphatase activity in endometrium cells ECC-1; HEC 1A) wasstudied.Results: Tibolone and its metabolites do not inhibit sulphatase activity inthe two bone cell lines, but in breast cells a strong inhibition wasobserved. EMATE has a stronger inhibitory effect in breast cells than inbone cells. These results suggest the sulphatase enzyme is differentlymodulated in these two cell types. Partial inhibition was observed in theendometrial cells. The lower observed inhibition may be due to thepresence of a high level of sulfotransferase activity in the endometrialcells.Conclusions: From these results we conclude that tibolone and itsmetabolites show tissue selectivity with respect to sulphatase inhibition.The inhibition of the enzyme as seen in breast and endomerial cells mayserve a lower stimulation of these tissues by tibolone
FC3.06 PREGNANCY - PATHOPHYSIOLOGY
FC3.06.01ROLE OF HEPARAN SULFATE PROTEOGLYCAN ONPLACENTAL THROMBOXANE PRODUCTIONM. Yamaguchi , T. Ikenoue and N. Mori, Department of OB/GYN,Miyazaki Medical College, Miyazaki, Japan
Objectives: In this paper, we sought to investigate the mechanism howantithrombin III (AT III) stimulate placental prostaglandin andthromboxane (TX) production.Study Methods1) Identification of the heparan sulfate proteoglycan (HSPG) of the
placental tissue: We tried to identify HSPG of the placental tissuecollected from 4 cases by immunohistochemical technique. For thispurpose, 10E4 antibody (detect intact HSPG, including perlecan andsyndecan), 3G10 (detect digested HSPG; DHSPG) and BB4antibody (detect syndecan 1) were used for first antibody.
2) Effect of AT III of placental TX production: Placental tissue wasincubated with Dulbecco’s PBS with or without AT III. TXconcentration of the medium was measured by enzymeimmunoassay.
3) Effect of heparitinase digestion on placental TX production: HSPGof the placental tissue was digested with 0.25mU/ml heparitinase for30 min. TX production by the placental tissue was determined byenzyme immunoassay.
Results1) HSPG was strongly positive in capillary endothelial and interstitial
tissue of the chorionic villous tissue. Syndecan 1 was stronglypositive in trophoblast and positive in endothelial cell of thechorionis villous arteriole.
2) DHSPG was not detected in chorionic villi. In heparitinase treatedtissue, HSPG and syndecan 1 were not detected. DHSPG wasstained in the heparitinase treated chorionic villous tissue
3) AT III increased TX production by the placental tissue4) Heparitinase digestion did not alter basal placental TX production.
However, TX production was decreased in heparitinase treatedtissue with AT III stimulation
Conclusions1) We could stain the HSPG of the placental tissue. Especially, we
showed the presence of syndecan 1 of the trophoblase.2) At III stimulated TX production of the placental tissue, (at least, in
part) by HSPG related mechanism.
FC3.06.02DOES PLASMINOGEN ACTIVATOR INHIBITOR 1 (PAI-1)CONTROL TROPHOBLAST INVASION ? A STUDY OFINTRAUTERINE, TUBAL AND MOLAR PREGNANCIES.C. Floridon , L. Sunde, JG. Westergaard, SG. Thomsen and B. Teisner.Dept. OB/GYN and Pathology, Odense University Hospital, Denmark.
Objective: Urokinase plasminogen activator, its receptor and theinhibitor PAI-1 are involved in proteolysis and remodelling of maternaltissue during implantation. Ectopic and molar pregnancies areabundantly associated with excessive placental invasion and necrosis.This study evaluate subcellular PAI-1 at the implantation site, basal plateand placental bed in normal, tubal and molar pregnancies.
WEDNESDAY, SEPTEMBER 6 25
Study Methods: PAI-1 was analysed by immunohistochemistry in 50normal, 50 tubal and 100 cytogenetically verified molar specimens from1st, 2nd and 3rd trimester pregnancies.Results: Basal plate and placental bed extravillous interstitialtrophoblasts as well as vascular trophoblasts were focally PAI-1positive. In the decidua, PAI-1 was located within the cytoplasm of non-invaded stromal cells. By contrast, when decidual invasion wasestablished, PAI-1 was seen membrane-associated or confined to theextracellular matrix. Only a few stromal cells distant from theimplantation site were PAI-1 positive and decidualization was notpresent in tubal pregnancies.Conclusions: The present data indicate that PAI-1 is a marker of specificinvasive trophoblast cells within the maternal decidua. Moreover,stromal cellular lack of PAI-1 in ectopic pregnancies or excessivedecidual necrosis in molar pregnancies seems to be associated with anuncontrolled placental invasion. We speculate that trophoblast invasionis primarily regulated by signals from decidual cells.
FC3.06.03THE RELATIONSHIP BETWEEN FETAL ANTIGEN ANDINTERLEUKIN MESSENGER RNAS IN MATERNAL PERIPHERALBLOODT. Tamura , T. Okuda, C. Kato, H. Kojima, M. Fukuoka, T. Yamamoto,H. Honjo, Dept. OB/GYN, Kyoto Prefectural University of Medicine,Kyoto, Japan.
Objectives: This study was designed to examine the immunologicalinteractions between fetus and the mother during pregnancy. Weexamined the relationship between the amount of fetal antigen flowedinto maternal peripheral blood and the maternal immunologicalresponses measured by the quantitative analysis of IL mRNAs inperipheral blood cells.Study Methods: With informed consent, peripheral blood was obtainedfrom pregnant women (n=450) and non-pregnant women (n=62). TotalRNA was prepared for RT. By quantitative RT-PCR method, wemeasured the expression amount of fetal hemoglobin gamma china(HbF-¡) mRNA as a representative fetal antigen. The relative expressionratio of HbF-¡ chain, IL-8, IL-18 and IL-4 mRNAs against b actinmRNA were measured.Results: In pregnant women, the expression of IL-8 and IL-18 mRNAswere suppressed and significantly lower than those in non-pregnantwomen, but between IL-8 or IL-18 mRNA and HbF-¡ mRNA, therewere significant positive correlations, respectively (IL8 and HbF:R=0.50, p<0.01) (IL18 and HbF: R=0.44, p<0.01). On the contrary, theexpression of IL4 mRNA in pregnant women was significantly higherthan in non-pregnant women, but no significant correlation wasobserved with HbF-¡ mRNA.Conclusions: In maternal peripheral blood cells, we could observe twokinds of immunological changes. The both were induced by pregnancy.One was influenced by the amount of fetal antigens flowed into maternalperipheral blood, but another was independent of it. It was suggestedthat there were two different mechanisms of immunoreactions inmaternal peripheral blood cells.
FC3.06.04MATERNAL SERUM AND CORD BLOOD LEPTIN IN NORMALPREGNANCYT. Lam1, I. Schulz-Lobmeyr 1, B.W. Hartmann1, O. Preyer1, P.Wagenbichler2
1University of Vienna Medical School, Dept. OB/GYN, Vienna, Austria2Ignaz-Semmelweis-Frauenklinik, Vienna, Austria
Objective: Based on the hypothesis of a non-communicating, 2-compartment model of fetoplacental leptin regulation, out aim was todetermine whether there is a difference in maternal leptin concentrationand cord blood concentration in normal pregnancies.Study Methods: In an observational study, we included one hundred andthirty-nine pregnant women identified as having an uncomplicatedpregnancy. Blood samples were collected immediately after delivery.Leptin was measured by radioimmunoassay, and its relationship to fetaland maternal anthropometrics was assessed by Spearman correlation.Differences in maternal and cord blood leptin levels between male andfemale infants were tested with the Mann-Whitney-U-test. Maternal andcord blood leptin were compared by the Wilcoxon Signed Rank test. We
also compared fetal birth weight, length, weight/length, and ponderalindex.In addition, we measured the maternal prepregnancy body mass index,pregnancy weight gain, relative weight gain, and body mass index atdelivery.Results: No correlations were found between maternal and cord leptinlevels. Maternal leptin concentrations were significantly higher thancord leptin concentrations (p<0.0005 for the male and female newbornsand the total group).Maternal leptin correlated with birth weight (Spearman’s p = 0.183; p =0.031). Fetal leptin correlated with birth weight (p = 0.665; p = 0.0001),length, (p = 0.490; p = 0.0001), poderal index (p = 0.260; p = 0.002),and weight/length (p = 0.625; p = 0.0001). No significant differences inleptin were observed between female and male infants.Conclusion: The fact that there is no correlation between maternal andcord leptin is consistent with the hypothesis of a non-communicating, 2-compartment model of fetoplacental leptin regulation.
FC3.06.05UMBILICAL ARTERIAL BLOOD GLUCOSE CONCENTRATION,pH, BASE DEFICIT AND BLOOD GASES IN PRETERM, GROWTHRETARDED AND NORMAL INFANTS.R. Rukaria-Kaumbutho , Dept. OB/GYN, University of NairobiM. Cortina- Borja, Department of Statistics, University of Oxfordand C. Redman, Nuffield Dept. OB/GYN, University of Oxford, JohnRadcliffe Hospital.
Objective: To determine the relationship between the pH, base deficitand glucose concentration in the umbilical arterial blood taken atcaesarean delivery.Study Methods: Umbilical arterial pH, base deficit, glucose and bloodgases were routinely assessed in 216 fetuses delivered by electivecaesarean section at the High Risk Pregnancy Unit of the John RadcliffeHospital in Oxford. The gestation, birth weight, reason for delivery,outcome and demographic factors were determined. Cases with insulindependent or gestational diabetes mellitus, multiple pregnancy wereexcluded.Results: The mean gestation at delivery was 232 days (SD 27), with arange of 169-294. The arterial glucose was 2.68 mmol /l (SD 1.21), themean pH was 7.23 (SD 0.09) and the mean base deficit was 4.52mm/l(SD 3.50). There was a significant linear correlation between theumbilical arterial pH and base deficit (t =16.524, P=0.000). Theumbilical arterial glucose and PO2 increased significantly with gestation(P<0.005) while the base deficit decreased. (p<0.005). Eighty four(38.9%) infants were SGA with birth weight less than the 3rd centile.SGA fetuses were found to be hypoxaemic, acidaemic, hypercapnic, andhypoglycaemic. Although glucose concentration by itself was not foundto be a determinant of base deficit, hypoglycaemic fetuses were not ableto generate high base deficit when there was concomitant hypoxaemia.Conclusion: Therefore the interpretation of fetal acid base balance musttake into account the glucose concentration in order to avoid missingfoetal distress.
FC3.06.06CLINICAL REPRODUCTOLOGY PROBLEMS OF NEWBORNSG. Ouchakova , S. Yolgina, Dept. OB/GYN, Kemerovo State MedicalAcademy, Kemerovo, Russia.
Objectives: Reproductive system has been formed morphologically bythe moment of birth. Complicated pregnancy, extragenital pathology in amother affect unfavorably the reproductive system of a fetus and thus ofa newborn. The aim of the study was to investigate the reproductivesystem of newborns in a physiological course of pregnancy.Study Methods: The content of FSH, LH, testosterone has been studiedon the delivery of 31 healthy women at the age of under 30 by theradioimmunologic method with a set of Byk Mallinckrodt and 11-OKSfluorometric method. Among those under study there were 20 boys and11 girls. All babies were born with 8-9 points according to the Apgarscore. External genital organs of boys and girls were formedappropriately.Results: Low content of FSH has been determined in mothers andnewborns: both girls and boys. The LH content in boys is high andobviously exceeds serum LH in girls. Testosterone content in boys does
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not differ from that of girls. 11-OKS in mother’s serum is high and doesnot depend on a baby’s sex.Conclusions: The study testifies sex differences during the reproductivesystem formation in newborns. Readiness of the system to extrauterinelife is formed by the moment of birth. Received statistic data ofhonadotrophic and some steroid hormones can be applied as indexeswhile assessing the state of reproductive system of newborns.
FC3.06.07PLASMINOGEN ACTIVATORS AND PLASMINOGENACTIVATOR INHIBITORS IN MYOMETRIUM OF PREGNANTWOMENM. Uszynski , K. Maciejewski, J. Kuczynski, The Rydygier MedicalUniversity, Bydgoszcz, Poland.
Objectives: The aim of the study was to find out whether myometriumcan produce and export fibrinolytic components to the blood stream viautero-placental circulation.Study Methods: The study group consisted of 32 women in the 36-40th
week of gestation with some gestational complications (pre-eclampsia in11 cases) or complicated labor (intrauterine asphyxia in 21 cases). 10non-pregnant women were the control group. During the cesareansection, strips of myometrium were obtained from the lower segment ofthe uterus, and the tissue extract was prepared. In extracts ofmyometrium, and in blood plasmas, the following components offibrinolysis were measured: tissue plasminogen activator (tPA),urokinase plasminogen activator (uPA), plasminogen activator inhibitor1 (PAI-1) and plasminogen activator inhibitor 2 (PAI-2). An ELISAmethod was used. Statistical analysis was performed using a t-Studenttest.Results: The contents of the fibrinolytic components in myometriumwere as follow: tPA – 46.60 ± 33.63 ng/lg, uPA – 17.18 ± 4.36 ng/lg,PAI-1 731.38 ± 370.63 ng/lg, PAI-2 – 814.71 ± 23.58 ng/lg. In the bloodof pregnant vs. non-pregnant women: tPA – 9,30 ± 4.30 ng/ml vs. 4.44 ±2.97 ng/ml; uPA – 0.70 ± 0.34 ng/ml vs. 0.48 ± 0.16 ng/ml; PAI-1 –48.50 ± 16.08 ng/ml vs. 19.08 ± 8.2 ng/ml; PAI-2 - 177.14 ± 56.12 ng/mvs. 1.80 ± 1.86 ng/ml.Conclusions: It is generally acknowledged that placenta is the mainsource of fibrinolytic components. Our results show that myometrium ofpregnant women may be considered to be an additional source offibrinolytic components.
FC3.06.08INHIBITION OF PLATELET AGGREGATION BY RATTROPHOBLASTSP.K. Mehrotra (1), R. Tewari (1), M.P. Singh (2), S. Farheen (1), and M.Dikshit (2)(1) Division of Endocrinology, Central Drug Research Institute,Lucknow, India(2) Pharmacology, Central Drug Research Institute, Lucknow, India
Objectives: The aim of the study was to determine the effect ofsuspended rat trophoblast cells on the adenosine diphosphate (ADP)induced platelet aggregation.Study Methods: The trophoblasts were isolated from ectoplacental cone(EPC), a preplacental tissue highly rich in there cells, developed in ratembryo on day 12 of pregnancy. The platelet rich plasma was obtainedfrom adult male rats. The trophoblasts were preincubated (37oC, 30min), suspended in the medium and re-incubated with platelet richplasma (PRP) for 3-5 min.Results: It was noticed that the cell at 5-7 X104 concentration inhibitedADP-induced platelet aggregation. But when the concentration wasincreased to 1-2 X 105 cells, proaggregatory phenomena was observed.However, there was no response when fixed trophoblasts or liveendometrial stromal cells were incubated with PRP.Conclusions: Findings indicated that the aggregation inhibition responsewas cell specific and concentration dependent The nature of inhibitoryor stimulatory factor is, however, not yet established.
FC3.06.09THE EFFECT OF RECURRENT HYPOXIA-REPERFUSION ONLIPID PEROXIDATION IN THE FETAL LAMB BRAIN: A PATHANALYSISM.S. Rogers (1), C.C. Wang (1), H.G. Murray (2)(1) Dept. OB/GYN, The Chinese University of Hong Kong, Prince ofWales Hospital, Shatin, N.T., Hong Kong.(2) Dept. OB/GYN, Hepean Hospital, Penrith, Australia.
Objectives: To determine the effects of variable recurrent oxidativestress on lipid peroxidation in the fetal brain.Study Methods: Setting: The Westmead Hospital Vivarium, Universityof Sydney and the Dept. OB/GYN of the Chinese University of HongKongPlasma lipid peroxide concentrations were measured in acutelyexteriorized fetal lambs under graded hypoxia induced by intermittenttotal umbilical cord compression in 30-, 60- and 90-second occlusionswith diminishing recovery periods of 3-, 2- and 1-minutes.Results: A rapid and profound rise in fetal cartoid artery organichydroperoxide (OHP) concentrations, but drop in fetal jugular venousconcentrations was found intermittent 30-second occlusions, withminimal fetal arterio-venous differences. Arterio-venous differencesappeared under severe hypoxic stress from 60-second occlusionsonwards. Path analysis of the changes in OHP concentration betweenarterial perfusate and venous drainage of the brain confirmed strongdirect associations from the variables occlusion length and duration ofexperiment, with moderate indirect associations through changes inoxygen saturation and in hypoxanthine concentration.Conclusions; The analysis supported the causal model as defined:occlusions leading to hypoxia with a rise in hypoxanthine; reperfusionduring intervals between occlusions leading to the acceleratedproduction of xanthine and uric acid and the generation of oxygen freeradicals, which, in turn, are responsible for the rise in lipid peroxidation.
FC3.07 FIBROIDS
FC3.07.01ARTERIAL EMBOLIZATION: A NEW TREATMENT OF UTERINEMYOMATA IN YOUNG WOMENJ.H. Ravina (1), A. Aymard (2), N. Ciraru-Vigneron (2), J. Clerissi (2),J.J. Merland (2)(1) Dept. OB/GYN, Clinique Spontini, Paris, France.(2) Dept. OB/GYN, Faculté St. Louis Lariboiserie, University of Paris
VII, Paris, France.
Objective: Nonsurgical treatment of symptomatic uterine myomata byparticulate arterial embolization in young women.Study and Methods: 59 women, aged 21 to 37 years, with symptomaticuterine myomata in whom surgery was initially planned after havingreceived precise information chose embolization. The size, the numberand the place of myomata were determined by pelvic ultrasound subseraland submucosol pediculed or sessile myomata were excluded.Performed under neurolept and local anesthesia, this interventionalvascular radiology technique is designed to induce necrosis ofmyomatous tissue. After retrograde transfemoral introduction of thecatheter (4 to 5 F), the left and right uterine arteries are successivelycatheterized. Ivalon particles are injected by free flow untildevascularization. It is important to preserve ovarian blood supply.Results: 55 patients were able to be evaluated. Complete resolution ofsymptoms was obtained in 51 cases and 4 failures were observed.Bleeding resolved in all but two patients. A marked reduction in the sizeof the myomata was observed as it was complete (7 cases) or greaterthan 80% in 27 out of 45 cases. The mean volume of single or dominantmyomata was 83 cm3 before embolization versus 9 cm3 afterembolization. 5 pregnancies were observed. The effects of embolizationon fertility are discussed.Conclusion: The very encouraging results of this preliminary series of59 cases (92.5% success) suggest that embolization, a new minimallyinvasive technique, can replace myomectomy in young women.
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FC3.07.02SUCCESSFUL TREATMENT OF UTERINE FIBROIDS WITHINTERSTITIAL LASER PHOTOCOAGULATIONRowan J Connell, National Medical Laser Centre & Department ofObstetrics and Gynaecology, University College London, UKAlasdair Gordon, Department of Obstetrics and Gynaecology,University College London, UK. Alfred Cutner, Department ofObstetrics and Gynaecology, University College London, UKStephen G Bown, National Medical Laser Centre, Department ofSurgery, University College London, UK
Objective: Interstitial laser photocoagulation (ILP) is a technique fordestroying lesions in solid organs, using low power laser energy togently coagulate the target tissue with no surface effects, and thereforeno collateral damage. Our aim was to assess ILP as a minimal accesstechnique of treating symptomatic uterine fibroids.Study Methods: This study was carried out at a London teachingHospital. Twelve women with symptomatic uterine fibroids (3-12 cmdiameter) were recruited. Under laparoscopic control, 1-4 pre-charred,bare tipped 400mm laser fibres from a semiconductor laser (805nm) wereinserted into fibroids through Tuohey needles and activatedsimultaneously, each delivering 3.5W for 300 seconds. Fibroid volumewas measured preoperatively and during follow up with MRI. Thistreatment is in contrast to laser myolysis (which uses powers up to50W).Results: We have MRI follow-up of 17 treated fibroids, with diametersranging from 4.5 cm to 11.5 cm (volumes 41 mls to 668 mls), in 12women with a mean age of 41 years (range 33-48 years). There were nocomplications and recovery was comparable to that after laparoscopy.Fibroid volume as a percentage of the untreated volume was a mean of175% (81-276%) 1 week after ILP; 93% (range 40-144%) at 4 weeks;41% (range 15-58%) at 20 weeks; 23% (range 18-32%) at 32 weeks; and28% (range 20-36%) at 52 weeks, and 18% at 80 months. ILP is safe, itsuccessfully shrinks fibroids and the shrinkage appears to be sustained.Conclusion: ILP is a successful minimal access technique, which can beused to safely treat uterine fibroids.
FC3.07.03HAEMOSTASIS DURING LAPAROSCOPIC SURGERY: ACOMPARATIVE STUDYA.M. Badawy , A. L. Magos*, Departement of OB/GYN, MansouraUniversity, Egypt. *Consultant Obstetrician and Gynaecologist, TheRoyal Free Hospital, London, UK.
The objective of this study is to determine the proper haemostaticmethod to be adopted during laparoscopic surgery. This study comprised213 patients undergoing laparoscopic hysterectomy, oophorectomy andsalpingectomy for various indications whom were randomly allocated tobipolar electrosurgery, Endo GIA 30 stapler or pre-tied sutures asprimary methods of haemostasis. The three study groups were comparedin regard to many details such as operative time, blood loss,postoperative discomfort, bowel function, medications, hospitalisation,resumption of activity and return to work. The study showed that bipolarelectrodesiccation is an effective, rapid, cheap and relatively safehaemostatic technique for almost all laparoscopic procedures. It waseffective in securing large pedicles such as infundibulo-pelvic ligamentand uterine vessels. Bipolar coagulation was also useful for ablation ofendometriosis, for ”bloodless” adhesiolysis and opening the peritonealpouches. Bipolar electrodesiccation was of comparable speed to staplesand significantly more rapid than sutures in most of the procedures.Bipolar coagulators have the versatility to be used in various situationsespecially in emergency conditions and have the capacity to cope withthe developing challenges of endoscopic surgery. We have not hadmajor complications from electrosurgery. We can confidentlyrecommend bipolar electrosurgery as the primary method of haemostasisfor most of laparoscopic procedures. Bipolar electrosurgery should be anessential part of the armamentarium of any endoscopist.
FC3.07.04MINIMALLY INVASIVE PERCUTANEOUS LASER ABLATION OFUTERINE LEIOMYOMAS.Law. P , Dept. Obstetrics & Gynaecology/Interventional MR,[email protected]’s , London, UK. Gedroyc. W, Dept. Interventional MR,St.Mary’s Hospital, London, UK. Regan. L, Academic Dept. Obstetrics& Gynaecology, [email protected]’s , London, UK.
Objectives: To develop an effective and accurate method for thermalablation of uterine fibroids using an open interventional magneticresonance (MR) scanner to guide percutaneous insertion of laser fibresand to monitor the extent of uterine fibroid coagulative necrosis duringtreatment.Study methods: Thirty women with symptomatic fibroids and completedfamilies were recruited from the gynaecology clinic at St. Mary’sHospital, London, to undergo percutaneous laser ablation.Four MR compatible needles were placed percutaneously under MRguidance through the anterior abdominal wall into the centre of thetargeted leiomyoma. Four bare laser fibres were then inserted into theleiomyoma via the outer needle sheaths. A diode laser heat source offive watts per fibre was used with a four-way splitter.Tissue effects ofthermal ablation were monitored throughout the procedure with real-time image processing software. (RTIP)Results: Three months after laser ablation, targeted leiomyoma volumehad decreased by 37.5%,which was maintained at six months. Total menstrual blood loss wasmeasured before and after laser ablation in five women with a meandecrease of 39.2%. Women reported symptomatic improvement afterlaser ablation using a validated gynaecological outcomes questionnaire.Conclusions: Preliminary work with percutaneous laser ablationsuggests that this minimally invasive day case procedure may offer analternative to traditional surgical treatment for symptomatic uterinefibroids.
FC3.07.05MYOMETRIAL RESECTIONS: PRELIMINARY REPORT OF AUTERINE-CONSERVING PROCEDURE FOR MYOHYPERPLASIAI. Babarinsa , M. Oladokun, I. Adewole, Dept. OB/GYN, University ofIbadan, Ibadan, Nigeria.
Introduction: Myohyperplasia in our limited experience, occursdiscretely, or in association with uterine fibroids or adenomyosis. Thedefinite treatment for myohyperplasia is hysterectomy, but the option isnot acceptable to women desirous of continuing childbearing ormenstrual function.Study Method: We evolved this technique following the occasional needto restore uterine form following enuclation of huge myomas. A midlineanterior uterine incision was the only approach. No tourniquet wasapplied or vasopressin used. The myometrium was carefully resected,short of the endometrium and reconstituted with scrosal closure all usingvicryl sutures.Results: Eight women had the procedure over 3 years. Five patients hadmyohyperplastic uteri, three in association with fibroids.Menstrual function was unaltered in 5, one patient had hypomenorrheaand another had irregular cycles. One patient got pregnant and wasdelivered by an elective cesarean section.Conclusion: Myometrial resection is an easily learnt procedure,acceptable to patients and worth considering in settings wherehysterectomy for myohyperplasia has hitherto been the practice.
FC3.07.06EXPERIENCE WITH MYOMECTOMYM. Sammour , H.Sammour, Dept. OB/GYN, Ain-Shams Faculty ofMedicine, Cairo, Egypt.
During the years 1991-1998, 582 myomectomies were carried in aPrivate Institute. The mean age was 32.6 years and the mean parity 2.4.The operation was carried n 26 unmarried females. Cervical myomasconstituted 8.5% broad ligament myomas 2.8%, 3 cases of peritonealmyomeas and the rest were corporeal. Submucous leiomyomas werepresent in 22.6% of the cases while the interstitial myomas were presentin 74.2% and the subserous in 36.5%. Single myoma in 32.5% of caseswhile 2-5 myomas accounted to 47.5% of cases while multiple myomasabove 5, were seen in 20% of our series. During myomectomy the cavity
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was explored in 35% of the cases with reconstruction and preservationof the endometrial surface. Pregnancy rate after myomectomy was thehighest in between the single interstitial and subserous myomas. Thelowest pregnancy rate in between the submucous myomas withexploration and reconstruction of the endometrial cavity. Closure of theserous layer after myomectomy and drainage of the pelvic peritonealcavity for at least 48 hours after the operation have improved our resultsconcerning the postoperative adhesions an the pregnancy outcome. Not asingle case of rupture myomectomy scar was encountered duringsubsequent delivery after myomectomy. The highest pregnancy rateoccurred during the first year after myomectomy.
FC3.07.07DISTRIBUTION OF TWO PROGESTERONE RECEPTORISOFORMS IN UTERINE LEIMYOMALihui Wei , Z. Tu, J. Wang. Dept. GYN, People’s Hospital, BeijingMedical University, Biejing, P.R. China, 100044.
Objectives: Human progesterone receptor(hPR) has two isoforms, hPR-A and hPR-B, and hPR-B has a longer NH2 terminus and functiondifferently from hPR-A. Thus, the relative expression of hPR-B/hPR-Ais likely to be important for the action of progesterone. To investigatethe role of two isoforms in generation and progression of leiomyoma,their distribution and ratio of messenger ribonucleic acid and protein inleiomyoma and myometrium were detected.Methods: Leimyoma and adjacent normal myometrium from 30 uteri,which were excised for leiomyoma, were used for location andquantification of hPR-A and hPR-B protein. Immunohistochemistry andwestern blot were applied respectively. 23 pairs of mRNA out of the 30cases were quantification by RT-PCR.Results: (1)Both hPR-A and hPR-B are nuclear receptors.(2)Concentrations of hPR-(A+B) and hPR-A in leiomyoma were higherthan those in myometrium (P=0.0415, Pa=0.000563). (3)Both isoformsare presented in leiomyoma and myometrium , with a consistentdominance of hPR-B over hPR-A (P=2.97*10-12, P=1.19*10-15).(4)hPR-B to hPR-A ratio is much lower in leiomyoma than that inmyometrium (P=0.0388). (5)More protein expression of hPR-A insecrete stage than that in proliferative stage, not only in leiomyoma butalso in myometrium (P=0.0368, P=0.0236). (6)mRNA of hPR-B andmRNA of hPR-A are both more in leiomyoma than those inmyometrium.Conclusions: Abnormal distribution of hPR isoforms may causemyometrium cell responds to progestin abnormally, that may be onemechanism of leiomyoma generation. hPR-A has a closer relationshipwith leiomyoma than hPR-B do, and may plays an important role inphysiological change of myometrium.
FC3.07.08CONSERVATIVE MANAGEMENT OF FIBROIDS WITH LONG-TERM COMBINATION OF GnRH-a AND LOW DOSE STEROIDSM. Mamopoulos , J.M. Tzafettas, D. Delkos, P.Petropolous, B.Karayiannis, G.Tektsides, G. Kalogeros, N. Klearchou, S. Anapliotis,Dept. OB/GYN, University of Thessaloniki, Thessaloniki, Greece.
GnRH-a have been used for the measurement of estrogen dependentconditions like fibroids, endometriosos, dysfunctional uterine bleedings,endometrial hyperplasias and more recently for advanced stages ofgynecological cancers. This treatment, though has been hampered by theassociated unpleasant climacteric symptoms and its time limitation, dueto the risk of osteoporosis.Objective: The aim of this study was to evaluate the beneficial effect oflong-term use of GnRH-a on the size of a fibroid uterus and to assess theprevention of osteoporosis and the amelioration of the climactericsymptoms with the parallel use of HRT treatment, in view of the factthat complete down regulation of the ovaries is not necessary in suchcases.Study Methods: In a prospective, randomized study, 36 patients (aged 34– 51) with fibroids that required surgical treatment, due to their size orpersistent bleeding, underwent treatment with leuproreline (Elityran,TAKEDA) and Trisequence (Novo-Nordisk) from the 3rd monthonwards and for an indefinite period. Prior to the treatment all patientswere subjected to clinical examination, serum bone metabolism tests andultrasound assessment, repeated every 3 months. Radiologicaldetermination of bone mineral density was repeated every 12 months.
Results: The duration of the treatment so far, has been 16±9 months (7-26). Significant reduction of the uterine size was noticed within threemonths and remained for the rest of the treatment. Except for fivepatients for whom the treatment had to be discontinued due to resistantmenorrhagia, this was well tolerated by the rest. The bone metabolismmarkers, after an initial deterioration around the 3rd month of thetherapy, showed a definite improvement afterwards. The same wasrecorded for the BMD in the lumbar spine. There was no significantchange in the HDL levels.Conclusions: The creation of a well balanced combination treatmentwith GnRH-a and the parallel use of low dose estrogen in the form ofHRT treatment might be a successful alternative to the surgicalmanagement of fibroids and other estrogen dependent conditions,especially in women of relatively younger age or those patients notsuitable for surgical management.
FC3.08 CURRENT TOPICS IN GENERAL GYNECOLOGY
FC3.08.01TISSUE RESPONSE TO THE STOPä DEVICE: A NEW APPROACHTO TRANSCERVICAL STERILIZATIONC.S. Carignan , Stanwood Associates, 392 Stablers Church Road,Parkton, MD USA 21120; T.C. Wright, Dept. OB/GYN Pathology,Columbia University, 630 W 168th St., NY, NY USA 10032; STOPäInvestigator Group, Conceptus, 1021 Howard Ave., San Carlos, CAUSA 94070
Objective: To examine the histological response to the new STOPätranscervical intrafallopian device in a multi-center prehysterectomystudy to evaluate the likelihood of the device remaining in the tube andto support its proposed mechanisms of action: loss of normal tubalarchitecture and occlusion of the tube.Study Methods: The STOPä device was inserted hysteroscopically in50 fallopian tubes of 28 women who were scheduled to undergo ahysterectomy. The women wore the devices from 8-99 days. At the timeof hysterectomy, the fallopian tubes were removed, embedded in methylmethacrylate and sectioned to observe the resulting local tissue responseto the device.Results: All devices that were properly placed remained in the tube. Onhistological examination, acute and chronic inflammatory cells; looseand dense fibrosis; and smooth muscle cells, migrating in between thecoils of the device and the PET fibers, characterize the reaction withproperly placed devices. In women who wore the devices for a longertime, the response is more marked with denser fibrosis, migration ofsmooth muscle cells, and signs of early neovascularization. In all casesthe reaction is limited to the area immediately surrounding the deviceand does not extend past the distal end of the device nor deep into thewall of the tube.Conclusion: The localized tissue response and notable absence of anynormal tubal architecture at the site of implantation is believed tocontribute to the contraceptive effectiveness the STOPä device and tothe long-term anchoring of the device.
FC3.08.02PREGNANCY AFTER FAILED TUBAL STERILIZATION INTEHRAN, IRANA. Mehdizadeh , A. Akbarian, H. Movahedi, E. Shirazi,R. Alaghehbandan, Dept. OB/GYN, Iran University of MedicalSciences, Nyayesh Street, Sattarkhan Avenue, Tehran, Iran
Objectives: Worldwide, tubal sterilization is the most commonly chosenform of contraception by women who have completed their desiredchildbearing. Also this method is accepted by most of married women inIran. Although pregnancy after tubal sterilization is uncommon, it canoccur. This study was carried out to determine the incidence ofpregnancy after tubal sterilization in Tehran, Iran.Study Methods: A register-based retrospective study was conducted inthe teaching hospitals affiliated to Iran University of Medical Sciencesin Tehran during 1992-98. A total of 2000 tubal sterilization wereperformed during the period of study. We entered all informationregarding the number of sterilization failure and type of procedure.Results: The patients' age ranged from 22 to 49 years (mean, 33.8).Their parity ranged from 1 to 14 (mean, 4.7). Of 2000 patients 1900(95%) had tubal sterilization by laparatomy and 100 (5%) by
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laparoscopy. The overall sterilization failure rate was 0.45% (9/2000)after 7 to 31 months of sterilization (mean, 9.6). There were 7 (0.35%)surgical failures (those who were pregnant after the procedure) and 2(0.1%) administrative failures (those who were pregnant at the time ofsurgical procedure). All 9 women had intra-uterine pregnancy and noectopic pregnancy was found. The sterilization failure rate was 3%(3/100) for laparoscopic methods and 0.3% (6/1900) for laparatomicsterilization. The pregnancy rate was 0.6% (4/663) in the group who hadhad a pregnancy terminated with their sterilization while 0.3% (5/1337)among those who their sterilization and termination of pregnancy wereseparately performed.Conclusions: Our study showed that tubal sterilization failure rate to belower comparing to the most previous reports. Our failure rate wasmainly attributed to the intra-uterine pregnancies. It should be stressedthat preoperative pregnancy testing to be done before tubal sterilization.The sterilization failure rate in laparoscopic methods was higher thannon-laparoscopic sterilization. Sterilization failure highly associatedwith combination of sterilization and termination of pregnancy.
FC3.08.03USE OF PLASTIC SURGICAL TECHNIQUES INRECONSTRUCTIVE GYNECOLOGYV. Chitale , M. Chitale, Chitale Clinic, Solapur, Maharashtra, India.
Objectives: There are many problems in day to day Ob/Gyn practice thatcan be better solved by using plastic and reconstructive surgery.Study Methods:1) Dehisced episiotomy wound was treated by doing split thickness
skin grafting by exposure method.2) Web contracture of the fourchette was treated by Z plasty.3) Transverse vaginal septum was treated by ‘Double cross plasty’.4) For congenital absence of vagina treated by lining the cavity by split
thickness skin graft: the use of a special mould (Condom-U-foam-catheter mould) will be emphasized.
Results: Results were satisfactory.Conclusions: Plastic and reconstructive surgery has an importantcontribution to offer for difficult Ob/Gyn problems.
FC3.08.04SELF-ADMINISTRATION OF CYCLOFEM® ONCE-A-MONTH-INJECTABLE CONTRACEPTIVE TROUGHOUT UNIJECT®DEVICE IN MEXICAN WOMAN.A. Morales-del Olmo , J.Garza-Flores, G.Perez-Palacios, Ministry ofHealth, Homero 213, DF, Mexico, 11750.
Once-a-month injectable contraceptives are well accepted in Mexico;since its incorporation to the National Family Planning Program in 1994,Cyclofem® (medroxiprogesterone acetate 25 mg and estradiol cypionate5 mg) formulation, has demonstrated its high efficacy, safety andacceptability. Nowadays, one of each five new acceptors of anycontraceptive method, select this formulation in Mexico.Objectives. To compare acceptability and continuation rates of monthlyinjectable contraceptive Cyclofem® in the new prefilled injectiondisposal Uniject®.Study methods. A multicentred, prospective and comparative clinicaltrial was conducted by governmental health institutions in Mexico.Seven hundred and eighty healthy women were randomly allocated intwo comparative groups; group I, included women who attend the cliniconce-a-month to receive contraceptive via Uniject® by the serviceprovider; and group II, included women who were trained in self-administration and were provided with 6 doses and instructed to applythem monthly at their home.Results. After life-table data-analysis, the study confirmed the proposedhypothesis that continuation rates are significative higher in group II,where injectable self-administration was performed. Furthermore,autoaplication was preferred by participating women.Conclusions. The high acceptability and safety of injectablecontraceptives, was confirmed demonstrating the high compliance ofparenteral administration. This study provided the elements toincorporate the new injection prefilled disposal to the contraceptiveoptions available in Mexico.
FC3.08.05BONE MINERAL CONTENT AFTER A 12 MONTH-PERIODTREATMENT WITH A CONTINUOUS COMBINED HORMONALREPLACEMENT THERAPY.Sauerbronn, A.V.D. ; Fonseca, AM; Bagnoli, VR; Assis, JS; Guerra,DMM; Halbe, HW & Pinotti, JÁ. Dept. Ob/Gyn, São Paulo UniversityMedical School, São Paulo, Brazil
Objectives: The aim of this study was to evaluate the bone mass as wellas clinical effects of a continuous combined HRT schema on climactericwomen.Study Methods: 20 postmenopausal women aged 45 – 58 years, withtime of menopause varying from 14 to 120 months, received apreparation with 28 tablets containing each one, 2 mg of estradiol and 1mg of noretisterone acetate, during 12 consecutive months. Weevaluated climacteric symptoms, Quetelet Index, blood pressure, andbone densitometry.Results: There was a good control of climacteric symptoms duringtreatment; the highest rate of irregular bleeding was 25% at cycles 5 and6; at the end of treatment, 85% of patients were amenorrheic, QueteletIndex (Kg/m2) remained unchanged (baseline = 26.56 ± 3.97; 12 months= 26.74 ± 4.26 – Mean ± SD); bone densitometry (standard deviation)remained unchanged at lumbar spine (baseline =–1,54±1,38; 12 months=–1,57±1,12) and decreased at femoral neck (baseline =–0,68±1,43; 12months =–0,83±1,40); blood pressure (mmHg) remained unchanged(systolic / diastolic: baseline = 118 ± 10.56 / 75.5 ± 8.25; 12 months =123.5 ± 17.85 / 77.5 ± 9.66).Conclusions: The continuous combined HRT preparation evaluatedpresented both good cycle and climacteric symptoms control. Mineralbone mass was maintained stable at lumbar spine, but decreased atfemoral neck. General tolerability was good, and Quetelet Index andblood pressure remained within baseline rates.
FC3.08.06INCIDENCE OF VAULT HAEMATOMA AFTER VAGINALHYSTERECTOMY AND ITS CORRELATION WITH POSTOPERATIVE MORBIDITYA.H. Khosla , J. Sen, S. Kumari, Dept. OB/GYN and Radiology, PGMIS,Rohtak, Haryana, India.
Objectives: To study the incidence of vault haematoma and itsrelationship with postoperative pyrexia, drop-in hemoglobin andpostoperative stay in patients undergoing vaginal hysterectomy andpelvic floor repair for uterovaginal prolapse.Study Methods: Prospective study of 72 patients undergoing vaginalhysterectomy with repair in one unit of Dept. OB/GYN, PGMIS,Rohtak, India from Jan. – Dec 1998. Pelvic peritoneum and vault wereclosed and all patients received prophylactic antibiotics. Transabdominaland transvaginal ultrasonography was done for vault haematoma onpostoperative day 3 or 4. Routine postoperative monitoring was done bystaff blinded to the ultrasound findings. Tests for significance done werec2 and two sample T-test.Results: Four (5.55%) of the 72 patients had a vault haematoma (Group1). Of these, 2 (50%) had low grade pyrexia. Of the 68 patients with novault haematoma (Group II), 6 (8.82%) had low grade pyrexia. Themean drop in hemoglobin was 1.33 grams/dl in group I and 1.43grams/dl in group II. The mean hospital stay was 8.4 days in group I and10.5 days in group II.Conclusions: The incidence of vault haematoma was 5.55% in this studycompared to 25% (Thomson et al) and 95% (Kuhn et al) in other studies.There was a significant increase in low grade pyrexia but no statisticallysignificant drop in hemoglobin or prolonged hospital stay in thesepatients. Ultrasound detection of vault haematoma does not add to thepostoperative care of patients of uterovaginal prolapse where all pediclescan be extraperitonealized during vaginal hysterectomy.
FC3.08.07STAGE TREATMENT OF PATIENTS WITH BENIGN EPITHELIALTUMORS OF OVARIES (BETO)V. Nagornaya , V. Marichereda, Dept. OB/GYN, Odessa MedicalUniversity, Odessa, Ukraine.
Objectives: To reveal the optimal volume of operation and necessity ofpost-operative treatment of patients with BETO based on the analysis of
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function of the hypothalamic-pituitary-ovarian system and the system ofproteolyctic enzymes.Study Methods: Radioimmune assay, immunoenzyme (FSG, LG, PRL,estradiol, progesterone), biochemical (acid, alkaline proteases, theirinhibitors) methods.Results: For 467 women of 17 – 40 years of age the level of hormonesand enzymes was determined in peripheral blood and enzymes in tissuesof ovaries before the operation in the 1st three months, and 1,2,3 andmore years postoperatively after BETO removal, performed asenucleation of tumor, resection or removal of the ovary. Three versionsof a hormonal dysfunction, rising of protease level, except elastase, anddecrease of inhibitor level have been revealed. For many patients thesedysfunctions are maintained after the operation and are determined bythe scope of the performed operation. In 19.27% of patients, tumors arerecurrent, in 58.24% these are benign tumors of uterus, mammary gland.For their prevention corrective therapy was conducted postoperatively.Within 4 years of the follow-up, recurrence of tumors has not beennoticed.Conclusions: The treatment of the patients with BETO should be done in2 stages. Stage I: operation at optimal scope (tumor enucleating), StageII: corrective hormonal and enzyme therapy.
FC3.08.08OUTCOME OF PREGNANCIES ASSOCIATED WITHINTRAUTERINE CONTRACEPTIVE DEVICE.EXPERIENCE FROM THE THIRD WORLDA. Ashmag , B. Ahmed, H Fawzi, Sudan Fertility Care Association,Police Hospital, Dept. OB/GYN, Khartoum, Sudan
Between January 1985 and January 1991, 200 women aged 18-38 yearsold were fitted with Copper T intrauterine device (I.U.C.D.). Insertion ofthe I.U.C.D. was performed immediately after menstruation by theauthor and a trained midwife. The women were instructed to self-checkthe I.U.C.D. tail after each menstrual period. All the women wereexamined after six weeks and were followed-up every six months.During this period, 150 women were lost to follow-up and 37 accidentalpregnancies occurred (Cumulative net pregnancy of 2 per 100 women).Thirty-five pregnancies were intrauterine and two were ectopic. Allwomen with intrauterine pregnancies elected to continue with theirunplanned pregnancies, as termination of pregnancy is not sociallyacceptable. Most of the accidental pregnancies occurred during the 18months of use. The I.U.C.D. was extracted during the pregnancy in onlytwo women. The incidence of spontaneous abortion was doubled whenthe I.U.C.D remained in utero. The chance of preterm birth wasincreased. There were no recognizable congenital anomalies detected inthis series.
FC3.08.09POSTMENOPAUSAL OSTEOPOROSIS – CURRENT TRENDS INDIAGNOSIS AND MANAGEMENTK. Mukherjee (1), G. Ganguli (1), A. Tripathi (1), K.D. Tripathi (2)(1) Dept. OB/GYN, MLN Medical College, Allahabad, U.P., India.(2) Dept. Orthopaedics, MLN Medical College, Allahabad, U.P., India
Objectives: The aim of the study was to diagnose the postmenopausalosteoporosis and to evaluate the role of alendronate & Vit D3 metabolitein osteoporosis management.Study Methods: One hundred and fifty postmenopausal womenattending out patient department of SRN Hospital, MLN MedicalCollege, Allahabad, India were included in this study. Bone MarrowDensity was measured by Dual Energy X-ray Absorptiometry (DEXA).The women who have BMD at least below mean for adults wererandomised to oral administration of alendronate (10mg/day), Calcitriol(0.25ug twice daily) and plain calcium (placebo) (500mg twice daily)and followed up by measurement of bone marrow density at six monthintervals up to two years.Results: In our study group only 9.33% of the women were found to behaving normal bone marrow density. 40% were in osteopenic range,33.32% were osteoporatic and 13.33% were severely osteoporotic. BMDwas increased by 3.6% and 1.8% in alendronate treated and calcitrioltreated groups respectively at 2 years. The safety and tolerability of bothwere comparable with those of the placebo.Conclusion: Dual Energy X-ray Absorptiometry is a sensitive andconvenient method to diagnose postmenopausal osteoporosis.
Management with alendronate and calcitriol progressively increasesbone mass and is generally a well tolerated treatment for osteoporosis inpostmenopausal women.
FC3.09 CURRENT TOPICS IN GYNECOLOGY
FC3.09.01CLINICAL TRIAL OF IMMUNOTHERAPY WITH PATERNALMONONUCLEAR CELLS FOR UNEXPLAINED RECURRENTMISCARRIAGEF. A. Saad , A. Al-Hilali*, Department of Obstetrics and Gynecology andDepartment of Laboratory and Blood Bank*, Hamad MedicalCorporation, Doha, Qatar.
O bj e c ti v e s : T he p ur p os e o f th is s t ud y w a s t o e va l ua te t h e e f f e c t of i m m un ot h e r a p y w it h p a t e r n a l l e u k oc yt e s f o r t he t r e a tm e n t o f u ne xp la i ne dr e c ur r e n t m i s c a r r ia g e .S tu dy M e th od s : D u r i n g th e p e r io d f r o m D e c e m b e r 1 9 94 t o J a n ua r y 19 98 ,w e im m u n iz e d 86 w om e n w i t h > 2 m is c a r r i a g e s , w it h a bo u t 0.5x 1 09
p a t e r na l m on o nu c l e a r c e l l s . A no t he r 6 3 r e c u r r e nt m i s c a r r ie r s , w ho c on c e iv e d du r in g th e s a m e p e r io d , w e r e us e d a s c o nt r o ls .Re s ul ts : T he r e w a s n o ov e r a ll p o s i ti v e e f f e c t of pa te r n a l le u ko c y te t r a ns f u s io n. H o w e ve r , a m o ng w om e n w i t h > 3 m is c a r r i a g e s , t he s u c c e s s r a t e w a s s ig n if ic a n t ly h i gh e r i n t he tr e a tm e nt g r ou p ( p < 0.01 ) c om pa r e d t o t he c on t r o ls ( 8 3.9% ve r s u s 51 .7 % ) . O n t he o t he r h a n d, i n t he s u bg r o u p of w om e n w i th h i s t or y o f on l y tw o m is c a r r i a g e s , t he s u c c e s s r a t e w a s s ig ni f i c a n tl y h ig he r i n t he c on t r o l g r o up ( p < 0 .0 5 ) th a n in t h e s t ud y g r o u p.W e f o un d s ig n if ic a n t ly h i gh e r s u c c e s s r a t e ( 90 % ) in t he gr ou p i m m un i z e dd ur in g p r e gn a nc y c o m pa r e d t o ( 6 0 % ) i n t he g r ou p i m m un iz e d be f or e p r e gn a n c y ( p < 0.05 ) .Con c l us i on s : A l lo im m un iz a ti on w i th p a te r n a l le uk o c y te s s ho w e d a p os it iv e e f f e c t i n a s ub s e t o f w om e n w i th > 3 m is c a r r i a g e s . T he th e r a pe ut ic e f f e c t f ou nd in t hi s s tu d y c o m p a r e d w it h ot h e r s t ud ie s m a y r e ly o n t he u s e o f a gr e a t e r do s e o f l e u k oc yt e s in je c te d. T h is t r e a tm e n t s ho u ld n ot be o f f e r e d to p a ti e n ts w i th hi s t or y o f o nl y tw o m is c a r r i a g e s a n d p r e f e r a b ly it s ho ul d b e pe r f o r m e d a s e a r l y a s po s s i bl e du r in g p r e gn a n c y.
FC3.09.02HOW UNIVERSAL ARE MEDICAL ETHICS AND LAW? ANEXAMPLE IN THE PERMISSIBILITY OF SURROGACYS.I.M.F. Ismail , Dept. OB/GYN, Singleton Hospital, Swansea, UK
Objectives: This study evaluated whether a single code of medical ethicsand law could be applied to all countries worldwide or a flexibleapproach is needed to match varied backgrounds. It made this evaluationin relation to surrogacy, upon which the position of Western and Muslimcounties vary considerably, as an illustration of how best to handlemoral differences as part of international co-operation in health care.Methodology: The study relied on published literature and theoreticalconsiderations. It considered rationality, relativism as well as toleranceas approaches to reconcile both stands on surrogacy. The study alsoexplored legal grounds for adaptation to local factors that vary betweensocieties and looked at different legal position on surrogacy.Results: Moral disputes in health care are subjective, such that looking atthe rationale of different stands on surrogacy or evaluating them inrelation to local features can not be made in an objective way andtolerance of varied views is preferred. This might have to be restrainedwhenever human suffering ensues, though it is difficult to reach anagreed definition of such suffering. Likewise, a single legal code isunlikely to suit all societies and law is better tailored to the place whereit is to be applied.Conclusions: It is difficult to agree on a single code of medical ethicsand law as moral diversity will necessitate a degree of flexibility.
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FC3.09.03HERPES SIMPLEX VIRUS IN INFERTILE COUPLES: DNASEQUENCE OF PCR PRODUCTN. El Borai (1), M. Araki (2), E. Naumova (3), M. Inoue (4), S. Kato (5),K. Yamamura (2), M. Yamamura (1)1) Dept. Mol Life Sc., Tokai University School of Medicine, Isehara,
Kanagawa, Japan.2) Gene Tehnology Center, Kumamoto University, Kumamoto, Japan.3) Tufts university School of Medicine, Boston, MA, USA.4) Sanno Hospital, Tokyo, Japan.5) Dept. PED, Tokai University School of Medicine, Isehara,
Kanagawa, Japan.
Objectives: To confirm the presence of the herpes simplex virus DNAdetected in semen and menstrual blood of infertile couples bysequencing the PCR (polymerase chain reaction) product.Study Methods: A specifically designed PCR assay with nested primerswas used to test (1) the menstrual blood of 25 infertile and 4 fertilewomen, (2) semen from 157 infertile and 25 fertile men, and (3) 50 cordblood samples as control.The PCR product of positive samples was sequenced.Results: The control virus sample herpes simplex 1 Tomioka strain gavepositive results with both the first PCR reaction and the second PCRusing the nested primers. The second PCR reaction with nested primersallowed the detection of low titers of virus, in 48% menstrual bloodsamples and 24% semen samples of infertile subjects. None of thesamples form fertile subjects or cord blood were positive. The sequenceof the PCR product of the infertile samples were the same as thepublished sequence of HSV-1, but differed form the HSV-1 Tomiokastrain.Conclusions: The PCR product of semen and menstrual blood sampleswere the same as the published sequence of herpes virus 1 but differentfrom the control virus Tomioka strain. The results confirm theimportance of excluding herpes virus as the reason for infertility beforemore specialized treatment is undertaken.
FC3.09.04HRT FOLLOWING HYSTERECTOMYD.K. Chakrabortti , Dept. OB/GYN, KMC Research Institute, Calcutta,India.
Objectives: The aim of this study is to evaluate the rationality ofundertaking hormone replacement therapy (HRT) to women followingsurgical menopause. The sudden drop of endogenous estrogen level isaccompanied by menopausal symptoms resolved to a great extent byHRT.Study Methods: The study comprises interviewing women pre-hysterectomy and 1 to 5 years after operation with respect to theirexperiences while using HRT, adherence to therapy, perceptions ofeffectiveness in relieving symptoms and appearance of new problems.The type of hormone prescribed, changes in serum FSH, E2, Lipidprofile, breast tenderness/lump and vaginal cytohormonal changesevaluated. This is a prospective study of 200 cases of abdominalhysterectomy for non-malignant indications among pre-menopausals.Results: Out of 200 cases 178 (89%) required HRT within 3 months ofoperation. In 22 cases (11%) hormone profile remained normal till 1year mostly where ovaries preserved.Conclusions: HRT is recommended for most women followinghysterectomy even when ovaries are retained. Study also revealed loss ofovarian hormonal functions in the majority (60%) within 3 months to 1year where ovaries retained during operation.
FC3.09.05BARTHAKUR'S THEORY OF WAITING: GENDER CHOICE BYNATURAL INSEMINATION1. Geeta Shroff OB/GYN, Nutech Mediworld (Ferti, Clinic), New Delhi-India. 2. Vera Hingorani, AIIMS & Batra Hospital MRC, New Delhi,India
Objectives: To clinically test the application of "Barthakur's Theory ofWaiting", gender choice could be made through natural insemination.The speedier short-lived Y-sperms would fertilise the ovum if the first ofthe cycle coitus took place when an ovum was waiting in the Ampulla ofthe Fallopian Tube (AFT), otherwise, if it had taken place hours/days
earlier to the arrival of an ovum in the AFT, the short-lived Y-spermswould perish, meanwhile, the waiting show-moving longer-lived X-sperms would fertilise the ovum on its arrival.A total of 385 couples - 375 wanting a son each, and 10 daughters, wereregistered. Baring two, others wanted a child of the opposite sex to theone(s) they had. BBT & U/S monitoring of follicle growth data was usedto advise the first coitus of the cycle for conceiving a child.Results: 200 couples have conceived a child of their choice. 6 aborted (6sex was not ascertained). Excluding -6- abortions, the success rate was98% for a child of the desiteed sex.Conclusions: The "Barthakur's Theory of Waiting" needs seriousconsideration world wide. In the countries where gender preferences arestrong, it will help to curb gender linked forticide, infanticide,population growth and improve mother & child health.
FC3.09.06HORMONE REPLACEMENT THERAPY (HRT) AND BREASTDISEASEPereira, PAA ; Fonseca, AM; Pasqualotto, EB; Bagnoli, VR; Penteado,SRL; Ramos, LO & Chnee, LH. Dept. Ob/Gyn, São Paulo UniversityMedical School, São Paulo, Brazil.
Objective: The objective was to evaluate the prevalence of breastdiseases in menopausal women submitted to hormone replacementtherapy (HRT).Methods: A total of 47 women who had abnormalities on mammographyduring their follow-up were included in this retrospective study.Patients’ ages ranged from 41 to 70 years (mean age of 57,8 years).Patients were divided into 2 groups: Group I (n = 23) patients whoseprevious mammography was normal, and Group II (n = 24) patientswhose previous mammography showed benign changes.Results: In group I we observed 9 cases of microcalcifications, 12 casesof breast node, 1 case of spike lesion and 1 case of undeterminedmammography finding. No malignancies were found in this group. Themean period of HRT administration in this group was 4,46 years. HRTdiscontinuation occurred in 6 cases. In group II we observed: a) 10patients had benign nodes beforehand with regression of the lesion in 3case, and no changes were found in 7 cases; b) 10 patients had initiallyfibrocystic disease. One of them had breast cancer, 1 node with atypicalproliferation, 2 cases with sparse microcalcifications, 5 normal and 1case with benign node; c) 2 patients had microcalcifications beforehandwithout changes during the follow-up; d) 2 patients had spike nodesbeforehand with the diagnosis of breast cancer in 1. In group IIdiscontinuation of treatment occurred in 7 cases and the mean period ofHRT was 4,4 years.Conclusions: In the group that received HRT and had initial normalmammography only benign findings were observed in the follow-up. Inthe group with benign lesions from the beginning, we observed 2 casesof cancer, 1 of atypical proliferation.
FC3.09.07THE PREMENSTRUAL SYNDROME AND ITS CLINIC INDIFFERENT AGE GROUPS OF WOMENShevchuk T.V ., Bodryagova O.I., Regeda S.I., Zakharenko N.F.Institute of Pediatrics, Obstetrics and Gyneacology, Kiev, Ukraine
Objective: The aim of study was to follow the peculiarities of PMS indifferent age groups.Study Methods: Three groups of patients were recruited into the study:28 women of 18-29 years (I group), 32 women of 30-35 years (II group)and 30 women of 36-45 years (III group). The study was carried out onthe base of complaints, clinical and ultrasonic investigations.We estimated 47 clinical symptoms of PMS in the lutein phase of cyclewith the Moos R.H. menstrual-distress questionnaire. Clinical gradationof different forms of PMS (neuropsychic, edematous, cephalalgic andcrisis) was based on Smetnik classification. According to the number ofsymptoms, their intensity and duration we determined the forms of PMS(light or severe), its stage (compensated, subcompensated,decompensated) based on gradation of Kuznetzova S.Results: The symptoms of PMS appeared 5,8±2,4 days beforemenstruation (I group), 6,1±3,0 days (II group), 7,3±4,7 days (III group)p<0,05. The most prolonged illness was reported in neuropsychic andedematous forms (12,4±3,8 and 9,8±3,5 days accordingly) of PMS. Theassessment of age peculiarities of PMS revealed that in early
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reproductive period (I group) prevailed the cephalalgic form (46,4%), inthe active reproductive age (II group) - neuro-psychic form (68,9%) andin the late reproductive period (III group) - neuropsychic (40%) andcrisis (30,05%) forms.Conclusions: The results of study have revealed the clinical peculiaritiesof PMS in different age group. It should be considered for thedevelopment of the individual program of treatment of PMS.
FC3.10 MATERNAL MEDICAL DISORDERS
FC3.10.01PREGNANCY IN SICKLE CELL DISEASEK. Al-Mulhim , King Farad Hospital, Al-Hofuf, Saudi Arabia.
Objectives: Aims of the study were to assess risk involved in pregnancyamong sickle cell disease patients (SCD) in Al-Hassa region of SaudiArabia.Study Methods: Retrospectively records of 64 SCD, 54 sickle cell trait(SCT) patient admitted during 1997-98 were analyzed and cross-matched with 84 controls admitted during the same period. Criteria forSCD was based on absence of HbA1, HbS more than 40 percent andpresence of HbA2 and HbF. Age, gravidity, parity, birth weight of fetus,mode of delivery, sickle cell crisis, blood transfusion and HbSpercentage were taken into consideration. Statistical analysis was doneusing and Epi-Info cartridge.Results: Mean age in SCD, SCT and controls was 26.3, 26.8, 27.6 yearsrespectively. Mean gravidity of SCD group was 4 which wassignificantly (p<0.05) lower than 5.1, 5.2 in SCT and control groups.Mean birth weight of fetus in SCD was 2856 grams, which wassignificantly (p<0.001) lower than in SCT controls (3168 & 3268 gms.).Cesarean section was required by 25.0% of SCD patients as compared to93% in SCT patients. Blood transfusion was required in 43.8% of SCDpatients. There was no maternal mortality and only one abortion in SCDpatients. Mean HbF concentration in SCD patients was 25.6%.Conclusions: High HbF concentration could be responsible for mildmanifestation of SCD and better outcome of pregnancy among SCDpatients in Eastern region of Saudi Arabia.
FC3.10.02HYPEREMESIS GRAVIDARUM – RELATIONSHIP BETWEENSEVERITY OF VOMITING AND THYROID FUNCTIONR.K.H. Chin , K.Y. Lee, C.Y. Li, Department of Obstetrics andGynaecology, Caritas Medical Centre and Princess Margaret Hospital,Hong Kong, China
Objective: To study the association between thyroid function andseverity of nausea and vomiting in patients with hyperemesisgravidarumStudy Methods: The association between abnormal thyroid function andhyperemesis gravidarum has been well-documented (1). In about a thirdof hyperemic patients both total thyroxine and free thyroxine levels wereraised (2). Whether thyroxine levels were related to the severity ofnausea and vomiting, however, has not been adequately studied. A majorissue in the interpretation of previous studies has been the use ofdifferent methods to qualify and quantify nausea, vomiting and relatedsymptoms. In the present study, the Rhodes Inventory (3) which isrecommended by The International Consensus on Standards forStudying the Efficacy of Pharmacological and Non PharmacologicalTherapies for Nausea and Vomiting of Pregnancy was used as a standardfor the study of this condition. On admission, hyperemic patients filledin the Rhodes Inventory questionnaire and thyroid function tests werealso performed. Correlation between thyroxine levels and the RhodesInventory was performed.Results: Twenty-six patients admitted to hospital with hyperemesisgravidarum between December 1998 and September 1999 were studied.They aged between 19 – 38 (mean 27). All patients were eitherexpecting their first or second baby. The nausea and vomiting scoreswere from 8 to 34 and do not correlate with the thyroxine levels.Conclusions: There was no correlation between the severity of nauseaand vomiting and thyroxine levels in patients with hyperemesisgravidarum.References :
1. Bouillon R., Naesens M., van Assche F.A. et al. Thyroid function inpatients with hyperemesis gravidarum. Am J Obstet Gynecol 1982; 143:922-9262. R K H Chin and T T H Lao. Thyroxine concentration and outcome ofhyperemetic pregnancies. Br J Obstet Gynecol 1988; 95: 507-5093. Rhodes VA, McDanial RW. The Index of Nausea, Vomiting andRetching: a new format of the Index of Nausea and Vomiting. OncologyNursing Forum 1999; 26(5): 88994.
FC3.10.03ASSOCIATION BETWEEN LOW BIRTH WEIGHT ANDMATERNAL ANEMIA IN VENEZUELAN PREGNANT WOMENG. Peña (1), G. Comunián (2), A. Martí-Peña (1),(1) Clinical Epidemiology Unit, Universidad de Carabobo, Miami, FL,
USA.(2) Ciudad Hospitalaria “Dr. Enrique Tejera,” Valencia, Venezuela.
Background: The anemia is main hematological complication duringpregnancy. Maternal anemia has been considered as a risk factor for lowbirth weight (LBW). Studies regarding association between maternalanemia and LBW are not known in Valencia, Venezuela.Objective: To determine the association and its magnitude betweenLBW and anemia in pregnant women in their third trimester and atlabor.Design: An incident case-control study was conducted using 2 controlsper case.Setting: Maternidad “Dr. JL Facchín de Boni,” Ciudad Hospitalaria “Dr.Enrique Tejera.” A tertiary hospital in Valencia, Venezuela.Patients: A total of 543 pregnant women (Cases: 181, controls: 342)Main Outcome Measure: Association between LBW (<2500 g, WHO)and maternal anemia (<11g/L, WHO) (Odd Ratio –OR-).Methods: Logistic regression was used to evaluate the data. Likelihoodratio test was done for model comparison.Results: Maternal anemia was found to be significantly associated withLBW (OR: 2.2, 95% CI = 1.5 to 3.2, P =0.001) after adjusting for age,placental abruption and premature rupture membranes.Conclusion: In Valencia, Venezuela, maternal anemia at the end of thethird trimester of pregnancy, at labor, was found to be associated with anincreased risk of LBW.
FC3.10.04TREATMENT OF IRON–DEFICIENCY ANEMIA IN PREGNANCYUSING IRON – PROTEINSUCCINYLATE SUPPLEMENTATION.S.Sifakis, E.Angelakis, E.Papadopoulou, E.Vardaki, E.Kolibianakis,Y.Koumantaki, E.Koumantakis , Dept of Obstetrics and Gynaecology,University of Crete, Heraklion, Crete, Greece.
Objectives: Approximately 75% of all anemias diagnosed duringpregnancy are due to iron deficiency. The purpose of this study was toevaluate the effectiveness of proteinsuccinylate iron supplementation inthe treatment of iron – deficiency anemia during pregnancy by assessingthe alterations of various clinical and hematological parameters.Study Methods: 100 pregnant women with confirmed iron-deficiencyanemia were studied. Hemoglobin levels below 11.5, 10.9 and 10.3 g/dlwere used for anemia diagnosis during 1st, 2nd and 3rd trimester ofpregnancy respectively. The determination of anemia type as well asdifferential diagnosis was performed by Hb electrophoresis,determination of MCV MCH, MCHC, reticulocyte count and plasmalevels of iron, ferritin and vitamin B12 in some of the cases. A dosage of1600-mg iron proteinsuccinylate per os was administered to each womandaily. Follow up included determination of various clinical andhematological parameters every two months. T-test for paired sampleswas used for statistical analysisResults: The iron supplementation improved the levels of Hb, Hct,MCV, MCH, and serum ferritin (p<0.05) as well as fatigue, lethargy,tachycardia, tachypnea, pallor, glossitis and cheilitis related to anemia.No adverse or side effects other than constipation and epigastric pain (insome cases) were observed. There was no statistical significant changein the levels of WBCs, PLTs, RBCs, and MCHC.Conclusions: The proteinsuccinylate iron is an effective, low cost,treatment of iron – deficiency anemia during pregnancy with minimaladverse or side effects. In addition it may contribute to the prevention ofsevere anemia in pregnancy which may lead to severe growth retardationas well as fetal prematurity.
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FC3.10.05PREGNANCY AND HEREDITARY SPHEROCYTOSIS – A REPORTON TWO CASEST. Tantanasis , P. Tampakoudis, K. Tsatalas, E. Vlachaki, D. Kelartzis, S.Mantalenakis, 1st Dept. OB/GYN, Aristotelian University ofThessaloniki, Greece.
Objectives: As there is little information with regard to pregnancycomplicated by hereditary spherocytosis (HS) we report on 2 patientswith this disorder who had a total of 5 pregnancies.Study Methods: Particularly, patient I suffered from HS since earlychildhood; the course of HS was mild therefore no splenectomy wascarried out. In her history, she had two 1st trimester abortions; lastly shepresented with twin gestation complicated by hemolytic crises. At week34 cesarean section was performed due to premature rupture ofmembranes; both newborns were clinically normal. Patient II underwentat age 10 a splenectomy. Her course was thereafter uneventful. She hadtwo completely normal pregnancies and she delivered at term givingbirth to two normal infants.Conclusions: Apart from the afore-mentioned report, it was a furthertarget of the current article to deal with problems related to thecoincidence between HS and pregnancy; therefore an overall review ofthe literature has been incorporated.
FC3.10.06ADMINISTRATION OF RECOMBINANT HUMANERYTHROPOIETIN (rHu-Epo) IN ANEMIC PREGNANT WOMENE. Cardamakis , T. Hatzis, V. Tsapanos, N. Linardos, H. Mantouvalos, V.Tzingounis, Dept. OB/GYN, University of Patras, Rio, “Mitera”Maternity and Surgical Center, Athens, Greece.
Objectives: The purpose of the study was to determine the effectivenessand safety of the rHu-Epo (Eprex, Janssen-Cilag) administration inanemic pregnant women.Study Methods: Pregnant women with Ht levels £30% at the 36th weekof pregnancy were divided in two comparable groups (for age, Ht levelsbefore delivery, and gestational age at delivery, p>0.1. Group A (n=85)received 200 iu/kgr rHu-Epo s.c. twice weekly 1600 mg iron proteinsuccinylate per os (Legofer, Elpen) daily and Group B (n=80) receivedonly the same dosage of iron. Hb and Ht levels were evaluated weekly,blood pressure daily. Moreover blood analysis was performed at theneonate blood units that were transfused, fatigue, weakness, headache,nursing problems, postpartum complication and side effects were record.Results:Table I. Ht Levels between the groups before and after treatment.
Eprex+Iron (Group) Iron (Group B) P
Ht 36th week 28.48+5.8 (26.2+29.6) 28.94.4.8 (26.8-29.9) 0.545
Ht 38th week 30.67+7.41 (29.7-33) 27.4+5.95 (24-29.7) <0.001
Ht at Delivery 33.54+2.85 (30-36) 30.10+3.43 (27-34) <0.001
Table II. Clinical Conditions during PuerperiumEprex+Iron Iron P
Anemia (Ht£28%)Transfusions
0 10 <0.001
Fatigue 0 11 <0.001Weakness 1 16 <0.001Headache 4 12 0.021Nursing Problems 3 13 0.004
Conclusions: Subcutaneous erythropoetin administration is rapidlyeffective in decreasing the risk of transfusions increasing the Ht levelsand decrease the incidence of major maternal problems associated withanemia during puerperium.
FC3.10.07EVALUATION OF THE EFFECT OF IM INJECTABLE IRON(BOLUS DOSE) IN ANAEMIC PREGNANT PATIENTSV. Agrawal , R. Agrawal, Dept. OB/GYN, G. R. Medical, Gwalior,India.
Objectives: Anemia is a major cause of maternal mortality in India tilltoday. The aim of the study is to investigate the effect and complicationsof IM perenteral iron (3 amp daily) in anemic pregnant patients.Study Methods: 150 patients were included in this study. Each patientwas investigated for degree, type and cause of anemia. Inj. Sorbital citric
acid complex (Inj-Jectofer) was given in first 50 cases 5 amps daily weregiven on tow consecutive days, but because of too much side affects inrest of 100 cases 3 amp IM was given daily. Side effect were evaluated.Results: Maternal mortality due to anemia for past 5 years was 30.8%,27.6%, 57.1%, 6%, 12.7% respectively. 16.6%, 73.3%, 10% weresuffering from severe, moderate and mild anemia respectively, 80%patients reported to hospital in 3rd trimester. Severity is more inmultigravida, illiterate, lower socioeconomic group. Worm infestation isa major causative fator – 87.9%. Malaria was present in 21.2%, 61.3%were suffering from hypochromic anemia. 100 cases who received 3amps of Jectofer daily had minimal side effects like dry retching whichwas insignificant and required no specific treatment. Nausea andvomiting observed in later does only. Improvement seen on follow upwas remarkable and encouraging with the average Hb% rise 4-6 gm%.Conclusions: In developing countries this may be one of the effectiveand acceptable method of treating anemic pregnant women to reducematernal and neuronatal morbidity and mortality.
FC3.10.08THYROID HORMONAL PROFILE DURING PREGNANCY ININDIAN WOMENA.Kumar , N.Gupta, Maulana Azad Medical College, 13-B, Ber Sarai,New Delhi, Delhi, India, 110016.
Objectives: The aim of the study was to evaluate the thyroid functionduring pregnancy.Study Methods: Sixty consecutively registered primigravidas wereincluded. Pregnant women with known metabolic and/or medicaldisorders were excluded. Thyroid function tests, i.e., totaltriiodothyronine (T3); total thyroxine (T4) and thyroid stimulatinghormone (TSH) were estimated by radioimmunoassay technique.Results: The mean age and weight of the subjects was 22 years and55.34 kg respectively. Of these, 75% were using iodised common salt.Normal refrence ranges are - T3: 1.2 to 3.1 nmol/L, T4: 78.5 to 151.9nmol/L, TSH: 0.5 to 5.0mIU/ml. The mean T3 values estimated were2.05 nmol/L, 2.51 nmol/L and 2.92 nmol/L in the first, second and thirdtrimester respectively. The mean T4 values estimated were 120.0nmol/L, 168.47 nmol/L and 173.5 nmol/L in the first, second and thirdtrimester respectively. The mean TSH values estimated were 1.67mIU/ml, 1.96 mIU/ml and 2.98 mIU/ml in the first, second and thirdtrimester respectively. Even though none of the patients weresymptomatic, 5 (8.3%) were found to have elevated TSH. This suggeststhat they could be having asymptomatic hypothyroidism.Conclusions: A careful vigilance is required by the obstetrician to detectasymptomatic hypothyroidism during pregnancy, especially in iodinedeficient areas.
FC3.10.09CORRECTION OF FETAL STATE IN PREGNANT WOMEN WHOUNDERWENT SURGICAL TREATMENT ON THYROID GLANDWITH SUPERIMPOSED PRE-ECLAMPSIAJ.Davydova , V.Dashkevich, E.Mikhaylenko, Institute of Pediatrics,Obstetrics and Gynecology, 8 Manuilsky str, Kiev, Ukraine, 252050.
Within 14 years after the radiation catastrophe in Ukraine we use toobserve the trend to increase of fertile age patients number with differentpathology of thyroid gland, which demanded the surgical intervention.One of the most spread complications in case of routine treatment ofpostoperative hypothyroidism is the early development of superimposedpreeclampsia which leads to placental insufficiency and disorders offetal well-being. According to this the advanced therapy of thispathology appears to be acute.Target. To study the efficacy of Sermion (Nicergoline, Pharmacia&Upjohn,USA) in patients underwent surgical treatment of thyroidgland with the gestation period complicated by superimposedpreeclampsia.Materials and methods. We observed 28 women with total and subtotalresection of thyroid gland. We prescribed Sermion 30 mg per day within14 days. We studied the levels of maternal estriol, placental lactogen inblood serum, time average velocity (TAV) and blood volume (Q) inuterine and funic arteries in color Doppler US before and after thetreatment.Results. In pregnant women after the implemented treatment wemanaged to reduce the systolic blood pressure on 20,8 + 5,8 mm Hg, the
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diastolic - on 10,0 + 8,7 mm Hg. We stated the improvement of TAVand Q indices in uterine and funic arteries (p<0,05), the mild increase ofestriol level in maternal blood serum. There was no evidence forsignificant increase of placental lactogen levels.Conclusions. Sermion implementation in pregnant women underwentsurgical treatment of thyroid gland with superimposed preeclampsia andfetal hypoxia is efficient: resulting the reduction of resistance and spasmof vessels we managed to improve the maternal-placental bloodcirculation and to achieve the optimization of transport and endocrineplacental functions.
FC3.11 NEW APPROACHES TO FETAL MONITORING
FC3.11.01A NEW METHOD OF COMPUTER AIDED ANALYSIS OF COLORCODED SONOGRAPHY OF THE HUMAN PLACENTAN. Kahn , H. Joern*, M. Baumann, S. Gerke*, J. Bosmann*, I. Wurdack,H. Schmid-Schoenbein, W. Rath*Institute of Physiology, Rhenish-Westfalian Technical UniversityAachen, GermanyDepartment of Obstetrics and Gynecology, Rhenish-WestfalianTechnical University Aachen, Germany*
Objective: Starting from the hypothesis that IUGR represented flowinhomogeneity, we developed and validated a new method forcomputerized analysis of sonographic power Doppler data during thesecond half of the pregnancy.Materials and methods: The texture of flow distribution can bevisualized using power Doppler sonography (Toshiba 270, data recordedusing DVR-Sony). To extract this information, the time series wereprocessed using a program of own design. In counting the color pixels ina given frequency range, allows to construct a power-time-diagram(water fall diagrams). Using arbitrary “intensity units”, the FFT of flowrelated signals are used to generate spectra.Results: Contrary to conventional haemodynamic rationale, high signalintensity was identified as sign of pathology: low signal intensity withinthe parenchymum was clearly identified as signum of physiologicalintervillous flow. Experiments corroborating this interpretation wereperformed with isolated human placenta specimen in vitro. Thispreliminary conclusion allows to interpret repetitive power Dopplersignal during the course of normal and pathological placentae. In aninformal clinical observation, the haemodilution resulted inaugmentation and more homogenous distribution of low power signals,interpreted as success in avoiding perfusion mismatch. Usingquantitative ratios (high power intensity/low power intensity), the re-homogenization can be quantified.Conclusions: Homogeneity analysis of power Doppler data allows todistinguish normally distributed and maldistributed intervillous bloodflow: quantitative parameters not only allow to identify IUGR, but thesuccess of a therapy.
FC3.11.02FETAL MONITORING BY A NOVEL NON-INVASIVE DEVICEFOR MEASURING OXYGEN SATURATIONA.Hasenburg (1), D. Waterman (1), D. Vogelgesang (1), D. Siker (2),D.G. Kieback (1)(1) Dept. OB/GYN, Freiburg University Medical Center, Freiburg,
Germany.(2) Dept. OB Scientific, Germantown, Wisconsin, USA.
Objectives: Fetal heart rates (FHR) monitoring has been accepted forassessing fetal distress. However, FHR does not translate to specificabnormal patterns predicting cord blood pH. Attempts to incorporateintrauterine fetal pulse oximetry (FPO) or fetal oxygen tension wereunsuccessful. This study will investigate the use of FPO compared toFHR monitoring. Maternal acceptance of the sensor, percentage of validdata acquisition times, and cord pH values will be analyzed.Study Methods: Paturients with labor of less than 30 minutes anticipatedbirths will be monitored with a FPO sensor placed, during a vaginalexam via the cervix with intact membranes (preferably) against the fetaltorso. Parturients with premature rupture of membranes, prematurelabor, low lying placenta, placenta praevia or abruption, vaginalbleeding, acute infection, polyhydramnios, oligohydramnios, fetaldistress, uterine congenital abnormalities are excluded from the study.
Results: FHR and FPO data from the FPO sensor will be correlated withFHR and auscultation data. Cord pH and Apgar scores will be comparedto FHR and FPO showing determining sensitivity and specificity of fetaldistress. All clinical decisions are based on FHR patterns and clinicaljudgement. All FPO saturations at or below 40% are discussed with theclinician, but at present there are no plans to use FPO for clinicaldecisions.This is an ongoing study approved and in progress at our hospital withpromising results. Our latest data will be presented, particularly thosecases that combine FHR and FPO, that reassure and predict fetalwellness as evidenced by neonatal exams and cord pH.
FC3.11.03FETAL PULSE OXIMETRY DURING LABOR WITH FETALHEART RATE ABNORMALITIES.M. Butterwegge , Dep. OB/GYN, Marienhospital Osnabrueck,Johannisfreiheit 2-4, 49074 Osnabrueck, Germany
Objectives: Routine electronic fetal monitoring intrapartum results in anincrease of operative deliveries. Measuring fetal oxygen saturation(FSpO2) during labour is a new technique currently under development.Important points of all studies is the fetal condition at birth (Apgar,acidbase and neurological status) compared with oxygen saturation.Study Methods: Conventional FHR monitoring plus pulse oximetry(Nellcor,USA) were measured during labor in 189 cases. 67 scalp pHwere indicated in times of non-reassuring or pathological FHR pattern.Simultaneous readings of FSpO2 and FBS obtained before birth werecompared to the neonatal status. This study will demonstrate therelationship between the measured FSpO2 values and gold standardmethods to assess fetal well- being, fetal blood sampling (FBS) and fetalheart rate (FHR) scoring.Results: At a 7.13 threshold for fetal scalp pH and 30% for fetal oxygensaturation the predicitive value of fetal pulse oximetry was similar tothat of fetal blood analysis. Correlation was found between decrease ofscalp-pH, the duration of low FSpO2 (p< 0.001) and depressed fetaloutcome (p< 0.01).There were few cases of false positive and negativecases. Transient fetal saturation values < 30% are common duringuncomplicated labor and did not predict fetal outcome. If prognosticallyunfavourable additional criteria with variable decelerations increase, atendency towards decreasing FspO2 is recognisable.Conclusions: These data demonstrate that this new technique allows toreduce obstetrical interventions without altering neonatal outcome. Incases of reducing SpO2- levels during labor an association to fetalcompromise and metabolic acidosis can be observed.
FC3.11.04GUIDELINES FOR THE USE OF FETAL PULSE OXIMETRYDURING LABOR AND DELIVERY.M.Kühnert (1) , M.Butterwegge (2), B.Seelbach-Goebel (3),G.C.DiRenzo(4), (1) University of Marburg, Pilgrimstein 3, Marburg,Hessen, Germany, 35033, (2) Marien Hospital, Osnabrueck, NDS,Germany, (3) University of Wuerburg, Wuerzburg, Bayern, Germany,(4) Universita Degli Studi di Perugia, Perugia, Italy.
Objectives: FSpO2 monitoring of fetal oxygenation is an adjunct toconventional CTG monitoring and clinical assessment in cases of non-reassuring fetal heart rate.Study Methods: Fetuses in labor with pathological fetal heart rate patternCTG plus FSpO2 monitoring of fetal oxygenation was done in fourcenters of Europe in appr. 1000 cases. Fetal scalp pH was checked for abaseline assessment, labor managed according to appropriate pHprotocol.Results: The use of FSpO2 monitoring can resolve clinical uncertaintyabout the current state of fetal oxygenation. If the FSpO2 is > 30% thefetus is presumed to be adequately oxygenated at present. This does notexclude the possibility of pre-existing acidosis from a prior period ofhypoxia. No additional scalp pH sampling is needed if the FSpO2remains > 30%. If the FSpO2 remains below 30% for more than 10minutes, fetal oxygenation may not be adequate and the fetus may be atrisk for hypoxic injury. If fetal scalp blood sampling is easily and rapidlyavailable, the impact of fetal hypoxia sufficient to cause acidosis may beconfirmed with scalp pH.Conclusions: This paper provides guidelines for the use of fetal oxygensaturation by pulse oximetry (FSpO2) monitoring in clinical practice.
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The guidelines were developed from the author´s extensive clinicalexperience with an N400 fetal pulse oximeter during labor.
FC3.11.05THE RELATION BETWEEN METABOLIC ACIDOSIS AND FETALARTERIAL OXYGEN SATURATION DURING LABORB. Seelbach-Göbel 1, M. Kühnert2, M. Butterwegge3, Dep. OB/GYN, University of Wuerzburg1, Marburg2, Marienhospital Osnabrueck3,Johannisfreiheit 2-4, 49074 Osnabrueck, Germany
Objectives: The present study compares fetal arterial saturation (FSpO2)with the change of Base Excess (BE) and lactate concentration in fetalblood from one fetal blood sampling (FBS) to the next in order to findcriteria to exclude or predict the development of fetal metabolic acidosisby fetal pulse oximetry during labor.Study Methods: FSpO2 was measured with an N-400 and FS 14-Bsensor in 135 deliveries with pathological heart rate and FBS wasperformed to exclude pre-existing acidosis. The change of pH, BE andlactate concentration (LC) were calculated between two adjacent bloodsamplings. The duration of low (<30%), medium (30-60%) and highFSpO2 (>60%) was measured between adjacent FBS´s and correlated tothe change of pH, BE and LC by Spearman´s correlation. ROC analysiswas performed to define an critical threshold value.Results: A highly significant correlation was found between the decreaseof pH and the duration of low FSpo2 (p<0.0001) and medium FSpO2(p<0.01). The decrease of Base excess of the increase of Lactate werecorrelated to duration of low FSpO2. No significant decrease of pH(>0.05 pH unit) and BE (>3mMol/l) corresponding to an increase ofLactate concentration by more than 2 mMol/l was observed unlessFSpO2 was < 30% for at least ten minutes.Conclusions: The development of metabolic acidosis seems predictableby intrapartum pulse oxi-metry measurements. No significant worseningof the acid base status and no significant increase of lactateconcentration are to be expected unless FSpO2 is < 30% for at least 10minute.
FC3.11.06RANDOMIZED CONTROLLED TRIAL OF CTG VERSUS CTG + STANALYSIS OF THE FETAL ECGI. Amer-Wåhlin (1), K. Marsal (1), H. Noren (2), C. Hellsten (3),Swedish STAN Study Group(1) Dept. OB/GYN, University Hospital, Lund, Sweden.(2) Dept. OB/GYN, University Hospital, Gothenburg, Sweden.(3) Dept. OB/GYN, University Hospital, Malmoe, Sweden.
Objective: ST waveform analysis of the fetal electrocardiogram duringlabor is validated as a new means to provide diagnostic information ofthe fetal condition. Basically, an increase in T wave amplitude identifiesa situation where the fetus is utilizing its prime defense – activation ofthe sympathetic system with enhanced myocardial performance andglycogenolysis. The opposite functional response is seen with STsegment depression (biphasic ST waveforms) negative T waves, thusindicating a fetus not capable of fully responding. The Plymouth trial(Westgate et al, Am J Obst Gynec, 169, 1151, 1993) focused on theability of the then newly developed STANÒ system to safely reduce thenumber of operative interventions for fetal distress. This primary aimwas fulfilled. Lately, refinements in digital signal processing hasallowed much enhanced signal quality and automatic assessment of STchanges. It was therefore decided to conduct a second randomized trialof CTG only versus CTG + ST to verify the ability of CTG + ST toreduce the incidence of cord artery metabolic acidos (pH<7.05 andBDecf>12.0 mmol/l) and the number of operative deliveries forthreatening asphyxia.Study Methods: Four Swedish labor wards were equipped with the newSTANÒ system (Neoventa Medical, Gothenburg). Term singletonpregnancies were enrolled after a decision had been made to apply asingle spiral scalp electrode. Clinical action was guided by conventionalCTG interpretation and computerized ST waveform assessment (STlogÒ). All ECG data was stored in both arms of the trial. After staffteaching and training the trial commenced in January 1999.Results: During the initial 6 months of the trial, obstetric managementcontinued to be based on CTG rather than CTG + ST. Six cases with STchanges and subsequent metabolic acidosis at birth convinced the staffof the potential value in ST assessment and after retraining the trial
continued. Current data of 1141 cases show a significant reduction ofoperative interventions in the CTG + ST arm (n=43) compared to theCTG arm (n=71), along with a reduction in the number of babies withmetabolic acidosis (CTG + ST arm n=2, CTG arm n=11).Conclusion: These data confirm the results of the Plymouth trial andsupports the ability of CTG + ST to safely reduce the number ofoperative interventions.
FC3.11.07INTRAPARTUM FETAL PULSE OXIMETRY (IFPO). THE TWOYEAR CZECH EXPERIENCEA. Roztocil , Dept. OB/GYN, Masaryk University, Brno, CzechRepublic.
Objectives: The aim of the study was to evaluate the attitudes towardsIFPO and its impact on perinatal results (decrease of C. Section rate) in10 maternity centers.Study Methods: 18.8% of births in the Czech Republic in 1998 tookplace in the delivery wards disposing with IFPO monitor N-400. Aquestionnaire comprising 18 questions was sent to the heads of thematernity centers. None of them refused the collaboration.Results:(1) The manipulation with the machine: easy (60%), rather easy (40%)(2) The insertion of the sensor: easy (40%), rather easy (60%)(3) Indications for fetal SpO2 measurements: fetal hypoxia 277
(67.5%), stained amniotic fluid: 84 (22.0%), other indications: 30(7.5%). Total 401 measurements.
(4) Side effects-pain: 0, unpleasant feelings – 0-100%, maternal, fetalinjury and or infection:0
(5) Duration of insertion: 15-77 min, mean value 37.5 min(6) False negative results: 1 (0.3%), false positive results: 22(5.5%)(7) Decrease in C. Section rate from the indication of acute fetal
hypoxia stated by means of CTG monitoring: mean value 50.3%(8) The attitudes of the health care providers towards IFPO: positive:
62.5%, rather positive 30.0%, rather negative 7.3%, negative 0.(9) The method is a positive contribution to the obstetrical practice:
yes 90%, rather yes 10%, no 0.Conclusions: IFPO proved to be an easy method in the accuratediagnosis of acute fetal hypoxia and it decreased the C. Section rateperformed from the indication of acute fetal hypoxia diagnosed bymeans of CTG tracing. It has no serious side affects and is well acceptedby the patients and the obstetric ward staff.
FC3.11.08FETAL PULSE OXIMETRY (FPO) WAS OBTAINED 80% OF TIMEDURING LABOR; CAN FPO REDUCE C-SECTION RATES?D. Siker +, J. Waters+, A. Lopez*, and O. Borre’*, +Cleveland ClinicFoundation, 9500 Euclid, Cleveland Ohio, USA - 44195 *Department ofOB/GYN University of Cartagena, Rafael Calvo Maternidad, Cartagena,Colombia, South America.
Objectives: Our intrauterine fetal pulse oximetry (FPO) and fetal heartrate (FHR) studies at Rafael Calvo Maternity Hospital have nowexceeded 150 births using a correlated FPO/FHR intrauterine sensor. Inthis study neonates most at risk for hypoxemia during labor and deliverywere studied using a FPO/FHR sensor to assess maternal and physicianacceptance of FPO.Study Methods – pilot report of our most recent 7 parturients.Parturients in active labor and intact uterine membranes were selectedbecause their FHRs were non-reassuring by auscultation and intermittentabdominal ultrasound (GE Logic1000). After informed consent, the FPOsensor was positioned beyond the cervix against the fetal torso awayfrom the placenta.Results: Although labor analgesia was withheld, parturients reportedminimal pain during insertion of the sensor. Labor duration was from 0.6– 3 hours. No membranes were ruptured during placement of the sensor.Summary data (Mean ± Standard Deviation) was FPO% = 66±11; FHR= 129±26; lowest FHR = 72±18; lowest FPO% = 45±13. SignificantFHR decelerations were noted in all patients but none had a FPO readingof less than 40% for any sample epoch. Six infants had complicatednuchal cords noted at birth. Patient # 7 was rushed to an emergent C-section with a FHR in the 60s with a mean FHR of 98 during a 40-minute labor. However, since her FPO tracing was never below 65%,
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she was allowed to deliver vaginally in the OR. Her baby’s Apgar -1min.=9/ 5min.=9).Conclusions: With FPO data consistently present 80% of the time,cesarean section was avoided in this group. Maternal and physicianacceptance of the current smaller sensor was excellent. In theseparturients sensor placement was easy, with little discomfort, and withno episodes of bleeding, chorioamnionitis, or rupture of membranes; weare encouraged to expand our studies. To date (n=153) parturients withnormal FPO (Sat%= 45–80) have delivered normal infants. Fourseverely depressed babies in this cohort had extended (>3 minute) FPOepochs below 35%.
FC3.11.09ANTENATAL FETAL ECG MONITORING – OUR HOSPITAL’SEXPERIENCEA Wong, SW Seng, GSH Yeo. Department of Maternal Fetal Medicine,KK Women’s and Children’s Hospital, 100 Bukit Timah Road,Singapore 229899
Objectives: The aim of our study was to determine the efficacy of thenon-invasive fetal ECG monitoring system in predicting an adversepregnancy outcome in full-term low risk antenatal women.Study methods: 309 consecutive patients attending the Obstetric DayCare Center for cervical priming were recruited.The fetal ECG monitoring system was used to obtain an average ECGcomplex from an abdominal tracing. The mean and standard deviationsof the ECG waveform was measured and calculated.Results: The occurrence of T wave inversion, ST elevation and T/QRSratios was correlated against outcome measures such as the APGARscores, neonatal special care and ICU admissions, and caesarean sectionor instrumental delivery for fetal distress.There was a statistically significant trend toward more neonatal specialcare admissions with poorer T/QRS scores. No significant differencewas found in the occurrence of T wave inversion and ST elevation withneonatal outcomes.Conclusion: The fetal ECG provides a new avenue for research intoantenatal fetal monitoring.Our study did not find the antenatal fetal ECG useful in predicting anadverse outcome in a low risk population. Further studies are needed todetermine if it is a useful tool in the high-risk population.
FC3.12 PREGNANCY AND LABOR
FC3.12.01FIVE YEAR REVIEW OF INDUCTION OF LABOR IN PATIENTSWITH A PREVIOUS LOWER SEGMENT CESAREAN SECTIONA. Adolph (1), L. Brydon (2), J. Thiel (2)(1) Dept. OB/GYN, Royal University Hospital, Saskatoon,Saskatchewan, Canada.(2) Dept. OB/GYN, Regina General Hospital, Regina, Saskatchewan,Canada.
Objectives: The study reviews the safety of the use of vaginalprostaglandin (PGE2) gel for induction of labor with a previous lowersegment cesarean section (LSCS).Study Methods: We conducted a retrospective review of 877 patientsdelivering at the Regina General Hospital between January 1992 andDecember 1997. Patients with a previous lower segment cesareansection on spontaneous labor were used as controls. Five groups wereanalyzed; Spontaneous labor, Spontaneous labor with augmentation,Syntocinon induction, PGE2 induction, PGE2 induction requiringSyntocinon augmentation. Primary outcome measures include uterinerupture and/or dehiscence. Secondary outcomes include cesareansection, instrumentation, length of first and second stage and neonataloutcome.Results: PGE2 gel induction in patients with previous LSCS hadstatistically significant increase in uterine rupture and/or dehiscence(p<0.02), as well as increased cesarean section rate (p<0.04). ComparingPGE2 gel with Syntocinon for induction of labor, there was an increasedrate of rupture/dehiscence when PGE2 was used, this was alsostatistically significant (<0.03).Conclusion: PGE2 gel induction in patients with a previous LSCS isunsafe. PGE2 gel compared with Syntocinon for induction also appearsto be less safe. Syntocinon augmentation of spontaneous labor is less
likely to cause a rupture than Syntocinon augmentation after PGE2 gel. Ifinduction of labor is indicated, other methods should be considered.
FC3.12.02MORE THAN ONE PREVIOUS CESAREAN SECTION DOES NOTEXCLUDE A TRIAL OF LABORW.A. Spaans (1), L.M.E. van der Vliet (1), O.P. Bleker (1), E.A.M.Röell-Schorer (2), J. van Roosmalen (2),(1) Dept. OB/GYN, Academic Medical Center, Amsterdam, The
Netherlands.(2) Dept. OB, Leiden University Medical Center, RC Leiden, The
Netherlands
Objectives: The aim of the study was to investigate pregnancy outcomeof women with a history of multiple previous cesarean sections (MPCS).Study Methods: All medical records of women with a history of MPCSwho gave birth during a 10 year period (1988-1997) in two largeteaching hospitals in the Netherlands were studied.Results: During the study period 30, 132 women gave birth at the twocenters, with a cesarean birth rate of 14.8%. there were 242 women witha history of MPCS: 188 (77.7%) delivered by elective repeat cesareansection, 54 (22.3%) had a trial of labor, of whom 45 (83.3%) had avaginal birth. Women with recurring indication had less often a trial oflabor than women with a non-recurring indication had less often a trialof labor than women with a non-recurring indication (OR 0.30; 95% CI0.15-0.62). Three uterine ruptures occurred after previous lower segmentcesarean sections without maternal or perinatal mortality; one during atrial of labor and a hysterectomy was necessary, one in a uterus bicornisplanned for elective repeat cesarean, and one suddenly at 30 weekspregnancy without any sign of labor. In the study group was no maternalmortality. Maternal morbidity did not differ between women with anelective repeat cesarean or a failed trial of labor. Women with a vaginalbirth after cesarean needed less often a blood transfusion. Perinatalmortality was not related to the mode of delivery.Conclusion: An elective repeat cesarean section is not the only answer toa woman with more than one previous cesarean section. A trial of laborcan be a safe option for a selected group of women.
FC3.12.03IS THERE A RISK OF INTRA UTERINE FETAL DEATH INUNCOMPLICATED SINGLETON POST TERM PREGNANCY?E.G. Tamale-Sali , Dept. OB/GYN, Ahmadi Hospital, Ahmadi, Kuwait.
Objectives: The purpose of this study was to examine the hypothesis thatthere is a risk of intrauterine fetal death in uncomplicated post termpregnancy.Study Methods: This was a retrospective study involving 283 patientswith uncomplicated singleton pregnancy. Only patients with a priorultrasound scan for dating before the 20th week of gestation wereincluded. During the same period, a study of all cases of intrauterinefetal deaths on or after the 28th week of gestation was also made.Results: In the post term group, the mean age was 27.1 (range 16-44),mean parity 2.9 (range 0-11). The mean fetal weight was 3539.5 mg(range 2130-5170 mg). The mean post term gestation was 298.5 days(range 295-325). The cesarean section rate for fetal distress was 7.4%,that for instrumental delivery 4.6%. Meconium stained liquor incidencewas 24.7% and the induction rate was 13%. There were neitherintrauterine nor neonatal deaths in this group. All the 115 intrauterinedeaths that occurred in the other group happened prior to the 290th day ofgestation. The mean fetal weight was 2248 (range 670-5150 mg). Mostof the pregnancies had an associated complication.Conclusion: Post term in uncomplicated singleton pregnancy appear tohave little or no risk at all of intrauterine fetal death. Therefore inductionof labor in these patients should be based on other factors other than postterm provided a good follow up is assured or is in place.
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FC3.12.04EFFICACY OF DROTAVERINE AND VALETHAMATE BROMIDEIN ACTIVE MANAGEMENT OF LABORB. Goswami , B. Goswami, M. Sarkar, B. Biswas, Dept. OB/GYN,Chittaranjan Seva Sadan College of OB/GYN, Calcutta, India.
Objective: Shortening the duration of first stage of labor by reducingcervical resistance.Study Methods: Active management of labor was conducted in 300demographically similar subjects divided into three groups of 100 caseseach:Group 1: Oxytocin + DrotaverineGroup 2: Oxytocin + Valethamate BromideGroup 3: Oxytocin alone (Control Group)Comparative analysis was carried out with regards to the rate of cervicaldilation per hour, duration of first stage of labor, side effects and safetyof the drugs on fetomaternal outcome.Results: In primigravid parturients, the rate of cervical dilation per hourwas 2.71± 1.41, 2.39±1.69 and 1.35±1.01 cm in Group 1, 2 & 3respectively. The duration of first stage was 174.7±90.76, 196±164.02and 344.7±257.28 minutes respectively. A similar trend was observed inmultiparas.The difference between the values in Group 1 and 2 was not statisticallysignificant, but that with Group 3 was highly significant.ConclusionBoth Drotaverine and Valethamate Bromide were observed to acceleratethe first stage of labor by enhancing cervical compliance.
FC3.12.05ACTIVITY OF HEXOKINASE GLUCOSE – 6 – PHOSPHATEDEHYDROGENASE AND GLUCOSE – 6 – PHOSPHOTASE INPLACENTA FROM PATIENTS WITH RHEUMATIC HEARTDISEASEE.E. El-Hassan , Maternity Hospital, Port Sudan, Red Sea State, Sudan.
Objectives: The aim of this study is to investigate the activity of theenzymes: hexokinase, glucose – 6- phosphate dehydrogenase andglucose –6 – phosphate in placenta from patients with rheumatic heartdisease after delivery.Study Methods: 62 patients with rheumatic heart disease (RHD) and 40normal women were included in this study. Hexokinase activity studiedby the method of Slein M. et al. (1950), glucose-6- phosphatedehydrogenase by the method Glock G. and Maclean p. (1953) andglucose-6-phosphotase by Swanson method (Swanson M.A. 1950). Non-organic phosphate by Baginski method (1960, 1967) and protein contentby the method of Ehersmann B. et al (1973). Enzyme activity expressedin micromole of reduced NADP for one minute per one gram of protein.Results: This study showed that the activity of the studied enzymesvaries in a wide range. Four types of enzymatic changes have beennoticed in placental homogenates from patients with RHD.Type I: characterized by normal hexokinase, significant increase inglucose-6-phosphate dehydrogenase activity and significant decrease ofglucose –6- phosphotase. It was found in 22 patients with compensated(Ho) RHD.Type II: characterized by significant increase of hexokinase and glucose–6- phosphate dehydrogenase and more reduction in glucose –6-phosphotase activity. It was seen in 18 patients with decompensatedRHD (H1).Type III: This had been found in 15 patients with severedecompensation. (H2) and characterized by significant increase in theactivity of the three studied enzymes, the increase is significant even if itis compared with type I and type II.Type IV: in this group the characteristic elevation of glucose-6-phosphate dehydrogenase, seen in all other three types, was not onlyabsent, but there was significant reduction of glucose –6- phosphatedehydrogenase activity. The gluscose-6- phosphotase remained normalwhile the hexokinase activity was raised. This type was found in only 7patients, 3 of them were in Ho and 4 in H1. 5 out of the 7 patients hadactive rheumatism. Clinical analysis showed that complications of labordue to abnormal uterine contractility were more seen in patients withtype III and type IV. Low birth weight and low Apgar score noticedmainly in patients with type III enzymatic changes.Conclusions: Hypoxia caused by heart decompensation and activerheumatic process seem to be the most important factors affecting theactivity of the studied enzymes.
Changes in glucose –6-phosphosphete dehydrogenase is the prominentfeature of enzymatic disturbances which might have an impact on thegeneration of NADP essential for protein and hormone synthesis.Management of patients with RHD should aim to prevent cardiacdecompensation and activation of rheumatism by prophylactic treatment.
FC3.12.06BIRTHS AND PERINATAL CARE IN FINLAND AND ESTONIAFROM 1992-1996 - CONVERGENT DIFFERENCES?H. Karro , Dept. OB/GYN, University of Tartu, 36 Lossi street, Tartu,Estonia, 51003; M. Gissler, National Research and Development Centerfor Welfare and Health, P.O. BOX 220, Helsinki, Finland, 00531;A.Tellmann, Institute of Experimental and Clinical Medicine, 42 Hiiustreet, Tallinn, Estonia, 11626;E. Hemminki, National Research and Development Center for Welfareand Health, P.O. BOX 220, Helsinki, Finland, 00531.
Objectives: The aim of the study was to describe the differences inchildbearing, in maternal care and in perinatal outcome in Finland andEstonia.Study Methods: Registry study using the data from the Finnish andEstonian Medical Birth Registries for years 1992 to 1996 (in total 324021 and 74 297 births respectively).Results: Compared with Finnish mothers, Estonian mothers wereyounger, had fewer multiple births, less prenatal care and fewerinterventions during pregnancy and delivery. The intervention ratesincreased in both countries, but this increase was more rapid in Estonia.The infant outcomes were poorer in Estonia, but the differences betweenEstonia and Finland decreased during 1992 to 1996.Conclusion: Changes in maternal backgrounds and improvements inprenatal care and in availability of appropriate equipment andtechnology may have caused improved maternal and infant health inEstonia, but this should be further investigated.
FC2.12.07MATERNAL AND PERINATAL OUTCOME IN PREGNANCYINDUCED HYPERTENSIONJ.D. Tank , D.K. Tank, A.M. Chati, E. Saldhana, P. Chikal, AshwiniMaternity and Surgical Hospital, Mumbai, India.
PIH remains the single most obstinate cause of maternal mortality andmorbidity. This is a retrospective study in which cases over the past 5years are studied. Patients who satisfied the ISSHP criteria for thediagnosis of PIH were included in the study. Patients whose fetuses hadcongenital abnormalities, patients with multiple pregnancies, associatedmedical disorders like diabetes, etc., were excluded from the study. Allpatients had a uniform pattern of antihypertensive drugs (either alfamethyl dopa or nifedepine) administered depending on the severity ofthe PIH. The incidence of eclampsia in our study was 2.5% of allpatients with PIH. All eclamptics were given magnesium sulfate as perthe Pritchard’s regime. The main outcome measures studied are a)gestational age at delivery and mode of delivery, b) maternal morbidityand mortality, and c) perinatal morbidity and mortality. The outcomewas also studied with respect to the regime used for eclampsia.
FC3.12.08ANGIOPROTECTOR GINKOR FORT IN COMPLEX TREATMENTOF PREGNANT WOMEN WITH VARICOSE DISEASE ANDPLACENTAL INSUFFICIENCY.B.L. Gurtovoy , N.V. Ordzhonikidze, Research Center of Obstetrics,Gynecology & Perinatology, Russian Academy of Medical Science,Moscow, Russia
The objective of the study was to investigate the therapeutic efficacy ofthe angioprotective drug GINKOR FORT in treatment of varicosis of thelower extremities in pregnant women with infection of viral and/orbacterial etiology. Thirty patients in the III gestation trimester wereincluded in the study.It was found that administration of GINKOR FORT (2 capsules x 3times a day in the course of 30 days) provided elimination of varicosissymptoms, such as pain, heaviness, or discomfort in the lowerextremities, nocturnal paresthesia, and cramps in most patients (96.6%).Tissue edema was also eliminated, which was manifested as significant
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decrease of medullar volume. Dynamics of hematological parameters,such as pO2, pCO2 and level of blood saturation with oxygen proved thatoxygen-carrying function of blood was enhanced. Hemorheologicalstatus of the patients was normalized. US-investigation revealedimprovement of blood circulation in popliteal artery, as well as in theblood vessels of mother-placenta-fetus system. Action of GINKORFORT was not associated with any adverse side effects.Thus, the results of the study provided evidence that use of GINKORFORT in treatment of varicosis in pregnant women with infection ofviral and/or bacterial etiology is justified pathogenetically.
FC3.12.09OUTCOME OF PROLONGED LABOR: A STUDY OF 100 CASES INA PERIPHERAL MEDICAL COLLEGE HOSPITALBANGALADESHR. Maliha , B. Mala, Dept. OB/GYN, Bangabandhu Sheikh MujibMedical University, Dhaka, Bangaladesh.
Objectives: To observe the causes and outcome of prolonged laboramong the patients admitted with this problem in Mymensingh MedicalCollege Hospital, Mymensingh, Bangaladesh.Study Methods: This study was undertaken in Mymensingh MedicalCollege Hospital between January and December 1998. We definedprolonged labor as one lasting for more than 12 hours. All patientsadmitted with labor pain lasting for more than 12 hours were broughtunder this study. The aim was to study 100 cases.Results: The main causes of delay were due to abnormal uterine action415, Relative fetal causes 40%, C.P.D. 11%, Absolute Fetal causes 2%and birth canal causes 7%. The mode of delivery of these 100 patientswas cesarean section 40%, forceps delivery 21%, destructive operation17%, spontaneous vaginal delivery 16%, internal podalic version 4%,breech extraction 2%. Maternal mortality was 3% and perinatalmortality was 21%.Conclusion: Prolonged labor is associated with high maternal andperinatal morbidity and mortality. It is a preventable condition sinceproper antenatal and intranatal care can prevent this problem in ourcountry. Unfortunately, most of the pregnant women of our country donot receive any antenatal care; as well, a majority does not receiveintranatal care either since only 6% of deliveries occur in hospitals. Forthis reason, prolonged labor still remains a major problem in ourcountry. Proper antenatal and intranatal care needs to be implementedwithout delay to prevent these disasters.
FC3.13 PRENATAL DIAGNOSIS
FC3.13.01PREGNANCY OUTCOME USING FETAL NUCHALTRANSLUCENCY AT 10 TO 14 WEEKSE.Horner, W. Holzgreve, I.Hösli, S.Tercanli, Dept. OB/GYN Women’sUniversity Hospital, Basel, Switzerland
Objectives: To evaluate the incidence of chromosomal and nonchromosomal defects and the pregnancy outcome with the nuchaltranslucency (NT) measurement.Study methods: A prospective study with 1355 consecutive NTmeasurements between 10 and 14 weeks gestation with a crown-lumplength (CRL) between 26 and 84 mm. Risk calculation was estimatedwith NT measurements in relation with maternal age and CRL (adjustedrisk), and the outcome of all our cases was documented.Results: In 83/1355 (6,1%) cases NT was ³ 2,5 mm (group A). Fetalkaryotype was abnormal in 33 (39.8%) cases. In 8 cases withNT³2,5mm and normal karyotype, other sonographic anomalies weredetectable and confirmed postnatally (e.g. exencephaly, LCHAD-deficiency). In fetuses with NT < 2,5 mm (group B) an abnormalkaryotype was diagnosed in 2 cases (trisomy 21, ring chromosome 22)and 22 cases with non chromosomal abnormalities were detected.Analyzing our data an unfavorable outcome was seen in 49,4 % in groupA, and 1,9 % in group B (p< 0,001).Conclusions: Our results confirm the most recent findings, that the NT isan important marker to detect chromosomal defects. Besides a highincidence of chromosomal anomalies there are frequently also otherassociated anomalies which justify a continuous sonographical followup.
FC3.13.02CHORIONIC VILLUS SAMPLING AFTER THE FIRSTTRIMESTER.M. Podobnik , S. Ciglar, M. Podgajski, B. Gebauer, Dept. OB/GYN,University Hospital Merkur, Zagreb, Croatia
Objectives: The purpose of this article was to evaluate the associationbetween late CVS (placental biopsy) and complications betweensampling and delivery.Study Methods: Late chorionic villus sampling under ultrasoundguidance was carried out in 2600 (86,7 %) cases in the second trimesterand 400 (13,3 %) cases in the third trimester of pregnancy. Out of 3000late CVS, 684 (22,8 %) were performed because of suspiciousultrasonographic findings. In the 500 patients between 13 and 16 weeksof gestation color Doppler was used to investigate the uteroplacental andfetal vessels before and after late chorionic villus sampling.Results: In 24 patients (0,8 %), complications between sampling anddelivery were found. There were only nine (0,35 %) spontaneousabortions four to six weeks after late chorionic villus sampling. Wefound 156 (5,2 %) chromosomal abnormalities. In the group withsuspicious ultrasonic findings (684 cases) we found significantoligohydramnios in 300 (43,8 %) and significant polyhydramnios in 150(21,9 %), and 105 (15,4 %) had chromosomal abnormalities. Among the156 patients with chromosomal abnormalities, ultrasonographic findingsin 85 (54,4 %) were detected after 20th week of pregnancy. There wereno significant differences in mean pulsatility indices betweenuteroplacental and fetal vessels before and after late chorionic villussampling. Preliminary data for twenty trisomic fetuses indicate anabnormally increased umbilical PI and abnormally decreased middlecerebral artery PI.Conclusions: Late CVS is a safe method of prenatal diagnosis for high-risk couples and does not significantly affect the outcome of pregnancy.
FC3.13.03CHORIONIC VILLUS SAMPLING FOR PRENATAL DIAGNOSISIN ZAGREB: EXPERIENCE WITH 3000 CASESM. Podgajski , M. Podobnik, Z. Duic, B. Gebauer, Dept. OB/GYN,University Hospital Merkur, Zagreb, Croatia
Objectives: This study comprises data from 3000 women allocated totranscervical CVS (TC-CVS), transabdominal CVS (TA-CVS) andtransvaginal CVS (TV-CVS). We have assessed the efficacy oftransabdominal CVS compared with transcervical CVS and transvaginalCVS, and examined factors that have been implicated in causingspontaneous abortion.Study Methods: Over a ten year’s period 3000 women underwentchorionic villus sampling at 9-12 weeks of gestation, by transcervical,(500 patients) transabdominal (2400 patients) and transvaginal technique(100 patients). Transvaginal color Doppler was used to investigate theuteroplacental and fetal vessels in 500 pregnancies between 11 and 12weeks of gestation (400 TA-CVS and 100 TC-CVS) before and afterCVS procedures.Results: Five hundred (16,7 %) patients underwent transcervical CVS(TC-CVS) and spontaneous abortion after TC-CVS occurred in fivecases (1,0 %). Two thousand and four hundred (80,0 %) patientsunderwent transabdominal CVS (TA-CVS) using a 20 gauge spinalneedle and abortion after TA-CVS occurred in ten cases (0,4 %). Onehundred (3,7 %) patients underwent transvaginal CVS (TV-CVS) usinga 20-gauge needle and abortion after TV-CVS occurred in three cases(3,0 %). The spontaneous abortion rate after CVS procedures was 0,6 %.One hundred twenty (4,0 %) cases showed chromosomal aberration. Thespontaneous abortion rate was lower among cases allocated to TA-CVSafter 11 weeks of gestation. There were no significant differences inmean pulsatility indices (PI) between maternal, fetal and intraplacentalcirculation, before and after CVS procedures.Conclusions: Transabdominal CVS has lower fetal loss rate thantranscervical and transvaginal CVS.
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FC3.13.04ANALYSIS OF FETAL DNA FROM A MATERNAL PERIPHERALBLOOD BY LECTIN _ PCR - SSCPM. Shinya (1) , A. Okamoto (1), M. Saitou (1), Y. Akiyama (2), H.Sagou (2), M. Kitagawa (2), T. Tanaka (1), (1) The Jikei UniversitySchool of Medicine and National Okura Hospital, Nishi-Shinbashi 3-25-8, Tokyo, Japan, 105-8461, (2) National Okura Hospitak, Tokyo, Japan.
Objectives: Fetal nucleated cells in maternal peripheral blood arenoninvasive source of fetal DNA for prenatal genetic diagnosis.However, the number of fetal cells present in maternal peripheral bloodis few. Therefore, fetal cell enrichment is generally considered necessaryto allow detection and subsequent genetic analysis of the rare fetal cells.In this study, we performed fetal cell separation from maternal bloodusing galactose / galactosamine - specific Lectin to concentrate fetalnucleated red blood cells (FNRBCs) , and we also performedPolymerase Chain Reaction - Single Strand ConformationPolymorphism ( PCR - SSCP) for paternal diagnosis.Methods: Fetal cell separation was performed using galactose /galactosamine - specific Lectin on PV-LA coated slide. Approximately20 cells consisting of a NRBC and its surrounding cells were collectedusing the Micromanipulator (NARISHIGE Co.) and the Laser micro-manipulator (ZWEISS Co.). DNA analysis was performed using 2 STSmarkers (D13S270, D18S474) by PCR - SSCP.Results: A specific band was detected in mixed DNA at theconcentration of 1: 20 by PCR SSCP analysis. Four out of 5 cases wereinformative at both or either at D13S270 and / or D18S474 loci (80%).Paternal specific bands were detected in all informative cases (100%).Conclusions : Lectin - Laser Micromanipulation - PCR - SSCP methodmay contribute the development of prenatal diagnosis.
FC3.13.05FREQUENCY AND STRUCTURE OF FETAL ANOMALIES INVORONEZHI. Tchembartseva , N Tchembartseva, Dept. OB.GYN, Voronezh MedicalAcademy, Voronezh, Russia.
The widespread of fetal anomalies all over the world had led to itsthorough study. According to Russian researchers, evidence of thefrequency of fetal anomalies is between 1.5% to 3% and 25-26% ofperinatal mortality is caused by it.Objective: Frequency study of fetal anomalies in Voronezh from 1995 to1998.Methods: Retrospective clinic and statistical analysis of individualmedical cards of the pregnants, deliveries and newborns from 1995 to1998.Results: In 1995, fetal anomalies were detected in 12 newborns (0.7%),from the total amount of 1691 newborns, while in 1996 – 50 infants(2.4%) from 2073 newborns. In 1997, 1682 were born with 54 havingfetal anomalies (3.2%), in 1998 55 newborns (3.3%) had fetal anomaliesfrom 1688 newborns.The structure of the fetal anomalies was the following:Cardiovascular anomalies -35 newborns (63.6%); support-locomotionsystem anomalies – 10 (18.2%); urogenital system anomalies – 4(7.3%); brancho-pulmonary system anomalies – 1 (1.8%);gastrointestinal anomalies – 1 (1.8%). Down’s syndrome was observedin 2 cases (3.6%) and 2 (3.6%) newborns had multiple fetal anomalies.Conclusions: Fetal anomalies in Voronezh reveal a distinct tendency tobe increasing. This indicates that the concerned problem is of crucialimportance and needs a number of prophilactic measures to reduce thefrequency of this pathology.
FC3.13.06SCREENING FOR TRISOMY 21: THE SIGNIFICANCE OF APOSITIVE SECOND TRIMESTER SERUM SCREENING INWOMEN WITH LOW RISK NUCHAL TRANSLUCENCY SCANA, Sau (1), K. Langford (2), B.Auld (3), D. Maxwell (2)1) Dept. OB/GYN, Medway Hospital, Bromley, Kent, UK.2) Dept. of Fetal Medicine, Guy’s Hospital, London, UK.3) Dept. OB/GYN, Conquest Hospital, St.Leonard-on-Sea, UK.
Objectives: To assess the efficacy of second trimester serum screeningin detecting Down’s syndrome in a population with a prior low risk NT(nuchal translucency) scan.
Study Methods: During the period November 1996 to November 1998,fetal nuchal translucency was measured on 2683 women between 10-14weeks of gestation. Women were considered high risk if the calculatedrisk was greater than 1 in 100 or nuchal thickness was above the 95th
centile for a given crown rump length. Second trimester (16 to 20weeks) maternal serum biochemical screening (Triple test - µFetoprotein, b subunit of hCG and unconjugated estriol), was performedin women who opted to have second screening after negative nuchalscan. A serum screening risk of greater than 1 in 250 was consideredhigh risk.Results: 74 (2.8%) women were referred to tertiary center for invasiveprocedure following high-risk NT results. Screening with nuchaltranslucency detected eight out of eight (100%) fetuses with Trisomy 21and 13 of 16 (81%) aneuploid fetuses. The positive predictive value ofNT in detecting Trisomy 21 was 10.9% with a false positive rate of2.5%. 1057 women had a triple test as a further method of screeningfollowing negative NT scan. There was no case of Down’s baby in thisgroup. The positive predicative value of Triple test was 0% with a falsepositive rate of 4.3% (46 of 1057).Conclusion: The value of second trimester serum screening for Trisomy21 in a population of women identified as low risk by NT screeningremains unclear. The data presented do not refute a case for secondtrimester maternal serum biochemisty following a negative NT screen;however, they certainly do not prove that it confers any benefit.
FC3.13.07RISK FIGURE FOR FIRST TRIMESTER MATERNAL SERUMBIOCHEMICAL SCREENING FOR DOWN'S SYNDROME INFINLAND.Marko Niemimaa *, Mikko Suonpää1, Maija Seppälä1, AnttiPerheentupa*, Seppo Heinonen, Aimo Ruokonen1, Markku Ryynänen*.Departments of Obstetrics and Gynecology and Clinical Chemistry,Oulu* and Kuopio1 University Hospitals, Wallac OY, Turku, Finland
Objectives. With the growing recognition of the frequency andimportance of congenital disorders and with current social trends towardsmaller families and delays in childbearing, prenatal diagnosis has animportant role in the management of most pregnancies in the westerncountries. Both the mothers and the medical profession wish this testingcould be carried out reliably already in the first trimester. We wished toset up Finnish medians for free b-hCG and PAPP-A, and nuchaltranslucency in the first trimester and determine the risk figure fortrisomies at a 5% screen-positive rate.Study methods. Written informed consent was obtained from all womenbefore being enrolled in the study. Blood samples were drawn inparticipating centers between the 10th and 14th week of gestation.Wallac analyzed serum samples. The laboratory was provided with thefollowing patient information: date of birth, weight, first day of lastmenstrual period, gestational age by ultrasound (if available), diabeticstatus, use of insulin, and the number of fetuses. Serum samples wereanalyzed by Wallac and the adjusted estimated risk for Down syndromewas calculated using Wallac 1T program.Results. Serum PAPP-A and b-hCG concentrations were analyzed in1,461 pregnancies. In the screenees, a total of 139 women (9.5%) hadthe adjusted estimated risk of at least 1 in 250 for Down's syndrome. Theoutcome of pregnancies in the all the women screened is not yet known.Until now one trisomy 21 and 18 has been identified. From these onlythe trisomy 18 was detected: both analytes were low, PAPP-A 0.6, b-hCG 0.1 and NT 3.8 MoM ( the risk figure was 1:10).Conclusions. The risk figure at a 5% screen- positive rate is in Finland1:120. The number of samples and known outcomes is still too small tofigure out the Fp and Fn. The study is going on. We have now Finnishmedians and the cut-off figure for invasive testing. Our aim is to furthervalidate this form of prenatal screening of chromosomal anomaliesduring the first trimester.
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FC3.13.08MORPHOLOGIC OBSTETRIC ULTRASOUND INDICATIONS ANDDIAGNOSTIC FINDINGS OF EXAMINATIONS PERFORMED IN AREFERENCE HOSPITALF. Dib A. Berezowski, G. Duarte, R. Yano, F. Costa, S. Cuhna, Divisionof Fetal Medicine, High-Risk Prenatal Care and Ultrasonography, Dept.OB/GYN, Clinic Hospital of Ribeirao Preto Medicine Faculty,University of São Paulo, São Paulo, Brazil
Objectives: To establish the profile of fetal abnormalities that exist in thepopulation assisted at an Universitary Hospital.Study Methods: From January to December, 1998, 176 pregnants werereferred to an Universitary Hospital to be submitted to a morphologicalobstetric ultrasound examination.Results: Most of fetuses were anatomically normal. The most commonabnormalities were from central nervous system, followed by genito-urinary tract abnormalities and multiple malformations. A completetable listing all diagnostics is available for presentations.Conclusions: Most of fetuses were anatomically normal. The mostcommon abnormalities were from central nervous system, followed bygenito-urinary tract abnormalities and multiple malformations. Underany suspected abnormality detected by routine ultrasound examinationsthe patient must be referred to a specialized center to confirm thediagnostic. Most of indications for morphological ultrasound hadrevealed normal fetuses, so this exam must be performed by well trainedprofessionals only. According to many reports the central nervoussystem and the genito-urinary tract abnormalities were the mostfrequent.
FC3.13.09FIRST-TRIMESTER NUCHAL TRANSLUCENCY AND SECOND-TRIMESTER SERUM SCREENING FOR FETAL DOWN’SSYNDROMEY.H. Lam(1) , C.P. Lee(1), S.Y. Sin(2), H.S. Wong(3), R. Tang(4),M.H.Y. Tang(1), S.F. Wong(5),(1) Dept of OB/GYN, University of Hong Kong, Tsan Yuk Hospital,
Hong Kong, China(2) Kwong Wah Hospital, Hong Kong, China(3) Princess Margaret Hospital, Hong Kong, China(4) Pamela Youde Hospital, Hong Kong, China(5) Tuen Mun Hospital, Hong Kong, China
Objectives: The efficacy of second-trimester maternal serum hCG andAFP screening for fetal Down’s Syndrome is well established. Weinvestigated the use of first trimester screening by nuchal translucency(NT) either in isolation or in combination with maternal age and secondtrimester serum markers.Study Methods: All pregnant women attending the obstetric clinic before15 weeks of gestation were recruited. An abdominal and/or vaginalultrasound examination was performed at 10-14 weeks to measure thefetal crown-rump length, bi-parietal diameter and NT. The NTmeasurements were not disclosed and acted upon. All women had serumAFP and hCG test at 15-20 weeks. The risk of having a Down’ssyndrome birth was calculated taking into account the maternal age,weight, AFP and hCG level. Amniocentesis was offered if this assignedrisk was ³ 1:250 or if maternal age was ³ 35.Results: Between January 1997 and February 1999, 13 453 women wererecruited (25% ³ 35 years of age). 656 defaulted the serum test at 10-15weeks after recruitment and these were excluded from analysis. NTincreased with gestational age and a log-linear model fitted the data well(NT median=100.0051x gestational day –0.2377). All the NT were converted tomultiple of the median (MoM). Of the 12 717 pregnancies analyzed, 32were affected by Down’s syndrome. The log means and SDs of NTMoM for affected and unaffected pregnancies were 0.22, 0.18 and 0,0.12 respectively. NT MoM was not correlated with age, AFP MoM andhCG MoM. At a false positive rate of 5%, the detection rate of Down’sSyndrome by NT alone, NT + age, serum hCG + AFP + age and NT +serum hCG + AFP + age were 56%, 67%, 78% and 87% respectively.Conclusions: First trimester NT and second trimester AFP, hCG test canbe used in combination to provide an effective method of screening forDown’s Syndrome.
FC3.14 PROLAPSE AND PELVIC FLOOR REPAIR
FC3.14.01SACROSPINOUS LIGAMENT FIXATION OF THE PROLAPSEDVAGINAL VAULT FOLLOWING HYSTERECTOMYU. Aufderhaar , A. C. Almendral, W. Holzgreve, A. Dellas. Dept.Obstetrics & Gynecology, University Hospital, Basel, Switzerland
Objectives: The purpose of this study was to assess the results of thesacrospinous ligament fixation for the treatment of vaginal vaultprolapse following hysterectomy.Study Methods: Between 1979 and 1996 sixty-three women underwent areconstructive operation due to vaginal prolapse following abdominal orvaginal hysterectomy. Sacrospinous ligament fixation was carried out inall women in combination with operative correction of either cysto-and/or rectocele.Results: Recurrent vaginal prolapse occurred in only one woman 3 yearsafter the operation. Temporary nerve damage was observed in twopatients. Six women reported urine loss due to stress incontinencefollowing sacrospinous ligament fixation.Conclusions: Vaginal vault suspension to the sacrospinous ligamentavoids major abdominal surgery and allows the surgeon to correctcoexistent cystocele and rectocele. Sacrospinous ligament fixation of theprolapsed vaginal vault should be carried out with colposuspension if amasked urinary stress incontinence is preoperatively detected.
FC3.14.02INDICATIONS, OPERATIVE TECHNIQUE, AND OUTCOME OFVAGINAL SACROSPINOUS COLPOPEXY: A PROSPECTIVEOBSERVATIONAL STUDY OF 230 CASES OF VAULT ANDUTEROVAGINAL PROLAPSEM. Hefni , T.A. El-Toukhy, Dept. GYN, Benenden Hospital, Kent, UK.
Objective: To identify the indications, determine the operative and longterm follow up outcome of sacrospinous colpopexy and to demonstratethe safety of the technique.Methods: Between September 1993 and February 1999, 230 womenunderwent transvaginal sacrospinous colpopexy. 128 women (55.6%)had previously undergone one or more pelvic operation, 102 (44.%) hadpost hysterectomy vault prolapse, and enterocele was present in 172(74.7%). Uterus was conserved in 36 women either because they wereover 65 years old or in young nullipara. Patient’s data were collectedprospectively at the time of initial recruitment, during hospital stay andat the end of each follow-up visit following surgery.Results: The main indications of sacrospinous colpopexy were vaultprolapse, procidentia, second degree uterine prolapse if the vaginal vaultremains at or bellow the hymenal ring at the completion of hysterectomyand as main management of enterocele. The mean blood loss was 82 ml(range 15 to 800). One patient (0.4%) had a rectal injury duringdissection of the recto vaginal space. There were no incidental bladderor ureteral injuries. During the mean follow up period of 15 monthsthere was 7 cases of recurrences vault prolapse , a success rate of 97%,12 (5%) recurrent symptomatic cystocele, 33 (14%) asymptomaticcystocele. There was 6 recurrences of rectocele but only one wassymptomatic. There was no recurrence of enterocele. All sexually activewomen were maintained there sexual function with adequate vaginaexcept two women needed Fenton’s procedure. 43% reportedimprovement in sexual function one year after the operation. Fourteenwomen presented with symptoms of fecal incontinence, 9 (64.3%)women reported cure and 4 (28.6%) improvement of their symptoms.Conclusions: This study demonstrated the safety of the technique withvariety of indications and high success rate. Vaginal sacrospinouscolpopexy maintains the vaginal apex at its normal level, the normalanatomical angle of the vagina over the levator plate and the sexualfunction, it is very valuable technique to correct level I defects (Cardinalligaments and paracolpium) and should replace the traditional vaginalhysterectomy and repair for procidentia and advanced utero vaginalprolapse.
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FC3.14.03PROPOSAL FOR A WORLDWIDE, USER-FRIENDLYCLASSIFICATION SYSTEM FOR PELVIC ORGAN PROLAPSESE Swift, RM Freeman , E. Petri, U. Ulmsten. Standardization ofTerminology Committee, International Urogynecology Association(IUGA)
Objective: The IUGS standardization of terminology committee wasapproached by the International Federation of Gynaecologists andObstetricians to review the current literature on pelvic organ prolapseclassification systems and describe a simple, reliable and reproduciblesystem that could be recommended for worldwide use.Materials and Methods: A review of the published literature on variousprolapse classification systems was done to assess the current state ofscientific study regarding various classification systems. We alsodeveloped and sent out a questionnaire to selected members of theInternational Continence Society (ICS) to query their opinions regardingseveral current systems in use. We asked whether or not they were usingthe pelvic organ prolapse quantification (POPQ) ICS system, the«halfway» system and the «New York» system. We also asked forcomments regarding the use of the various systems.Results : In reviewing the literature, only the «halfway» system and thePOPQ system had been investigated to determine their intra- and inter-examiner reliability. They were both deemed reliable. Also, it wasobserved that the POPQ system is gaining recognition as the standard forscientific literature in studies regarding pelvic organ prolapse. Thequestionnaire results demonstrated that individuals were using amultitude of systems with no clear consensus. Only 20% of the membersof ICS polled were using the POPQ system despite the fact that the ICSmembership endorsed it as the standard pelvic organ prolapseclassification system. The most common reason cited for not using thePOPQ system was that there were difficulties in learning and teachingthe complexities of this system. The committee then developed asimplified version of the POPQ that retained the ordinal staging systemof the POPQ. The simplified version continues to require description ofthe anterior, apical and posterior segments of the vagina but onlyrequires one point for each segment. Also, it allows for continued use ofthe familiar terms cystocele, rectocele, and enterocele. The proposedsystem is as follows:Stage 1: Prolapse that descends to within one centimeter above thehymenal remnants.Stage 2: Prolapse that descends to the introitus defined as one centimeterabove or below the hymenal remnants.Stage 3: Prolapse that descends past the introitus but does not representcomplete vaginal eversion or complete procidentia uteri.Stage 4: Complete vaginal vault eversion or complete procidentia uteri.Conclusion: There continues to be no consensus regarding aclassification system for pelvic organ prolapse. There is a need for asimple, user-friendly classification system which will allow for accuratedescription of prolapse for physicians worldwide. The IUGAStandardization Committee proposes this simplified version of thePOPQ system and recommends further study to determine its usefulnessand reproducibility.
FC3.14.04HYSTEROSUSPENSION THROUGH ABDOMINALAPONEUROTIC FASCIA FLAPS AS CONSERVATIVETREATMENT OF UTERINE PROLAPSEV Vavala , A. Monaco, E. Solima, G. Matonti, L. Muzii*, A. ScribantiOb/Gyn Dept. Ospedale degli Infermi, Biella, Italy*Ob/Gyn Dept. Libero Istituto Universitario Campus Biomedico, RomeItaly
Objectives: The authors describe a conservative surgical technique ofhysterosuspension by means of flaps developed from the aponeuroticabdominal fascia in patients with severe hysterocele.Material and Methods: Forty-one patients, aged 26 to 41 years,underwent the technique described. Patients were followed for a meanperiod of 5.5 years to evaluate possible recurrence. No intra- orpostoperative complication occurred.Results: All the patients were satisfied with the surgery. After a follow-up ranging from 2 to 23 years (mean : 5.5), only two patientsnecessitated further surgery, one for cystocele that developed three yearsafter the initial procedure, and one patient underwent total abdominalhysterectomy for multiple myomas six years after the procedure. In two
patients, a normal intrauterine pregnancy was carried to term anddelivered vaginally.Conclusions: The present series suggests that a conservative techniqueof hysterosuspension to abdominal fascia flaps can be offered to patientswho express their desire of preserving the genital anatomy. Thetechnique presented here appears to be safe and effective in theconservative treatment of genital prolapse.
FC3.14.05OPERATIVE MANAGEMENT OF POST-HYSTERECTOMYVAGINAL PROLAPSE AND INCONTINENCEG. Ohlenroth , M. Butterwegge, Dep. OB/GYN, MarienhospitalOsnabrueck, Johannisfreiheit 2-4, 49074 Osnabrueck, Germany
Objectives: Complete genital or vaginal prolapse affects a large numberof middle aged to elderly females. Satisfactory correction of prolapsehas been a challenge to the pelvic surgeon for many years and multipleoperative vaginal or abdominal methods are described.Study Methods: A retrospective analysed examination was carried out inpatients with posthysterectomy vaginal vault prolapse. Two hundredfourtyeight patients, aged 48 to 90 years (mean age 71), underwentabdominal fixation using Williams and Richardsons method and Burchprocedure in cases of stress incontinence in 76 cases. Conjunction withenterocele repair (92 patients), vaginal hysterectomy (56 patients), orboth (46 patients).Results: Two hundred eleven patients were followed up at a mean of23.3 months (range 6.5 to 39). Recurrence of enterocele or vaultprolapse occurred in 3 patients (1.2%; 3/248) All patients who hadpreoperative stress incontinence were cured of leakage. Complicationswere rare, and there were no instances of vaginal foreshortening, urinaryretention, vaginal skin necrosis, bladder perforation, or rectovaginalfistula. Neither dyspareunia nor stress urinary incontinence were seen ascomplications of our procedures. The patients who were sexually activehave begun having normal sexual intercourse again.Conclusions: Our survey confirms the information and the good result ofthis technique in the treatment of the total vaginal dome prolapse. Theoperation allows a secure fixation of the prolapsed-vault of the vaginawith nearly optimal anatomic and functional restoration of the vagina.
FC3.14.06MORBIDITY OF ABDOMINAL, VAGINAL AND LAPAROSCOPICHYSTERECTOMIESMäkinen J . et al., Department of Obstetrics and Gynecology, UniversityCentral Hospital of Turku, Turku, Finland
Objectives: The aim of the study was to evaluate the influence of thetype of surgery, abdominal, vaginal or laparoscopic, in causing oravoiding certain complaints is, however, controversial.Study Methods:We conducted a prospective nationwide studycomprising all hysterectomies for benign disease performed in Finlandduring 1996. An evaluation of the operation-related morbidity, commonsurgical details, operative complications and short-term outcome up to 3months were compared between the types of operation.Results: A total of 10110 hysterectomies, including 5875 abdominal,1801 vaginal and 2434 laparoscopic operations showed a low rate ofoverall complications, 17.2 %, 23.3 % and 19.0 %, respectively.Between the three groups, the laparoscopic approach was associatedwith the longest operation time and the shortest hospital stay and sickleave. Infections were most common complications with the incidenceof 10.5 %, 13.0 % and 9.0 % in the abdominal, vaginal and laparoscopicgroup, respectively. The most common type of infections was urinarytract infections with the highest rate in the vaginal group (7.3%). Themost severe type of hemorrhagic events (intra-abdominal bleeding)occurred in 2.1, 3.1 and 2.7 % in the abdominal, vaginal andlaparoscopic group, respectively. Ureter injuries had a predominance inlaparoscopic group (RR 7.2 cf. abdominal) while bowel injuries weremost common in vaginal group (RR 2.5 cf. abdominal). Surgeons whohad performed over 30 laparoscopic hysterectomies had a significantlylower incidence of ureter and bladder injuries (0.5 and 0.8 %,respectively) than those who had performed 30 or less operations (2.2and 2.0 %, respectively). A decreasing trend of bowel complications wasseen also with increasing experience in vaginal hysterectomies.Conclusions: This large series of hysterectomies provide novel rates ofmorbidity that a gynecologist can face when performing either
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abdominal, vaginal or laparoscopic approach. It also proves theimportance of the experience in reducing severe complications,especially in laparoscopic and vaginal hysterectomies.
FC3.14.07SURGICAL TREATMENT OF VAGINAL PROLAPSE AFTERHYSTERECTOMYV. D. Petrova , S.N. Buyanova, M.N. Ioseliani, A. A. Popov, MoscowRegional Scientific Research Institute of Obstetrics and Gynecology,Moscow, Russia.
Objectives: To define the optimum methods of surgical treatment ofvaginal prolapse after hysterectomy.Study Methods: We have operated on 65 patients because of therecurrence of prolapse. Of these 65, 24 developed recurrent prolapseafter vaginal hysterectomy and 41 after abdominal. 27 patients sufferedstress incontinence (tipe I-II of ICS). All patients were operated upon:aponeurotic vaginopexy (abdominal or laparoscopic approach). In 27women, this operation was supplemented with Berch’s operation. Therestoration of the pelvic diaphragm was essential.Results: 3 years later, the results of the operation were satisfactory. 2years later, the prolapse (rectocele) was recurrent in 5 patients (7.7%).Stress incontinence recurred in 3 patients, 2 years later (11.1%).Conclusions: The aponeurotic vaginopexy (or MESH-vaginaopexy) wasthe most effective method for correction of the recurrence of prolapse. Itwas obligatory for the patients with stress incontinence to be treated witha combination of operations.
FC3.14.08SURGICAL TREATMENT OF PROCIDENTIAA. Y. Goldina , S. M. Semyatov, A. O. Dukhin, Dept. OB/GYN,Maternity Hospital N 25, Russian Peoples’ Friendship University,Moscow, Russia.
Objectives: This study was undertaken to evaluate the effectiveness ofsurgical treatment of procidentia (P) in menopausal and postmenopausalwomen.Study Methods: During 1995-1999, 113 patients with P aged 62-91years old were performed the Le Fort operation, which in some caseswas combined by the reconstruction of the levator ani group.Results: Pre-operative investigation detected that all patients were notsexual active, 62 complained of sense of heaviness and “foreign body”in perineal area, 18 had difficulties with micturition and defecation andtrophic ulceration was diagnosed in 58 women. There were markedvarious accompanying somatic diseases (arterial hypertension, bronchialasthma etc). Before operation all patients underwent thorough clinicalinvestigation, received procedure improving the trophics of vaginalwalls, got treatment of trophic ulceration and somatic diseases. 90patients were operated on under epidural anaestesia.. In 23 women theLe Fort operation was performed in combination with levatoroplastybecause of expressed incompetence of the pelvic floor muscles and itallowed to prevent the displacement of anterior wall of rectum in allcases. For long-term coaptation of wound surfaces the synthetic absorbsuture were used. Postoperative period was uncomplicated in allpatients. Follow-up (for five years) showed any no case of relapse of thedisease.Conclusions: The Le Fort procedure especially carried out with thelevatoroplasty is the optimal method of surgical treatment of P andprovides the improvement of “quality of life” in menopausal andpostmenopausal periods.
FC3.14.09SURGICAL CORRECTION OF UTERINE PROLAPSE.G.Savelieva , L.Kappusheva, B.Baisova, Dept.OB/GYN, Russian StateMedical University
The prolaps of the uterus (PU) has makes up a significant portion amonggynecological diseases. PU occurs not only in older age? but also inyoung women. Surgical intervention is the optimal method of tratmentof PU. There have been suggested about 500 types of operations, butrecurrence rate may be from 2,3 to 33%.Follow-up results of 427 patients operated on for PU (the age rangesfrom 31 to 82) have been analysed: 263 after vaginal hysterectomy by
Mayer with the application of the suturing device; 73 - after Williamson-Richardson-Krasnopolsky technique with flaps aponeurosis; 54 - afterventrofixation of the cervix or vagina;60 - after Manchester operation.The follow-up results showed the recurrence of prolaps in 1 patient aftervaginal hysterectomy, in 2 patients after fixation with flaps aponeurosisand in 1 patient after ventrofixation of the cervix. All these patientsunderwent sacrocolpopexia with good results.The choice of surgical intervention in PU depends on the age,occupation, stage of the disease, concomotant gynaecological pathology,the presence of urinary incontinence.Our results lead to the conclusion, that the method of choice for PU ofII-III stages for elderly patients is vaginal hysterectomy by Mayer, inyoung patients - is fixation (uterus, cervix, vagina) of flaps aponeurosisor sacropexia. For PU of I-II stages with elongation of the cervix -Manchester operation.
FC3.15 TECHNIQUES IN CESAREAN SECTION
FC3.15.01COMPARATIVE STUDY: CESAREAN (CS) VERSUS VAGINALDELIVERY (VD) - DOES A MODIFIED TECHNIQUE OF CS HAVEAN EFFECT ON MATERNAL MORBIDITY?D. Fauck (1), M. Naett (1), J.H. Ravina (2),(1) Dept. GYN, Clinique Sully, Maison Laffitte, France.(2) Dept, OB/GYN, Clinique Spontini, Paris, France.
Maternal morbidity is known to be higher after CS than VD. The twomajor causes are infections and consequences of late mobilization due towound pain.We have used a latero-vertical incision of rectus abdominalis fascia,which provides less pain and better port-operative comfort. In additionwe have used an extraperitoneal technique as described by Norton tominimize the role of infection.During 36 months we performed 200 CS. Each CS was matched in acomparative study with the closest VD following or preceding. All CSand all VD were considered, without sub-groups.The studied factors were: blood loss, infection, analgesia, pain, intestinalpassage, mobilization, and hospitalization.The result in our study shows that maternal morbidity and discomfort arenot increased by extraperitoneal CS with vertical aponevrosis incisioncomparing to VD.
FC3.15.02IS CATHETRIZATION ESSENTIAL FOR CAESAREAN SECTION?H. Senanayake , University of Colombo, Kynsey Road, Colombo 08, SriLanka.
Introduction: Catheterization of the urinary bladder is considered anessential safety precaution for caesarean section (LSCS). It may increasethe risk of urinary tract infection (UTI) and discomfort to the mother.Objectives: To determine the feasibility and safety of performingcaesarean section without urethral catheterizationMethod: The study was conducted in two phases. The first phaseincluded 50 subjects who voided urine within an hour before electiveLSCS. They were catheterized for the duration of surgery. The volumeof urine collected in the bag at the time of entry into the peritonealcavity (Volume A) and at the end of surgery (Volume B) was measured.In the second phase of the study 200 women underwent elective LSCSwithout catheterization. The degree of distension of the bladder wasnoted.Results: The average of volume A was 25.5ml. (SD= 11.4) and that ofvolume B was 42.8 ml. (SD= 24.3). These volumes could be containedin spherical spaces whose diameters are 4.0 and 4.8cm respectively. Inthe second phase of the study without catheterization, the bladder wasnot filled to be visible above the symphysis pubis in 129. In the other 71it was visibly filled, but was completely covered by Doyen's retractor.None of the second group had UTI, damage to the bladder orpostoperative urinary retention.Conclusions: During elective LSCS without a urinary catheter, thebladder does not distend to a volume that compromises ease of surgeryor safety. Catheterization for LSCS as a routine is unnecessary.
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FC3.15.03SINGLE LAYER CLOSURE OF CAESAREAN SECTION - ACOMPARATIVE STUDY.E. Lodh , P. Bhattacharjee, Indira Gandhi Memorial Hospital,Krishnanagar, Agartala, Tripura, India
Objectives: The aim was to introduce a safe simple and cost effectivetechnique of Caesarean section.Study methods: The study was conducted at IGM Hospital, Agartala,India. In the study group 5000 women underwent Caesarean section insingle layer closure technique and another 5000 cases (controlledgroup) had section in conventional method. Both the groups includedprimi and multi-gravida, elective and emergency cases with similarindications in same age group. Technique - A transverse skin incision ismade 2.5 - 3 cm above the symphysis pubis. A nick is made in the rectussheath which is stretched cranially and caudially. A hole is made withfinger in the parietal peritoneum which is widened. Lower segment isincised. Delivery of baby and placenta done as usual. Uterine wound isclosed in single layer with continuous unlocked suture. Visceralperitoneum is repaired. Parietal peritoneum is not stitched. Rectus sheathand skin are stitched as usual.Results: In the study group mean operative time is 23 minutes. Operativeblood loss is minimal, IV fluid requirement is less, ambulation is earlier.Incidence of PPH, Postoperative pain and morbidity is much less and thehospital stay is shortened.Conclusions: Patients operated in this technique has faster post-operativerecovery and are better able to take care of their babies. The single layertechnique should be included in text book.
FC3.15.04SINGLE LAYER –VS- TWO LAYER CLOSURE OF UTERUSDURING CAESAREAN SECTION – AN INSTITUTIONALEXPERIENCEB. Mukhopadhyay , Dept. OB/GYN, Calcutta Medical ResearchInstitute, Calcutta, India.
Objectives: Closure of a low transverse cesarean incision with one layeris associated with less per operative complications and post-operativemorbidity compared with the traditional two-layer closure.Study Methods: A prospective randomized controlled study wasperformed in our institution during the period January 1997 to October1999. A total of 412 women were randomized to closure of a lowtransverse cesarean section with one continuos layer of non-lockingnumber 0 vicryl suture or two continuos layers with the first one locked.Preoperative and post-operative outcome were then compared.Results: A significant decrease in operating time and post-operativefabrile morbidity was found for the singe layer closure (p<0.01). Nodifferences were found for operative blood loss or post-operativehysterographic evaluation of the scar.Conclusions: Continuous no-locking, single layer closure of the uterus isnot only expedient but also promises a safer post-operative course.
FC3.15.05COMPARISON OF NEW (“LANIADO”) AND STANDARDTECHNIQUE FOR LOW ISTHMIC TRANSVERSE CESAREANS. Lurie , M. Feinstein, Y. Mamet, Dept. OB/GYN, Laniado Hospital,Netanya, Israel.
Objective: To evaluate the efficacy and maternal morbidity of a newmethod for low isthmic transverse cesarean. The highlights of the newmethod are: Pfannenstiel incision, blunt expansion of subcutaneoustissue and the fascia, blunt expansion of subcutaneous tissue and thefascia, blunt opening of the parietal peritoneum, vertically, nointraperitoneal swabs, blunt expansion of the uterus, double layer closureof the uterus, nonclosure of visceral and parietal peritoneum, continuousnon-locking suture of the fascia and nonsuturing of the subcutaneoustissue.Methods: The study group included all patients who underwent a firstcesarean by new method during the 1998 (n=51). The control groupincluded patients who underwent a first cesarean by standard methodduring the same year matched for age (within two years), parity(primiparous vs. multiparous) and gestational age at delivery (within oneweek) (n=51).
Results: The mean (±SD) operation time was shorter in the new methodgroup as compared to standard method group, 14.5±5.5 minutes and31.4±8.1 minutes, respectively (p<0.05). The postoperative morbidity issimilar in both groups of patients regardless whether the operation wasperformed using the new method or the standard one. The mean (±SD)hospital stay was similar, 5.1±2.5 days and 6.8±1.3 days, respectively(p=0.62).Conclusion: Both methods are equivalent in maternal morbidity. Weemphasize the simplicity, efficacy, and safety of the new (“Laniado”)method for low isthmic transverse cesarean.
FC3.15.06SINGLE-LAYER REPAIR OF THE UTERINE INCISION INCESAREAN SECTIONS, A VERY SAFE AND TIME SAVINGTECHNIQUE.C. Baruah , Dept. OB/GYN, OIL India Hospital, Duliajan, Assam, India.
Objectives: The aim of this study was to assess the effectiveness ofsingle-layer repair of uterine incision in cesarean section in both electiveas well as emergency cases.Study Methods: Two hundred and fifty-six cesarean operations wereperformed using continuous locked single layer stitch using No. 1polyglactin suture material to repair the uterine incision. Out of these148 (57.9%) cases were emergency operations and 108 cases (42.2%)were elective. 190 cases (74.3%) were first cesarean, 40 cases (15.7%)were repeat cesarean, and 16 cases (6.3%) were repeat cesarean for thethird time. Patients were discharged from hospital as early as 4 days to10 days. Patients were observed for any fever, pain, signs of infectionand particularly PPH and evaluated again at 2 weeks, 1 month and 3month intervals when ultrasonography was done to see the uterine scar.Results: Out of 256 cases, only 2 cases (0.8%) had severe PPH whichwas treated conservatively. In the rest, the post-operative period wasuneventful. 35 women conceived again within 6 months, in whomtermination of pregnancy was done in 15 (5.9%) and 20 (7.9%) of thewomen had full term pregnancy. Out of them, 14 women (5.5%) wentfor repeat cesarean. In no case was there any weakness in ultra-sonography or rupture of uterine scar. Incidence of placenta accreta wasnil.Conclusion: Single layer repair of uterine incision in cesarean section isvery effective which saves time without any short and long termcomplications.
FC3.15.07EVALUATION OF MATERNAL MORBIDITY AND PERINATALMORTALITY IN DIFFERENT TYPES OF CESAREAN SECTIONSA.A. Youssef , A.M.Sabra, N.M. Fahmy, H.A. Abdel-Hafize, Dept.OB/GYN, Assiut University Hospital, Assiut, Egypt.
Objectives: The study was done to determine the relation of maternalintrapartum and postpartum complications and the newborncomplications to the type of cesarean section.Study Methods: The study was prospective and included 400 pregnantwomen undergoing cesarean section (CS); 131 women (32.8%) hadundergone elective CS (group 1); 239 women (59.8%) had undergoneselective CS (group 2) and 30 women (7.5%) had undergone CS afterneglected labor or failure of instrumental vaginal delivery.Results: Regarding the maternal intraoperative complications theincidence of intraoperative hemorrhage was 26% in group 3, 16% ingroup 1, 15% in group 2, the difference was statistically higher in group3 than in group 1 and group 2. The incidence of postoperative maternalfebrile morbidity and urinary tract infection in group 3 was statisticallyhigher in group 3 than in group 1 and group 2. The perinatal mortalityrate was 20% in group 3 compared to 11.4% in elective cases and 7.9%in selective cases, thus perinatal mortality rate in group 3 wassignificantly higher than in elective and selective cesarean section.Conclusion: Cesarean section carried out after neglected labor or afterfailure of instrumental vaginal delivery had significant maternalmorbidity and perinatal mortality than elective and selective cesareansection.
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FC3.15.08MYOMECTOMY IN COURSE OF CAESAREAN SECTIONWojciech Kazimierak , Maria Brzozowska, Teresa Pajszczyk-Kieszkiewicz, Medical University of Lodz, Lodz, Poland
The study was performed in the group of 144 women with uterinemyomas delivered by cesarean section between 1986 and 1999 year.The study group was divided on three subgroups:• the first one consisted of 22 cases of the uterine myomas, which werethe only indications to the cesareansection because of pain, locationmaking the normal delivery impossible, large size or necrosis confirmedby ultrasound; • the second one consisted of 45women with small uterine myomas (to40 milimeters in diameter) recognized during the pregnancy, who weredelivered by cesarean section because of the other indications• three subgroup consisted of 77 women with small size uterine myomasrecognized in the course of cesarean section done because of the otherindications (their location making an ultrasound detecting during thepregnancy impossible).The small size uterine myomas were enucleated as a whole. The largesize uterine myomas were removed by progressive dismemberment - thismethod reduces the possibility of the intraoperative hemorrage.The good hemostasis was achieved fast owing to an application thecontinuous suture through all layers of the site of the myoma removal.The hemoglobine concentration in blood measured in the second twenty-four hours post operation, time of hospitalization following the operationand incidence of high temperature were compared with control group.No significant difference between these parameters in the both groupswas confirmed.The myomectomy in the course of the cesarean section does notinfluence the incidence of the postoperative complications. Thisprocedure seems to be of profit to the patients, because it allows them toavoid the next operation.
FC3.15.09CRITICAL ANALYSIS OF MATERNAL DEATHS FOLOWINGCAESAREAN SECTIONS. Sapre , S. Surana, Dept OB/GYN, Gajra Raja Medical College,Gwalior, Madhya Pradesh, India
Objective: The aim of the study was to investigate the causes of deathafter caesarean and suggest remedies to reduce the number of deaths.Study Methods72 maternal deaths following caesarean from January 1994 to December1998 were analyzed.Results: Out of 20 293 deliveries in K.R.H. 4646 (22.9%) delivered bycaesarean section 0.72 (1.5%) died following caesarean section. Onanalysis, 90.3% unbooked, 97% from rural population and 93%emergency caesarean. Indications of operation were obstructed labor29%, eclampsia 23%, sepsis 20.8%, anemia 20.8%, hemorrhage 8.3%and embolism 8.3%.Conclusion: Majority of deaths can be avoided by proper utilization of3E’s ® Essential antenatal care, early detection of complications andefficient emergency services, with creation of awareness of maternalhealth, safe delivery by trained person at periphery with prompttransport facilities, adequate blood transfusion.
FC3.16 ABDOMINAL HYSTERECTOMY
FC3.16.01RANDOMISED, PROSPECTIVE, DOUBLE-BLIND COMPARISONOF ABDOMINAL VERSUS VAGINAL HYSTERECTOMYTariq Miskry , A. Magos, NSW, Australia
Objectives Although vaginal hysterectomy is feasible in the majority ofpatients undergoing surgery for benign indications, most hysterectomiesworld wide are done abdominally with the exception of cases of genitalprolapse. One reason cited for this practice is a lack of controlledevidence in favour of vaginal surgery. We report a prospectiverandomised comparison of vaginal with abdominal hysterectomy inwomen suitable for either approach.Methods 36 patients attending the University Department of Obstetricsand Gynaecology, Royal Free Hospital, London, UK were recruited andrandomised in the operating theatre immediately prior to surgery. All
hysterectomies were carried out by experienced surgeons, and at the endof surgery identical wound dressings were placed on the lower abdomenirrespective of hysterectomy route. Carers and patients remained blind toroute of surgery until the day of discharge. The time of discharge wasthe primary end-point and was patient determined.Results There were no significant differences in peri-operative patient orsurgical characteristics. Vaginal hysterectomy was associated with areduction in hospital stay compared to abdominal hysterectomy (medianstay 3 days vs 5 days, p < 0.01). In addition patients undergoing vaginalhysterectomy had reduced analgesic requirements (75.4 mg vs 131.4 mgmorphine equivalent, p < 0.01), shorter need for intravenous hydration(25.3 hours vs 32.7 hours, p <0.05), and faster return of bowel action(median 3 days vs 4 days, p <0.001). They also returned to normaldomestic activities (median 5 weeks vs 8 weeks, p = 0.03) and work(median 7 weeks vs 11.5 weeks, p < 0.01), and completed their recovery(median 8 weeks vs 12 weeks, p=0.02) more quickly.Conclusions: Vaginal hysterectomy is associated with significantbenefits in terms of reduced hospital stay and improved patient recoveryand as such should be considered the route of choice in the majority ofcases.
FC3.16.02CLOSURE VERSUS NON-CLOSURE OF PERITONEUM ATABDOMINAL HYSTERECTOMY AND SHORT-TERMMORBIDITY: A RANDOMIZED STUDYA.W.M. Afify , M.E. Ibrahim, A.B.M Al-Nashar, Dept. OB/GYN, BanhaUniversity Hospital, Nasr City, Egypt.
Objective: To compare closure and non-closure of the visceral andparietal peritoneum at abdominal hysterctomy with respect to short-termpost-operative morbidity.Study Methods: Prospective controlled study included 86 womenundergoing elective abdominal hysterectomy and were randomlyassigned to one of three groups: visceral and parietal peritoneum open(Group A, n=34), visceral peritoneum open (Group B, n=24) orperitoneum closed as control (Group C, n=28). The main outcomemeasures were operative time, febrile morbidity, analgesia required,ileus, unassisted ambulance and hospital stay.Results: Population characteristics were similar between the threegroups. The operative time of the study group A was significantly lessthan the study group B and control group C and the study data indicatesthat febrile morbidity was significantly related to operative time length.The control group C had non-significant less wound infection anddehiscence and urinary catheterization compared to the other studygroups. The study groups A and B had less non-significant wouldhematoma, cystitis, ileus and blood transfusion compared to the controlgroup. The study groups A and B had significantly less febrile morbiditycompared to the control group and the mean number of analgesic dosesrequired and time to oral intake were significantly higher in the controland study group B compared to study group A.Conclusion: Non-closure of the peritoneum at abdominal hysterectomyis advantageous and not associated with increased incidence of short-term morbidity. So we advocate the use of the non-closure of thevisceral and parietal peritoneum technique at abdominal hysterectomywhich is simpler than the traditional peritoneal closure technique.
FC3.16.03RANDOMISED TRIAL OF TOTAL VERSUS SUBTOTALHYSTERECTOMY: POSTOPERATIVE COMPLICATIONS.H.Gimbel, Dept.OB/GYN, Hvidovre Hospital,Denmark , V.Zobbe,B.Andersen, Dept.OB/GYN, County Hospital of Roskilde, T.Filtenborg, Dept.OB/GYN, County Hospital of Slagelse, K.Jacobsen, C.Sørensen, K. Toftager-Larsen, Dept.OB/GYN, County Hospital ofHillerød, E.M.Madsen,Dept.OB/GYN, County Hospital of Gentofte,N.Møller, K. Sidenius, Dept.OB/GYN, County Hospital of Glostrup, A.Rosgaard, Dept.OB/GYN, County Hospital of Holstebro, M. Vejtorp,H.Clausen, Dept.OB/GYN, County Hospital of Herlev, B.Ottesen,A.Tabor, Dept. OB/GYN, Hvidovre Hospital, Denmark.
Objectives: The aims of this study are to assess the effect ofhysterectomy with and without conserving the cervix on postoperativecomplications, bladder, bowel and sexual function, pelvic pain,descensus of the vaginal top/cervix uteri, vaginal bleeding andpsychological well-being.
WEDNESDAY, SEPTEMBER 6 45
Study Methods: This multicenter Danish, randomized trial includedwomen undergoing hysterectomy for benign disease from 1 April 1996to 31 April 2000. The sample size was estimated as 320 women basedon the assumption that subtotal hysterectomy reduces the incidence ofurological complications by 10% (test of significance at 5% level, power80%). The endpoints are postoperative complications, bladder, boweland sexual function, pelvic pain, descensus of the vaginal top/cervixuteri, vaginal bleedings and psychological well-being. These aremeasured by validated, questionnaires filled out by the women beforeand 8 weeks, _ year, one, five and 10 years after the operation.Information about postoperative complications was collected by filesfilled out by the operating gynecologist. The automatic randomisationprocedure was computer generated using block randomisation andstratification by center and ovarian status. An independent data-monitoring committee (DMC) has supervised the study. Their interimanalyses regarding postoperative complications and urinary incontinencehave not caused the study to be stopped.Results: As 300 patients have been included by 15 January 2000,recruitment for the study is estimated to be finished by May 2000. Dataregarding the complications during the first eight weeks after theoperation will be presented.Conclusions: present data from the first randomised trial of total versussubtotal hysterectomy.
FC3.16.04THE TECHNIQUE, SAFETY, AND COST-EFFECTIVENESS OFMINIMAL INVASIVE ABDOMINAL HYSTERECTOMY (MIAH)USING STANDARD LAPAROTOMY EQUIPMENTF. Lee , C. Gupta, Dept OB/GYN, University of Manitoba, Winnipeg,Manitoba, Canada
Objectives: To demonstrate the technique, safety, and cost effectivenessof MIAH.Study Methods: One hundred and fifty-two women with non-malignantdisease who were not suitable for vagina hysterectomy were included inthis study. Hospital stays were compared with hysterectomies done byopen laparotomy, vaginal and laparoscopic assisted vaginalhysterectomy (LAVH) techniques.Results: One hundred and twenty-seven women had TAH and 25women had sub-total abdominal hysterectomy by choice. Spinalanesthesia was used in 122 women. The average weight of women was69 kg with 40 women ranging form 80 to 160 kg. Sixty-five women hadprevious major abdominal surgery. Average weight of uterus was 183grams, ranging from 44 to 1400 grams. Average surgical time was 54minutes. No major complications encountered. Average length ofhospital stay was 2.2 days compared to regional hospital stay of 4.4 daysfor abdominal hysterectomy, 3.5 days for vaginal hysterectomy and 2.7days for LAVH.Conclusions: The technique of MIAH using standard open surgeryequipment is safe, decreases patient morbidity and is cost effective.
FC3.16.05TOTAL LAPAROSCOPIC HYSTERECTOMY VERSUS TOTALABDOMINAL HYSTERECTOMY: A CONFRONT OF 101 VS 100CASES IN A PROSPECTIVE RANDOMIZED STUDYG. Cucinella , G. Gugliotta, B. Adile, Dept. OB/GYN, Villa SofiaHospital, Palermo, Italy.
Objectives: In this prospective randomized study, 101 cases oflaparoscopic hysterectomy (LH) were compared to 100 cases of thetraditional abdominal hysterectomy (AH). Patients were enrolled in thisstudy from January 1997 and September 1999 at our Dept. of OB/GYN,Villa Sofia Hospital.Materials and Methods: The criteria for choosing LH were generallybased on uterus volume which should not exceed that of 18 weekspregnancy. The indications were the same for both LH and AH included:abnormal uterine bleeding or menorrhagia in 30 pts, enlarged uterus withmyomas in 60 pts, pelvic pain in 27 pts, abnormalities of pelvic floor in15 pts and adnexal mass in 19 pts.The study was randomized and patients had given their informedconsent to undergo either LH or AH. Blood loss during LH wascalculated as the difference between the volume of liquid introduced andthe volume of liquid aspirated during the operation. Post-operative painwas assessed in three days after surgery using the visual analogic scale
(VAS) from 0=no pain to 10=max pain. A temperature of 38°C startingfrom the second post-operative day was considered as post-operativefever. The following parameters were also evaluated: post-operativedrop of hemoglobin (Hb) complications, duration of post-operative stay.Results: The average time employed for LH was about 104.1± 26.98 min(range 72-163). Average intraoperative blood loss was significantlylower in LH as opposed to AH, with lower first post-operative day Hbdrop in the pts who underwent LH (table I). It was never necessary toconvert LH to abdominal. Patients who underwent LH had less intensepost-operative pain than pts in the group of AH (table II). Post-operativecomplications in the LH group were fever in one pt. And a ureteral-vaginal fistula diagnosed 10 days after surgery in one patient, for whichit was necessary to introduce a ureteral splint. In the AH two cases ofhematoma of the vaginal cuff and 4 cases of fever.
Table I : Comparison of post-operative results of laparoscopic andabdominal operations
Parameters Laparoscopic Abdominal P valuehysterectomy hysterectomy T test(No. pts: 101) (No. pts: 101)
Age 47.8 ± 7.42 47.6 ± 7.39 P-nsBody weight 62.71 ± 4.49 64.14 ± 4.52 P-nsParity 2.27 ± 1.48 2.35 ± 1.42 P-nsUterine weight (gm) 368 ± 125.3 389 ± 143.9 P-nsBlood losses (ml) 140 ± 41.5 406 ± 103.9 P<0.001Post-operative day1 Hb drop(gm/ml) 0.37 ± 0.22 1.59 ± 0.35 P<0.001Post-operative stay 2.38 ± 0.30 6.23 ± 1.85 P<0.001Data presented as mean ± SD ns = non-significant
Table II: The comparison of postoperative pain for laparoscopic andabdominal hysterectomyPost-operative pain (VAS) Laparoscopic Abdominal
hysterectomy hysterectomyDay 1* 4.1 ± 1.2 6.9 ± 1.8Day 2* 2.3 ± 1.6 5.4±1.3Day 3* 1.0±0.7 3.1±0.9
Data are presented as mean ± SD *P <0.001Conclusions: This study has demonstrated that after LH pts. recoveredfaster, had less pain and the incidence of complications was low.
FC3.16.06ROLE OF SUPRACERVICAL HYSTERECTOMY IN THETREATMENT OF MENORRHAGIAV Vavala , A. Monaco, E. Solima, G. Matonti, Ob/Gyn Dept. OspedaleDegli Infermi, Biella, Italy
Objectives: to compare intraoperative and postoperative outcome ofsupracervical hysterectomyMaterials and Methods: Between 1997 and 1999, 253 women underwenthysterectomy for unresponsive to medical treatment of menorrhagia atOb/Gyn Dept.of Biella hospital. Of these operations, 58.7% wereperformed by Supracervical Hysterectomy. The remainder, wereperformed either by total abdominal hysterectomy or vaginalhysterectomy. Comparative data of these surgical techniques concerningpatients' characteristics, blood loss, operating time, hospital stay, uterineweights, postoperatively used analgesics, bladder and rectal dysfunctionwere recordedConclusion Supracervical hysterectomy patients showed a statisticallysignificant reduction of intraoperative and postoperative complicationrate. Bladder dysfunction symptoms were more frequent in patientssubmitted to total hysterectomy either laparotomic or vaginal.
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FC3.16.07FAST TRACK HYSTERECTOMYC.Moeller , H.Kehlet, L.Schouenborg, B.Ottesen, S.G.Friland, C.Lund,Hvidovre University Hospital, Hvidovre University Hospital, Hvidovre,Denmark, DK-2650.
Objectives: The purpose of this prospective, descriptive study was toidentify factors limiting early discharge after hysterectomy in a fast tracksetting with emphasis on information, treatment of pain, earlymobilization and early food intake.Study design:1) Thirty-two unselected women were allocated to either abdominalhysterectomy (n=16) or laparoscopically assisted vaginal hysterectomy(LAVH) (n=16). The patients received the same information, care,advice and restrictions for the perioperative period except for anassumed one-day hospital stay in the LAVH-group and two days in theabdominal group.2) Thirty unselected women were assigned for abdominal hysterectomyin an assumed one-day hospital stay.Postoperative mobilization, gastro-intestinal function, length of stay,time for resumption of normal daily activities and work were registered.Results1) Median hospital stay was 1 day (1-3) after LAVH and 2 days (2-4)after abdominal hysterectomy. Work was resumed after median 23 daysin the abdominal group and after 28 days in the LAVH-group (NS).2) Median hospital stay was 2 days (1-4). Work was resumed aftermedian 19 days and leisure activities were resumed median 14 days afterthe operation.Conclusions: The study questions the proposed advantages of shortenedhospitalization and convalescence after LAVH compared withabdominal hysterectomy, since a fast track setting reduced the need forhospitalization and convalescence. Further studies with activerehabilitation are needed to demon trate differences betweenlaparoscopic and open hysterectomy.
FC3.16.08TRIAL OF OPEN VERSUS CLOSED VAGINAL VAULT INRELATION TO POSTOPERATIVE MORBIDITY AFTERABDOMINAL HYSTERECTOMYA.Anwer , Dept. OB/GYN, Military Hospital of Rawalpindi, Islamabad,Pakistan.
Objectives: The aim of the study was to evaluate and compare the resultsof two surgical techniques of abdominal hysterectomy; closed vaginalvault with single layer interrupted stitches versus open vaginal vaultwith continuous locking stitch.Study Methods: A prospective trial was carried out at Military HospitalRawalpindi Pakistan. One hundred and forty –two total abdominalhysterectomies were carried out. Patients were observed forcomplications during the postoperative hospital stay and reviewed 4-6weeks later.Results: In seventy cases (Group A), vault was left open while inseventy-two cases (Group B), it was closed. Post-operative abdominalwound infection was seen in five patients (7.1%) of Group A and inseven patients (9.7%) of Group B. Febrile morbidity was recorded in3.2% (Group A) and 4.8% (Group B). Vault granulation was observed in15% and 12% respectively. A single case of vault abscess was seen inclosed vault subjects. Vault haematoma was detected in three patients ofGroup A (4.2%) only.Conclusion: This study failed to show any advantage with regards topostoperative morbidity improvement with either of the techniques.However, vault haematoma seen in cases with vault open impressesupon the fact that vault collections can still occur laterally. A careful &thorough homeostasis remains a must.
FC3.16.09MINILAPAROTOMY TECHNIQUES FOR VARIOUSGYNECOLOGICAL SURGERIESJ.B. Sharma , Dept. OB/GYN, MAM College, New Delhi, India.
Objectives: The aim of this study was to assess the feasibility and safetyof minilaparotomy (incision up to 6 cm) for various gynecologicalsurgeries.
Study Methods: One hundred and thirty women were included in thisprospective study where surgery was successfully completed byminilaparotomy hysterectomy (Group A), thirty women of tubalrecanalization and tuboplasty (Group B) and thirty women of surgery forectopic pregnancy (Group C).Results: The mean operating time, day of mobility, starting normal dietand discharge from hospital were 45 minutes, 65 minutes, and 30minutes; 18 hours, 12 hours, and 10 hours; 2 days, 1.5 days, and 1.4days; 3.8 days, 3.2 days, and 3.1 days respectively in the three groups.Mean blood loss was 120 ml, 38 ml, and 375 ml and blood transfusionwas required in 4, 0, and 24 cases respectively in the three groups. Thepost operative complications were fever in 5, 2, and 3 cases, paralyticileus in 2, 0, and 2 cases, UTI in 4, 3, and 2 cases, urinary retention in 3,2, and 1 cases and wound infection in 2, 1, and 2 cases respectively inthe 3 groups.Conclusions: The minilaparotomy appears to be a safe and effectivetechnique for various gynecological surgeries.
FC3.17 DIABETES AND PREGNANCY
FC3.17.01INTRAPARTUM GLUCOSE-INSULIN INFUSION ANDNEONATAL METABOLIC PROFILE IN GESTATIONALDIABETES MELLITUSS. Ilic , L. Jovanovic, D. Pettitt, K. Hugo, Samsun Medical ResearchInstitute, Santa Barbara, California, USA.
Objectives: The main objective was to evaluate the impact of glucoseand insulin infusion intrapartum in women with gestational diabetesmellitus (GDM) on neonatal metabolic outcome.Methods: Ten insulin requiring women with GDM received anintravenous glucose-insulin infusion throughout labor and delivery(Group 1) in order to achieve stable maternal glucose concentrations,and 31women did not (Group 2). Glucose control was followed byHbA1c and glucose profiles in all 41 GDM throughout pregnancy. Atbirth, glucose, C-peptide, insulin and leptin were measured in maternaland cord blood. Neonatal glycemia was followed for 24 hours after birth.Results: Both groups maintained excellent glucose control (HbA1c = 4.9± 0.1, and 5.2±0.1, respectively for Group 1 and 2). At delivery,maternal glucose concentration was significantly lower (p=0.0018) inthe Group 1 (94.8±4.1 mg/dl), than in the Group 2 (121.4±4.7 mg/dl).Cord glucose concentrations did not differ between groups, however,five neonates in the Group 2 and none in the Group 1 had hypoglycemiaat birth (difference in proportions = 0.16, 95% confidenceinterval=0.03–0.29). Mean maternal and fetal C-peptide and insulinconcentrations and maternal leptin did not differ between groups.However, 4 of 5 neonates who experienced hypoglycemia at birth had aninsulin concentration of 2 or more standard deviation above the mean (inthe range 26.99-35.39mU/ml). Neonatal cord blood showed higher leptinconcentrations (t=1.8260, p=0.044) in the Group 2 (19.08 ng/ml) than inthe Group 1 (12.51 ng/ml). No newborn in either treatment groupdemonstrated macrosomia, intrauterine growth restriction, or fetalabnormality.Conclusions: Even excellent diabetes control through pregnancy is notsufficient to prevent neonatal hypoglycemia and hyperleptinemia. Tightbalance achieved during labor and delivery is equally important forachieving good neonatal metabolic outcome. In the presence of excellentantepartum glucose control, tight regulation of the intrapartum maternalglucose concentration will minimize neonatal hypoglycemia andhyperleptinemia.
FC3.17.02CAUSE OF FETAL DEATH IN MOTHERS WITH GESTATIONALDIABETESI. Colon (1) , D.Singer (2), K.Adamsons (3), (1) Harvard MedicalSchool, 75 Francis Street, Boston, Massachusetts, United States, 02115,(2) Women & Infants Hospital, Providence, Rhode Island, U.S.A., Dep.of Obstetrics and Gynecology, San Juan, Puerto Rico, U.S.A.
There is no scientifically validated explanation for fetal death in lategestation among diabetic mothers. We propose that fetalhyperinsulinemia causes structural changes in the fetal liver, whichproduces umbilical venous hypertension, thus resulting in edema of villi,and compression of the intervillous space (IVS). Initially the diminution
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of the IVS perfusion is tolerated, because of the facilitated means of thefetus of anaerobic glycolysis, but ultimately the fetus dies of progressivehypoxia. To test this hypothesis, hyperinsulinemia was produced in 10fetal Rhesus monkeys by implanting insulin ejecting micropumpsbetween 113 and 120 days of gestation (term= 167 days). After 3 weeksthe fetuses were delivered by hysterotomy. Three fetuses had died onday 19, 20 and 21. Organs were subjected to morphometric andhistologic examination. The hyperinsulinemic fetuses, as compared tocontrols had 34% increase in body weight, 61% increase in liver weight,and 67% in placental weight. Examination of liver revealed extensiveinfiltration with erythroblasts, cytoplasm of hepatocytes partly filledwith neutral fat, and reduction of portal vessels. There was markeddiminution of the IVS due to crowding and edema of villi, andproliferation of the throphoblast. We conclude that structural changes infetal liver, and increased proliferation of the throphoblasts, caused byhyperinsulinemia, are responsible for umbilical venous hypertension,edema of villi, and a progressive decrease in the perfussion of IVS,leading to fetal death.
FC3.17.03HOW USEFUL IS GLYCATED HAEMOGLOBIN IN PREDICTINGTHE OUTCOMES OF DIABETIC PREGNANCIES?P. Scriven (1) , R. Searle (2), P. Sinha (3), F. Fairly (4), (1) RotherhamGeneral Hospital, Moorgate Road, Rotherham, Yorkshire, UnitedKingdom, (2) Northern General Hospital, Sheffield, Yorkshire, UK, (3)Conquest Hospital, St Leonards on Sea, East Sussex, UK, (4) JessopHospital For Women, Sheffield, Yorkshire, UK.
Objective: Glycated haemoglobin is the common assay of glycaemiccontrol in diabetes and is frequently used as an indicator of potentialmaternal and neonatal morbidity. This study assesses the usefulness ofHbA1c in predicting pregnancy outomes of type one diabetic mothers.Study Method: A retrospective analysis of 126 pregnancies of type onediabetic mothers who delivered between 1 January 1986 and 1 June1998 at Jessop Hospital and Northern General Hospital, Sheffield.Glycated Haemoglobin was determined using a Pierce & WarrinerGlycotest IItm system with an interassay coeffiecient of variability 0f0.6%. A mean value for glycated heamoglobin was determined using atleast three measurements from at least two trimesters. Outcomesmeasured: birth weight, gestational age at birth, perinatal morbidity(measured as an overall score) and mode of delivery. In order tocompare birth weights of all infants it was necessary to normalise forgender and gestational age to give a birth weight ratio. Results wereanalysed by linear regression and Students t-test.Results: No statistically significant association was found betweenglycated haemoglobin and birth weight ratio, perinatal morbidity ormode of delivery.Conclusion: Given the poor predictive value of glycated haemoglobinshould we be using other methods of assessing the diabetic pregnancy?
FC3.17.04THE PREDICTIVE VALUES OF THREE CLINICAL TESTS INPREDICTION OF GESTATIONAL HYPERTENSIONN. Zainal Shah , I. Abdul Samad. N.N. Aung, Dept. OB/GYN, UniversityHospital, Sains Malaysia, Seremban, Malaysia.
Objectives: To determine the predictive values of three clinical tests,namely, roll over test (ROT), mean arterial pressure (MAP) andisometric exercise test (IET) for predicting gestational hypertension.Study Methods: This was a hospital-based survey involving 158pregnant women. Each woman had all three clinical tests performed onher. Then they were followed up by their own obstetricians. Neither thepatients nor their obstetricians were aware of the results of these tests.Data on outcome of their pregnancies were collected only after theirdeliveries. Using 2x2 table, predictive values for gestationalhypertension were calculated for each test.Results: Out of 158 pregnant women, 129 were normotensive, 27 hadgestational non- proteinuric hypertension and 2 had gestationalproteinuric hypertension. None of them developed gestationalproteinuria or eclampsia.For ROT, its sensitivity was 55.2%, its specificity was 78.3%, positivepredictive value of 36.4%, and negative predictive value of 88.6%.For MAP, its sensitivity was 41.4%, its specificity was 94.6%, positivepredictive value of 63.2%, and negative predictive value of 87.8%.
For IET, its sensitivity was 93.1%, its specificity was 89.1%, positivepredictive value of 65.9% and negative predictive value of 98.3%.Conclusion: Among the three tests, MAP showed the highest specificitybut IET showed the best sensitivity, positive as well as negativepredictive values.
FC3.17.05PREGNANCY OUTCOME OF DIABETIC PREGNANCY IN ADEVELOPING COUNTRYL.A. Banu , Dept. OB/GYN, Birdem Hospital, Dhaka, Bangladesh.
Objectives: Effect of good ANC and meticulous control of blood sugarimproves the pregnancy outcome of diabetic patient to a great extent.Study Methods: In this retrospective study, patients delivered fromJanuary 1995 to June 1999 taken the total number of patients deliveredwas 2994 of which Diabetic were 1405 (47.7%) and non-diabetic(52.3%).Results: Vaginal delivery occurred in 988 (33.5%) patients of whichdiabetic were 364 (36.8%) and non diabetic 634 (63.2%) and cesareansection was done in 1956 *66.5%) patients of which diabetic were 1041(53.2%) and non-diabetic 915 (46.8%) patients. Most of the patientswere in 20-39 years are irrespective of diabetic or non diabetic. Thepromising part is fetal condition. The average fetal weight was 3.2 kg,death within 7 days was only 51 (5.8%) amongst 873 babies sent toSCABU (special care baby unit). Main fetal complication werehypoglycemia (57.2%), preterm (47.2), LGA (34.9%), Jaundice (28.9%).Congenital anormaly was about 5%.Conclusions: This study was compared with some studies in Jamaica,Norway, Mauritius, Poland and Barcelona. CS rate was 46.7% inJamaica, 45% in Norway, 59.7% in Barcelona and 66.7% in Bangladeshstudy. Hypoglycemia was found more in present study. Other parameterswere non-significant. From the above study it has been said that regularsystemic ANC and meticulous glycaemic control and the deliveryfacility with special baby care unit, the pregnancy outcome issatisfactory.
FC3.17.06GAS CHROMATOGRAPHIC MASS SPECTROMETRIC ANALYSISOF URINARY SUGAR AND SUGAR ALCOHOLS DURINGPREGNANCY.M. Tetsuo (1), C.Zhang (2), H. Martsumoto (3), J. Ishimatsu (4)(1) Dept OB/GYN, Tetsuo Hospital, Nagasaki, Japan.(2) Matsumoto Institute of Life Sciences, Kanazawa, Japan.(3) Mils Clinic, Kanazawa, Japan.(4) Dept OB/GYN, Kumamoto City Hospital, Jumamoto, Japan
Objectives: Since carbohydrates metabolism during pregnancy isconsidered to be diabetogenic, our interest was concentrated onevaluating the metabolic deviation by assessing the excursion and fluxedof urinary sugar and sugar alcohols during normal pregnancy andpregnancy with abnormal carbohydrate metabolism.Study Methods: Subject included 353 women with normal pregnancies,48 women with suspected abnormal carbohydrate metabolism as definedby urinary glucose values and 41 non-pregnant women served as control.After urease treatment of urine, trimethylsilyl derivative of glucose,sorbitol, fructose, myo-inosito and 1.5 anhydro D glucitol (1.5-AG) werequantified by using capillary gas chromatography-mass spectrometrycomputer system.Results: The urinary glucose level declined with statistical significancein the first trimester of pregnancy, and was unchanged in the second andthird trimesters. Sorbitol level increased in the first trimester and steadilyincreased as the pregnancy progressed. Fructose and myo-inositol levelsincreased in the first trimester and remained unchanged in ht second andthird trimesters. 1.5-AG level increased transiently in the first trimesterand the declined. The compared to that in pregnant women (p<0.01),while concentrations of sugar alcohols are significantly higher inpregnant women (p<0.001 for sorbitol. Fructose, myo-inositol and 1.5-AG). The level of each sugar and sugar alcohols in women withabnormal glucose metabolism increased and the standard deviationbecause wider with advancing gestation.Conclusions: The results suggest that the changes of the levels of urinarysugar and sugar alcohols may reflect a mild alteration in carbohydratemetabolism that goes undetected by conventional diabetic indicators.
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FC3.17.07CORRECTION OF SPECIFIC AUTOIMMUNE DISORDERS FORPREGNANT WOMEN WITH DIABETES MELLITUSV. Petrukhin, T. Budikina , F. Burumkulova, A. Poletaev. V. Gurieva, N.Volkova, Moscow Regional Scientific Research Institute of OB/GYN,Moscow, Russia
Objectives: As shown in our previous experiments, for diabetic womenis characteristic the increased levels of insulin (AT-1) and its receptors(AT-2) antibodie3s. These antibodies, linking the factor of growth ofnerves, conduct to the disturbances in the nervous system of a fetus andnewborn. The aim of our work was estimate the efficiency of differentmethods of correction of these autoimmune disorders and improving thepregnancy outcome.Study Methods: 126 diabetic pregnant women with increased serumlevels of AT-1 and AT-2 (measured by an original method on a basis ofimmunofermentic assay) were divided into 4 groups depending on akind of received treatment. 42 pregnant women received the heparinuminhalation, 28 – system enzymotherapy (wobenzym), 26 – the specificdesensitizing therapy by insulin and 30 – only strictly metabolic control.Results: The management of heparinum and wobenzym has resulted in adecrease of the serum contents of AT-1 and AT-2 on 60-65% frominitial levels. Usage of insulin as specific desensitizing therapy also hasresulted in a decrease of studied antibodies on 62%. In group with onlystrictly metabolic control the levels of antibodies significantly did notvary. The positive influencing of selected methods of therapy ongestation and neurological status of newborns is marked.Conclusions: The therapy, lowering specific serum immunoreactivity indiabetic pregnant women, allows to achieve the better outcome ofpregnancy for fetus and newborn and to optimize tactics of management.
FC3.17.08ASSOCIATION BETWEEN GLYCOSYLATED HEMOGLOBIN INTHE FIRST TRIMESTER OF PREGNANCY AND MAJOR FETALMALFORMATIONSV. Mazneikova , S.Ivanov, K.Todorova, P.PopivanovaState University Hospital of Obstetrics and Gynaecology “MaichinDom”, Sofia, Bulgaria
Objectives: The aim of the study was to evaluate the incidence of majorcongenital malformations among unselected pregnant women withinsulin-dependent diabetes mellitus and to determine whether aconsistent association can be demonstrated, after adjustment formaternal age and White classification, between glycosylated hemoglobin(HbA1c) values in the first trimester of pregnancy and fetal outcome(major malformations).Study Methods: The retrospective study comprised 180 unselectedpregnancies complicated with pre-existent insulin-dependent diabetesmellitus admitted to the High Risk Pregnancy Department between 1995and 1999. The patients were referred from regional hospitals which didnot fulfill the guidelines for the management of pregnancy in diabeticwomen. Only 2% of pregnancies were planned. All diabetic patients hadHbA1c determinations in the first trimester of pregnancy. Women withgestational diabetes were excluded from the study.Results: Among 180 pregnancies, 121(68%) resulted in a liveborninfant, 27 (15%) aborted spontaneously, five (2%) resulted in stillbirth,and 27(15%) were terminated. Of the terminations, twenty were forcongenital malformation. The prevalence of congenital malformationsvaried between 13 and 15% compared with 2% in the generalpopulation.Relative risk calculations indicated a highly significant and consistentcorrelation between HbA1c values above 7% and major fetalmalformations after adjustment for differences in maternal age andWhite classification.Conclusions: In an unselected population the infants of women with pre-existent insulin dependent diabetes mellitus have a 6-8-fold greater riskof a congenital malformation than infants in the general population. Ourdata support a clinically significant and consistent relationship betweenfetal malformations and HbA1c in the first trimester of pregnancy ofmothers with pre-existent insulin-dependent diabetes mellitus.
FC3.17.09HAVING INSULIN THERAPY IN INADEQUATE GLUCOSETOLERANCES. Djordjevic , M. Gojnic, S. Petkovic, T. Mostic, University ofBelgrade, Clinical Centre of Serbia, Institute for Gynecology andObstetrics, Belgrade, Yugoslavia.
Objectives: The aim of this study was to present the necessity of makingfrequent test of glucosae intolerance in high risk pregnancies.Study Methods: Last year we started to make routine repetition of oralglucosae tolerance test (OGTT) in pregnancies. We looked afterpostpranduial glicemia in all women. We made the diabetic diaet and insome cases insulin therapy.Results: In 81.25% (13 women of the 16 examined) the test waspathological at the end of the second trimester, and in the first one it wasnormal. In 76.9% of pathology second test, we gave insulin to futuremothers and in only 23% diabetic therapy was adecvate.Conclusions: We wanted to suggest that the necessity of routine repeatedOGTT, in cases when it was normal in first trimester and a morefrequent use of insulin in those cases.
FC3.18 ENDOMETRIAL AND OVARIAN CANCERPROGNOSTIC MARKERS
FC3.18.01ASSOCIATION OF CYCLIN D1 GENE (CCND1) POLYMORPHISMAND CLINICAL OUTCOME IN EPITHELIAL OVARIAN CANCERK.K.Dhar , R.E.J.Howells, C.W.E.Redman, P.W.Jones, R.C.Strange,A.A.Fryer, P.R.Hoban. Centre for Cell and Molecular Medicine,University of Keele School of Postgraduate Medicine, NorthStaffordshire Hospital, Stoke-on-Trent, UK, Department of Obstetricsand Gynaecology, City General, Stoke-on-Trent, UK, Department ofMathematics, Keele University, Staffordshire, UK.
Objectives: The cyclin D1 gene (CCND1) contains a frequentpolymorphism (A/G substitution) within the splice donor region of exon4. CCND1 Genotype is associated with clinical outcome in non-smallcell lung cancer and squamous cell cancer of the head and neck. In thisstudy we investigate the influence of CCND1 genotype on clinicaloutcome in 138 women with epithelial ovarian cancer.Study Methods: CCND1 genotypes were identified from peripheralblood DNA by polymerase chain reaction and restriction fragmentlength polymorphism (PCR-RFLP) analysis. Patients CCND1 genotypeswere compared with clinical details, tumour characteristics, response tochemotherapy, progression free interval and survival data.Results: The frequency of CCND1 genotypes in the cases and 191unrelated women controls were similar (p=0.29). We observed nocorrelation between the genotypes and FIGO stage, amount of residualtumour, differentiation and histological type of the tumour and responseto chemotherapy. There was no significant difference in overall survivaland progression free interval (PFI) among patients with differentgenotypes. Analysis of data from patients who responded topostoperative chemotherapy revealed that women with CCND1 AAgenotype was associated with early disease progression (p=0.020, HR4.58, 95% CI 1.27-16.48) and reduced survival (p=0.026, HR 4.48,95%CI 1.19-16.79) compared to that of CCND1 AG and GG genotypes.Conclusion: These data show that CCND1 genotype does not influenceoverall prognosis in epithelial ovarian cancer, however, it is associatedwith disease progression following initial response to chemotherapy.
FC3.18.02TYPE III AND TYPE I COLLAGEN METABOLITES ASPREDICTORS OF PROGNOSIS IN OVARIAN CANCERM. Simojoki*, M. Santala*, J. Risteli**, L. Risteli**, A. Kauppila** Dept. OB/GYN, Oulu University Hospital, 90220 Oulu, FINLAND**Dept. Clin. Chemistry, Oulu University Hospital, 90220 Oulu, Finland
Objectives: The aim of the study was to investigate the usefulness ofaminoterminal propeptide of type III procollagen (PIIINP) andcarboxyterminal telopeptide of type I collagen (ICTP) in relation to CA125 in predicting prognosis of ovarian cancer patients.Study methods: Fifty-six women with epithelial ovarian cancer werestudied through PIIINP, ICTP and CA 125 determinations from serumsamples collected before operation and three, six, nine and 12 months
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after operation. The follow-up time was three years. The patients weredivided in two groups: patients who were alive three years after thesurgery, and patients deceased. The variables were compared using theMann-Whitney U-test, c_-test and multivariate Cox regression analysis.The survival analyses were carried out using the Kaplan-Meier method.Results: Before the operation the frequency of high serum PIIINP(P=0.034) and ICTP (0.002) concentration was significantly higher ofthe patients with a poor prognosis than of the patients with a goodprognosis. This did not apply to the CA125 (0.2029). At nine and 12months, there were significantly more patients with high PIIINP (P=0.007, = 0.005, respectively), ICTP (<0.0001, =0.0005) and CA125(=0.007, =0.0001) concentrations in the group of poor prognosis than inthe group of good prognosis. In the Kaplan-Meier survival analysis, thepreoperative, nine-month and 12-month PIIINP (P= 0.0422, =0.0062, =0.0062, respectively) and ICTP (P= 0.0004, <0.0001, = 0.0005)concentrations distinguished the patients with good prognosis from thepatients with poor prognosis, while as to the CA125, the differencecould only be seen at the nine- and 12-month follow-up (P= 0.0003,=0.0004). In the multivariate analysis on preoperative specimens, theICTP was the only independent and significant determinant of theclinical outcome of ovarian cancer.Conclusions: The preoperative PIIINP, and the ICTP in particular, arebetter than the CA 125 in the prediction of clinical outcome in ovariancancer, whereas during the year following the operation these variablescomplement each other in this function.
FC3.18.03IMMUNOCYTOCHEMICAL LOCALISATION OFSOMATOSTATIN RECEPTOR SSTR1 AND SSTR5 EXPRESSIONIN OVARIAN TUMORSG.H. Hall (1), L.W. Turnbull (1), I. Richmond (2), L. Helboe (3), S.L.Atkin(4)(1) Dept. Radiology, University of Hull, Hull, UK.(2) Dept. Histopathology, Castlehill Hospital, Cottingham, UK.(3) Dept. Medical Anatomy, The Panum Institute, Copenhagen,
Denmark(4) Dept. Medicine, University of Hull, Hull, UK.
Objectives: The potential role for antiangiogenic compounds in therapyof ovarian tumors has been suggested by the relationship betweenvascular endothelial growth factor expression and poor prognosis.Somatostatin analogues are a group of antiangiogenic compoundsalready in clinical trials in other malignancies. This study aims toexamine SSTR1 and SSTR5 expression in ovarian tumors.Study Methods: Archival specimens of 28 ovarian tumors of mixedhistological type were dewaxed, microwaved, blocked and incubatedwith rabbit polyclonal antibodies raised against SSTR specific peptides.Signal was amplified with biotinylated tyramide and visualized by theHRP-StrepABC method with DAB. Staining was graded by intensityindependently by two observers.Results: 18/28 (64%) tumors showed strong or medium staining ofepithelium or stroma, for either one or both SSTR1 and SSTR5. Strongepithelial staining was demonstrated with both SSTR1 and SSTR5 in4/28 (14%) patients and for either SSTR1 Or SSTR5 in 9/28 (32%)cases. Stromal staining occurred in 6/28 (21%) of cases which wassubjectively stronger for SSTR1. 4/28 (14%) of specimens showedmoderate staining of intratumoral vessels with SSTR1 and none showedsimilar with SSTR5. 10/28 (36%) tumors showed either mild or nostaining.Conclusions: Over 50% of ovarian tumors demonstrate expression ofeither SSTR1 or SSTR5. This indicates a potential role for somatostatinin the molecular biology of ovarian carcinoma, and a potential role forsubtype specific somatostatin analogues in the therapy of these tumors.Further work will examine the expression of the other receptor subtypesand correlate the results with histology and prognosis.
FC3.18.04PROGNOSTIC AND PREDICTIVE VALUE OF P53/WAF-1EXPRESSION IN EPITHELIAL OVARIAN CANCERS.Fracchioli (1) , E.P.Diamandis (2), M.Massobrio (1), D.Katsaros (1),(1) University of Turin, via Ventimiglia, 3, Turin, Italy, 10126(2) University of Toronto, Toronto, Ontario, Canada.
Objectives: This study was designed to determine whether patients whoreceived adjuvant chemotherapy for epithelial ovarian cancer could bestratified into groups with different prognosis based on theimmunoassay-quantified expression levels of two proteins – the p53tumor suppressor and its downstream mediator WAF1 (p21/CIP1/SDI1)– rather than by conventional immunostaining.Methods: The concentrations of both proteins, measured in ovariantumor extracts from 120 patients, by an immunofluorometric assaydeveloped by the authors (p53) and by a commercially availableimmunoassay (WAF1), were also compared between groups differing onthe basis of treatment response.Results: Whereas p53 levels were elevated in patients with advancedstage disease (p=0.02) or poorly differentiated (p=0.03), suboptimallydebulked tumors (p=0.02), as well as in patients who failed to respond tochemotherapy (p=0.03), statistically significant association betweenconcentrations of p53 and WAF1 were not found. Although also notsignificantly associated with treatment response and clinicopathologicmarkers of prognosis, WAF1 expression was suggested to be reduced inmore advanced disease. Univariate analysis showed that p53concentrations above the median indicated higher relative risks (RR) forrelapse (p=0.04) and death (p<0.01) and provided evidence for a dose-response effect between p53 concentrations and risks for relapse(p=0.04) and death (p<0.01). Multivariate analysis confirmed theseobservations (RR=1.50; p=0.05 for relapse and RR=1.92; p=0.03 fordeath).Conclusions: p53 expression was an independent indicator of prognosisin ovarian carcinoma patients treated with adjuvant platinum-basedchemotherapy, and was associated with responsiveness. Prognostic andpredictive implications of WAF1 expression in our patients, however,could not be demonstrated.
FC3.18.05IDENTIFICATION OF DIFFERENTIALLY EXPRESSED mRNA INNORMAL, HYPERPLASIA ENDOMETRIUM AND ENDOMETRIALNEOPLASMLihui Wei , Y. Meng, J. Wang. Dept. GYN, People’s Hospital, BeijingMedical University, Biejing, P.R. China, 100044.
Objectives: The aim of the study was to investigate the related gene ofendometrial carcinoma. This should help us a better understanding of themechanisms of transformation.Study Methods: Individual mRNA species from normal and neoplasticendometrium obtained from the same patient were comparativelystudied by exploiting the Differential Display methodology. ThemRNAs were isolated from the tissues, reverse transcribed to cDNA,andthen amplified by PCR. The PCR products were displayed on apolyacrylamid gel by silver staining and the differentially expressedbands were retrieved and reamplified. Subsequently we screened each ofthese sequences from normal endometrium and endometrial carcinoma,selected four sequences named T1.7,T2.7,T3.8 and N2.11for furtheranalysis.Results: cDNA homology was analysed by searching through GenBanksequence databases and indicated that T1.7 (438bp)is no significantsequence homology with any sequence of known function, the othersequences is partially homology with other cDNA sequences. Homologyof T2.7,T3.8 and N2.11 are 85%,24.3% and 97.3% respectively. Furtherstudy appears that T1.7 recognizes an mRNA which is expressed moreabundantly in endometrial carcinoma than hyperplasia endometrium, notexpressed in normal endometrium. We are studying the distribution ofthe T1.7 in the other normal tissues and tumoral tissues.Conclusions: T1.7 is a new EST. It expressed more abundantly inendometrial carcinoma than hyperlasia endometrium,not in normalendometrium. After we study the ditribution of it ,we will search thewhole length of gene through RACE.
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FC3.18.06ALTERATION OF CD44 AND CADHERINS EXPRESSION:POSSIBLE ASSOCIATION WITH AUGMENTEDAGGRESSIVENESS AND INVASIVENESS OF ENDOMETRIALCARCINOMAM. Leblanc (1), C. Poncelet (1), D. Soriano (1), F. Walker-Combrouze(3), P. Madelenat (2), J.Y. Scoazec (4), E. Darai (1)(1) Service de Gynécologie, Hôpital Hôtel-Dieu, Paris, France.(2) Service de Gynécologie-Obstétrique, Hôpital Bichat-Claude
Bernard, Paris, France.(3) Service d’Anatomie et Cytologie Pathologiques, Hôpital Bichat-
Claude Bernard, Paris, France.(4) Laboratoire de Biologie Cellulaire, INSERM U327, Paris, France.
Objective: Cadherins and CD44 isoforms are transmembraneglycoproteins with diverse functions in cell-cell and cell-matrixinteractions and may be a determinant of metastatic and invasivebehavior in carcinomas.Study Methods: The immunohistochemical expression of cadherins andCD44 in a tissue sample from 15 normal endometrium and 33endometrial adenocarcinomas were examined. Theimmunohistochemistry analysis was performed by using the monoclonalantibody HECD-1 against E-cadherin, the polyclonal antibody againstN-cadherin, the monoclonal antibodies 2C5, binding to CD44s and allthe variants encoded by exons 3 to 10, 3G5, specific for CD44-v3 and2F10, specific for CD44-v6.Results: E-cadherin and N-cadherin expressions were statistically lowerin endometrial adenocarcinoma than in normal endometrium (P=0.0001)and (P<0.001) respectively. In contrast, an overexpression of CD44isoforms (P<0.01) and CD44-v3 (P<0.01) expressions was found inendometrial adenocarcinomas as compared with normal endometrium.No difference was noted for CD44-v6. An association was foundbetween a decrease in E-cadherin expression and the occurrence ofmetastasis and recurrent disease. An association was found betweenCD44 overexpression and lymph space involvement and myometrialinvasion.Conclusion: Our results suggest that cadherin and CD44 expressions inendometrial carcinomas may have both diagnostic and prognostic value.Alteration of CD44 seems to be related o local invasion. While alterationof E-cadherin seems to be associated with dissemination of the disease.
FC3.18.07EXPRESSION OF PROLIFERATING CELL NUCLEAR ANTIGEN(PCNA) IN ENDOMETRIOID ADENOCARCINOMAM. G. Giusa-Chiferi , W. J. Goncalves, M. T. Seixas, E. C. Baracat,Dept. OB/GYN, São Paulo Federal University, São Paulo, Brazil.
Objectives: The am of this study was to investigate the value ofimmunohistochemical staining for the cell cycle protein proliferatingcell nuclear antigen (PCNA) in patients with endometrioidadenocarcinoma and if the PCNA index could be related to otherprognostic indicators including stage, grade, and deth myometrialinvasion.Study Methods: We studied 77 patients with postmenopausal bleedingtreated at Sao Paulo Hospital – Paulista School of Medicine 0- SaoPaulo Federal University. All patients were submitted to transvaginalultrasound, histeroscopy and endometrial biopsy. When the resultsshowed adenocarcinoma, the patient was submitted to surgery(Abdominal exploration, TAH-BSO, Omental biopsy, peritonealwashings and pelvic lymph node biopsy). PCNA index was studied byusing an immunohistochemical technique (PC10 – avidin-biotin method)using the paraffin blocks. A computerized image analysis system(IMAGELAB) was used to determine the percentage of nuclear areastained.Results: The average age was 63.13 (46-88) years. We found 33(42.86%) patients with endometrioid adenocarcinoma, 22 (28.54%)polyp and 22 (28.54%) atrophic endometrium. Among these 33 patientswith adenocarcinoma, 23 (69.7%) had diagnosis of Stage I disease, 5(15.15%) Stage II disease and 5 (15.15%) Stage III disease. Amongthese 33 patients 21 (63.64%) had diagnosis of grade 1, 10 (30.30%) ofgrade 2 and 2(6.06%) of grade 3. We also found that 20 (60.61%)patients have less than 50% of myometrial invasion and 13 (39.39%)have more than 50% of myometrial invasion. The mean of PCNA indexbetween patients with atrophic endometrium was 2.49% (0.09-12.14%)with polyp 8.89% (0.01-26.25%) and for endometrioid adenocarcinoma
was 60.12% (11.3-92.3%). We correlated the PCNA index with stage,grade and myometrial invasion and we did not find any difference(P<0.001).Conclusions: The PCNA index was higher in patients with endometrialadenocarcinoma and the difference was statistically significant. IntensePCNA expression was not significantly associated with othersprognostic indicators including stage, grade and myometrial invasion.
FC3.18.08SIGNIFICANCE OF VASCULAR ENDOTHELIAL GROWTHFACTOR EXPRESSION IN OVARIAN CARCINOMASG. Shen (1), M. Ghazizadeh (2),(1) Dept. OG/GYN, Beijing Hospital, Beijing, China.(2) Dept. Mol. Pathol., Institute of Gerontol., Nippon Medical School,
Kawasaki, Japan.
Objectives: The purpose of this study was to investigate the significanceof vascular endothelial growth factor (VEGF) expression in relation tothe established clinicopathological features and prognosis of ovariancarcinoma.Study Methods: Paraffin tissue sections from 64 ovarian carcinomas, 13borderline and 17 benign ovarian tumors were immunostained for VEGFusing affinity-purified polyclonal antibody. RT-PCR was used to assessthe differential expression of VEGF mRNA isoforms in frozen tissuesfrom normal ovary and a number of benign and malignant ovariantumors.Results: Of the malignant, borderline, and benign ovarian tumors,respectively, 2 (3%), 4 (31%) and 16 (94%) were negative, 31 (48%), 7(54%) and 1 (6%) had low expressions, and 31 (48%), 2 (15%) and 0(0%) had high expressions of VEGF. Nested PCR amplification ofcDNA prepared from frozen sections showed that the predominantisoforms were VEGF121, 165, and 189 in ovarian adenomas andcarcinomas. A high VEGF expression was associated with disease stage(p=0.002), histologic grade (p=0.0004), and patient outcome (p=0.0002).The survival of patients with high VEGF expression was significantlyworse than those with low and negative VEGF expression. In amultivariate analysis, disease stage and VEGF expression wereindependent prognostic indicators.Conclusions: These results suggest that high VEGF expression plays animportant role in the tumor progression and may bean independentprognostic factor for patients with ovarian carcinomas.
FC3.19 CURRENT TOPICS IN GYNECOLOGY
FC3.19.01RETROSPECTIVE ANALYSIS OF 195 CASES FOR TREATMENTOF ABNORMAL UTERINE BLEEDING TO COMPARE CLINICALAND ECONOMIC OUTCOMESJay Berman , Wayne State University School of Medicine, Southfield,MI, United States
Study Objective: To compare clinical and economic outcomes forabdominal hysterectomy, rollerball ablation and endometrial ablationusing the Hydro ThermAblator* (HTA*).Study Methods: Retrospective analysis of 20 abdominal hysterectomies,50 roller ball ablations and 125 treatments with the HTA. Patient followup is 12 months. One hundred ninety five women (ages 30-50) withabnormal uterine bleeding. All women underwent pretreatment testing.Endometrial pretreatment was administered for roller ball or HTAtreatments. Treatments occurred in hospitals and hospital run surgerycenters. Abdominal hysterectomy, roller ball ablation or endometrialablation using the HTA.Summary: Clinical outcome measurements, including efficacy andsafety; the mean direct cost per case, including operating room time,anesthesia, and equipment; and indirect costs, including recovery andlost productivity, for abdominal hysterectomy, roller ball ablation andthe HTA treatment will be compared.
# of Efficacy Safety (Intra/Postoperative Complications)cases Time (ave min.) Direct Cost/case
Hysterectomy 20 100% 12 60 9742.03*730.35RB Ablation 50 85% 6 35 4912.50*560.66HTA*Ablation 125 94% 4 23 4967*500.98
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Conclusion: Treatment with the HTA is a safe and effective treatmentfor menorrhagia that may reduce economic costs and risk associatedwith the procedure when compared to abdominal hysterectomy androller ball ablation. Additional long-term post treatment follow up datamust be gathered.
FC3.19.02ALTERNATIVE MANAGEMENT OF MENORRHAGIA WITHLEVONORGESTREL RELEASING INTRA-UTERINE SYSTEM(LNG-IUS)Ibrahim, MN, Sinha, P , Michelle Mammom, Conquest Hospital,St-Leonards-On-Sea, United Kingdom
Objectives: To assess the efficiency, side effects, patient’s satisfactionand outcome after insertion of the Mirena coil in-patients withmenorrhagia after failed medical treatment.Study Method: Retrospective case note analysis, 65 patients wereincluded in this study between 1st November 1998 to 31st October 1999.Follow up was arranged after 6 weeks, 3 months,6 months and 12 months. During the follow up patient’s satisfaction wasnoted by giving a set of questionnaires including associated undesirableside effects.Results: Significant improvement in menstrual flow was noted in 40patients (61.5%). There was no symptomatic improvement in 6 patients(9.2%). Out of these 6 patient 4 had prolonged bleeding and out of these:1 had endometriosis, 2 had an ovarian cyst and 2 had hysterectomy after11 months. Indications for hysterectomy were – adenomyosis andendometrial polyp. The symptoms did not improve in one of the patientsbecause the coil had been expelled, (the patient being excessivelyobese). Six patients did not attend for follow up – on enquiry they werehappy. Thirteen (29.3%) are still awaiting their first follow up afterinsertion.Conclusion: Most patients had their menstrual flow reduced. Thecommonest side effects were prolonged spotting which carried on for upto 10 months in some patients.Patients with adenomyosis and endometrial polyp had not achieved thedesired effect.Despite being a small study, it does suggest that the Mirena coil is thetreatment of choice before surgery. It should be noted however thatproper counselling is still important andthat we recommend proper uterine examination is performed before anytreatment is undertaken.
FC3.19.03THE EFFICACY OF A 125 MG/DAY REGIMEN OF FLUTAMIDE INMAINTAINING THE CLINICAL RESULTS IN HIRSUTE WOMEN.S. Venturoli, A. Bagnoli, F. M. Colombo, B. Ravaioli, F. Vianello ,F. Mancini. Institute of Reproductive Physiology and Pathology,University of Bologna, Bologna, Italy
Objective: To evaluate the safety and efficacy of a 125 mg/day regimenof flutamide in maintaining the clinical results previously achieved usinghigher doses, in women suffering from hirsutism.Study Methods: Forty-three women suffering from several etiologicalhirsutism were enrolled in the study. Six dropped out of the study. Thewomen received 250 mg/day of flutamide as an initial treatment for 12months. Subsequently they received 125 mg/day of flutamide for anadditional 12 months as a maintenance treatment. Hirsutism wasevaluated by the Ferryman-Gallwey score, and hair diameter and hairgrowth rate were determined by a special image analysis processor(IBAS: sensitivity of 0.001 mm). Biochemical, clinical and hormonalparameters were evaluated in basal conditions and every 2-6 months.Results: The initial treatment period produced a significant decrease inthe hirsutism score (-50%), hair diameter (-21%) and hair growth rate (-41%). At the end of the maintenance treatment period, the hirsutism+score further decreased, and hair diameter and growth rate wereconfirmed. Free Testosterone (-44%), Androstenedione (-28%) and 17-P(-36%) levels progressively decreased up to a maximum level at the endof the maintenance treatment period. T (-25%) and DHAS (-27%) levelsdid not further decrease after the initial treatment period, while DHT (-21%) and DHA (-37%) levels, after the decrease observed in the initialtreatment period, showed an increase during the maintenance treatmentperiod thus suggesting a reduction of the suppressive effect. During theinitial treatment period, very few transient side effects were observed but
four subjects (9%) registered an increase of aspartate aminotrasferaseand alanine aminotrasferase and dropped out. During the maintenancetreatment period, no subjects registered side effects or complications.Conclusions: Satisfactory management of hirsutism with flutamideseems to be represented by an initial treatment period using 250 mg/dayfollowed by a long maintenance treatment period using 125 mg/day,once satisfactory results have been obtained with higher doses.
FC3.19.04THE EFFECTS OF TWELVE MONTH USE OF AGESTODENE/ETHINYLESTRADIOL CONTRACEPTIVE PILL BYPREMENOPAUSAL WOMEN ON LIPID AND LIPOPROTEINMETABOLISM AND HEMOSTATIC PARAMETERSI.H. El-Nashar (1), G.H. Sayed (1), M. El-Kabsh (2), A. Nasr (1), M.M.Shaaban(1), Departments of (1) OB/GYN and (2) Clinical Pathology,Assiut University Hospital, Assiut, Egypt
Objectives: To study the effects of a 12-month use of a low-dosecombined gestodene-containing combined oral contraceptive (COC)preparation on serum lipids, lipoproteins and some hemostaticparameters.Study Methods: One hundred premenopausal women above 40 used aCOC preparation containing ethinylestradiol 0.03 mg plus gestodene0.075 mg for 12 months. An age-matched comparison group of 50women used the T-Cu-380 intrauterine contraceptive device (IUD).Blood samples were taken at admission and after 3, 6 and 12 months ofuse. Statistical analysis was determined by Student t-test and X2 test.Results: No statistically significant differences between the 2 groupswere observed at admission. Pill use resulted in a significant reduction invasomotor symptoms and Apolipoprotein-A after 12 months of use.Triglycerides increased significantly after 12 months of use.Antithrombin-III activity showed an early and sustained decrease. TheCOC group showed a significant increase in a2-antiplasmin after 6 and12 months of use. The IUD group showed no significant change in anyof the measured parameters.Conclusion: Use of the gestodene containing low-dose COC by womenover 40 favorably changes a number of parameters of cardiovascular riskmainly increased HDL cholesterol and Apolipoprotein-A but mayotherwise result in some unfavorable changes, mainly reducingantithrombin-III levels.
FC3.19.05MAJOR SYMPTOMS OF PREMENSTRUAL TENSION (PMS) AREREDUCED BY FEMAL, A HERBAL PRODUCT.K. Winther (1), E. Shytte (2), E. Rein (2), C. Hedman (3)(1) Dept. of Clinical Chemistry, Gentofte Hospital, Copenhagen,
Denmark(2) Institute for Clinical Research, Kolding, Denmark(3) Sahlgrenska Biomedical Innovation Centre, Gothenborg, Sweden
Objectives: The presents randomized, double-blind, placebo-controlled,cross-over study aimed to test if Femal, a natural product containingpollen pistil and grain extract, PI 82, from the plant family Graminea, anextract, GCFEM, form pollen of the plant Secale Cereale, Royal Jelly,which is produced by working honey bees and finally a small amount ofvitamin E, can influence mayor symptoms of (PMS).Study Methods: 32 woman, 20-54 years of age (mean 39.4) with regularmenstrual cycles and no signs of depression, all having the diagnose ofPMS for a mean period of more than 10 years, were included. Twotablets of Femal, each containing 90.9mg of the active ingredients or twoplacebo tablets of similar taste and size were given twice daily for twomenstrual cycles. Then the group initially receiving Femal was changedto placebo and vice versa. At the end of each of the two treatmentperiods, premenstrual weight gain and PMTS self and observer ratingscales were evaluated. Likewise tension, irritability, edema and generalfeeling of well being were tested using visual analogue scales.Results: Femal reduced weight gain by 60%, p<0.001, and PMTS selfand observer rating scales by more than 35%, p<0.05. A decline intension, irritability and edema and an increase in well being by morethan 40%, p<0.05 was also observed during Femal treatment.Conclusions: The present data suggest that women suffering frompremenstrual tension symptoms can benefit from Femal.
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FC3.19.06EFFECTS OF ESTROGEN REPLACEMENT ISOLATED ANDASSOCIATED WITH GESTRINONE IN OOPHORECTOMIZEDADULT RATS WITH EXPERIMENTAL ENDOMETRIOSISVR Lobo ; E Schor; EC Baracat; CE Lang; V Freitas; MJ Simões; JMSoares Jr; G Rodrigues de Lima. Department of Gynecology - EscolaPaulista de Medicina, Federal University of São Paulo, São Paulo,Brazil.
Objective: The aim of this work was to analyze the effects of conjugatedequine estrogens and gestrinone in oophorectomized adult ratspreviously submitted to endometrial implants.Study Methods: 50 adult female rats in which an endometrialimplantation was made on the lateral abdominal wall. After four weeks anew laparotomy was achieved where implant sizes were measured,followed by bilateral oophorectomy. After six weeks, the animals wererandomly divided into five groups: G I (n=10) received 0,5 ml/day ofpropylenoglycol (control), GII (n=10) received CEE (50 mg/day), GIII(n=10) received CEE (25 mg/day), G IV (n = 10) received CEE (25mg/day) associated with gestrinone (2,5 mg/day); GV (n = 10) receivedCEE (50 mg/day) associated with gestrinone (2,5 mg/day). All animalswere daily treated for 21 consecutive days by subcutaneous route. Afterthis period the animals were submitted to a new laparotomy and theimplants were measured and resected for light microscopy analysis.Results: The results showed a meaningful growth of endometrialimplants group GII, which presented as vesicles with clear liquidcontent. Light microscopy showed the presence of endometrial tissuecontaining stroma, glands and well-developed cysts. There wasregression of implant in groups GI, GIII, GIV and GV, and itslocalization was possible only due to the presence of surgical material.Conclusion: Only 50mg CEE promote growth of endometrial implantsand gestrinone opposed the CEE effects.
FC3.19.07METHOTREXATE IN THE THERAPY OF SYMPTOMATICUTERINE LEIOMYOMASAleksandar Zivanovic , S. Arsenijevic, M. Brkic, S. Djukic-Dejanovic,Sazdanovic P. Clinic of Gynecology and Obstetrics, Clinical-Hospital-Center, Kragujevac, Yugoslavia
Background: Abnormal bleeding occurs in about one third of patientswith symptomatic uterine myoma. Estradiol increases a number ofglandular mitosis in endometrium. Binding of thimidin in endometriumincreases during follicular phase. Methotrexat is an antimetabolite drugthat inhibits enzyme dihydrofolat-reductase. Due to that cells have a lackof reduced folan acids and therefore there is no possibility for synthesisof thimidin. The aim of this study is to evaluate effects ofsubendometrial methotrexat injections in perimenopausal women withsympthomatic myoma uteri, on menstrual bleeding and volume ofmyomas.Methods: Twenty premenopausal women with myoma uteri wereanalyzed. Methotrexat was applied as subendometrial injection infollicular phase, in dose of 5 mg/2ml per cycle during three menstrualcycles in total dose of 15 mg. The Pictorial Blood Loss AssessmentChart (PBAC) was used to assess the level of menstrual flow, before,through and after therapy. The volume of myoma before and aftertherapy was measured with Aloca 640 ultrasound.Results: Analysis of mean values of PBAC score before therapy and asecond cycle showed a statistically significant decrease in menstrualflow (t=11.49, p<0.001). The most evident difference between a meanvalue in PBAC scores was observed before and after therapycompletition (t=20.47, p<0.001). The difference in volume of myomasbefore and after therapy was tested by Wilcoxon pair sample test. Thevolume of myomas was diminished with statistical significance ofz=3.17, p=0.0015.Conclusion: These preliminary results suggest that methotrexat can beuseful in the treatment of perimenopausal women with symptomaticmyoma uteri.Key words: Uterus, Leiomyoma, Methotrexat, and Therapy.
FC3.19.08THE EFFECT OF LONG-RELEASED LEVONOGESTREL ON BONEDENSITY OF REPRODUCTIVE WOMENS. He , Reproductive Medical Center, National Research Institute forFamily Planning, Beijing, China
Objectives: The aim of the study was to evaluate the effect of long-releasing levonorgestrel only on the bone density and bone metabolismof reproductive women who used Implant type I, II and Norplant forthree years.Study methods: Eight women who used LNG Implant and forty-threecontrols were recruited into the cross-section study. Except generalstates, calcium intake, movement and private habits, to compare themean level of serum E2, biochemical indicators of bone metabolism:serum calcium (Ca), phosphate (P), alkaline phosphate (ALP) andosteocalcin (BGP); concentration of calcium (Ca), OH-praline (HYP)and cretonne (Cr); and the mean value of the bone density at middle-distal forearm.Results: The mean levels of estrogen (E2) were lower at normal level inthree groups and was no significant difference compared to the controlgroup. The period formation of bone peak in all groups was 30-40 yearsold. There was no line-relationship between mean level E2 and BMD inthree groups except control group. The changes of BMD. Ca/Cr andHyp/Cr in women who used Norplant was suggested the bone absorptionto be slight strengthens.Conclusions: Long-released LNG implant type I, II and Norplant forthree years were no significant effect on BMD and other indicators ofbone metabolism in women comparing with control. It was safe on bonemetabolism in reproductive women.
FC3.20 OBSTETRICS: LABOR
FC3.20.01USING THE MEDICAL AUDIT TO IMPLEMENT GUIDELINESFOR INDUCTION OF LABOURT.A. Mahmood , H. Mousa, C.K. Tan, Dept. OB/GYN, Forth ParkHospital, Kirkcaldy, Scotland, United Kindgom
The incidence of induction of labor is steadily rising. Inappropriate useof prostaglandins can not only increase the risk of iatrogenic fetaldistress but also of emergency cesarean delivery and therefore has beencited as an important contributing factor towards subclinical care.(CESDI 1997; Why Mothers Die, 1998-UK). Clinical guidelinesfacilitates implementation of evidence based practice.Objectives: The aim of this study was to determine whetherimplementation of guidelines for induction of labor could reduceinduction to delivery interval. A “medical audit cycle” was used todemonstrate the delivery of a high quality evidence based health care.Study Methods: A retrospective audit of 380 consecutive case noteswhere labor had been induced in 1995 was carried out to identifyinconsistencies in clinical management. New strategies for laborinduction directed pre-induction cervical priming and use of low dosagesof vaginal prostaglandins were developed and implemented. The effectwas monitored prospectively during 1996, 1997, and 1998. Results wereanalyzed with X2 test.Results: A total of more than 2000 women were studied. They all had aviable singleton pregnancy, a cephalic presentation, no uterine scar and agestational age greater than 37 weeks. They all had their labors induced.After management change, a significantly higher proportion of womenhad pre-induction cervical priming (change from 20% to 85%,p<0.0001). Although a significantly reduced amount of prostaglandingel was used, there was a significantly reduced induction to deliveryinterval (p<0.001), with no increase in cesarean rate.Conclusion: Implementation of guidelines on induction of laborsignificantly shortened induction to delivery interval.
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FC3.20.02SHOULDER DYSTOCIA IN A BUSY OBSTETRIC UNITH.J.A. Carp 1, S. Kees1, V. Margalit2, E. Schiff2, S. Mashiach2, 1Herzelia University, Herzelia, Israel 2Department of Obstetrics &Gynecology; Sheba Medical Center, Tel Hashomer, Israel
Objectives: To assess the incidence and complications of shoulderdystocia in a busy obstetric unit and whether they could be avoided.Study Methods: Review of the notes of patients with shoulder dystociabetween 1966-1969 to determine whether macrosomia, diabetes, heightof the head at full dilatation, length of the second stage and instrumentaldeliveries could have predicted shoulder dystocia. Fetal asphyxia,brachial plexus injury, and the manoevres used to free the shoulderswere assessed, and the incidence of injury according to the manoevre. Incases of Erb’s palsy, we tried to determine whether the experience of theattendant affected the outcome, and whether these cases could have beenavoided.Results: There were 56 cases of shoulder dystocia in 24,000 births. 59%occurred after spontaneous delivery. McRoberts manoevre was used in48 deliveries, but sufficed as a solitary procedure in only 9 cases. Theaddition of suprapubic pressure was sufficient for 25 patients, 27 whenbilateral episiotomy was also used. Corkscrew procedures were requiredin 12 patients. Midwives were involved in 35 cases. They requiredassistance in 27 of these cases. Senior staff were called to intervene in25 cases, and were involved in another 13 cases where they carried outthe delivery. Macrosomia above 4000g was only a feature in 20 infants,and diabetes in 6 infants. Signs within labor such as the height of thehead or length of the second stage were not helpful. There were 13 casesof Erb’s palsy. Seven after vacuum delivery and six after spontaneousdelivery. Eight of these cases were associated with McRobert’sprocedure and suprapubic pressure, two with no procedure, and threewith the corkscrew procedure.Conclusions: Certain cases of shoulder dystocia can be prevented bycesarean section. However, even if all infants above 4000g had beendelivered by cesarean section, there would still have been 36 cases ofshoulder dystocia. If the ultrasonic estimated weight were used to selectpatients for cesarean section, only 7 cases would have been diagnosed.Therefore, there will always be unexpected cases of shoulder dystocia.Inorder to lessen the degree and incidence of fetal injury, labor ward staffare urged to become as familiar as possible with these techniques.
FC3.20.03INTRAVAGINAL MISOPROSTOL IN INDUCTION OF LABOR ONVIABLE CHILD AFTER 38 WEEKS OF AMENORRHEA:RETROSPECTIVE STUDY OF 63 CASESK. Salihy, A. Desroches , P. Megier, Dept. OB/GYN, Regional Hospital,Orleans, France.
Objectives: Retrospective clinical study about efficacy and safety ofintravaginal misoprostol in induction of labor on viable child after 38weeks of amenorrhea.Study Methods: The population is composed of 63 paturient womenwith a singleton pregnancy having benefited by an induction of labor inthe Department of OB/GYN of the Regional Hospital of Orleans. Mainindications were prolonged pregnancy and fetal macrosomia. 50 mg ofmisoprostol were applicated intravaginally every 4 hours (with amaximum of 5 doses), without any dispensation of oxytocin. Statisticalanalysis of data was realized with c2 test and Fischer test, using SPSSsoftware.Results: Only one failure of induction was observed. 62 patients weredelivered during the 24 hours following the first application ofmisoprostal (H O ). Two doses were sufficient for 74.5% of patients. Theinterval between H O and the beginning of labor was 6.02±3.41 hours.The interval between H O and the delivery was 10.19±4.03 hours. Thecesarean section rate was 22.2%. The cesarean section rate forabnormalities of the fetal heart rate was 16%. A tachysystole wasobserved in 12.3% of cases. Seven neonates needed care in neonatalunit. No side-effects of misoprostol was noted.Conclusion: Intravaginal misoprostol in induction of labor on viablechild after 38 weeks of amenorrhea offers a satisfactory efficacy andsafety. The rage of abnormalities of the fetal heart rate and of cesareansections seems higher in cases of immature uterine cervix, with a Bishopscore inferior or equal to four.
FC3.20.04INTRAVENOUS NITROGLYCERIN IN THE MANAGEMENT OFRETAINED PLACENTAP. Chedraui , D. Insuasti, Dept. OB/GYN, Enrique Sotomayor Maternity,Guayaquil, Ecuador
Objectives: Evaluate the efficacy, safety and optimal dose ofnitroglycerin (NTG) in the management of retained placenta and itseffects on hemodynamics parameters.Study Methods: 30 patients in third stage of delivery with retainedplacenta were studied in a prospective experimental manner, to receiveintravenous nitroglycerin for the management of retained placenta. Westudied maternal, labor and neonatal data.Results: The average time of the procedure was 5.3±1.1 min. with arange dose of 50 to 200 mcg of NTG. The systolic and diastolic bloodpressures fell by a mean of 8.5mmHg and 7.33 mmHg respectively.(p<0.05) Although there were differences statistically significant in thehemodynamic parameters, this was not true clinically, and there were nocomplications.Conclusions: Intravenous NTG at a dose of 200 mcg or less is SAFE,EFFECTIVE and PREDICTABLE in the management of retainedplacenta and could obviate the need of general anesthesia.
FC3.20.05MISOPROSTOL: AN EFFECTIVE ALTERNATIVE TO OXYTOCINFOR LABOR INDUCTION IN TERM PREMATURE RUPTURE OFMEMBRANE AND UNFAVORABLE CERVIXT.S. Thach (1), S. Jamulitrat (2), V. Chongsuviwatong (3), A. Geater(3), T.D. Pham (1)(1) OB/GYN Hospital, Ho Chi Minh City, Vietnam.(2) Songklanagarind Hospital, Hat Yai, Songkla, Thailand.(3) Epidemiology Unit, Prince of Songkla University, Songkla,
Thailand.
Objective: To test the hypothesis that vaginal misoprostol is an effectiveand safe alternative to oxytocin for inducing labor in women withpremature rupture of membrane (PROM) at term and unfavorablecervix.Study Methods: The randomized, controlled trial was carried out atHungvuong OB/GYN Hospital, Vietnam. 172 eligible subjects wererandomly assigned to receive either misoprostol or oxytocin. 25 mgmisoprostol was placed in the posterior vaginal fornix. Subsequent dosesafter 4-hour intervals were only given if uterine contractions were notsufficient. Oxytocin was administered intravenously by a standardincrement infusion protocol. Study subjects were closely monitoredduring intra- and postpartum period. Interval from start of induction tovaginal delivery and infection complications were primary outcomes.Survival analysis was carried out to take the occurrence of cesareandelivery into account.Results: There were no significant differences with regards to laborduration, intra- and postpartum complications and neonatal morbidities.The interval from induction to vaginal delivery, adjusted for cesareansection, was similar between the two study group (Hazard ratio = 1.06and 95% confidence interval (CI)=0.54, 2.06). Chorioamnionitis wasdiagnosed slightly more frequently in the misoprostol group (riskratio=1.7; 95% CI:0.6, 4.4; P=0.29).Conclusion: Vaginal misoprostol at the conservative dosing regimencould be taken into consideration as an alternative to intravenousoxytocin for induction of labor in term PROM associated withunfavorable cervix. Both treatments give similar induction-to-vaginaldelivery interval and similar complications. Further study is required toaddress the rare outcomes, namely neonatal long-term morbidity andmortality.
FC3.20.06RASPBERRY LEAF TABLETS AND THEIR EFFECT ON LABORAND BIRTH OUTCOMESM. Parsons , Dept. OB, Westmead Hospital, Sydney, Australia.
Objectives: The aim of the study was to investigate the effect of theraspberry leaf herb, consumed in tablet form by nulliparous women from32 weeks gestation until birth, on their labor and birth outcomes.Study Methods: One hundred and ninety healthy, nulliparous womenwere included in this double-blind, placebo-controlled, randomized,
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observational study which was conducted at one hospital in Sydney,Australia. Mothers whose baby was delivered by cesarean section wereexcluded from analysis of some variables.Results: Although not statistically significant, on average mothers in theraspberry leaf group had a slightly shorter gestation period (in days)[MRx=278.95, Mc=280.35, t(156)=1.07, p=29], and length of time in firststage of labor (in minutes) [MRx=291.11, Mc=431.67, t(122)=1.08,p=28].Conclusions: The raspberry leaf herb, consumed in the form of tablets atthe rate of 2400mg per day was found to shorten labor with no knownside effects.
FC3.20.07THE INFLUENCE OF UMBILICAL VEIN OXYTOCIN ON BLOODLOSS AND LENGTH OF THE THIRD STAGE OF LABORN. Jovanic , N. Lazic, S. Savic, S. Sibincic, Clinical Centre - Banja Luka,Dvanaest beba 2, Banja Luka, Republic of Srpska, Bosnia andHerzegovina, 78000.
Objectives: The aim of the study was to investigate the effect oftransumbilical technique of oxytocin application.Study Methods: Blood loss and duration of the third stage of labour weremonitored in four groups of thirty patients each. The third stage oflabour in Group 1 patients was physiologically managed. Patients inGroup 2 were injected 30 ml. of 0,9% solution of NaCl into umbilicalvein. Patients in Group 3 were injected 30 ml. of 0,9% solution of NaClwith 10 IU of oxytocin. Patients in Group 4 were injected 30 ml. of 0,9%solution of NaCl with 20 IU of oxytocin. T-test was done as a statisticalmethod on significance level of 0,01.Results: Application of 10 IU or 20 IU of oxytocin through umbilicalvein leads to statistically shortened third stage of labour (p < 0,01) andstatisically significant decreased blood loss in the third stage of labour(p < 0,01). Dose increase of oxytocin for 100% no relation to neitherduration of the third stage of labour (p > 0,01) nor blood loss in the thirdstage of labour (p > 0,01).Conclusions: There were no complications during the applications ofoxytocin through umbilical vein.The transumbilical technique ofoxytocin application has unjastifyably rarely used in the third stage oflabour although it is easely accesible, simple, painless and safe.
FC3.20.08RIPENING OF THE UTERINE CERVIX IN GRANDMULTIPAROUSWOMEN WITH PROSTAGLANDINS E2: PERIPARTUMCOMPLICATIONS AND SAFETYT. Silberstein , S. Eyal, Z. Ben Aroya, M. Hallak, D. Yochai, M. Katz,M. Mazor, Dept. OB/GYN, Soroka University Medical Center, Facultyof Health Sciences, Ben Gurion University of the Negev, Beer Sheva,Israel.
Objective: To determine whether the use of vaginal prostglandings E2
(PGE2 ) for ripening of uterine cervix in grandmultiparous (parity 5 ormore) women is associated with a higher rate of peripartumcomplications.Study Methods: We included 11,167 grandmultiparous women, whodelivered in our institution between the years 1989-1995. Ripening ofthe cervix with vaginal administration of 0.5 mg of PGE2 wasperformed in 315 women (study group). All patients were monitored forfetal heart rate and uterine contractions for 3 hours after PGE2administration. Additional PGE2 doses were administered every 6 hoursif indicated. The control group consisted of 10,852 grandmultiparouswomen who did not undergo ripening of the cervix by PGE2. Statisticalanalysis included chi square and Fisher’s exact test when appropriate;power analysis of major variables was >80% assuming a type one errorrate of µ = 0.05.Results: No significant differences were found in any of the peripartumcomplications between the PGE2 treated patients and the control group.
Study group Control group pN=315 (%) n=10,852 (%)
Placental abruption 5 (1.6) 98 (0.9) NSIPFD 2 (0.6) 11 (0.1) NSPPH 0 43 (0.4) NSUterine rupture 0 11(0.1) NSRetained placenta 1 (0.3) 65 (0.6) NSManual lysis 3 (0.9) 43 (0.4) NSVaginal tears 18 (5.75) 488 (4.5) NSFetal distress 12 (3.8) 412 (3.8) NSVacuum deliveries 5 (1.6) 152 (1.4) NSCesarean sections 42 (13.3) 1159 (11.6) NS
Conclusions: Ripening of uterine cervix in grandmultiparous patientswith vaginal PGE2 was not associated with a higher rate of peripartumcomplications. Therefore, the use of PGE2 in grandmultiparous womenfor ripening of the cervix should be considered relatively safe.
FC3.20.09ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR - ACOMPARATIVE STUDYJasmine Rajwani, Khadilkar, Survana, Grant Medical College - Camaand Albless, Government Hospital, Mumbai, India
Objectives: The aim of the study was to compare the effect ofintramuscular methergin, intra-umbilical vein oxytocin andintramuscular prostaglandins in the management of third stage of labor.Study Methods: A study was carried out on 120 patients of normal labor.Patients were selected randomly and divided into three groups:Group1- 40 patients were treated with injection methyl ergometrine0.2mg intramuscular following delivery of the placenta,Group2- 40 patients were treated with instillation of 5 units of oxytocinin 10ml of normal saline into the umbilical vein,Group3 - 40 patients were treated with injection prostaglandins 250mgintramuscular. Pre and post delivery estimation of haemoglobin andpacked cell volume was done, duration of third stage and amount ofblood loss was noted.Results: The amount of blood loss in patients with intramuscularprostaglandins was less, average of 4% as compared to 7% withintraumbilical vein oxytocin and 9% with use of intramuscularmethergin.The duration of third stage was less with use of prostaglandins ascompared to the other groups.Conclusion: Use of prostaglandins was most effective in reducingamount of blood loss in third stage of labor as compared tointraumbilical vein oxytocin and intramuscular methergin. However,intraumbilical vein oxytocin was particularly useful in cases ofpregnancy induced hypertension, heart disease patients and it seems tobe a promising treatment for retained placenta obliviating the riskinvolved in the procedure of manual removal of placenta.
FC3.21 HRT: CENTRAL NERVOUS SYSTEM AND OTHEREFFECTS
FC3.21.01THE EFFECT OF SHORT-TERM ESTROGEN REPLACEMENTTHERAPY ON SLEEP – A RANDOMIZED PLACEBO-CONTROLLED DOUBLE-BLIND CROSS-OVER TRIAL INPOSTMENOPAUSAL WOMENP. Polo-Kantola (1), R. Erkkola (1), K. Irjala (2), O. Polo (3), Universityof Turku, Turku, Finland(1) Dept. OB/GYN(2) Dept. Clin. Chem.(3) Dept. Physiol.
Objectives: To evaluate the effect of estrogen replacement therapy(ERT) on subjective and objective sleep quality in postmenopausalwomen and to assess the predictive factors involved.Study Methods: A 7-month prospective, randomized, double-blind,cross-over study consisting of two 3-month treatments with estrogen andthe placebo treatment with one month’s wash-out period in-between.Out of 71 recruited women, 62 completed the follow-up. Subjectivesleep quality was evaluated with 8 visual analogic scale (VAS)statements. For objective sleep quality measurement all-night
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polysomnography and static-charge-sensitive bed (SCSB) were assessed.Self-reported climacteric symptoms for 14 days were also carried out.Serum E2- and FSH-levels were controlled.Results: ERT effectively alleviated climacteric symptoms, such as hotflushes (p<0.001), sweating (p<0.001), sleep complaints (p<0.001),headache (p=0.002) and depression (p=0.055). ERT improved sleepquality, facilitated falling asleep and decreased nocturnal restlessnessand awakenings (p<0.001). The subjects were less tired in the morningsand in the daytime (p<0.001) on ERT. These effects were associatedwith alleviation of vasomotor symptoms (r range 0.27-0.55), alleviationof somatic symptoms (palpitation and muscular pain r range 0.26-0.36)and alleviation of mood symptoms (r range 0.28-0.37) on ERT. Inpolygraphic sleep studies altogether 11,570 arousals were observed.ERT decreased the frequency of movement arousals, while increasingthe frequency of EEG arousals. Regardless of the treatment sleepefficiency, sleep latencies and distribution of various sleep stagesremained similar.Conclusions: ERT significantly diminished sleep complaints amongpostmenopausal women. Alleviation of climacteric symptoms is themost important predictive factor for the beneficial effect of ERT. ERTimproves objectively measured sleep quality by alleviating thefrequency of movement arousals without having any effect on sleeparchitecture. Because of these beneficial effects, ERT should beconsidered as a treatment of choice for postmenopausal sleepcomplaints.
FC3.21.02CEREBRAL GLUCOSE METABOLIC RESPONSE TO PREMARIN®
AND EVISTA® IN HEALTHY POSTMENOPAUSAL WOMENJ.T. Metz , L.H. Kinnunen, M. Cooper, Micro Inc., Chicago, IL, USA.
Objective: We sought to determine the effects of Premarin® and Evista®
on regional cerebral metabolism of glucose (rCMglu).Study Methods: In a double-blind crossover study, eight normal healthyfemale subjects (aged 63-78) received, for two weeks each, Premarin®
(0.625 mg/day), Evista® (60 mg/day) and placebo. At the end of eachtwo week period, subjects participated in an FDG/PET study. Metabolicimages were analyzed to reveal areas in which either drug differedsignificantly from placebo.Results: While no differences in overall cerebral metabolism behavioralstare, or mood were observed, both drugs produced effects on CNSrCMglu. Premarin® significantly increased relative rCMglu in rightfrontal and temporal cortices, and decreased relative rCMglu in leftfrontal cortex. Evista® increased relative rCMglu in right frontal cortexand thalamus, and decreased relative rCMglu in parietal and temporalcortices.Conclusions: Estrogen’s CNS effects, including protection againstdementia and other cognitive dysfunctions, are likely to be mediatedthrough, or indicated by, the metabolic changes induced in cerebralregions by Premarin®. Because Evista® had different CNS effects, itsbehavioral consequences are likely to be different.
FC3.21.03EFFICACY AND SAFETY COMPARISON OF ESTROGEL® GELAND PLACEBO IN THE TREATMENT OF VASOMOTORSYMPTOMSD.F. Archer , for the ESTROGEL® Study Group; Eastern VirginiaMedical School, Norfolk, VA, United States
Objectives: This was a randomized, placebo-controlled, double-blind,multicenter study of the efficacy and safety of ESTROGEL® Gel 1.25 gand 2.5 g daily for the treatment of vasomotor symptoms in menopausalwomen.Study Methods: Postmenopausal women who experienced a minimumof 7 daily or 60 weekly moderate-to-severe hot flushes were randomlyassigned to ESTROGEL® Gel 1.25 g, 2.5 g or placebo once daily for 12weeks. Efficacy was evaluated from the frequency of hot flushes. Safetywas assessed by a battery of physical and laboratory examinations andrecording adverse events.Results: Among 221 women randomized (75 to 1.25 g, 73 to 2.5 g, and73 to placebo), the mean percent change in the frequency of hot flushesdecreased in both ESTROGEL® Gel dose groups from Weeks 1 to 12(1.25 g dose: –26.7% to –74.6%; 2.5 g dose: –26.9% to –82.3%;placebo: –26.2% to –56.7%). Statistically significant differences from
placebo were observed beginning at Week 3 for the 2.5 g dose and atWeek 6 for the 1.25 g dose. Overall, both doses of ESTROGEL® Gelwere well-tolerated with a low incidence of unrelated serious adverseevents.Conclusions: Overall, ESTROGELâ Gel was shown to provide effectiverelief of postmenopausal vasomotor symptoms. ESTROGEL® 2.5 g wasthe most effective dose in alleviating the frequency of hot flushes,compared to placebo. The 1.25 g dose, however, also demonstratedimprovement over placebo and should be considered the starting dosefor symptomatic patients
FC3.21.04COMPARATIVE EFFECTS OF PREMARIN, EVISTA, ANDPLACEBO ON SLEEP ARCHITECTURE, SLEEP QUALITY, ANDHOT FLUSH FREQUENCY IN POSTMENOPAUSAL WOMENM, Scharf , R. Stover, J. Withrow, D. Berkowitz, Center for Research inSleep Disorders, Cincinnati, Ohio, USA.
Objectives: The purpose of the study was to evaluate and compare theeffects of Premarin, Evista, and placebo on sleep efficiency and qualityin postmenopausal women who complain of night sweats and hotflushes.Study Methods: Thirty subjects between the ages of 45 and 60 who wereat least 6 months post menses and who had complaints of at least oneepisode of hot flushes per night were enrolled in a single, blind, placebocontrolled trial. All subjects maintained daily diaries during a two-weekperiod followed by 4 weeks of treatment with Premarin, 0.625mg,Evista, 60mg, or placebo administered 2-4 hours prior to bedtime. Thediaries were checked to assess sleep quality and frequency of hot flushevents. The first three nights of both the placebo baseline and thetreatment periods were spent in the sleep laboratory. Split screenaudiovisual recording was carried out to allow for simultaneousobservation of polysomnographic data and the patient’s verbal report ofhot flush/night sweat events. Data were analyzed using an analysis ofcovariance that corrects for baseline differences between the groups.Results: Patients on Premarin showed less wake after sleep onset withthe total number of awakenings significantly below that of the placebogroup (p<0.005). The decrease in awakenings was in part due to thedecrease in the number of nocturnal hot flush events. Patients receivingPremarin showed a significant reduction in the overall number of hotflushes per day compared to the placebo (p<0.001) and to Evista(p<0.005) as well as the number of nocturnal hot flush events recordedin the laboratory compared to placebo (p<0.05) and to Evista (p<0.05).No differences were noted in hot flush frequency in the laboratory or athome between patients receiving Evista or placebo. Daytime physicalfunction measured by the Quality of Life Questionnaire was perceivedas diminished on Evista compared to placebo or Premarin.Conclusions: Premarin reduces but Evista maintains daily hot flushfrequency in postmenopausal women. Concomitantly, the reduction inhot flush events with Premarin is accompanied by fewer nocturnalawakenings. Daytime physical function was perceived as worseon Evistacompared to Premarin or placebo after 4 weeks of treatment. Poornocturnal sleep can significantly impact on quality of life issues.
FC3.21.05EFFECTS OF TRANSDERMAL HRT ON VASOMOTORSYMPTOMS USING EITHER A SEQUENTIAL REGIMEN OR ACONTINUOUS COMBINED REGIMENM. Notelovitz (1), M-P Dain (2)(1) Women Institute Research Center Inc America. Gainesville, Florida,United States.(2) Rhône-Poulenc Rorer, Antony, France.
Objectives: To evaluate the efficacy and tolerability of sequentialestradiol/norethisterone acetate (E2/NETA) transdermal therapy(EstalisÒ Sequi) and continuous combined E2/NETA transdermaltherapy (EstalisÒ), in reducing moderate-to-severe post-menopausalvasomotor symptoms compared to placebo alone, were evaluated.Study Methods: Two separate, randomized, double-blind, multicenter,quality of life (QoL) studies were done over 12 weeks. In both trials,healthy post-menopausal women (age 40-70 years) with an intact uterusand with at least 8 hot flushes per day, were assigned to one of fourtreatment groups, a transdermal patch containing either placebo or oneof three different regimens of E2/NETA. Sequential therapy consisted of
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a transdermal patch releasing 17 b-estradiol (E2) 50 mg/day alone fordays 1 to 14 of each cycle and a combination E2/NETA patch releasingE2 50 mg/day plus NETA 140, 250 or 400 mg/day for days 15 to 28 ofeach cycle. Continuous combined therapy consisted of transdermalE2/NETA 50/140, 50/250 or 50/400 (mg/day hormone delivery), appliedevery 3.5 days. Vasomotor symptoms, patch tolerance and adhesionwere rated by a patient questionnaire.Results: Transdermal E2/NETA as either sequential or continuouscombined therapy significantly reduced the mean number of hot flushesand sweating (from 8 to <1/day, p=0.001), reduced sleep disturbancesand improved sexual function, with all trial dosages, compared toplacebo.Conclusion: Both regimens significantly reduced vasomotor symptoms.The QoL of post-menopausal women can be effectively improved bytreatment with either of these regimens of transdermal E2/NETA. Patchtolerance and adhesivity were both excellent for each regimen.
FC3.21.06THE INFLUENCE OF HORMONE REPLACEMENT THERAPY ONTHE AGE-RELATED CHANGE IN COGNITIVE PERFORMANCE.E.L.Løkkegaard (1) , A.T.Pedersen (1), P.Laursen (2), I.P.Loft (2),S.Larsen (2), T.Jørgensen(2), (1) Hvidovre University Hospital,Kettegård Allé 30, Hvidovre, Denmark, DK-2650, (2) CopenhagenCounty Centre of Preventive Medicine, Glostrup University Hospital,Denmark.
Objective: To analyze over an 11-year observation period the impact ofhormone replacement therapy(HRT) on age-related changes in a broadspectrum of cognitive functions and to assess if women choosing HRTare characterized a priori by better cognitive function.Study Methods: The analyses were based on data from a longitudinalprospective sub-cohort of 226 women from a large population-basedstudy. A psychological examination was performed twice, 11 years apartapplying a computer-aided test technique - the Cognitive FunctionScanner®, including 28 cognitive parameters. The final analysescomprised 126 "never users" of HRT, 40 "current users" at follow-upand 30 "future users", defined as women who started HRT subsequent tobaseline registration during the eleven-year observation period. Thesegroups were compared according to cognitive performance usingmultivariate statistical methods to adjust for confounding factors.Results: A tendency that ”current users” of HRT exhibited a lesspronounced decline in cognitive function over an eleven-yearobservation period compared to "never users" was found. This tendencywas, however, only significant for three parameters of thecomprehensive applied battery of cognitive tests. We also found ageneral tendency that women subsequently choosing HRT arecharacterized by better cognitive function at baseline.Conclusions: It appears that HRT postpones the age-related decline inspecific areas of cognitive function. However, women choosing HRT arecharacterized by better cognitive functioning a priori, which mightinduce a potential selection bias.
FC3.21.07EFFICACY OF TRANSDERMAL STRADIOL/NORESTHISTERONEACETATE VS. OTHER HRT’S ON VASOMOTOR SYMPTOMS INPOSTMENOPAUSAL WOMENH. Burger (1), D.F. Archer (2), M. P. Dain (3)(1) Prince Henry’s Institute of Medical Research, Monash Medical
Centre, Victoria, Australia.(2) Dept. OB/GYN, Eastern Virginia Medical School, Norfolk, VA,
USA.(3) Rhône-Poulenc Rorer, Antony, France.
Objective: To compare the efficacy of continuous combined andsequential transdermal estradiol/noresthisterone acetate (E2/NETA)HRT (Estalis® and Estalis® Sequi) vs. transdermal E2 and oral progestrinand oral E2/NETA (Kliogest®) on vasomotor symptoms and endometrialhyperplasia in healthy postmenopausal women. The primary endpointwas the incidence of endometrial hyperplasia.Study Methods: 4 separate randomized, double-blind studies, over 400women with ³ 3 hot flushes/day received the following HRT regimens:2 groups received either a patch releasing E2 50 mg/day or acombination E2/NETA patch delivering E2 50 mg/day and either 140,250 or 400 mg/day NETA for 52 weeks; 1 group received transdermal
E2 50 mg/day and sequential transdermal E2/NETA delivering NETA250 or 400 mg/day or continuous transdermal E2 50 mg/day (EstradermTTSÒ) plus sequential oral dydrogesterone 10 mg/BID for 14 days in a28-day cycle during 24 weeks; 1 group received a continuous E2/NETApatch delivering 50 mg E2 and 140 or 250 mg/day NETA or 2/1 g/dayoral E2/NETA for 24 weeks.Results: The studies showed a much lower incidence of endometrialhyperplasia with transdermal E2/NETA than with E2 alone. All studiesshowed that the incidence of hot flushes and sweating declined frombaseline. All patches were well tolerated and treatment-related adverseevents and urogenital bleeding were comparable between treatmentgroups.Conclusions: Continuous combined and sequential transdermalE2/NETA was comparable to transdermal E2 alone, Estraderm TTSÒ
plus oral progestin and oral E2/NETA for reducing vasomotor symptomsamongst postmenopausal women. The studies shoed a much lowerincidence of endometrial hyperplasia with E2/NETA than with E2 alone.
FC3.21.08EFFECT OF TRANSDERMAL CONTINUOUS COMBINEDESTRADIOL/NORETHISTERONE ACETATE VS ESTRADIOLALONE ON QUALITY OF LIFE IN POSTMENOPAUSAL WOMENS. Shumaker , The Bowman Gray School of Medicine, Wake ForestUniversity, Winston-Salem, North Carolina, USA.
Objectives: To investigate the effects of three doses of norethisteroneacetate (NETA) administered together with estradiol (E2) in acontinuous combined regimen vs. transdermal E2 alone on quality of life(QoL) in postmenopausal women.Study Methods: In a 1-year, multicenter, randomized, double-blind,parallel-group study a total of 625 healthy post menopausal women aged40-70 years with an intact uterus were randomized into four treatmentgroups: E2 50 mg/day, with one of three doses of NETA 140, 250 or 400mg/day (50/140, 50/250, 50/400) compared with E2 50 mg/day alone.Study endpoints were selected QoL parameters. Effects on vasomotorsymptoms and genital bleeding were also monitored.Results: In all treatment groups sexual arousal improved from baselineto study endpoint. Sleep disturbances decreased significantly frombaseline to endpoint in all E2/NETA groups (50/140, p=0.050; 50/250,p=0.036 and 50/400, p<0.001). Improvements in urinary incontinenceand cognitive function were significantly greater in the 50/400 groupcompared to those receiving E2 alone (p<0.001). The E2/NETAcombination patch demonstrated effects comparable to E2 alone withrespect to vasomotor symptoms. During cycles 10, 11 and 12, thepercentage of women who were amenorrheic decreased to 35% in the E250 group and increased to 39% in the 50/250 group and to 44% in the50/400 group. The percentage of women who were amenorrheic showedlittle change in the 50/140 group (48 to 53%).Conclusions: Overall the combined E2/NETA patch improved QoL inpostmenopausal women. E2/NETA combination HRT (EstalisÒ) hasbeen shown to have greater benefits on QoL parameters thantransdermal E2 alone.
FC3.21.09ANTIDEPRESSANTS AND HORMONAL REPLACEMENTTHERAPY IN TREATMENT OF DEPRESSIVE DISORDERCAUSED BY POST-OVARIOECTOMY.Y. Svetlana (1) , S. Vera (1), K. Galina (2), K. Valery (2), (1) ResearchCentre of Ob\Gyn & Perinatology, Oparino 4, Moscow, Russia, 117815,(2) Moscow Institute of Psychiatry, Moscow, Russia.
Objectives: The goal is the study of effective of using antidepressantsand hormone replacement therapy (HRT) in the treatment depressivedisorder caused by postovarioectomy.Study Methods: Pharmacological, psychometric methods with speciallydeveloped map, Hamilton's dials of anxiety and depression.Results: In 57,5 % cases dysthymia was diagnosed, in 22,5 % casesdepressive episode (easy and middle degrees of Redness) was diagnosed(ICD-10). During the treatment of HRT somatovegetative disorders werereduced (group A). During the initial use of tianeptine (25 mg),sertraline (50 mg) mood disorder was decreased (group B).Conclusion: Influence on the pathogenic mechanisms of depressionmakes different class of medicines use effective.
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FC3.22 HYSTEROSCOPY: DIAGNOSIS
FC3.22.01OUTPATIENT DIAGNOSTIC HYSTEROSCOPY WITHHYDRODILATATIONM. A. Siddig Dept. OB/GYN Royal Cornwall Hospital, Truro, Cornwall,UK
Objectives: To evaluate the success, indications, complications andresults 286 diagnostic hysteroscopies performed with hydrodilatation(without anaesthesia) in a district general hospital.Design: Retrospective analysis of hysteroscopy charts between 1996 and1998.Setting: Royal Cornwall District General Hospital,Patients: 286 patients referred for outpatient diagnostic hysteroscopy fordifferent indications.Intervention: Diagnostic hysteroscopy was performed in 86% of patientswithout anaesthesia or cervical dilatation. Hydrodilatation technique wasused by increasing the pressure of the infused saline to 200cm H2O. Thehysteroscope was introduced under direct vision using a camera.Results: The most common indication for hysteroscopy was PMB(26.5%). Hysteroscopy was successfully performed in 90.9%. In 86% ofwomen we accessed the uterine cavity with hydrodilatation techniqueunder direct vision without premedication, local anaesthesia or cervicaldilatation. In 39.8% intrauterine pathology was diagnosed and in 10%further surgical treatment in the form of hysterectomy was carried out.The most common cause of failure was cervical stenosis (61.4%).Conclusion: Diagnostic outpatient hysteroscopy with hydrodilatationand introduction of the hysteroscope under direct vision is feasible inoverwhelming majority of cases without local anaesthesia. The lowcomplication rate and the high detection rate for intrauterine pathologyjustifies performing this procedure in the office as routine in the newcentury.
FC3.22.02THE ACCURACY OF HYSTEROSCOPIC VISUAL IMPRESSIONFOR DIAGNOSING ENDOMETRIAL COMPLEX ATYPICALHYPERPLASIA OR CANCERG. Del Priore , S. Feinstein, F.S.Williams, A. Lui, NYU School ofMedicine, 530 First avenue, suite 9R, New York, NY, United States,10016.
Objective: The aim of the study was to determine the accuracy ofhysteroscopic visual impression (HSC) for diagnosing endometrialcomplex atypical hyperplasia (CAH) or endometrial cancer (CA).Methods: Using the medical record and pathology department databasesfrom 1994 to 1998, we identified all patients diagnosed with CAH orCA. Those patients who had also had hysteroscopy with dilation andcurettage (HSC D&C) as part of their work-up are the subjects of thisstudy.Results: There were approximately 700 patients with either CAH or CA,44 of which had a HSC D&C. Medical records were available for all ofthem. Patient ages were between 23 and 87 years with a mean of 58.1.Uterine size was between 4 and 13 weeks with a mean of 6.8. Theindication for HSC D&C was abnormal uterine bleeding in 54.5%, asuspicious prior office biopsy in 20.5%, abnormal sonogram in 13.6%,other in 4.5% and not specified in 9.1%. The pre-operative diagnosiswas rule out cancer or CAH in 26.8%. This number did not change afterHSC. However, in two patients, the pre-operative diagnosis of CAH orcancer was changed to an incorrect benign diagnosis. In two otherpatients, who had not been diagnosed pre-operatively with CA or CAH,visual impression under hysteroscopy led to these correct diagnoses. Theoperative findings were reported as completely normal in 7.3% andvarious other benign findings were reported in 82.9%. The preoperativediagnosis was changed by hysteroscopic appearance in 9.8% of cases.Compared to final pathologic diagnosis, the intra-operative HSCdetection of CA or CAH (sensitivity 26.8%) added nothing to the pre-operative clinical impression (sensitivity 26.8%).Conclusions: The operative impression based on HSC appearance rarelymatches the post-op pathologic diagnosis of CAH or CA. Cancer ismissed by HSC even when the clinical scenario suggests malignancy.We found that physicians are not more likely to correctly predict CAHor CA with HSC information. Further study is needed. However, thedata suggests that hysteroscopy is of little benefit in diagnosing CAH orCA.
FC3.22.03INTEROBSERVER VARIATION IN THE ASSESSMENT OFHYSTEROSCOPIC IMAGESJ. Bernardes , M. Martinho, P. Xavier, J. Monsanto.Departamento de Ginecologia e Obstetrícia, Hospital de S. João,Faculdade de Medicina do Porto, Portugal
Objective: Evaluation of interobserver agreement in the assessment ofhysteroscopic images.Methods: Sixty consecutively recorded hysteroscopic video-tapes withgood quality image were selected, obtained with a 5 mm Hamou IIhysteroscope and saline as distension media. The tapes were reviewedby three experienced specialists in hysteroscopy, who were asked todetect and identify intra-cavitary lesions as polyps, myomas, neoplasia,adhesions, malformations and IUD and to classify the endometrialpattern as atrophic, proliferative, secretory or hyperplastic. For statisticalanalysis, the proportions of agreement (PA) and the k statistic, with 95%confidence intervals (95%CI) were used.Results: Interobserver agreement was excellent regarding the detectionof intra-cavitary lesions (PA=0.86, 95%CI 0.84-0.89; K=0.79, 95%CI0.70-0.89), but only fair to good in the classification of the endometrialpattern (PA=0.65, 95%CI 0.61-0.69; K=0.49, 95%CI 0.40-0.59).Conclusions: A good agreement between specialists is found inhysteroscopic detection of intra-cavitary lesions, but less so in theclassification of endometrial patterns. Care should be taken in theinterpretation of endometrial patterns as obtained through thehysteroscope, as this may not be very reproducible.
FC3.22.04CLASSIFICATION OF MICROHYSTEROSCOPIC IMAGES ANDTHEIR CORRELATION WITH HISTOLOGICAL DIAGNOSESJ.E. Dotto , B. Lema, Instituto Argentino de Diagnóstico, Buenos Aires,Argentina.
We have suggested a method for the systematic classification ofhysteroscopic images based on our experience with 1436 hysteroscopiesand their corresponding biopsies. Images are classified as follows:normal hysteroscopy, benign disease, low risk hyperplasia, high-riskhyperplasia and carcinoma.There is a strong correlation between the classification of images and thehistological diagnosis; in the first two groups the correlation was presentin every case; there were some false positives and false negatives in thelow and high risk hyperplasias and carcinomas, the causes of which havebeen analyzed. If this classification system is used for the diagnosticexploration and submitted to the final histological diagnosis it can beuseful for a systematic approach to hysteroscopic findings and toimprove communication between specialists involved in a case. It isbased on the degree of hysteroscopic suspicion aimed at the earlydetection of endometrial cancer and its precursor lesions.Correlation between microhisteroscopy images and histopatologicalconfirmation
N.H. B.D. S.H. C.H. CARC. TOTAL IMAGES
N.H.I. 1040 0 0 0 0 1040
B.D. 0 290 0 0 2 292
L.R.H. 0 10 60 0 0 70
H.R.H. 0 0 4 11 0 15
CARC 0 0 0 0 19 19
Total Histopath.
Confirm.
1040 300 64 11 21 1436
N.H.I.: NORMAL HYSTEROSCOPIC
IMAGE
B.D.: BENIGN DISEASE
L.R.H.: LOW RISK
HYPERPLASIA
H.R.H.: HIGH RISK
HYPERPLASIA
CARC: CARCINOMA N.H.; NORMAL HISTOLOGY
S.H.: SIMPLE HYPERPLASIA C.H.: COMPLEX
HYPERPLASIA
The correlation was significant (p<0.001) Cramer V correlation coefficient = 0.925
The Lambda coefficient = 0.96
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FC3.22.05NATIONAL SURVEY OF OUT-PATIENT HYSTEROSCOPY INTHE UKL. Rogerson , S. Duffy, Dept. OB/GYN, St. James’s University Hospital,Leeds, UK.
Objectives: The investigation of women with bleeding using outpatienthysteroscopy has been established in a number of units in the UK. Thebenefit to patients and the Health Service is currently under review. Theextent to which outpatient hysteroscopy is available to patients is notclear, possibly due to preferred alternative clinical practice. In 1994-1995 over 100,000 diagnostic procedures were undertaken formenorrhagia in England alone, with only 30,000 of these performed inthe out-patient setting.This survey is designed to explore the current practice in relation tooutpatient hysteroscopy with staffing levels, training facilities andequipment used with the underlying reasons as to why it may not be inuse.Study Methods: We sent postal questionnaires to all consultantgynecologists in the UK with no reminder sent for non-responders.Results: Of 1148 questionnaires sent 629 were returned (55%) responserate, a previous study in 1996 initiated at Bradford in the UK had aresponse rate of 43%. The findings relating to the differing practices willbe presented in detail but 48% of respondents had an interest in minimalaccess surgery. 54% had out-patient hysteroscopy available to them andof the ones with no facility 76% would like it instituted.Conclusions: Out-patient hysteroscopy is widely available and in theunits where it is not, there is a significant desire for the facility to beinitiated. There is a huge variation in equipment, facilities and staffingfor out-patient hysteroscopy.
FC3.22.06FLEXIBLE OUTPATIENT HYSTEROSCOPY AT A DISTRICTGENERAL HOSPITAL: PATIENT'S PAIN RELIEF ANDSATISFACTION WITH A COMBINATION OF ORAL AND LOCALANALGESIA.A C Paul , Bangladesh Medical College, Dhaka, Bangladesh.M A Debono, Dept. OB/GYN, Halifax General Hospital, Salterhebble,Halifax, U.K.
Objectives: To study the effect of oral diclofenac and lignocaine spray tothe cervix on level of patients pain relief and satisfaction duringoutpatient flexible hysteroscopy.Study Methods: From July 1998 to October 1999, patients havingoutpatient flexible hysteroscopy were invited to participate into thisprospective study and 160 of them agreed. For analgesia, they had oraldiclofenac and local lignocaine spray. Hysteroscopy was performed witha 3mm flexible hysteroscope. The data was collected from astandardized data collection form filled by the patients immediately afterand at 15 minutes of the procedure. A visual analogue chart was used todocument pain as mild, moderate and severe. To assess theirsatisfaction, patients were asked whether they would consider thisprocedure in future.Results: The most common indication for hysteroscopy was abnormalvaginal bleeding. There were 51(31%) postmenopausal and 59(36%)perimenopausal women with abnormal vaginal bleeding. During theprocedure, 44 (27%) women had no pain and in 63(39%) the pain wasmild. Moderate pain was complained by 46(29%) and in 7 (4%) the painwas severe. Hysteroscopy was completed in 157(98%) and 155(96%)had endometrial biopsy. At 15 minutes after hysteroscopy, 90(56%)complained of no pain. Mild, moderate and severe pain was reported by47(30%), 18(11.25%) and 5 (3%) of the women respectively. If requiredfor them, 156(97.5%) of the women will consider this procedure infuture.Conclusions: Outpatient hysteroscopy with oral diclofenac andlignocaine spray to the uterine cervix is a well tolerated procedure andhighly appreciated by the patients.
FC3.22.07DOES THE "Y" IN OUT-PATIENT HYSTEROSCOPY MATTER?P. Quinn , P. Mc Gurgan, P O'Donovan, MERIT Centre, Bradford RoyalInfirmary, U.K.
Objectives: Evaluate the preconceptions and perceptions of patientshaving out-patient hysteroscopy, with emphasis on their attitudestowards the gynaecologist's gender.Study methods: Prospective anonymous questionnaire used before andafter the procedure for women referred to an out-patient hysteroscopyclinic in a district general hospital, where the surgeon was randomlyallocated, and blinded to results.Results: Out patient hysteroscopy was performed on 77 patients, (38 and39 patients had a male or female surgeon respectively).The two groups of patients were similar in age, parity, ethnicity, referralsource and pre-medication use.Fifteen (39%) of the patients allocated to a male, and 9 (23%), of thepatients allocated to a female would prefer a female hysteroscopist. Thiswas not statistically significant (p= 0.12), no patients expressed apreference for a male.Gender preference had no significant effect on pre-operative anxiety(p=0.58), or procedure discomfort (p=0.76), or satisfaction (p=0.28).Patients treated by a male were more likely to state that the procedurewould have been improved by having a female surgeon (p=0.054).Conclusions: The preference rates for gender are comparable to otherpublished studies.Patients treated by operators of different genders do not have anydifference in discomfort or satisfaction scores, but women treated bymen perceive that the procedure would be improved if they were treatedby a female operator.For future practice, women should be given a choice of gender werepractical, however it does not appear to have any effect on discomfort orsatisfaction.
FC3.22.08RANDOMIZED PLACEBO CONTROLLED TRIAL TO ASSESS THEROLE OF LIDOCAINE AEROSOL SPRAY IN OUTPATIENTHYSTEROSCOPYD. Soriano , S. Ajaj, T. Chuong, B. Deval, A. Fauconnier. E Daraï,Service de Gynécologie, Hôpital Hôtel-Dieu, Paris. France.
Objective: We conducted a randomized, placebo-controlled trial toassess the efficacy of lidocaine spray during outpatient hysteroscopy inreducing the procedure pain and to identify risk factors for thisdiscomfort.Study Methods: One hundred twenty one patients undergoing outpatienthysteroscopy were randomly assigned to have application of lidocainespray or placebo to the uterine cervix, during outpatient hysteroscopy.Main Outcome Measures was the evaluation of pain during hysteroscopyon a visual analogue scale.Results: There was no statistically significant difference between thestudy and the control groups in the mean ± SD age of the patients, therate of nulliparity, postmenopausal state, the need for cervical dilation,or in the percentage of women using hormone replacement therapy. Theindications for diagnostic hysteroscopy were similar in the two groups.Women in the anesthetic group had statistically significant less painduring the procedure in comparison with women in the placebo group2.2 ± 1.9 and 3.7 ± 2.5 respectively (p<0.0004). Women with abnormaluterine findings (endometrial cancer, submucose myoma, endometrialpolyp, or intra-uterine adhesions) had a significantly higher pain scorethan women with normal cavity 2.2 ± 1.9 and 3.2 ± 2.4 respectively(p<0.002). The use of aerosol anesthesia and normal uterine findingswere independently associated with less pain. No procedure had to beabandoned due to excessive pain or development of complications andno women required hospital admission.Conclusion: Women treated with lidocaine spray experiencedsignificantly less pain. Abnormality of the uterine cavity may beassociated with higher degree of pain during hysteroscopy. Furtherevaluation of this finding is needed.
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FC3.22.09DIAGNOSTIC WORK-UP AND THERAPEUTIC MODALITIES FORPERSISTENT DYSFUNCTIONAL UTERINE BLEEDING (DUB)M. Salah , M. Fathalla, H. Abdel-Aleem, I. El-Nashar, A. El-Samman,Dept. OB/GYN, Faculty of Medicine, Assiut University, Assiut, Egypt.
Objectives: To evaluate a diagnostic work-up for DUB consisting ofD&C biopsy, diagnostic hysteroscopy, ultrasound examination, Dopplerand screening for thyroid, liver and blood diseases. Secondly, tocompare between the results of hysterectomy versus endometrialablation.Study Methods: 82 patients with DUB who failed to respondsatisfactorly for a reasonable trial of medical, hormonal treatments andseveral D&Cs, were evaluated using the items of the diagnostic work-up. Treatment options (hysterectomy versus endometrial ablation) werecompared using computer package software (SPSS).Results: Uterine polypi were diagnosed definitely by ultrasound only in28.5% suspected in 5% and false negative results in 21.5% of cases.Doppler indices were lower in cases with hyperplasia than proliferativeendometrium. Positive findings on hysteroscopy were found in 31 cases(polyps in 41.9%, submucous fibroids 29% and polypoidal endometriumin 12.9%). Thyroid disorders were found in 30 cases (3.6%) and blooddiseases in 3 (3.6%). 38 cases were treated with hysterectomy and 38with electrosurgical ablation. Intraoperative and postoperative morbidityare higher in the hysterectomy group. Postoperative hospital stay andpain are less in the ablation group.Conclusions: D&C has a false negative rate of 37.8%, hysteroscopicexamination proved to be an excellent method for detection ofintracavitary lesions. Transvaginal sonography is a single non-invasivemethod of detection of gross uterine and ovarian abnormalities but has alimited value in the diagnosis of small polypi. When the Doppler indiceswere higher (³85) the presence of simple hyperplasia was <10% andthere were no organic lesions. Hysterectomy is an ultimate choice fortreatment of bleeding problems with an excellent satisfaction rate(>90%). However, it is associated with relatively high morbidity and isconsidered an overtreatment for benign conditions. Endometrial ablationis an attractive, alternative line of treatment with less morbidity andreasonable satisfaction rate of 80%.
FC3.23 LOWER GENITAL TRACT: INTRAEPITHELIALNEOPLASM
FC3.23.01AVALIATION OF THE CERVICAL AND VAGINALINTRAEPITHELIAL NEOPLASIAS FOUND IN 3105COLPOSCOPIES REALIZED IN CLASSES A AND B WOMENS.K. Alperovitch , D. Alperovitch, Paulist Association of Medicine, SãoPaulo, Brazil.
Objective: The objective in this work is the study of frequency of CINand VAIN in 3.105 colposcopies realized in classes A and B women inSaint Paul City.Study Methods: The diagnosis was done by histopathologicalexamination obtained by directed biopsies.Results: We found 06 cases of CIN (3 CIN I) and 03 cases of VAIN (2VAIN I).Conclusions: We concluded that in class A and B women the frequencyof CIN and VAIN occur in 0.19% and 0.09%, and the use of colposcopyis important in cervical cancer prevention.
FC3.23.02RISK FACTORS FOR HIGH RISK HPV TYPES AMONG 18-35AGED WOMENR. Nadisauskiene , M. Kliucinskas, T. Spukaite, Z. Padaiga, Dept.OB/GYN, Kaunas University of Medicine, Kaunas, Lithuania.
Objectives: The aim of the study was to evaluate risk factors for thepatients with high malignancy risk HPV types between 18-35 year oldwomen.Study Method: 475 women participated in the cross sectional study.Non-anonymous questionnaire with structured and open questions wasused, gynecological examination, Pap smear, Schiler test were done;HPV was detected by Hybrid Capture testing.
Results: High malignancy risk HPV types were found in 29% of cases.After logistic regression analysis we found out that significant riskfactors for high malignancy risk HPV types was sexual debut <18 yearsOR 2.07 CI (1.35-3.17); > 1 partner/year OR 2.17 CI (1.42-3.34);smoking OR 2.73 CI (1.64-4.55); important risk factors were other STDse.g. syphilis OR 1.89 CI (0.46-7.89).Conclusions: Risk factors for high malignancy risk HPV types aresimilar to the risk factors for other STDs.
FC3.23.03THE ROLE OF HUMAN PAPILLOMAVIRUS TESTING INCERVICAL SCREENING.Paraskevaidis E 1, Koliopoulos G1, Paschopoulos M1, Kontostolis E1,Zikopoulos K1, Pappa L2, Malamou-Mitsi M2, Kalantaridou SN1,Georgiou I3, Kitchener HC4, Lolis DE1.1Gynecologic Oncology Unit, Department of Obstetrics andGynecology; 2Department of Cytopathology; and 3Laboratory ofMolecular Biology, Department of Obstetrics and Gynecology,University of Ioannina School of Medicine, University Hospital,Panepistimiou Avenue, 45500, Ioannina, Greece, 4Department ofObstetrics and Gynecology and Reproductive Health Care, St Mary’sHospital, Manchester, UK
Objective: To investigate whether human papillomavirus (HPV) testingshould be performed as a screening test along with Papanicolaou (pap)smear for the detection of cervical intraepithelial neoplasia (CIN) lesionsnot detected by pap smear.Study Methods: HPV typing by using semi-quantitative PCR/ELISA(subtypes 16/18 and 31/33) was performed in 1000 women who wereself-referred for routine Pap-smear. Women were further referred forcolposcopy following a smear indicating squamous intraepitheliallesions (SIL) or positive HPV testing. Large loop excision of thetransformation zone (LLETZ) was performed in all the women withcytologic and colposcopic findings of SIL. Shallow loop excision of thetransformation zone was performed in women with positive HPV testingand colposcopic impression of SIL.Results: Pap smear examination was suggestive of HPV infection in22.3% of the women, CIN1 in 2.1%, and CIN2/3 in 1.8%. LLETZ wasperformed in 64 cases. Histologic evaluation revealed HPV infection in3 cases (5%), CIN1 in 34 (53%), and CIN2/3 in 27 (42%). Positive HPVtyping was found in 46 (6%) of the remaining 738 women. Shallow loopexcision of the transformation zone was performed in 11 of the above 46women due to colposcopic impression of SIL. Histologic examinationrevealed HPV infection in 6 cases (55%), CIN1 in 4 (36%), and CIN2/3in 1 (9%). Overall, pap test detected 94% of the cases with CIN (61 outof 66) whereas HPV typing detected 6% (5 out of 66).Conclusions: In a screening program, pap test detected 94% of womenwith CIN. HPV typing resulted in the identification of 6% of womenwith CIN which would have been missed by standard cytologicscreening. Randomized trials are required to determine the role of HPVtesting in cervical screening.
FC3.23.04PAPANICOLAOU TEST RESULTS AND COLPOSCOPY FINDINGSIN WOMEN WITH BACTERIAL VAGINOSISJ. Sisovic 1, A. Georgijevic2, S. Djukic-Ivancevic2, M. Bujko3 1
1Gynecology Department of Outpatient Clinic Vozdovac, Belgrade,Yugoslavia2Institute of Microbiology and Immunology, School of Medicine,University of Belgrade, Yugoslavia3Institute of Public Health, School of Medicine, University ofMontenegro, Podgorica, Yugoslavia
Objectives: The aim of the study was to investigate what arePapanicolaou test results and colposcopy findings in women withbacterial vaginosis (BV).Study methods: Ninety-six women of reproductive age were examinedin the Gynecology Department of one Belgrade Outpatient Clinic. Thepregnant women were excluded. Each woman was examinedgynecologically and with the colposcope, and for every woman thePapanicolaou test was done and also microbiological analysis of hervaginal secretion. Diagnosis of BV was made by Nugent criteria. UsingNugent scoring system women were divided into three groups: womenwith BV, women with intermedial vaginal flora and women without BV.
WEDNESDAY, SEPTEMBER 660
The data were statistically analyzed using χ2-test and FisherÆsexact test.Results: Twenty (21%) of examined women had BV. Among them six(30%) had normal colposcopy findings compared to 86% (56 vs 65) ofwomen without BV (p<0.01). Vaginal hyperemia with vaginal dischargewere found in 30% (6 vs 20) of women with BV and in 4% (3 vs 65) ofwomen without BV (p<0.01). Chronical cervicitis had 15% (3 vs 20) ofwomen with BV and 2% (1 vs 65) of women without BV (p<0.05).Leukoplakia was found in 20% (4 vs 20) of women with BV and in 3%(2 vs 65) of women without BV (p<0.05). Papanicolaou test results of all96 (100%) examined women showed normal findings (p>0.05).Conclusions: Women with BV have more often some pathologicalcolposcopy findings such as leukoplakia, chronical cervicitis and vaginalhyperemia with vaginal discharge compared to women without BV.Papanicolaou test results are normal for women with BV and for womenwithout BV.
FC3.23.05SIGNIFICANT INFLAMMATION IS NOT NECESSARY FORCLEARANCE OF EXTERNAL GENITAL WARTS BY IMIQUIMODRL Miller , TL Fox, HB Slade, M Smith, MA Tomai, 3MPharmaceuticals, St-Paul, MN, USA.
Objectives: Imiquimod (IQ) is new immune response modifier which isavailable for the treatment of external genital and perianal warts (EGW).The associations of significant inflammation with the clearance of EGWwas examined.Study Methods: In two randomized, placebo-controlled trials patientsapplied IQ 5% cream three times/week until total wart clearance, or for amaximum of 16 weeks.Results: In a Phase III trial, patients with mild or no erythema at thetreatment site had a complete clearance rate of 47% (29/62) and patientswith moderate or severe erythema, 57% (25/44). In mechanism ofaction, study, treatment of EGW with topical IQ demonstrated cytokineinduction. Biopsies were taken at baseline, wk 6 and end of treatmentfrom IQ (n=16) or placebo (n=3) patients. RT-PCR using specificprimers showed relative increases from baseline for mRNA levels ofcytokines and cell markers and decreases in HPV gene products. PCRshowed a decrease in HPV DNA copies/cell. All IQ treated patients had>75% reduction in wart area and seven totally cleared their lesions.Three of these seven had mild erythema. One IQ patient had an 88%reduction in lesions and no erythema. Increases in mRNA forproinflammatory cytokines did not correlate with clearance of lesions.Conclusion: Local erythema is often seen during clearance EGW lesionsby IQ but significant inflammation is not necessary for clearance of thelesions.
FC3.23.06A RANDOMIZED PROSPECTIVE STUDY OF COLD KNIFE,LARGE LOOP EXCISION AND NEEDLE EXCISION OF THETRANSFORMATION ZONE FOR TREATMENT OF CERVICALINTRAEPITHELIAL NEOPLASIAA L. Sadek , O. Istre, G B. Trolle, Dept. OB/GYN, Hedmark CentralHospital, Elverum, Norway, and H. A. Schiøtz, Dept. OB/GYN,Vestfold Central Hospital, Tønsberg, Norway.
Objectives: To compare Needle excision of the transformation zone(NETZ), in which a new, specially designed diathermy needle is used,with Large loop excision (LLETZ) and Cold knife for the treatment ofCIN.Study Methods: A prospective study was done on 105 women withhistologically verified CIN. They were randomized to three groups, eachof 35 patients. Surgery was done under local anesthesia as outpatientprocedures. There were no statistically significant differences betweenthe groups. Follow-up time is three years; all patients wereevaluated at 3, 6, 9, 12, 18, 24 and 36 months after surgery. Descriptivestatistical analysis, one way Anova and Pearson c2 statistics were used.Results: The following statistically significant differences betweengroups were seen: a) mean operating time including anesthesia (NETZ7.4 minutes, LLETZ 8.6 minutes, cold knife 17.7 minutes, p=0.001), b)conversion to general anesthesia (NETZ 11%, LLETZ 22%, cold knife37%, p=0.04), c) free resection margins (NETZ 85%, LLETZ 37%, coldknife 68%, p=0.002), d) residual disease (NETZ 2%, LLETZ 28%, coldknife 14%, P=0.006), e) mean postoperative duration of vaginal
discharge (NETZ 9 days, LLETZ 12 days, cold knife,13 days, p=0.008)and f) success rate after single treatment (NETZ, 97.1%, cold knife85.7%, LLETZ 71.4%).Conclusion: NETZ was associated with fewer problems during surgeryand a higher success rate after single treatment. LLETZ had a higher rateof residual disease, and cold knife a higher rate of conversion to generalanesthesia.
FC3.23.07RELATION BETWEEN SEXUAL PRACTICES AND HUMANPAPILLOMAVIRUS (HPV)INFECTION IN THE OROPHARINGEALCAVITY EPITHELIUMP.C.Giraldo (1) , A.K.Gonçalves (2), F.Ribeiro (1), D.Ayrton (1),S.Witkin (3), (1) University of Campinas/UNICAMP, AlexanderFlemming, 101, Campinas, São Paulo, Brazil, 13083-970, (2) FederalUniversity Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, (3)Weill Medical School of Cornell University, New York, NY, UnitedStates.
Objective: To check the frequency of HPV in the oral cavity of womendiagnosed with genital HPV infections and correlate it to sexualpractices.Material and Methods: HPV infected women (102) were investigated forevidence of HPV in the oral cavity by means of Pap- smears. Thesubjects were questioned about sexual practices, STD history andsmoking. HPV diagnosis in the oro-pharynx was based on the presenceof Koilocitosis and Discariosis on the cytological smear.Results: Oral and anal sex were practiced by 66.6% and 51.9% of thecases, respectively. HPV in the oral mucusa was confirmed in 22 cases(21.5%), in 31 cases (30,4%) there was a cytological suspicion of HPVand the remaining 49 women were HPV negative. Oral and Anal sexwas practiced by 72.2% and 63.6% respectively of the oral HPV positivewomen. A history of privious STD was stated in 27.2% versus 34.7%,smoking in 18.1% versus 24.5% and the presence of tooth cavities in63.6 versus 75.5% of the HPV+ and HPV- respectively, in the oro-pharynx. The statistical analisis, using two-tailed Fisher exact testshowed no significant differences with regards the practice of oral sex(p=. 61), anal sex (p= .23), tooth decay (p= .39) and smoking (p= .76)comparing oro-pharyngex HPV + and - women.Conclusion: The data suggests a high frequency of HPV in theepithelium of the oro-pharynx of women with genital HPV. Thepractices of oral and anal sex do not seem to influence the carriage ofHPV in the oro-pharynx
FC3.23.08TOPICAL TREATMENT OF HPV GENITAL INFECTIONS USINGRIBAVIRIN – YES OR NOV. Stanimirovic 1, B. Stanimirovic2, D. Nikolic3, A. Nikolic4
1 Galenika R&D Institute, Belgrade; 2 GYN/OB Clinic “Narodni front”,Belgrade; 3 Clinical Center "Bezanijska kosa", Belgrade; 4 ClinicalCenter "Dragisa Misovic", Belgrade
Objectives: Ribavirin, a nucleoside similar to guanosine, has bothvirustatic and immunological potentials. The objectives of thisprospective study (Phase IIb) were to assess the efficacy and predict thelevel of response to ribavirin in patients with HPV genital infection(types 6 and 11), as well as to determine the safety of topicallyadministered ribavirin in these patients.Study Methods: Fifty eligible patients with detected early clinical andsubclinical forms of HPV infection (types 6 and 11) involving skin,mucosa and lower genital tract (LGT) were evaluated in this open,individually-controlled study.The following diagnostic methods have been used in detection andverification of HPV changes: clinical observation, cytology, colposcopy,virology (in situ hybridization).The 28-day treatment period was succeeded by a 28-day follow-upperiod. During the treatment period 7.5% ribavirin cream was appliedfour times a day to HPV changes. The regression of the symptoms andsigns of the disease was monitored in the course of both periods.Results: In 96% of patients a partial clinical and/or laboratory responsewas noted. The regression of local symptoms associated with theinfection (burning, pain, pruritus) started on Day 8 of the treatment in50% of patients, while at the end of the treatment period none of thepatients had the above symptoms. During and after the treatment period
WEDNESDAY, SEPTEMBER 6 61
no local or systemic adverse effects were reported resulting fromribavirin administration.Conclusions: Topically applied ribavirin has an effect on regression ofthe clinical manifestations of HPV genital infection. Further studies arerequired (with new dosage and pharmaceutical forms) in order toelucidate fully the relationship between ribavirin and HPV genitallesions.
FC3.23.09CERVICAL COLPOSCOPY, CYTOLOGY AND HISTOLOGY:REVIEW OF 3605 RECORDSUma Devi.K ., U.D.Bafna., V.K.Ahuja., E.Vallikad, Kidwai MemorialInstitute of Oncology (KMIO) Bangalore, India
The case records of 3605 women underwent Colposcopy at thedepartment of Gynaecologic oncology between January 1989 andDecember 1997 has been reviewed.All women without any obviousmalignant lesion of the cervix were examinedwith the colposcope. Anattept has been made to correlate colposcopic observations with CervicalCytology and Histology. Majority (86.2%) were above the age of 30years and 86% belonged to lower socioeconomic groups. The Cervicalsmears were taken in 3114 women, reported as class I and II in 88.7 %and has reported as class III and above in 10.7%. The colposcopicobservations were graded usingCoppleson's classification. A satisfactory colposcopic examination couldbe performed in 56.79%, Grade I changes were observed in 29.37% andonly 4.75% had Grade III changes. A normal Transformation Zone wasseen in 19.5% women, Grade I changes were assosciated with smears ofclass I & II in 92.8% and histology of Normal or Inflammatory in82.8%. Grade III changes were assosciated with smears of class III andin 14.45% and histology of CIN III or Invasive Cancer in 84.4%.
FC3.24 MANAGEMENT OF LABOR
FC3.24.01ASSESSMENT OF LIFE SAVING SKILLS (LSS) IN VIETNAMNL Sloan 1, B Winikoff1, DT Hieu2, NTN Ngoc3, C Quimby4, GFassihian1
1Population Council, New York, NY United States;2Ministry of Health MCH/FP, Hanoi, Vietnam; 3Hung Vuong Hospital,Ho Chi Minh City, Vietnam; 4American College of Nurse Midwives,Washington, D.C., United States.
Objective: To assess whether LSS training of clinicians in primary andfirst referral care facilities and providing EOC equipement and suppliesimproves delivery care.Study Methods: A controlled quasi-experimental study in Bac Thai andLam Dong provinces, rural Vietnam, was conducted. LSS trainingcenters were created in Hanoi and Ho Chi Minh City. Qualifiedpractitioners from primary health facilities and district hospitals receivedtwo weeks of intensive competency-based LSS training, LSS manualsand midwifery kits. Obstetricians from district hospitals received a one-week LSS and one-week refresher cesarean training. Essentialequipment and supplies were provided. Data were collected inintervention and comparison facilities over 12- to 20-months on themanagement of deliveries.Results: The intervention improved detection of life-threateningobstetric conditions at primary care facilities and district hospitals butonly improved their management (including referral) at district hospitals.Conclusion: Primary health care facilities may see too few patients tomaintain skills required for EmOC. To improve referral to secondaryhealth facilities, less comprehensive courses should be evaluated inprimary health facilities.
FC3.24.02ACTUAL INTAKE DURING LABOR IN THE NETHERLANDS.LACK OF CALORIC INTAKE LEADS TO A HIGHER RISK OF ANINSTRUMENTAL DELIVERY.H.C.J. Scheepers , M.C.J. Thans, P.A. de Jong, G.G.M. Essed, S. LeCessie, H.H.H Kanhai., Leyenburg Hospital, The Hague, TheNetherlands
Objectives: In the Netherlands, women are in most cases, allowed to eatand drink. In this study the actual intake of nutrients during labor isstudied and related to the course of the delivery.Methods: Dutch midwives (n=32) and gynecologists (n=34) includedeach 5 consecutive nulliparous women, who were asked to write downwhat caloric intake they had during delivery. 213 women (65%) couldbe evaluated. A multivariate logistic regression model comparedspontaneous deliveries with instrumental deliveries due to a nonprogressing second stage. Caloric intake, duration of labor, fetalpresentation and weight, the use of pain medication, a high versus lowrisk delivery and spontaneous start of labor versus induced labor wereused as prognostic factors.Results: During labor, 38% of the women had intake other than water, ofwhom 74% ate solid food. Women without caloric intake had a higherprobability of an instrumental delivery due to a non progressing secondstage, even after adjusting for the other prognostic factors.Conclusion: Caloric intake during labor results reduces the chance of aninstrumental delivery because of a non progressing second stage. Solidfood, contributes less to the available energetic substrate, if it remains inthe stomach, and is in case of aspiration more damaging. Therefore, theuse of caloric liquids is probably preferable.
FC3.24.03INSTRUMENTAL DELIVERY: AN EXPERIENCE AT ATEACHING HOSPITAL IN NEPALR. Jha , L. Shrestha, M. Singh, M. Dongol, Dept. OB/GYN andPediatrics, Tribhuwan University Teaching Hospital, Maharajgunj,Kathmandu, Nepal.
Objectives: The aim of the study was to compare vacuum extractionwith forceps delivery and evaluate its role in modern obstetric practice.Study Methods: Tribhuwan University Teaching Hospital serves about210,000 patients annually and is one of the tertiary care hospitals inNepal. In a five year period (April 1995 to April 1999) a total of 13,333Nepalese women delivered out of which 239 (1.7%) women had aninstrumental vaginal delivery at term in the Obstetrics unit of TribhuwanUniversity Teaching Hospital, were studied. Out of this number 101 hadforceps delivery while 138 had vacuum extraction.Results: The vacuum delivery rate fluctuated between 0% and 1.7%while the forceps delivery rate fluctuated between 0.2% and 1.4%.During this time period the cesarean section rate had steadily increasedfrom 10% to almost 16%. With the exception of fetal distress there wereno significant differences found in the indication for forceps deliveryand vacuum extraction. Both consultants and residents seemed to usevacuum extraction more than forceps deliveries. The reapplicationstation position and cervical dilation differ in both infants delivered byvacuum extraction had higher incidence of neonatal jaundice, transientcosmetic deformities including chignon and cephalhematoma. Whereasinfants delivered by forceps had skin ecchymoses /abrasions andsubconjunctival hemorrhage more frequently. Apgar scores in infantsborn by vacuum extraction did not differ from those of infants deliveredby forceps. Vacuum extraction has gradually assumed more prominencethan forceps delivery in our unit in the study period. There was nomaternal mortality in the groups.Conclusion: Forceps delivery was associated more with genital tracttrauma, whereas vacuum extraction had a higher incidence of cosmeticdeformations and neonatal jaundice. Many women and their babies havebenefited from this timely and expertly performed procedure. Thus,there is a continuing role for the judicious use of instrumental assistancein modern obstetric management.
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FC3.24.04CONSERVATIVE POLICY OF INDUCTION OF LABOR INUNCOMPLICATED POSTDATED PREGNANCIESS.Chakravarti , B.Goenka, Dept. OB/GYN, Vivekananda Institute ofMedical Sciences, Calcutta, India.
Objectives: To assess the outcome of induction of labor after completing42 weeks of gestation in uncomplicated postdated pregnancies asopposed to the established policy of routine induction within 41 weeks.Study Methods: Over a period of one year, 231 primigravidae fulfilledthe selection criteria of low risk, uncomplicated post dated pregnantpatient with confirmed dates. 117 of these patients were randomlyallocated to the study group. The remaining 114 patients were managedas per established protocol of induction within 41 weeks of pregnancy.In the study group, fetal surveillance was done by daily fetal movementcount (DFMC) and biophysical profile (BPP) and ultrasonography(USG). Patients undelivered at 42 completed weeks of gestation wereinduced following cervical ripening, if indicated, by prostaglandin E2
gel.Results: 54 patients out of 117 (46%) had spontaneous onset of laborduring the period of study and the rest had to be induced. 94 (84%)patients achieved vaginal delivery, 48 in the spontaneous onset groupand 46 in the induced group. 8 patients were delivered by forceps and 20patients underwent cesarean section (7 in the spontaneous onset groupand 13 in the induced group). In 114 patients, who served as controls, 29(25.4%) were delivered by cesarean section. Neonatal mortality andmorbidity were unaltered in this group of 231 patients.Conclusions: If DFMC and fetal BPP by USG are unsatisfactory, onemay well wait until 42 completed weeks in an otherwise uncomplicatedpostdated pregnancy even without the help of antenatal fetalcardiotocography. Furthermore, this policy helps in reducing thecesarean section rate.
FC3.24.05SHOULD THE PARTOGRAM BE ADAPTED FOR TERM VAGINALBREECH DELIVERIES?I. Babarinsa , M. Oladokun, A. Adeyemo, I. Adewole, Dept. OB/GYN,University of Ibadan, Ibadan, Nigeria.
Introduction: Active management of labor is traditionally practiced withcephalic fetal presentation. The use of a partograph is believed toprevent prolonged labor. Few papers have documented experience withbreech labors managed with aid of a partograph.Study Methods: This was a 10-year comparative prospective study of thepartographic documentation of labors between babies presentingcephalic and by the breech. Augmentation was not done in either group.All partographs were retrieved and 10 variables extracted. Analysis waswith EPI-INFO version 6.0.Results: Two hundred and nine (209) consecutive breech presentingbabies were compared with (209) cephalic presenting babies. Meanduration of entire labor was shorter in breech (OR 2:1:8), but duration ofsecond stage was shorter in cephalic. Five minute Apgar scores weresimilar, but 1-week of life status was worse for breeches (OR 0.75:1).Conclusions: Intrapartum care of breech presenting babies using thestandard partograph will require major validation, modification andadaptations related to estimated fetal weight.
FC3.24.06ELECTRO-ACUPUNCTURE FOR PAIN CONTROL IN LABORM. Dunjic . M. Jevremovic, B. Dunjic, N. Sulovic, S. Stanisic,P. Momcilov, Dept. OB/GYN University Clinic, School of Medicine,Pristina, Belgrade, Yugoslavia.
Objectives: The aim of this study is to estimate the role of Electro-acupuncture (EA) as an ancient healing art and proven analgesic methodon pain in labor, uterine contractions and the fetus.Study Method: In this study are included 36 women in the treated groupand 20 women in the control group. In the treated group we used onlyEA as a uterotonin and for sedation and analgesia during labor. In thecontrol group we used Oxytocin as a uterotonin and Meperidine 100mgfor analgesia. For EA we used metal needles and WQ 10DIelectroacupuncturoscope. We used next acupuncture points: Baihui,Sishencon, Shenmen, Hegu, Sanyinjiao, Ciliao, Zusanli, Guanyuan and
Taichong. For estimation of pain we used Visual Analog Scale (VAS)on 4 cm, 7 cm, and 10 cm of cervical dilatations.Results: On 4 cm on cervical dilatation, pain was lower in treated group(t=2.20; p<0.05); on 7 cm (t=3.60; p<0.001); on 10 cm (t=4.23;p<0.001). Apgar score in 1st min. was higher in treated group (t=4.47;p<0.001); in 5th minute there were no differences between the twogroups. All women had vaginal delivery. There was no differencebetween the groups in length of first stage of labor.Conclusions: EA had no side effects on labor, women and fetus. EA hasa better analgesic effect than Meperidine (in given dose). EA has asedative effect. EA can be used for induction of labor.
FC3.25 OBSTETRIC AND GYNECOLOGY HEALTHDELIVERY
FC3.25.01MAKING THE GRADE ON WOMEN'S HEALTH: A NATIONALAND STATE-BY-STATE REPORT CARDM. Berlin (1), S.Ginsburg (2), M.Greenberger (3), (1) University ofPennsylvania, 423 Guardian Drive, 915 Blockley, Philadelphia, PA,United States, 19104, (2) The Lewin Group, San Francisco, CA, UnitedStates, (3) National Women's Law Center, Washington, D.C., UnitedStates.
Objectives: The mission of the Report Card is to provide a national andstate-by-state overview of U.S. women's health to be used bypolicymakers, researchers, and advocates in creating public policy topromote the health of women. This project assesses the overall well-being of U.S. women and identifies steps to maintain and improve theirhealth.Study Methods: The Report Card uses a definition of health thatemphasizes well-being as consistent with that of the Beijing's FourthWorld Conference on Women and the U.S. Healthy People 2010(HP2010) objectives. The Report Card uses a set of health status andpolicy indicators to rate how well the U.S. and it's states are addressingthe needs of women. The health indicators go beyond the reproductiveneeds of women; they provide a common metric for women's healthresearchers and comprise the analytic foundation for the Report Card.These health indicators are linked to policy analyses and measures ofpublic investments in women's health.Results: Health status indicators describing the spectrum of healthconditions from mortality and morbidity to prevention and wellness havebeen chosen. Companion policy indicators that support and amelioratehealth conditions have been selected. Important gaps in data collection,availability, and analysis have been identified and described (includingrace/ethnicity, age, geography, and literacy issues).Conclusions: By regularly reporting on women's well-being, the ReportCard serves as a policy and advocacy tool to improve U.S. women'slives. Over time we will monitor and incorporate trends and investmentsin women's well-being.
FC3.25.02MATERNAL SATISFACTION WITH THE METHOD OFDELIVERY IN PREGNANCYY. Sajjad (1) C. Nwosu (1), H. Hamed (1), G. Ramsden (2)(1) Dept. OB/GYN, Whiston Hospital, Merseyside, UK(2) Warrington Hospital, Merseyside, UK
Objectives: The aim of the study was to assess maternal satisfaction withthe actual method of delivery compared to the woman’s choice.Study Design: Three thousand four hundred and fifteen pregnant womenwere recruited in pregnancy prior to the onset of labor. Women wereasked to complete a questionnaire indicating their preferred method ofdelivery if given the choice. Following delivery, they were asked tocomplete another questionnaire indicating their satisfaction and to whatdegree they feel they contributed to the method of delivery.Results: 3,197 women (93.6%) felt they had influenced events to a highdegree in labor and delivery and were therefore very satisfied with theoutcome and method of delivery. 164 (4.8%) women felt that labor andthe method of delivery was all right, having contributed to some degreeto events while 54 (1.6%) women were not satisfied. Majority of theunsatisfied women had not been granted their wish for delivery bycesarean section.
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Conclusion: The majority of women are satisfied with their method ofdelivery as long as they feel they have been involved in making thedecision of the method of delivery.
FC3.25.03SOME ASPECTS LINKING INDONESIAN AND BALINESETRADITIONAL CULTURE TO HUMAN REPRODUCTIONI.B.G. Manuaba , Suwiyoga, P. Kemara, Dept. OB.GYN, School ofMedicine, University of Udayana, Bali, Indonesia.
Indonesia has a long and rich historical tradition. Hinduism, Buddhismand Islam add to the population’s understanding of human life.According to these religions’ beliefs, life begins at conception andcarries a moral status that must be protected and cared for. Any activitythat disturbs this developing life form is considered murder (“ahimsakarma”), according to basic philosophies (“Pancacrada”). According toIndonesian traditional culture, all life consists of “four brothers”:membranes, amniotic fluid, placenta/retroplacental circulation and thefetus itself – all of which need antenatal care. Traditionally, to create thebest quality of human being, the time for procreation must beindividually selected (“Suputra”). Episodes from the Mahabratha, aHindu holy book, specifically describe the care of the fetus and newbornfor the Hindu Dharma population of Indonesia.Aspects of Indonesian cultural experience can also speak to assistedreproduction technology and surrogate motherhood.Also discussed are comparisons between Ausculapious’ original writingsand findings from the Ayur Vedic, the original Hindu medical texts.
FC3.25.04DIFFERENCES IN KNOWLEDGE AND ATTITUDE TOWARDSTHE RISK APPROACH STRATEGY AMONG HEALTH ANDHOSPITAL-BASED PERSONNEL IN MALAYSIAK. Shamsuddin (1), S. Selvaraju(2)(1) Dept. of Community Health, University Kebangsaan, Faculty of
Medicine, Kuala Lumpur, Malaysia(2) Family Health Development Division, Ministry of Health,
Kualalumpur, Malaysia
Objectives: The aim of this study was to compare the knowledge andattitude of the risk approach strategy in maternal health care as practicesby the government public health personnel.Study Methods: A cross sectional survey of different categories of healthstaff working in the public health and the hospital sectors was conductedin 1997. Data was collected through self-administered questionnairedistributed to staff working in different health facilities in 16 randomlyselected health districts in Peninsular Malaysia.Results: Based on weight analysis, there were 1473 and 1522 health andhospital-based staff respectively participating in this survey. Both healthand hospital-based staff are highly awareness of the existence of riskapproach strategy in maternal care in Malaysia (99.3% versus 97.3%respectively). 95.1% of health-based personnel have relatively highknowledge of the strategy compared to 77.7% among hospital-basedstaff. With regards attitude towards the risk approach strategy comparedto 77.6% of hospital-based staff reported that there were no monitoringsystem for the strategy. Among those who reported problems in theimplementation of the strategy, very few reported lack of training as aproblem. Among health-based staff, lack of support especially lowfeedback from the hospital staff had been identified as a problem, whilefor hospital-based staff, differences in management and practice hadbeen identified as a problem in the implementation of the risk approachstrategy.Conclusions: The risk approach strategy requires close cooperationbetween the health and hospital-based personnel in managing maternalhealth care for high-risk mothers. Both heath and hospital-based staffhave high awareness and positive attitudes towards the strategy.However, knowledge of the hospital-based staff on the risk approach aspracticed by the health-based staff is rather low and problems identifiedby health and hospital-based are different. Steps must be taken to bridgetheir differences.
FC3.25.05KNOWLEDGE AND PRACTICE (KAP) ABOUT MATERNALHEALTH AND NUTRITIONG. Mahmud , K.Iqbal, Y.Hasebe, T.Nakasa, Pakistan Institute of MedicalSciences, Islamabad, Pakistan,
Objectives: Baseline information about maternal health indices is scarcein Pakistan and no such local data is available. The ICT (IslamabadCapital Territory) area was chosen by the JICA/PIMS MCH Project asmodel area for long term evaluation of training programme for MaternalHealth Education.Methodology: A comparison between two samples before and after (Pre& Post) design witha control group was used to evaluate the trainingprogram in Rural ICT. The study area was divided into two. Interventionareas were Rawat and Jhang Sayyadan. Control areas were Bhoker,Gagri, Tumair and Chirah.Study Population: All women delivered within the last three months.Open ended questionnaire was designed, pretested and modified beforeadministration. 10 doctors and nurses were trained for the interviews inthe respondent's home with the help of local lady health workers(LHWs). Data entry and analysis was done by using SPSS and Excel.Results: 257 confinements within last three months. Study period wasMay 24 to June 5, 1999. 66.3% of women were of 20-29 years in theintervention and 59.3% in the control group. 62.7% of women had 1-3children. 55% were illeterate. 14% never seek antenatal care. 41.1% sawa health personnel less than 3 times. 90% of women were seen at leastonce by LHW. 61% were home deliveries. 50% by Traditional BirthAttendant (TBA) and only 11% by Lady Health Visitors (LHV).Majority never used contraception.Conclusion: Large gaps exists between Knowledge and Practice aboutMaternal Health.
FC3.25.06IMPACT OF SOCIAL MOBILISATION ON MATERNITY CARE INA RURAL AREA OF BANGLADESHS. Chowdhury , F. Rahman, F. Islam, MQ. Hassan, A. Rahman,N. Begum. Institute of Child and Mother Health, Matuail, Dhaka,Bangladesh.
Objectives: The study aimed to evaluate the impact of SocialMobilisation on Maternity Care in a rural community of Bangladesh.Study Methods: It was a community trial in which a ‘socialmobilisation’ was launched in an area of about 30,000 population forone year and another similar area was kept as control. In each area 150randomly selected pregnant women were interviewed at pre and postintervention periods. Social mobilisation programme included advocacyand group meeting, rally, enter-education by folk songs and video. Afterintervention the outcome variables regarding maternity care werecompared between study and control area.Results: The change in the mother’s attitude towards the utilisation ofAntenatal care (ANC) services was found significantly higher inintervention area than control after social mobilisation (29% vs 4%, p<.001). Again ANC service utilization improved 43.1% from base line inintervention area compared to 7.5% in control. Although no significantincrease in the proportion of hospital delivery was observed as a resultof social mobilisation, there was a dramatic increase (from 19% to 42%)in the proportion of trained delivery attendants in intervention areacompared to no change in the control. An over all 12% decrease in theproportion of delivery complications from baseline to after SM atintervention area compared to only 4% decrease in control (p<.001).Conclusions: Social mobilisation programme is effective in improvingthe maternity care in the rural area of Bangladesh.
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FC3.25.07A REVIEW OF DEATH CASES FOLLOWING MEDICALTERMINATION OF PREGNANCY IN MAHARASHTRA WITHSPECIAL REFERENCE TO IMPLEMENTATION OF M.T.P. ACT-1971 IN MAHARASHTRAM. Mandakini (1), C.K. Bazpande (2)(1) Public Health Dept., Govt. of Maharashtra, Mumbai, Maharashtra,
India.(2) Health Services, Mumbai, Maharashtra, India.
Objectives: In India, abortions were prohibited unless medicallyindicated to save pregnant women until1 971, when the MedicalTermination of Pregnancy Bill was passed. Until then, as per IndianPanel Code (45 of 1866), the termination of pregnancy was an offence.In Maharashtra until December 1999, around 2270 M.T.P. centers areregistered and approx. 130,000 M.T.P. Procedures are performed everyyear. The study was conducted to assess the impact of M.T.P. Act inproviding the safe abortion of the women.Study Methods: In the last ten years, 52 cases of M.T.P. deaths werereported in Maharashtra with a total no. of 2270 M.T.P. centersapproved.Results: By critical analysis of M.T.P. program in State it was observedthat M.T.P. is a predominating urban program. Performance-wise, 55%of the cases were performed in metropolitan cities of Bombay and Pune,30% in other municipal areas and the rest (15%) in rural areas. In 52cases of death reported, 40% of cases were done by unqualified doctors.38% of the cases were reported from District Hospitals, 22% of the casesfrom teaching institutes. The number of deaths reported in the 2nd
trimester abortion was 54.4%. The total number of legation case donealong with M.T.P. was 42.5%. Detailed inquiries were conducted in allthe death cases.Conclusion: A conclusion is drawn to take major steps to improve theimplementation of M.T.P. program in the state. To make these facilitiesmore accessible at the rural level, abortion kits, trained personnel andhired services of expert gynecologists in the area are provided (Govt. ofIndia guidelines). To upgrade one equip government institutions in ruraland district places. To motivate the N.G.O. for approval M.T.P. centersand smooth reporting of all cases, also the death cases.
FC3.25.08REPRODUCTIVE HEALTH IN FEMALES OF THE ARAL SEAAREAD. Alieva . Dept. of Surgical and Conservative Gyn., Research Instituteof OB/ GYN, Tashkent, Uzbekistan
Objectives: Anthropogenic impact of unfavorable factors of the dryingAral Sea, worsened social and economic life conditions resulted insubstantial health deterioration of the Aral Sea area population. In thisconnection the epidemiological investigation undertaken was aimed atstudying a reproductive health in females of the region.Study Methods: Bacterioscopy and colpocytological studies as well asquestionnaires were used to identify the health status in 120 females of afertile age, 86 of which were 19 to 35 yrs old, 34 females older than 36yrs.Results: The questionnaire study revealed a high incidence ofextragenital diseases. Every second female suffered from inflammationof the gastroenteric and urinary tracts, chronic bronchitis and endocrinedisorders. Inflammation of the vulva and vagina as disbiosis andbacterial vaginosis were noted in 110 females. Diseases of the neck ofthe uterus in the form of erosion and pseudoerosion, inflammatoryprocesses of the uterus were registered in 29 females (24.2%), uterineappendages in 58 (43.3%), menstrual function disturbances in 24 cases(20%), amenorrhea in 2 (1.7%), primary sterility in 7 (5.8%), secondarysterility in 8 subjects (6.7%), uterine hypoplasia in 2 females examined.Ptosis of the internal sex organs, colporrhexis and perineal lacerationwere noted in 22 (18.3%) females.Conclusions: The results of the study dictate the need in undertakingmeasures to restore a reproductive health in females of the Aral Sea area.
FC3.26 OBSTETRIC PRACTICE
FC3.26.01ACCESS TO MIDWIFERY CARE IN THE U.S.: FINDINGS FROMTHE SECOND NATIONAL SURVEY OF NURSE-MIDWIFERYPRACTICEDeanne Williams 1, L.L. Payne2, L.M. Koontz3. 1 American College ofNurse-Midwives, 818 Connecticut Ave, NW #900, Washington, DC,20006, USA; 2 Boston University School of Public Health, Boston, MA;3 Maternal and Child Health Bureau/HRSA, Rockville, MD.
Objectives: to determine selected characteristics of certified nurse-midwives in US; impact of managed care on women and CNMs; andinvolvement of CNMs in federal and state funded MCH programsStudy methods: 6,365 CNMs surveyed, 40% response rate. Dataanalyzed using SPSS and QSR NUD*IST software.Results: On average, CNMs were 45 y/o with 10 yrs experience. 87%were in clinical practice. From 1992 to 1997, number of uninsuredclients increased from 8% to 16%; non-white clients increased from40% to 50%; and care in rural settings increased from 21% to 26%. 29%of clients were less than 20 y/o, 21% were over 35 y/o. Of therespondents, 51% reported changes in health care financing had negativeimpact on practice. Fewer than 25% were directly involved in federallyfunded MCH programs.Conclusions: Between 1992 -1997, the national CNM data baseincreased from 4,303 to 6,635 and the number of births recorded wentfrom 185,005 to 258,227. During this time, a large portion of care byCNMs was for women who were more likely to have limited access tohealth care. Many CNMs believe that the system of health care financinglimited access to services for women and hindered their ability toprovide the midwifery model of care. CNMs had limited interaction withstate MCH and Medicaid programs.
FC3.26.02IMPROVING OBSTETRIC PRACTICES IN UPPER EGYPTA. Abdel Megdeid , R. Gipson, T. Coles, John Snow Inc, Cairo, Egypt.
Objectives: The overall objective of the HM/HC results Package is toprovide an integrated package of services for the reduction of maternaland perinatal mortality in high risk groups and in the population ofUpper Egypt. HM/HC Project activities focus primarily on the districtand community level as the sites for implementation.Study Methods: The Healthy Mother/Healthy Child Project (HM/HC),MOHP completed an assessment of health need as well as training andmanagement support need in Upper Egypt Governorates based on thecriteria in essential maternal and child health service standards andmonitoring checklists. Governorate, district and facility managementteams have been trained in how to use these service standards to monitorand improve the quality of essential service provision.The use of service standards and monitoring checklist is a practicalmeans of governorate, district and facility health level teams to assessthe quality of service provision, plan for improvement, implement andmonitor steps to improving services against the criteria in the standards.The HM/HC Project has developed management systems as well as acompetency-based training program development process which meetthe need to strengthen the quality of service provision. The system andtraining methodology can be disseminated and replicated more widelythroughout the MOHP service system, the private sector as well asthrough medical and nursing educational institutions.Results: Service standards and monitoring checklists are practical meansfor assessing the level of managerial and clinical competence inproviding essential maternal and child health service. The developmentof these tools followed a systematic process:1. Health and training needs assessed,2. Competency-based job analysis completed,3. Clinical protocols developed,4. Management systems materials developed,5. Management and service provider teams trained in requisite skills.Conclusions: For the quality of services to comply with the criteria inthe service standards, facilities had to be renovated, equipment procuredand distributed, governorate, district and facility level managementteams established and trained, the supervisory and training infrastructurestrengthened, service providers trained to a level of clinical skillmastery.
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FC3.26.03COMMUNITY BIRTH ATTENDANT IN BANGLADESHA.B. Bhuiyan (1), F. Begrum (2)(1) OGSB Maternity Hospital, Dhaka, Bangladesh.(2) Dept. OB/GYN, Sir Salimullah Medical College, Dhaka,
Bangladesh.
Objectives: To review the situation of Community Birth Attendant inBangladesh.Study Methods: Review of literature and situation analysis.Results: In Bangladesh annual expected number of deliveries are 32, 49,520; of which 95% are home delivery. Maternal Mortality Rate is 4.3per 1000 live births and maternal morbidity is about 20 times ofmortality. Only 5% of complicated cases receive medical care atinstitution level. Only around 15% of deliveries were conducted bytrained health workers. The community is mostly served by TBA. Theywere supposed to offer clean birth practices but studies show that thereis not much change even after training. Under this circumstancesGovernment of Bangladesh (GOB) has responded to the WHO guidelinefor community midwives and intended to developed skilled birthattendant at the grassroots level. The Obstetrical and GynecologicalSociety of Bangladesh (OGSB) was given the responsibility to frame tothe curriculum and training guide for community midwife. It has alreadybeen developed by OGSB and GOB is in the process of implementingthe training of community midwives. Initially 250 FWV (FamilyWelfare Visitors/ Paramedics) are trained for six months at districthospitals. OGSB with the technical expertise and credibility ofestablishing Emergency Obstetric Care (EOC) at all level is entrustedwith the community midwife program by GOB.Conclusions: Bangladesh is already in the process of implementingSkilled community Birth Attendant. The professional society has gottremendous role in supporting the GOB program particularly inreproductive health/pregnancy care.
FC3.26.04CERVICAL RIPENING WITH PROSTAGLANDINS AFTERPREVIOUS CESAREAN SECTIONZ. Tóth , O. Török, J. Lukács, Dept. OB/GYN, University of Debrecen,Hungary.
Objectives: The aim of the study was to analyze the outcome ofdeliveries after previous cesarean section with special concern to casesin which for unfavorable cervix cervical ripening by local prostaglandinsneeded to be applied.Study Methods: This is a retrospective analysis of 468 cases out of atotal of 7112 deliveries during the last 2 _ years at our department.Elective repeat cesarean section was performed in 90 cases for maternaland/or fetal indication. These cases were excluded from the study. Therate of repeat cesarean section was analyzed in cases with spontaneousonset of labor and in cases after induction of labor.Results: In the group of 214 women commenced into laborspontaneously the cesarean section rate proved to be 40%. In 126 caseswith premature rupture of membranes cesarean section was performed in39,6%. In 26 cases of the latter group with an unfavorable Bishop scoredinoprotone gel was applied for cervical ripening. In this way thefrequency of cesarean deliveries was reduced to 35%. Out of the 38cases, 8 women with a Bishop score ³5 delivered vaginally. In the 30pregnancies with unripend cervix Prepidil gel was applied. In this groupthe cesarean section rate could be reduced to 50%. No severecomplication due to prostaglandins was observed.Conclusions: Our data support that under strict criteria locallyadministered prostaglandins can safely and effectively be applied inpatients with a history of previous cesarean section. This practice mightfurther decrease the number of repeat cesarean sections.
FC3.26.05EFFECTIVENESS OF TRADITIONAL BIRTH ATTENDANTSL. M. Sibley , T. A. Sipe, Prime-American College of Nurse-Midwives,Washington DC, United States
TBAs remain a major workforce in maternity care in developingcountries. Yet, after more than three decades, evidence in support ofTBA training is still limited (WHO, 1992). Although TBAs have beenshown to favorably impact on neonatal mortality (Levitt, 1997), their
current impact on reducing maternal mortality is uncertain (Fortney &Smith, 1997; UNICEF, 1997). A meta-analysis of TBA trainingeffectiveness is currently being conducted to determine the effect oftraining on TBAs and on pregnancy outcomes.To date, 57 documents published or written between 1974 and 1997have been admitted into the meta-analysis as a result of the five-stagedliterature search strategy and review process. The 57 published andunpublished documents concerning TBA training evaluation contained70 separate studies from 24 countries.Six separate coding forms were developed to code 147 substantive,methodological, and outcome variables. Each study was coded by a teamof two trained research assistants who met on a regular basis to resolvediscrepancies. Effect size coding and calculations are currently inprogress. The majority of the outcome variables are reported asproportions, thus effect sizes will be calculated using the arcsinetransformation (Lipsey 1990). An unweighted effect size mean, as wellas an n-adjusted effect size mean, for each category of outcome variablewill be calculated (Hedges & Olkin, 1985). Homogeneity tests will beconducted on the distributions of effect sizes to check for variability.Sensitivity analyses will be conducted to explore variability in effectsize distributions. (Greenhouse & Iyengar, 1994).There are 4 TBA attributes (knowledge, attitude, behavior, advice) and23 MCH content areas being investigated, as well as maternal andnewborn outcomes. Preliminary results show, for example, a mediumweighted mean effect size for knowledge and a small effect size forbehavior and advice regarding maternal risk factors and problemsneeding referral.References:Fortney, J. & Smith, J. (1997). Traditional birth attendants: Abibliography. Research Triangle Park, N.C.Family Health International.Greenhouse J. B., & Iyengar, S. (1994). Sensitivity analysis anddiagnostics. In H. Cooper & L. V. Hedges (Eds.), The handbook ofresearch synthesis (pp. 383-398). New York: Russell Sage.Hedges, L.V., & Olkin, I. (1985). Statistical methods for meta-analysis.Boston: Academic Press.Levitt, M.J. (1997, April). When the training of TBAs is cost effective:Trained TBAs and neonatal essential care in South Asia. In:A. Costelloand D. Manandhar (Eds.). Improving health of the newborn infant indeveloping countries: Conference draft. (Kathmandu Mother and InfantResearch Activities (MIRA) and Institute of Child Health, UniversityCollege, London Medical School, UK. Compilation of papers for theconference held in Kathmandu, NepalUNICEF (1997). Report on the consultation on attendance at birth:community birth attendants. Health Section, Programme Division,UNICEF/New York, June 9-10, 1997.World Health Organization. (1992). Traditional birth attendants: A jointWHO/UNICEF/ UNFPA statement. Geneva: World Health Organization
FC3.26.06A NEWER APPROACH TO PRE-INDUCTION SCORINGG. Radhakrishnan , N. Vaid, Rashmi, University College of MedicalSciences & GTB Hospital, Shahdara, Delhi, India
Prolonged pregnancies are mostly associated with unfavorable cervix,thus making the universally accepted Bishop Score unsuitable. Increaseduterine activity, which can predict preterm labor, may also influenceinducibility in postterm pregnancies.Objectives: To evaluate a new Pre-induction scoring systemincorporating uterine activity (UA) in predicting inducibility and tocompare it with Bishop Scoring (BS) in cases of prolonged pregnancies.Patients and Methods: 75 patients with uncomplicated singletonpregnancies at 41-42 weeks gestation underwent pre-inductionevaluation by BS and the new scoring system which incorporates: (a)Cervical effacement, (b) cervical dilatation, (c) station of presentingpart, along with (d) parity, (e) number of uterine contractions in 10minutes and (f) strength of contraction expressed as area under thecontraction curve. Variables (a), (b) & (c) were scored 0-3 and (d), (e) &(f) were scored 0-2 making the total score to be 15. Interval frominduction to full dilatation, and the total oxytocin required werecompared for the two scores.Results and Conclusions: 73.33% cases had a poor BS of 5 or less and66.66% cases had a score of 6 or less by the new scoring method.Patients with a score >6 by the present system had a significantly shorterlabor and decrease in total oxytocin requirement as compared to those
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with a BS >5. With further evaluation of this scoring method, cervicalripening methods may be obviated in many cases.
FC3.26.07THE EFFECT OF INTRACELULLAR Mg2+ IN PRE-ECLAMPSIAAna Mitrovic , Milan Djukic, Snezana Rakic, Nikola AnticClinic of Gy and OBS/Narodni Front, Medical Faculty, University ofBelgrade, Yugoslavia
Approximately 2-10 % of pregnancies are complicated by pre-eclampsia.The pathophysiology of preeclampsia is general arteriolarconstriction and increased vascular sensitivity to pressor peptides andamines. The etiology of preeclamsia is unknown.We examined (105 gravids) prospectively the corelation between intraand extracelullar magnesium deficit and Uterine artery Doppler inwomen with preeclampsia. We used bilateral early diastolic notch at 24weeks as the definition of an abnormal waveform (circulatoryparametars-Pi, Ri, of gravids art.utrina were excluded). For evaluation ofRBC and plasma magnesium and calcium level we used AAS-atomicapsorption spectrophotometry.According to our results, in majority of cases, we determinatedsignificatly low level of intracellular magnesium 0,86 +0,22 mmol/l ingroup with bilateral notch, and positive corelation between bilateralnotch,intracelular magnesium deficiency, increase level of intracelullarcalcium (0,63 + 0,18 mmol/l) and preeclampsia.These results support hypothesis that disbalance of intracelullarelectrolites, expecially intracelullar magnesium and calcium are strongdeterminants of risk of preeclampsia because these facts could causegrater excitability of vascular smooth muscle contraction.
FC3.27 OVARIAN CANCER MANAGEMENT
FC3.27.01SUPRACERVICAL HYSTERECTOMY: QUESTIONNAIRE OF THESOCIETY OF GYNECOLOGIC ONCOLOGISTS MEMBERSHIPR.Chalian (1) , R.Smith (2), M.Silverstein(1), G.Del Priore(1), (1) NYUMedical Center, New York, New York, United States, (2) ImperialCollege, London, United Kingdom.
Objectives: To determine the opinion of the Society of GynecologicOncology membership on supracervical hysterectomy (SCH).Methods: A one-page questionnaire was mailed to all members of theSGO as listed in the 1998 Directory. Possible responses were listed ascategories of ranges therefore medians, modes and ranges are reportedbelow. Eight hundred, sixty-one questionnaires were sent out.Results: To date, 303 have been returned (41% response rate); 20.4%were women and 79.6% male. Women were significantly younger with amedian range of 36-40 yrs vs 46-50 yrs for men (Kolmogorov-Smirnov2-Sample Test p<.001). Median time from medical school graduationwas 14-18 yrs for women vs 24-28 yrs for men(p=.001). Hospital settingwas reported as "urban" by 93% and "teaching" by 84% of respondents.There was no difference by gender in the number of hours/week spentseeing patients (median range 11-20hrs/wk) and 79.4% seeing between20-60 patients/wk; 13.4% saw 60 patients/wk. The mean number ofhysterectomies/month was 6.8 for female oncologists and 6.2 for malephysicians (p=.51). The majority, 91%, reported having performed aSCH with 76% of both genders stating that they considered performing aSCH because it "decreased operative morbidity" while 7.8% sited"preservation of sexual function". When presented with a case ofsuboptimal debulked ovarian cancer, 50% reported that they wouldperform a SCH while 99.8% would not consider a SCH in a patient withendometrial cancer. Of the oncologists who did not perform SCHs, 91%did not do so because it had "no additional benefit" and 46% cited anincrease risk of cervical neoplasms. There was no difference in anyresponse based on gender or type of hospital setting.Conclusions: The majority of gynecologic oncologists have performed aSCH. Consensus opinion suggests it may be reasonable in cases ofsuboptimal ovarian cancer but rarely an option in endometrial cancer.Concern regarding cervical neoplasms continues to be an issue althoughthe potential benefits of a SCH are also acknowledged. Given thediversity of opinion, a randomized clinical trial may be feasible.
FC3.27.02DETECTION OF EPITHELIAL OVARIAN CANCER INASYMPTOMATIC POSTMENOPAUSAL WOMENS. Skates (1) , R. Knapp (2), I. Jacobs (3), (1) Massachusetts GeneralHospital, Fruit Street, Boston, MA, United States, 02114, (2) Brigham &Women's Hospital, Boston, MA, United States, (3) St. Bartholomew'sHospital, London, United Kingdom.
Objectives: To determine whether utilizing the Risk of Ovarian CancerAlgorithm (ROCA) using serial CA 125 levels for the preclinicaldetection of ovarian cancer increases the specificity, sensitivity andpredicative value sufficiently to be considered for clinical utilization.Study Methods: Serum CA 125II samples were assayed from 5,500women in a Stockholm series and 22,000 women postmenopausal in aLondon series, Using statistical modeling, we developed a method forcalculating the serum level for each woman over time to estimate therisk of ovarian cancer, The ROCA combined the four variables; age,initial assay (intercept), serial assays over time (exponential slope) andassay variability. Data is divided into training and validation sets. Thetraining set is used to develop the algorithm which differentiates cancerand noncancer. Validation set validates the algorithm and calculates thenumber of false positives.Results: Thirty five ovarian cancers developed and the ROCA detected30. The sensitivity and specificity is 85% and 99.7%. The positivepredictive value is 16% for the assay alone without the addition ofultrasound.Conclusions: On the basis of the ROCA, women can be allocated to oneof three groups: normal ROCA*0.05%, annual assay; intermediate ROCA 0.05%-4.0% repeat assay;elevated ROCA >4.0% refer TVS.
FC3.27.03SERUM ALPHA L-FUCOSIDASE ENZYME ACTIVITY INOVARIAN AND OTHER FEMALE GENITAL TRACT TUMORSH. Abdel-Aleem (1), A. Sabra (1), A. Ahmed (1), M. Zakhari (2), M.Soliman (2), H. Hamed (1).(1) Dept. OB/GYN, (2) Dept. of Biochemistry and Radiology, Faculty ofMedicine, Assiut University, Assiut, Egypt.
Objectives: To assess the value of serum a-L-fucosidase as a tumormarker in the diagnosis of ovarian and other female genital tract tumors.Study Methods: One hundred and fifty-one patients were studied; 101had different genital tract tumors [malignant ovarian tumors (48),carcinoma of the cervix (13), endometrial carcinoma (6), carcinoma ofthe vulva (6) and benign tumors (28)]. Fifty healthy females acted ascontrols. Serum a-L-fucosidase activity was determined in all patientsand controls. Serum CA 125 level was also determined in patients withmalignant ovarian tumors.Results: Patients with malignant ovarian tumors showed the lowest levelof a-L-fucosidase activity in comparison to other malignant and benigntumors of the female genital tract and also in comparison to controls.The majority of ovarian carcinoma patients (90%) had a serum level of <275 u/ml of a-L-fucosidase activity, while more than 90% of thecontrols and other genital tumors had a serum level of > 275 u/ml. Thesensitivity and specificity of serum a-L-fucosidase activity indiagnosing epithelial ovarian tumors were 88.5% and 98%, respectively(using a cut-off level of < 275 u/ml). The corresponding figures for CA125 were 96.2% and 100% (using cut-off level of > 35 u/ml).Conclusions: Serum a-L-fucosidase enzyme activity can be useful as atumor marker in diagnosing advanced malignant epithelial ovariantumors. Its sensitivity and specificity are comparable to CA 125.However, there is a lack of data to support its usefulness in the diagnosisof early stage disease (Stage 1). The cost of doing the test is one-thirdthat of CA 125 and the test can be more widely applied in developingcountries.
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FC3.27.04LYMPHADENECTOMY IN PRIMARY CARCINOMA OF THEFALLOPIAN TUBEM. Klein (1), A. Rosen (2), A. Graf (3), M. Lahousen (4),(1) Dept. GYN, Hanusch Hospital, Vienna, Austria,(2) SMZ Ost., Vienna, Austria,(3) LKH Salzburg, Salzburg, Austria,(4) University Graz, Graz, Austria.
Objectives: The bad prognosis of primary carcinoma of the Fallopiantube is ascribed to early lymphogenous metastasis. Due to the rarity ofcases, there exist only few and divergent results on the importance oflymphnode metastasis in the relevant literature. Thus, our study aimed atdetecting the incidence of lymphnode metastases and their influence onoverall survival, as well as at evaluating the therapeutic effect of radicallymphadenectomy.Study Methods: We studied 109 cases in a retrospective multi-centeranalysis. Group I (n=38) consisted of patients who were subjected toradical pelvic and para-aortic lymphadenectomy in addition to TAH,BSO and omentectomy. The control group II (n=71) underwent the samesurgical procedures but without radical lymphadnecetomy.Results: In group I 42.1% showed lymph node metastases. Lymphaticdissemination was observed only after the carcinoma had spread beyondthe organ (intra-abdominal stage II); the incidence of lymphnodemetastases rose significantly (p=0.02) with growing intraperitonealtumor masses. Pelvic and para-aortic metastases occur simultaneously. Ifradical lymphadenectomy is performed (group I) the median survivaltime increases to 43 months compared to 21 months in group II(p=0.095).Conclusions: Correct staging is obtained only on the basis of pelvic andpara-aortic lymphadenectomy. Radical lymphadenectomy in tumors ofequal size may markedly prolong survival.
FC3.27.05VALIDITY OF COMPLETE PARAAORTIC LYMPHADENECTOMYIN APPARENT STAGE I (pT1) OVARIAN CARCINOMAS. Sakurai , Y. Shimizu, S. Umezawa, K. Shimizu, T. Kato, K. Hasumi,Dept. of Gynecology, Cancer Institute Hospital, Tokyo, Japan.
Objectives: To assess the validity of paraaortic lymphadenectomy inapparent stage I (T1 of TNM classification) ovarian carcinoma.Study Methods: Clinicopathologic analyses were made on 119consecutive patients (pts) with pT1 ovarian carcinoma who underwentsystematic pelvic and paraaortic lymphadenectomy up to the upper levelof renal vessels in addition to hysterectomy, radical bilateral adnectomy,and omentectomy from January 1989 to December 1998.Results: The average number of pelvic (PLNs) plus paraaortic lymphnodes (PANs) removed was 66.5 (range: 32 to 110). The incidence ofpositive lymph nodes (LNs) by T subdivisions was 12.2% (7/57) inpT1a, 66.7% (4.6) in pT1b, 25% (14/56) in pT1c, and thus 21.0%(25/119) in pT1 ovarian carcinoma. The sites of LN metastasis werePANs alone in 15 pts and both PLNs and PANs in the remaining 10 pts.Thus, all of 25 LN positive pts had positive PANs. The sites of PANsinvolved in 25 pts were located between the bifurcation site of inferiormesenteric artery (IMA) and the renal vein. Of 25 LN positive pts 11had a solitary LN involvement and the sites were limited to PANssuperior to the IMA. The LN positive rate by histopathologic grade (G)was 1.6% (1/61) in G1, 27.0% (10/45) in G2, and 66.7% (14/21) in G3.The LN positive rate by histologic type was 44/4% (8/18) in serous, 80%(4/5) in transitional, 3/2% (1/31) in endometrioid, 24.4% (10/41) in clearcell, and 8.7% (2/23) in mucinous carcinoma.Conclusions: The results indicate that PANs superior to the IMA is aprimary site of LN involvement of ovarian carcinoma. The high positiverate of LN involvement, especially in high grade and “chemo-resistant”clear cell type, validates a complete PALA in apparent stage I ovariancarcinoma.
FC3.27.06REVIEW OF OVARIAN CANCER IN TEHRAN, IRANM. Ashrafi , R. Alaghehbandan, S. Tavajjohi, Dept. OB/GYN, IranUniversity of Medical Sciences, P.O. Box 19395-4644, Tehran, Iran
Objectives: Epithelial ovarian cancer is the most lethal of gynecologicmalignancies. Although the incidence of ovarian cancer has remained
stable over the last three decades in developed countries, increasingincidence has been reported in developing countries. The aim of thisstudy was to determine the frequency of epidemiological risk factorsamong epithelial ovarian cancer patients.Study Methods: The records of 203 patients with epithelial ovariancancer who were treated at four gynecologic oncology centers in Tehran,during the 10 year period from 1989-1998 were reviewed. Demographicdata and associated risk factors were investigated.Results: The median age of diagnosis was 47 years (range, 17-81 years).61% of patients (124/203) were in the 30-60 age group. 46.3% ofpatients (94/203) were diagnosed as having serous tumors, 22.1%(45/203) had mucinous tumors, 20% (40/203) had unclassifiedadenocarcinomas, and 4% (8/203) had endometrioid carcinoma. Themedian parity was 3, and 15.7% of patients (32/203) were nulliparouswomen. 88% of patients (179/203) did not use oral contraceptives. Themost common blood group was group O (35%), followed by group A(31%) and group B (19%). The rate of tubal ligation was 3% (6/203). In11.3% of patients positive family history for gynecologic malignancieswere found. The most common presenting symptoms were abdominalpain (43%), abdominal swelling (21%), palpable mass (14%), andvaginal bleeding (13%).Conclusions: Our study showed that the median age of the patients to belower comparing to the most various reports. Also it seems that the rateof factors associated with decreasing in risk is relatively low. However,further investigation through large epidemiological studies is required.
FC3.27.07PREDICTIVE VALUES OF SERUM TETRANECTIN AND CA125 INOVARIAN CANCER.C. Høgdall 1,5, E. Høgdall2,4, J. Blaakaer3, L. Christensen2, E. Glud2, J. Vuust4, B. Nørgaard-Pedersen5, J. Bock1 and S. Krüger Kjaer2*.Dept. Gyn/obst, Rigshospitalet, Copenhagen1 Institute of CancerEpidemiology, Danish Cancer Society, Copenhagen2, Dept. Gyn/obst,Aarhus University Hospital, Skejby3, Lab. Mol. Biology4 & Dept. Clin.Biochemistry, Statens Serum Institute, Copenhagen, Denmark5
(*Principal investigator).
Objectives: The aim of the study was to evaluate the predictive values ofserum tetranectin (TN), CA125 and a mathematical index, based on thetwo serum markers, in a possible screening setting for ovarian cancer(OC)Study methods: In the MALOVA study blood samples were collectedfrom 1331 healthy control women and pre-operatively from 124 patientswith a borderline ovarian tumor, 106 with a FIGO stage I OC, 39 stageII OC, 225 stage III OC and 58 with a stage IV OC. The stage relateddistributions of TN and CA125 were examined by Mann-Whitney andthe Spearman’s correlation tests. Sensitivities and specificities wereevaluated by receiver operator curves (ROC).Results: Significant differences were found between respectively the TNand CA125 levels in every of the above mentioned tested subgroups(median controls: TN 12.7 mg/l, CA125 8.7 U/ml; Borderline: TN 11.2mg/l, CA125 24.8 U/ml; Stage I: TN 9.6 mg/l, CA125 46 U/ml; Stage II:TN 8.8 mg/l, CA125 269 U/ml; Stage III: TN 8.0 mg/l, CA125 569U/ml; Stage IV: TN 6.3 mg/l, CA125 622 U/ml. Highly significantcorrelations were found between TN, CA125 and stage. In the ROCanalyses TN and CA125 supplemented each other in all stages. For stageI an increase in sensitivity was found from 30% for CA125 alone to 43%for the index at a specificity of 99.8%.Conclusions: TN is highly correlated to the stage of OC. TN and CA125supplement each other, resulting in an increase in sensitivity without anydecrease in specificity, when the variables are used in a mathematicalindex. TN may be valuable in a panel of tumor markers for OCscreening.
FC3.27.08MALIGNOMAS OF FALLOPIAN TUBER. Radosavlievic , J. Popovic-Lazic, R. Maglic, E. Garalejic, N. Antic, B.Stanimirovic, B. Terzic, J. Milosevic, Dept. of Pathology, University ofBelgrade, OB/GYN Clinic “Narodni Front”, Belgrade, Serbia,Yugoslavia.
Objectives: The aim of this study is to analyze the frequency and type ofthe primary-malignomas of the fallopian tube.
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Study Methods: Retrospective analyses were conducted on materialobtained from operated patients in the OB.GYN Clinic “Narodni Front”in Belgrade, Serbia form 1993 to 1998 for primary neoplasm of thefallopian tube. We analyzed the age of the patients, location adhistological type of the tumors and presence of metastases.Results: In our study, we analyzed 563 patients. Among them we found11 (1.99%) with primary neoplasm of the tube, 4 (36%) were malignantand 7 (64%) were benign. The average age of the women was 55 years(36 to 69 years). The most frequent malignancy was serous papillaryadenocarcinoma (3) and one case of squamous cell carcinoma. Twoadenocarcinomas were moderately differentiated and located on the righttube (one with metastases in the ovaries and the other without). Oneadnocarcinoma was well differentiated, at the right fimbria and withmetastases on the omentum, colon and ovaries. Among the benigntumors, the most frequent were leiomyoas 3 (2R and 1L), 3 adenomatoidtumors (1R and 2L) and one mature teratoma on the left fallopian tube.Conclusions: The most frequent malignomas are serous papillaryadenocarcinoma. Average age of patients is 55 and the location with theworst prognosis is on the fimbria. The frequency of the primaryneoplasm of the uterine tube is in correlation with literature data.
FC3.27.09SURGICAL ULTRASONIC TUMOR ASPIRATION IN ADVANCEDOVARIAN CANCER.P. Bratila , O. Nicodin, N. Niculescu, Gynecological Clinics, CentralMilitary Hospital of Bucharest, Bucharest, Romania
Objective: To evlaute the efficency of tumor cytoreduction using anultrasonic surgical suction device in cases of ovarian cancer.Materials and Methods: The Cavitron Ultrasonic Surgical Aspirator(CUSA) was used for removal of superfical metastatic lesions found atthe time of hysterectomy, omentectomy and removal of other adnexalorgans. This method of cytoreduction was used in 56 patients selectedduring February 1997 through June 1999. Study patients averaged 62years of age and were diagnosed with ovarian cancer, the majority ofwhich were stage IIIC.Results: CUSA was used to aspirate tumor fragments from thediaphragm, liver, stomach, small bowel, bladder, sigmoid and rectumwithout any organ injury. A pre and post operative ultrasound evaluationwas performed on the removed tumor. The meat time of use was fifteenminutes and there were no intraoperative complications.Conclusions: CUSA cytoreduction facilitated the removal of primarytumor as well as metastatic lesions. This technique helps reduce thepotential for resection of extragenital organs and facilitatedchemotherapy application. Overall, it improved survival rates andpatient quality of life.
FC3.28 PREGNANCY COMPLICATIONS
FC3.28.01OBSTETRIC AND NEONATAL OUTCOME AFTER RECURRENTMISCARRIAGE: A RETROSPECTIVE OBSERVATIONAL STUDYS. Jivraj , B. Anstie, F. Fairlie, T. Li, Dept. OB/GYN, Jessop Hospital forWomen, Sheffield, England.
Objectives: To determine the obstetric and neonatal outcome in womenwith a history of recurrent miscarriage.Study Methods: Women who attended the recurrent miscarriage clinic atthe Jessop Hospital between 1st January 1992 and 30th June 1998 werestudied. Those who progressed beyond 24 weeks gestation wereincluded in this study. There were 178 deliveries in this group. Theiroutcome was compared with a background population of 24,699deliveries for the same period of time (1992-1998).Outcome measures studied were: incidence of hypertension, diabetes,small for gestational aged babies, preterm delivery rate, mode ofdelivery and perinatal mortality rate.Chi squared test was used for statistical analysis.Results: The incidence of hypertensive disorders (7.3%) and diabetes(1.7%) was not significantly different from the control population.Preterm delivery rate (13.3%), incidence of small for gestational age(13%), emergency cesarean section rate (18%), elective cesarean sectionrate (18%) and perinatal mortality rate (2.5%) was significantly higher(p<0.05) in the recurrent miscarriage population than the controlpopulation (4%, 2%, 10.2%, 6.5% and 1% respectively).
Conclusions: Patients with recurrent miscarriage have a higher incidenceof small for gestational age babies, preterm delivery, cesarean sectionand perinatal loss. These patients represent a population at high risk ofobstetric problems and close surveillance in the antenatal period istherefore advisable.
FC3.28.02TREATMENT OF UNRUPTURED ECTOPIC PREGNANCY WITHMETHOTREXATE – A UK EXPERIENCEM. Sau (1), A. Sau (2), J.K. Roberts (3), W.O. Goldthorp (3)(1) Dept. OB/GYN. Stafford General Hospital, Stafford, UK.(2) Dept. OB/GYN, Medway Hospital , Gillingham, UK.(3) Dept. OB/GYN, Tameside General Hospital, Ashton-U-Lyne, UK.
Objectives: To evaluate the effectiveness and complication rates ofmultiple dose of systematic methotrexate in the treatment of unrupturedectopic pregnancy in a District General Hospital.Study Methods: Twenty-six cases of ectopic pregnancy treated withmethotrexate were analyzed retrospectively. A diagnosis of ectopicpregnancy was made by estimating the serum b hCG (human chorionicgonadotropin) level, transvaginal scan and/or diagnostic laparoscopy.All women were counseled and informed consent was obtained beforemethotrexate treatment. The success rates and adverse effects ofmethotrexate treatment, subsequent tubal patency and fertility rates wereanalyzed.Results: Out of 26 cases, 27% f women were primigravida and 19% hadprevious ectopic pregnancy. The mean pre-treatment human chorionicgonadtrophin level was 2931.9±7572.5 miu/ml. All but four patients hadlaparoscopy for confirmation of diagnosis. The majority of women(73%) received four doses of methotrexate, two women received twodoses, four received three doses and one had five doses of methotrexate.All 26 women responded to methotrexate. The mean time to resolutionwas 22.9±15.8 days. There were no major side effects fromchemotherapy. Three (11.5%) women showed elevated level of AST onthe eighth day, which returned to normal within 48 hours of completionof therapy. Post treatment hysterosalpingograms demonstrated tubalpatency on the ipsilateral side in 75% of women. Of those attempting toachieve pregnancy, 66% became pregnant, 95% intrauterine and 5%ectopic.Conclusion: Our results support the use of systemic methotrexate, whichis a safe and effective treatment for unruptured ectopic pregnancy. Italso preserves future reproductive performances.
FC3.28.03A RANDOMIZED STUDY OF CONSERVATIVE MANAGEMENTVERSUS SURGICAL UTERINE EVACUATION FOR INCOMPLETEMISCARRIAGE (INTERIM ANALYSIS)T.A. Mahmood , K.I. Shehata, K.J. Thong, Forth Park Hospital,Kirkcaldy, Scotland, UK.
Evacuation of the uterus remains the management of choice for womenpresenting with spontaneous incomplete miscarriage during the firsttrimester of pregnancy. Two small studies (Mansur,1992; Neilson, 1995)have reported that retained products of conception (volume <15 mm)can be managed conservatively. However there remains a concern aboutinfectious morbidity and effects on subsequent fertility. This study wasfunded by the Chief Scientist’s Office, Scottish Home and HealthDepartment, Edinburgh.Objectives: The aim of this randomized study is to compare surgicaluterine evacuation versus conservative management of women withincomplete miscarriage with gestation less than 13 weeks.Study Methods: In order to demonstrate that infectious morbidity is notsignificantly increased following conservative management, 500 womenneed to be randomized into one of the management regimes. Women inboth groups are screened for infection and observed prospectively formany weeks. So far 287 women have been randomized, 154 to theconservative management and 133 to the surgical evacuation group.Results: So far 14 women required surgical procedures for persistentuterine bleeding, 9 (6%) in the conservative group and 5 (4%) had re-evacuation in the surgical group. 29 patients needed antibiotic treatmentfor suspected upper or lower genital tract infection, 15 (10%) in theconservative group and 14 (11%) in the surgical group. Data will bepresented on return to ovulation, pregnancy rates and quality of life.
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Conclusion: The interim results of the study so far suggest thatexpectantly managed women had a similar outcome to surgicalevacuation of the uterus.
FC3.28.04HYSTEROSCOPY IN THE EVALUATION OF PATIENTS WITHRECURRENT PREGNANCY LOSS (RPL)G. Ventolini (1), R. Samlowsky (2)(1) Dept. OB/GYN, Good Samaritan Hospital, Cincinnati, Ohio, USA.(2) Dept. Fam. Pract. Med., U.C., Cincinnati, Ohio, USA.
Introduction: The purpose of this study was to determine the prevalenceof structural uterine defects (SUD) in patients with RPL attending alarge family medicine practice and o determine the effectiveness of thetherapeutic intervention.Materials and Methods: This prospective cohort study from 10/95 to10/98 included 23 patients, ages 23 to 35 (mean age 28.1 years) withotherwise unexplained three or more 1st trimester miscarriages and nolive births. All couples were not tobacco or alcohol users and had normalcytogenetic examinations and testing. Their jobs were unrelated tochemical handling. All patients underwent a complete history, physicalexamination and hysterosopy with directed biopsy. They had normalvalues for: complete blood count, sedimentation rate, urinalysis andculture, (GC, Chlamydia, Syphilis, Hepatitis B, HIV), Lupusanticoagulant, anticardiolipin antibodies, progesterone and pelvicultrasound.Results: Fourteen patients (60.9%) had normal hysteroscopy (withbiopsies), nine patients (39.1%) had SUD as follows: five patients(21.8%) had intrauterine adhesions, two patients (8.7%) had septateduterus, one patient (4.3%) had submucosal myoma and one patient(4.3%) had multiple factors. After appropriate therapy of the SUD sevenpatients (77.8%) achieved successful pregnancy and two patients(22.2%) had recurrent miscarriages. The normal hysteroscopy group hadeight patients (57.1%) with recurrent miscarriages, two patients (14.3%)with infertility and four patients (28.6%) achieved successful pregnancywith no further therapy.Conclusions: The prevalence of SUD in our studied population was39.1%. The rate of live birth pregnancies in these patients afterappropriate treatment was 77.8%. Since SUD are the most treatablecauses of RPL, these patients should be identified early after otherpotential causes of RPL are eliminated.
FC3.28.05AN EVIDENCE-BASED APPROACH TO THE MANAGEMENT OFFIRST TRIMESTER MISCARRIAGEJ. Shelley , Centre for the Study of Mothers' and Children's Health, LaTrobe University, Melbourne, Victoria, Australia
Background and objectives: Improvements in medical care, e.g.antibiotics and ultrasound, and the improved health status of women,mean that the basis for surgical evacuation of the uterus following firsttrimester miscarriage may no longer apply. This paper reviews theevidence on the effectiveness of two other management approaches,synthetic prostaglandins and expectant care.Study Methods: All randomised trials examining medical or expectantmanagement of incomplete miscarriage were identified from MEDLINEsearches or citations in other articles. The trial methods weresummarised and results meta-analysed where possible.Results: There were seven randomised trials of management ofspontaneous miscarriage: four comparing synthetic prostaglandins tocurettage, two comparing expectant care to curettage, and onecomparing prostaglandins to expectant care.The total number of women randomised to curettage was 448, 496received prostaglandins and 184 had expectant care. Almost all thestudies had fewer than 100 women in each treatment arm.There was considerable heterogeneity between studies in eligibilitycriteria, dosages, definitions and timing of outcome assessments. Meta-analysis of results was not possible.Rates of successful evacuation with curettage were 97 to 100%, withmisoprostol 13%, 50.5% and 100%, and with expectant management76% and 79%. Only one study reported psychological outcomes, tworeported later reproductive outcomes, and only one economic evaluationwas located.
Conclusions: There is insufficient evidence available to date to supportmedical or expectant care for the management of incompletemiscarriage. Further randomised trials are needed to enable the risks andbenefits of the different approaches to be fully assessed.
FC3.28.06A PROSPECTIVE RANDOMIZED CONTROL TRIAL COMPARINGMEDICAL AND SURGICAL TREATMENT FOR EARLYPREGNANCY FAILUREC. Demetroulis , E. Saridogan, D. Kunde, A.A. Naftalin, Dept. OB/GYN,Newham General Hospital, London, England.
Objectives: To assess the effectiveness of single dose misoprostoladministered intravaginally compared to surgical evacuation for thetreatment of early pregnancy failure.Study Methods: Eighty women with a diagnosis of early pregnancyfailure were randomized to study and control groups. 800mg ofmisoprostol was administered vaginally in the study group patients. Thecontrol group patients had surgical evacuation of the uterus undergeneral anesthesia. Success of treatment, side effects as assessed during,immediately after and ten days after treatment, and patient satisfactionwere recorded.Results: Intravaginal misoprostol was successful in 82.5% of thepatients. None of the control group patients required a repeat evacuation.The number of patients who experienced significant abdominal painfollowing treatment did not differ between the groups. The duration ofpain was shorter in the control group, however, they required moreanalgesics during this short period. The number of patients withsignificant vaginal bleeding, the duration or severity of bleeding did notshow any significant difference between the groups. All thirty-threepatients in the study group who had successful treatment expressedsatisfaction, whereas 58% of the study group did so.Conclusion; This randomized control study demonstrated the efficacyand safety of the administration of 800mg of misoprostol intravaginallyfor the management of early pregnancy failure.
FC3.28.07A RANDOMIZED CLINICAL TRIAL COMPARING ORAL ANDVAGINAL MISOPROSTOL FOR MEDICAL EVACUATION OFSPONTANEOUS ABORTIONS.M.W. Pang , T.K.H. Chung, Dept. OB/GYN, Prince of Wales Hospital,The Chinese University of Hong Kong, Hong Kong, China
Objectives: To compare the efficacy and side effects of vaginal versusoral misoprostol in the management of spontaneous abortion.Study Methods; Two hundred and one women with incomplete abortionwere randomized to receive either oral or vaginal misoprostol formedical evacuation (800 mcg for 2 doses, 4 hours apart). The subjectswere reviewed the next day after treatment and 2 weeks later forevidence of retained product of conception and side effects of thetreatment. The efficacy of uterine evacuation and the short-term sideeffects of the two treatment regimes were compared with chi-square testand Mann-Whitney U test.Results: The efficacy of uterine evacuation of oral and vaginalmisoprostol was comparable (64.4% vs. 61.1%, p=0.62). There was asignificantly lower incidence of diarrhea (13.6% vs. 65.3%, p£ 0.01)with the use of vaginal misoprostol.Conclusions: Vaginal misoprostol was as effective as oral misoprostol inmedical evacuation of patients with spontaneous abortion. There wasalso a significant reduction in the incidence of diarrhea with the use ofvaginal misoprostol. We believe that vaginal misoprostal should beconsidered a better regime than oral misoprostol for medicalmanagement of spontaneous abortion.
FC3.28.08THE USE OF PERIDURAL CATHETER IN SHUNTING FETALSURGERYM. Saito , C.R. Araújo, E.C. Marinai, L.A.B. Martins, P.T. Oliveira, L.A.Silva, J.C. Massoneto, Faculdade de Ciências Médicas de Santos, SãoPaulo, Brazil.
Objective: To evaluate the use of peridural catherer to shunting fetalpleura effusion and urinary tract obstructions.
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Methods: Between January 1994 and July 1999 we performed fetalshunting in 16 cases of fetal anomalies, 9 cases were due to urinary tractobstruction and the others to pleural effusions. Initially, the periduralcatheter was prepared as described by Leite and Cabral to change youroriginal form and transform in a “pigtail” (as a Rodeck Catheter).Cannúla with a trochar were substituted by a peridural needle. Theprocedure was guided by ultrasound and after the tip of the needle hadreached the fluid collection the guide of the needle was removed andthen the catheter was then inserted inside the needle. After theintroduction of the half of the catheter, the tip of the needle is moveduntil the amniotic cavity and then with the proper guide were pushedout. Once the catheter was placed, ultrasound monitoring indicatedweekly detecting any displacement or blockage.Results: In all 16 cases the catheter was sited in desired position. In twocases, the monitoring established that the catheter was displaced and asecond catheter was then introduced. After one week, in one case weidentified that the catheter was displaced and blockage in two others.The ultrasound monitoring that the catheter was functioning support bythe reduction of the volume of the pleural effusion or the urinary tractobstructions. Indeed the reduced number of the cases we believe thatthese methods can be used as an alternative way to fetal shunting.
FC3.28.09FETAL CORTICOTHERAPYM. Saito , L.A. Silva, A.C. Silva, F.L.P.S. Souza, G.R. Maniov, A.L.S.Pontes, J.C. Massoneto, Faculdade de Ciências Médicas de Santos, SãoPaulo, Brazil.
Objective: Report 4 cases of fetus submitted to intra-muscular and intra-peritoneal corticotherapy.Case report: Case 1 – CSA, 22 years old, 29 weeks gestational age. Case2 – MSO, 18 years old, 24 weeks gestational age. Case 3 – AFS, 32years old, 33 weeks gestational age. Case 4 – MSD, 32 years old, 24weeks gestational age. All patients were in their first pregnancies and allof them were sent by the diagnosis of anencephaly. The ultrasound scanexcluded other associated abnormalities and confirmed the suspectedmalformation. All patients were submitted to cordocentesis to evaluatethe fetal karyotype and hematalogic parameters. The results were normalin 4 cases. In the 3 previous cases were injected 0.3 mg/kg ofdexamethasone in the buttock region of the fetus and in the last case, itwas injected the same dose but intra-peritoneously. One of the fetus thatwas injected in the buttock region was dead a week later the procedure.After the birth of the 4 fetus, we observed that there were no alterationsin the puncture local in all cases. The case in which the fetus wasinjected intra-peritoneously, there was an increase inlecitine/esphingomieline concentrations, a week after the procedure hadbeen done.Discussion: The administration of corticostheroids directly into the fetushad been reported in cases in which there is maternal contra-indicationof the procedure. The intra-muscular injection had been correlated withlocal complications (tissual necrosis). The intra-peritoneal injection hadbeen rarely related. In our cases, in spite of the death of one of the fetus,we had not observed any local puncture complication. The increase inlecitine/ espphingomieline concentrations may justify the efficacy of thistype of preocedure.
FC3.29 PREGNANCY PATHOLOGY
FC3.29.01THE PIGTAIL URETERAL CATHETERIZATION – A PERFECTMINIMALLY-INVASIVE THERAPY OF HYDRONEPHROSIS INPREGNANCYG. Schindler, U. Retzke , R. Illing, H. Graf, Dept. OB/GYNZentralklinikum Sudthuringen, Suhl, Germany.
Objectives: The aim of this study was to assess the use of pigtail ureteralcatheterization in cases of acute hydronephrosis in pregnancy incomparison with other worldwide commonly applied procedures.Study Methods: From 1988 through 1999, we retrospectively identified38 pregnant women suffering from hydronephrosis. The indication, theprocedure and the relevant results for mother and child aredemonstrated.Results: In comparison to formally performed procedures treating acutehydronephrosis in pregnancy like operative or percutaneous
nephrostomy drainage, the ureteral catheterization has much less sideeffects. There is no use of x-rays or general anesthesia. The patients canbe treated fast, effective and without pain. Ultrasound is sufficient tocontrol the position of the ureteral catheter. Sometimes and exchange ofthe ureteral catheter is necessary after four weeks. The termination ofpregnancy can be avoided by this procedure.Conclusions: In all cases, the termination of pregnancy was notnecessary. Only a few hours after the ureteral catheterization patientsrealized a relief of their discomfort. The high motivation for this methodis based on the elegant videocystoscopical technique with minimal localanesthesia. The pigtail ureteral catheterization has completely displacedthe invasive methods of acute hydronephrosis in pregnancy in ourhospital.
FC3.29.02THE INFLUENCE OF ANTIBIOTICS IN PRETERM LABOR ONTHE INHERITED INFECTION RATE IN NEWBORNSP. Oszukowski , A Pieta, M. Nowak, Polish Mother’s Memorial HospitalResearch Institute, Lodz, Poland.
Objectives: The purpose of this study was to evaluate the influence ofantibiotic therapy in women with preterm labor and intact membranes onthe incidence of inherited infection in their newborns.Study Methods: Our prospective randomized study group comprised of154 women selected by the following criteria: singleton pregnancy,gestational age below 36 weeks, intact membranes, regular uterinecontractions (at least one every ten minutes), cervical dilation < 4 cm, nosigns of infection at admission. We applied the expectant managementwith the use of tocolysis (intravenous: verapamil and salbutamol).Patients were monitored with frequent vital signs, fetal heart rateevaluation and blood tests (e.g. C-reactive protein, white blood cellcount). The further inclusion criterion was delivery within 14 days fromadmission. Antibiotics (amoxicillin/clavulanic acid) were administeredas a result of randomization. Inherited infection of newborns wasestablished on the physical examination, chest X-ray film, blood andurine culture, blood morphology and serum C-reactive protein.Results: Antibiotics were administered in 63 women. In 91 patientsexpectant management didn’t include antibiotic therapy. There were nostatistically significant differences between these two groups of womenaccording to gestational age at delivery (mean +/- SD: 31.7 +/- 3.4 vs.32.7 +/- 2.9 weeks), birth weight of their newborns (1686 +/- 568 vs.1863 +/- 626 grams) and 1 minute Apgar score (6.3 +/- 2.5 vs. 7.1 +/-2.2). The incidence of inherited infection in newborns of women whoreceived antibiotics was 36.5% (23/63) and didn’t differ significantlyfrom inherited infection rate 31.9% (29/91) in the non-prenatalantibiotics group.Conclusions: Our data revealed that antenatal antibiotic therapy didn’tincrease the incidence of inherited infection in newborns of women withpreterm labor and intact membranes.
FC3.29.03CIRCULATING LEVELS OF TBARS AND VITAMIN E ASPRECLINIC PREDICTIVE AGENTS OF PREGNANCY-INDUCEDHYPERTENSION AND GESTATIONAL DIABETES.Galimberti D. M ., Joao M., Fernandez C.A., Cortelezzi M., CaramesV., Holland M. and Aparicio N. J. Obstetrics Department T. AlvarezHospital, Aranguren 2701, Buenos Aires – Argentina
Diabetes Mellitus and arterial hypertension are associated with oxidativestress, but the temporal association between lipoperoxidation markersand plasma’ s antioxidant activity and the clinical development ofgestational diabetes (GD) and pregnancy-induced hypertension (IH) isstill not known. Objective: to determine the circulating levels of TBARSand vitamin E in healthy primigravidas at the moment of the firstconsult. Material and methods: 91 (healthy at the moment ofincorporation) primigravidas (age between 17 and 32 years) wereincorporated at the moment of the first consult (between the 8th and 12th
week of pregnancy). Blood was extracted from each one of them duringthe first, second and third trimester of pregnancy (8th to 12th , 22nd and32nd week of pregnancy, respectively). The patients were controlledclinically on a weekly basis since incorporation until delivery. TBARSlevels were determined in each sample (intraassay variation 4.7% andinterassay 6.9%) (in mmols/l) as well as vitamin E (intraassay var. 4%and interassay 6.1%) (in mmols/l). Results: 85 patients had a normal
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gestation, whilst 6 of them developed induced hypertension between the27th and 32nd week, and 2 of them, besides, developed gestationaldiabetes. TBARS levels in normal primigravidas were (mean ± SD) 2.00± 0.22, 2.11 ± 0.53 and 1.92 ± 0.39 respectively for the three trimesters;the maximun and minimun figures being 1.4 and 2.87. The respectivevalues for vitamin E were 29.0 ± 5.8, 27.1 ± 4.9 and 29.3 ± 6.4 for thethree trimesters with an absolute minimun of 21.0 and an absolutemaximum of 48.1. Four out of the six patients who had inducedhypertension (two of them with GD) presented TBARS levels clearlyhigh (between 3.3 and 5.66 mmols/l) already in the first trimester and allof them presented high levels in the 22nd week, maintaining this until the32nd week. Vitamin E scores were low (less than 12.0) in all the patientswith IH except one.Conclusions: a) TBARS and vitamin E levels were determined in thethree trimesters of normal primigravidas; b) the values were similar tothe ones found in a healthy population of eumenorrhoeic women; c) Thegestants who finally had induced hypertension ( 2 of them withassociated DM) presented clearly high levels of TBARS and, in most ofthem, low levels of vitamin E preceding by several months themanifestation of the clinic signs; d) The determination of circulatinglevels of TBARS and, eventually, vitamin E, could well be useful for apreclinical prediction of a late development of induced hypertension andgestational diabetes. e) A discussion of these results in view of thecurrent concepts of the mechanism of development of IH will beperformed.
FC3.29.04ENDOTHELIAL FUNCTION FOLLOWING GESTATIONALDIABETES MELLITUSM.M. Hannemann , W.Liddell, A.C. Shore, J.E. Tooke, Dept. VascularMedicine, University of Exeter, UK.
Objectives: Previous gestational diabetes mellitus (GDM) confers a 30-50% risk of Type 2 Diabetes Mellitus (NIDDM), which is characterisedby endothelial dysfunction. The aim was to investigate the presence andnature of endothelial dysfunction prior to the development of NIDDM.Study Methods: 17 GDM women were matched with controls for bodymass index, menstrual cycle phase, smoking, age, blood pressure, andlipid profiles. All were normally glucose tolerant. Tests of endothelium-dependent and –independent vasodilatation were performed:(i)Maximum dorsal foot skin hyperaemic response to a standard thermalstimulus, measured by laser doppler fluximetry, (ii) vasodilatoryresponses of forearm skin to iontophoresis of acetylcholine and sodiumnitroprusside, measured by laser doppler perfusion imaging, and (iii)ultrasound estimation of brachial artery flow mediated (FMD) andnitrate (GTN) –induced dilatation.Results: (i) Maximum hyperaemia (Subjects(S) =1.15(0.73-1.73)Vmedian(range) v. Controls(C)=1.5(0.7-2.29)V; p=0.02), (ii)Iontophoresis of acetylcholine(S=1.59(0.32-2.55)V v. C =1.79(0.72-2.06)V ; p=0.81) and sodium nitroprusside (S=1.39(0.8-3.14)V v.C=1.41(0.34-2.19)V ; p=0.68). (ii) Brachial FMD (S=1.65(-0.5-9.07)%v. C=2.77(0.63-6.6)% ; p=0.42) and GTN-induced dilatation(S=9.16(6.64-20.91)% v. C=8.9(3.94-22.09)% ; p=0.43).Conclusions: Maximum hyperaemia, which differed significantly, is acomplex indicator of vascular function, including that of endothelium.The other tests, more specific to the endothelium, did not differ. ThusGDM patients have a diminished microvascular dilatory reservecompared to controls, but this is not explained in this study bydysfunction of ACh-, shear-mediated, or vascular smooth musclepathways.
FC3.29.05OUTCOME OF SINGLETON BREECH PRESENTATIONS INWOMEN TREATED WITH ORAL SALBUTAMOL AS ATOCOLYTIC AGENTM.O. Okoronkwo , St Michael’s Hospital for Women, Umuahia, Nigeria.
Objectives: The aim of the study was to determine out-come of singletonbreech presentations (SBPs) in women treated with oral Salbutamol at26 – 37 weeks’ gestation.Study Methods: This randomized prospective study involved threehundred and fourteen consecutive women with SBPs: 157 womentreated with oral Salbutamol (as sulphate) 4 mg thrice daily for sevendays and 157 control women on bed rest.
Results: 133 spontaneous cephalic versions (SCVs) (84.7%) wererecorded in treated women vs 29 SCVs (18.4%) in control women(P=0.51). Incidence of SBPs at term was 0.6% in treated vs 2.5% incontrol women.Conclusions: This study revealed association between SBPs andpremature uterine contractions. It has enabled us to understand moreabout mechanism of SBP and possible measures against it.
FC3.29.06STUDY OF PLASMA FIBRINOGEN LEVEL AND FIBRINMONOMER POLYMERIZATION FUNCTION IN PRE-ECLAMPSIAM. Y. Gao , S. Q. Liao, L. Zhou, A. N. Rao, L. Z. Zhang, Dept. ofOB/GYN, The Second Affiliated Hospital of Guangzhou MedicalCollege, Guangzhou, China.
Objectives: The aim of the study was to investigate the changes ofplasma fibrinogen (Fbg) level and fibrin monomer polymerizationfunction (FMPF) in preeclampsia.Study Methods: Fbg and FMPF were determined by ActualaseHydrolyzed Fibrinogen and Calculator Automatic Detection System in80 cases or normal pregnancy (37-40 Wks) as control and in 20 cases ofsevere preeclampsia (37-40 Wks).Results: In the severe preeclampsia (1) The Fibrin MonomerPolymerization Reaction Speed (FMPV) was 0.898±0.110. (2)Maximum attraction luminosity (Amax) was 0.573±0.060. (3)Fibrinogen concentration of 797±(73 (mg/dl). (4)FMPV/Amax was1.992±0.180. (5) Reaction delayed time (DT) was 17±4 (sec). Theplasma Fbg level and the FMPF value were significantly higher than thatof the controls (p<0.05).The higher value of the FMPF along with the increased level of Fbg inpatients with preeclampsia may have some significance in predictingpreeclampsia.
FC3.29.07TRANSVAGINAL COLOR DOPPLER STUDY OF THESUBTROPHOBLASTIC BLOOD FLOW IN EARLY PREGNANCYA. Persona-Sliwinska , J. Brazert, R. BiczyskoDepartment of Gynecology and Obstetrics, Karol MarcinkowskiUniversity of Medical Sciences, Pozna, Poland
Objectives: The aim of this study was to compare the values ofresistance index (RI) and pulsatility index (PI) in subtrophoblasticvessels of the uteroplacental circulation and the maternal serumconcentration of progesterone and _-hCG in normal and threatenedabortion first trimester pregnancies.Study Methods: We have analysed 89 pregnant women between 5th and12th weeks of pregnancy - 32 with threatened abortion as a test groupand 57 with normal intrauterine pregnancy taken as controls. In allpatients transvaginal ultrasound with pulse color Doppler wasperformed. The RI and PI values were calculated for radial and spiralarteries. The concentration of progesterone and _-hCG in maternalserum were evaluated by immunoassays. The results obtained wereanalysed by means of the following statistical methods: t-Student,Mann-Whitney, Pearson’s correlation.Results: There was statistically significant difference between RI and PIin normal and threatened abortion pregnancies only for spiral arteries in11th to 12th weeks of pregnancy (p<0,01; p<0,05). Hormonesconcentrations were within normal ranges in all patients in the controlgroup. In the tested group in 40,63% of patients the level ofprogesterone was abnormal, in 37,5% of patients the level of _-hCG wasabnormal. There was statistically significant difference between serumprogesterone concentration in the tested group and controls from 5th to12th week of pregnancy (p<0,001) and between serum _-hCGconcentration from 7th to 12th week of pregnancy (p<0,001).Conclusions: The combination of Doppler blood flow analysis in spiralarteries and hormones evaluation in the maternal serum performed in thefirst trimester may be useful for the early selection of high riskpregnancies which require intensive fetal monitoring.
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FC3.29.08OBSTETRIC AND PERINATAL OUTCOME OF PREGNANCIESWITH TERM LABOR AND MECONIUM-STAINED AMNIOTICFLUIDS.M. Ziadeh , E. Sunna, F. Abu-Kteish, Dept. OB/GYN, Dept. ofPediatrics, Jordan University of Science and Technology, Amman,Jordan.
Objective: To determine prospectively the risk of adverse neonataloutcome among infants born through clear or Meconium-stainedamniotic fluid (MSAF).Setting: Princess Badeea Teaching Hospital, North Jordan.Study Methods: We compared prospectively the outcomes in 390 termsingleton cephalic presentation with meconium and controls comprisedsimilar women but with clear AF (400).Intervention: Most babies born through MSAF, though oropharyngealsuction as soon as the head was delivered followed by immediateintratracheal intubation and suctioning in infants depressed at birth.Results: Virtually meconium staining of the amniotic fluid wassignificantly associated with poor neonatal outcome in all outcomemeasures assessed.FHR abnormality was significantly increased with Mod – Thickmeconium (P=0.01) and thin meconiium alone was not associated withadverse outcome except respiratory distress. Severe fetal acidemia atbirth (PH£7.00) increased from 5 per 1000 to 10 per 1000 withmeconium (P<0.001). Apgar score £3 at 1 min and 5 min wassignificantly increased with meconium (p<0.001 and <0.003respectively). Meconium Aspiration Syndrome (MAS) was significantlymore common with Mod-thick meconium, and those with clear AF. Theneed for mechanical ventilation or oxygen support was relatively similarbetween infants with clear AF, thin stained fluid, and mod-thick fluidwho were not suctioned, but was significantly greater among suctionedinfants (P<0.01).Cesarean delivery increased with mod-thick meconium from 7 to 14%(P<0.001). Perinatal mortality increased from 2 per 100 births with clearamniotic fluid to 10 per 1000 births with meconium (P<0.001).
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PANELS
RT3.01 QUINACRINE NONSURGIAL STERILIZATION
RT3.01.01QUINACRINE NON-SURGICAL FEMALE STERILIZATION INBANGLADESHS.N. Bhuiyan , R. Begum, Dept. OB/GYN, Chittagong Medical CollegeHospital, Chittagong, Bangladesh.
Objective: To evaluate the efficacy, safety and acceptability oftranscervical applications of quinacrine along with other adjuvant asampicillin and ibuprofen for sterilization.Design: Cohort study.Setting: Family planning clinic in Chittagong Medical College Hospital,Bangladesh.Clients: Seven hundred and fifty normal women who requestedsterilization and volunteered for this method.Interventions: Several different protocols were tried over the years fromOctober 1989 to April 1999. Each woman received one or two insertionsof 180 mg or 252 mg quinacrine with adjuvant such as ibuprofen 55.5mg and ampicilin 125 mg. Supplementary contraception was oralcontraceptive pills, barrier methods of medroxyprogesterone for 3months. Details of each protocol will be described in text.Results: The gross pregnancy failure rate for 180 mg cases (N=489) was4.4% compared to 1.5% for 252 mg cases (n=261). There were noserious complications and side effects were transient.Conclusions: Quinacrine non-surgical sterilization is a safe acceptablyeffective method when two insertions of 252 mg quinacrine withmedroxyprogesterone for 3 months supplementary contraception is used.
RT3.01.02QUINACRINE STERILIZATION: ASSESSMENT OF SAFETY ANDEFFICACYJ. Lippes , School of Medicine, State University of New York at Buffalo,Buffalo, New York, USA
Objectives: To assess the safety and efficacy of a method of nonsurgicalfemale sterilization.Study Methods: Review of literature, including www.quinacrine.com,and unpublished reports known to the author.Results: No deaths have been reported in over 100,000 quinacrinesterilizations performed in 25 countries. Major complications are 1/50th
that reported for surgical sterilization. Ectopic pregnancy risk is similarto that following surgical sterilization. Follow-up for 19 years shows noincreased risk of cancer. Pregnancy failures are 1 to 2 per 100 womenafter 2 years of use.Conclusions: Quinacrine sterilization should be an option for all well-informed women who desire no more children
RT3.01.03QUINACRINE NON-SURGICAL FEMALE STERILIZATION:EXPERIENCE IN CHILEV. Trujillo , San José Hospital, Santiago, ChileJ. Zipper, University of Chile, Sotero del Rio Hospital, Santiago, ChileA. Dabancens, Faculty of Medicine, University of Chile, Santiago, ChileS. Guzman, Regional Hospital of Valdivia, Valdivia, Chile
Objectives: To evaluate the safety and efficacy of quinacrine nonsurgicalsterilization from experience in 3 hospitals in Chile.Study Methods: Clinical data for 2592 Chilean women receivingquinacrine sterilization involving 2 or 3 transcervical insertions of 252mg quinacrine in the proliferative phase of the menstrual cycle between1977 and 1998 in three public hospitals are analyzed.Results: For the 2592 women receiving quinacrine sterilization,cumulative life-table pregnancy rates per 100 women at 10 years variedfrom 5.2 to 6.9. The addition of intrauterine antiprostaglandins asadjuvants did not affect these rates. Physicians and midwives showedsimilar efficacy. No birth defects among pregnancies carried to termwere detected. There were 9 ectopic pregnancies (0.34%) among a totalof 119 pregnancy failures, which is similar to our experience with IUDsand lower than for surgical sterilization. There were no life threateningcomplications and side effects were mild and transient.
Conclusions: Quinacrine sterilization is a safe option for women who aresure they desire no more children.
RT3.01.04QUINACRINE STERILIZATION AMONG HIGH RISK WOMENA. Sarin , Aastha Medical Center, Patiala, India
Objectives: A nonsurgical method of female sterilization is neededbecause many women are at high risk of complications for standardsurgical methods, especially in developing countries. Also, some womenwho desire sterilization refuse it for fear of surgery. To meet thesespecial needs, we initiated a trial of quinacrine sterilization (QS).Study Methods: A trial of a nonsurgical sterilization method involvingtranscervical insertion of 252 mg quinacrine as pellets by a modifiedIUD inserter plus 50 mg of diclofenac in the proliferative phase of themenstrual cycle was initiated among 134 women requesting sterilizationat a medical school family planning clinic. This insertion was repeated amonth later and a 150 mg injection of depo medroxyprogesterone wasadministered at time of the first insertion.Results: Among 134 women of reproductive age entering this trial, 92were considered high risk for surgery, 27 refused surgery and 15 werecases of failed surgical sterilization. Mean follow-up was 3.46 years. Nopregnancies or serious complications were experienced. The main sideeffect was menstrual irregularities, probably due to depomedroxyprogesterone.Conclusions: QS is a suitable option for women at high risk of surgicalcomplications.
RT3.01.05QUINACRINE STERILIZATION: ENDOMETRIAL ASSESSMENTBY VAGINAL ULTRASONOGRAPHYCRC Ferreira , DRB Magalhaes, MZ Hanan, DC Ferreira, Faculdade deMedicina da UFMG, Belo Horizonte, Brazil
Objectives: To observe endometrial thickness before, during and aftertranscervical administration of quinacrine for nonsurgical sterilization.Study Methods: 80 women out of a planned study of 150 womenrequesting sterilization at the family planning clinic of a medical schoolhospital in Bela Horizonte, Brazil volunteered to participate in thisstudy. Each received 2 consecutive monthly transcervical insertions of252 mg quinacrine as pellets delivered by a modified Copper T IUDinserter in the proliferative phase of the menstrual cycle. Follow-upvisits were scheduled at 1, 3, 6 and 12 months. Transvaginal pelvicultrasonography was performed before, during and after insertions and ateach follow-up visit.Results: Of 80 subjects admitted in the study, transient side effects werenoted as follows: headache – 4 cases, light bleeding – 12, mildabdominal pain – 12, vaginal pruritis - 8, and yellow vaginal dischargefor 7 to 10 days – 64. No major complications, infections or pregnancyfailures were noted. A decrease in endometrial thickness was observedduring the first 6 months, which corresponds to incidence ofoligomenorrhea.Conclusions: Quinacrine sterilization was found safe and acceptablewhen offered as an option to women requesting sterilization. A decreasein thickness of endomentrium and oligomenorrhea appears to betransient over a 6-month period.
RT3.01.06QUINACRINE STERILIZATION: APPROPRIATENESS FORPRIVATE PRACTICE AND SERVICE PROGRAMSM. Hanson , Private Practice OB/GYN, Minneapolis MN, USA
Objectives: To assess risks and benefits of quinacrine sterilization (QS),a nonsurgical method for women.Study Methods: Literature review, including www.quinacrine.com, ofQS, which involves transcervical application of quinacrine 252 mg in theproliferative phase of two consecutive menstrual cycles. This iscompared to laparoscopic surgical sterilization in the USA.Results: The present protocol for QS shows an estimated pregnancyfailure rate of one per 100 women at 2 years of use, which isapproximately twice that of surgical sterilization. On the other hand, QShas a much lower incidence of side effects and serious complicationsand there are no reported case fatalities for QS in over 100,000 cases,
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whereas for surgical sterilization in industrialized countries, as the USA,the incidence is 3 per 100,000 procedures. Long-term sequelae of QS,such as risk of cancer and birth defects appear to be very remote andectopic pregnancy risk among pregnancy failures is not higher than forsurgical sterilization. Obviously, the cost of QS is lower than for surgicalsterilization.Conclusions: QS should be an option for any woman who is sure shewants no more children. This method is now appropriate for use inprivate practice and service programs in the USA, where it is legal forthis off label use on prescription filled by compound pharmacists.
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V3.01 VIDEO SESSION: MISCELLANEOUS TOPICS
V3.01.01VAGINAL ADNEXECTOMY FOR BENIGN OVARIAN CYST ATVAGINAL HYSTERECTOMYS. S. Sheth , Sheth Nursing Home, Breach Candy Hospital, Mumbai,India
Objectives: Vaginal surgeon to consider adnexectomy for a benign,mobile ovarian cyst at vaginal hysterectomy without laparoscopicassistance.Study Methods: Pre-operative, clinical examination under anesthesia,imaging and tumor marker indicated that the ovarian pathology wasbenign and freely mobile in 80 women of 40 years and above, scheduledfor hysterectomy. Adnexectomy was performed at vaginal hysterectomy.Laparoscopy was performed to evaluate the pelvic findings in 8. Theyare then compared with 115 cases with benign adnexal pathologysubjected to total abdominal hysterectomy with bilateral salpingo-oophorectomy.Results: All 80 had successful vaginal hysterectomy with adnexectomyfor ovarian cyst and prophylactic oophorectomy on the opposite sidewithout difficulty and complication. Laparoscopic assistance was nottaken in any of the cases. Laparotomy was performed in 3 as frozen HPstudy revealed malignancy. When compared with the abdominalapproach, morbidity, hospital stay and cost were significantly reducedwith more rapid recovery.Conclusions: Vaginal approach is effective, reduces morbidity andspares opening of the abdomen as well as laparoscopic assistance. It isthe least invasive.
V3.01.02WATER DELIVERY A DIFFERENT CHOICEG. Acosta-Osio , Dept OB/GYN, Metropolitan University & Hospital,Barranquilla, Colombia
Objectives: The aim of this there is to show to our colleagues theobstetricians world wide what the water delivery is, how the pregnantwoman may give birth, and giving birth in a different way.Study Methods: A video showing three water deliveries is presented.During the presentation an explanation will be given on how relaxed thewoman feels, how lukewarm water favors the stretching and dilation ofmuscular fascicles, the moment of episiotomy, if necessary, the fact thatthere is no risk of harm for the baby or the mother, and that thepuerperium care is similar to the one given in a conventional delivery.Does this type of delivery reduce the cesarean incidence?Conclusions: Water delivery is another choice where the mother decideshow she wants to deliver her baby, enjoying it with the family, makingthe delivery an enriching and pleasant experience, free of traumas andfears.
V3.01.03PREGNANCY COMPLICATED BY HUGE UTERINE MYOMAPRAEVIA – SURVEILLANCE, DELIVERY AND THERAPYV. Pazin , S. Rakic, N. Antic, B. Damnjanovic, S. Dragojevic,T. Moskovic, OB/GYN Clinic ²Narodni Front², Belgrade, Yugoslavia
Objectives: Our intention was to present our way of conduction,surveillance and therapy of this extremely complicated high-riskpregnancy from the early postconceptional period until myomectomyseveral months after delivery.Study Methods: A 34 years old primigravida showed in 4-th week ofgestation complicated by myoma located in isthmico-cervical region ofanterior uterine wall, 7 cm in diameter.After thorough consideration wedecided to continue the pregnancy under intensive surveillance.We usedbimanual, ultrasonographical, color-Doppler and biochemicalexaminations as often as neccessary.When uterine contractions haveoccured, bed rest and three-week permanent intravenous tocolysis hasbeen performed, followed by peroral tocolytic therapy.Long-termantibiotic treatment has been ordered to solve intermitent febrile stateand leukocytosis due to possible intraamnial infection or tumornecrosis.Caesarean section was the only way of delivery in case of hugemyoma praevia, enlarged to 15 cm in diameter, filling the whole minorpelvis.Myomectomy was performed several months after delivery.Results: Fortunately, we have got healthy baby and the uterus preparedfor the new high-risk pregnancy as the results.
Conclusion: Intensive surveillance and perinatal care using all means ofup to date technology in diagnostics and therapy of very complicatedhigd-risk pregnancy can oftenly be granted by perinatal success, whichmeans – healthy baby and happy mother.
V3.01.04MYOMECTOMY IN THE COURSE OF PREGNANCYWojciech Kazimierak, Teresa Pajszczyk-Kieszkiewicz , MedicalUniversity of Lodz, Lodz, Poland
Presence of myomas in pregnancy may be dangerous for the normaldevelopment of fetus and the course of pregnancy. They may affectnormal blood circulation in the placenta, distort the shape of uterus, andlead to fetal hypotrophy and compression. Myomas are frequent sourcesof complaints in pregnancy, causing pain and uterine contractions, whichmay lead to premature labour. In our clinic, we qualify such patients foroperation only when the risk for a mother or fetus is greater withtherapeutic treatment. Myomectomy in pregnancy is performed in thefollowing cases:- Severe pain with peritoneal signs.- Position of the mayoma above the placenta, which impairs bloodsupply.- Indenation into the uterus with compression of the fetus.Between 1986 and 1999 we have opereted 23 pregnant women withuterine myomas: 14 primigravidas and 9 multipara. Surgery was donebetween 11th and 31st weeks of pregnancy. The size of enucleatedmyomas.Varied from several to 20 cm, with tumors over 10 cm prevailing. In 23operated women 20 pregnancies terminated after 36 weeks: 22 healthychildren were delivered. There was one case of twins.Conclusions: Enucleation of myomas in pregnancy is relatively safeprocedure, nevertheless it should be proceded by thorough analysis ofindications and conditions. Operation in pregnancy enables furtherproper course of pregnancy till term and removes complaints connectedwith the presence of tumor. New generation of absorbable suturesenables proper technique of sewing with good hemostasis and rendersbetter endurance of site removedmyoma.
V3.01.05SAVE THE MOTHERS. Chowdhury , F. Islam, A K M Shahabuddin, H. Hasan, Shaheen.Institute of Child and Mother Health, Matuail, Dhaka, Bangladesh.
Objective: The video has been prepared to create awareness about somefactors of maternal deaths and to encourage the family of pregnantwomen for maternity careStudy Methods: The script of the video was written with targetingprimarily the pregnant women’s family and secondarily the heath careproviders of grass root level. Policy makers were also considered astertiary target audience during its preparation. Story based on a fact of apregnant women, Momotaz Begum. Momotaz Begum, wife ofSolimuddin a farmer of a rural area of Bangladesh, was on her fifthpregnancy with labour pain. The labour was prolonged for more than 24hours with two sun rises. At that time she was attended by an untrainedbirth attendants, mother and mother in law. Momotaz was exhausted andextremely tired because of her prolonged labour However at the end of24 hours she managed to deliver on baby. But following that she startedpost partum haemorrhage. Then Momotaz’s mother requestedSolimuddin to ask for a doctor to rescue Momotaz. Then started thedelays’ in transporting the patient from home to hospital. But at lastMomotaz Begum passed away living all the arrangements and planningmade for her. That was they end of part one and at this point a newcouple entered at the scene. This couple had regular ante-natal care anddelivery care and at the end a happy mother with a healthy baby.Results: The video was well accepted by the audience.Conclusions: The messages of the video include ensure antenatal carefor all pregnant women, provide extra food during pregnancy, and iflabour pain prolonged for 12 hours refer the woman to hospital.
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V3.01.06PATIENT SAFETY: A HUMAN FACTOR ANALYSIS OF ACOMPLICATED VENTOUSE DELIVERYB.L.Pedersen , Dept. OB/GYN, Copenhagen University and CooperationHospital, Hvidovre, Denmark.
Objectives: A ten minute video of a complicated ventouse delivery ispresented.The video was taped by a relative to the delivering woman. A24 year old nullipara presents 12 days postterm after an uncomplicatedpregnancy.After 8 hours of labor she is fully dilated but there is no furtherprogression in spite of oxytocin augmentation. When the patient haspushed for morethan one hour the midwife calls in the obstetrician whodecides to deliverthe child by ventouse. The position of the head is +1,the rotation is not described. The ventouse slips of six times and theobstetrician pulls during 23 contractions before one of the midwifes callsin the chief obstetrician who delivers the child after a moderateshoulderdystocia. The distressed asfyxiated child develops severebraininjuries.Study method: The video is analyzed according to human factoranalyses of latent and active failures.Results: The analysis raises some questions that all department shoulddeal with in order to prevent a similar case. These includes : Whenshould a vaginal operative delivery be tried, should there be a maximumtime from applying vacuum on the ventouse and until delivery, shouldthere be a maximum number of pulls, when should a midwife call in amore senior obstetrician etc.Conclusion: In order to improve patient safety all adverse event shouldbe analyzed in order to prevent similar cases. Departments might learnfrom adverse events in other departments.
V3.01.07VIDEO-PRESENTATION ON MANAGEMENT OF SHOULDERDYSTOCIAR. Deshpande , Dept. OB/GYN, Shri Banshankari Hospital, Solapur,Maharashtra, India
Objectives: To study the effect of learning shoulder dystocia drill on themodel of baby and the pelvis and its effect on the management.Study Methods: In the year 1991-1999, 4450 women at term, in laborwere studied, 5 cases of shoulder dystocia were noted. Two groups werestudied. Group A, between 1991-1995, when the drill was not appliedand Group B between 1995-1999 when drill was practiced on the model.Results: All the babies (3) in Group B were saved without any long termmorbidity and mortality, by application of Woods-Screw Maneuver.Conclusion: By practicing the shoulder dystocia drill on baby-pelvismodel, management of shoulder dystocia can improve and reduceneonatal morbidity and mortality.
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POSTERS
P3.01 ANTENATAL CARE AND DIAGNOSIS
P3.01.01ACARDIAC TWINS: A REPORT OF SIX CASESB. Ben Romdhane , A. Masmoudi, L.Smaili, A. Mabrouk,M.B. Chanoufi, F. Zouari, H. Chelli, S. Gaigi, Dept. Fetopathology,Center of Maternity and Neonates of Tunis, Tunis, Tunisia.
Objectives: The aim of this study was to determine the frequency ofacardiac fetuses in our institution, to precise the means of prenataldiagnosis and the neonatal management of this malformation. A reviewof the literature is made.Study Methods: We reviewed retrospectively six cases of acardiacfetuses diagnosed in the Center of Maternity and Neonates during aperiod of 7 years (January 1993-December 1999). The diagnosis wasmade or suspected by ultrasound examination and confirmed by autopsyin all the cases.Results: The prevalence of this malformation was estimated to 1/8000births. Prenatal ultrasound examination finding a cardiac abnormality inone of the twins was carried out at an average term of 30 weeks. Thediagnosis was evident before birth only in one case: ultrasoundexamination showed no heart area at all. In the other cases, the diagnosiswas suspected by the absence of cardiac pulsation in a living fetus.Three cases of acardius acephalus and three other cases of acardiusancepts fetuses were found on autopsy. The prognosis of the pump-twinwas worse in 4 cases (3 neonatal deaths and 1 intrauterine death). Thetwo other babies developed a congestive cardiac failure.Conclusion: The diagnosis of acardiac fetus in twin pregnancies must besuspected on ultrasound when this latter show no cardiac pulsationespecially if another malformation is associated. The development of thenormal twin must be regularly evaluated by repeated ultrasoundexamination.
P3.01.02AMNIOTIC FLUID BILIRUBIN DELTA EXTINCTION AS APREDICTOR FOR INTRAUTERINE INTRAVASCULARTRANSFUSION IN SECOND TRIMESTER FORERYTHROBLASTOSIS FETALISL.J. Mirkovic (1), D. Plecas (1), M. Popovic (2), N. Radunovic (1), V.Milenkovic (1), M. Radovic (1)(1) Institute of Gynecology and Obstetrics, Clinical Center of Serbia,
Belgrade, Yugoslavia.(2) National Blood Transfusion Institute, Belgrade, Yugoslavia.
The severeness of fetal anemia and initiation of intrauterine transfusiontreatment were analyzed on basis of the numeric value of deltaextinction per 450 nm of amniotic fluid bilirubin (DE 450 nm) in thisperiod 18-32 weeks of gestation in 40 Rh-alloimmunized pregnantwomen.The validity of the extrapolation of Liley risk zones in second trimesterwas studied and the fetal hematocrit values (fetal blood obtained bycordocentesis) were correlated with the DE 450 nm values.The numeric DE 450 nm value indicates the existence of a hemolyticprocess but it is not a reliable indicator of fetal anemia. By extrapolationof Liley risk zones in the second trimester of pregnancy is not a reliablepredictor of severity of fetal anemia. Chemical determination ofamniotic fluid bilirubin cannot be used as an independent diagnostic andprognostic parameter of fetal anemia.Anamnestic data, Coombs Rh-antibodies titer, ultrasound monitoring,chemical and spectrofotometric determination of amniotic fluidbilirubin, are complementary diagnostic and prognostic methods forprompt cordocentesis. The need for intrauterine transfusions is assessedon the fetal hematocrit values, which are the method of choice intreatment of severe fetal hemolytic disease.
P3.01.03DETERMINATION OF FETAL LUNG SURFACTANT MATURITYBY A SIMPLE CROMATOGRAPHIC PROCEDUREA. Bazarra (1), A. Castro(2), J. Aguilar(2)1) Health Sciences, University of La Coruna, La Coruña, Spain2) Medicine, University of La Coruña, La Coruña, Spain
Objectives: Analyzing fetal lung phospholipids in a basic laboratorywith efficacy and efficiency using a simple and cheap method.Study Methods: 173 samples of amniotic fluid were analyzed from 148pregnant women, between the 25 and 44 weeks of gestation age. Fordetection of phospholipids two dimensional thin-layer cromatographywas used, by means of a technique simplified by us, we do not use therotavapor, the precipitation with cold acetone, the aspiration bell of thedouble beam densimeter. We have only checked the presence orfosfatidilglicerol absence. Lecithin/sphingomyelin ratio was measuredby planimetry. For the statistical analysis the program BMDP was used.Results: In normal gestations phosphatidylglycerol was detected for firsttime to the 35 weeks and 3 days of gestational age. No newborn sufferedthe respiratory distress syndrome when the phosphatidylglycerol wasdetected in the amniotic fluid. In 7 cases without detectingphosphatidylglycerol, the newborn did not develop respiratory distresssyndrome. Specificity 98.1%. Positive predictive value 85.7%. With acutoff for the lecithin/sphingomyelin ratio of 3.1 there is no respiratorydistress syndrome (p<0.001).Conclusions: With a cheap and simple technique that can be carried outin any elementary laboratory, a control of the fetal lung maturity ispossible. And so, to prevent the respiratory distress syndrome withexactitude, precision, efficacy and efficiency avoiding big cost ofhospitalization facilities and expensive instruments.
P3.01.04EVALUATION OF THREE SCREENING TESTS FOR PREGNANCYINDUCED HYPERTENSION IN SECOND TRIMESTER OFPREGNANCYA. Barua , S. Kumar, S. Mittal, V. Dadhwal. Dept. OB/GYN, All IndiaInstitute of Medical Sciences (AIIMS), New Delhi, India.
Objective: To evaluate Doppler flow study of uterine arteries in secondtrimester of pregnancy for prediction of pregnancy induced hypertensionand its comparison with roll over test and isometric exercise test.Study method: Prospective, non-randomized study included 111nullipara attending antenatal clinic at AIIMS Hospital, New Delhi. Eachsubject underwent isometric exercise test before 20 weeks and roll overtest between 20-28 weeks. Doppler flow study of uResults: Out of the 111 subjects, 13 had developed PIH. Of the 18subjects with positive isometric exercise test, 5 developed PIH(X2=0.67, p=0.0540, OR=4.09, 95% CI=1.16-14.41) and out of 27patients with positive roll over test, 3 developed PIH (X2=0.0Conclusion: Doppler flow study of uterine arteries in second trimesterwas found to be a better test for prediction of PIH than isometricexercise test or roll over test.
P3.01.05INDUCTION OF ANTENATAL PERIVENTRICULARLEUKOMALACIA BY HEMORRHAGIC HYPOTENSION IN THECHRONICALLY INSTRUMENTED FETAL SHEEPK. Okuyama , T. Matsuda, K. Cho, Y. Kobayashi, T. Kishida, T Kusaka,S. Fujimoto, Dept. OB/GYN, Hokkaido University School of Medicine,Sapporo, Japan
Objectives: The purpose of this study was to determine whethersystemic hypotension induced by rapid withdrawal of fetal blood wouldinduce periventricular leukomalacia in the brain of premature fetalsheep.Study Methods: At 110 days of gestation, catheters were placed in fetalsuperior vena cava, inferior vena cava, and distal abdominal aorta and 3electrodes were fixed to fetal chest wall by means of hysterotomy. At113 days of gestation, systemic hypotension (mean blood pressure<30mmHg) of fetus was induced by withdrawing approximately 35% offetoplacental blood volume in hemorrhage group (n=6), whereasisovolemic exchange transfusion was carried out in control group (n=4).Physiologic parameters were monitored periodically during experiments.
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Six days after the insult, fetal brains were removed and processed forhistologic investigation.Results: Five of 6 fetuses in the hemorrhage group exhibitedperiventricular white-matter lesions, consisting of nodular coagulationnecrosis or diffuse axonal swellings, or both. There were accumulationof activated forms of microglia-macrophages and migration ofphagocytizing macrophages in necrotic foci. Immunohistochemicalstaining revealed anti-Alzheimer precursor protein A4 expression inthese lesions. None of fetuses in control group developed centralnervous system lesions.Conclusions: Antenatal hemorrhage hypotension apparently inducedbrain lesions in the chronically instrumented fetal sheep similar to thoseof periventricular leukomalacia in human neonate. It should besuggested that fetal hypotension plays an essential role in thepathogenesis of periventricular leukomalacia in premature fetuses.
P3.01.06PECULIARITIES OF FREQUENCY AND SPECTRUM OFCHROMOSOME ABERRATIONS IN THE EMBRYOS OFRADIOPOLLUTED TERRITORIESOlena V. Kravchenko , Bucovinian State Medical Academy, Chernivtsi,Ukraine
With the aim to estimate genotoxicity of the environmental pollution wehave studied the frequency and spectrum of chromosome aberrations inembryoes on the territories suffered from Chornobyl disaster. Humanembryo lymphocytes were received from the cellular suspension of theliver tissue after artificial abortion (80 embryoes - polluted area, 20 -control area). This method enables us to observe chromosome changeswhich appear in a certain ecological surroundings excepting the factor ofcultivation influence.The analysis of the level of chromosome aberrations revealed that thenumber of aberrant metaphase plates in embryoes and fetuses of thepolluted regions exceeded data of the control population (7,0 + 0,57%,3,78 + 0,5%), p<0,05; besides, both indices of chromosome (2,15 +0,32%, 0,64 + 0,12%) and chromatid elisions (5,0 + 0,48, 3,14 + 0,46%)p<0,05 were higher.As to the structural changes of chromosome aberrations according to thesex of embryoes and fetuses we have determined that metaphase plateswith chromatid elisions of several chromosomes were more frequentlyadmitted with 46XY karyotype. In ecologically polluted regionsubstantial difference in the frequency of metaphase plates with circularchromosomes in the male embryoes (46XY - 8 cases, 46XX - 2 cases)was found, that is the most objective radio-induced cytogenetic marker.Thus, mutation changes in embryoes and fetuses in the region sufferedfrom the consequences of Chornobyl disaster are much higher that ofaverage-population indices and are indicative of chemical andradioactive influence as well.From our point of view it is the sensitivity of embryo cells that should bea criterion in the estimation of possible harmful substancesconcentrations considering their high genetic risk.
P3.01.07PERINATAL OUTCOME AMONG SHORT STATURED WOMEN INNEPALR. Jha (1), D.S. Malla (1), A. Rana (2),(1) Maternity Hospital, Thapathali, Kathmandu, Nepal.(2) Dept. OB/GYN, Tribhuvan University Teaching Hospital,
Kathmandu, Nepal.
Objectives: The study was conducted to determine the effect of maternalshort stature on perinatal outcome.Study Methods: It was a prospective study of 360 women admitted inMaternity Hospital, Thapathali for the management of labor over aperiod of 35 days. All the women fulfilled the inclusion criteria –primigravida, sure date of last menstrual period, singleton viablecephalic fetus of ³ 28 weeks of gestation and without any complication.Maternal height and weight at the time of delivery and a detail historywas taken. Nature of labor, mode of delivery and complications werenoted. Weight of fetus, admission in special care baby unit (SCBU),morbidity and mortality were noted.Results: The study has identified £144 cm stature as high risk height forNepalese women. Mothers £144 cm in height had one and half timeshigher chance of preterm delivery in comparison to women ³145 cm
(11.29% vs. 6.71%). Mothers £144 cm height had 2.29 times more riskof giving birth to low birth weight babies. 11.29% of babies born toshort mothers (£144 cm) were severely asphyxiated at 1 minute of birthin comparison to 2.6% among mothers £145 cm in height. Babies ofshort mothers had a higher rate of admission in SCBU in comparison tobabies of taller mothers (20.96% vs. 0.67%).Conclusions: It has been found that maternal height is significantlyassociated with perinatal outcome. Short statured mothers are at a higherrisk of poor perinatal outcome and therefore, need early identification,special care and delivery in a well-equipped hospital.
P3.01.08PRENATAL DIAGNOSIS OF A CASE OF LETHAL DWARFISMA.Desroches , P. Megier, Y. Le Brun Keris, Unit of Ultrasonography ofDept. OB/GYN, Pluridisciplinary Center of Prenatal Diagnosis,Regional Hospital, Orleans, France
Objectives: Prenatal diagnosis of a case of lethal dwarfism and follow-up of the pregnancy after refusal of a medical termination of pregnancy.Study Methods: A 23 year old gravida 2 para 1 benefited by a systematicultrasonography at 22 weeks of amenorrhea. We observed a micromelia,with telephone-receiver-shaped femoral bones and a severe thoracichypoplasia. The forehead was high and bulging. We laid down thediagnosis of lethal dwarfism. The couple was informed by theobstetrician and the pediatrician about the lethal prognosis of themalformation. They did not choose the medical termination of thepregnancy because they are Muslim. The psychological escorting wasdifficult by fact of a linguistic barrier.Results: The ultrasonographic follow-up showed the persistence of theabnormalities, the apparition of a polyhydramnios, a macrosomia and anhyperdeflection of the fetal head. In spite of repeated information withtranslators, we think that the couple failed to appreciate the severity ofthe fetal prognosis. We realized a cesarean section at 39 weeks ofamenorrhea on account of a fetal-pelvic disproportion. The female childdied just after her birth on account of an acute respiratory distress. Herweight was 2850g. The macroscopical examination confirmed theprenatal diagnosis. A radiological study was realized before the burial.Conclusion: Prenatal diagnosis of lethal dwarfism is easy. Thisobservation shows the difficulty of prenatal diagnosis in patients whoare not used to investigation techniques and the consequences of theirresults.
P3.01.09PRIMIGRAVIDAS-HOW DO THEY GET INFORMATION ABOUTTHE DIFFERENT MODES OF PAIN RELIEF IN LABOUR ANDWHEN DO THEY DECIDE ON THE MODE OF PAIN RELIEF.Y Sajjad *, T Sajjad+, *Dept Of Ob & Gyn, Warrington GeneralHospital, Warrington, + Dept of Anaes & Pain Relief, Royal LiverpoolUni Hospital, Prescot Street, Liverpool, United Kingdom.Objectives:1. To determine the source or sources from which the primigravidas
obtain information about the different methods of pain relief inlabour.
2. To investigate what percentage of primigravidas, have chosen themode of pain relief before the onset of labour (during pregnancy).
3. To investigate, what percentage of primigravidas chooses the modeof pain relief, after admission to labour ward.
4. To determine the single most important person, who influences thechoice of pain relief.
5. The involvement of husband / partner in helping the primigravida inchoosing the mode of pain relief.
Study Design: This is a prospective, ongoing study being carried out atArrowe Park Hospital, Wirral, Liverpool, United Kingdom. It has beenapproved by the Hospital Ethical committee and informed consent isobtained from each patient. The patients are requested to fill aquestionnaire within 36 hours of delivery. This information will becorrelated with patient's level of education and employment status.Conclusions: The study will help us in determining, firstly the sourcesprimigravidas use to gain information about different modes of painrelief available in labour. Secondly, we will be able to find out whenwould be the best time to deliver information about different modes ofpain relief in labour to the prospective first time mothers, and lastly whowould be the best person to effectivelydeliver this information.
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P3.01.10THE EARLY EXTERNAL CEPHALIC VERSION (ECV) TRIAL: ARCT OF ECV BEGINNING AT 34 WEEKS’ VS DELAYED ECVBEGINNNING AT 37 WEEKS’ GESTATION FOR SELECTEDBREECH PREGNANCIES.E.K.Hutton, M.E.Hannah , E.D.Hodnett, K.Kaufman, K.Amankwah, forthe Early ECV Trial Group, University of Toronto, ON, Canada. Fundedby MRC, Canada
Objective: This multicentre RCT will recruit 232 women to determine if,for selected women with a fetus in breech presentation, an early ECVbeginning at 34-36 weeks’ gestation will decrease the likelihood of noncephalic presentation at birth when compared to delayed ECV that is notinitiated until 37-38 weeks’ gestation.Study Methods: There is good research evidence to support delayedECV beginning at 37 weeks’ gestation. However the success rate ofdelayed ECV is poor among nulliparous women and those with a frankbreech presentation, particularly in North America and Europe. Theselection criteria for entry to the study will ensure that only thosewomen who may potentially benefit from the early ECV procedure willbe included. The inclusion criteria: 1. nulliparous women with anybreech presentation or multiparous women with a suspected frank breechpresentation 2. live singleton fetus 3. gestational age between 34 and 36weeks. The exclusion criteria: 1.contraindication to labour or vaginalbirth 2. any contraindication to ECV 3. any contraindication to earlyECV 4. plans to move to a non-trial centre prior to delivery.Prior to undertaking an appropriately sized RCT to assess the effect ofearly vs. delayed ECV, in selected women, in terms of need for CS orrisk of fetal complications, we believe that we first need to prove thatearly ECV will result in a clinically important decrease in the number ofnon-cephalic presentations at birth. The primary outcome of this trial,therefore, is the rate of non-cephalic presentation at birth. Additionaloutcomes include, 1.CS, 2. serious fetal complications, 3. preterm birth(<37 weeks) and 4. women’s views.Results: Recruitment has begun at three Canadian centres with 20women enrolled as of January 25, 2000. An additional 10 centres inCanada and the UK are awaiting recruitment or local ethics approval.Other interested centres, are welcome to contact Early ECV Trial c/oMIRU (FAX 416-351-3771; email [email protected])
P3.01.11THE EFFECT OF ABORTION ON OUTCOME OF SUBSEQUENTPREGNANCYM. Ghaffarnejad , M. Hejazi, F. Ebrahimi, Dept. OB/GYN, MirzaKuchakkhan Hospital, Tehran University of Medical Sciences, Tehran,Iran.
Objectives: The aim of the study was to investigate the effect of one ormore spontaneous abortion on subsequent pregnancy outcome.Study Methods: In a historical cohort study, we evaluated the effects ofone or more spontaneous abortion on subsequent pregnancy outcome.1693 pregnant women were classified in three groups: 1100 without anyprior pregnancy, group (1) 550 with history of one spontaneous abortion(G2Ab1), group (2) 43 with two or more prior spontaneous abortion andno other prior pregnancies. We collected data through interview,patient’s records and physical examination. We matched the patientsaccording to their age, subgroups, history of chronic disease, drugadministration, radiation during current pregnancy and familialmarriages. Then we compared adverse outcome of present pregnancy ingroup 1 and 2 with the women without prior pregnancy. The data wasanalyzed with chi-square and Fissure’s exact methods.Variables: Premature labor, prolonged rupture of membrane, abruptioplacenta, placenta previa, pre-eclampsia, eclampsia, low birth weight,stillbirth and difficult delivery.Results: We resulted that history of one spontaneous abortion had noeffect on subsequent pregnancy except in prolonged rupture ofmembrane (p<0.0001), but history of two or more abortion significantlyaffects occurrence of stillbirth (RR=29, p=0.003) and placenta previa(RR=8.5, p=0.03).Conclusions: These findings suggest that women with history of two ormore spontaneous abortion need special prenatal care.
P3.01.12THE IMPACT OF PRENATAL DIAGNOSIS (PND) ON THEOCCURRENCE OF CHROMOSOME ABNORMALITIES ANDOBSTETRICAL PRACTICEY. Y. Yang , S. Y. Ho, P. T. Chang, M. C. Chao, Dept. OB/GYN, Foo-Yin Hospital, Taiwan, R.O.C.
Objectives: To measure the impact of PND on the incidence of all typesof chromosome abnormalities resulting in improved obstetrical outcome.Study Methods: The study population consisted of 875 pregnant womenin 1999, undergoing chorionic villus sampling and amniocentesis forprenatal diagnosis, who were maternal age 35 years or older, positivescreening test (over 1/270) for Down syndrome, an abnormal fetalultrasonographic scan or an increased risk of chromosomal fetalabnormality. Cell culture with in situ method, karyotype analysis at least20 cells.Results:(1) A total of 875 patients were included in this study, of which 2.63
% (23 cases) were chromasomally abnormal. The incidence ofautosomal trisomies was 1.37 % (12 cases), sex chromosomeabnormality was 0.8% (7 cases), balanced translocation 0.45% (4cases), and 3 cases of culture failure.
(2) The indications of PND are mostly due to abnormal serum marker(417 cases, 47.6%) and advanced maternal age (324 cases, 37%);These results are associated an increase in the number andproportion of chromosome abnormal fetus detected (8 cases and 13cases respectively) and slight decrease in the prevalence ofchromosome abnormalities among live births.
(3) “Suspected fetal pathology” categories increased in frequency (129cases, 15%). While “Sonography abnormal fetus” category stillremained low in frequency (5 cases, 0.5%).
(4) The proportion of first trimester tests performed with chorionicvillus sampling decreased significantly.
Conclusions: A wide-ranging screening program of pregnant women hasto be used to significantly reduce the birth of chromosome abnormalfetus. Further, we can offer patients early trimester detection forkaryotyping or genetic diagnosis resulting in the option of saferpregnancy termination which will improve the obstetrical outcomes.
P3.01.13THE USE OF INTRAVAGINAL MISOPROSTOL FOR INDUCTIONOF LABORD. Casagrandi Casanova , Havana, Cuba
Abstract: Misoprostol, a synthetic drug analog of prostaglandin E1 hasbeen used to provoke cervical ripening and induction of labor. The aimof this study was to evaluate the efficacy and safety of intravaginal forlabor induction. A total of 198 pregnant women were included in thestudy and fractionated doses (25 microgram) of misprostol were appliedevery three hours until a maximum of four doses or beginning of labor.The most common indications for induction of labor were prematurerupture of membranes (28%), post-datism (21%) and pregnancy inducedhypertension (19.5%). 45.5% of patients started with uterinecontractions in the first hour after vaginal application of misoprostol.Normal cardiotocography was observed in 96 cases (48%), 46 (23%)had tachysistole and 17 (8.5%) had variable decelerations. Oxitocininfusion was used in 64 patients (32.3%), almost always after the fourthdose of misoprostol. The cesarean section rate was seen in 5 patients(2.5%). No maternal side effects and neonatal adverse effects werenoted. We conclude that intravaginal misoprostol admiinistration withlow doses is an effective method for labor induction, but furtherinvestigations should be done to evaluate its real safety.
P3.01.14USE OF RANDOM URINE PROTEIN/CREATININE RATIO TOESTIMATE PROTEINURIA IN PREGNANCYA.M.B. Ongkiko Cagayan ,Quezon City, Philippines
Objective: To determine whether random urine protein/creatinine ratiocan be used to determine proteinuria in pregnancy.Design: Prospective study assessing accuracy of quantitation ofproteinuria.Setting: Intensive Maternal Unit of the Department of Obstetrics andGynecology of Philippine General Hospital.
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Population: Pregnant women admitted to the hospital.Method: Three random urine specimens and 24-hour urine collectionwere ordered for 90 subjects. Random urine protein/creatinine ratio andestimated total urine protein were compared with the 24-hour urineprotein.Main Outcome Measures: Correlation of random urine protein/creatinineratio and estimated total urine protein with the 24-hour urine proteinexcretion; 2. Sensitivity, specficity, positive and negative predictivevalues of random urine protein/creatinine ratio for significant andnephrotic-range proteinuria.Results: Log random urine protein/creatinine ratio and log estimatedtotal urine protein showed good correlation with log 24-hour urineprotein (r=0.70 to 0.80; p=0.0001). A log/log transformation of data wasnecessary due to the wide variability of values. A protein/creatinine ratio>300 mg/g was the discriminant value for significant proteinuria, withsensitivity and specificity of 70-80% and a positive predictive value of90%. However, its negative predictive value was only 20-30%. Aprotein/creatinine ratio >3000 mg/g was the discriminant value fornephrotic-range proteinuria, with sensitivity, specificity, and negativepredictive value of 80-90% and positive predictive value of 70%.Conclusion: Random urine protein/creatinine ratio may be useful indetermining proteinuria in pregnant women. Because of large standarddeviations associated with this method,caution must be taken in applying overconfidence to the values obtainedwith this technique.
P3.02 CERVIX
P3.02.01ABNORMAL PAP SMEAR IN ADOLESCENCETacla , M. ; Tubaki , M.E.; Schwarzschild , M.M.S.; Luca , P.D.;Meniconi , M.C.; Barrueco , A.K.; Lopes, E.A.; Duarte , M.I.S.Laboratório Fleury - São Paulo - Brazil
Objective: The purpose of this retrospective study is to evaluate the agedistribution of cytologic abnormalities in adolescence and its correlationwith the histopathologic findings.Material and Methods: Between January 1994 to December 1999, 3.483cervicovaginal smears from upper and middle class adolescents rangingfrom 11 to 19 years old , that were referred to Laboratório Fleury , weretaken. 155 smears were identified as abnormal . Colposcopy,vaginoscopy and/or colposcopically directed biopsy were performed in110 adolescents.Results :Table I: Cervicovaginal Smear Age Distribution
Age
Total of
Cervicovaginal
Smears
Abnormal Smears
Percentage of
Abnormal Smears
( % )
11 13 - -
12 15 - -
13 24 - -
14 55 1 1.8
15 146 6 4.1
16 312 12 3.8
17 669 31 4.6
18 956 44 4.6
19 1293 61 4.7
Table II: Abnormal Cervicovaginal Smear Age DistributionAge LSIL HSIL TOTAL: n = 155
14 1 0 1 0.6 %
15 6 0 6 3.9 %
16 11 1 12 7.7 %
17 31 0 31 20 %
18 42 2 44 28.4 %
19 53 8 61 39.3 %
101 cervical biopsies were performed resulting in: 1 CondilomaAcuminatum , 2 Condiloma Acuminatum + CIN II , 9 ChronicCervicitis, 45 Chronic Cervicitis + HPV , 1 Endocervicitis , 38 CIN Iand 5 CIN II.Conclusion: The importance of these data is to establish the correlationbetween the age distribution of abnormal cytology and histopathology inthe screening of cervical cancer and evaluate the severity of these
abnormalities. Screening of cervical intraepithelial neoplasia amongadolescents is essential to avoid the early evolution of this disease.
P3.02.02CERVICAL CANCER IN PEMBROKESHIRE SINCE NATIONALCANCER SCREENING PROGRAMME: IS SCREENINGDISINVESTMENT DESIRABLE?S.N. Roy , W.M.Clow, J.Hall, Withybush Hospital, Dept. of Obstetrics &Gynaecology, Haverfordwest, Pembrokeshire, United Kingdom, SA 612PZ.
Objectives: In the light of possible screening disinvestment, to assess thepresentation of Cervical Cancer in Pembrokeshire since the starting ofNational Screening Programme (1988).Study Methods: Retrospective study of Cervical Screening history ofpatients diagnosed with Cervical Cancer in Pembrokeshire between1988-1998. The screening coverage of the population was also assessedduring the same period.Results: Screening coverage in Pembrokeshire was only 45% in 1988.This rapidly escalated to 81% in 1991 and stayed around 85% since1993. Total 83 patients developed Cervical Cancer. Ten of these wereabove the age of 65 at 1988 and therefore not included in screening. Thehighest incidence of Cervical Cancer was in women who were neverscreened. A large number of cases were detected at the time of first callfor screening (29). In the 'recal' programme, there were 7 intervalcancers. Five of these were diagnosed because of 'unscheduled' smears.Six cases in this group (30%) would have not been diagnosed ifscreening was curtailed at the age of 50 for well screened patients.Conclusion: The present policy of 3 yearly screening till the age of 65should be continued in Pembrokeshire.
P3.02.03CONIZATION - POSTOPERATIVE COMPLICATIONSM. Temelkovski , M. Trajanova, J. Kostadinov, A. Sopova, SpecialGynecology and Obstretrics Hospital, Skopje, Macedonia
Cervical conization is a rapid and relatively save surgical procedure. Theadvance is both, diagnostic and therapeutic.Analyzed were154 conization cases performed in two techniques.Patients were between 28 and 54 years old, and different pregnanciesand births number.90 patients (59%) had two, 17 (11%) had three and the remaining 32(21%) more than 3 children. 41 (27%) had 2 artificial abortions and 46(30%) had one. Indications were: unsatisfactory colposcopy followingabnormal cervical smear, colposcopy prediction of early invasion orsuspicion of cytology invasion, early invasion on direct biopsy, positiveendocervical curettage, cytology discrepancy with colposcopy or directbiopsy and recurrent disease following previous ablative therapy. Theoperative technique is classical conization; hemeostasis obtained with acircular suture in 70 % (108 cases) and Shtrumdorf suture 30% (46).Postoperatively was ordinated for 3-5 days: cephalosporin, sulfonamideor tetracycline.Complications occurred in 7,79% (12 patients). Postoperativehemorrhagy within 1 to 10 days appeared: 0-2 days 1 (0.64%); 3-5th 3(1.94%); 6-8th 2 (1.29%); 9-10th 2 (1.29%), postoperative cevicitis l(0.64%), urinary infections 3 (1.94%) and one had adhesions of thecervical channel. Preoperative findings were: CIN III in 98 cases(63.63%), CIN II in 32 (20.77%); suspicious invasion in 24 (15.58%).There was a high correlation between pathohystological results andpreoperative findings with the postoperative diagnosis in 93% (143)cases, and the conization technique associated with the postoperativecomplications revealed no differences with the literature.
P3.02.04DETERMINING THE COST EFFECTIVENESS OF MASSSCREENING FOR CERVICAL CANCER USING COMMONANALYTIC MODELSS. Sato , G. Matsunaga, A. Yajima, Dept. OB/GYN, Tohoku UniversitySchool of Medicine, Sendai, Japan.
Objectives: To estimate the cost per life-year saved (cost-effectivenessratio [CER]) for cervical cancer and to evaluate the influence of thedecreased incidence upon the cost per life-year saved.
WEDNESDAY, SEPTEMBER 6 81
Study Methods: We established hypothetical cohorts at 10 year intervalsbetween 30 and 79 years of age, each of which consisted of 100.000asymptotic female subjects, and estimated the cost and effect of singlemass screening for cervical cancer. To investigate the influence of CER,we performed a sensitivity analysis of each item, including theconsultation rate for further examination, prevalence rate and cost ofmedical treatment.Results: The estimated CER per one expected life-year of survival waslowest for subjects in their 30s and highest for those in their 70s. Thedifference between the two was more than five-fold. Sensitivity analysiswas rarely affected by changes in the cost of medical treatment and theprevalence rate, but the effectiveness rate could be fairly affected by theconsultation rate for closer examination.Conclusions: Mass screening for cervical cancer is acceptable in termsof economic effectiveness. Moreover, mass screening for cervical cancercould decreased the morbidity rate for scores of years thereafter.
P3.02.05DIAGNOSTICAL-PREVENTIVE VALUE OF BILLINGSOVULATION METHOD FOR VAGINAL-CERVICALPATHOLOGIESA.L. Astorri , G. Pompa, E. Terranera, E. Giacchi, A.Cappella. Center forStudy and Research on Natural Fertility Regulation, Catholic Universityof the Sacred Heart, Rome, Italy
Objectives: The Billings Ovulation Method (BOM) is one of the mostmodern and valid methods which allows a woman to regulate herfertility in a natural way by identifying fertile and infertile phases in hermenstrual cycle through a self-observation of cervical mucus secretion.The visual observation of mucus and the recording of the sensationproduced by the mucus at vulva (mucus symptom) are demonstrated toenable the woman to identify the beginning and the end of the fertilephase in menstrual cycle, as well as the day of maximum fertility (peakof the mucus symptom).This study analyzes the eventual diagnostical-preventive value of BOMfor vaginal-cervical pathologies (VCP).Study Methods: A group of 72 BOM users has submitted togynaecological examination because they observed an atypical pattern ofthe mucus symptom which did not appear to be imputable to anendocrinous disfunctional pathology (as it was observed by hormonalassays and basal body temperature assessment).In these patients, an accurate check of the low genital tract wasperformed through cytologic-colposcopic examination and vaginal-cervical cultures.Results: In a significative average of cases an atypical pattern of mucussymptom leads to an early diagnosis of clinically remarkable VCP suchas HPV and other sexually transmitted diseases (63,9%).After thephysical and/or pharmacological treatment the symptom became normalor better.Conclusions: Our study confirms the importance of mucus symptom as afaithful indicator of cervical function and the BOM usefulness for anearly diagnosis of VCP, some of them are frequently present assubclinical and asymptomatic forms.Nowadays, VCP have acquired considerable interest in healthenvironment either for their diffusion (for instance in case of sexuallytransmitted diseases) and in relation to the possible difficulty ofdiagnosis and therapy as well as to their oncogenic potentiality and theprospective consequences on the woman’s health and fertility.
P3.02.06EPIDEMIOLOGICAL CHARACTERISTICS OF PATIENTSSUBMITTED TO HYSTERECTOMY FOR CERVICALINTRAEPITHELIAL NEOPLASIA (CIN) GRADE III, FROM 1996TO 1999, IN A WOMEN'S REFERENCE CENTER OF SÃO PAULO,BRAZIL.M. Dos Santos , M.A. Gonçalves, G. Ferreira, D. Ferreira, HospitalPérola Byington, rua Bergamota, 470/121A, São Paulo, Brazil, 05468-000.
Objectives: This study was developed in order to evaluateepidemiologically women submitted cone excision and, also theoutcome of those who were submitted to hysterectomy because ofresidual lesions from 1996 to 1999.
Methods: Four-hundred women submitted to traditional cone or LoopElectrosurgical Excision Procedures (LEEP) for cervical intraepithelialneoplasia (CIN) III were studied. Histological cone results were dividedinto: with residual lesion, who were indicated to hysterectomy and,absence of residual lesion. Epidemiological characteristics of populationpresenting residual lesions were analysed, concerning the year ofsurgery, to estabilish a possible epidemic distribution of the lesion, allover the years.Results: On cone histology, 321/400 (80.25%) patients showed absenceof residual lesion and 79/400 (19.75%) residual lesions. During 1996,23/79 (29.12%) were treated: 6/23 (26.09%) from 21 to 30 years old;10/23 (43.47%) 31-40; 5/23 (21.74%) 41-50 and, 2/23 (8.70%) > 50years old. Considering 1997, 18/79 (22.79%) patients in the same order:3/18 (16.67%); 9/18 (59%); 4/18 (22.23%) and, 2/18 (11.11%). During1998, 25/79 (31.65%) patients, in the same order: 4/25 (16%); 10/25(40%); 6/25 (24%) and, 5/25 (20%). During 1999, 13/79 (16.46%)patients, in the same order: 3/13 (23.08%); 4/13 (30.77%); 4/13(30.77%) and, 2/13 (15.39%).Conclusions: The majority of cases occurred from 21 to 40 years old, thehighest rates (75.67%) being in 1997 and, the lowest ones (53.85%) in1999. This fact reflects a protocol change, in which nowadays onlyindicates a conservative two-years follow-up for residual non-invasivelesions.
P3.02.07MANAGEMENT OF CERVIX UTERUS EROSION INNULLIPAROUS WOMENN. G. Pryadko , G. V. Belousov, Donetsk State Regional Center ofMaternity and Child Care, Donetsk, Ukraine.
Objectives: The aim of the investigation is to study the efficacy of short-wave therapy in young women having cervix uterus erosionaccompanied by chlamydial infection based on colposcopic andmorphologic evaluation of the cervix uterus epithelium condition.Study Methods: 32 women aged 16-25 were examined. Anamnesis wasstudied, gynecologic examination, clinical and bacteriologicalinvestigation of vaginal discharge, simple and extended colposcopy,histological investigation of cervix uterus tissue bioptates were done.Antibiotic therapy in combination with an isolated effect of short-wavetherapy on biologically active acupuncture points was sued.Results: There were no die effect in patients after short wave therapy.In 33.3% of cases initial transformation epithelium was demonstrated. In37.8% cases the ectopic area decreased because of the extension oftransformation and formation “lingualae” zone mainly on the back lip ofcervix uterus.By the 8th week from the beginning of treatment full epithelization wascolposcopic diagnosed in 42.7% patients, in 32.4% of them stratifiedpavement epithelium was unripe, that demonstrated in segments withnegative or feebly positive Shiller test.In 12 weeks full epithelization took place in 47.1% cases, in 36.8% ofthem Shiller test was positive. The treatment hasn’t brought positiveoutcomes in 6(8.8%) cases.Conclusions: It is possible to explain obtained outcomes by modulatingeffect of electromagnetic millimeter wave range on natural processes ofstratified pavement epithelium transformation. If there is andinflammation in a combination with antibacterial treatment, the short-wave therapy stimulates initial processes of stratified pavementepithelium regeneration and promotes decreasing of inflammatoryresponses in tissues.
P3.02.08POSSIBLE TRIAGE SOLUTION FOR EQUIVOCAL PAPSC-L.Chang , Y-C. Yang, S-Y.Wang, C-C.Wu, Mackay MemorialHospital, No 92, section 2, Chung-Shan North Rd, Taipei, Taiwan, 105.
Objective: The reported frequency of high-grade CIN in equivocal Papsmears has been more than 10%. But testing for HPV as a triageproposal is still debated. In this study we try to use the alteration ofmicrosatellite patterns predicting the clinical outcome of this wide-ranged population. Study Design: Patients with cytologic ASCUS whowere followed periodically and have a conization as final outcome wereenrolled. The exfoliated cells in initial cervical swab were subjected tocompare with the normal stromal cells in paraffin-embedded tissue ineach case by their microsatellite patterns.
WEDNESDAY, SEPTEMBER 682
Methods: PCRs with 5 pairs of primer labelled with fluorescence(D3S1110, D3S1228, THRB, D3S1289, D6S291) was done using DNAextracted from exfoliated cells and control stromal cells. The size andnumber of PCR products were relatively defined by GeneScan. Ratiobetween two allelic bands was compared between normal and tumorcells to determine the loss of heterozygosity (LOH). RESULT: LOH oralteration in one locus and two loci as a marker for HISL showed 82.2%and 64.7% in sensitivity, 74.1% and 91.6% in positive predictive value,61.5% and 92.4% in specificity and 72.7% and 66.7% in negativepredictive value, respectively. Conclusion: Microsatellite alteration as apossible triage for equivocal Paps is better than HPV testing.Pathologically it is more related to late event in carcinogenesis ratherthan early event involved by HPV.
P3.02.09RETROSPECTIVE ANALYSIS OF MULTIPLE PRIMARYMALIGNANT TUMORS (MPMT): GENERAL CHARACTERISTICSAND PRINCIPAL ASSOCIATIONS.M.A. Gonçalves , A.L.Pinto, F.Savoy, F.Laginha, Hospital PérolaByington, rua Bergamota, 470/121A, São Paulo, Brazil, 05468-000.
Objectives: This work seeks to study Multiple primary malignant tumors(MPMT) focusing the main associated neoplasms, distribution accordingto time interval occurrence and, epidemiological characteristics ofaffected population.Methods: Twenty women harbouring MPMT attending on OncologyService of Hospital Pérola Byington from 1983 to 1999 were studied.Neoplasms were classified according to their occurrence as sincronic(till 6 months interval between tumors) and metacronic (more than 6months interval among tumors occurrence). Tumors with similarhistological features were excluded from the analysis. The followingepidemiological characteristics were considered: age at the time oftumors diagnosis; neoplasm interval; parity; menopausal status.Results: From the total of neoplasms analysed, 19/20 (95%) was adouble association and 1/20 (5%) was a triple one. Fifty per cent wassincronic and 50% metacronic. Breast-ovarian was responsible for 20%of associations, (75% metacronic, 25% sincronic); breast-cervix for 20%(100% metacronic); breast-endometrium for 15% (100% sincronic);endometrium-ovarian for 10% (100% sincronic); cervix-ovarian for 10%(50% sincronic, 50% metacronic) and others for 25%. Age at the firstneoplasm diagnosis ranged from 34 to 81 years old (median 60), at thesecond diagnosis was from 38 to 81 (median 62.2) and, at the third onewas 71 years old. Considering metacronic tumors, diagnosis intervalvaried from 1 to 13 years (median 5.2). Parity ranged from 0 to 16deliveries (median 2.8). At the moment of the first tumor diagnosis, 75%of patients were at menopausal status.Conclusions: The most freqüent organ involved in multiple tumors wasthe breast, in 55% of cases, probably due to embriologic or commometiologic factors. Menopause seems to be directly related to MPMTappearance, thus, as a routine, it is very important to screen allmenopausic women harbouring a breast neoplasm, for a secondsincronic or metacronic tumor.
P3.02.10ROLE OF INTRAVAGINAL ISO SORBIDE MONONITRATE INCERVICAL RIPENING PRIOR TO 1ST TRIMESTER MTPV. Agrawal , T. Batham, N. Jain, R. Agrawal, Dept. OB/GYN, G. R.Medical College, Gwalior, India.
Objectives: The aim of the aim of the study is to evaluate the adequacyand side effects of pre treatment of intravaginal 40 mgm iso-sorbidenominitrate to ripen the cervix before first trimester termination ofpregnancy.Study Methods: One hundred women scheduled for first trimestersurgical termination were assigned to receive 40 mgm iso-sorbidemononitrate per vaginum 1/2hr. before surgery. Results were comparedwith women who received Inj. Prostodin 3 hrs. before surgery.Results: The study reveals that more women remained symptom freeafter iso-sorbide monosorbitrate that Inj. Prostodin (4/100 vs 53/100).Pre treatment with Prostodin resulted in abdominal pain in 25%, nausea8%, vomiting 12%, diarrhoea 2%, whereas women developed headacheafter iso-sorbide mononitrate 4%. Cervical resistance was lower inProstodin group than iso-sorbide mononitrate achieved 7.8 mm wholewith Prostodin 8.48 mm. Intraoperative blood loss was lower after pre
treatment Prostodin but no effect was observed after iso sorbidemononitrate.Conclusions: Vaginal administration of the nitric oxide donor iso-sorbide mononitrate can induce effecting ripening of human cervix.Women remained symptom free after it except in 4% women developedheadaches.
P3.02.11STUDY OF THE GLANDULAR ENDOCERVICAL EPITHELIUMCELLS FROM POST MENOPAUSED WOMEN RECEIVINGHORMONAL REPLACEMENT THERAPY COMPARING AMORPHOLOGIC ANALYZES WITH PCNA IMMUNOEXPRESSIONMarcos Ymayo , J. Robalta, J. Focchi, J. de Lima. Escola Paulista deMedicina - Federal University of São Paulo, Av. Brigadeiro LuizAntonio, 2819 #8d, São Paulo, Brazil, 01401-902.
Objectives: This study was undertaken to develop objectivemorphometric data on the cells of glandular epithelium collected frompost menopaused women receiving hormonal replacement therapy(HRT). We analyzed the following outcomes: nuclear(NA) and cellulararea(CA), nuclear(ND) and cellular major diameter(CD), nuclear(NV)and cellular volume(CV), epithelium thickness(ET) and PCNAimmunoexpression (PCNA).Study Methods:10 cases with a mean age of 62.8 years were selected atThe Federal University of São Paulo – Escola Paulista de Medicina -Ambulatory of Colposcopy . The oral HRT, was done with 0.625mg ofconjugated estrogen for 28 days and 5mg of medroxyprogesteroneacetate from the 14th to 28th day, which one had been exposure for atotal of 84 days. Biopsies samples were obtained from the endocervix onday 0, 28, 56 and 84. The morphometric and PCNA data were analyzed .Results were statistically analyzed by descriptive parametric tests forthe comparison of the means.Results: The results for each outcome from the absent of hormones toHRT 84 days is described: NA from 40.74 to 61.44mm2 (p<0.001), NDfrom 10.91 to 12.70mm (p=0.010), NV from 52.29 to 68.00mm3(p<0.001), CA from 119.95 to 272.15mm2 (p<0.001), CD from 19.29 to37.64mm (p<0.001), CV from 125.99 to 294.20mm3 (p=0.003), ETfrom 17.50 to 33.64mm (p<0.001) and PCNA from 15.97% to 55.47%(p<0.001).Conclusions: The cells increased the areas, major diameters, volumesand epithelium thickness after 84 days of HRT. We observed positivePCNA higher than 50% after 56 days. The above average cellsmeasurements, in general, follow the positive PCNA raising, during thehormonal effects.
P3.02.12TAKING A SATISFACTORY CERVICAL CYTOLOGIC SMEARA. Baheiraei (1), N. Jamshidy (2), M. Noorian (2), M. Pourheidary (1),A. Mehran (3), Z. Khakbazan (3), Tehran University of MedicalSciences, Tehran, Iran.(1) Dept. Midwifery, Faculty of Nsg. & Midwifery(2) Dept. of Pathology(3) Dept. of Vital Statistics
Objectives: The aim of the study was to investigate the quality ofcervical papanicolaou smears by teaching pap smear procedure tomidwives.Study Methods: The study used a papanicolaou smear database of 1850specimens collected in health and treatment center in Semnan Provincein Iran. The proportion of pap smears with inadequate (absentendocervical cells), obscure and badfixation was determined before andafter teaching.Results: The number of smears before and after teaching of papsmearprocedure has been 950 and 900 sample respectively. Before teaching,of 950 smears, 3115 (33.16%) classified as unsatisfactory or satisfactorybut limited (19.58% inadequate, 9.68% badfixation, 3% obscuring ofcell specimens), after teaching of 900 smears (10.22%) were classifiedas unsatisfactory or satisfactory but limited (5.78% inadequate, 3.22%badfixation, 1.22% obscuring of cell specimens).Conclusion: Greater skill with smear sampling is associated with fewerunsatisfactory smears.
WEDNESDAY, SEPTEMBER 6 83
P3.02.13THE MANAGEMENT OF MILD CERVICAL DYSPLASIA DUE TOHPV INFECTIONM. Grigore , G. Costachescu, A.C. Anton, I. Lupascu, Dept. OB/GYN,University of Medicine, Iasi, Romania.
Objectives: The study is conducted in order to detect the appropriatemanagement of the mild dysplasia of the cervix caused by HPVinfection.Study Methods: In the period 01/02/97 to 01/01/99 we analyzed andtreated 75 cases of mild cervical dysplasia caused by HPV (humanpapiloma virus) infection. The diagnosis of mild dysplasia was posed bycitology combined with colposcopy and biopsy.Results: From those cases, 30 (40%) which had associated vulvar orvaginal HPV infection, underwent cervical local treatment with dia-thermocauthery and 45 (60%) cases were managed by expectancy. Theone year follow-up after the initial exam and treatment shoed nosignificant differences between the two groups of patients regarding therecovery after HPV infection.Conclusions: In spite of those results, we recommend local treatment ofall mild cervical dysplasia because of two reasons: cervical localtreatment enhance local immunity (making the local treatment of othersites of HPV infection like vulva or vagina not necessary any more) anddecrease the possibility of transmission of the disease during theintercourse (this way decreasing the possibilities of spreading the HPVinfection).
P3.02.14THE MEASUREMENT OF CERVICAL ECTOPY:COMPUTERIZED PLANIMETRY VERUS CLINICALASSESSMENTC. Morrison , P. Bright, I. Yacobson, C. Kwok, Z. Pan, E. Wong, FamilyHealth International, P.O. Box 13950, Research Triangle Park, N.C.,USA, 27713. P. Blumenthal, S. Zdenek, Planned Parenthood ofMaryland, 610 N. Howard St., Baltimore, M.D., USA, 21201
Objectives: To determine the reliability of cervical ectopy measurementsmade by computer planimetry and by clinical (visual) assessment.Study Methods: Women seeking contraceptive services at two healthcenters in Baltimore underwent a pelvic examination. After applyingacetic acid, clinicians rated the relative size of ectopy by directvisualization and took cervical photographs using a 35 mm camera. Twoindependent raters measured the absolute and the relative size of ectopyusing the digitized images and an analytic software program. Agreementlevels between raters, between multiple readings by the same rater, andbetween the two measurement methods were quantified using theintraclass correlation coefficient (ICC) and weighted kappa (k).Results: Intrarater agreement for computer planimetry measurementswas excellent for the absolute (ICC = 0.97; 95% CI 0.95-0.98) andrelative (ICC = 0.89 95% CI 0.85-0.92) size of ectopy. Interrateragreement for computer planimetry measurements was also very highfor the absolute (ICC = 0.83; 95% CI 0.76-0.88) and relative (ICC =0.85; 95% CI 0.79-0.89) size of ectopy. Agreement levels betweenclinician assessment and computer planimetry for the relative size ofectopy were moderate (k=0.48; 95% CI 0.43-0.53) but somewhat higherwhen limited to measurements by a single, experienced clinician.Conclusion: Measurement of cervical ectopy by computer planimetrywas highly reliable. Use of computer planimetry appears appropriate forevaluating the role of cervical ectopy in the acquisition of cervicalinfections. Clinical assessment of ectopy may be used whenmeasurement by computer planimetry is infeasible.
P3.02.15USE OF IMIQUIMOD 5% CREAM IN LOW GRADE CERVICALDYSPLASIAR.Chung Garay , L.Uribe, V.Moreno, D.Espinosa, Cervical DysplasiaClinic, 2380-5 Hildago Ave, Guadalajara, Jalisco, Mexico, 44150.
Objective: The aim of this study was to evaluate the safety and efficacyof intravaginally administered imiquimod 5% cream for the treatment oflow grade cervical dysplasia.Study Methods: Ninety patients with a cytological and histologicaldiagnosis of CIN I were enrolled in an open-label study. After a baseline
pap smear and colposcopy with biopsy, each patient applied 1 sachet ofimiquimod by tampon overnight, 2 times per week for 8, 10, or 12weeks. Repeat pap smear and colposcopy with biopsy were performed at8 and 12 weeks. Patients with other cervical or vaginal pathology wereexcluded.Results: After 8 weeks of treatment, 18/90 patients had negative papsmears and colposcopy with biopsies. An additional 26/90 patients hadnormal pap smears but were acetowhite positive. These patients weretreated for 2 more weeks. After 12 weeks of treatment, the 26 patientstreated for 10 weeks had normal test results and the remaining 46/90patients that were treated for 12 weeks also normalized. Almost everypatient experienced one or more adverse reactions, which includedvaginal and vulvar erythema (85%), erosion (25%), edema (20%), andburning (33%).Conclusions: The human papillomavirus is the primary etiological agentin external genital warts and cervical dysplasia/cancer. Imiquimod is animmune response modifier indicated for the treatment of external genitalwarts. Our data suggests that intravaginally administered imiquimodmay be an effective therapy for the treatment of cervical dysplasia.However, long term, prospective studies are needed to assess thepotential of this promising therapy.
P3.03 CESAREAN SECTION 1
P3.03.01AN ANALYSIS ON TIME-RESPONSE IN IMMEDIATECAESAREAN SECTIONG. Pandis , D. Gibb, Dept. of Women and Child Health, King’s CollegeHospital, London, UK.
Objective: The aim of the study was to examine the time-response fromdecision to delivery by immediate caesarean section.Study Methods: A computerised database search for 1998 identified allimmediate procedures. 50 obstetric records were reviewed withparticular interest in the assessment of decision to delivery time, numberof medical personnel involved in each assessment, neonatal outcome andmaternal morbidity.Results: The mean internal decision to delivery time was 27.9 minutes.37% of babies were delivered within 20 minutes. The mean internalassessment to decision time was 16 minutes with 72% of decisions beingmade within 20 minutes. This was independent of the number of doctorsinvolved in each case. Preterm delivered comprised 40% of cases with25% of them being <32 weeks. Mean Apgar score was 5.6 at 1 minuteand 32% of babies had a cord pH <7.15. Half of neonates requiredadmission and there was a correlation between need for admission andprematurity or low Apgar score at 1 min. Women spent an average ofseven days in the hospital. Postoperative pyrexia was evident in 30% ofcases, while half of the remaining women developed post-operativecomplications such as wound haematoma or pelvic abscess.Conclusion: Immediate caesarean section is associated with increasedneonatal and maternal morbidity. Delivery within 20 minutes fromdecision is a difficult but realistic aim. Possible causes of slow responseand potential time saving measures should be considered during the“second phase” (decision to delivery) of the overall response time(assessment to decision to delivery).
P3.03.02BREECH PRESENTATION - ANALYSIS OF MODE OF DELIVERYA. Havalda , B. Tibor, M. Borovsky, D. Mracnova, M. Korbel Dept.OB/GYN, Conenius University, Bratislava, Slovakia.
Objectives: The aim of the study was to analyze the mode of delivery ofbreech presentation in 1994 – 1998 in the Bratislava region, to determineneonatal mortality and morbidity in non-malformed singleton infantsdelivered in breech presentation and identify a possible correlationbetween outcome on the one hand, and mode of delivery, parity andbirth weight on the other.Study Methods: We analyzed 873 singleton breech deliveries of non-malformed infants in the Bratislava region between 1994-1998. Processand outcome measure: mode of delivery, gestational age, birth weight,congenital malformations, intrapartum death, Apgar scores and earlyneonatal death.Results: A total of 252 (28.9%) infants were delivered vaginally,extraction was used in 49 (5.6%) deliveries, 301 (34.5%) were delivered
WEDNESDAY, SEPTEMBER 684
by elective and 277 (30.0%) by emergency cesarean section. Infantsdelivered vaginally and by emergency cesarean section had higher ratesof mortality (intrapartum and early neonatal death) and morbidity (lowApgar scores) when compared to those delivered by elective cesareansection. 73% of all primiparas and 52.5% of all multiparas weredelivered by cesarean section.Conclusions: Vaginal delivery is associated with increased mortality andmorbidity.
P3.03.03CESAREAN SECTION (CS) WITH AUTOLOGOUSBLOOD/PLASMA TRANSFUSION (ABT/APT) CAN PREVENTPOSTPARTUM COMPLICATIONS.S. Chermnich (1), I. Mogilevkina (2), I. Knurov (1)1. Donetsk State Regional Center for Mother and Child Care, Donetsk,
Ukraine.2. Dept. OB/GYN, Donetsk State Medical University, Donetsk,
Ukraine.Objectives: To study the benefit of ABT/APT in elective CS patients.Study Methods: Two-hundred and forty-four elective CS patients wereincluded. ABT was performed in 150 pregnant women (I), APT in 34women (II). Homologous blood transfusion was used in 30 (III) and noblood transfusion in 30 (IV) women. 3-4ml per kg was collected in ABTpatients within 4-10 days before CS. 500-600ml of plasma was donatedin donor plasmapheresis in third pregnancy trimester. Coagulation,hematological and immunological indexes were studied.Results: We did not find any negative hematological and hemodynamicchanges after blood donation and plasmapheresis. No negativeconsequences were defined in fetus well being. Postpartum period inABT/APT patients was characterized by significantly higher levels ofHb (I – 109.9±3.1; II – 108.8±3.0 ; III – 105.2±3.2; IV – 98.6±4.1 g/l),Ht (I – 32.6±0.7; II – 32.8±0.6; III – 31.0±1.4; IV – 29.6±1.0 g/l),erythrocytes (I – 3.3±0.1; II – 3.2±0.1; III – 3.0±0.1; IV – 2.9±0.1 T/l),and IgG (I – 15.0±0.6; II – 15.0±0.5; III – 14.8±0.6; IV – 13.0±0.6 g/l).53% of group I and 55% of group II patients have had postpartumanemia (70% in group III and 80% in group IV). Puerperal infection wasidentified in 47% of group IV, 17% of group III and just 10% of group Iand 6% of group II patients.Conclusion: ABT/APT are safe procedures for mother and fetus.Positive hematological and immunological changes in ABT/APT groupswere accompanied by postpartum anemia as well as puerperal infectiondecline.
P3.03.04CAESAREAN SECTION- SAME PROCEDURE: THEN WHYDIFFERENT PRACTICES?M. Khaled . Dept. OB/GYN, Prince Charles Hospital, Merthyr Tydfil,CF47 9DT, UK.
Objectives: This retrospective study was to compare the practice ofCaesarean section in two nations to try and establish the possible reasonsfor the difference in practicesStudy Methods: The 1996 labour word records in the two selected units(one in UK and the other in the UAE) were studied in great detail. Dataincluded all relevant information in the two units.Results: Remarkable differences in the rates (19% vs 10%) andindications for both elective and emergency Caesarean sections wereidentified in both units. All these differences were statisticallysignificant. Maternal request, while being on the increase in the UK, it isgrowing in UAE. Previous Caesarean as an indication for repeatCaesarean noted to be significantly different in the two populations(42% vs 12%).Conclusions: Caesarean section rates and indication are different fromone unit ton another. There is a wide variation in the practice despitesame training. Population type is only one aspect but there are manyreasons for the differences. The need for local , national andinternational protocols is required to standardize practice. Regular auditwithin each unit is essential in improving the quality of care given
P3.03.05CESAREAN SECTION IN ECLAMPSIA AT A RURAL REFERRALCENTERT. Deka , H. Kalita, R. Deka, Nalbari Maternity Hospital, Nalbari,Assain, India
Objectives: The aim of the study was to investigate whether liberalcesarean section in eclampsia improves maternal & perinatal salvage.Study Methods: Fifty-five cases of eclampsia were included in the study,over a period of 4 years between Oct. 1995 to Oct. 1999. 30 weredelivered by cesarean section (Group A) and 25 cases were deliveredvaginally (Group B). Magnesium sulfate was the anticonvulsant andNifedipine was used as the antihypertensive. All the cesarean sectionswere performed under general anesthesia.Results:-Incidence of cesarean section in the present study is 54.5%-Fit recurrence with Magnesium sulfate anticonvulsant regime isminimal-Maternal mortality is less in the patients delivered by cesarean section(3.3%) in comparison to vaginal delivery (12%).-Fetal salvage could be improved by early resort to cesarean section.PNMR-10% vs. 28% in Group A & Group B respectively.Conclusions:-Magnesium sulfate is an effective anticonvulsant in eclampsia-A policy of “More section in eclampsia” has improved the maternal andperinatal outcome
P3.03.06CESAREAN SECTION INDICATIONS IN THE PERINATALCENTERN. Shpatusco , M. Shatalova, I. Mogilevkina, Dept. OB/GYN, DonetskState Medical University, Donetsk, Ukraine.
Objectives: To study indications for cesarean section in the perinatalcenter.Study methods: Retrospective cohort study of cesarean section caserecords had been performed at Donetsk Regional Center for Mother andChild Care in 1998. 366 cases (89.4%) were analyzed. All perinatalmortality cases were excluded.Results: Cesarean section rate was 20.7%. Among those, 86.1% (315)were at term, 13.7% (50) pre-term, and 0.5% (2) post-term.Hysterectomy was performed in 27 women (7.4%). Indications forcesarean section were divided into; mother’s - 291 (79.3%), and fetus’ -75 (20.7%). Mother’s indications included: contracted pelvis – 5 (1.4%);obstructed labor – 6 (1.6%); placenta previa – 4 (1.0%); placentaabruption – 19 (5.2%); previous cesarean section – 47 (13.2%); cervixdistocia – 2 (0.5%); delayed labor – 34 (9.3%); preeclampsia – 55(15%); common diseases – 101 (27.7%); others – 16 (4.3%). Fetus’indications included: hypoxia – 29 (8%); malpresentation – 33 (9.1%);cord prolaps – 3 (0.8%); IVF – 6 (1.7%); others – 4 (1.1%).Conclusions: Mothers’ indications were more often reason for cesareansection in the perinatal center. Among those common diseases werecrucial. Preeclampsia was the second one followed by previous cesareansection and delayed labor. To decline cesarean section rate, vaginaldelivery in both previous cesarean section and preeclampsia should bediscussed. Hysterectomy in cesarean section patients is still a matter ofgreat concern.
P3.03.07COAGULATION DISTURBANCES DURING CAESAREANSECTION (CS) AND THEIR PREVENTION BY INTRAOPERATIVETRANSFUSION OF AUTOLOGOUS FRESH-FROZEN PLASMA(AFFP)S. Hodoroja , R. Comendant, U. Topor, Dept. OB/GYN, State Medicaland Pharmaceutical University, Chisinau, Republic of Moldova.
The normal activity of anticoagulant mechanisms is essential inpreventing activation of clotting system during CS. This activation oftenprogress to disseminated intravascular coagulation with subsequentdevelopment of hemorrhagic, as well as thromboembolic complications.The objective of out study was to examine coagulation disturbancesduring CS in pregnants with high risk factors of bleeding orthromboembolism (repeat CS in Association with preeclampsia, placenta
WEDNESDAY, SEPTEMBER 6 85
praevia, grand multparity, obesity, gross varicose veins) and to asses theeffectiveness of AFC transfusion in their prevention.Study Methods: In 56 patients with above mentioned risk factorscoagulation parameters (fibrinogen, platelet count, APTT, thrombinclotting time, and antithrombin III activity (AT III) were measuredduring CS and the first 5 postoperative days.This group was compared with 58 patients who met the same criteria forhemorrhage and thromboembolism. In this group (II) in the III trimesterof pregnancy 600-900 ml of AFFP was collected by means ofplasmapheresis and used intaoperatively to restore coagulation inhibitorAT III and to stop depletion of clotting factors.Results: In the first group haemostasiological evidences of consumptioncoagulopathy detected at the end of CS (reduction of fibrinogen from4.2±0.23 g/l to 2.7±0.21 g/l and platelets from 240±7.6·10 /l to194±6.4·10 /l) were preceded by intraoperative reduction in AT IIIactivity (73.5±1.2%).In the second group, after intraoperative transfusion of AFFP and size ofAT III level to 86.4±2.2% (p<0.05) the consumption of coagulationfactors was stopped (fibrinogen – 3.84±0.36 g/l (p<0.05), platelets -216±9.1·10 /l (p<0.05).AT III activity >80% in these patients was detected during all the first 5postoperative days, while in the fist group AT III returned to normalvalues only on the fifth day after operation.Conclusion: Intraoperative transfusion of AFFP increases anticoagulantactivity, prevents coagulation disturbances during CS and be effectivelyused to reduce the incidence of hemorrhages and thromboemboliccomplications in patients with high risk factors delivered by CS.
P3.03.08COMPARATIVE ANALYSIS OF OWN MODIFICATION OFMISGAV-LADACH (MML) AND PFANNENSTIEL METHODS FORCESAREAN SECTION IN THE MATERIAL OF FETAL-MATERNAL MEDICINE DEPARTMENT PMMH-RI BETWEEN1994-1999P. Pawlowicz (1), J. Wilczynski (1), T. Stetkiewicz (2)(1) Dept. of Fetal-Maternal Medicine, Polish Mother’s MemorialHospital, Research Institute, Lodz, Poland.(2) Dept. of Gynecology and Menopause, Polish Mother’s MemorialHospital, Research Institute, Lodz, Poland.
Objectives: Comparative analysis of modification of Misgav-Ladach(MML) and Pfannenstiel methods for cesarean section in the material ofFetal-Maternal Medicine Clinical Department of PMMH-RI between1994-99.Study Methods: Study group consists of 242 patients. In all women fromthis group we performed cesarean section using modification of Misgav-Ladach method. Among all patients from control group (counting 285women) we performed cesarean section applying Pfannenstiel method.To analyze clinical postoperative course in both groups we took intoaccount several parameters.Results: Statistical analysis revealed that most of clinical postoperativecourse parameters had significantly better values in the study group inwhich we performed cesarean section using the modification of Misgav-Ladach method.Conclusions: The benefits of modification of Misgav-Ladach method,with less pain post-operatively and quicker recovery, are all a by-productof doing the least harm during surgery and removing every unnecessarystep. This method is appealing for its simplicity, ease of execution andits time saving advantage.
P3.03.09EFFECTS OF PHYSICIAN AND PATIENT PREFERENCES ONCESAREAN DELIVERYO.A. Olatunbosun , A. Ravichander, L. Edouard, R.W. Turnell, Dept.OB/GYN, Gynecology & Reproductive Services, College of Medicine,University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Objectives: Despite and overall cesarean delivery rate below the nationalaverage, a wide range of variation exists between individualobstetricians’ rates at Saskatoon Health District. Our objective was totest the hypothesis that physician and patient preferences influencedcesarean delivery rates. We evaluated the preventability of cesareandelivery to determine the contribution of physician and patient factors.
Methods: Retrospective analysis of data on 290 unselected patients whohad term primary cesarean delivery during a twelve-month period wasconducted. Eighty-four percent were residents of the district whereas theother 16% had been transferred from smaller health districts. Patientcharacteristics, indications for, and preventability of cesarean deliverywas assessed by reviewers who were blind to the identity of theobstetricians.Results: Overall, 66 (23%) of the cesarean deliveries were deemedpreventable: 41 (62%) of those cases were considered preventable bypatients and 25 (38%) by obstetricians. The preventable cesarean sectionrate was significantly higher in Saskatoon residents as compared to non-residents (24% vs. 13%; P< 0.05). The two main indications accountingfor preventable cesarean sections were breech presentation and dystocia.Conclusions: The choice of patients and individual obstetricians’ normalpractice appear to influence recourse to cesarean delivery. Addressingthe perspectives on breech presentation and dystocia by obstetricians forclinical management and by patients for their choice may facilitate theproper utilization of cesarean delivery.
P3.03.10FETAL SURVIVAL DESPITE UNRECOGNIZED UTERINERUPTURE RESULTING FROM PREVIOUS UNKNOWNCORPOREAL SCARM. Erman-Akar , Z. Yilmaz, O. Gökmen, Dept. OB/GYN, Zekai TahirBurak Maternity Hospital, Ankara, Turkey.
Cesarean scar rupture of a gravid uterus with unknown corporeal scar iscommon. Our case was a 35-year-old woman, gravida 2, para 1,presented at 38 weeks gestation. She was admitted to our hospital forroutine follow-up. She had no signs or symptoms of labor. However,eight hours after the initial examination, she came back to the hospitalwith signs of shock and acute abdomen. Immediately, she was referredto surgery. Intraoperatively, a complete rupture of the classical corporealincision was observed, but the fetus was enclosed within the anteriorlying placenta. The fetus was delivered with one minute apgar score 3and five minute apgar score 8.According to this case, we conclude that spontaneous uterine rupture ofthe classical uterine scar can be observed even without uterinecontractions. So women with the possibility of previous classical uterineincision should be delivered once fetal maturity is documented.Key words: uterine rupture, classical incision, fetal survival.
P3.03.11HYSTERECTOMY CAESAREAR. Ljubomir Ristic , P. Branislav, R. Goran, M. Ivana, M. Nemanja,Gynecology & Obstetrics Clinic, Belgrade, Yugoslavia.
The authors, in the paper, presented results of hysterectomies duringCaesarean Section at the Gynecology and Obstetrics clinic at Prishtina inthe period 1989-1998.During this period there were 3870 deliveries at the Gynecology clinicof which 7274 (9.84%) were with Caesarean Section.At the same period they were 73 cases (1.00%) Hysterectomy duringCaesarean Section. Authors analyzed the indications of hysterectomy:Abruptio placentae 7 (9.58%), Utery-placentae apoplexy 29 (39.72%),Placenta previa centralis 14 (19.17%), Placenta accreta 13 (17.80%),Ruptura utery completa post C.S. 6 (8.21%) and Atonio utery 4 (5.47%).The authors also show that the patients were operated in a very wickedcondition by reason of abundant bleeding, presentation of developedinfection and exhausted patients. Operative procedures presented a bigrisk with the intensive preoperative reanimation of patients, and the needof a surgeon with experience, and postoperative care.The results in this paper have shown that there were no seriouscomplications in the cases and there were no cases of mortality.
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P3.03.12OBESITY AT DELIVERY AND RISK OF CESAREAN SECTION: ATEN-YEAR EXPERIENCED. Czukerberg , E. Charles Lampley Jr., J. Blankstein, Dept. OB/GYN,Mount Sinai Hospital, Chicago, Finch University Health Sciences,Illinois, USA.
Objective: Obesity is a pervasive public health problem among womenin United States and is associated with significant excess of morbidityand morality.The objective of this study was to determine if women with obesity atdelivery are more likely to deliver by cesarean section compared to non-obese women.Study Methods: A search of all records of singleton deliveries of womenwho delivered only once a t Mount Sinai Hospital between January 1st
1987 and December 31st 1997 was done from the perinatal computerizeddatabase. The body mass index (BMI) at delivery (weight in kilogramsdivided by the square of height in meters) was calculated for eachrecord. Records with: a) missing or inappropriate height and/or weight,b)BMI<12kg/m2, c) age<11 and > 47 years old, and d) birth weight <500grams, were excluded. Obesity was defined as BMI³30 kg/m2 atdelivery. The relative risk of cesarean section of obese women comparedto non-obese was calculated.Results: Total 20,372 records met the inclusion and exclusion criteria.Only 291 records (1.4%) were previously excluded. Forty percent ofwomen (8,213) were obese at delivery and 60% were not (12,159). Thecesarean section rate for the obese group was 16.9% (1391) compared to9.6% (1178) for the non-obese group. The relative risk of cesareansection for obese women is 1.75 (95% confidence interval 1.63-1.88;P<0.00000001) compared to non-obese women.Conclusions: Obese women at delivery have almost twice the risk ofdelivering a singleton by cesarean section than non-obese women.
P3.03.13RISK FACTORS FOR CESAREAN SECTIONS.A.T. Essinger , A.A. Cunha, S.C. Machado, A.M.S. Catharino,Faculdade de Ciências Biológicas e da Saúde, Universidade IguaçuMaternidade, Escola, Universidade Federal do Rio de Janeiro, Rio deJaneiro, Brasil.
Objective: To identify the risk factors for cesarean section.Study Methods: Cross sectional study. From January 1st 1998 to May31st 1999, 3926 deliveries were observed at the Hospital Universitário(Universidade Iguaçu). The factors were those from the BirthCertificate: (maternal age, maternal education, number of prenatalappointments,sex, gestational age, multiple gestation).Results: The odds ratios were: sex OR=1.01 (CI 0.88-1.16); pre-term(22-36 weeks of gestational age) OR=0.98 (CI 0.70-1.36), reference 37and over weeks; multiple gestation OR=3.38 (CI 2.09-5.48); maternalage: adolescence (19 years) OR-0.56 (CI 0.47-0.67), late pregnancy(>=35 years) OR=1.53 (CI 1.21-1.94), reference 20-34 years; prenatalappointments: 1-6 OR=1.11 (CI 0.83-1.50), >6 OR=2.18 (CI 1.63-2.91),reference no prenatal care; education: fundamental OR=1.72 (CI 0.83-3.66), high school OR=2.60 (CI 1.25-5.52); university OR=5.64 (CI2.13-15.21), reference no education.Conclusions: The risk of cesarean section was associated with multiplegestation, late pregnancy, more than 6 prenatal appointments, and highereducation. The adolescence was a protective factor.
P3.03.14SURGICAL TREATMENT OF ATYPIC MYOMA OF THE UTERUSDURING PREGNANCYT.N. Senchakova , I.I. Levashova, L.S. Logutova, S.N. Buyanova,Moscow Regional Scientific Research Institute of Obstetrics andGynecology, Moscow, Russia.
Objectives: To define the optimum surgical technologies, tactics, pre-and post-surgery treatment of atypic myoma of uterus during pregnancy.Study Methods: We have performed myomectomy on 23 pregnantwomen with atypical nodes of various locations and sizes (16-19 weekgestation). At this stage of pregnancy placenta provides a lower risk ofmiscarriage. The peculiarities of handling such patients include: carefulperformance during surgery, meticulous hemostasis, optimal suturing,
pre- and post-surgery tocolythic therapy, monitoring the condition of thefetus.Results: None of the patients had miscarriages. No stillborns. Whileexamining the area of the uterus from which nodes had been removed,no pathological changes were found.Conclusions: The myomectomy in pregnancy patients must in optimalsize of gestation with tocolythic therapy. Delivery by cesarean section at38 weeks.
P3.03.15THE USE OF VACUUM EXTRACTOR IN CAESARIAN SECTIONS.N. Tripathy, Dept. of OB/GYN, S.C.B. Medical College, Cuttack,Orissa, India
Objective: As the C.S. rate is increasing and more elective C.S. arebeing done for liberal indications, the incidence of lhigh mobile head athe time of C.S. is very often encountered. It poses considerabledifficulty to the operator, the options available to him or her are toemploy fundal pressure and use considerable force to extract the head, orincrease the incision, or apply forceps which slips most often. Invariablythe incision gets extended and there is profuse haemorrhage. Vacuumextraction has got a lot of advantages over in a vaginal delivery. So theaim of the study is to evaluate the use of vacuum to deliver a difficulthead in C.S. delivery.Study Methods: This prospective study was carried out in 100 caseswhere a floating head was encountered. All were elective, single ton,term pregnancies. Thirty-five cases were delivered by vacuumextraction, 25 cases by wrigly’s forceps, and 40 cases by fundalpressure. They were matched for age, parity, foetal wt and S.E. status.The statistical analysis was done by Odd’s Ratio.Results: The failure rate with vacuum and forceps were 2.8% and 12%respectively. (OR -0.21) with no significant maternal injuries (16% withforceps, 7.5% with fundal pressure, none with vacuum. Haemorrhage (asubjective assessment) was more in cases of forceps. The face and scalpinjury was more in forceps, though the cephalohaematoma rate wasmore in vacuum as well as the maternal worry over chignon. (OR –3.7).Conclusion: The study has been made almost on a healthy population inthe best place, best time, in optimum ideal conditions and done by theconsultant. The series is small. A large no. of cases has to be done togive this instrument a place in C.S., In English Literature I could notfind any one adoptin the instrument in C.S.
P3.03.16VESICO-VAGINAL FISTULA: IS THERE A SHIFT INAETIOLOGICAL DETERMINANTS?E. P. Gharoro , C.O. Okonkwo, Dept of Obstetrics and Gynecology,University of Benin Teaching Hospital, Benin City, Nigeria
Background: The occurrence of VVF is universal but the causativefactor varies depending on the state of industrialization of the nation.Vesico-vaginal fistulas in the developed nation are rare but mainly occuras a result of gynecological operations or malignancy. However, theypresent a great challenge to the gynecologist.Objective: To investigate the localization and etiological factorsassociated with VVF at the University of Benin Teaching Hospital(UBTH) Benin, NigeriaMaterials and method: Records on 96 patients treated by the authors atthe gynaecological ward of the UBTH between January 1992 andDecember 1999 were analysed. Information extracted included data onsocio-biological, demographic, and obstetric event of the antecedentpregnancy. These were subjected to statistical analysis using appropriatesoftware.Results: The majority (92.7 %) of fistulas are obstetric in origin, while5.21% were due to total abdominal hysterectomy and 2.08% due to postirradiation for advanced gynecological malignancy. 53(55.21%) hadsome form of obstetric operative intervention (forceps or vacuumextract, and or Caesarean section). Caesarean section contributed23.96% to the total figure. Juxta-cervical fistula was the most frequent,next mid vagina and followed by vesico-uterine (32.98%, 24.47% and19.15% respectively).Conclusion: These findings have shown that obstetrics surgicalintervention by care providers is a major cause of VVF formation withparticular reference to Caesarean section in our environment today. The
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incidence of fistulas due to gynecological operations and malignancy ison the rise.
P3.04 CONTRACEPTION
P3.04.01A TWELVE MONTH EVALUATION OF CONTRACEPTION ANDBREAST FEEDING PATTERNS IN WOMEN FROM A LOWERSOCIOECONOMIC BACKGROUND IN THE SOUTHWESTERNUNITED STATESW. Volker , T. Layton, J Hazen, J. Wrightson, R. Hernandez, Dept.OB/GYN, University of Nevada, School of Medicine, Las Vegas,Nevada, USA.
Objectives: This study evaluated women who were patients of awomen’s clinic in Las Vegas, Nevada. This resident clinic offerscomplete obstetrical and gynecological care to all women withinsurance, on Medicaid, or with no insurance. The goals were to identifyand characterize these women, determine their breast feeding patterns,and evaluate contraception choice, compliance, satisfaction, and failurerates.Study methods: Retrospectively, 248 patients who were seen postpartumat their six week visit were identified. Of these, 101 women weresampled 12 to 14 months after their delivery date. Medical charts werereviewed. Patients were contacted by phone and information wasobtained from a standardized questionnaire.Results: The clinic serves primarily minorities: 52% Hispanic, 10%black, 4% Asian/other, and 34% white. 53% of these patients had noinsurance and 40% were on Medicaid. 78% of women received breastfeeding information postpartum. 59% chose to breast feed with anaverage duration lasting only 2.2 months. Contraception was begun by69% of women with 34% using OCPs, 23% Depo Provera, 12%condoms, and 9% underwent tubal sterilization. Failure rates weresubstantially high: 15% OCPs, 17% condoms, and 4% Depo Provera.Overall 11 of the 101 women were pregnant 12 months after delivery.Conclusions: In this predominantly minority, lower socioeconomicstatus population, these women breast feed for a very short period oftime and had a high failure rate on contraception entirely related to non-compliance.
P3.04.02CLINICAL EXPERIENCE OF CU-T380A IUCD INSERTED WITHIN12 HOURS AFTER ABORTIONM. Rocca , Dept OB/GYN, Shatby Maternity Hospital, Alexandria,Egypt.
Objectives: To assess the clinical performance of Cu-T380A IUCDinserted within 12 hours after evacuation of the uterus in cases of firsttrimester spontaneous abortion.Study Methods: Three hundred women who consented to use an IUCDafter abortion and have no contraindication for IUCD application had theCu-T380A IUCD inserted before they were discharged from the hospital(maximum 12 hours following evacuation of the uterus). All womenwere asked to come for follow-up visits every 3 months for the first yearafter the IUCD insertion.Results: 39 women did not attend for follow-up and were excluded fromthe study. No cases of uterine perforation or acute pelvic infection werereported during the IUCD application. After one year of use there wasone case of pregnancy and 5 cases of expulsion. 46 women reportedbleeding and pain and they were severe enough to necessitate removal ofthe device in only 14 cases. Twelve women opted to remove the IUCDbecause of the desire for another pregnancy. The continuation rate afterone year of application was 87.7%.Conclusions: IUCD insertion in the immediate post-abortion period is assafe and effective as the interval IUCD application. This contraceptiveoption should be available in all health care sites that offer the abortionservices.
P3.04.03EFFECTS OF TRIMONTHLY INJECTION OF DEPO-MEDROXYPROGESTERONE ACETATE (DMPA) ON HORMONALPROFILENR Melo , RM Burgos, LM Pompei, W Muniz-Oliva, WM Ariê, AZMelo, HW Halbe, JA Pinotti, Medical School of São Paulo University,Brasil
Objective: To study the effect of injectable contraceptive consisting oflong-acting progestin on hormonal profile.Methods: Forty-six DMPA-user patients were studied retrospectively(average age, 44.4 y). They used 150 mg of DMPA every 3 months ascontraceptive for at least 5 years (average use, 10.6 years). It was testedserum levels of FSH, LH, estradiol (E2), prolactine (PRL), testosterone(T), androstenedione (D4), dihydroepiandrosterone sulphate (DHEAS),T3, T4, TSH. One hundred and twenty six intrauterine-device-userwomen (IUD) (average age, 43.5 y), were the control group.Results: The mean values of the studied parameters are in the followingtable:Group FSH
IU/l
LH
IU/l
E2
pg/ml
PRL
ng/ml
T
ng/dl
D4
ng/ml
DHEAS
ng/ml
T3
ng%
T4
mcg%
TSH
mcIU/ml
DMPA 14.31 6.98 36.96 5.94 22.35 1.19 849.86 126.08 9.86 2.21
Control 13.46 9.66 86.00 7.61 30.05 1.26 975.45 123.58 9.92 2.48
The following parameters had differences with statistical significance:LH (p<0.05), E2 (p<0.001), T (p<0.01).Conclusions: Long-acting-progestin injectable had an important effecton sex steroids, with a very important decrease in E2 and a decrease intestosterone, being explained by central supression to release of pituitaryhormones, so it was expected that levels of FSH was lesser in DMPAgroup, what have not occurred. Other androgens (DHEAS and D4) wereless affected because their non-ovary production are more importantthan with testosterone. Prolactine was a little decreased, but the valueswere normal in both groups and without statistical significance. Thyroidhormones and TSH were not influenced by DMPA.
P3.04.04EFFECTS OF TRIMONTHLY INJECTABLE OF DEPO-MEDROXYPROGESTERONE ACETATE (DMPA) ON BONENR Melo , RM Burgos, LM Pompei, MTJ Sacilotto, W Muniz-Oliva, AZMelo, HW Halbe, JA Pinotti, Medical School of São Paulo University,Brasil
Objective: To study the effect of trimonthly injectable contraceptiveconsisting of 150 mg of depot-medroxyprogesterone acetate (DMPA) onbone mineral density.Methods: Forty-six DMPA-user patients were studied retrospectively.Their average age was 44.4 and they used DMPA as contraceptive for atleast 5 years (average use duration: 10.6 years). The dose of DMPA was150 mg every 3 months. Bone densitometry of lumbar spine andproximal femur was obtained of every patient in a Hologic QDR-4500Abone densitometer. The effect of DMPA on bone mineral density (BMD)of lumbar segment L1-L4, femur neck and total femur was studiedcomparing to a group of 126 intrauterine-device-user women (IUD),with average age of 43.5 years (control group).Results: The mean results of DMPA-group and control-group were:BMD of L1-L4 was 0.924 g/cm2 in DMPA group and 1.024 g/cm2 incontrol group, thus the DMPA group had a BMD 9.78% less thancontrol group (p<0.001). Femur neck had 0.829 g/cm2 of BMD inDMPA users and 0.889 g/cm2 in control, a difference of 6.75% inDMPA users (p<0.05). Finally, total femur had a BMD of 0.890 g/cm2
in DMPA group and 0.951 g/cm2 in control, so a difference of 6.52% ofBMD in DMPA group (p<0.05). The differences in all these parametershad statistic significance.Conclusions: The DMPA used as a trimonthly injectable contraceptivefor several years (at least 5) was associated to a lesser bone mineraldensity in lumbar segment and proximal femur than in control group.This fact may be explained by the inhibition of pituitary-ovarian axiswith reduction of ovarian steroids.
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P3.04.05EFFECTS OF TRIMONTHLY INJECTABLE OF DEPO-MEDROXYPROGESTERONE ACETATE (DMPA) ONCARBOHYDRATE METABOLISMNR Melo , RM Burgos, LM Pompei, WM Ariê, W Pinheiro, AZ Melo,HW Halbe, JA PinottiMedicine School of São Paulo University, Brasil
Objective: To study the effect of trimonthly injectable contraceptiveconsisting of 150 mg of depot-medroxyprogesterone acetate (DMPA) oncarbohydrate metabolism.Methods: Forty-six DMPA-user patients were studied retrospectively.Their average age was 44.4 and they used DMPA as contraceptive for atleast 5 years (average use duration: 10.6 years). The dose of DMPA was150 mg every 3 months. To evaluate carbohydrate metabolism, it wasobtained Quetelet's index, abdomen-gluteus ratio, glycemia, seruminsulin and glycoside-hemoglobin. It was used a group of 126intrauterine-device-user women (IUD), with average age of 43.5 years,as control to comparison.Results: The mean results of DMPA-group and control-group were:Quetelet's index was 27.79 in DMPA users and 27.41 in control group.Abdome-gluteus ratio was the same in both groups (0.94). Glycemia waslesser (92.13 mg/dl) in DMPA than in control (96.11 mg/dl), but it wasnormal in both groups (normal between 70 and 110 mg/dl). Seruminsulin was 15.24 mcIU/ml in injectable group and 15.65 mcIU/ml incontrol, but in both it was normal (less than 20 mcIU/ml). Finally,glycoside-hemoglobin was 6.06% in the study group and 6.18% incontrol group. The differences between the two groups, when present,had not statistic significance.Conclusions: The DMPA used in a trimonthly injectable form withdoses of 150 mg did not affect adversely the studied carbohydratemetabolism parameters.
P3.04.06EFFICACY AND SAFETY OF A LOW–DOSE MONOPHASICCOMBINATION ORAL CONTRACEPTIVE CONTAINING 100mgLEVONORGESTREL AND 20 mg ETHINYL ESTRADIOL INWOMAN 35 AND OVERA. DelConte (1), D. F. Archer(2),(1) Wyeth-Ayerst Research, St. Davids, PA, USA.(2) Jones Institute for Reproductive Medicine, Norfolk, VA, USA.
Objective: To evaluate the efficacy and safety of a low-dose, 21-daycombination oral contraceptive containing 100mg of levonorgestrel(LNG) and 20 mg of ethinyl estradiol (EE) in women 35 and older.Study Methods: Women (1,708) age 15 and older with regular menstrualcycles were administered a 21-day combination oral contraceptivecontaining 100 mg LNG/20mg EE for 3 years. The efficacy and safety ofthe OC was evaluated in a subset of 218 women age 35 and older.Results: During 3,859 cycles evaluated for efficacy, 1 pregnancyoccurred (Pearl index = 0.34). This is consistent with the Pearl indexescompiled from other studies with 100 mg LNG/20 mg EE (range 0.2 to0.9). Breakthrough bleeding (with or without spotting) occurred in11.3% of the cycles, and spotting alone occurred in 11.5% of the 3,859cycles evaluated. The two most common adverse events cited as reasonsfor discontinuation were hypertension (3% of subjects) and metrorrhagia(2%).Conclusions: Overall, the results of this study demonstrate that the low-dose, monophasic regimen of 100 mg LNG/20 mg EE offers effectivecontraception, acceptable cycle control, and good tolerability in womenage 35 and older.
P3.04.07EFFICACY OF MISOPROSTOL CERVICAL PREPARATION ANDMANUAL VACUUM ASPIRATION FOR EARLY SECONDTRIMESTER TERMINATIONSC.S. Todd , M.E. Soler, L.D. Castleman, M.K. Rogers, P.D. BlumenthalJohns Hopkins Bayview Medical Center, Baltimore, MD, U.S.A.
Objective: To determine the efficacy of using manual vacuum aspirationfor abortion up to 18 weeks gestation after cervical preparation withmisoprostol.Methods: Subjects were obtained from a case series of over 100 patientspresenting for dilatation and evacuation at Johns Hopkins Bayview
Medical center. 800mg of buccal misoprostol was given for cervicalpreparation. Dilatation and evacuation was then performed using manualvacuum aspiration primarily to remove amniotic fluid and placenta.Fetal parts were removed as necessary with appropriate forceps.Results: Complete abortion was effected in 100% of cases. No casesrequired resorting to an electric vacuum source. In all cases, the cervixwas adequately prepared to allow either the immediate introduction of asize 14 mm suction cannula or could be easily dilated to allow passageof same. Procedure time was not significantly different when manualvacuum source was used than that for procedures in which an electricvacuum source was used.Conclusion: Although manual vacuum aspiration (MVA) is known to besafe and effective for termination of pregnancy in the first trimester, thisreport indicates that it can also be safely and effectively used in 2nd
trimester procedures. This is important for settings where electricvacuum sources are either unavailable, unreliable, or cannotaccommodate the large bore equipment required for D&E procedures.Similarly, the use of misoprostol to provide cervical preparation, waseffective and offers an alternative in settings where laminaria are notavailable. MVA and buccal misoprostol should be more widelyinvestigated for this purpose.
P3.04.08EVALUATION OF LIPIDIC PROFILE IN TEENAGE LONG TERMUSERS OF ORAL HORMONAL CONTRACEPTIVEC. Guazzelli , P.C. Lindsey, F.F. Araújo, R.M. Santana, R. Mattar, M.Barbieri, L. Kulay Jr., Family Planning Service, Federal University ofSão Paulo, EPM, Brazil.
Objectives: In adolescence, the beginning of the association of factors ofrisk for cardiovascular diseases is frequently observed. In this period oflife important transformations occur, such as changes in food ingestionand physical activity habits, initiation to smoking, alcohol abuse and sex.Such modifications can have repercussions throughout life, the mosthazardous of which leads to arterosclerosis. Early commencement ofsexual activity combined with the frequent use of oral hormonalcontraceptives by teens has concerned specialists, mainly if used forlong periods. Oral hormonal contraception has widespread use amongteenagers because of its high effectiveness, facility of use and also due tobenefits related to the menstrual cycle, dysmenorrhea and acne. Bearingin mind the importance of this subject, we decided to investigate theeffects of monophasic combined OHC containing 30 mg ofetinilestradiol and 75 mg of gestodene over teenagers lipidic metabolism.Study Methods: 33 young women aged 14 to 19 years, users of OHC fora period of three years were evaluated. These parameters were analyzed:total cholesterol, HDL-C, LDL-C, VLDL-C, triglycerides, Castelli I andII risk indices. These exams were performed before starting OHC andone, two and three years after utilization of the method.Results: Statistical analysis showed an increase in total cholesterol,HDL-C, LDL-C, VLDL-C and triglyceride levels when compared to theinitial values of one, two and three years of utilization of OHC. Indeed,the averages didn’t exceed normal ranges. No significant statisticalvariation in Castelli I and II indices was found.Conclusion: The use of combined monophasic hormonal oralcontraceptive containing 30 mg of etinilestradiol and 75 mg of gestodeneover a period of three years causes an increase in total cholesterol levels,its fractions and triglycerides. These data emphasize the importance ofevaluation of lipidic profile before and periodically during the use ofOHC in order to get better follow-up and prevention of cardiovasculardiseases.
P3.04.09EVALUATION OF THE EFFECTIVENESS AND ACCEPTABILITYOF THE DIAPHRAGM AS CONTRACEPTIVE METHODNR Melo , RM Burgos, LM Pompei, ML Elluf, P Nicolau, LO Ramos,JA Pinotti, Medicine School of São Paulo University, Brasil
Objectives: To evaluate the contraceptive effectiveness and theacceptability of diaphragm.Methods: They were retrospectively studied 44 women that used thediaphragm as contraceptive method, and 84.1% used spermicide gelassociately. Everyone received exhausting orientation for correct way ofemployment of the method. The time of use varied from 10 to 121months (average: 45.3 months), being equal to 124.6 woman-years.
WEDNESDAY, SEPTEMBER 6 89
Insertion of the diaphragm happened between 5 and 180 minutes beforecoitus (average: 47.9 minutes) and removing happened between 6 and 18hours after (average: 8.3 hours). Results: There were 2 not-wantedpregnancies during the use. Therefore, the failure rate was of 1.61 per100 woman-years. Only 2 patients did not manage to learn how to usediaphragm (4.5%) and 4 ones did not like the method (9.1%). Sixwomen told to feel the diaphragm (13.6%), being uncomfortable to 5ones (11.4%). Two patients (4.5%) told discomfort during coitus and 11ones told the partner felt the diaphragm (25%), but only 5 of themreferred that there was uncomfortable (11.4%). Four women referredthat there was interference in the rhythm of the sexual relationship(9.1%), but just one told decrease of libido (2.3%). The use ofspermicide gel caused discomfort to 12 patients of 37 that used it(32.4%). Urinary symptoms occurred in 13 of 44 patients (29.5%).Conclusions: Diaphragm associated to spermicide gel is effective whenpatients received a good orientation. Patient and her partner'sacceptability is high.
P3.04.10IS THE INTRAUTERINE DEVICE APPROPRIATECONTRACEPTION FOR HIV-INFECTED WOMEN?C. Morrison , D. Weiner, C. Kwok, Family Health International, P.O.Box 13950, Research Triangle Park, N.C., USA, 27713C. Sekadde-Kigondu, S. Sinei, D. Kokonya, Dept. OB/GYN, Universityof Nairobi, Nairobi, Kenya
Objectives: The World Health Organization and the InternationalPlanned Parenthood Federation recommend against use of intrauterinedevices (IUDs) in HIV-infected women due to concerns about pelvicinfection and female-to-male HIV transmission. We investigatedwhether the risk of complications is higher in HIV-infected women thanin uninfected women in the 2 years following IUD insertion.Study Methods: 649 women (156 HIV-infected, 493 HIV-uninfected) inNairobi, Kenya who requested an IUD and met local eligibility criteriawere enrolled. We gathered information on IUD-related complicationsincluding pelvic inflammatory disease (PID), removals due to infection,pain or bleeding, expulsions, and pregnancies at 1, 4, and 24 monthsafter insertion by study physicians masked to participants’ HIV status.Cox regression was used to estimate hazard ratios (HR).Results: Complications were identified in 94 of 636 women returning forfollow-up (14.7% of HIV-infected, 14.8% of HIV-uninfected). IncidentPID was rare in both infected (2.0%) and uninfected (0.4%) groups.Multivariate analyses suggested no association between HIV-1 infectionand increased risk of overall complications (HR=1.0; 95% CI 0.6-1.6)adjusted for marital status, study site, previous IUD use, ethnicity, andIUD insertion problems. Infection-related complications (anytenderness, IUD removal for infection or pain) were also similarbetween groups (10.7% of HIV-infected, 8.8% of HIV-uninfected;p=0.50), although there was a nonsignificant increase in infection-related complications among HIV-infected women with IUD use longerthan 5 months (HR=1.8; 95% CI 0.8-4.4). Neither overall nor infection-related complications differed by CD4 (immune) status.Conclusions: HIV-infected women often have a critical need for safeand effective contraception. The IUD may be an appropriatecontraceptive method for HIV-infected women with ongoing access tomedical services.
P3.04.11LONG TERM FOLLOW UP OF PATIENTS BEING STERILISEDUSING THE FILSHIE CLIP WITH LOCAL ANAESTHESIA IN AFAMILY PLANNING CLINIC SETTINGG. M Filshie , Dept OB/GYN, University of Nottingham, Nottingham,UK
The Family Planning Association Clinic, Nottingham, offered both maleand female sterilization procedures as well as contemporary familyplanning methods. This study recruited patients for female sterilizationfrom March 1982 to June 1992. During this time 464 patients werecounseled and 30 of these sere excluded. Of the 434 patients who wereoperated on, 278 have so far been followed up. 13 cases required generalanesthesia, 8 electively and 5 were transferred from local anaesthetic togeneral anaesthetic because of pain or failure of insufflation. Patientswere followed up by postal questionnaire or telephone consultation.Major problems included one shot-term failure due to miss-application
of a chip and one patient who received a small bowel injury followingthe insertion of the Verres needle. The procedure was acceptable to bothpatients and staff. The Methodology, intra partum findings andsubsequent surgery will be discussed.
P3.04.12SMOKING REDUCES THE EFFECT OF ORAL CONTRACEPTIVESE.E. Andreasen , K. Hindsoe, B. Andersen, Dept. OB/GYN, KoldingHospital, Denmark, Europe.
Objectives: The aim of the study was to investigate the use of oralcontraceptives among women referred to an induced abortion andcorrelated to their smoking habits.Study Methods: Prospective study of 854 women referred to inducedabortion, and all were registrated consecutively during 3 years.Results: The participation-rate was 97.3% = 831 women, and the rate ofsmokers = 51%. We found that 35% had used their contraceptivemethods in a regular way, but became pregnant nevertheless (group A).Another group of 33% had forgotten to use their contraceptives for a fewdays and became pregnant by an accident. The rest = 32% of the womendid not use any methods.In group A, 55 women had used oral contraceptives 100% correctly, andhere we found a rate of smokers = 87%, and this is significantly differentfrom the smoking-rate of 51% among the 831 women in the studypopulation.Conclusions: This study shows, that smoking reduces the effect of oralcontraceptives in a significant way (p<0.001 using the chi-square test).
P3.04.13TREATMENT OF DEPO-PROVERA CONTRACEPTIONCOMPLICATIONSV. P. Kvashenko , G. M. Adamova, I. L. Samarina, State MedicalUniversity, Donetsk, Ukraine.
Objectives: The aim of the investigation is to analyze the efficacy Dep-provera contraception (150 mg) for treatment of bleeding.Study Methods: 150 women aged 23-45 taken Depo-provera wereexamined. Women with bleeding during contraception were divided intotwo subgroups. In subgroup A women took tamoxifen 10 mg 2 times aday for 3-5 days, in subgroup B women took lo-femenal till bleedingsstopped. Treatment efficacy was evaluated by sonography, endometriumaspitate and volume of hemorrage.Results: Hemorrhage had 38 (25.3%) patients. Bleeding stopped in thefirst cycle in 4 (20%) women on the 2nd day of tamoxifen taking, in 10(50%) – on the 3rd day, in 4 (20%) – 4th day, in 2 (10%) – 5th day.Bleeding was jugulated in the next cycle in 7 (36%) women on the 2nd
–3rd day, in 1 (4%) – 5th day. Bleeding stopped in the third cycle in 1(4%) of women on the 2nd day of tamoxifen taking.In subgroup B bleeding stopped during the first cycle in 2 (11%) womenin three days of lo-femenal taking, in 12 (67%) -–in the 4-5 days, in 4(22%) the dose was doubled because of treatment non-efficacy.Bleeding was jugulated in the next cycle in 8 (44.5%) women byproscribing lo-femenal 1 pill a day, in 4 (22%) – 2 pills a day.Conclusions: Tamoxifen proscribing is effective for treatment ofbleeding by for Depo-provera contraception.
P3.04.14USE OF NORPLANT-6 IN IMMEDIATE POSTPARTUM PERIODAMONG ASYMPTOMATIC HIV-1 POSITIVE MOTHERSS. Taneepanichskul , C. Tanprasertkul, Dept. OB/GYN, ChulalongkornUniversity, Bangkok, Thailand.
Objective: To study the bleeding patterns of Norplant-6 contracetpiveimplants in immediate postpartum asymptomatic HIV infection.Study design: Prospective descriptive study.Setting: Family planning clinic, Dept. OB/GYN, Faculty of Medicine,Chulalongkorn University.Subjects: 98 immediate postpartum asymptomatic HIV infection womenwho had vaginal delivery at gestational age ³37 weeks or birthweight³2500 grams chosen for Norplant-6 subdermal contraception.Main Outcome Measure: After complete three months of use, weinterviewed about their bleeding patterns and other adverse effects.
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Results: Eight-eight women completed the study. Irregular bleeding,amenorrhea and regular bleeding occurred in 55 (62.5%), 29 (33.0%),and 4 (4.5%) women, respectively.Others adverse effects were headache (10, 11.4%) and weight gain (10,11.4%). No other serious side effects were found.Conclusion: Most of asymptomatic HIV infection women who usedNorplant-6 subdermal contraception immediately postpartum hadirregular bleeding pattern in the first three months.
P3.05 ENDOMETRIOSIS
P3.05.01BLADDER ENDOMETRIOSIS - REPORT OF TWO CASESS.K. Lam , Department of Gynaecology, Our Lady of MaryknollHospital, Kowloon, Hong Kong SAR, China
Objectives: To report and review two cases of bladder endometriosisReport A 34 years old woman presented in 1990 with dysmenorrhoea.Laparotomy showed pelvic endometriosis, 4 cm right chocolate cyst andadhesions of the left fallopian tube and ovary. Rightsalpingooophrectomy (S.O.) was performed followed by a six-monthcourse of progestogen therapy. She has recurrent endometriosis of theleft ovary and total abdominal hysterectomy and left S.O. was performedin 1992. Premarin was given subsequently for hormone replacement.She complained of non-cyclical haematuria in 1998 and cystoscopyshowed a 1 cm papilloma over the posterior wall of bladder. Biopsyconfirmed endometriosis. Hormonal replacement was stopped andtransurethral resection of the endometriotic nodule was performed.Repeat cystoscopy three months later showed no recurrence andhormonal replacement was restarted. She remained asymptomatic tillnow.The second patient 34 year old presented with dysuria one day beforeand one day after the period; there was no haematuria. In view of the co-existing dysmenorrhoea, laparoscopy was arranged. There was onlyminimal endometriosis over the left pelvic peritoneum. Cystoscopyshowed a small patch of pinkish white flat submucosal lesion 0.5 cm atthe trigone, likely to be endometriosis. Biopsy was not taken. Medicaltreatment was discussed but patient was reluctant and finally defaultedfollow up.Conclusion: Bladder endometriosis is rare and a high index of suspicionis required for diagnosis.
P3.05.02CAVATERMÔ ENDOMETRIAL ABLATION, UTERINETEMPERATURE DISTRIBUTIONB. Friberg , Dept. OB/GYN, University Hospital, Lund, Sweden.
Objectives: CavatermÔ is a method for endometrial destruction bythermal coagulation. Before a new method is employed as a form ofclinical routine treatment, it is important to know that it is safe.Study Methods: First, experimental studies were performed. Thereafter,since August 1993, the treatment has been used in our department. Wehave treated more than 230 out-patients.Results: No thermal effects on the outer uterine surface or on adjacentorgans were found. There have been no immediate preoperativecomplications. In the first 60 women treated we performedmeasurements of balloon mean surface temperature and cervical meantemperature. Balloon mean surface temperature was 73.0 (range 55.0 –84.8)°C. Cervical mean temperature was 40.7 (range 27.9 – 50.0) °C.Conclusions: A low mean temperature in the cervical region with its thinendometrium is essential in order to avoid thermal damage to the bladderwall. With the low mean temperature in the present series, where thetemperature exceeded 43°C in only 22% (13/60) of cases, and was above45°C in only one case, the risk of coagulation is low. Furthermore, thepart of the catheter running through the cervical canal is now insulated.We found the CavatermÔdevice safe for the patient.
P3.05.03CHARACTER OF LOCAL METABOLIC CHANGES IN FOCI OFENDOMETROID HETEROTOPIESL.V. Potapova , V.I. Grishchenko, N.A. Shcherbina, Dept. OB/GYN,State Medical University, Kharkov, Ukraine.
Objectives: Particularly interesting in the study of endometriosisdevelopment are problems of the control and regulation of localhomeostasis of tissues and mechanism of immune regulation.In this connection, the objective was to investigate the peculiarities ofmetabolic processes in endometrioid tissues and leukocytes of patients.Study Methods: The study was performed on endometrioid tissues andleukocytes of patients aged 22-47 with generalized forms ofendometriosis. Intensity of free-radical oxidation of lipids in tissues asan indication of tissue-destructive processes, as well as metabolicactivity of leukocytes was investigated.Results: In generalized forms of endometriosis, a reliable increase in thecontent of client conjugates and malone dialdehyde was observed, otherexamined parameters and lipid peroxidation (LPO) remaining withinnormal values and antioxidant activity (AOA) of tissue decreasing. Thedata obtained are indicative of development of chain reactions of free-radical oxidation, they becoming prevailing and uncontrolled by AOAsystem. Besides, activation of basic metabolic cycles and production ofcytotoxic forms of oxygene in leukocytes were observed.Conclusions:lationship of LPO and metabolism in tissues and leukocytesapparently creates conditions for development of endometrioidheterotopies.
P3.05.04COMPARISON OF LEPRORELIN VS. LYNESTRENOL INPATIENTS WITH ENDOMETRIOSISP.-A. Regidor (1). M. Regidor (1), G. Lubben (2), E. Kienle (2), P.Fortig (2), A.E. Schindler (1)(1) Dept. of Gynaecology, University of Essen, Essen, Germany.(2) Takeda Pharma Germany, Aachen, Germany.
Objectives: Comparison of leuprorelin acetate depot (LAD) 3.75 mgs.c./month vs. Lynestrenol (LYN) 5 mg p.o./b.i.d. regarding the efficacyand safety in patients with active endometriosis, r-AFS-score II-IV.Study Methods: Open prospective randomized single-center study.Results: For n=28 (LAD) and n=27 (LYN) patientsr-AFS-points
First look laparoscopy Second look laparoscopy Number of
progression
At diagnosis Post-operative At diagnosis Post-operative
LAD LYN LAD LYN LAD LYN LAD LYN LAD LYN
Means 31.4 34.1 21.9 24.5 10.6 23.7 3.8 8.5 1 8
+/- S.D 24.3 26.7 19.6 25.6 14.8 25.8 9.3 16.5
Change of dysmenorrhoea after 6 months of treatmentImproved No change Deterioration
LAD 23 4 -
LYN 14 13 -
Serum oestradiol levels of 28 LAD and 27 LYN patientsOestradiol level before
therapy
Oestradiol level after 3
months
Oestradiol level after 6
months
Pg/ml
LAD LYN LAD LYN LAD LYN
Means 94.33 87.09 26.69 27.69 27.4 41.14
+/- S.D. 74.27 72.43 8.98 16.02 9.06 53.06
Conclusions: Leuprorelin is obviously more effective to treat an activeendometriosis. The reduction of the r-AFS score is significantly higherin the LAD treated group (p<0.001, Mann-Whitney). A reliablesuppression of the oestradiol level in all patients will only be achieved inpatients treated with LAD. Improvement of dysmenorrhoea was morepronounced in the LAD group (p=0.017; U-test). Regardingendometriosis progressions LAD is more favorable.
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P3.05.05CORRECTION OF IMMUNE DYSFUNCTION INGYNECOLOGICAL PATIENTS BY LOCAL IMPULSIVEMAGNETIC FIELDS THERAPYO.N. Rogovaya , A.O. Khrebtov, Donetsk State Regional Center ofMaternity and Child Care, Donetsk, Ukraine.
Objective: The aim of the investigation is to study the local effect ofimpulsive magnetic field (IMF) as non-medicamentous procedure onseparate links of the immune system in patients with genitalendometriosis.Study Methods: 122 women aged 18-45 with genital endometriosis(main group – 76; compared – 46, control – 30 gynecological healthywomen).Cell immunity (CD3, CD4, CD8, CD22) and humoral immunity quotients(Ig G, A, M) were studied before, during and a month after thetreatment.Results: It has been stated that genital endometriosis is revealed in CD4,and CD8, suppression and CD22 activation, and also factors of humoralimmunity (on the whole, Ig M) in patients’ blood with I-II stages ofendometriosis in 1. 2 – 1.6 times, III stage – in 1.8 times, IV – 2.1.Immune status disturbances correlate with changes in hormonal systemdepending on disease duration. For magnetic therapy IMF is used. Itsplace is field of uterus and uterine appendage plus spleen projection,time – 15-20 minutes daily beginning on the 12-14th day of menstrualcycle.In comparison group treated with traditional hormonal therapy underdanazol influence the number of CD3 CD4, and CD8 is decreased andCD22 is increased.In main group treated with both hormonal and magnetic therapy,immune status improved, the number of CD3 is increased by 12-14%,CD4 – by 14%, and CD8, by 16%. CD22 is decreased by 12%. There wereno side effects.Conclusions: Magnetic therapy can be used for complex treatment ofpatients with endometriosis for the local effect on separate links of theimmune system.
P3.05.06EFFICACY AND SAFETY OF LONG-TERM LOW-DOSEDANAZOL IN WOMEN WITH ENDOMETRIOSIST. Adachi , A. Shionoiri, R. Saito, H. Ota, Dept. OB/GYN, TokyoWomen’s Medical University, Tokyo, Japan.
Objectives: The aim of the study was to investigate the efficacy and thesafety of long-term low-dose danazol for women with endometriosis.Study Methods: Fifteen women, aged from 28 to 46 years old, wereenrolled in this study with informed consent. Three had endometriosisafter hysterectomy, 11 had uterine adenomyosis and/or ovarianchocolate cysts, and the remaining one patient had pneumothoraxaccompanying her periods. Patients were started on 400 to 200 mg/dayof danazol for 8 weeks, and then maintained at 100 mg/day. The follow-up period ranged from 13 to 38 months, and the examinations, includinggynecological examination, pelvic ultrasonography, evaluation ofmenstrual cycles, symptoms during periods, serum hormone levels, bonemineral density (BMD) measured by DEXA, were made at 27.1±8.8months (M±SD) from the initiation of this study.Results: Every patient had less pain or relief from other deleterioussymptoms during periods. The size of the endometriosis decreased.Patients except those who had a hysterectomy had hypomenorrheicperiods; irregular cycles with genital spotting were often observed forthe first 3 months, followed by regular cycles of 25 to 40 days. Liverdysfunction was not observed. Relatively high E2, normal testosterone(T), low sex hormone binding globulin, and higher free-T were shown.BMD values, calculated by comparing with mean values of normalwomen at the same age, were represented as 101.3±10.3%.Conclusion: Long-term low-dose danazol for women with endometriosiswas effective and safe.
P3.05.07EMBRIOTOXICITY AND IMMUNOLOGICAL MODIFICATIONSFROM WOMEN WITH ENDOMETRIOMAS UNDER TREATMENTWITH GnRH ANALOGS AND rIL-2 LEFT INTRACYST.MJ. Gómez-Torres , I. Velasco, A. Campos, R. Bermejo, P. Acién. Dept.OB/GYN and Immunology, School of Medicine, “Miguel Hernández”University, Alicante, Spain. (Supported by FIS 97/0778).
Objectives: The aim of this study is to analyse modifications in theembriotoxicity of serum from women with endometriomas undertreatment with GnRH analogs and 600,000 IU of rIL-2 left intracyst, andthe correlations with the immunological parametres.Study Methods: Serum from 20 women with endometriomas wereanalyzed before, during and after treatment. Embriotoxicity assays ofserum were made with two-cell embryos CB6F1 of female mice.Lymphocyte populations (CD25, CD28, CD29, CD3, CD3-CD25, CD4,CD4-CD29, CD45, CD4-CD45, CD8) were analysed by flow cytometryand cytokines production (IL-1b, IL-2, IL-6, IL-8, IL-10, IL-12, IL-17)were evaluated by ELISA.Results: After treatment decreased the serum embriotixicity in thosepatients with whom rIL-2 was used. These women also had thecytokines productions and the levels of lynphocytes decreased, whilecells CD45 decreased significantly in patients who did not receive rIL-2.Conclusions: The rIL-2 left intracyst decreased serum embriotoxicity ofwomen with endometriomas and favoured the immunological response
P3.05.08EMBRIOTOXICITY OF PERITONEAL FLUID AND CYTOKINESPRODUCTION IN WOMEN WITH ENDOMETRIOSIS.MJ. Gómez-Torres , I. Velasco, A. Campos, P. Acién. Dept. OB/GYNand Immunology, School of Medicine, “Miguel Hernández” University,Alicante, Spain. (Supported by FIS 94/0478).
Objectives: Endometriosis is classically defined as the growth ofendometrial cells at sites outside the uterus. It is common diseasecharacterised by infertility, chronic pain and adhesion formation. Wehave assessed whether the peritoneal fluid from women withendometriosis is toxic to the mouse embryo early development in vitro.IL-6, IL-8 and INF-g well placed to play a key role in the extensivetissue remodelling required to accommodate menstruation, implantationand pregnancy.Study Methods: The subjects in this study were 42 women ofreproductive age undergoing laparoscopy for suspected endometriosis.Embriotoxicity assay of peritoneal fluid was made with two-cellembryos CB6F1 of female mice. IL-2, IL-6, IL-8 and INF-g in peritonealfluid were determined by ELISA.Results: Patients with high levels of cytokines in peritoneal fluid shownincreased embriotoxicity on embryo development, in all concentrationsused in vitro. This effect is dose-dependent (maximum toxicity wasobserved with cultures suplemented with 20% of peritoneal fluid), andwe suspect that can affect to cytokeratin expression.Conclusions: There is a inverse relationship between, low levels ofcytokines in peritoneal fluid and few embriotoxicity of this peritonealfluid, and fertility of patients with endometriosis.
P3.05.09EXPRESSION OF P450AROM GENE IN ENDOMETRIOTIC IMPLANTLOCATED IN POSTOPERATIVE SCARA.J. Jakimiuk, R. Tarkowski. L.P. Putowski. J.A. Jakowicki . Dept.Ob/Gyn, University School of Medicine. Lublin, Poland.
Objective: The expression of P450AROM gene in the scar after cesareansection and episiotomy.Methods: The total RNA and DNA were extracted simultaneously fromendometriotic samples. The P450AROM mRNA level was measured usingquantitative RT-PCR.The results were calculated per DNA content in the sample.Results: The expression of aromatase gene has been detected in allendometriotic implants collected from the scar after cesarean section,however, the values were lower than in proliferative (75 pg RNA/ugDNA ± SEM 31.6) and secretive (162.5 pg RNA/ug DNA + SEM 14.6)endometrium. In the five cases the expression values were within therange 4.4 - 30.8 pg RNA/ug DNA and in one case the level ofexpression was close to that observed in proliferative endometrium. In a
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53-year-old woman with regular menses and with low level of aromataseexpression the estimation of FSH (5 mlU/ml) and estradiol (120 pg/ml)excluded the menopause. The aromatase expression in endometrioticimplants located in the scar after episiotomy was 6.6 pg RNA/ug DNAin one patient and it was not detected in the other one. Low serumestradiol was observed in the second case.Conclusion: The aromatase gene is expressed in endometriotic implantbut its expression is much lower comparing to proliferative and secretiveendometrium.
P3.05.10KI-67 EXPRESSION IN THE ENDOMETRIUM OF HEALTHYWOMEN AND PATIENTS WITH PERITONEAL ENDOMETRIOSISV.A.Bourlev., S.V.Pavlovitch, N.I.Volkov, D.A.Stygar, Research Centrefor Obstetrics, Gynecology and Perinatology, Moscow, Russia
Objectives: The aim of the study was to investigate the expression of theproliferative marker Ki-67 in the endometrium of healthy women andpatients with peritoneal endometriosis in the different stages of themenstrual cycle.Study Methods: Expression of the proliferative marker Ki-67 wasevaluated in the stroma and glandular epithelium of endometrium from 6healthy women and 25 patient with laparoscopically confirmedperitoneal endometriosis. Serial 5.0 mkm sections of endometrium hadbeen performed and studied immunogistochemically using Ki-67monoclonal antibodies (Immunotech, Marseille, France). The laboratorypart of the investigation was carried out in the Department of Obstetricsand Gynecology of the Uppsala University, Sweden with scientificsupport of prof. B.Lindblom.Results: The percentage of Ki-67 positive cells in the stroma ofendometrium from healthy women elevated from proliferative to latesecretory phase. Expression of the marker in the gladular epithelium wasminimal in the secretory phase. In endometriotic patients Ki-67expression’ changes in the glandular epithelium were similar. Stromalmaximal expression of Ki-67 was in the early secretory phase, and was 2times higher than in healthy patients. In the late secretory phase Ki-67expression was significantly lower in endometriotic patients both in thestroma and in the glandular epithelium.Conclusions :Revealed changes in the proliferative activity in theendometrium of patients with peritoneal endometriosis indicate on theirpossible role in the pathogenesis of this pathologic condition.
P3.05.11POSSIBLITIES OF INSTRUMENTAL METHODS IN THEDIAGNOSIS OF ADENOMYOSISO.M. Nosenko , V.K. Chaika, I.V. Vasilenko, Donetsk State RegionalCentre for Maternity and Childhood Protection, Donetsk, Ukraine.
Objectives: The aim of the study was to investigate the possibilities ofinstrumental methods in diagnosis of adenomyosis on the basis ofcomparison of instrumental data of patients’ investigation andhistological investigation results of corresponding operative materials.Study Methods: 107 women were operated on for adenomyosis. Berforeoperation hysterography, transvaginal sonography, hysteroscopy andmiometrium’s hysteroscopic needle biopsy were carried out by thewhole patient. The sections of operative materials were studied throughlight microscope.Results: The informativity of hysterography has made 5.6%, sonography– 19.6%, hysteroscopy – 11.1% and miometrium’s hysteroscopic needlebiopsy – 50.0%. That kind of informativity we explained with thefollowing revealed histosructural features of adenomyosis:endometriotic lesions and glands in them with the sizes more than 1-2mm were met accordingly in 29.0% and 19.6% of cases; endometrioticglands of the round form were prevailed in endometriotci lesions; thecommunication of large tubular endometriotic glands gaps with uteruscavity was met in 5.6% of patients; “menstruate” endometriotic lesionswere met in 11.1% of supervisions; connective capsule around ofendometriotic lesions was absent in the whole cases; the combination ofadenomyosis with uterus myoma was met in 56.1% of cases.Conclusions: Low informativity of instrumental methods in thediagnosis of adenomyosis we connected with histostructural features ofthis pathology.
P3.05.12PREGNANCY COMPLICATED BY SPONTANEOUS RUPTURE OFUTERUS AND ENDOMETRIOSES AND OVARIANENDOMETRIOMAL.M. Lopes , R.A.M. Sa, I.B. Costa Jr., P.C. Gomes, P.R. Marinho, M.N.Ritto, A.L.M. Dourado, Dept. Maternal Fetal Medicine, LaranjeirasClinica Perinatal, Rio de Janeiro, Brazil.
Case Report: A 31 year-old Brazilian woman, gravida 1, Para 0, wasadmitted to Laranjeiras Clinica Perinatal at 26 weeks gestation with thechief complaint of mid-abdominal pain and vaginal bleeding. She hadbeen treated with b-adrenergic for preventing preterm labor 45 daysbefore admission.Physical examination revealed normal blood pressure and pulse. Thefetal heart rate was 146 bpm and the size of the uterus was consistentwith 26 weeks gestation. The significant laboratory findings included ahematocrit of 25% and hemoglobin of 8.2g/dl. A real-time ultrasoundscan showed fetal biometry consistent with 26 weeks gestation,oligohydramnios, and 05 myomas. Doppler of fetal circulation wasnormal.Nausea, vomiting, hypotension, abdominal pain and vaginal bleedingbegan 12 days before admission. The initial clinical impression wasabruptio placentae. Exploratory laparotomy was performed and uponopening the abdomen a sanguineous fluid was encountered. The uteruswas elevated and multiple myomas were seen. In the posterior wall(occupying the cul-de-sac) was a chocolate-colored tumor and a uterinedisruption. Both ovaries were adherent to the uterus with a chocolate-colored fluid-filled cyst measuring 15cm (on the left) and 20cm (on theright).She delivered by Cesarean a 2045g infant. Apgar 6. Hysterectomy andbilateral anexectomy was done.Histopatologic Observations: Uterine fibroids, adenomyosis and bilateralovarian endometrioma.Follow up: Both mother and infant did well one year later.
P3.05.13PSYCHOLOGICAL PECULIARITIES IN PATIENTS WITHENDOMETRIOSISL. Radzetskaya , A.Fomin, L.Suprun, Dept. OB/GYN, Vitebsk MedicalUniversity, Vitebsk, Belarus.
Objectives: The aim of this study was to investigate the psychologicalpeculiarities in patients with endometriosis.Study Methods: We used a modified Russian version of the MinnesotaMultiphase Personality Inventory (MMPI) and Spilberger’s test. Weexamined 54 patients with endometriosis and 23 controls.Results: We stated that patients with endometriosis had an elevatedMMPI profile. Scale 5(M-F) had the lowest value –56,91,5 T-scores.The scales 8(Sc), 6(Pa), 4(Pd) and 7 (Pt) reached to 70 T-scores andeven more (p<0.05). The scales 2(D) and O(Si) were higher than 65 T-scores (P<0.05). Scales of healthy controls were not higher than 30-60T-scores. The psychological alterations directly related to the severityand duration of disease. Psychological disadaptation was registered in allpatients with disease duration more than 6 years compared with only20% of women with disease duration less than 2 years. The patients withmild endometriosis had less than 4 peaks of maximum 65 T-scores. Thepatients with severe endometriosis had at least 5-9 peaks of maximum87 T-scores. MMPI profile did not depend on the endometriosislocalization. The state of high anxiety in the patients was confirmed byresults of Spilberger’s test too.Conclusions: MMPI test demonstrated that patients with endometriosiswere very anxious and had low possibilities of psycho-social adaptation.The results obtained allow us to assume a constitutional predispositionto forming the state of anxiety in such patients.
P3.05.14THREE-STEP THERAPY IN ENDOMETRIOSIS WITHDECAPEPTYL-DEPOTA. Keresztúri , J. Daru, S. Koloszár, Z. Borthaiser, A. Pá., Albert Szent-Györgyi Medical University, Dept. OB/GYN, Szeged, Hungary.
Introduction: The aim of the authors study was evaluate the relativesafety and efficacy of triptorelin (Decapeptyl-Depot, FERRING) asprimary treatment for endometriosis and obtain data about the ovarian
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and liver function during, and pregnancy rate in patients after thetreatment.Materials and Methods: The authors used the “gold standard” in themanagement of endometriosis caused infertility. A total of 30 womenaged 20-43 years (mean age, 28 years) had clinical symptoms ofendometriosis. At the initial laparoscopy the disease was stagedaccording to the American Fertility Society (AFAS) classification andthe lesions surgically removed or electrocauterised. During the 6 monthstreatment patients were followed at monthly intervals, the nafarelinadministered intranasaly everyday. The authors perform blood-samplingfor CBC, chemistry t hormone assay at pre-admission, at 3rd, at 6th and atthe 7th month of the treatment. The follow-up laparoscopy wasperformed within 6 weeks of the last GnRH administration. All the 30patients were followed up for at least an additional 6 months and thoseattempting pregnancy for another 6 months.Results: The serum oestradiol level decreased in the postmenopausallevel at the 3rd month of the treatment, and increased in the normal levelafter the 6th month treatment. No significant changes in the bloodchemistry. The pregnancy rates were 33% (n=10), there were 1spontaneous abortion and was no ectopic pregnancy. The GnRH analogeliminated dysmenorrhoea during the therapy, and significantlydecreased the dyspareunia. The pregnancy rates were 34% (n=35), therewere 4 spontaneous abortion and 1 ectopic pregnancy. Some of the sideeffects (hot flashes, night sweats, sleeping problems, headache,dizziness) reported during the tiptorelin treatment remained aftertreatment.Discussion :Nowadays, an attractive alternative method to treatendometriosis and preserve the fertility capability is the “down-regulation” of pituitary-ovarian function by means of GnRH superactiveagonists (GnRH-A), when the chemical alterations of the amino-acids atpositions 6 and 10 produce synthetic derivatives of GnRH, that resistcleavage by endopeptidases but retain a high affinity for the pituitaryGnRH receptor.Considering the high rate of spontaneous conceptions and the lowabortion and complication rates, the combined therapy of GnRHagonists followed by laparoscopy removal of endometriosis represents amajor step forwards in the effective treatment of sterility in patients withendometriosis.
P3.06 HIGH-RISK PREGNANCY
P3.06.01A COMPARISON OF THE EFFECT OF NIFEDIPINE ANDHYDRALIZINE IN TREATMENT OF PREGNANCY-INDUCEDHYPERTENSIONF. Yassae . Department of Obstetrics and Gynecology, TaleghaniHospital, Shaheed Behesht University, Tehran, Iran.
Objectives: The prevalence of hypertension during pregnancy and itssever complication led us to conduct the following study to compare thetherapeutic effects and side effects of nifedipine and hydralazine inpregnant women with preeclampsia.Study Methods: In this sequential randomized trial, 37 inpatientsreferred to Mahdieh Hospital in 1995 with a pregnancy over 26 weekswere studied. Preeclampsia was dignosed based on a blood pressure over140/90 mm Hg associated with proteinuria or generalized edema.Laboratory studies were conducted to differentiate sever preeclampsia. Ifblood pressure did not return normal after 24/48 hours resting, patientswere sequentially assigned to one of two randomized groups. One groupreceived 10mg nifedipine three times a day, and the other 10 mghydralazine three times a day. This regimen was continued untildelivery. Therapeutic effects were measured based on changes insystolic and diastolic blood pressure and termination of pregnancy, andthe side effects studied were flushing, maternal tachycardia, and severhypotension.Results: Nifedipine was given to 16 patients and the remaining 21received hydralazine. The two groups were statistically similar regardingeducation, ABO and Rh typing, number of fetuses, age, weight, height,and number of previous pregnancies. Both drugs reduced hypertension,but changes in blood pressure were not significant in the nifedipinegroup (-4.4 ± 13.8 and – 8.5 ± 16.8), while these changes werestatistically significant in the hydralazine group (-5.8 ± 7.1 and 9.6 ±11.2, P <0.001). No remarkable side effect or difference in the rate ofpregnancy termination was observed in the two groups.
Conclusion: We conclude that hydralazine is a better choice for thetreatment of pregnancy-induced hypertension.
P3.06.02AN ANALYSIS OF TEENAGE PREGNANCIES IN A TEACHINGHOSPITAL IN MALAYSIAH.H. Siraj , N.N. Ismail, Dept. OB/GYN, National University Hospital ofMalaysia, Kuala Lumpur, Malaysia.
Objectives: To study the extent of teenage pregnancies and theirobstetric outcomes in the Department of O&G, National UniversityHospital of Malaysia.Study Design: A cross-sectional study was designed to involve allpregnant patients under the age of twenty who delivered in the hospital(study group). Demographic data, antenatal and intrapartum progress aswell as the pregnancy outcomes were studied. The group was thencompared to a group of patients between the age of twenty to thirty-fourof age (control group).Results: Seventy-eight patients under the age of twenty were deliveredin the department throughout 1998. The incidence of teenage deliverywas 1.9%. Only one patient was under sixteen years of age. There weresignificantly more teenage pregnancies which were unbookedthroughout the pregnancy (neglected pregnancy), unemployed andunmarried. The proportion of Indian patients among the study group(14.1%) was significantly higher than in the control group (3.8%). Therewas no significant difference between the gestation at birth, mode ofdelivery, duration of labor and Apgar score of newborns between thetwo groups. However, the average birth weight of the newborns in thestudy group (2712 grams) was significantly lower than in the controlgroup (2975 grams), p<0.05.Conclusions: Older teenagers (age 16 and above) comprised the majorityof teenage deliveries in the department. The only significant poorobstetric outcome for the teenage pregnancies was the lower birthweight of the newborns. Although the study indicated that teenagepregnancies did not impose detrimental obstetric outcomes, it is obviousthat there are many social factors and difficulties that need to beaddressed and overcome.
P3.06.03ANTEPARTUM FETAL DEATH: OBSTETRICAL RISK FACTORS.E. Sheiner , M. Hallak, T. Oron, T. Silberstein1, I. Shoham-Vardi,M. Katz, M. Mazor. Dept Ob/Gyn and Epidemiology, 1SorokaUniversity Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
Objective: The incidence of antepartum fetal death (APFD) remainsunchanged during the past 12 years. The objective of the study was todetermine obstetrical risk factors for APFD.Study Design: Retrospective analysis of our perinatal database wasperformed. We included 68,870 singleton deliveries between the years1990-1997. Fetuses weighting less than 1000 gram at birth and thosewith structural malformations and/or known chromosomal anomalieswere excluded from the study.Results: The rate of APFD was 0.4% (246/68,870). The followingobstetrical factors were found to be significantly correlated to APFD in amultiple logistic regression model: High parity (OR=1.3, 95% CI 1.1-1.5), lower gestational age (OR=1.1, 95% CI 1.1-1.3), IUGR (OR=2.6,95% CI 1.4-4.8), gestational diabetes A2 (OR=2.3, 95% CI 1.1-5.0),oligohydramnion (OR=2.5, 95% CI 1.5-4.1), abruption placenta(OR=6.5, 95% CI 4.4-9.8) and meconium stained amniotic fluid (OR3.0,95% CI 2.2-4.0).Conclusion: APFD was significantly associated with IUGR,oligohydramnion, gestational diabetes A2, multiparity, pretermdeliveries, placental abruption and meconium stained amniotic fluid.These conditions should be carefully evaluated during pregnancy inorder to decrease the incidence of APFD.
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P3.06.04ANTIPHOSPHOLIPID SYNDROME, LONG-TERM TREATMENTWITH LOW MOLECULAR WEIGHT HEPARIN AND PREGNANCYOUTCOME.M.G. Genievskaya , A.D. Makatsaria. Department of Obstetrics andGynecology, Sechenov Moscow Medical Academy, Bolshaia,Pirogovskaya St.2/6, Moscow, 119881, Russia.
Thrombophilia and endothelial dysfunction plays crucial role in thepathogenesis of adverse pregnancy outcome in patients with APS.Pathogenically grounded therapeutic approach with minimum sideeffects, which is safe in outpatient base and convenient for patients, is tobe determined.Under our observation were 55 women with confirmed APS. Amongthem 8 patients with heart pathology – mitral regurgitation (1), aorticstenosis (1), mitral valve prolapse with regurgitation (5), artificial heartvalves (1). Previous pregnancy loss varied from 2 to 6 (10 patients failedwith other regimes). Lupus anticoagulant (LA) was assessed by diluteRussel Viper Venom Time (dRVVT) and APTT with plateletsneutralization procedure. ACL (anticardiolipin antibody) IgM and IgGwere detected by ELISA. 41 patients were positive for LA alone, 2 – foraCL (in diagnostic titters) alone. In 12 cases both LA and aCL weredetected. Increased level markers of thrombophiIlia such as TAT weredetected in 32 cases (58%), FDP in 15 cases (27,2%). Platelet’shyperactivation tests were positive in 30 cases (54%).Therapy included LMWH (Fraxiparine) alone from the moment ofpregnancy detection (26 cases) or first antepartum visit at 12-16 weeks(29 cases). Dose was 150 ICU/kg 1 time/day s.c. While on therapypatients demonstrated positive dynamic markers of thrombophilias,normal and even decreased platelets activation tests.Thromboprophylaxis with LMWH continued 7-10 days postpartum withswitch on oral anticoagulants or low dose aspirin. During observation nothromboembolic complications or fetal loss have been seen. No case ofthrombocytopenia occurred. Complications included preterm delivery(6), mild/severe preeclampsia (4/2), more prominent in group with lateonset treatment, slight vaginal bleeding at 6 week (1) and deep venousthrombosis postpartum in patient who refused oral anticoagulants due tobreast feeding.Early onset treatment with LMWH (Fraxiparine) due to its positiveinfluence on endothelium provides appropriate placenta development,reduces incidence of placenta insufficiency, IUGR and evenpreeclampsia and gives most promising results in APS pregnancyoutcomes.
P3.06.05BETHAMETASONE AS INDUCTOR OF FETAL LUNG MATURITYIN PREGNANCIES WITH LATE DIAGNOSIS OF GESTATIONALDIABETESVH. Ruz-Cervera, M. Ponce-Avila, JL. Garcia-Benavides, HospitalAngeles de las Lomas, Huixquilucan, Estado de Mexico, Mexico.
Objectives: The purpose of the study was to evaluate the clinicalevolution and rates of complications for patients with late diagnosis ofgestational diabetes who received bethametasone to induce fetal lungmaturity.Study Methods: We studied the cases of 23 patients with gestational agebetween 32-26 weeks and premature labor. Gestational diabetes wassuspected for the presence of fasting hyperglucemia. In those patientswas performed an oral glucose challenge test. Patients with negativelung maturity tests were metabolically stabilized, and afterbethametasone 12 mg/day (two doses) was administered to induce fetallug maturity.Results: There were no major medical neither obstetric complications isstudied patients. In 80% of patients insulin was applied as maximumduring these days after bethametasone treatment. On the other hand,only 13% of newborn babes develop mild respiratory distress.Conclusions: These data suggest that patients with late diagnosis ofdiabetes have a good prognosis when is performed an intensivetreatment metabolic disturbances. In controlled patients, bethametasonecan be used safely to induce fetal lung maturity.
P3.06.06BIOCHEMICAL PARAMETERS IN AMNIOTIC FLUID INPREGNANCIES COMPLICATED WITH INTRAUTERINEGROWTH RETARDATIONJ. Teliga , R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski,E. Romejko, K. Czajkowski, R. Szczecina Dept. OB/GYN, WarsawMedical School, Warsaw, Poland.
Objective: The aim of the study was to investigate fetal condition inpregnancy complicated with intrauterine growth retardation evaluatingfollowing parameters of amniotic fluid: glucose, bilirubin, total estrogenand human placental lactogen. There were also clouding test (absorption570nm), foaming test and lecithin/sphingomyelin ratio performed.Study Methods: 36 pregnant women with IUGR (the studied group) and72 women with eutrophic pregnancies (the control group) entered thestudy. The biochemical analysis of parameters listed above wasperformed.Results: All women were in the third trimester of pregnancy and therewas no significant difference in mean gestational age between studiedand control groups: 36.0±2.3 vs. 36.5±2.5 weeks respectively. Womenin the studied group verses control group showed followingconcentrations in the amniotic fluid: glucose 1.21±0.41 vs. 1.77±0.64micromol/l; p<0.001, biliruvin 2.91±1.54 vs. 1.50±0.72 micromol/l;p<0.001, total estrogen 2495±500 vs. 2749±769 nmol/l; NS, humanplacental lactogen 1363±502 vs. 1700±920 ng/ml; p<0.05, clouding test0.261±0.19 vs. 0.434±0.32; p<0.01, foaming test 2.4±1.5 vs. 3.0±1.4units; NS, L/S ratio 2.20±0.45 vs.2.30±0.45;NS.Conclusion: The decreased concentration of glucose in amniotic fluid ofthe studied group might be related to the acidosis and hypoxemia. Theevaluated concentration on the bilirubin, low value of clouding test andhuman placental lactogen in the amniotic fluid might suggest fetalimmaturity. Fetuses with IUGR showed maturation of the lungsadequate to the eutrophic ones.
P3.06.07CALCIUM THERAPY DURING PREGNANCY AND ITS EFFECTON BLOOD PRESSURE, SERUM CALCIUM, SERUM URIC ACIDAND PREGNANCY OUTCOMEZ. Arshad , Shilpa, J. Ahmad, N.A. Sabzposh. Dept. OB/GYN, J.N.Medical College, Aligarh Muslim University, Aligarh, U.P. India.
Objectives: To see if there is beneficial effect of oral Calcium Therapy(2gm/day) on blood pressure (B.P), serum calcium (SC), serum uric acid(SUA) and pregnancy outcome.Study Methods: Prospective study was conducted on 95 pregnantwomen. Thirty cases served as controls (gp-I) and 65 cases as studygroup (gp.II). Study was started at 16-20 weeks. All cases had normalB.P. at the start. Group-I was given 1gm and gp.II was 2gms of calciumper oral per day till delivery. Serum calcium, SUA were estimated at 16-20, 28-32 weeks and at term.Results: A significant fall in B.P was observed in gp.II primigravidae ascompared to primi- in gp.I. There was a fall in B.P in gp.IImultigravadae as compared to gp.I multi- but was not significant. Pre-ecampsia (PE) developed in 20% of gp.I and 6% of gp.II. At term serumcalcium level fell in gp.I (P< 0.001) and increased in gp.II (P< 0.001).Women who developed PE in gp.II had less increase in serum calciumlevels. SUA was lower at 16-20 weeks and increased in 3rd trimester inboth gps (P< 0.001). At term mean SUA levels in normotensive womenwere 3.68±0.51 and 3.5± 0.30 mg/dl for gp.1 and II (P<0.05) while PEcases it was 5.8± 0.06 and 5.65± 0.17 mg/dl for gp.I and II (P< 0.001).Intrauterine growth retardation was observed in 16% of gp.I and nil ingp.II, preterm births were 13% in gp.I and 4% in gp.II. Mean gestationalage at births was more in gp.II than in gp.I (P< 0.001). Mean birthweight of babies was more in gp.II. Anti-hypertensive therapy wasrequired in lesser number of PE cases of gp.II than gp.I.Conclusions: Two grams of calcium per day starting at 16-20 weeks ofpregnancy and given till delivery lowers B.P, Pre-eclampsia and serumuric acid. It increases serum calcium levels and improves pregnancyoutcome.
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P3.06.08CONSERVATIVE TREATMENT OF CERVICAL PREGNANCY:CASE REPORTSlobodan Arsenijevic , A. Zivanovic J. Djuric, M. Brkic, A. Dimitrijevic
The case of a 37-year-old woman presenting with cervical pregnancy isdescribed. The both sides of lateral isthmico-cervical part of uterus wasstitched by cremated catgut to temporary stop the circulation throughdescendent branch of artery uterine. Than the gestation sack is removedwithout incident.Key words: cervix, pregnancy, treatment
P3.06.09EVIDENCE FOR AN INTERRELATIONSHIP BETWEENPREGNANCY AND MYELODYSPLASTIC SYNDROMES INJAPANK. Shimizu , J. Ishii, H. Osada, S. Doi, O. Eguchi, T. Nishiwaki, S.Sekiya, Dept. OB/GYN, Chiba University School of Medicine, Chiba,Japan.
Objectives: Myelodysplastic syndromes (MDS) are a heterogeneousgroup of bone marrow disorders. We examined whether pregnancycould influence MDS.Patients and Methods: We retrospectively reviewed the charts of 1715patients (pts) who delivered between 1995 and 1999. We found 5 ptswith MDS, and compared these pts with 21 pts with MDS duringpregnancy reported previously in the literature.Results: 4 of the 5 pts (age 20-29) were diagnosed with MDS duringpregnancy. One pt was diagnosed as MDS derived from aplastic anemia,and another had a diagnosis of idiopathic thrombocytopenic purpurabefore pregnancy. All 5 pts in our review were defined as havingrefractory anemia without chromosomal abnormalities. All 5 pts showedboth macrocytic anemia and thrombocytopenia, with Hb8.3±0.6 gm/dLand PLT42200±9000/mm3. The anemia and thrombocytopenia(PLT<20000) was found in 3 of the 5 pts. Severe hypertension wasnoted in 2 of the 3 pts with severe thrombocytopenia. Although all 5 ptsclinically improved after delivery within 3 months, one pt developedthrombocytopenia and an increase of marrow blasts 4 months afterdelivery.Conclusions: The macrocytic anemia and thrombocytopenia beingresistant to treatment during pregnancy suggest MDS, and bone marrowexamination should be performed. The high incidence of severehypertension in those with severe thrombocytopenia underlines theimportance of aggressive management of MDS during pregnancy.Although the prognosis improved after delivery for our pts, furtherinvestigation is needed to evaluate the correlation between pregnancyand MDS.
P3.06.10EXAMINATION OF ADHESIVE MOLECULE EFFECT ONPREECLAMPSIA AND IUGRK. Nagahashi , T. Maemura, S. Kobayashi, R. Asami, M. Tanaka, H.Kubo, S. HirakawaDept. OB/GYN, Toho School of Medicine, Tokyo, Japan
Objective: It has been reported that some kinds of adhesive moleculesare participating to completion process of pregnancy and formation ofplacenta. We suppose that the adhesive molecules are also participatingto complete preeclampsia and Intra Uterine Growth restriction (IUGR).Count the adhesive molecules, using antibodies of them, and compare itto that of non-pregnancy and latter term of normal pregnancy cases.Study Methods: We use neutrophils stratum of blood samples ofpregnant women who complicate preeclampsia or IUGR. Cases whichcomplicate infection and malformation are expected.We measured the fluorescence quantity of CD11a, CD11b, CD11c,CD18 adhesive molecules, which specific to neutrophils, using FACscan (Becton Dickinson) and compare it to that of non-pregnancy andlatter term of normal pregnancy cases.Results: Fluorescence quantity which measured by blood samples ofpregnant women who complicate preeclamspsia (n=13) are 513.25 forCD11a, 498.62 for CD11b, 510.5 for CD18. And that complicate IUGR(n=16) are 468.6 for CD11a, 452.6 for CD11b, and 506.4 for CD18.These are significantly high rate compare to the cases of non-pregnancy(n=12) and normal pregnancy (p<0.01).
Conclusions: According to our experiment, it is expected that reactivatedneutrophils stick to hemagioendothelium cell through medium ofadhesive molecules and increasing production of activated oxygens andcytokine and that causes cell disorder, the basal pathologic physiology ofpreeclampsia and IUGR.
P3.06.11EXPRESSION OF PROTEIN THIOL/DISULFIDEOXIDOREDUCTASE FAMILY IN PREECLAMPTIC PLACENTAE. Shibata (a), K. Ejima (b), N. Toki, C. Koyama, M. Kashimura,(a) Dept. OB/GYN(b) Health DevelopmentUniversity of Occupational and Environmental Health, Kitakyushu,Japan.
Objectives: Recent studies have indicated that preeclamptic cases areaffected by an increased oxidative stress. We examined whetheroxidative stress is accelerated in preeclamptic placenta. Furthermore, weexamined an expression of protein thiol/disulfide oxidoreductase family,which is antioxidant system and plays a crucial role in the regenerationof oxidatively damaged proteins.Study Methods: Seven placentas from severe preeclamptic patients andseven placentas from normal cases were studied. First, to explorewhether oxidative stress is accelerated in preeclampsia, we examined theaccumulation of HNE (4-hydroxy-2-nonenal) – modified proteins, whichis a marker of oxidatigve stress, by Western blotting analysis. Second, toexamine protein thiol/disulfide oxidoreductases, we analyzed theexpression of thioredoxin (Trx), thioredoxin reductase (TR),glutaredoxin (Grx), and protein disulfide isomerase (PDI) by Westernblotting and immunohistochemistry.Result: Western blotting analysis revealed that the accumulation ofHNE-modified proteins was enhanced in preeclamptic placentas. Theexpression of Trx, TR, Grx, and PDI was also enhanced in preeclampticplacentas. Furthermore, these proteins were mainly localized introphoblast.Conclusions: Preeclamptic placentas showed an accelerated oxidativestress. Furthermore, as a protective mechanism, antioxidant family wasinduced in preeclamptic placentas. This study indicated that proteinthiol/disulfide oxidoreductases may play an important role to preserveplacental function against oxidative stress.
P3.06.12MAGNESIUM, CALCIUM, PHOSPHORUS AND RENALFUNCTION IN PREECLAMPTIC WOMENK. Czajkowski , P. Piekarski, E. Romejko, R. Smolarczyk, J. Wojcicka-Jagodzinska, J. Teliga, T. Maciejewski, 2nd Dept. OB/GYN, WarsawMedical School, Warsaw, Poland.
Objective: The effect of preeclampsia on calcium-phosphorus-magnesium homeostasis in the third trimester of pregnancy wasinvestigated.Methods: 38 women with preeclampsia (the studied group) and 30healthy women (the control group) entered the study. All women were inthe third trimester of pregnancy. Concentrations of calcium, phosphorusand magnesium were determined in the serum and diurnal urine. Thebiochemical assessment of renal function was also performed.Results: There was no significant difference in mean gestational agebetween studied and control groups (35.5±2.18 vs. 36.0±2.20 weeks).Women of the studied group presented blood pressure169.5±11/104±6.3 mmHg and proteinuria 4.72±2.17 g/24 hrs. Womenof the studied group versus control group showed the following serumconcentrations of: magnesium: 0.63±0.06 vs. 0.70±0.10 mmol/L,p<0.0001; total calcium 2.17±0.13 vs. 2.25±0.12 mmol/L, p<0.01;ionized Ca2+ 1.04±0.06 vs. 1.05±0.07 mmol/L, NS; inorganicphosphorus 1.62±0.17 vs. 1.31±0.22 mmol/L, p<0.001. The results indiurnal urine: magnesium 3.94±1.37 vs. 2.16±0.50 mmol/24 hrs,p<0.001; calcium 2.14±1.59 vs. 6.70±3.50 mmol/24 hrs, inorganicphosphorus 22±6.6 vs. 27.4±7.30 mmol/24 hrs, p<0.005; diurnal urinevolume 901±155 vs. 1265±450 ml/24 hrs, p<0.001; urea 5.18±2.35 vs.3.22±0.83 mmol/L, p<0.001; uric acid 40.5±9.04 vs. 19.0±3.6micromol/L, p<0.001, K+ 4.35±0.53 vs. 4.20±0.20 mmol/L, NS; Na+
140±1.7 vs. 138±3 mmol/L, p<0.01; Cl- 109±1.53 vs. 107±3 nmol/L,p<0.003. Acid-base balance: pH 7.40±0.036 vs. 7.420±0.025, p<0.05;pO2 11.01±1.61 vs. 11.34±1.06 kPa, NS; pCO2 4.43±0.38 vs. 4.26±0.41
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kPa, p<0.05; base excess –2.97±0.34 vs. –1.8±1.2 mmol/L, p<0.001,standard HCO3
- 21.5±0.99 vs. 23.0±1.2 mmol/L, p<0.001; total CO2
22.2±1.23 vs. 22.8±1.8 mmol/L, NS.Conclusions: There were marked disturbances in calcium-phosphorus-magnesium homeostasis observed in women with preeclampsia causeddue to renal function impairment: hypomagnesemia, hypocalcemia,hyperphosphatemia, hypermagnesiuria, hypocalciuria.
P3.06.13MAGNESIUM, CALCIUM, PHOSPHORUS AND RENALFUNCTION IN PREGNANT WOMEN WITH PRIMARYHYPERTENSION AND PROTEINURIAR. Smolarczyk , P. Piekarski, E. Romejko, J. Wojcicka-Jagodzinska, K.Czajkowski, J. Teliga, T. Maciejewski, 2nd Dept. OB/GYN, WarsawMedical School, Warsaw, Poland.
Objectives: The effect of primary hypertension with proteinuria oncalcium-phosphorus-magnesium homeostasis in the third trimester ofpregnancy was investigated.Methods: 22 women with primary hypertension with proteinuria (thestudied group) and 30 healthy women (the control group) entered thestudy. All women were in the third trimester of pregnancy.Concentrations of calcium, phosphorous and magnesium weredetermined in the serum and diurnal urine. The biochemical assessmentof renal function was also performed.Results: There was no significant difference in gestational age betweenthe studied and the control groups (36.3±2.28 vs. 36.0±2.20 weeks).Women of the studied group presented blood pressure 164±12/101±6mmHg and proteinuria 2.44±1.62g/24 hrs. Women of the studied groupvs. control group showed following serum concentrations of: magnesium0.65±0.085 vs. 0.70±0.10 mmol/L, p<0.05; total calcium 2.18±0.11 vs.2.25±.12 mmol/L, p<0.04; ionized Ca2+ 1.00±0.054 vs. 1.05±0.07mmol/L, p<0.05; inorganic phosphorus 1.63±0.11 vs. 1.31±0.22mmol/L, p<0.001. The results in diurnal urine: magnesium 3.29±0.76 vs.2.16±0.50 mmol/24 hrs, p<0.001; calcium 2.42±1.43 vs. 6.70±3.50mmol/24hrs, p<0.001; inorganic phosphorus 23.6±6.3 vs. 27.4±7.3mmol/24 hrs, p<0.05; diurnal urine volume 1330±426 vs. 1265±450ml/24 hrs, NS. Renal function parameters: creatinine 89.3±23 vs.66.3±4.4 micromol/L, p<0.001; urea 4.98±1.83 vs. 3.22±0.83 mmol/L,p<0.001; uric acid 36.3±9.5 vs. 19.0±3.6 micromol/L, p<0.001, K+
4.23±0.31 vs. 4.20±0.20 mmol/L, NS; Na+ 143±2.4 vs. 138±3 mmol/L,p<0.001; Cl- 110±1.8 vs. 107±3 mmol/L, p<0.001. Acid-base balance:pH 7.391±0.025 vs. 7.420±0.025, p<0.001; pO2 11.57±1.33 vs.11.34±1.06 kPa, NS; pCO2 4.67±0.28 vs. 4.26±0.41 kPa, P<0.001; baseexcess –3.41±1.5 vs. –1.8±1.2 mmol/L, p<0.001, standard HCO3
-
18.8±1.62 vs. 23.0±1.2 mmol/L, p<0.001; total CO2 21±1.41 vs.22.8±1.8 mmol/L, p<0.001.Conclusions: Marked disturbances in calcium-phosphorus-magnesiumhomeostasis in women with primary hypertension is related toproteinuria and renal function impairment.
P3.06.14MAGNESIUM, CALCIUM, PHOSPHORUS AND RENALFUNCTION IN PREGNANT WOMEN WITH CHRONIC RENALDISEASES AND PROTEINURIAR. Smolarczyk , P. Piekarski, E. Romejko, J. Wojcicka-Jagodzinska, K.Czajkowski, J. Teliga, T. Maciejewski, 2nd Dept. OB/GYN, WarsawMedical School, Warsaw, Poland.
Objectives: The effect of chronic renal diseases with proteinuria oncalcium-phosphorous-magnesium homeostasis in the third trimester ofpregnancy was investigated.Methods: 20 women (the studied group): 10 with chronicglomerulonephritis, 4 with chronic pyelonephritis, 1 with renalhypoplasia, 3 after reflux operation, 2 with nephrolithiasis and 30healthy women (the control group) entered the study. All women were inthe third trimester of pregnancy. Concentrations of calcium,phosphorous and magnesium were determined in the serum and diurnalurine. The biochemical assessment of renal function was also performed.Results: There was no significant difference in gestational age betweenthe studied and the control groups (36.4±2.61 vs. 36.0±2.20 weeks).Women of the studied group presented blood pressure 166±17/104±12mmHg and proteinuria 3.84±2.61g/24 hrs. Women of the studied groupvs. control group showed following serum concentrations of: magnesium
0.63±0.15 vs. 0.70±0.10 mmol/L, p<0.04; total calcium 2.19±0.11 vs.2.25±.12 mmol/L, NS; ionized Ca2+ 1.08±0.065 vs. 1.05±0.07 mmol/L,NS; inorganic phosphorus 1.55±0.21 vs. 1.31±0.22 mmol/L, p<0.01.The results in diurnal urine: magnesium 3.20±1.00 vs. 2.16±0.50mmol/24 hrs, p<0.001; calcium 2.34±1.56 vs. 6.70±3.50 mmol/24hrs,p<0.001; inorganic phosphorus 21.6±7.6 vs. 27.4±7.3 mmol/24 hrs,p<0.01; diurnal urine volume 1089±253 vs. 1265±450 ml/24 hrs, NS.Renal function parameters: creatinine 137.0±22.1 vs. 66.3±4.4micromol/L, p<0.001; urea 7.99±1.49 vs. 3.22±0.83 mmol/L, p<0.001;uric acid 41.05±11.3 vs. 19.0±3.6 micromol/L, p<0.001, K+ 4.85±0.41vs. 4.20±0.20 mmol/L, NS; Na+ 142±2.5 vs. 138±3 mmol/L, p<0.001;Cl- 109.2±2.1 vs. 107±3 mmol/L, p<0.001. Acid-base balance: pH7.350±0.028 vs. 7.420±0.025, p<0.001; pO2 11.04±1.33 vs. 11.34±1.06kPa, NS; pCO2 4.79±0.31 vs. 4.26±0.41 kPa, P<0.001; base excess–5.45±1.68 vs. –1.8±1.2 mmol/L, p<0.001, standard HCO3
- 18.8±1.62vs. 23.0±1.2 mmol/L, p<0.001; total CO2 19±1.51 vs. 22.8±1.8 mmol/L,p<0.001.Conclusions: Chronic renal diseases with proteinuria are related tohypomagnesemia, hyperphosphatemia, hypermagnesuria, hypocalciuria,hypophosphaturia.
P3.06.15PREGNANCY AFTER RENAL TRANSPLANTATION:EXPERIENCE IN SINGAPORE GENERAL HOSPITALP.K. Tan , V. Anantharaman, A. Tan, Dept OB/GYN, Dept of RenalMedicine, Singapore General Hospital, Singapore
Objectives: The aim of the study was to examine the overall outcome ofpregnancy after renal transplantation in Singapore General Hospital(SGH).Study Methods: 22 women whose pregnancies after renal transplantationwere jointly managed by the department of OB/GYN and Renalmedicine in SGH between December 1986 and November 1998, formedthe subjects of this retrospective study. Antenatal and postnatal details ofthe pregnancies for each woman were retrieved from their obstetric andneonatal records respectively.Results: Of the 34 post-transplant among the 22 women, 12 (35.2%)were unsuccessful because of 6 (50%) spontaneous miscarriages, 3(25.0%) therapeutic abortions, 2 (16.7%) ectopic pregnancies and 1(8.3%) stillbirth. The remaining 22 (64.8%) successful pregnancies werecomplicated by maternal anemia (63.6%), superimposed hypertension(45.5%), premature rupture of membranes (31.8%), urinary and lowergenital tract infections (22.7% each), abnormal glucose tolerance test(13.6%), premature delivery (45.5%), low birth weight babies (45.5%)and intrauterine growth retardation (22.7%). 19 (86.4%) of thepregnancies were delivered by caesarean section and 3 (13.6%) by thevaginal route. There were no documented cases of multiple pregnancies,congenital anomalies or intrapartum or postpartum deterioration of renalfunction.Conclusions: Successful pregnancy is possible in women after renaltransplantation. Such pregnancies are often associated with increasedmaternal and fetal morbidity and should be managed with amultidisciplinary approach in a tertiary center.
P3.06.16PREVENTION OF P.E.T.P. Paul , Dept. OB/GYN, Narishikshaashram Hospital, Silchar, India.
Objectives: The aim of this study is to prevent development of Pre-eclamptic Toxemia (P.E.T.)of pregnant women to reduce the morbidityand mortality of both mother and fetus.Study Method: 200 cases of primigravida of average wt and obese wereselected for the study. At every antenatal visit, urine R.E., W.T., B.P.oedema were recorded along with other routine exams. From thebeginning of pregnancy they were advised not to take butter, ghee, egg,milk, milk product, fried food, oily fish, fatty food, and use as little oil aspossible during cooking. Strict advice was given to drink 6 – 10 glassesof water daily. Medication was given liberally to prevent constipation,acidity, indigestion. In a few cases, women developed edema around 24– 30 weeks and were promptly treated with bed rest, reduction ofcarbohydrates and fatty foods in their diet. They responded well.Results: Not a single case developed high BP, albuminuria, or excessivegaining of WT.
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Conclusion: PET can be prevented with: a) dietary restriction of fattyfood, b) liberal intake of water, c) constipation or any discomfort in thebody may accelerate BP, thus precipitating toxemia.
P3.06.17PROPHYLAXIS OF THROMBOEMBOLIC COMPLICATIONS INPREGNANT WOMEN WITH VEINOSE INSUFFICIENCYN.V. Ordzhonikidze , B.L. Gurtovoy, Yu.V. Boykova.Research Center of Obstetrics, Gynecology & Perinatology RussianAcademy of Medical Science, Moscow
The objective of the study was to investigate the therapeutic efficacy ofthe angioprotective drug GINKOR FORT in treatment of varicosis of thelower extremities in pregnant women with infection of viral and/orbacterial etiology. Thirty patients in the III gestation trimester wereincluded in the study.It was found that administration of GINKOR FORT (2 capsules x 3times a day in the course of 30 days) provided elimination of varicosissymptoms, such as pain, heaviness, or discomfort in the lowerextremities, nocturnal paresthesia, and cramps in most patients (96.6%).Tissue edema was also eliminated, which was manifested as significantdecrease of medullar volume. Therapeutic effect of the drug wasachieved due to improvement of oxygen-carrying function of blood, aswell as rehabilitation of patients’ hemorheological status. Positivedynamics of blood circulation in popliteal artery, as well as in the bloodvessels of mother-placenta-fetus system, was also noted.Obviously, GINKOR FORT is an effective medication for treatment ofvaricosis in pregnant women in the III gestation trimester.
P3.06.18PROTEINS, LIPIDS AND RENAL PARAMETERS IN AMNIOTICFLUID IN PREGNANCIES COMPLICATED WITH INTRAUTERINEGROWTH RETARDATIONP. Piekarski , E. Romejko, R. Smolarczyk, J. Wojcicka-Jagodzinska, K.Czajkowski, R. Szczecina, 2nd Dept. OB/GYN, Warsaw Medical School,Warsaw, Poland.
Objective: The aim of the study was to evaluate metabolic changes inamniotic fluid in pregnancies complicated with IUGR and physiologicalones. The following parameters of amniotic liquid were investigated:total protein, albumin, total cholesterol, total fraction LDL, uric acid,urea, creatinine.Methods: Thirty-six pregnant women with IUGR (the studied group) and72 women with eutrophic pregnancies (the control group) entered thestudy. The biochemical analysis of parameters listed above wasperformed.Results: All women were in the third trimester of pregnancy and therewas no significant difference in mean gestational age between studiedand control groups: 36.0±2.3 vs. 36.5±2.5 weeks respectively. Womenin the studied group versus control group showed followingconcentrations in the amniotic fluid: total protein 4.3±1.5 vs. 6.0±2.5 g/l;p<0.001, total fraction LDL 0.241±0.109 vs. 0.450±0.334 g/l; p<0.001,albumin 23.18±4.35 vs. 42.02±10.14 micromol/l; p<0.001, totalcholesterol 0.21±0.08 vs. 0.25±0.23 mmol/l; NS, uric acid 79.1±29.1 vs.76.7±26.8 micromol/l; NS, urea 8.7±3.3 vs. 8.0±3.1 mmol/l; NS,creatinine 188.3±30.9 vs. 200.7±32.7 micromol/l; p<0.05.Conclusions: The lowered concentrations of total protein, albumin,LDL-cholesterol are noted in amniotic fluid in pregnancies complicated withIUGR. This might be an indicator of fetal malnutrition or immaturity.The decreased level of creatinine in amniotic fluid in IUGR mightsuggest a mild immaturity of fetal kidneys and/or might be related to thesmaller fetal creatinogenic muscle mass compared to eutrophicpregnancy.
P3.06.19SEXUAL BEHAVIOR AS AN ETIOLOGIC FACTOR OFPREGNANCY HYPERTENSIONE. Szabo , B. Kellner, Dept OB/GYN, Semmelweis Hospital,Kiskunhalas, Hungary
Objectives: The aim of the study was to focus on the exploration ofrelationships between gestational hypertension and the length of sexuallife, as well as the frequency and duration of sexual activity before theconception.Study Methods: Clinical data of 1010 successive patients managed,treated and delivered over a two-year period were collected fromobstetrical records and interviews made with the patients.Results: Gestational hypertension developed in 11.9% of nulliparous,4.7%in multiparous (with the same partners), and 24% amongmultiparous (women with new partners). Inverse relationship was foundbetween the sexual activity, duration of cohabitation and the incidenceof gestational hypertension (p<0.0001).Conclusions: The risk of developing hypertension is less dependent onnulliparity; rather, it is related to primipaternity. Repeated exposition tosperm antigens can lead to the evolution of a certain level of protectionagainst pregnancy hypertension. The presumptive role of repetitiveexposure to sperm antigens may influence the education of patientsduring preconceptional management.
P3.06.20SIGNIFICANCE OF DETECTION OF LUPUS ANTICOAGULANTAND THROMBOPHILIA MARKERS IN PATIENTS WITH MISSEDABORTION BEFORE [email protected]. Tsintsadze , N. Kamernitskaya, M.G. Genievskaya, A.D.Makatsaria, Dept. OB/GYN, Sechenov Moscow Medical Academy,Moscow, Russia.
Objective: Patients with missed abortion due to circulation of lupusanticoagulant (LA) have double risk of thrombotic complication afterD@C procedure as LA aggravate DIC and coagulation defects caused bylong embryo retention in utero.Study Methods: We studied 47 women with missed abortion beforeD@C procedure. 27 patients (57.4%) were positive for lupusanticoagulant (LA). Among them based on history of thromboticepisodes, fetal loss syndrome and/or thrombocytopenia antiphospholipidsyndrome (APS) was diagnosed in 21 cases (77.8%), 6 patients hadpositive LA without APS. Majority of patients with APS was under 30years old. 2 patients had missed abortion after IVF/ET.Results: Lupus anticoagulant (LA) was assessed by dilute Russell ViperVenom Time (dRVVT) and APTT with platelets neutralizationprocedure (Stago, France). Increased level markers of thrombophilliasuch as TAT were detected in 13 cases, FDP in 9 cases. Platelet’shyperactivation tests were positive in 13 cases.Therapy included infusion of fresh frozen plasma pre- and intra-operatively and low-doses heparin in post-op period for 7 days. Suchapproach prevented decompensation of DIC during D @ C andthromboembolic complications post-op.Conclusion: Detection of LA and thrombophilias markers in patientswith missed abortion allows to perform timely and adequate correctionof hemostasis defects and suggests appropriate management option forfuture pregnancy.
P3.06.21THE EFFECT OF HYPERVENTILATION ON MATERNALCEREBRAL BLOOD FLOW VELOCITY IN PREECLAMPTIC ANDNORMAL PREGNANCIES: IS THERE EVIDENCE FOR ANALTERED CEREBRAL VASOREACTIVITY?J. Zatik (1), T. Major (1), A. Jakrab (1), Z. Tóth (1), B. Fülesdi (2),University Medical School of Debrecen, Debrecen, Hungary.(1) Dept. OB/GYN(2) Dept. Anesth. and Intensive Care
Objectives: The purpose of the study was to investigate cerebralarteriolar vasoreactivity function in preeclampsia.Study Methods: Preeclamptic and healthy pregnant patients hadundergone transcranial Doppler sonography of the middle cerebral arteryat rest and after 60 seconds of hyperventilation (HV). Systolic, diastolicand mean blood flow velocities of the middle cerebral artery were
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recorded. The percent change of the blood flow velocities after HV wascalculated.Results: Mean blood flow velocity of the middle cerebral artery(MCAV) was higher in preeclamptic women as compared to healthypregnants. No difference could be detected in percent change of middlecerebral artery blood flow velocities after HV between the two groups.Conclusions: There is no evidence of small vessel vasoconstrictionamong preeclamptic patients. The role of vasoconstriction of the largecerebral arteries and vasodilation of the resistance arterioles as well as acombination of these two pathomechanisms in determining cerebralblood flow in preeclampsia and eclampsia has to be investigated infurther studies.
P3.06.22THE OPTIMIZATION OF CENTRAL HEMODYNAMICPARAMETERS IN PYELONEPHRITIC PREGNANT PATIENTSI. Nikolskaya , N. Mazurskaya, I Tkacheva, I. Shouginin, V. Shepatov,Moscow Regional Scientific Research Institute of OB/GYN, Moscow,Russia.
Objectives: The aim of the study was to investigate the centralhemodynamic parameters in 159 pyelonephritic pregnant womenwithout gestosis and the comparison of these characteristics to normalpregnant women. The parameters of blood circulation in 53pyelonophritic patients with gestosis were also compared to gestosispatients, but without pyelonephritis.Study Methods: The methods of echocardiography and impedancerheocardiography by Kubicvek were used.Results: The pyelonephritic patients without gestosis were divided intothree groups. I – 45 gestational pyelonephritis patients, II-61 chronicpyelonephritis patients III – 53 chronic pyelonephritis patients with otherrenal diseases (renal anomalies, hydronephrosis, urolitic disease, singlekidney after operation). In the I group the hemodynamics parameterswere the same as in healthy pregnant patients. In the II group theseparameters had tendention of angiospasm. The III group patients hadnon significant peripheral angiospasm. The 53 pyelonephritic patientswith gestosis had the most significant changes in their hemodynamicsparameters in comparison with gestosis patients without pyelonephritis.Conclusion: These changes may be explained by the decrease ofmyocardial contratilyty in pyelonephritic patients as the result ofinfection process. The use of metabolic therapy and Chofitol optimizedthe hemodynamics parameters and myocardial contractility.
P3.06.23THROMBOPROPHYLAXIS WITH LOW-MOLECULAR WEIGHTHEPARIN AFTER CESAREAN SECTION IN PATIENTS WITHANTIPHOSPHOLIPID SYNDROME (APS)S.G. Ismailova , V.O. Bitsadze, A.D. Makatsaria, Dept. OB/GYN,Moscow Medical Academy, Moscow, Russia.
Objectives: APS – an acquired thrombophylic state provided by thecirculation of antiphospholipid antibodies (AA). It can be the cause ofthrombotic event in patients, especially after cesarean section, which initself is the high risk factor of thrombosis.Study Methods: We examined 20 women aged 22 – 32 years old withfetal loss syndrome and a history of thrombosis, who had operativedeliveries. The control group consisted of 10 women in post-operativeperiod. The signs of thrrombophyllia were revealed with specialcoagulation tests: TAT, F1 +2, prothrombin fragments.The LMWH (Fraxiparin) therapy began and continued during the wholepregnancy and was stopped a day before the surgery. After 8 hourspostpartum, the LMWH therapy was restarted at the dosage of 0.3 (150ICU/kg) once daily and lasted for 10 days under the condition ofmaintained lactation.Results: The LMWH (Fraxiparin) therapy was found to be effective andsafe for thromnoprophylaxis in women with APS during postoperativeperiod. All neonates wre born alive, without any sign of asphyxia. Therewere no hemorrhages or thromboembolic complications during thepostoperative period.
P3.07 HUMAN SEXUALITY
P3.07.01A PAIN CONTROL COURSE FOR WOMEN WITH VULVARVESTIBULITIS SYNDROME.Ph.Weijenborg , M.ter Kuile, Dept Psychosom Gyn & Sexology,Leiden University Medical Center, Leiden, The Netherlands
Objectives: Evaluation of the effect of a pain control course for womenwith VVS.Study methods: 48 of 58 women with VVS (83%) completed astructured course on vulvovaginal pain control. During each course oftwelve two-weekly sessions of two hours, 6-8 women could participate.The programme is based on cognitive- behavioural programmes forchronic pain and sex therapy.Different standardized questionnaires as well as a gynaecologicalexamination were used to assess the effect of the course at pretreatment,posttreatment and three months follow-up.Results: At posttreatment women reported less pain in different sexualsituations. They increased their internal locus of pain control anddecreased their external locus of pain control; they perceived themselvesas more effective in controlling and decreasing their pain; they reportedlower levels of sexual problems. These results remained at follow-up.Moreover at posttreatment less painfull spots on the vestibule wereobserved.A decrease in the level of pain was associated with a decrease in sexualproblems and an increase of perceived pain control at posttreatment. Nosignificant association was found between changes in pain and theamount of painfull spots.Conclusions: A pain control course for women with VVS results in lesspain during sexual activities, higher scores on the internal locus of paincontrol and perceived pain control and reduction of sexual problems.
P3.07.02A PAIRED COMPARISON STUDY OF THE EFFECTS OF ABREATHABLE FEMININE HYGIENE PANTILINER VERSUS ATRADITIONAL NON-BREATHABLE PANTILINER ONREDUCING SKIN HYDRATION AND RELATIVE HUMIDITYA. Kanti (1), M. Bramante (2), S. Wang-Weigand (1), M. Roddy (1), F.Sarbaugh (1), A. Theil (1), E. Bookland (1).(1) The Procter & Gamble Co., Cincinnati, Ohio, USA.(2) Procter & Gamble GmbH, Schwalbach, Germany.
Objective: Under continuously hydrated conditions, skin can be moresensitive to possible irritation. A new vapor permeable backsheet wasdeveloped and tested using a physiological forearm model to evaluatethe effects of a breathable backsheet on skin hydration and relativehumidity.Study methods: A paired comparison study was conducted using aforearm model with 16 women wearing pantiliners loaded with 0.5mlsaline on each forearm for 6 hours. A double layer of cotton crotchmaterial was placed on top of the pantiliners to simulate realistic wearconditions. Each woman wore a breathable pantiliner (Alldays AlwaysBreathable Odor Control Pantiliner, Procter & Gamble) and a non-breathable reference (Alldays Always Odor Control Pantiliner, Procter& Gamble) on the opposite forearm. Baseline transepidermal water lossmeasurements (TEWL, Dermalab) were taken after a 30 min acclimationperiod in a temperature (20-25ºC) and RH (40±5%) controlled room.After panelists wore the products for 5.5 hr, Relative Humidity (RH) andtemperature were recorded at the center of covered test area (GeneralEastern Model 880) for 3 minutes. TEWL measurements were taken atdefined intervals over a 15 min. period after product removal. Productweight was taken within 1 min. from product removal.Results: All parameters measured showed statistically significantdifferences (paired-t test, p<0.0001) from the non-breathable backsheet.The parameters evaluated included lower skin surface, water loss(SSWL) in the breathable pantiliner (area-under-curve at 15 min: 0.267vs 1.201),lower RH and temperature in the breathable pantiliner (RH:63.269% vs 89.131%; Temp: 83.037F vs 83.994F) lower TEWL in thebreathable pantiliner (0.286 vs 1.335), and increased backsheet waterloss in the breathable pantiliner (16.62 vs 1.557 g/m2/24hr).Conclusions :Breathable pantiliners reduce skin hydration and relativehumidity as compared to non-breathable pantiliners. These resultscorrelate well with superior comfort experienced by women during
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normal use (consumer research) and support breathable pantilinerssuitability for daily use.
P3.07.03DEVELOPMENT OF RELATIONSHIOP IN COUPLES AFTERASSISTED REPRODUCTION – A PROSPECTIVE LONGITUDINALSTUDYM. Wadsby (a), G. Sydsjo (b),(a) Division of Child & Adolescent Psychiatry,(b) Division of OB/GYN,Department of Health & Environment, Linköping University,Linköping, Sweden.
Objectives: The purpose was to follow the development of relationshipand parenthood in couples pregnant after IVF-treatment, and comparethem with spontaneous primiparous couples. Furthermore, the study thechildren’s health, temperament and behavior in these two groups.Study Methods: Ninety primiparous couples pregnant after IVF, and anage-matched control group. Method used was the ENRICH MaritalInventory. The infant’s behavior was measured with the Baby andToddler Behavior Questionnaire. Obstetrical and neonatal records werestudied.Results: The vast majority of both men and women in both groups weresatisfied with their relationship during pregnancy. When the childrenwere 12 months old, no major changes in the ART-couples’ relationshipwere noted, while a significant decrease was present in the controlgroup. No significant correlation between maritalsatisfaction/dissatisfaction and infants’ health temperament and behaviorwas noted. There were no differences in the obstetrical variables such assection rates and neonatal health status even though there were 14duplex in the ART group compared to 2 in the control group.Conclusions: The birth of the first child implied no decline in ART-couples’ satisfaction with their relationship a decline that was present inthe control group. Surprisingly, duplex pregnancies had no negativeimpact on the medical variables or experience of the relationship.
P3.07.04THE EFFECT OF A GROUP PROGRAMME ON FEELINGS OFPSYCHOLOGICAL DISTRESS IN WOMEN WITH THE MAYER-ROKITANSKY-KÜSTER-HAUSER SYNDROMEPh.Weijenborg , M.ter Kuile, Dept Psychosom Gyn & Sexology,Leiden University Medical Center, Leiden, The Netherlands
Objectives:Evaluation of the effect of a group programme on feelings ofpsychological distress in women with the Mayer-Rokitansky-Küster-Hauser (MRKH) SyndromeStudy Methods: Seventeen women, diagnosed as MRKH-women,participated in a semi-structured programme of seven sessions, dealingwith different themes of the syndrome. The Symptom Check List-90(SCL-90) was used to assess feelings of psychological distress.Measures were taken at the first visit 3 - 6 months before the groupprogramme was started (pretest 0) , at the first (pretest ) and at the lastgroup session (posttest). In this study the women were their owncontrols.Results: The posttest subscale scores for anxiety, depression,interpersonal sensitivity and the total score for psychological distresswere significantly lower than the pretest-0 and pretest scores (p<0.05).No significant differences were found between pretest-0 and pretestsubscale and total scores.Conclusion: A semi-structured group programme seems valuable inhelping women with the MRKH-syndrome to deal with theirpsychological distress.- Paper is accepted for publication by the British Journal of Obstetricsand Gynaecology
P3.07.05FLUOXETINE IMPROVES SOCIAL FUNCTIONING IN WOMENWITH PREMENSTRUAL DYSPHORIC DISORDER (PMDD)J. Dillon (1), M. Steiner (2), R. Judge (1), E. Brown (3)(1) Lilly Research Laboratories, Lilly Corporate Center, Indianapolis,
IN, USA.(2) McMaster University, St. Joseph’s Hospital, Hamilton, Ontario,
Canada.(3) Eli Lilly and Co., Nederland, CO, USA.
Objective: A previously reported, placebo-controlled multi-site trialfound fluoxetine effective in mediating PMDD mood symptoms; thesedata are now used to determine fluoxetine’s effectiveness on socialfunctioning in women with PMDD. Though cyclical mood disturbanceis the pathognomonic feature of PMDD, impairment of socialfunctioning frequently contributed to the severity of presentation.Methods: Social functioning was assessed in 320 PMDD patients whowere randomized to fluoxetine 20 mg/day, fluoxetine 60 mg/day, orplacebo. Symptoms were assessed by social impairment subtotals of theself-rated and observer-rated Premenstrual Tension Syndrome Scale(PMTS-SR, PMTS-O). Items rated on the PMTS-SR subtotal were:avoid social commitments, avoid family, cancel scheduled socialactivities, difficulty completing house/job routine, more accidents indaily housework/job, stopped seeing best friends and physical symptomssevere: unable to function. Outcome measures were change from meanbaseline luteal phase scores to mean treated luteal phase scores.Results: Fluoxetine treatment (20 and 60 mg/day) statisticallysignificantly improved social functioning compared with placebotreatment when measured on the PMTS-SR and PMTS-O socialimpairment subtotals (all analyses significant, p<.05). For allcomparisons, 20 mg/day and 60 mg/day doses were not significantlydifferent.Conclusion: Fluoxetine treatment was statistically significantly superiorto placebo in improving frequently reported PMDD associated socialfunctioning as measured by derived social impairment subtotals of thePMTS-SR and PMTS-O.
P3.07.06FLUOXETINE VERSUS SERTRALINE AND PAROXETINE INMAJOR DEPRESSION: LONG-TERM CHANGES IN WEIGHTM. Fava (1), J. Rosenbaum (1), R. Judge (2), S. Hoog (2), D. Millard(2), and S. Koke (2)(1) Massachusetts General Hospital, Boston, MA, USA(2) Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, In,Usa
Objective: To assess the effects to extended SSRI treatment on weight,and to examine whether different agents have differential effects.Study Methods: Patients with major depression were randomly assignedto fluoxetine, sertraline, or paroxetine. Patients whose symptomsresponded within 6 to 12 weeks of active treatment continued treatmentfor a total of 26-32 weeks. The mean percent change in weight wasanalyzed, as was the number of patients who had ³ 7% weight increasefrom baseline.Results: Paroxetine-treated patients experienced a significant weightgain, fluoxetine-treated patients had a modest, but nonsignificantdecrease in weight, and sertraline-treated patients had a modest, butnonsignificant increase in weight. The number of patients who had>=7% weight increase was significantly greater for paroxetine comparedwith either fluoxetine or sertraline.Conclusion: Extended SSRI treatment is associated with different risksfor weight gain. Patients treated with paroxetine experienced largerincreases in weight, possibly due to the greater antocholinergic effects.
P3.07.07SEXUAL FUNCTIONING DURING ACUTE AND CONTINUATIONTHERAPY WITH FLUOXETINE: A PROSPECTIVE ASSESSMENTDavid Michelson , Mark E. Schmidt Eli Lilly and Company, LillyResearch Laboratories, Indianapolis, Indiana, USA
Background: Sexual dysfunction has been reported as an unwantedeffect associated with SSRI therapy, but the nature and frequency ofsuch effects have not been systematically characterized, not has the
WEDNESDAY, SEPTEMBER 6100
interaction of effects of mood improvement and specific drug effects onsexual function been adequately studied.Methods: Using a 4-item self-report assessment of sexual interest/desire,vaginal lubrication/erection, orgasm and overall sexual function, westudied depressed patients participating in a multi-center trial of acuteand continuation fluoxetine therapy. Patients were evaluated at baseline,after 13 weeks of fluoxetine 20 mg daily, and during 25 weeks ofcontinuation therapy with either fluoxetine 20 mg daily, fluoxetine 90mg weekly, or placebo.Results: Acutely 557 patients on fluoxetine 20/day and duringcontinuation therapy 181 fluoxetine 20/day, 181 fluoxetine 90/week, and119 placebo patients were assessed. At baseline, mean reports of sexualfunction showed mild-moderate impairment of all aspects for bothwoment and men. After acute flouxetine therapy, overall sexual functionwas improved in 51.9% of women and 38.2% of men, unchanged in34.5% of women and 42.7% of men and worsened in 13.6% of womenand 19.1% of men. Worsening of orgasmic functions was modestlygreater compared with other aspects (19.2% and 23.7% in women andmen respectively). During 25 weeks of continuation therapy, changes insexual function were not different between treatments for any aspect,and worsened sexual function in all aspects was strongly associated withworsened depressive symptoms.Conclusion: Sexual dysfunction reported prior to treatment tends toimprove as mood improves during treatment with fluoxenine. Somepatients (15-20%) experience worsened sexual function during acutetreatment, and orgasm may be most affected. Worsening during long-term treatment is associated with return of depressive symptoms, anddoes not appear to be a drug-specific late-onset event.
P3.08 HYSTEROSCOPY
P3.08.01COMPARISON OF THE TISSUE ALTERATIONS INDUCED BYELECTRIC ENERGY AND BY SUTURE MATERIALS USEDDURING LAPAROSCOPIC SUBTOTAL HYSTERECTOMY (LSH).A.S.Gasparov, P.A.Basanov , A.G.Melikian ; Dept.PEPR. ScientificCenter for Obstet., Gynecol. and Perinat; 4, ak.Oparina street, Moscow,117513, Russia.
Objective: The aim of this study is to compare tissue alterations inducedby electrocoagulation or by suturing used in LSH carrying out.Study methods: 100 women of the reproductive age (from 22 to 54years) were included in this study. Every patient underwent LSH. Allpatients were divided in 2 groups: in 1 group electrocoagula-tion wasused and suturing was selected for 2 group. Comparative analysis wasperformed using matching method (analogous gynecologic pathologyand electrocoagulation or suturing).Results: Level of the tissue destruction products was reliably higher in 1group, than in 2 group.Conclusion: Use of suture materials brings less tissue alteration thanelectrocoagulation performed during LSH in the case of the analogousgynecologic pathology.
P3.08.02ENDOMETRIAL BALLOON ABLATION WITH THE CAVATERMTHERMAL BALLOON: RESULTS OF 69 CASESA. Alaily , Dept. of OB/GYN, Conquest Hospital, St.Leonards, EastSussex, UK
Objectives: To determine the performance of Cavaterm, a relative new,safe and cost effective procedure that can treat menorrhagia without theneed for surgery or drugs in women between the ages of 35-55 as daycases.Study Methods: The study is based on a balloon catheter that combinesheat with pressure to destroy the endometrium and underlyingmyometrium. All women undergo pre-treatment tests, which includeendometrial biopsy and hysteroscopy, and any contra-indications areexcluded from this procedure. All patients had the procedure performedunder general anaesthetic and were followed up at three, six and ninemonths and up to two years.Results: There were no complications of treatment. Sixty-nine patientswere treated. Three patients had repeated ablations. 19% of patients hadamenorrhoea at three months, 60% had light bleeding and 4 % hadnormal periods. At six months 40% had amenorrhoea, 42% had light
bleeding and 5% had normal loss. Nine months showed 47% withamenorrhoea, 38% with light bleeding and 7% with normal loss. At twoyears, 41% of those followed up had amenorrhoea and a further 41% hadlight periodsConclusions: Endometrial balloon ablation compares favorably withestablished techniques. It has a low capital cost and is safe and userfriendly. Success rates for this procedure are good and patientssatisfactions high.
P3.08.03HYSTERO-FIBERSCOPIC MANAGEMENT IN DIFFICULT IUDREMOVALJ. Li , H. Fan, Dept. Family Planning, Peking OB/GYN Hospital,Beijing, P.R. China
Objective: To assess the importance of flexible hysteroscope in complexremoval procedure of IUD.Study Methods: Forty-eight women with the history of failed IUDremoval or leaved part of IUD in uterus were treated by HYF-1THystero-Fiberscope with instrument under epidural anesthesia (lesscases) or intravenous sedation (Dolatin).Results: All of the cases were managed successfully by Fiberscope“HYF-1T” without complications: 8 cases with incarceration in thecornu of the uterus, 12 cases with untramural incarcered partly, 14 caseswith uterine or cervical cannel adhesion, 12 cases with rest of IUD, 10cases with break of IUD, 4 cases with uterine hysteromyoma, 1 casewith uterine malformation, another one just with uterine retroflexion.Only 3 cases without any problems, of course some cases gotcomplicated (two or three problems).Conclusions: Hystero-Fiberscope is safe and easy to use, because theoperation can be performed directively and exactly in which the neckneedn’t be expanded, and it is effective and useful due to tip deflectionof 120o in two directions of maximum orientation accuracy so thatcomplete examination and difficult IUD removal, which is almostanywhere in the uterus, could be made properly.
P3.08.04HYSTEROSCOPIC SURGERY USING VERSAPOINTM. Paschopoulos , D. Lolis, E. Paraskevaidis, K. Zikopoulos, G.Adonakis, S. Kaladaridou, A. Kaponis, F. Avgoustatos, Obstetric-Gynecology Clinic, University Hospital of Ioannina, Opl. Poutetsi 2,Ioannina, Epirus, Greece, 45100.
Objective: The aim of this study was the evaluation of electrosurgeryusing bipolar system ( Versapoint, Gynecare, J&J Co. ) in order toperform hysteroscopic surgery.Method: Hysteroscopic surgery was performed in 52 women, using theBettochi System Hysteroscope ( Storz, Tuttligen, Germany, 3,5 mmdiameter ). Normal saline was used for dilatation of the uterine cavity.The mean age of women was 32 years ( range 24-53 ).Results: Endometrial polyp was treated in 10 cases ( 5 cases under localanesthesia ), endometrial septum in 13 cases ( 6 cases under localanesthesia ), submucus fibromas in 13 cases, and endometrial adhesionsin 16 cases.Conclusions: Hysteroscopic procedures using Versapoint is an effectiveand safe technique. The procedures may be performed under localanesthesia using normal saline.
P3.08.05PATIENT ACCEPTANCE OF MICROWAVE ENDOMETRIALABLATION UNDER LOCAL ANESTHESIAM.A. Ellard , T. Hayes, N.C. Sharp, Dept. OB/GYB, Royal UnitedHospital, Bath, UK.
Objectives: To investigate patient acceptance of Microwave EndometrialAblation (MEA) under local anesthesia (prilocaine/octapressin, Astra,UK) compared to general anesthesia.Study Methods: Randomized comparative study with 50 pre-menopausalwomen undergoing MEA. The main outcome measures were a painscore measured on a visual linear analogue scale (0-10) at 1, 4, 24 and48 hours post procedure. Amount and type of post-operative analgesiause.
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Results: No patients required conversion from local to general anesthesiato complete the MEA procedure. Median pain scores at each timeinterval are shown below.
Time post MEA (hours) Local Anesthesia General Anesthesia
1 2.5 2.0
4 3.0 2.95
24 0.4 0.75
48 0.0 0.0
There was less use of analgesia 1 hour post operatively in the localanesthesia group but at each subsequent time interval there was nodifference in the use of codeine/paracetamol, non-steroidal anti-inflammatory or opiate preparations.Conclusions: Prilocaine provides an effective block during the MEAprocedure. There is no difference in pain scores between the two groupsat each time interval. Local anesthesia appears as an effective alternativeto general anesthesia providing the possibility of MEA being used as anoffice procedure.
P3.08.06THE UTERINE CAVITY EVALUATIOND. Pérez , M. Pesaresi, R. Papera; GYN/OBS Division, Durand Hospital,Buenos Aires, Argentina.
Objetives: Our purpose was to determine the role of four different testsin the diagnosis of abnormalities in the uterine cavity.Study Methods: In a prospective study, 61 patients showing differentreasons for investigation, underwent transvaginal ultrasound,transvaginal ultrasonography, hysteroscopy and endometrial biopsy.Ultrasound and ultrasonographic findings were evaluated on the basis offinal diagnosis by hysteroscopy and histologic examination.The sensitivity, specificity, positive and negative likelihood ratio werecalculated. Hysteroscopic findings were correlated with the histology.Results: The transvaginal ultrasound demonstrated a sensitivity of 85%in diagnosing abnormalities in the uterine cavity and a specificity of70%. The positive likelihood ratio was 2.8 and the negative likelihoodratio was 0.2 Ultrasonography demonstrated a sensitivity of 87% and aspecificity of 90.4%. The positive likelihood ratio was 8.7 and thenegative one was 0.1. Hysteroscopy was an excellent investigative toolfor the uterine cavity. 32% of the studies were normal.It is important to point out that histological confirmation was obtained inonly 23% of the cases of hysteroscopic observation of polyps.Hysteroscopic observation was unable to detect 50% of simplyhyperplasias.Conclusions: Transvaginal ultrasound is an excellent first diagnosticmethod in the evaluation of the uterine cavity and for excluding othergenital abnormalities.Both sensitivity and specificity of the different tests are influenced bythe hormonal condition of women.Hysteroscopy as well as endometrial biopsy are the gold standards foruterine cavity evaluation.
P3.09 INFECTIONS IN OBSTETRICS AND GYNECOLOGY
P3.09.01A CLINICAL-MICROBIOLOGICAL STUDY OF BACTERIALVAGINOSIS IN PREGNANT WOMEN AND CLINICALLYSIGNIFICANT SEQUELAES. Tanchev , A. Chervencova, M. Sredcova, B. Plevneli, S. Pachcova,Dept. OB/GYN, Dept. Microbiology and Virology, Higher MedicalUniversity, Pleven, Bulgaria.
Objectives: The aim of the study was to investigate the frequency ofspreading BV in pregnant women at different stages of pregnancy andthe results of the delivery among the positive group.Study Methods: We held a study of 106 pregnant women aged between15 and 35, registered at the Pregnancy Consultation Office in Pleven.We used the clinical and microbiological methods.Results: About half of the women did not have data for vaginaldischarge and microbiological analyses showed normal vaginal flora.Two thirds of the rest of the investigated women had data forcandidiasis, bacterial vaginosis or both. Group B streptococci insignificant quantity was found in five cases. Pregnant high-risk women(with a prior preterm birth) was five. The analysis of the delivery
showed different complications at BV-positive women: low birthweight, preterm birth, premature rupture of the membranes.Conclusion: The investigation showed high frequency of spreading ofBV in pregnant women and clinically significant sequelae. All pregnantwomen with BV (high and low risk) should receive therapy for BV toprevent a possible complication.
P3.09.02A NEW PROPOSAL TO THE HISTOLOGIC FINDINGS OF THERECURRENT SUBAREOLAR BREAST ABSCESS (RSBA)L.F. Sampaio Neto , R. Hegg, P.H.N Saldiva, PUCSP Medical School,Sao Paulo, Brazil.
Objectives: There is evidence that between 88.3% to 91.9% of smokingwomen have the RSBA. We suppose that the elastic system of the breastis affected by the elastase activation induced by the tobacco smoking.Study Methods: 54 breasts of RBSA patients were studied, 51 breasts ofnormal women served as control group. They were colored by the HEand Weigert resorcin to the morphometric study of its hytsologicalcomponents and the elastic system.Results: The tobacco smoking was greatly related to the presence ofRSBA (90.7%). The morphometric results revealed bigger area ofconnective tissue and less areas of adipose tissue in the RSBA group.Through the specific coloring for the elastic system, we found that thehigher concentrations of elastic fibers took place around the ducts,especially in the RSBA population.Conclusion: These findings suggest that the ductile ectasia is related toRSBA and the concentration of elastic fibers around these ducts isbigger in the RSBA patients that could be related to elastic fibersdisorder.
P3.09.03BACTERIOLOGY IN INFECTED ABORTIONA. Farinati (1), C.O. Soler (2), G. Pagniez (1), L. Gliosca (1), J.Casellas(1), R. Guntin (2), E. Gambaro (2), J.Soutric (3), H. Arenoso (3), N.Caruso (3)(1) Centro de Estudios Microbiológicos, Martinez, Argentina.(2) Dept. OB/GYN, Hospital Dr. Diego Paroissien, Isidro Casanova,
Buenos Aires, Argentina.(3) Laboratoires Baga Sa, Buenos Aires, Argentina.
Background: Abortion is the clinically diagnosed stoppage of pregnancy,before its 20th week. In Latin America around 800,000 women areadmitted annually due to complications of provoked abortions(FLASOG 1997).Objective: To know what microorganisms (MO) are involved in infectedabortions (IA) in order to determine an adequate empirical antibiotictherapy.Study Methods: In this prospective study, 45 patients (p) have beenrecruited so far. Before uterine scrape samples were obtained fromendocervix (EC)/endomtrium (EM) and for blood cultures (BC). Afterthe scrape: EM y BC. The etiology was attributable to germs categorizedas vaginal flora (VF) when these were isolated from BC or EM only orwith inflammatory response from both EC and EM. The isolation fromEC and/ or EM was enough for the germs not considered as VF. Thesusceptibility of the isolates to the Amoxicillin+Sulbactam combination(Ax+Sb) was assessed.Results: Cultures (clt) from 33p. were positive (73.3%); in 17p. only oneMO was isolated; in 16 p., two or more. 80% of the p. admitted previousabortive intervention and the remaining 20% did not, which does notallow us to state that they were spontaneous abortions or due toinfection. All isolates were susceptible to Ax+Sb except 3 strains: 1 E.coli, 1 Enterobacter spp. And 1 Morganella morganii.
Microorganisms Before uterine scrape After uterine scrape
EC EM BC EM BC
Enterobacteria* 14 15 7 15 4
Gram (+) cocci # 21 22 4 2 1
Anaerobes 7 5 3
Otros 2 4 1
*E. coli, Enterobcter spp, P. mirabilis, K. oxytoca, M. morganii.#E. faecalis, S. viridans, GBS, GAS, S. areus, S. epidermidis.Conclusion: The MO involved in this study on infected abortion aresimilar to the ones found by our group in a previous study on puerperal
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endometritis, in which Ax+Sb proved clinically effective as empiricaltherapy.
P3.09.04BUSCHKE-LOWENSTEIN TUMOR OF THE VULVA: HOW WECAN DO DIFFERENTIAL DIAGNOSIS WITH CONDYLOMAACUMINATUMN.S. Carvalho , C.A. Maestri, E. Schunemann, R.P.G. Xavier, A. Bini.Dept OB/GYN, Clinic Hospital, Federal University of Parana, Parana,Brazil
Giant condyloma acuminatum or Busche-Lowenstein tumor of the vulvaand perinal regions is a uncommon entity that has not been extensivelystudied. Sometimes the appearance of common condyloma acuminatumwith large size shown any doubts about the correct diagnosis.In this short communication, we discuss the clinical features, thehistological criteria for diagnosis and methods of treatment availableabout this rare vulvar and perennial regions tumor. To illustrate thetheme we show our experience with five cases about it.
P3.09.05CHARACTERISTICS OF NEUTROPHIL SUPEROXIDEGENERATION IN HUMAN FETUSESH. Komatsu , K. Tsukimori, K. Hata, H. Nakano, Dept. OB/GYN,Graduate School of Medical Sciences, Kyushu University, Fukuoka,JAPAN
Objectives: To investigate the defensive sysytem against bacterialinfections in human fetuses, we studied neutrophil superoxide generationin fetuses and adults.Study Methods: After an appropriate informed consent, neutrophils wereobtained from cord blood of neonates immediately after transvaginaldelivery, which consisted of two groups: group I, 11 neonates (22 to 36weeks’ gestation) and group II, 10 neonates (37 to 41). Ten healthyadults served as controls (group III). A SOD-inhibitable MCLAchemiluminescence assay was used to evaluate O2
- production activity ofneutrophils stimulated by PMA and fMLP. The [3H]fMLP binding assaywas performed according to the modified method of O’Flaherty et al. aspreviously described. Statistical analysis was performed using one-wayANOVA and Bonferroni test.Results: For PMA-stimulated O2
- production activity of neutrophils, bothgroup I (1.42±0.18_107cpm; mean±SEM) and II (1.64±0.15_107) weresignificantly lower than group III (2.37_107±0.22_107) (p<0.05),whereas no significant difference was noted between group I and II. InfMLP-stimulation, O2
- production activity in group II (9.90±0.97_106)did not differ from group III (10.5±0.11_106). Group I (6.07±0.81_106)was significantly lower than the other groups (p<0.05). Scatchardanalysis of [3H]fMLP binding to neutrophils demonstrated a two-receptor site model in all groups. However, the number of high-affinityreceptors per neutrophil in group I was lower than those in the othergroups.Conclusions: These findings indicated that the fMLP-induced O2
-
production activity of neutrophils in term fetuses, which was differentfrom that in preterm fetuses, expressed the same level as that in adultsby increasing the number of high-affinity receptors per cell. Thisevidence suggests that term fetuses acquire the defensive system againstbacterial infections.
P3.09.06DISTURBANCES OF INTERFERONAL STATUS AND ITSCORRECTION BY VIFERON IN PATIENTS WITH ACUTE TUBE-OVARIAN INFLAMMATORY DISEASESA.N. Strizhakov , V.V. Malinovskaya, J.A. Kagramanova, Dept.OB/GYN, Moscow Medical Academy, Moscow, Russia.
Objectives: The aim of the study was to investigate the disturbances ofinterferonal status and to improve complex treatment of tube-ovarianinflammatory by viferon, which include human a2 interferonrecombinantly and antioxidants.Study Methods: 50 women were included in the study of interferonalstatus in the blood serum.Results: 96% of the patients had deep decrease of interferonal status (a-and g- interferon on 70%) after antibioticans only. After
immunocorrection therapy by viferon rectal suppositorians, theparameters of the interferonal status has achieved normal meanings.Conclusions: Complex antibacterial treatment of acute tube-ovarianinflammations in combination with viferon 500000 IU was found tohave a significant effect in 94% of patients.
P3.09.07GNRH-AGONIST INDUCED OVARIAN CYSTS ASPIRATION:THEIR IMPACT ON CONTROLLED OVARIANHYPERSTIMULATION AND PREGNANCY OUTCOMEW. El Deeb , S. Farid, H. Assem, S. El Sahwi, International FertilityCenter (IFC) Lauran, Alexandria, Egypt.
Objective: To evaluate the impact of GnRH-a induced ovarian cystsaspiration on controlled ovarian hyperstimulation (COH) and pregnancyoutcome.Study Methods: The design was a retrospective study.Patients and intervention: Eighteen patients form our IVF & ICSIprogram with who administration of GnRH-a failed to induce pituitarydesensitisation as evidenced by both the presence of an ovarian cyst, andprolonged high oestrogen (E2) level. All patients underwent 23 cyclesand had a baseline transvaginal sonographic evaluation prior to GnRH-aadministration (Superfact, Hoechst, Frankfurt, Germany) O.3 ml twotimes daily S.C. starting from the second day of the menstrual cycle as afollicular phase long protocol. D10, inappropriate pituitarydesensitization was considered if we have an ovarian cyst and prolongedhyperestrogenaemia. D11 we had 16 cycles in which transvaginalultrasonographic guided cyst aspiration (TSVA) was performed, the restof the cycles (7cycles) we had either very small cyst to be aspirated orpersistent hyperestrogenaemia without cyst formation. D14 the patientswere re-evaluated by ultrasonography and serum E2 concentration,HMG was stared when serum E2 was below 50pg/ml and routinefollow-up of the patients until HCG administration.Main outcome measures: Ovarian responsiveness to subsequent COHand pregnancy outcome.Results: Out of the 23 cycles, 13 trials were completed (all had TSVA).Nine were cancelled due to ovarian irresponsiveness to COH and in onecycle a single injured oocyte was retrieved. We had four pregnanciesand the pregnancy rate per transfer was 30% and 17% per cycle. Thiscompares favorably with our concurrent pregnancy rate in the center.Conclusion: Aspiration of GnR-H-a induced ovarian cysts do not appearto interfere with COH and outcome.
P3.09.08PREVENTION OF VERTICAL HIV TRANSMISSIONC. Manchese , O. Parada, M. Martinez, B.Chomski, R. Voita, R.H.Winograd, Dept. OB, Argenich Hospital, Buenos Aires, Argentina.
Objectives: We sought to determine the decrease of perinataltransmission in pregnant women who are seropositive for the humanimmunodeficiency virus (HIV) that had been treated with antiretroviraldrugs.Study Methods: We examined 85 newborns of mothers seropositive(HIV). During the period from 1995 to 1999 treated with the protocol0.76 and other drugs.We evaluated several factors:1. Condition clinical maternal2. Antiretroviral drugs during the pregnancy; two or more drugs.3. Rupture of the membranes4. Delivery or cesarean section.Results: In the last 2 years (1998-1999), the 53 to 70% of the pregnantwomen (HIV) positive had in plasma HIV 1 RNA less than 5,000copies/ml, and CD4 T cell count more than 200.During the period 1998-1999, the 42% of pregnant women HIV positivewere treated with AZT associated to one or two drugs during thepregnancy.There was no difference respect the rupture of the membranes occurredless than 4 hours prior to delivery; we have 91% of patients in theseconditions.Cesarean section was increased from 25% to 47% during 1999.Was significant the reduction of vertical transmission during the period(1998-1999), to the 6% incidence respect the period (1995-1997) in ourmaternity.
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Conclusions: The prevention during the pregnancy with the protocol0.76 and other drugs had reduced the vertical transmission byapproximately two thirds. This is one of the most important variables toreduce the cases of pediatric HIV.
P3.09.09IMMUNOCORRECTIVE THERAPY IN COMPLEX TREATMENTOF PREGNANT WITH PLACENTAL INSUFFICIENCY ANDHERPES VIRUS INFECTIONZaidieva Z.S., Tioutiounnik V.L., Ordzhonikidze N.V. Research Centreof Obstetrics, Gynecology & Perinatology, Moscow, Russia
Objectives: To evaluate the efficency of immunocorrective therapy incomplex treatment of placental insufficiency in pregnant women withherpes virus infection (herpes simplex virus infection andcytomegalovirus).Methods: 107 cases with disease relapses and asymptomatic eliminationof virus were examined.Results: Discovered disorders in immune and interferon statuses allow toprescribe for these patients immunocorrective therapy. For this purposewe have used intravenous injections of immunoglobulin (250 mg/kg) 3times a day in I, II and III trimesters of pregnancy. We have also usedrectal suppositories with viferon (which consist of 150 000 ME alpha-2binterferon) 2 times a day for 5 days since 28 to 34 weeks of gestation.Viferon suppositories consisted of 500 000 ME of alpha-2b interferonhave been prescribed 2 times daily after 35 weeks of gestation. Totallywe use a 12 week courses of viferon for 5 days.Conclusions: It was found that this therapy leads to a firm normalizationof immune and interferon status in pregnant women with herpes virusinfection and improves the effect of complex treatment of placentaldeficiency in these patients.
P3.09.10MECHANISM OF PLACENTAL DYSFUNCTION AND ABRUPTIOPLACENTAE IN INFLAMMATORY MOUSE PLACENTALMODEL: OXIDATIVE STRESS AND APOPTOSISK. Ejima (1), E. Shibata (2), H. Nanri (1), M. Ikeda (1), M. Kashimura(2), University of Occupational and Environmental Health, Kitakyushu,Japan.(1) Dept. of Health Development(2) Dept. OB/GYN
Objectives: Recent studies have indicated that oxidative stress is one ofthe pathogenesis in preeclampsia and inflammatory diseases. In thisstudy, we examined the expression of antioxidant system and theinduction of apoptosis in mouse placenta exposed to lipopolysaccharide(LPS), which produces radical oxygen species.Study Methods: We used placentas from pregnant mice injected withLPS or saline as a control. We analyzed the occurrence of placental cellapoptosis and the role of Fas and Fas ligand (L) in that process in anLPS-induced inflammatory placenta. The accumulation of 4-hydroxy-2-nonenal (HNE)-modified proteins, which is a marker of oxidative stress,and the expression of thioredoxin and thioredoxin reductase, which wereantioxidant enzymes, were evaluated by Western blotting andimmunohistochemistry.Results: Analysis of the isolated DNA in agarose-gel electrophoresisrevealed a typical ladder pattern of bands consisting of 180-200 bp afterLPS injection. Histochemical analysis using TUNEL revealed that nucleipositive for double-stranded DNA breaks were found in placentasexposed to LPS. Western blot analysis indicated that LPS increased theexpression of Fas as well as Fas L in the placenta after injection,respectively. The cells expressing Fas as well as Fas L were identified asdecidua and trophoblasts by immunohistochemistry and “in situ”hybridization. Furthermore, when the accumulation of HNE-modifiedproteins was assessed to evaluate the relation of oxidative stress elicitedby LPS to the induction of apoptosis, again, decidua and trophoblastswere positive. Western blot analysis revealed that injected LPSenhanced the expression of thioredoxin and thioredoxin reductase.Conclusions: Oxidative stress may be involved in the occurrence ofplacental dysfunction and abruptio placentae.
P3.09.11PREVALENCE AND RISK FACTORS OF STREPTOCOCCUSAGALACTIAE (GROUP B) COLONIZATION IN MOTHERS ANDTHEIR NEONATES AT SRINAGARIND HOSPITAL, KHON KAEN,THAILANDY. Werawatakul , C. Wilailuckana, S. Taksaphan, J. Thinkumrup, Dept.OB/GYN, Khon Kaen University, Khon Kaen, Thailand.
Objectives: To determine the carriage rate of streptococcus agalactiae(group B) in pregnant women at the onset of laborTo find out the risk factors of streptococcus agalactiae (group B)colonization in mothers and neonatesTo evaluate the role in neonatal infection.Study Methods: 901 cases of pregnant women and their neonates werecultured for streptococcus agalactiae (group B) at labor room.Results: There were 56 cases (6.4%) of maternal colonization and 14cases (1.6%) of neonatal colonization. Oral sex during pregnancy was arisk factor of streptococcus agalactiae (group B) colonization in mothersand their neonates. All cases of neonatal colonization did not have anyclinical of neonatal infection.Conclusions: In this study we found lower prevalence of streptococcusagalactiae (group B) colonization in mothers and their neonatescompared with western countries.
P3.09.12PROPHYLACTIC ANTIBIOTICS IN ABDOMINALHYSTERECTOMYC. Chongsomchai (1), P. Lumbiganon (1), J. Anansuwanchai (1), J.Ounchai (2)(1) Dept. OB/GYN, Faculty of Medicine, Khon Kaen University, KhonKaen, Thailand.(2) Dept. OB/GYN, Khon Kaen Regional Hospital, Khon Kaen,Thailand.
Objective: To compare the efficacy of a single dose of ampicillin orcefazolin in preventing febrile and infectious morbidity after electiveabdominal hysterectomy.Study Methods: A multi-center randomized controlled trial wasconducted at Khon Kaen University and Khon Kaen Regional Hospital.Three hundred and thirty women undergoing elective abdominalhysterectomy were randomly allocated into each of the 3 groups:placebo, ampicillin or cefazolin group. These women received 3 cc.Sterile water or 1 gm. of ampicillin or 1 gm. of cefazolin intravenouslyaccording to the random assignment 30 minutes before the operation.Febrile and infectious morbidity, assessed by blinded independentevaluators, were used as main outcome measures.Results: Three hundred and twenty-one subjects were eligible for dataanalysis, 108 in placebo, 106 in ampicillin and 107 in cefazolin group.Febrile morbidity occurred in 12.0%, 13.2% and 11.2% of subjects inplacebo, ampicillin and cefazolin groups respectively. Infectiousmorbidities were found in 26.9%, 21.7% and 10.3% of subjects inplacebo, ampicillin and cefazolin groups respectively. The commoncauses of infectious morbidity were urinary tract infection, vaginal cuffinfection and surgical wound infection.There were no statistically significant differences in febrile morbiditybetween the 3 groups. Regarding infectious morbidity, there wasstatistically significant difference between placebo and cefazolin groups(p=0.002). Among placebo and ampicillin, the result showed nosignificant difference (p=0.375). There was a statistically significantdifference between cefazolin and ampicillin groups (p=0.023).Conclusions: Antibiotic prophylaxis should be considered in electivetotal abdominal hysterctomy to prevent infectious morbidity. Cefazolinappeared to be more effective than ampicillin.
P3.09.13SPECIES SPECIFIC PREVALENCE OF VULVOVAGINALCANDIDIASIS IN DIABETIC WOMENV. Dadhwal , R. Goswami, U. Banerjee, N. Kochupillai, S. Mittal, Dept.OB/GYN/Microbiology/Endocrinology, All India Institute of MedicalSciences, New Delhi, India
Objectives: To study the species specific prevalence of vulvovaginalcandidiasis in diabetic women.Study Methods: Study comprised of 166 subjects, 78 patients with
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diabetes mellitus and 88 healthy controls matched for age and body massindex. All subjects were clinically assessed for symptoms and signs ofvulvovaginal candidiasis. Discharge was collected from high vagina fordirect microscopy and culture Glycemic, control was judged by totalglycosylated hemoglobin. Pearson chi-square test was used for statisticalanalysis.Results: Overall 36 of 78 (46%) diabetic women shoed Candida growthon culture as compared to 21 of 88 (22%) healthy subjects (P=0.0025).The species isolated from diabetic patients were C.glabrata (39%),C.albicans (25%) and C.tropicalis (17%), C.albicans and C.haemulonicomprised 29% each in control group, none of control group isolatedC.tropicalis (P<0.05). In the diabetic women, total glycosylatedhemoglobin was significantly higher (P=0.001) in cases withvulvovaginitis.The sensitivity and specificity of clinical examination in predictingcandida growth was 41% and 58% in diabetic patients and 25% and 78%in controls respectively. Whereas the sensitivity and specificity of directmicrosocpy for predicting candida growth in diabetic patients was 58%and 93% and in control was 38% and 97% respectively. False negativeresults were predominantly due to nonalbicans species.Conclusion: The relative risk for vulvovaginal candidiasis n diabetics is2.45 in this study. The risk was associated with glycemic control.Nonalbicans Candida cause infection in a high number of diabeticpatients.
P3.09.14THE PECULIARITY OF PSYCHO-EMOTIONAL STATUS INWOMEN WITH CHRONIC NON-SPECIFIC PELVICIMFLAMMATORY DISEASESV.V. Podolsky , V.L. Dronova, Dept. of Family Planning, Institute ofPediatrics, Obstetrics and Gynecology, Kiev, Ukraine.
Chronic non-specific infection of the female pelvis is one of the threatsfor the health and reproductive function of women.It is a well known fact that the conditions of life of modern women arechanging, increasing the role of women in the decisions ofsocioeconomic problems, all of which intensify the psycho-emotionaland stress load on the woman’s organism. The problems in the sphere ofinter personality and sexual contacts in women with chronicinflammatory diseases of genitals are changing for the worse the psycho-emotional status in these patients.Objectives: The purpose of our investigation was to study the peculiarityof psycho-emotional status in women with chronic non-specificinflammatory diseases of genitals.Study Methods: During our investigation we used a few psychologicalmethods, such as modification of color test by Lusher, modification ofvariant of inter personality diagnosis by T. Liri and the scale ofpsychological stress by L. Rider. We examined 50 women with chronicnon-specific inflammatory disorders of genitals. All of these women hadthe disorders in psycho-emotional status. The level of psycho-emotionalstress correlated with the clinical characteristic and the age of thediseases. The highest level of psycho-emotional stress by the Rider’sscale registered in 40% of patients with the age of diseases before twoyears. The investigation of inter personality peculiarity in these patientsshowed that 10% of the women had the “distrusting” type of interpersonality relations, 30% had “envious and obedient” type of interpersonality relations, 44% had “obedient and embarrassed” type of interpersonality relations.Results: We discovered that women with chronic non-specificinflammatory diseases had great psycho-emotional disorders, whichcorrelated with peculiarity different ache during their sexual contacts,15% had decreasing libido, 8.75% lost the libido, 11.25% had absence ofsatisfaction, 20% had decreasing of personal and character of diseases.Conclusion: The results of our investigation can improve the quality ofmedical treatment in these patients with the use of psychotherapymethods.
P3.09.15TREATMENT OF NONSPECIFIC VAGINITIS BY REPOPULATIONOF VAGINAL FLORA WITH CULTURE OF SACCHAROMYCESCEREVISIAEC.A.Marques (1) , M.Costa (2), J.C.Conceição (2), M.Vettore (2),M.Pedrosa (2), (1) Agamenon Magalhaes Hospital, Rua Ribeiro de Brito573/6, Centro Empresarial Guararapes, Recife, Pernambuco, Brazil,51021-310, (2) Federal University of Rio de Janeiro, Rio de Janeiro,Brazil.
The objective of this prospective, open clinical trial was to evaluate theefficacy of repopulation of vaginal flora with Saccharomyces Cerevisiae(SC), an yeast with bactericide activity and production of B vitamins, inpatients with nonspecific vaginitis. After informed consent andbacteriological diagnosis, 82 patients with nonspecific leukorrhea weretreated with 7 days applications of the yeast solution. They werereevaluate within 30 days. It has been evaluated the smear, pH,symptoms and adverse events. The age varied between 19 and 75 yearsold with an average of 38,5. The results showed improvement of thesymptoms in 58 patients (70,7%), no alteration in 21 (25,6%) andworsening in 3 (3,7%). Adverse events were verified in 14 patients(17%), mainly itching, burning and pruritus. We concluded that therepopulation of vaginal flora with SC is well accepted and improved thesymptoms in most of the patients with nonspecific vaginitis.
P3.09.16VAGINAL AMEBIASISPangemanan WT, Dept. OB/GYN, Sriwijaya University, 1528 BasukiRahmat Street, Palembang, South Sumatera, Indonesia.
Objectives: The aim of this review is to report about Vaginal amebiasiscase. Vaginal amebiasis is a very rare case, thus, it is difficult to find innewer literatures reported in US, China, Central America and inundeveloped countries.Case Report: A 50 year-old woman has been a widow for 20 years, hasan occupation as a farm worker, resides on rural community that has ahabit of relieving themselves in rivers, come with complain of whitedischarge with offensive odor, alongside with pain, and rash on hervagina. At first a vaginal malignancy was suspected. After a biopsy wasdone, and amebic cyst was found. Afterward, the patient was admittedinto hospital care and was treated with oral metronidazole 3 x 500 mgand vaginal suppositoric metronidazole 2 x 1 gram and vaginal toilettwice a day. The patient was pronounced cured after 14 days of hospitalcare with negative culture result and no ameba found on vaginal swab.Conclusion: Vaginal amebiasis is a rare case and a problem on diagnosisis difficulties to directly make a correct diagnosis, while treatment canbe done by giving metronidazol.
P3.10 INFERTILITY/ASSISTED REPRODUCTIVETECHNOLOGY
P3.10.01A COMPARISON BETWEEN QUARTER, PARTIAL AND TOTALLASER ASSISTED HATCHING (LAH) IN SELECTED GROUPS OFINFERTILITY PATIENTSE. Mantoudis , B. Podsiadly, G. Venkat, A. Gorgy, E. Kelada, S. Rogers,and I. Craft, London Fertility Centre, 112a Harley Street, London, W1N1AF, UK
Objectives: LAH has been used in order to improve implantation rates inselected groups of patients. Total LAH was first introduced in our centrein June 1998, initial results did not meet our expectations andsubsequently the technique was modified initially to partial LAH andfinally to quarter LAH. In this study we analysed the results from thethree types of LAH.Study Methods: A total of 322 cycles of laser assisted hatching wereundertaken in our Centre between June 1998 and September 1999. Thepatients were divided into 3 groups, group 1 with total LAH, group 2with partial LAH and group 3 with a quarter LAH. The patients werealso divided into 4 categories according to their indication for LAH.Category A were patients over 37 years of age undergoing IVF/ICSI,category B were patients undergoing FER, category C were patientswere women with more than 2 previous failures and category D werewomen who were poor responders. Statistical analysis was performed by
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means of logistic regression.Results: The pregnancy rate was 14.6% with a clinical pregnancy rate of5.2% in group 1, 20.9% with a clinical pregnancy rate of 18% forpatients in group 2 and 29.0% with a clinical pregnancy rate of 22.1%for patients in group 3.Conclusion: Overall there was firm statistical evidence that a quarterLAH is more effective in improving the pregnancy rate, when comparedwith partial and total LAH.
P3.10.02A PROSPECTIVE RANDOMIZED CONTROLLED STUDY ON THECOMPARISON OF THE RESULTS BETWEEN THE DAY-3EMBRYO TRANSFER AND DAY-5 BLASTOCYST TRANSFERT. Utsunomiya , C. Ikeda, K. Hirai, K. Hirotsuru, Dept. OB/GYN, St.Luke Clinic, Oita City, Japan.
Objectives: To determine the effectiveness of day-3 and day-5 ET on thepregnancy and cancellation rate following in vitro fertilization (IVF) andintracytoplasmic sperm injection.Study Methods: One hundred sixty four cycles in patients (average age:34 (25-45)) were treated by IVF and ICSI. All zygotes were cultured today-3 in HTF for day-5 in Blastocyst medium or G1/G2 medium.Pregnancy rate and cancellation rate were compared between the groupsof day-3 ET and day-5 ET.Results: The results were as follows: the pregnancy rate (cycles) of day-3 ET was 18.3% and day-5 ET was 14.8%. The cancellation rate of day-3 ET was 2.4% and day-5 ET was 25.6%.Conclusions: The pregnancy rate of conventional day-3 ET using HTFmedium was better than the new method as day-5 ET using blastocyststage culture medium. The theories of blastocyst stage culture and day-5ET might be very good and ideal procedures. From our results, however,the condition of blastocyst stage culture should be discussed more.
P3.10.03CAUSES OF INFERTILITY IN INFERTILITY CENTER OFMASHHAD UNIVERSITY, IRAN FROM 1998 TO 2000D.M. Dehghani , D.Z. Yousefi, D.H. Salare, D.M. Amere, Dept.OB/GYN, Ghaem Hospital, Mashhad University, Khorasan, Iran.
Objectives: Evaluation of Causes of infertility in infertility centerMashhad University, Iran.Study Method: 1846 patients with infertility were evaluated withretrospective method. 1515 patients had primary infertility and 331patients had secondary infertility.Result: 654 patients were with male factors and 715 patients had femalefactors and 248 patients with male and female factors and 238 patientswith unexplained factors.Conclusion: Ovulatory disorder was the main cause for female factors,whereas varicocle the main cause for male factors.
P3.10.04CHROMOSOMAL ANALYSIS OF FAILED-FERTILIZED HUMANOOCYTES RESULTING FROM IN-VITRO FERTILIZATION ANDINTRACYTOPLASMIC SPERM INJECTIONS. Kunthikom , O. Makemaharn, S. Suksompong, Dept. OB/GYN, SirirajHospital, Mahidol University, Bangkok, Thailand.
Objectives: The aim of the study was to evaluate the incidence ofchromosomal abnormalities in “failed – fertilized” oocytes derived fromin-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)procedure.Study Methods: 164 oocytes from 62 IVF patients and 64 oocytes from32 ICSI patients were selected on the basis of availability of oocytes andstaff. Chromosomal analysis was performed using the method describedby Tarkowski.Results: 111 (67.7%) of the IVF and 56 (87.5%) of the ICSI oocyteswere successfully karyotyped. Of 111 IVF oocytes, 73 (65.8%)exhibited normal haploid and 38 (34.2%) were abnormal. Theabnormalities included 25 aneuploid (22.5%), 11 diploid (9.9%) and 2structural anomalies (1.8%). Of 56 ICSI oocytes, 52 (92.9%) werenormal haploid and only 4 (7.1%) were aneuploid. The sperm nucleiwere observed in 43 IVF oocytes (38.7%), composed of 38 (34.2%)premature chromosome condensation (PCC) and 5 (4.5%) decondensed
sperm heads. Evidence of successful sperm delivery was found in all 56ICSI oocytes; 25.0% (14/56) showed PCC, 17.9% (10/56) showeddecondensed sperm heads, and 57.1% (32/56) showed intact spermheads.Conclusions: This study suggested that about one-third of unfertilizedoocytes exhibited chromosomal abnormalities. The difference ofaneuploidy between IVF and ICSI oocytes needs further studiesanalyzing larger number of oocytes.
P3.10.05COMPARISON OF OVULATION INDUCTION WITH TWODIFFERENT RECOMBINANT FOLLICLE-STIMULATINGHORMONE PRODUCTS (PUREGON 50 AND GONAL F 75) FORIN-VITRO FERTILIZATIONN. Kanakas (1), T. Mantzavinos (2), K. Arvaniti (1), G. Creatsas (2)Euromedica IVF Unit, Athens, Greece.2nd Dept. OB/GYN, University of Athens, Athens, Greece.
Objective: Using the recombinant technology a new product of FSH hasbeen widely introduced in the IVF programs. The purpose of this studywas to compare the two commercially available recombinant FSHhormones regarding the IVF outcome and pregnancy rate.Study Methods: Retrospective data analysis between the two rec FSHhormones in an IVF centre. This study was carried out in 107 cycles(group A) receiving Puregon 50 IU (Organon, The Netherlands) and in102 cycles receiving Gonal F 75 IU (Serono, Switzerland) (group B)who participated in a comparative study between June 1997 andDecember 1999. Ovulation was induced using the same short protocol ofGnRH analogue (Buserelin, 1.2 mgr/day) and rec FSH was administeredstarting on day three of the cycle. Both products were administeredintramuscularly. A similar number of patients had their oocytesferitilized with the classical IVF method and the intracytoplasmicmethod (ICSI) in both groups. The mean age of the patient was 34.77years and 35.06 for group A and B respectively.Results: There were no statistical significant differences observed in theaverage number of ampoules administered per cycle (27.37 ± 8.43Puregon 50 IU and 28.69 ± 9.7 Gonal F 75 IU), in the duration oftreatment 7.97 ± 1.59 days (Puregon 50) and 8.71 ± 1.80 days (Gonal F75), in the cancellation rate, in the oocytes recovery rate (6.06 ± 4.3Puregon 50 – 5.82 ± 4.3 Gonal F 75) and in the number of embryostransferred between group A and B (2.7 ± 2.02 and 2.59 ± 1.73). Nosevere hyperstimulation was observed in both groups. Estradiol on theday of HCG administration did not differ between both groups (1435.21± 931.6 pg/ml in Puregon 50 IU group compared to 1608 ± 720.3 pg/ml,in Gonal F 75 group). Clinical pregnancy rates per embryo transfer didnot differ between both groups (19.1% for group A and 20% for groupB).Conclusions: Administration of the two different rec FSH products gavesimilar results in a significant number of cycles.
P3.10.06DIMINISHED T CELL ADHESION TO EXTRACELLULARMATRIX PROTEINS IN WOMEN WITH ANTIPHOSPHOLIPIDANTIBODIESM.Jerzak , W.Baranowski, J.Pajak, A.Gorski, Ludwik Hirszfeld Instituteof Immunology and Experimental Therapy, Polish Academy ofSciences, 53-114 Wroclaw, Weigla Street 12, Wroclaw, Poland, 53-114.
Objectives: Recent data emphasize the important role of extracellularmatrix (ECM) proteins in the regulation of T cell function. Evidence isaccumulating that activation of the immune system can influenceimplantation and may be responsible for unexplained infertility andpregnancy loss. Our previous data suggest the association of abnormallyhigh T cell adhesion to ECM proteins with recurrent spontaneousabortion (RSA). The aim of this study was to determine T cell adhesionto ECM proteins in antiphospholipid (APA) positive women.Study Methods: Thirty women with unexplained infertility, includingwomen with RSA, and ten normal healthy women with the previoussuccessful pregnancy outcome were studied. We investigated phorbolacetate myristate (PMA) and phytohemaglutinin (PHA) activatedperipheral blood T cell adhesion to the following proteins ofextracellular matrix: collagen IV (C-IV), elastin (E) and fibronectin(FN). APA concentration was measured by ELISA method.Results: We determined that PHA-activated T cell adhesion to C-IV and
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FN is significantly lower in APA positive women compared to APAnegative women.Conclusions: Our data suggest the existence of disturbed T cell: ECMinteractions in infertile women. Further studies are needed to determinethe role of those abnormalities in reproductive failure.
P3.10.07EVALUATION, INCIDENCE AND OUTCOME OF I.U.I ININFERTILITY CENTER, MASHHAD UNIVERSITY, IRAN, FROM1997-1999D.-H. Salare , D.Z. Yousefi, Dept OB/GYN, Mashhad University,Khorasam, Iran
Objective: Evaluation incidence and outcome of I.U.I in infertilitycenter, Mashhad university, Iran.Study Methods: 826 women who had I.U.I. were studied byretrospective analytic method.Results: In females, rate of pregnancy was mostly due to ovarian factors(26.4%) and lastly for tubal factors (9.9%) and multifactors (6.6%).Conclusions: I.U.I. is a cheap, good and available method that can beused in any center without much complication.
P3.10.08EVALUATION OF THE CERVICAL FACTOR IN INFERTILITYA.L.Astorri , G.Pompa, E. Terranera , A. Mancini*, A.Cappella Centerfor Study and Research on Natural Fertility Regulation * Institute ofEndocrinology, Catholic University of the Sacred Heart, Rome.
Objectives: A cervical factor of infertility has been widely proved. Infact, it could be recognizable in 15% of couples. However, an accurateevaluation of this factor of infertility is still at a preliminary level and soits real incidence is likely to be underestimated. The present studyanalyzes the cervical factor in a diagnostic-therapeutic protocol forinfertility.Study Methods: The study of cervical factor has been carried outthrough cytologic-colposcopic examination and cervical cultures. Forthe evaluation of cervical function we have referred to the BillingsOvulation Method. It is one of the most recent and effective methods toevaluate cervical secretion through the woman's self observation.Results :Out of 187 couples in the protocol, 94 women (50,27%) showeda vaginal-cervical pathology (VCP). The highest concentration of VCPcases was found in the group of infertility due to couples factors (66cases, equals to 70,21%).The study especially analyzes 45 patients resulted to show VCP as theonly female factor, isolated (15 cases) or associated with male factor (30cases).Conclusions: From our study results that the evaluation of the cervicalfactor of fertility comes out to be an important step in the screening ofinfertility and it may also be a contribution to the need for an accuratereproductive health care.
P3.10.09INDUCTION OF OVULATION IN INFERTILE WOMEN BYINTRAVENOUS ADMINISTRATION OF PERGANDLIZ. Dubossars’ka , Dept. OB/GYN, Dnipropetrovsk State MedicalAcademy, Dnipropetrovsk, Ukraine.
20 women with infertility of endocrime genesis and 10 practicallyhealthy women with retained reproductive function underwent complexinvestigation. Diagnostic program included not only tradidtional clinicalbut also hormonic investigation (the level of honadosteroic, steroid andcorticosteroid hormones, cyclic nucleotides). The condition ofprostaglandine system and complex investigatgtion of a sexual partner.20 women were given pergandli for induction of ovulation according tothe following scheme: pergandli3 ampules daily for 3 days, starting withthe first day of menstrual cycle. Then 2 ampules a day during thefollowing 9 days. We used US-monitoring, kept under control the“cervical number” and the content of estradioli in peripheral blood bythe method of radiommune analysis. In addition we injectedintramuscularly 10 000-30 000 units of prophasi once a day starting with12th day of menstrual cycle, then added 10 000 units of prophasiinjections on the 5th and 7th days after the increase of basal temperature.Special attention was paid to the androgens and their metabolits in the
urine. When the level in 17 neutral ketosteroids in 24-hour urine washigher than 38.6 1,4 Mk-mol the patients were given the evening _ tabletof dexametzon (0.005 mg) under the control of dehydroepinandrosteron:the women the basal temperature rose the doze of demetazon waslowered up to _ tablet. The worked-out tactics of treating allowed toachieve the rehabilitation of the reproductive function with 33.7% ofpatients, 62% of whom gave birth to mature children and 38% - topremature children.
P3.10.10INFLUENCE OF THE DAYLIGHT ON QUALITATIVECHARACTERISTICS OF SPERM IN PATIENTS WITHOLIGOSPERMS. Khmil , S Halnykina, A. Nychyk, B. Keisa, Dept. OB/GYN, TernopilState Medical Academy, Ternopil, Ukraine.
Objectives: Because of natural conditions the non-collision ofspermatozoa with the light impelled us to learn the influence of thenatural daylight on spermatozoa in patients with complicatedoligosperm.Study Methods: We conducted a cytoluminestsentic test of spermatozoaof two randomized groups of patients with complicated oligosperm. Allmanipulations with sperm of patients (n=32) of the first group fromgaining to investigation were kept in the dark (in the dark room). Spermof patients of the second group (n=38) was taken and kept in room withnatural daylight. The results of the investigation were made statistically,using Fisher’s criterion.Results: Spermogram of patients of the first group was characterized bythe authentic increase (p<0.05) of quantity of spermatozoa, colored byacredine-orange in red colour.Conclusions: It is obvious that the aggressive action of the natural lightagainst the background of exhaustion of compensatorily – adjustedmechanism in patients with complicated oligosperm is detrimental tonuclear structures of spermatozoa.
P3.10.11MEDICAL TREATMENT FOR NONOBSTRUCTIVEAZOOSPERMIA MAY OBVIATE THE NEED FOR SPERMTESTICULAR RETRIEVALN.Abdulwahid , Reproductive Endocrinologist, Amman, Jordan
Objectives: Because multiple Testicular sperm extraction ( TESE)procedures can cause transient and permanent alterations in testicularfunction (Ostad et al, Urology 1998; 52:692). Therefore medicaltreatment for male infertility may play a role in NonobstructiveAzoospermia ( NOA) so as to avoid surgical sperm retrieval.Study Methods: This is a prospective study of 10 men with NOA treatedwith medical treatment for 3-6 months. Men investigated at time ofpresentation. And divided into 2 groups. Group 1 is 6 patients withtesticular biopsy of Germ Cell Hypoplasia. This problem is due toVaricocel in 2 patients and idiopathic in 4 patients Age (mean+_sd) 37+-7.8 Infertility duration 9.3+_7. Group 2 is 4 patients with testicularbiopsy of Maturation Arrest .Age 41+_5.9.Infertility duration 14.3+_5.6. All 10 men were treated by four medications (Tamoxifen 20 mg,Polljuven, Juvelon, Trental) for 3-6 months. Assisted reproductivetechniques offered to all but refuse for financial reasons except ICSIdone for 2 cases and IUI done for other 2 cases of group 1 only.Results: Group 1 Sperm retrieval from semen samples achieved in 5 outof 6 patients after 3 months medical treatments in all cases .One ICSIprocedure was done using semen sample with successful fertilization butno pregnancy. The only azoospermic man ICSI was done with TESE forwhom fertilization achieved but no pregnancy. As far as the other fourpatients whom refuse ICSI for financial reasons extended medicaltreatment up to 6 months resulted in one pregnancy with IUI and anotherspontaneous pregnancy with successful delivery in both thosecases.Group 2 All those patients remain azoospermic at the end of 6months medical treatments.Conclusion: Medical treatments have a role in NOA patients with GermCell Hypoplasia prior contemplating ICSI procedures.
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P3.10.12OVULATION STIMULATION AND INTRAUTERINEINSEMINATION IN THE TREATMENT OF INFERTILITYM. Vasiljevic , N. Antic, M. Prorocic, E. Garalejic, S. Dragojevic,B.Arsic, O. Dzatic. Clinic of Gynaecology and Obstetrics "NarodniFront" University of Belgrade, Yugoslavia
The aim of this study was to analyze the success rate of ovulationstimulation and intrauterine insemination in infertile patients whoseovulation was stimulated by three different protocols, and to determinethe most successful of the protocols applied.Materials and methods: The study included 49 infertile patients ofaverage age 32.3 years (25-34 years), with a mean infertility duration of4.7 years (1-8 years). Infertility causes were: cervical factor,anovulation, male factor and unknown causes. For ovulation stimulationthe following protocols were applied: In the first group of patients(n=18), follicle-genesis was stimulated with human menopausalgonadotrophins (Pergonal), the second group of 16 patients wasstimulated by pure urinary follicle stimulating hormone (Metrodin); andthe third group consisted of 15 patients who were stimulated withrecombinant follicle stimulating hormone (Puregon).The cyclestimulation started on the fifth day of the cycle. Pergonal wasadministered in the dose of 150 IU, every other day. Metrodin wasadministered daily with 1 ampule of 75 IU, and Puregon with 1 ampuleof 50 IU daily. The follow up of the follicle growth and developmentwas done by vaginal ultrasonography, as well as determining theoestradiol concentration and lutenizing hormone in serum. Intrauterineinsemination was done 24 hours after the administration of Pregnyl, andthe sperm samples were prepared according to the “swim up” method.Results: In 49 patients 68 cycles were stimulated. Eighteen patientsachieved pregnancy which means that the percentage rate per patientwas 36.7%, and per stimulated cycle 26.7%. The pregnancy rate perpatient in the different patient groups was: in the first group 22.2% (4out of 18); 43.7% (7 out of 16) in the second group; and 46.6% (7 out of15) in the third group. The pregnancy rate per stimulated cycle in thethree groups was: 15.3% (4 out of 26) in the first group; 31.8% (7 out of22) in the second group; and 35% (7 out of 20) in the third group ofpatients.Conclusion: The best results are achieved when cycles are stimulatedwith Metrodin and Puregon.
P3.10.13PRONE POSITION OF THE PATIENT AFTER LOCAL REPAIR OFV.V.F.S.A. Talukder , Dept. OB/GYN, Sher-E-Bangla Medical College,Barisal, Bangladesh.
Objectives: The aim of the study was to investigate the effect of proneposition on local repair of V.V.F.Study Methods: 10 V.V.F. patients were operated by local repair underspinal anesthesia in a district level hospital where anesthetist was notavailable. So anesthesia was given by the author himself. Later on anuntrained nurse maintained the anesthesia. The assistants were also theuntrained nurses in absence of trained doctors.Results: Out of 10 V.V.F. patients 9 cured completely. One patient wasnot cured due to blockage of the catheter. She was cured after threemonths in second attempt.Conclusion: Prone position after local repair of V.V.F. has a good effecton the success of the operation.
P3.10.14RESTORATION OF THE UTERINE TUBES PATENCY BYEMPLOYMENT OF LOCAL LOWERED PRESSURED.Y. Mirovich , I.G. Gerasimov, Research Institute of Family MedicalProblems of Donetsk Government Medical University, Donetsk,Ukraine.
Objectives: The local lowered pressure (LLP) was applied for restorationof the uterine tubes patency in women with different types of the tube-peritoneal infertility.Study Methods: The influence of LLP was exerted on small pelvisregion and abdominal organs, limited from above by low brims of ribsand from below by upper third of hips. The pressure was applied on 75mmHg lower than atmosphere one, in permanent and broken regime.
Duration of procedure (15 – 20 on course) was 5 – 20 minutes.According to indications, the course was repeated up to five times withinterval 1 – 2 months in period between menstruations. The effect oftreatment was assessed by the kymopertubation and thehisterosalpingography data (direction and percent of changes coincided).Results: Results of the employment of LLP are a restoration of theputerine tubes patency on 42.1 – 74.6% that is higher rate than withoutuse of LLP. The effect of the treatment of primary infertility less than ofsecondary one (57.4 – 61.8% and 63.5 – 74.6% accordingly) and inbilateral pathology than in unilateral (63.1 - 71.0% and 61.1 – 67.9%accordingly). Single results of treatment were assessed in 1 – 3 years byquestionnaire data of 216 women. Pregnancy had advanced in 98patients (45.4%); 5 (2.3%) of them had miscarriages and 7 (3.2%) hadextrauterine pregnancy; 203 women (39.4%) had labors with successfuloutcomes.Conclusions: So, LLP is effective method of the uterine tubes patencyrestoration.
P3.10.15SERUM CONCENTRATIONS OF INHIBIN AND ACTIVIN ADURING OVARIAN HYPERSTIMULATION WITH FSHG. Bartzke (1), F.W. Casper (2), R.J. Seufert (2), K. Pollow (2)(1) Dept. OB/GYN, Urei Surankenhaus, Rottweil, Germany.(2) Dept. Endocrinology, University of Mainz, Mainz, Germany.
Objectives: Recently, it has been reported an increase in totalimmunoreactive inhibin levels after the administration of exogenousgonadotropins for ovulation induction.Study Methods: We have investigated serial changes in plasmaconcentrations of inhibin A, inhibin B, pro alpha C and activin A in 51women undergoing stimulation with recombinant FSH bevor artificialinsemination. Blood samples were collected at the early follicular phase,during stimulation with FSH, at ovulatory triggering and during theluteal phase of the menstrual cycle.Results: During stimulation and a day after ovulatory trigger, levels ofboth inhibins and pro alpha C are markedly increases, whereas activin Awas largely unaltered. Statistical analysis demonstrated a closecorrelation between the number as well as the sonographic diameter offollicles and the inhibin response. Women with no Graaf-follicle showedunchanged serum levels of inhibins.Conclusions: The positive correlation observed between inhibin levelsand the number of follicles larger than 15 mm suggest that inhibin maybe useful as a marker of dominant follicle development in artificialinsemination. Furthermore these data indicate that ovarian production ofinhibins in women is gonadotropin-dependent.
P3.10.16THE COMPARISON OF NITRIC OXIDE AND MOTIONCHARACTERISTICS OF TWO PREPARATION METHODS INHUMAN SPERM: 3-LAYER PERCOLL AND PURESPERMMETHODG. J. Wu , D. C. Ding, Division of Reproductive Endocrinology, Dept.OB/GYN, Tri-Service General Hospital, National Defense MedicalCentre, Taipei, Taiwan, R.O.C.
Objectives: To compare two different spermatozoa methods: three layersPercoll and Puresperm method with respect to recovery, motioncharacteristics and Nitric Oxide (NO) production of the supernatant aftercentrifugation.Study methods: Each of 39 semen specimens was divided and eachaliquot was prepared using two methods mentioned above. The recoveryrate and motion parameters were measured for each semen specimens(n=39) prepared with the two methods. The NO was measured with usethe chemiluminscence method after centrifugation.Results: Recovery rate was higher in Puresperm method (45.4±28.7%).The other motion characteristics were improved than fresh semensamples. Hyperactivation of the sperm was improved in purespermgroup comparing to the fresh sperm (Percoll:24.7±16.9%, Puresperm:20.5±10.5% vs fresh: 9.2±9.2%). NO produced in the Puresperm wassignificantly lower than in the Percoll (0.24±0.3 uM vs 0.54±0.91uM)
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Conclusions: Our data suggest that Puresperm method had a betterrecovery rate, but other motion characteristics are not to demonstrate anysignificant difference. The NO produced lower in the Purespermpreparation method may suggest the good quality of human spermachieved is due to the decreasing NO production.
P3.10.17THE EFFECT OF ASPIRIN AND PREDNISOLONE ONINCREASING THE CHANCE OF IMPLANTATION IN WOMENWITH AT LEAST TO FAILED IMPLANTATION CYCLESA.Aflatounian 1,2,3, MA. Karimzaeh Meybodi2,3, SM Kalantar1,3, MH Amir Arjmand1,3 and M. Solimani1,3
1Research & Clinical Centre for Infertility, 2Department of Obs. & Gyn.Medical Sciences University, Yazd-Iran. 3Madar Hospital for Women,Reproductive and Genetics Research Unit, Mahdieh Square, 89167,Yazd-Iran
Objective: Although the fertilization rate in ART cycles are high,however, implantation rate is remained low. The aim of the study was toassess the effect of prescription of Asiprin / Prednisolone (ASP/PRE) onthe time of embryo transfer on implantation rate. PrednisoloneStudy Methods: 38 women who had underwent at least previous twoembryo transfer cycles without chemical pregnancy were enrolled in thisstudy. The ART treatment cycles were done for these couples accordingto the cause of their infertility. From the first day of treatment cycleswomen undertake Aspirin (75mg/daily) and Prednisolone (10mg/daily)till the termination. Fertilization rate (FR), number of embryo transferred(ET) and pregnancy rate (PR) were assessed. Significant differencebetween cycles with (+) and without (-) (ASP/PRE) was analyzed byANOVA using SPSS.Results: In four cycles embryo transfer was not performed. There wasnot significant difference between FR% in positive and negative cycles,60.9% ± 7.9 and 75.5% ± 6.3 (mean ± SE), respectively (p>0.05). Also,fertilization rate was not significantly different between (+ASP/PRE)cycles (n=85) and (-ASP/PRE) cycles, 68.1± 8.5 and 64.25 ± 7.1,respectively (p>0.05). In 8 out of 34 (23.5%) cycles pregnancy wasconfirmed by positive b HCG and subsequently by sonography, one EP,3 healthy babies was born in 3 cycles and 4 ongoing pregnancy.Conclusions: Our result showed that in the case of cycle's treatment withAspirin and Pyrandazol increased the chance of implantation in patientswith implantation failure. It would suggest to use Aspirin andPyrandazol in patients with low or failure implantation history duringART treatment cycles.
P3.10.18THE IMPACT OF NUMBER OF FACTORS ON QUALITY-OF-LIFEIN EARLY POSTOPERATIVE PERIOD AFTER SURGICALTREATMENT OF ECTOPIC PREGNANCY.E.K ira , V.Bezhenar, I.Berlev, N.Ruhliada, Russian Medical MilitaryAcademy, Lesnoy st. 4-74, St.Petersburg, Russia, 194044.
Objective: to estimate the influence of different factors on health-relatedQuality-of-Life in patients in early postoperative period after surgicaltreatment of ectopic pregnancy.Material: we evaluated the QOL with the help of our originalquestionnaire for QOL estimation after tubal surgery in 3 and 14 daysafter surgery. For all patients (n=92) we fulfilled the cross-matchcorrelation of clinical data and QOL parameters, estimated thecorrelation (r) expression. The correlation was supposed to bestatistically significant in r>0,7.Results: The correlation analysis performed has revealed the existence offollowing QOL dependencies:- of time to hospitalization; the longer that period, the worse QOLparameters in 3 days postoperation (r=0,846). The worst meaning wasfound in women, hospitalized later 72 hours since the first symptomshad appeared (Integral QOL Index =138,3±11,2 points Integral QOLIndex = hospitalized later 72 hours since the first simptoms had appeared()s)- of hospital preoperative stay; the longer the time before operation, theworse QOL in 3 and 14 days after it (r=0,712).- of laparotomy surgery length; the longer the operation - the worse theQOL in 3 and 14 days postoperation (r=0,711). For laparoscopictreatment there was found no significant correlation (r=0,073).- of hemodynamics, estimated with Allgever’s shock-index (pulse
rate/systolic BP); the higher the meaning - the worse QOL (r=0,81).on 14 postoperative days - of preoperative preparation provided,including infusion, on indications - hemotransfusion and intraoperativeblood reinfusion. In full-volume and non sufficient pre-op preparation:Emotional condition (4,3±0,2 and 6,5±0,1 points) and PhysicalFunctioning (5,5±1,2 and 8,6±0,1 points), p<0,05.Conclusion: early hospitalization, fast diagnostic of EP, the rationalpreoperative preparation, the wide use of laparoscopy, that leads tosurgery and hospital stay shortening - are the factors, that have asignificant impact on patients’ QOL in early postoperative period.
P3.10.19THE ROLE OF LAPAROSCOPY IN THE THERAPY OFINFERTILITYZ. Sleberenyi , A. Rucz, Dept. OB/GYN, Rethy Pal Hospital, Bekeslaba,Hungary.
Objective: The problem of relatively expensive IVF methods callattention to the other procedures in the treatment of infertility. Thelaparoscope is an excellent instrument of these procedures and it isuseful in smaller hospitals as well.Study Methods: The treatment of hydrosalpynx by laparoscopy is verysimple: with monopolar hook-electrode the tuba is opened in Y form.After this procedure with the “back” of hook – with little power –coagulate the side of injury, turn it out. Then we have to see the endothelof tuba: if it is thin, discolored, it is better to perform salpingectomy andsend the patient to the IVF center. The solution of PCO-sy is thesimplest in the laparoscopic surgery of ovars.30-40 follicals arecoagulated in each side with monopolar needl-electrode.Results: Laparoscopic myomenucleation is a difficult procedure. A moredifficult thing is the right indication of operation. It is very important toinform exact the patient. We cannot leave out of consideration, that weoften find big myoms in unfavorable places in pregnancies withoutcomplaints. At the same time during myomenucleation, we can get suchbleeding that results hysterectomy. In the myomenucleation followingpregnancy could happen silent uterus rupture as well. The patient mustknow it. First of all, by the operation, the environment of myom isinfiltrated with POR 8 solution, then the uterus is opened withmonopolar hook-electrode. It is very important to find the right layerquickly, then the blunt preparation. When we are in equator of myom,the patient must get iv.oxytocin After removing myom, we close theinjury of uterus with forthrunning PDS stitch in the end PDS clips.Conclusion: The best instrument for the solution of endometriosis is thelaser. Without laser, we can use monopolar needle-electrode as well. Wecan vaprise and preparate with it too. By retrocervical endometriosis, thesurgeon’s right hand held the needle-electrode and with left hand hehelps himself in the vagina. It is not comfortable, but very good methodfor preparation. The renaissance of tuba-recanalization is thanks tolaparoscop.
P3.10.20THE ROLE OF TESTICULAR BIOPSIES IN SEVERE MALEFACTOR INFERTITYGy. Bógyi,1, T. Kirösi2
1Kenézy Hospital & Polyclinic, Department of Urology and2Department of Obstetrics and Gynecology, Infertility Unit, UniversityMedical School of Debrecen, Hungary
Objective: To assess the value of testicular biopsy during infertilityworkup.Materials and Methotds: We have evaluated 377 infertile men in ourDepartment between January 1, 1994 and December 31, 1999. Out ofthese subjects 98 patients required testicular biopsy. The indications forthese procedures are outlined in the WHO standard protokollResults: In this study group 50 men (51%) were eligible formicromanipulation while 48 patients (49%) received medical treatmentto improve the spermcount.Conclusion: Testicular biopsies are helpful to select patients with severemale factor infertility for appropriate therapy.
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P3.11 MATERNAL MORBIDITY ANDMORTALITY
P3.11.01A STEP FORWARD ON THE PATHWAY TO MATERNAL ANDPERINATAL SURVIVAL: GUATEMALA’S MOTHERCAREPROJECT (1994-98)E. Bocaletti , Institute of Tropical Medicine, VA, United States
Objectives: Guatemala has a Maternal Mortality Ratio of 248 per100,000 live births, the third highest in the Western Hemisphere. Themajority of births take place at home with traditional birth attendants.The MotherCare Project aimed to bring the communities and healthfacilities together to save the lives of women and newborns. Methods:Recognition of life-threatening complications and their danger signs andwhere to go for help were emphasized during TBA training, broadcastby radio to communities, formed the basis for counseling during prenatalcare, and were a major focus in the discussions with women’s groups.Tutorial training followed by monthly supervisory visits, includingsensitization to local birthing traditions strengthened their counselingand clinical skills.Outcome Measures & Results: Rural departments in project areas havewitnessed increases in use rates of 50 to 77%. Met Need has doubled inproject area hospitals (meaning a greater proportion of women havingcomplications seek care). Equity has improved through increased use ofEOC services by women. The confidence and skills of providers toperform high quality maternal and newborn care have significantlyimproved, and continues more than 2 years after completion of thetraining course. The trained providers and facility directors report animproved attitude toward providing care and working in a team, as wellas providers’ enhanced ability to recognize problems early and tointervene skillfully.Conclusions: Nearly a third of the country has been reached by thiscommunity-based approach to reach women and newborns withessential obstetric services. The next steps are to sustain currentactivities and expand them across of the country.
P3.11.02A TWO YEAR REVIEW OF THE PATTERN OF MATERNALMORTALITY AMONG MIGRANTS IN MALAYSIAZ. Shamsuddin , Dept. OB/GYN, Hospital Kuala Lumpur, KualaLumpur, Malaysia.
Objectives: The aims of the study were to investigate the pattern ofmaternal deaths among migrant mothers and to review its impact on thenational maternal mortality statistics in Malaysia.Study Methods: This study was part of a detailed retrospective analysisof all maternal deaths occurring in Malaysia in 1995 and 1996 reportedto the National Confidential Enquiries into Maternal Deaths. Deathsamong migrants were identified and analyzed as a separate cohort.Results: In 1995 there were 251 maternal deaths with a MMR of46.91/100,000 live births of which, 79 (15.5%) were migrant mothers.For 1996, 220 deaths were reported, with a MMR of 40.7/100,000, ofwhich 40 (18%) were also migrants. Most of these deaths wereIndonesians and Philippino migrants. Deaths were mainly from post-partum hemorrhage, obstetric pulmonary embolism and complications ofpregnancy induced hypertension. Increased risks were associated withage 25-29, parity 1-5, poor uptake of contraceptives, failure to obtainantenatal care and late transfer to hospital.Conclusion: While a migrant status-specific MMR was difficult toobtain due to the lack of known denominators. Almost a fifth of thematernal deaths in Malaysia were migrants. Migrant mothers werecertainly at risk of dying from PPH, OPE and PIH. Socio-economicfactors clearly influenced maternal mortality, overriding bothgeographical and cultural differences. Illegal entry and lack of validtravel documents prevented migrant mothers from seeking antenatal carefor fear of deportation despite the health care authorities relativeindifference to citizenship status.
P3.11.03ACCURACY OF THE BLOOD LOSS ESTIMATION IN THE THIRDSTAGE OF LABORW. Prasertcharoensuk , U. Swadpanich, P. Lumbiganon, Dept. OB/GYN,Faculty of Medicine, Khon Kaen University, Khone Kaen, Thailand.
Objectives: The aims of the study were to assess the incidence ofpostpartum hemorrhage in vaginal delivery and to assess the diagnosticperformance of visual estimation in detecting postpartum hemorrhage.Study Methods: 228 [regnant women who had vaginal delivery atSrinagarind Hospital from Dec. 1, 1996 to Mar. 1, 1997. Blood lossthrough vagina following vaginal delivery was visually estimated andalso directly measured. Postpartum hemorrhage was defined as bloodloss of at least 500 ml.Results: The mean visually estimated blood loss was 263.81 ml(SD=152.06) whilst the mean measured blood loss was 362.89 ml(SD=298.85). The incidence of postpartum hemorrhage by visualestimation and direct measurement were 5.70% and 27.63%respectively. Visual estimation resulted in a 88.88% underestimation ofPPH. The sensitivity, specificity and accuracy of visually estimatedblood loss in detecting postpartum hemorrhage were 15.87%, 98.18%and 75.43% respectively.Conclusions: Visual estimation primary is very insensitive in detectingpostpartum hemorrhage. Obstetricians should be aware of thisunderestimation and use other signs and symptoms in the managementof third stage labor.
P3.11.04BURDEN OF ILLNESS-CHRONIC SEVERE ANAEMIA INOBSTETRIC PATIENTS IN RURAL NORTH INDIAA.H. Khosla, K. Sangwan. Dept. OB/GYN. PGIMS, Rohtak, Haryana,India.
Objectives: To collect relevant information about chronic severeanaemia (CSA) in the obstetric population of rural North India(Haryana) with a view to devise strategies which wil reduce maternalmorbidity and mortality by focussing on the high risk population.Study Methods: A prospective study (Jan. to Dec. 1998) in which allpregnant patients with haemoglobin £ 6 grams/dl excluding those withacute blood loss i.e., abortions, antepartum and postpartum haemorrhageadmitted to the department of obstetrics an gynaecology, PGIMS,Rohtak (Haryana) India were interviewed.Results: There were 5124 deliveries at PGIMS, Rohtak in the studyperiod. There were 386 patients (7.53%) of CSA admitted who receiveda total of 1083 units of blood (mean 2.80 per patient). There were 2maternal deaths due to CSA. A total of 246 of the 386 women could beinterviewed in detail. The demographic features of these women(anaemic group) were compared with 100 pregnant women withhaemoglobin >10 grams/dl (non anaemic group). In the amaemic group81.7% were illiterate, 62.1% had no antenatal check up, 78.8% had noaccess to safe drinking water, 90.6% had no toilet facilities and usedopen fields for defecation; 63.0% reported having diarrhoea andabdominal pain off and on during pregnancy and 20.73% gave historypassage of worms in the stools. 82% had no regular income and had adiet poor in protein, calories iron and calcium. All were vegetarians. Thefigures for the non anaemic group were illiterate 34%, antenatal checkup in 76%, no toilet facilities in 55%, no safe drinking water in 38%,diarrhoea 6%, history of passage of worms in stool 2%.Conclusions: Pregnant women with no regular source of income,illiterate, without any public health facilities should be the beneficiariesof any programs for women and child health. These health interventionswould be more cost effective comparing the cost of hospitalization,blood transfusions and DALYs (Disability Adjusted Life Years).
P3.11.05CONSERVATIVE MANAGEMENT OF SPONTANEOUSABORTIONP. Busacchi , T.Perri, P.Pocognoli, C.Oliverio, C.Flamigni, University ofBologna, Via Massarenti, 9, Bologna, BO, Italy, 40138.
Objectives: The aim of the study was to evaluate the benefit of aconservative therapy in spontaneous abortion.Study methods: We recruited 27 pregnancy patients admitted to ourhospital with the diagnosis of spontaneous abortion. Their mean age was
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31.7 years and the mean period of amenorrhea at the time of abortionwas 6.9 weeks. Each patient underwent an ultrasound examination (US)to asses that the endometrial thickness was < 12mm; blood samples wereused to evaluate the hematic parameters (Hb-Ht) and the decrease ofbeta-hCG. The mean endometrial thickness was 5.3 mm; the mean beta-hCG value was 425.9 mU/ml. Each patient received, at discharge, atherapy consisting in uterotonic and antibiotic drugs, respectively for 5and 3 days. The follow-up consisted in a US control and beta-hCGdosage a week after the discharge, beta-hCG and Hb-Ht dosage after twoweeks; and US and b-hCG dosage after 4 weeks.Results: The mean value of beta-hCG at the third control has beenremarkably reduced to 9.6 mU/ml. The mean value of endometrialthickness was 8 mm. In all cases, except one, the vaginal bleedingdisappered during the therapy with no complications.Conclusions: Conservative therapy seems to be a good approach forpatients with spontaneous abortion if opportunely selected.
P3.11.06DESTINATION – SAFE MOTHERHOOD – INDIAN PERSPECTIVES. Patwardhan , Dept. OB/GYN, Sai Seva, Pune, India.
Objective: Increase awareness about the dangers a woman faces as shetakes on the challenge of motherhood and how to prevent them.Study Methods: The message rides across the country as a series ofbicycle rallies and sessions on Safe Motherhood.Symbol of Trust: Pedaling achieves instant rapport with the ruralpopulation. Visibility has played a major role in making ‘SafeMotherhood’ a people’s movement. It is a live message for the urbanpopulation in eradicating pollution and enhancing fitness.Safe Motherhood and Cycling: Safe Motherhood primarily deals withMaternal Mortality. On a broader canvass, protecting the Mother Earthfrom pollution is also our responsibility. Hence pedaling.Simplicity: The concept of promoting Safe Motherhood with the use of abicycle is simplicity personified.Savings: Both Safe Motherhood and Cycling result in substantialsavings. The same is true for cycling. The minimal cost involved is adefinite bonus.Unique features of ‘Destination – Safe Motherhood’: Physical eventwith a social purpose, going close to the people we serve, generatinggoodwill, increased interaction between societies, participation bymedico’s form other branches and pathies and participation by motivatedindividuals from other walks of life are the unique features of thismovement. It is the first time that lay people have taken such interest inunderstanding what ‘Safe motherhood’ is. Many groups have begun inMaharashtra (India) using pedaling for this purpose.Conclusion: Destination – Safe Motherhood has been a tremendoussuccess in making ‘Safe Motherhood’ a mass movement.
P3.11.07EPIDEMIOLOGY OF INCONTINENCE, BIRTH TRAUMA ANDUTERO-VAGINAL PROLAPSE IN RURAL WOMEN IN THEGAMBIA, WEST AFRICAC. Scherf 1, G. Ekpo2, L. Morison3, G. Walraven1 1Dept. Medicine, University of Wales, Cardiff CF14 4NX, UK2Medical Research Council Laboratories, P.O. Box 273, Banjul, TheGambia3London School of Hygiene and Tropical Medicine, Keppel Street,London WC1E7HT, UK
Objectives: To explore the epidemiology of incontinence, utero-vaginalprolapse and other signs of injury related to childbirth in a highly parouscommunity in rural Gambia.Study methods: 1,151 women underwent gynaecological examination aspart of a community-based survey of women aged 15 to 54 resident in20 villages in The Gambia (see abstract Walraven et al.). Women withgenital prolapse and/or incontinence were identified and classified intoanterior, posterior or uterine prolapse with three different stages ofseverity.Results: Utero-vaginal prolapse was present in 488 (42%) of women;cystocele 25%, enterocele 14%, urethrocele 12%, rectocele 8% anduterine prolapse 7%. 13% of all women would have warranted surgicalintervention (moderate, severe or symptomatic prolapse). 14% of thosewith any genital prolapse reported symptoms. This increased to 37%symptomatic women among the ones warranting surgery. Risk of
prolapse increased with parity up to 4 deliveries. Other types of birth-trauma found were functional damage of the anal sphincter muscle (3%)and vesico-vaginal fistula (0.1%). Symptoms of urinary incontinencewere reported by 82 (7%) women.Conclusions: This large community-based study confirms a highprevalence of birth-trauma consistent with previous smaller studies indeveloping countries. The rate of urinary incontinence was lower thanexpected with this degree of uterovaginal prolapse and birth-trauma.Few women with prolapse complained of problems indicating that self-report is a poor measure of the true prevalence of uterovaginal prolapse.
P3.11.08GRAVID UTERINE RUPTURE - A MALAYSIAN EXPERIENCE INKLANGK.L.Wong , W.K.Tan, K.Y.Ng. Tengku Ampuan Rahimah Hospital,Jalan Langat, Klang, Selangor D.E., Malaysia, 41200.
Objectives: To determine the incidence, the etiological factors andfetomaternal outcomes of gravid uterine rupture.Study Methods: A 5 years (1995-1999) retrospective study of graviduterine rupture to analyze the predisposing factors, clinical presentation,management, maternal and fetal complications.Results: Of the 77046 deliveries, there were 21 cases of uterine rupture,an incidence of 1:3669 deliveries. Majority of the cases identified wereMalays (62%). However, the highest incidence was among the'immigrants' from neighboring countries (1:2393 deliveries). Otherpredisposing factors include maternal age more than 35 years,grandmultiparity and previous uterine surgery. The two commonestclinical features were sudden fetal death and vaginal bleeding (both52%). 14% of the cases were silent. Maternal morbidity was high (84%).Majority had DIVC (81%) and hypovolemic shock (67%). 71% hadhysterectomy performed and all needed blood transfusion. 76% neededadditional transfusion of DIVC regime. There was 1 maternal death and8 perinatal deaths in this series.Conclusions: The incidence of uterine rupture has improved ascompared to the incidence reported in 1991 in University MalayaHospital. Factors contributing to this achievement include: (i) faithfuladherence to the partogram (WHO, 1991) and early recourse toCaesarean section in suspected fetomaternal disproportion, (ii) reductionin the use of ECV, (iii) the improved health care facilities. However,injudicious use of oxytocics in cases with prior uterine surgery, poorcontraception leading to grandmultipartiy and increased maternal age arestill the crux of the problem. Majority of the cases survived despite thedevastating complications.
P3.11.09GYNECOLOGICAL PROBLEMS AMONG HONG KONG CHINESEWOMEN IN THE FIRST THREE MONTHS FOLLOWINGDELIVERYT.N. Leung (1), D.T.S. Lee (2), S.K. Yip (1), T.K. H. Chung (1), (1)Dept. OB/GYN and (2) Dept. of Psychiatry, Prince of Wales Hospital,The Chinese University of Hong Kong, Hong Kong, China
Objectives: To identify the common gynecological problemsencountered by Hong Kong Chinese women in the first three monthsfollowing delivery and test if their magnitude is related to theirpsychological well-being.Methods: 320 Chinese women who gave birth in the Prince of WalesHospital, Hong Kong, were followed up at 3 months after delivery.Interviews were conducted using structured questionnaires.Gynecological problems, choice of contraception and feeding practicewere recorded. The levels of general psychological well-being were alsoassessed using GHQ.Results: The mean age of the study group was 29.6 years. It took anaverage of 29.6 days for the lochia to disappear in the postpartum periodbut 13.8% of women had persistent lochia at 6 weeks postpartum. 83.4%of women had return of menstruation at follow-up and the mean time forthe menstruation to return was 8.4 weeks. 22.8% experiencedpersistently increased menstrual flow while 10.5% of womencomplained of more pain during menstruation. The majority (67.8%)experienced some form of perineal pain but only 2.5% persisted at 3months. 90.6% had resumed coitus at follow-up and the median time ofresuming coitus was 49 days. Condom contraception was the mostpopular means of contraception (66.6%). Immediately after delivery,
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38.1% had breast-feeding, but it was reduced to 8.4% at 3 months. ‘Afear of insufficient milk production’, ‘sore nipples’ and ‘inadequate rest’were the 3 most frequent complaints among breast-feeding mothers.Forty-eight (15%) had a GHQ score of ³ 5. There was no associationbetween the GHQ score and the frequency of any of the gynecologicalproblems.Conclusions: A significant portion of women had increasedgynecological morbidity at 3 months after delivery, which cannot beattributed to psychological factors.
P3.11.10HELLP SYNDROME AND ACUTE FATTY LIVER OFPREGNANCYP. Vigil-De Gracia , Dept. OB/GYN, Complejo HospitalarioMetropolitano de la Caja de Seguro Social, Panama, Panama.
Objective: To investigate the relationship of clinical and laboratoryfindings between HELLP syndrome (HS) and acute fatty liver ofpregnancy (AFLP).Study Methods: Ten cases with AFLP and 75 with HS managed duringthe past 3.5 years were studied with emphasis on presenting symptoms,laboratory findings, maternal complications and neonatal outcome.Results: The main symptoms of HS were headache (75%) and epigastricpain (51%); in patients with AFLP were general malaise (100%), nauseaand/or vomiting (70%), epigastric pain (70%) and jaundice (60%). Twomaternal deaths occurred with HS (2.7%) and two with AFLP (20%).The perinatal mortality was 17.5% for HS and 18.2% for AFLP.DIFFERENTIATION OF HS AND AFTP
HS (76) AFLP (10) SIGNIFICANCE
Maternal age (yr) 29.07±6.18 29.00±4.67 NS
Gestational age (wk) 34.0±4.1 35.8±3.4 NS
Parity 2.25±1.5 1.4±0.7 P<0.006
Platelets (x1000/mm3) 62.2±27.15 76.3±50.48 NS
LDH (IU/L) 1398±930 993±407 P<0.02
AST (IU/L) 281±311 444±358 NS
ALT (IU/L) 202±180 392±247 P<0.04
Glucose (mg/dl) 76±17 37±19 P<0.00001
Total bilirubin (mg/dl) 1.36±0.7 11±8.8 P<0.007
WBC (x 1000) 17±5.3 27.4±7.75 P<0.002
Fibrinogen (mg/dl) 482±199 136±120 P<0.00001
Cholesterol (mg/dl) 210±73 72±45 P<0.00001
Triglyceride (mg/dl) 247±100 101±54 P<0.00001
Renal Failure (#) 15 9 P<0.0002
DIC (#) 5 7 P<0.00001
Ascites (#) 5 3 P<0.048
Stay (day) 7.3±2.4 13.1±5.0 P<0.005
Blood transfusions (#) 26 8 P<0.01
Conclusion: Our results suggest that AFLP have clinical and laboratoryfindings significantly different from HS. Thus, the diagnosis of AFLPand HS rests primarily on history, physical examination and laboratorydata.
P3.11.11IMPROVEMENT IN MATERNAL MORTALITY IN RURALGAMBIAG.Walraven 1, M. Telfer2, J. Rowley1, C. Ronsmans3 (1) Medical Research Council Laboratories, P.O. Box 273, Banjul, The
Gambia(2) Divisional Health Team North Bank East, State Department for
Health, Banjul, The Gambia(3) London School of Hygiene and Tropical Medicine, Keppel Street,
London WC1E7HT, UK
Objectives: To estimate maternal mortality, its causes and contributingfactors in a demographic surveillance area in rural GambiaStudy methods: Maternal mortality is estimated from a reproductive agemortality survey of all deaths in women aged 15-49 between January1993 and December 1998.Results: 18 maternal deaths were identified by verbal autopsy from the74 deaths in women aged 15-49. Over the same period there were 4,245live births which corresponds to a maternal mortality ratio of 424 per100,000 live births. Nine of the deaths were attributed to a direct
obstetric cause, six of these from haemorrhage. The indirect obstetricdeaths were most commonly classified as caused by anaemia (4/9).Substandard obstetric referral health care, not recognising the severity ofthe problem at the community level, delay in starting the decision-making process to seek health care, lack of transport and sub-standardprimary health care were all identified more than once as probable orpossible contributing factors.Conclusions: This maternal mortality estimate is substantially lower thanthose generated in the same area in the 1980s (1,005 to 2,362 per100,000 live births). In the early 1980s medical facilities and healthprofessionals in the study area were limited, as was transportation andcommunication. This has improved greatly since then, and it is thereforevery likely that improved availability of and access to essential obstetriccare has played a major role in this reduction.
P3.11.12LONGITUDINAL CHANGES IN VISCERAL FAT DEPOSITIONDURING PREGNANCYT. Kinoshita , S. Fukaya, T. Saitou, K. Ootaka, M. Itou, Dept. OB/GYN,Toho University, Sakura Hospital, Japan.
Objectives: To investigate whether pregnancy affects body-fatdeposition of maternal body.Study Methods: Fifty women were enrolled. The thickness of thepreperitoneal fat layer (P) and subcutaneous fat layer (S) were measuredby ultrasonography during pregnancy. The P ratio was calculated asindicator of visceral fat deposition.Results :The correlation coefficient between PS ratio and gestationalweek was r=0.338 (g=0.341+0.009X, 95% CI 0.007, 0.011 p<0.0001).The PS ratio of 0.65±0.25 of the third trimester was significantly higherthan those of the first and second (0.49±0.18, 0.52±0.20 respectivelyp<0.001). The PS ratio of postpartum was elevated (0.72±0.20) but didnot reach statistical significance. The P thickness was correlated with thegestational week (r=0.159, 95% CI 0.08, 0.236, p<0.0001). Nosignificant correlation between PS ratio and BMI was observed acrossthe study period. The PS ratio in lean and obese women was observed inthird trimester. There was no difference between lean and obese women.Conclusions: The visceral fat deposition increases during pregnancy.Pregnancy affects change of body-fat distribution of maternal body.
P3.11.13MATERNAL DEATHS ASSOCIATED WITH CESAREAN SECTIONIN ENUGU NIGERIAB. Ozumba , S. Anya, Dept. OB/GYN, University of Nigeria TeachingHospital, Enugu, Nigeria
Objectives: In view of the high maternal mortality ratios in Nigeria, weundertook to study factors associated with cesarean section fatalities atthe University teaching hospital.Study Methods: Clinical records of twenty six maternal deaths followingone thousand six hundred and eighty four cesarean sections over a sixyear period were studied. Maternal age, parity, indication for surgery,rank of surgeon and anesthetist, cause of death and perinatal outcomewere noted. Epi info version 6 statistical package was used for analysis.Results: Cesarean section rate was 25.6% and the cesarean sectionfatality rate was 15.4 per 1000 operations. The mean age of the fatalitieswas 29.7±5.9 years and the mean parity was 2.3±2.4. 84.6% of deathswere associated with emergency cesarean section. Hypertensivedisorders in pregnancy, prolonged obstructed labor, previous cesareansection and antepartum hemorrhage were associated with 96% ofmaternal deaths. Residents performed 96% of these operations. Perinatalmortality was very high (19%).Conclusions: Measures to reduce this unacceptably high maternalmortality rate include wider usage of improved antenatal care facilities.Greater consultant involvement in peri and intra-operative managementof emergencies is recommended.
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P3.11.14MATERNAL MORTALITY – AN AUDITA.Boruah Madhab , S. Mahanta, Dept. OB/GYN, Pragati Hospital andResearch Center, Sibsagar, India.
Objectives: To determine the MMR and evaluate the reasons ofmortality.Study Methods: Seven retrospective observational study.Setting: Records of four hospitals (2 government, 2 private) in theSibsagar district of Assam, India.Methodology: Retrospective analysis of the hospital records to locate thetotal no. of live births, maternal deaths from November, 1992 to October1999, and also to review the cause of death.Results: 86 maternal deaths were recorded during the observationalstudy. Corresponding live births observed were 17 893 and the resultantmaternal mortality ratio was 480. Post partum hemorrhage (36%) wasthe major killer in our study followed closely by unsafe abortion (30%).94.18% (81/86) of these women were of lower socio-economic groupand 43% (37/86) had no antenatal care what so ever. The delay inseeking care was evident from the records in all but seven women. Thetiming of deaths were 3 antepartum , 10 intrapartum and 47 postpartum.Emergency obstetric care was available at al the settings of the study.Conclusions: Maternal mortality is still rampant in this part of the globe.Poor socio-economic status is the single most important determinant.Status of the women must be improved upon if we are to achieve thegoals of ICPD, 1994, Cairo Declaration.
P3.11.15MATERNAL MORTALITY DURING HOSPITAL ADMISSION FORDELIVERY: A RETROSPECTIVE ANALYSIS USING ASTATEWIDE POPULATION DATABASES. Panchal (1), A.M. Arria (2), S.A. Labhsetwar (3)(1) Johns Hopkins University School of Medicine, Baltimore,
Maryland, USA.(2) Johns Hopkins University School of Hygiene and Public Health,
Baltimore, Maryland USA.(3) St. Charles Hospital, Oregon, Ohio, USA.
Objectives: There are currently no data available examining obstetricoutcomes during hospital admission for delivery utilizing a statewidepopulation database. The specific aims of this study were to (i)determine maternal mortality ratios from January 1984 throughDecember 1997, and (ii) identify possible risk factors associated withmaternal mortality.Study Methods: Data was extracted from January 1984 throughDecember 1997 from the Maryland Uniform Health Discharge Data Set(UHDDS). A case-control framework was used to estimate the strengthof association between suspected risk factors and outcomes.Results: During the study period there were 822,591 hospitalizations fordelivery. There were 135 deaths resulting in an overall maternalmortality ratio of 15.9. Patients who died were significantly more likelyto be African-American (60.7% versus 33.3%; OR=5.4, 95% CI=2.83-10.1, p<0.001), or to have undergone a cesarean section (60.0% versus26.7%; OR=5.3, 95% CI=3.10-8.98, p<0.001). The five most commondiagnoses associated with maternal morality werepreeclampsia/eclampsia, postpartum hemorrhage/obstetric shock,pulmonary complications, cerebrovascular event, and blood clot and/oramniotic embolism.Conclusions: By identifying at-risk groups for maternal deaths, potentialopportunities exist for early intervention and preventative strategiesaimed at decreasing maternal mortality.References: Maresh M. Quality in obstetrics and gynecology: Theexample of the enquiries into maternal mortality. J Qual Clin Practice1998; 18: 21-28.Jacob S, et al. Maternal Mortality in Utah. Obstet Gynecol 1998; 91:187-91.
P3.11.16MATERNAL MORTALITY IN A UNIVERSITY HOSPITAL INTURKEY: 1995-1999E.Malatyalioglu (1), F.F.Yanok (1), A.Yanok (2), A.Kökçü (1),(1) Ondokuz Mayo’s University, Samsun, Turkey, 55139, (2) SSKSamsun Hospital, Samsun, Turkey.
Objectives: To determine the maternal mortality ratio and the causes ofdeaths in Ondokuz May’s University Hospital within the last five-yearperiod.Study Methods: Direct and indirect obstetric deaths, as well asaccidental or incidental deaths which occured during pregnancy orwithin 42 days after the termination of pregnancy were prospectivelyrecorded between 1.1.1995 and 31.12.1999. Maternal mortality ratio wascalculated as the number of direct and indirect obstetric deaths over thenumber of live births within the same time period.Results: During the study period, 35 direct obstetric, 7 indirect obstetric,and 1 incidental deaths were observed. Maternal mortality ratio wascalculated to be 1088.9/100000 live births (42/3857). The leading causesof death were toxemia (n=16), hemorrhage (n=10) and infection (n=5).Conclusions: Maternal mortality ratio is unacceptably high in ourinstitution. This is probably because Ondokuz May’s University is theonly reference center in the Middle Black Sea region of Turkey, andhigh-risk pregnancies are referred here. Normal pregnancies anddeliveries are generally witheld in the maternity hospitals. However,toxemia, hemorrhage and infection are the leading causes of death whichmay be largely prevented with proper antenatal and intrapartum care.
P3.11.17MATERNAL MORTALITY IN CARDIAC MOSCOW MATERNITYHOUSEA.I. Beilin , O.S. Alyautdina, V.O.Bitsadze, S.G. Belitskaya, A.D.Makatsaria, Dept. OB/GYN, Moscow Medical Academy, Moscow,Russia.
Objective: The aim of the study was to establish the main causes ofmaternal mortality (MM) in our maternity house and to follow thestructure of MM.Study Methods: There were more than 85,000 deliveries from 1964 to1999 in our hospital, 32,000 of which were in women with cardiacpathology. 98 women died during this period.Results: The causes of MM in 60s – 70s were cardiovascular diseases(75%), extragenital disorders (18%) and obstetric causes (7%). Duringthe last two decades not a single obstetric cause was responsible forlethal outcome. The structure of MM has changed during the last tenyears. It can be explained by changing of the pregnant’s associateddiseases. Studies of patients with cardiovascular diseases underlineddifferent types of thrombophylia that leads to thromboemboliccomplications, which became fatal for some women. In this particulargroup, Antiphospholipid syndrome and genetic forms of thrombophylia(factor V Leiden mutation, AT III deficiency) are diagnosed more often.We have applied the special coagulation tests to reveal thethrombophylic state in pregnant women with cardiac pathology. Thetherapy with low-molecular-weight heparin (Fraxiparin) was found to beof high benefit in thromboprophylaxis of such patients.Conclusion: But still high reserves are remained for improvement ofsituation: prenatal diagnosis and consultation, appliance of recentconcepts of family planning in real practice, pregnancy planning andothers.
P3.11.18MATERNAL MORTALITY IN SÃO PAULO, BRAZIL:INVESTIGATION OF 5 YEARSK. Boyaciyan (1), C.E.P. Vega (1), L.C. Pazero (1), P.A.F. Marcus (1),R. Mattar (2), S.A. Barbosa (1)(1) Dept. OB/GYN, City Hall, São Paulo, SP, Brazil.(2) Dept. OB/GYN, Federal University of the State, São Paulo, SP,Brazil.
Objectives: The aim of this study is to establish the maternal mortalityrate (MMR) for São Paulo city over a 5-year period and to know theethiology of these deaths.Study Methods: Revision of 323306 death certificates of S. Paulo city,from 1994 to 1998. A group of 2134 women from 10 to 49 years old
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whose deaths were apparently related to MM were separated. All thesecases were evaluated through their medical reports and home visits.Analysis of the results was done according to the ICD (WHO 10th
Revision) and to the number of live births (LB) in the same period(1065324 LB).Results: There were 711 cases of MM distributed as direct obstetriccauses (336), indirect obstetric causes (245), non-obstetric causes (77)and late MM causes (53). Exclusion of 1312 cases from the total of 2134was necessary after evaluation of data showing that they could not beconsidered as MM. Investigation is not yet complete for 111 cases. Itwas observed under the marked notification: 70.09% (239 casesundeclared as MM/418 declared). The most frequent direct obstetriccauses were: preeclampsia-eclampsia (96 cases), hemorrhage (92),abortion complications (68) and puerperal infection (54). The mostfrequent indirect obstetric causes were cardiac diseases (61),bronchopneumonia (39) and chronic arterial hypertension (26).Conclusions: The MMR in the study was 54.53 deaths/100000 LB,which is considered high according to WHO. The main causes of MMare evitable and a program of prevention has to be implemented in ourcity.
P3.11.19MATERNAL MORTALITY – 10 YEARS REVIEWC. Karki , Dept. OB/GYN, CT House, Lalitpur, Nepal.
Maternal mortality is still 10 times higher in developing countries thanin developed countries. This study was carried out in Western RegionalHospital, Pokhara, Nepal from 1987 – 1996. Total number of deliveriesduring this period were 32,190. The 1st 5 year period’s (1987-1991)figures were compared with the figures of next 5 years (1992-1996).MMR was declined from 173/100,000 live birth in group 1 to124/100,000 live birth in group 2. A higher incidence of maternal deathin younger age (30%) and nulliparous (35%) women were found ingroup 2 cases. About 70% of deaths were due to direct obstetrical causesand 30% due to indirect causes in both the groups. The incidence ofsepsis, hemorrhage and toxemia remained the same in both the groups.Incidence of ruptured uterus, septic abortion and viral hepatitis remainedthe same in both the groups.
P3.11.20OBSTETRIC EMERGENCIES REQUIRING CRITICAL CAREG. Radhakrishnan , N. Vaid, Rashmi, N. Agarwal, University College ofMedical Sciences & GTB Hospital, Shahdara, Delhi, India, 110095.
Objectives: To review the clinical profile of obstetric patients requiringventilatory support and evaluate the benefits offered by amultidisciplinary approach of these critically ill patients at GTBHospital, Delhi, IndiaMaterials and methods: Records of 120 obstetric patients requiringventilatory assistance in the critical care unit (ICU) at the GTB Hospital,between Aug 1993 and Dec. 1999 were analysed for indications andoutcome of ICU treatment.Results: The indications for admission to the ICU were obstetrichemorrhage (50%), complications of PIH (34%) and sepsis (16%). Ashigh as 75% patients with hemorrhage had reported to the hospital inshock. Hypertensive patients manifested uncontrolled seizures and / orhypertension or severe PIH with other complications. ARDS was themain indication for ventilatory support in cases with sepsis.The duration of assisted ventilation ranged 24 hours -48 days. Themortality rate was 30% with nearly 80% deaths occurring within 24 hrs.of admission and with the mortality directly correlating with thepatient’s condition at admission. The morbidity ranged from fulminantbronchopneumonia in 5 cases, consolidation in 3 cases , to varyingdegrees of wound sepsis in 18% cases.Conclusions: Except for cases with sepsis, as most of the obstetriccomplications are inevitable, it is mandatory to have a team approach inmanaging these cases. Mortality is very high in the initial 24 hours, butthe survival of patients requiring assisted ventilation beyond 48 hours isentirely dependent on the rigorous monitoring which only an ICU set-upcan offer.
P3.11.21POST-PARTUM HEMORRHAGE AS COMPLICATION OFDELIVERIES STIMULATED WITH OXYTOCINA. Mladenovic , M. Milenkovic, G. Hajdukovic, Z. Mladenovic, KBCZvezdara, Rifata Burdzevica 31, Belgrade, Serbia, Yugoslavia Serbiaand Montenegro, 11000.
Objectives: The aim of the study was to investigate if postpartumhemorrhage appears more often in deliveries stimulated with oxytocin.Study Methods: Our study method was the retrospective revue of thedata of deliveries during last four years.Results: There were 8453 deliveries in our hospital from 1996-1999.4980 were stimulated with oxytocin. 45 of all were complicated with thepostpartum hemorrhage (0,52%). Most of the women were primiparous(29 ; 64,40%). The average newborn weight was 3340 gr. The averageduration of labor was 7 h 20`. V.E. was used in 3 cases (6,60%) and onlyone labor was with vertex presentation. In 2 cases (4,40%) the primmerdiagnosis was FMU with consecutive development of DICK. Only onedelivery was inducted with PGE2. In 28 cases (62%) there was need totreat anemia with blood transfusion.Conclusion: Our revue shows that there is no significant deference inoccurrence of postpartum hemorrhage between deliveries stimulatedwith oxytocin (0,54%) and those who were not (0,52%)
P3.11.22PREGNANCY-RELATED CHANGES IN STANDARDLABORATORY PARAMETERS DURING NORMAL PREGNANCYW. Straube (1), E. Panzig (2), J. Luedemann (3), (1) Dept. OB/GYN, (2)Dept. Clin. Chem and (3) Dept. Epidem. & Social Med., Ernst MoritzArndt University, Greifswald, Germany
Objectives: The aim of this cross-sectional study was to investigate theeffect of normal pregnancy on some standard laboratory parameters.Study Methods: Eight hundred and thirty-two healthy pregnant womenwere compared to a control group of three hundred and sixty-twohealthy non-pregnant women. All the women were aged between 20 and40 years. The following serum parameters were estimated:Liver enzymes, electrolytes, creatinine, white blood cells (total),hemoglobin and red blood cell indices, platelet count, coagulationfactors and C-reactive protein as a marker of inflammation. All of thewomen came from the same region and all serum parameters wereestimated in the same laboratory. Statistical significance was shown withnon-parametric tests.Results: Some parameters increase to a different extent during normalpregnancy, such as white blood cells, fibrinogen and thromboplastintime. Some parameters decrease, e.g. hemoglobin, platelets, creatininand serum calcium. A number of parameters are unchanged, e.g. CRP,PTT, uric acid, sodium, potassium and aminotransferases.Conclusions: The occurrence and the absence of physiological changesin laboratory parameters during normal pregnancy must be considered inthe diagnosis of diseases during pregnancy.
P3.11.23PROBLEMS RELATED TO REDUCING THE MATERNALMORTALITY RATE IN INDONESIAA.Sofian , D. Lutan, D. Siddik, Dept. OB/GYN, Faculty of Medicine,University of North Sumatra, Indonesia.
Currently, the Indonesian Maternal Mortality Rate (MMR) is at the highlevel of 390 per 100,000 births. Our challenge entering the year 2000 isto reduce Indonesia’s MMR to 225 per 100,000.The majority of maternal mortality in Indonesia was due to classicaltriad (hemorrhage 30-35%, infection 20-25% and eclampsia 15-17%)and other diseases that become worse because of pregnancy or child-bearing.Health care and safe motherhood practices are being applied in theefforts to reduce MMR. These efforts include: increasing familyplanning programs (from 26% in 1976 to 61% in 1997), publishing andexpanding the protocol for post-abortion treatment use the safe andeffective vacuum manual aspiration (VMA) method, antenatal careservices (more than 80%) and expanding referral systems, application ofthe WHO’s partograph (in study of Dr. Pirngadi Hospital Medandecreased MMR from 0.44% to 0.06%). Although it is not enough yet,there were 18,900 midwives that had been distributed into rural area (the
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target is 50,000), because 65.3% of deliveries in the rural area werehelped by Traditional Birth Attendants (TBAs). Training TBAs byvillage midwives and coordinating with administering department cameto be one of the six basic elements of safe motherhood in Indonesia.The present economic crisis is predictable as holding back effortstowards safe motherhood and the programs to cut the MMR. An increasein family planning program drop out (example in DKI Jakarta provinceis almost 30% and in Kutai regency in east of Kalimantan province is8.92% in 1998) will cause a “baby boom” and greater MMR in thefuture, particularly, deaths due to direct obstetrical causes and abortion.The economic crisis also causes use of untrained TBAs, rising risks andcausing a predictable increase in MMR.
P3.11.24PUERPERAL PSYCHOSIS: SOCIODEMOGRAPHICCHARACTERISTICS, OBSTETRIC EVENTS AND DISEASEPATTERNM. Mtawali , Dept. OB/GYN, Muhimbili University College of HealthScience, Tanzania
Objectives: To determine sociodemographic characteristics, obstetricevents and disease pattern among women with puerperal psychosis.Study Methods: Sixty-seven women with puerperal psychosis wereincluded in this Descriptive Hospital Based Study conducted betweenMarch and December 1998. Information was obtained using a structuredquestionnaire, physical and mental status evaluation with selectedLaboratory Investigations such as Hemoglobin, Blood Slide for malariaparasite, endocervical swab for microbiological studies and ELISA testfor HIV Antibodies. Data was entered and analyzed using EPI Infocomputer program number 6.4 May 1996 version.Results: Majority 95.8% of the women were primipara, married 44.8%with age less than 2 years (76%). Most of them were housewives andhad attained primary level of education. Among those who weremarried, 59% received support from the partners but only 27% of themgot satisfied. Majority had labored between 12 and 24 hours withspontaneous vertex delivery and a near birth weight of 3.4kgs. Most ofthe babies born were healthy. The commonest organic symptoms wereheadache, body weakness and abnormal vaginal discharge while thepsychotic symptoms were affective in nature, 19% of the women hadsevere anemia and 42% moderate anemia. 24.3% had Falciparummalaria infection, 16.1% had a positive endocervical swab forEscherichia Coli infection and 16% had a positive HIV test.Conclusions: There is a need to conduct a case control study todetermine it’s risk factors.
P3.11.25SEVERE PREECLAMPSIA AND HYPERTHYROIDISMASSOCIATED WITH A PARTIAL HYDATIFORM MOLE AT 20WEEKS GESTATIONM.L. Cañete , A.Sanchez-Dehesa, M.V. Bravo, J.C. Moreno, P. Rincon,Dept. OB/GYN, Hospital Virgen de la Salud, Toledo, Spain.
Objectives: Partial hydatiform mole is a histopathologic entitycharacterized by focal trophoblastic proliferation and hidropicdegeneration together with a coexisting fetus. We report a case in whichclinical findings are unusual since preeclampsia and hyperthyroidismassociated with large thecal luteal cysts and high B-HCG titers occurless frequently in patients with partial moles.Case report: A 27-year-old white female, gravida 1, para 0, at 20 weeksgestation, presented with gestational hypertension, legs oedema,proteinuria and elevated liver enzymes. An ultrasonographicexamination revealed an abnormal hydropic placente and a growthretarded, microcephalic fetus with cerebral ventricular dilation, bothovaries were enlarged with thecal luteal cysts. Fetal karyotyping byfuniculocentesis revealed a triploid fetus (69 XXX), B-HCG titers weregreater than 500,000 IU/L. Further tests detected asymptomatichyperthyroidism. A cesarean section was performed delivering a 190 gmale fetus. After two months of follow-up, B-HCG titers were plateaud,requiring treatment with methotrexate.Conclusion: Partial hydatiform mole is usually diagnosed as missed orincomplete abortion. The complete clinical syndrome includingpreeclampsia before the 20th week of gestation, hyperthyroidism, largethecal luteal cysts and high B-HCG titers is highly unusual in partial
moles. Nevertheless, B-HCG must be determined until negative sincemetastatic disease is always a possibility.
P3.11.26SOCIAL PROBLEMS AND MATERNAL MORTALITY –PAKISTAN’S PERSPECTIVES. Saleem (1), S. Syed (2)(1) Hamdard University Hospital, Pakistan.(2) Sobhraj Maternity Hospital, Pakistan.
Though there are many reasons for increase in mortality amongchildbearing women in Pakistan, yet, the social reasons are perpetuatingthe gloomy state of affairs. A series of interviews were conducted onwomen attending the antenatal and postnatal clinics in large maternityhospitals over a period of one year. It was recorded that lack ofinvolvement of community, male members of family, poverty, illiteracy,gender bias and ignorance were the major contributing factors leading tomaternal ill-health, pregnancy related complications and maternal death.These issues need urgent attention. This can be achieved throughimprovement in socioeconomic conditions, awareness, improvement inservices and health education. This paper also discusses the plight ofselected women who were the victims of “unfortunate circumstances”.Key words: Maternal mortality, gender bias, maternal health
P3.11.27TENDENCIES IN MATERNAL MORTALITY IN THE REPUBLICOF UZBEKISTANSh.S. Mukhamedova . Dept. of Surgical and Conservative Gyn.,Research Inst. of OB/ GYN, Tashkent, Uzbekistan
Objectives: The aim of the investigation was to study the structure andclinical aspects of maternal mortality in the Republic of Uzbekistanwithin 1989 and 1998.Study Methods: A retrospective analysis of medical documentation oflethal outcomes was undertaken with the subsequent computer-assistedprocessing.Results: The study was undertaken to analyze 2,694 cases of maternallethal outcomes within the mentioned period. The analysis demonstratedthat 88.2% pregnant women in labor died at the gestation term of 28weeks and more, 11.0% at the term of up to 28 weeks includingmortality from abortion, 0.87% from ectopic pregnancy.The reasons for the death of pregnant females, those in labor puerperasdied at the gestation term of 18 weeks were the following ones: bleedingin 29.1% of cases, septic postnatal diseases in 16.1%, gestosis in 15.4%,hysterorrhexis in 5,6%, embolism due to amniotic fluid in 3.1%. 14.7%females died due to extragenital diseases, in 13.0% cases the death wascaused with reasons not related with their pregnancies(thromboembolitic complications in 32.3%, acute renal insufficiency in30.4%, complications due to anesthesia and resuscitation mistakes in18.3%, anaphylactic and hemotransfusion shock in 11.5% and 7.1% ofcases respectively). In 3.0% of females lethal outcomes were due touncertain reasons as autopsy was absent.The analysis demonstrated that 6.5% of females died pregnant, the otherwomen died in the postnatal period, 28.5% of women died within thefirst 24 hrs and 55.0% during the first week after labor.According to an expert evaluation lethal outcomes were inevitable in72.3% of the women died.Conclusions: The results of the study urge the necessity in developmentof effective ways in pregnancy, natal and postnatal follow-up to decreasematernal mortality.
P3.11.28THE MANAGEMENT OF OBSTRUCTIVE UROPATHY INPREGNANCYE. Alexopoulos , P. Sakellariou, S. Karpathios, G. Siampalioti,N. Kyritsis, M. Stathi, C. Papanicopoulos, K. Kakoullis, G. Pavlides,Alexandra Maternity Hospital, Athens, Greece
Objectives: The aim of the study was to investigate the clinical efficacyof the insertion of a double J ureteral catheter in the management ofpatients with upper urinary tract dilatation secondary to obstruction.
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Study methods: Symptomatic pregnant women who were treated forobstructive uropathy during the period 1988-1998 are included in thisdescriptive retrospective study.Results: Eighteen patients presented with symptomatology of urinaryobstruction; eight of them suffeted from recurrent urinary tractinfections. Whilst investigated an ultrasound scan performed, confirmedthe presence of upper urinary tract dilatation. Their mean age was 26.8years (ranging from 19 to 34 years) and the mean gestational age was31.2 weeks (ranging from 29 to 35 weeks). When a double J ureteralcatheter was placed patients’ symptoms regressed without any furtherserious complications for the rest of the antenatal period and labour.This self-sustained ureteral catheter was removed between 6th and 10th
day postpartum.An ultrasound scan of the kidneys and urinary tract was performed afterthe removal of the catheter. The patients were followed up for twelvemonths with a repeat scan and intravenous pyelogram at 6 months post-delivery. Fifteen of them remained asymptomatic and three had minorurological problems.Conclusions: Dilatation of the upper urinary tract in pregnancysecondary to obstructive uropathy could be safely and effectivelymanaged in selected cases by insertion of ureteral catheters in order torelieve patients’ symptoms and prevent renal insufficiency.
P3.11.29THROMBIN GENERATION IS INCREASED IN WOMEN WITHTWIN PREGNANCIES VS WOMEN WITH SINGLETONPREGNANCIESS. Tamada , H. Minakami, A. Izumi, A. Ohkuchi, R. Iwasaki, S.Matsubara, T. Takayama, I. Sato, Dept. OB/GYN, Jichi Medical School,Tochigi, Japan.
Objectives: Antithrombin III (AT-III) activity is likely to decrease inwomen with twin pregnancies compared with women with singletonpregnancies. It is not known whether thrombin generation is increased inwomen with twin pregnancies.Study Methods: 15 women with twin pregnancies and 208 women withsingleton pregnancies were examined. Peripheral blood specimen fordeterminations of AT-III activity, thrombin-AT-III complex (TAT), andplasmin-a2 plasmin inhibitor complex (PIC) was obtained.Results: AT-III activity gradually decreased in twin pregnancies withadvancing gestation (104±11% at 27.3±1.6 weeks [n=10], 96±19% at31.8±1.1 weeks [n=15], 86±10% at 35.3±1.0 weeks [n=24]), whereas itdid not show a significant change in singleton pregnancies (101±13% at27.8±1.5 weeks [n=73], 99±13% at 31.5±1.1 weeks [n=67], 98±15% at36.6±1.6 weeks [n=137]). TAT levels, 9.4±5.1 mg/L at 27.3±1.6 weeks(n=10) and 12.9±12.4mg/L at 31.8±1.1 weeks (n=15) in twinpregnancies were higher than those (5.4±2.4 mg/L at 27.8±1.5 weeks[n=73] and 10.9±22.3 mg/L at 31.5±1.1 weeks [n=67]) in singletonpregnancies, respectively. TAT level exhibited a significant negativecorrelation with AT-III activity (r=-0.44, p=.002) and a significantpositive correlation with PIC level (r=0.41,p=0.005) in twin pregnancies,but not in singleton pregnancies.Conclusions: It is suggested that thrombin generation is increased intwin pregnancies as compared with singleton pregnancies. This mayexplain why AT-III activity is likely to decrease in twin pregnancies.
P3.11.30UNSAFE ABORTION: MAJOR CAUSE OF MORBIDITY ANDMORTALITY IN YOUNG WOMENS. Sapre , V. Joshi, S. Yadav, Dept. OB/GYN, Gajra Raja MedicalCollege, Gwalior, Madhya Pradesh, India
Objective: The aim of the study was1. Investigate the cause of morbidity and mortality in unsafe abortions2. Reasons of getting abortions done by untrained person, at unsafe
places, by adolescent and young womenStudy Methods: 134 cases of unsafe abortions in last five years, 1994 to1998 were analyzed in detail including seven deaths.Results: 134 cases analysis showed, 76% were adolescent (10-19 years)24% (19-30 years), 70% of low socio-economic status, 85% from ruralareas, 68% primigravida. 58 cases required laparotomy, 20 requiredrepair of perforation of uterus, 3 cases ileal anastomosis, 16 casesdrainage of abscess, in 12 cases subtotal hysterectomy done forperforation and sepsis. 7 cases died, 5 were primigravida. All cases
between age of 20-30 years, illiterate with low socio-economic status,unaware of facilities of medical termination of pregnancy andcontraceptives. All seven died within 72 hours of admission in hospital,due to septicemia (4), anemia (1), DIC (1), and renal failure (1).Conclusion: Female literacy, health education, counseling, disseminationof knowledge of contraceptives and MTP services, with increasednumber of trained doctors, availability of facilities in rural areas andutilization of services of safe abortion by women of remote areas, withearly diagnosis of pregnancy and termination in first trimester, canremarkably reduce the number of mortality in the prime of life ofwomen.
P3.11.31UNSCARRED UTERINE RUPTURE AFTER THE INDUCTION OFLABOR WITH MISOPROSTOLSüleyman Engin Akhan, Alkan Yıldırım, Erkut Attar, AbdullahTurfanda, Department of Obstetrics and Gynecology, IstanbulUniversity Faculty of Medicine, Istanbul, Turkey.
Uterine rupture is an emergent situation that threats the life of fetus andmother. In this article we present a case of intrapartum rupture of intactuterus after using intravaginal misoprostol for cervical ripening andlabour induction at term.The Case: A 30 years -old healthy women at 42 weeks of gestation wasadmitted to the hospital for induction of labor because of a low amnioticfluid index (4.3 cm.) and postmaturity. The obstetric history includedtwo term pregnancies, and there was no other remarkable point.The initial Bishop’s score was two on admission. The first 25 mgr.misoprostol tablet applied to posterior vaginal fornix with 4 h intervalsfor a maximum of three times. 3h 45 minutes after the second dose ofmisoprostole the hyperstimulation was noted. Misoprostol withheldbecause of the tachysystole and variable decelerations, patient turned herleft side and oxygen was administered. After 45 minutes atypicalvariable decelerations were deceased. However, tachysytol was persistedfor consequent 1 h. The fetal heart rate was stable during this period oftime.Cervix was 10cm dilated, vertex at +1station after 19 hours of the firstmisoprostol administration. Fetus developed bradycardia and vacuumextraction was performed. A 3630 gr infant was delivered with theApgar scores of 4 and 7 for 1 and 5 minutes, respectively. The arterialcord blood pH was 6.926. After delivery of the placenta patient wastaken to the recovery room for postpartum monitorization. Patientdeveloped tachycardia and cyanosis 30 minutes after the delivery.Uterus was contracted but very mobile, therefore palpated above thenormal localisation. Laparotomy was performed in emergencyconditions. Approximately 2500-3000 cc haematoma localised in theretroperitoneal area was encountered. A 9-cm linear defect extendedfrom right isthmus of cervix to the fundus of uterus was noted. Rightuterine artery involved with this defect, the serosa was intact.Hysterectomy was performed, and right hypogastric artery was ligated.Totally 9 unite blood and 8 unite fresh frozen plasma was transfused.Patient and infant were discharged from the hospital 8 days after theoperation.Conclusion: The development of this rare and catastrophic conditionkeeps its uncertainty, because uterine rupture can be developed innulliparous. The physiopathology of the condition, factors that can effectthe myometrium, the course of the rupture development are the majorquestions to be answered. Therefore, we decided that misoprostol onlycan not be the cause of the uterine rupture.
P3.12 MEDICAL AND SURGICAL COMPLICATIONS
P3.12.01ABRUPTIO PLACENTAE AND EPH GESTOSISB. Boskovski, J. Efremovski, J. Kostadinov; Special Hospital forOB/GYN Cair, Skopje (Macedonia)
Objectives: The aim of our work is evaluation of connection betweenabruptio placentae and severe forms of EPH Gestosis together withfactors from which it is caused.Study Methods: Our work includes 15 years material , from 1985-2000.It is analyzed: the age of patient, parity, body weight of fetuses, way ofdelivery and sex of fetuses.
WEDNESDAY, SEPTEMBER 6116
Results: There were 63853 childbirths in period of 15 years. Abruptioplacentae occurred in 465 (0,73%) cases. In 38 cases or 8,6% abruptioplacentae were associated with severe form of EPH Gestosis what meanthat frequency rate is 11 time greater than in other pregnancies.Deliveries in 52,5% of cases with abruptio placentae and gestosis wasfinished with SC. 129 (28,01%) fetuses were dead before admitting inhospital. The mean age of the patient with this condition was 28,2 years.Conclusion: The analysis of data on our material is in conformity withresults of other authors. Prognosis for mother and newborn depends onestablishing diagnosis on time and appropriate therapy of EPH Gestosis.The severe forms of EPH Gestosis with abruptio placentae demandedurgent finishing of delivery and very often expose to danger life ofmother and caused the dead of fetus.
P3.12.02ACTIVITY OF LACTIC DEHYDROGENASE (LDH), CREATINEKINASE (CK) AND GAMMA-GLUTAMYLOTRANSFERASE (gGT)IN THE COURSE OF INTRAHEPATIC CHOLESTASIS INPREGNANCYK. Czajkowski , R. Smolarszyk, J. Wojcicka-Jagodzinska, P. Piekarski,E. Romejko, J. Teliga, A. Malinowska, K. Dragowska, The 2nd Dept.OB/GYN, Warsaw Medical School, Warsaw, Poland.
Objectives: The activity of LDH, CK and gGT in blood serum of womenwith intrahepatic cholestasis in pregnancy was investigated. Diagnosis ofintrahepatic cholestasis was based on anamnesis, clinical examinationand laboratory tests.Study Methods: 41 women with intra hepatic cholestasis (the studygroup) and 30 healthy women (the control group) entered the study. Allwomen were in the third trimester of pregnancy. The prevalence rate ofintrahepatic cholestasis in pregnancy in our Department is 1%. Allwomen of the study group presented an intensive pruritis and hadnegative hepatitis B antigen. The also presented negative results oflaboratory tests. Clinical examination and anamnesis concerning otherhepatitis.Results: There was no significant difference in mean gestational agebetween study and control group (35.1±2.8 Vs 36.0±3.0 weeks).The results of biochemical tests in study Vs control group:(1) total bilirubin 33.3±18.8 Vs 8.55±3.4 microMol/L; p<0.001,(2) direct bilirubin 25.6±14.2 Vs 1.7± 1.7 microMol/L; p<0.001,(3) indirect bilirubin 7.7±2.22 Vs 8.55±3.4 microMol/L;NS,(4) alkaline phosphatase (AP) 168.4±61.2 Vs 96.8± 14.9 IU/L;
p<0.001,(5) heat-stable AP 99.8±38.7 Vs 64.1±20.9 IU/L; p<0.001,(6) bile acid 28.6±20.0 Vs 4.5±1.5 microMol/L; p<0.001,(7) AlAT 158±100 Vs 5±3 IU/L; p<0.001,(8) AspAT 97±31 Vs 8±3 IU/L, p<0.001,(9) de Ritis ratio AspAT/AlAT 0.61±0.31 Vs 1.6±0.4; p<0.001,(10) total protein 61.8±5.6 Vs 66.0±6.0 G/L; p<0.001,(11) albumine 450±34.8 Vs 484.0±37.7 microMol/L; p<0.001,(12) FE++ 26.0±3.8 Vs 12.71±2.15 microMol/L; p<0.001,(13) total cholesterol 8.81±1.87 Vs 6.68±1.04 mMol/L; p<0.001,(14) total LDL 6.80±1.57 Vs 4.80±0.81 G/L; p<0.001,(15) LDH 211±48 Vs 134±33 UI/L; p<0.001,(16) CK 51.0±33 Vs 45±14UI/L; NS,(17) G-GT 49±22 Vs 23±8 UI/L; p<0.001.Conclusions: An increase of LDH is related to the significantimpairment of hepatocytes. An increase of gGT confirms the retention ofbile in intrahepatic ducts. CK does not present prognostic value inintrahepatic cholestasis in pregnancy.
P3.12.03HELLP SYNDROME – ASYNTOMATIC GESTOSIS, EXORDIUMIN PUERPERIUM, EVOLUTION IN CIDM.G. Mazza , D. Galea, G. Masciari, Dept. OB/GYN, General Hospital,Crotone, Italy.
This syndrome can occur, as in our case, also in the course ofasyntomatic gestosis in the early hours of puerperium growing in cid in asecond time.Clinic Case: M.G. arrives at our observation at 38th week. At her arrival:the objective general and ostetric and urinic exams were normal, P.A.120/80, HCT 39.6, MCV 89.5; MCH 30.5; MCHC 34.1; PLT179/10^3/ul. The birth was done in the same day of the arrival. Soon
after the birth occurred in a spontaneous way after about 6 hours fromthe entrance the hospital, (alive and vital fetus, 3470 gr. P.A. 130/90) theclinic conditions showed a quick worsening with presence of abdominalbar ache of the arterial pressure with ipertensive crisis (180/110),subsequent eclamptic crisis with alterations of the following indexes oflaboratory: a quick and drastic reduction of HCT (36.2) MCV (93.3)MCH (32.9) MCH (35.2); emoglobinuria, fragments of granularcylinders; a quick reduction of the pyastrinic count (33/103/ul); a strongincreasing of the whole bilirubyna (4.05 mg/dl);an alteration of epaticenzymes with a strong increasing of GOT, GPT, CK, LDH levels;iperuricemia; rightness of the emocoagulative tests. Moved into theintensive therapy, the following day remarkable emocoagulativealterations appeared (HCT 33.2; MCV 87.9; MCH 31.4; MCHC 35.7;PLT 21/103/ul) becoming later cid (antitrombina III A 43.88%;antiplasmina 33.58%; product of phybrogen degradation>40 mml).Considerations: The H.S. according to us, can occur then the birthevolving in cid quickly, disegrecing with the data of literature wheresuch a syndrome occurs in the course of the gestosyc pregnancy and itimproves quickly after the birth. In our case the H.S. occurs in the hoursfollowing the birth matching to a worse of the symptoms of the gestosy,occurring the H.S. as essential element putting in evidence a gestosicsyndrome up to then asyntomatic. The mother prognosis in spite of theseriousness of the clinic situations through which it occurred, is good,with a constant clinic improvement in the weeks following the birth.
P3.12.04HYSTERECTOMY IN THE OBSTETRIC PRACTICE FOR THEPERIOD 1993-1998N.D. Nicolova , Grueva, Dept. OB/GYN, The District Hospital, Rousse,Bulgaria.
The Cesarean hysterectomy and the hysterectomy after vaginal deliverytogether with their indications, complications and the outcome for themothers are observed during the period 1993-1998.The most common indications for Cesarean hysterectomy are: infecteduterus, hemorrhage, myoma and cancer of the uterine cervix (80%). Thehemorrhage and the rupture of the uterus (75%) are the main indicationsof hysterectomy after vaginal delivery. We had three fatal outcomesafter hysterectomy following vaginal delivery. The authors recommendthe organ-preserving approach.For the first time successful Cesarean hysterectomy was performed byEduardo Porro – 1876. Together with the hysterectomy after vaginaldelivery, it is the most severe intervention, done in the surgical obstetricpractice for the benefit of the mother.Materials and Methods: The hysterectomies were done over a period offive years in the dep. of obstetrics and gynecology in the DistrictHospital of Rousse. During that period we had 10 010 deliveries.Cesarean section was done on 550 cases. We did 10 hysterectomies - 7Cesarean and 3 after vaginal delivery. The indications that led tohysterectomy were divided into 6 groups:1.lnfected uterus2.Primary hemorrhage3.Secondary hemorrhage4.Myoma of the uterus5.Cancer of the uterine cervix6.Rupture of the uterusWe have studied the severe complications after the hysterectomy and theoutcome of the mothers.Results: The rate of the hysterectomies over the studied period is…..The rate of the Cesarean hysterectomies is…..The rate of the hysterectomies after vaginal delivery is…..Groups Of Indications For Hysterectomy In The Obstetric Practice1993-1998
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Table No.1HYSTERECTOMY
GROUPS OFINDICATIONS
CESAREAN AFTER VAGINALDELIVERY
Infected uterus 2 -
Primary hemorrhage 2 1
Secondary hemorrhage - -
Myoma of the uterus 1 -
Cancer of the cervix - -
Rupture of uterus 1 2
TOTAL 6 3
While in the group of the Cesarean hysterectomies the main indicationsare the infections of the uterus and the primary hemorrhage (total of 7cases - 60%), in the group of the hysterectomies after vaginal delivery,the main indications are the primary hemorrhage and the rupture of theuterus (3 cases - 80%). Until 1995 there have been done 6hysterectomies and during the second period- 4 hysterectomies. It isobvious from the table that this reduction is mainly due to the Cesareanhysterectomies - 3 cases, compared to the 2 cases during the secondperiod.
Pathology, Which Has Led To Caesarean Hysterectomy AndHysterectomy After Vaginal Delivery (1993-1998)Table No.2
DISEASE HYSTERECTOMY
Hypo- and atonic uterine
bleedings
- -
Infected uterus 1 2
Rupture of the uterus
Placenta accreta 2 1
Myomautery 1 -
Cancer of the cervix - -
The Willebrandt disease - -
Thrombocytopenia 1 1
The previous Cesarean section leads to increased risk of pathology of theplacenta and rupture of the uterus in the time of the next delivery. Wehave 3 cases with hysterectomy for uterine rupture - 2 cases after aprevious Cesarean section and 1 case after inadequate treatment withuterustonics. In these 3 cases the hysterectomy was done on women,which had already fulfilled their reproductive program, an approach withwhich today we do not agree. We support the position of A.S.Slepih(1985) for the organ preserving intervention as a basic operativetreatment.The cases with hypo- and atonic uterus show equal rates in occurrenceand as an indication for hysterectomy.The both cases with infections of the uterus were from the describedperiod 1993-1995.The new drug and surgical treatment approaches (partial suture of theabdomen with ampoxen, intraoperative lavage with antibiotics,postoperative intermittent irrigation with antibiotics of the uterine cavityafter Cesarean section) lead to reduction of the relative share of thisindication.We think that the myoma of the uterus can be an indication forhysterectomy mainly at the age of 40 and over for the Cesarean sectiondelivery, especially for patients with multiple myomas.In our cases we did not have complications of the hysterectomy like:damage of the urinary bladder and the uterus, which we explain with thelow relative share of the total hysterectomies and the well-performedtraditional operative techniques.During the observed period there had not been fatal outcomes for themothers.Discussion: The analysis of our data show that the hysterectomy in theobstetric practice, although rare, is not casuistry and it has its place as anintervention performed for the benefit of the mother.Good results are achieved by properly indicated and done operativeintervention.
P3.12.05MATERNAL AND PERINATAL OUTCOME IN DIFFERENTGRADES OF ANAEMIAM. Malhotra , J.B.Sharma Ob/Gyn, MAM College, New Delhi, India
Objectives: The aim of this study was to see the maternal and perinataloutcome in different grades of anaemia in pregnancy in a teachinghospital of New delhi.Study Methods:Four hundred and forty three women who deliveredbetween January'99 to October'99 in Lok Nayak Hospital, New Delhiwere assessed to observe the maternal and perinatal outcome in differentgrades of anaemia which included 123 (27.7%) of normalhaemoglobin(Group A: Hb >= 11gms%), 214 (48.3%) mild anaemia(Group B: Hb 9-11gms%), 79 (17.8%) Moderate anaemia (Group C: 7-9gms%), 27(6.09%) Severe anaemii (Group D Hb <= 7 gms%)Results: The parity was the highest and average gestational age thelowest in severe anaemia(Group D). The Caesarean section rate washighest in severe anaemia(7.4%) in contrast to 4.8%, 3.7%, 6.3% innormal, mild, moderate anaemia groups respectively.Instruemental delivery rate was also highest in severe anaemia(7.4%).Duration of labour was 5 hours, 6.2 hours, 4.8 hours and 9.5 hours in A,B, C, D respectively.Fetal weight decreased progressively with severity of anaemia being 2.5Kgs in Group D. There were only two still births one each in moderateand severe anaemia.Conclusion: The perinatal outcome varies in direct proportion withseverity of anaemia.
P3.12.06OSMOLARITY AND MICROALBUMINURIA IN THE COURSE OFINTRAHEPATIC CHOLESTASIS IN PREGNANCYR. Smolarczyk , K. Czajkowski, J. Wojcicka-Jagodzinska, E. Romejko,P. Piekarski, J. Teliga, A. Malinowska, K. Dragowska, The 2nd Dept.OB/GYN, Warsaw Medical School, Warsaw, Poland.
Objectives: The osmolarity in blood serum and urine as well as themicroabluminuria in women with intrahepatic cholestasis was based onanamnesis, clinical examination and laboratory tests.Study Methods: 38 women with intrahepatic cholestasis (the studygroup) and 30 healthy women (the control group) entered the study. Allwomen were in the third trimester of pregnancy. The prevalence rate ofitrahepatic cholestasis in pregnancy in our Department is 1%. Allwomen of the study group presented an intensive pruritus and hadnegative hepatitis B antigen. They also presented negative results oflaboratory tests, clinical examinations and anamnesis concerning otherhepatitis.Results: There was no significant difference in mean gestational agebetween study and control group (35.8±3.1 Vs 36.0±3.0 weeks;NS). Theresults of biochemical tests in study Vs control group:1. total bilirubin 29.6±15.4 Vs 8.55±3.4 microMol/L;p<0.001,2. direct bilirubin 23.1±10.4VS 1.7±1.7 microMol/L;p<0.001,3. indirect bilirubin 6.5±1.7 Vs 8.55±3.4 microMol/L;NS,4. alkaline phosphatase (AP) 174.3±64.1±Vs97.8±14.9 IU/L; p<0.001,5. heat-stable AP 90.9±31.3 Vs 64.1±20.9 IU/L; p<0.001,6. bile acid 25.4±18 Vs 4.5±1.5microMol/L;p<0.001,7. AlaT 139±91 Vs 5±3 IU/L; P<0.001,8. AspAT 78±440 Vs8±3IU/L; p<0.001,9. de Ritis Ratio AspAT/AlAT 0.56±0.22 Vs1.6±0.4; P<0.001,10. total protein61.1±4.8 Vs 66.0±6.0 G/L; p<0.001,11. albumine 439±30.4 Vs 484.0±37.7 microMol/L; p<0.001,12. Fe++24.5±4.3 Vs 12.71±2.15 microMol/L; p<0.001,13. total cholesterol 8.40±1.79 Vs 6.68±1.04 mMol/L; p<0.001,14. total LDL 6.78±1.54 Vs 4.80±0.81 G/L; p<0.001,15. osmolarity in serum 284±4.16 Vs 281±3,52 mOsm/KH H2O;
p<0.005,16. osmilarity in urine 567±180.5 Vs 664±208, mOsm/KG H2O;
p<0.05,17. microalbuminuria 40.3±9.8 Vs 11±4mg/24hrs; p<0.001.Conclusions: Disturbances in osmilarity and microalbuminuria arerelated to renal function impairment, therefore intrahepatic cholestasis inpregnancy should be considered as a general disease.
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P3.12.07TBARS AND VITAMIN E AS PRECLINIC PREDICTIVE MARKERSOF PREGNANCY-INDUCED HYPERTENSION ANDGESTATIONAL DIABETES.Galimberti D . M., Joao M., Fernandez C.A., Cortelezzi M., CaramesV., Holland M. and Aparicio N. J. Obstetrics Department T. AlvarezHospital, Aranguren 2701, Buenos Aires, Argentina
Diabetes Mellitus and arterial hypertension are associated with oxidativestress, but the temporal association between lipoperoxidation markersand plasma’ s antioxidant activity and the clinical development ofgestational diabetes (GD) and pregnancy-induced hypertension (IH) isstill not known. Objective: to determine the circulating levels of TBARSand vitamin E in healthy primigravidas at the moment of the firstconsult. Material and methods: 91 (healthy at the moment ofincorporation) primigravidas (age 17 to 32 years) were incorporatedbetween the 8th and 12th week of pregnancy. Blood was extracted at 8th to12th , 22nd and 32nd week of pregnancy, respectively. The patients werecontrolled clinically on a weekly intervalsm until delivery. TBARSlevels were determined (intraassay variation 4.7% and interassay 6.9%)(in mmols/l) as well as vitamin E (intraassay var. 4% and interassay6.1%) (in mmols/l). Results: 85 patients had a normal gestation, whilst 6of them developed IH between the 27th and 32nd week; 2 of them,besides, developed gestational diabetes. TBARS levels in normalprimigravidas were (mean ± SD) 2.00 ± 0.22, 2.11 ± 0.53 and 1.92 ±0.39 respectively for the three trimesters; the maximun and minimunfigures being 1.4 and 2.87. The values for vitamin E were 29.0 ± 5.8,27.1 ± 4.9 and 29.3 ± 6.4 for the three trimesters (absolute minimun of21.0 and absolute maximum 48.1). Four out of the six patients who hadIH (two of them with GD) presented TBARS levels clearly high(between 3.3 and 5.66 mmols/l) already in the first trimester and all ofthem presented high levels at the 22nd week, maintaining this until the32nd week. Vitamin E scores were low (less than 12.0) in all the patientswith IH except one.Conclusions: a) the values of TBARS and Vit. E in the three trimesterswere similar to the ones found in a healthy population of eumenorrhoeicwomen; b) The gestants who finally had IH ( 2 of them with associatedDM) presented high levels of TBARS and, in most of them, low levelsof vitamin E preceding by several months the manifestation of the clinicsigns; c) The determination of TBARS and, eventually, vitamin E, couldbe useful for a preclinical prediction of a late development of inducedhypertension and gestational diabetes.
P3.12.08UNUSUAL PRESENTATION OF NON-PUERPERAL UTERINEINVERSION: A CASE REPORTB.R. Choudhury , Dept. OB/GYN, Sir Salimullah Medical CollegeHospital, Dhaka, Bangladesh.
Objectives: The objective of my case report is to highlight the rapiddiagnosis and prompt management of a rare gynecological emergencycase.Study Methods: A rare case of noon puerperal or gynecological uterineinversion caused by large fundal myoma in a 40 years lady resulting inshock with intractable hemorrhage with lower abdominal pain wasadmitted in SSMC & Mitford Hospital, Dhaka, on 15-01-98 wasreported.Results: After prompt diagnosis and resuscitation operation was doneand patient quickly recovered and no complication occurred.Conclusions :Non-puerperal inversion of uterus is a rare event. In day today clinical practice, puerperal inversion of uterus are met withacuteness and high mortality rate. This case was a gynecologicalemergency and management is discussed along with review of literature.
P3.13 MENOPAUSE
P3.13.01A TWO-YEAR PROSPECTIVE RANDOMIZED TRIAL OF ORALCONTRACEPTIVE AND HORMONE REPLACEMENT THERAPYON BONE DENSITY, LIPID-LIPOPROTEIN AND COAGULATIONPROFILES IN POSTMENOPAUSAL WOMENN. Taechakraichana (1), K. Limpaphayom (1), K. Panyakhamlerd (1),S. Chaikittisilpa (1), T. Ninlagarn (2), N. Dusitsin (2)Dept. OB/GYN, Chulalongkorn University, Bangkok, ThailandHealth Research Institute, Chulalongkorn University, Bangkok, Thailan.
Objectives: The aim of the study was to investigate the effects of oralcontraceptive (OC) and hormone replacement therapy (HRT) on bonemineral density (BMD), lipid-lipoprotein and coagulation profiles inpostmenopausal women.Study Methods: 80 healthy postmenopausal women visited a menopauseclinic at Chulalongkorn Hospital and were randomly assigned to a cyclicregimen of OC containing 30 mg of ethiyl estradiol and 150 mg ofdesogestrel or HRT containing 0.625 mg of conjugated equine estrogens21 days per cycle and 5 mg of medrogestone 10 days per cycle for 24months. BMD of lumbar spine and hip, lipid-lipoprotein and coagulationprofiles were evaluated. Intention to treat analysis was done. Student t-test, general linear model (repeated measures) with Bonferronicomparison and analysis of covariate (ANCOVA) were used where itwas appropriate.Results: After 24 months, BMD of lumbar spine, trochanter,intertrochanteric region and total hip significantly increased in bothgroups. Only OC treatment was associated with a significant increase inBMD of femoral neck and Ward triangle. Percent increases of BMD oflumbar spine, femoral beck and Ward triangle were significantly higherin the OC group than in the HRT group. Total cholesterol and low-density lipoprotein cholesterol significantly decreased in both groups.Only the OC therapy showed a significant increase in triglyceride level.There was no clinically significant changes of coagulation profiles inboth groups.Conclusion: Both OC and HRT increased BMD of lumbar spine and hipwith more obvious effects in the OC group. Both methods favorablyaffected these cardiovascular parameters during the 24 months oftreatment.
P3.13.02CONTRACTION OF SMALL ARTERY IN PERIMETRIUM OF RATUTERI AFTER TREATMENT WITH LH-RH AGONISTK. Hamasaki (1), Y. Doi (2), M. Seki (1), M. Kashimura (1), S.Fujimoto (2), University of Occupational and Environmental Health,School of Medicine, Fukuoka, Japan.(1) Dept. OB/GYN(2) Dept. Anatomy
Objectives: The aim of this study was to compare ultrastructuralalteration of the rat uterine vasculature after treatment with luteinizinghormone-releasing hormone (LH-RH) agonist to those of theoophorectomized rat.Study Methods: For experimental groups, adult female rats receivedeither subcutaneous injection of LH-RH agonist (buserelin) oroophorectomy. Both experimental and control (untreated) groups wereprovided for scanning electron microscopic specimens using corrosioncast. Plasma ET-1 concentration was measured by ELISA in bothgroups.Results: Cast images showed the remarkable contraction of smallarteries in the perimetrium of both buserelin-treated andoophorectomized rats. Plasma ET-1 levels significantly increased in theexperimental rats when compared to that of the control ones.Conclusions: These findings indicated that treatment with eitherbuserelin or oophorectomy induces the small artery contraction in theperimetrium as well as the increase in plasma ET-1 levels. Since ET-1 isknown to regulate local blood flow by its potent vasoconstractive action,it seems that ET-1 may be one of the candidates that induce the arterialcontraction.
WEDNESDAY, SEPTEMBER 6 119
P3.13.03EFFECT OF TRANSDERMAL ESTRADIOL/NORETHISTERONEACETATE (ESTALISÒ SEQUI) VS. PLACEBO ON VASOMOTORSYMPTOMS IN POSTMENOPAUSAL WOMENR. Rebar (1), M. Notelovitz,(1) University of Cincinnati, Cincinnati, Ohio, USA.(2) Women’s Research Center’s Inc.,Gainsville, USA.
Objectives: To evaluate the efficacy and tolerability of a sequentialcombination of estradiol/norethisterone acetate (E2/NETA, EstalisÒ
Sequi) versus placebo for relief of moderate to servere vasomotorsymptoms in healthy postmenopausal women.Methods: In a 12-week double blind trial a total of 220 women with atleast eight hot flushes per day during single-blind placebo therapy wererandomly assigned to placebo or one of three doses of therapy consistingof a transdermal patch releasing E2 50mg alone for days 1-14 of eachcycle and a combination patch releasing E2 50mg/day plus NETA 140,250 or 400 mg/day for days 15-28 of each cycle. Vasomotor symptoms(including sweating and hot flushes), patch tolerance and adverse eventswere recorded for three 28-day cycles.Results: A total of 220 women completed the study. From baseline toendpoint, the change in mean hot flushes/day ranged from –9.3 to –9.7in the E2/NETA groups compared with –5.5 in the placebo group(p<0,001). The incidence of adverse events was comparable with allthree E2/NETA treatments and with placebo. With active patches only4% to 7% of women experienced an application site reaction.Conclusions: Overall, a combination E2/NETA transdermal HRTadministered in a sequential regimen was effective in treating moderateto severe vasomotor symptoms in postmenopausal women. EachE2/NETA treatment was significantly better than placebo in reducingdaily hot flushes and sweating.Symptom relief was observed as early as week 2 of treatment.
P3.13.04EFFECT OF TRANSDERMAL ESTRADIOL/NORETHISTERONEHRT VS. ESTRADIOL ON QUALITY OF LIFE INPOSTMENOPAUSAL WOMENA.A. Licata (1), S. Shumaker (2), M-P. Dain (3)(1) Cleveland Clinic Foundation, Cleveland, Ohio, USA.(2) The Bowman Gray School of Medicine, Wake Forest University,Winston-Salem, North Carolina, USA.(3) Rhone-Poulenc Rorer, Antony, France.
Objectives: To investigate the effects of three doses of transdermalnorethisterone acetate (NETA) ± estradiol (E2) administeredsequentially vs. continuous E2, on quality of life (QoL).Study Methods: A 1-year, multicenter, double-blind, parallel-groupstudy. The study included a total of 646 postmenopausal women withvasomotor symptoms aged 40-70 years with an intact uterus. Subjectsreceived either transdermal estradiol 50mg/day, twice weekly for weeks1 – 4 or transdermal E2 50mg/day twice weekly for weeks 1 – 2 followedby E2 50mg/day together with NETA 140, 250, 400 mg/day (50/140,50/250, or 50/400) transdermally during weeks 3 and 4 of a cycle.Selected QoL parameters were measured on a point indices scale.Results: Within the groups receiving combined HRT, overall health-related QoL mean values improved from baseline to study endpointcompared with a slight reduction in patients receiving E2 alone. Valuesin the E2/NETA 50/250 group were significantly better than those in theE2 only group (p=0.011). Sexual function (arousal), sleep disturbance,depressive symptoms and cognitive function scores improved frombaseline to study endpoint in all treatment groups. The 50/250 group hadsignificantly better improvement in sleep disturbance scores than the E2-only group (p=0.001).Conclusions: The combination patch administering E2/NETA*improved quality of life in postmenopausal women with an intact uterus.The 50/250 patch was significantly better at improving sleepdisturbances and overall health-related QoL scores than E2 alone.*Trademark - Estalisâ Sequi
P3.13.05EFFECT OF TRANSDERMAL ESTRADIOL ANDNORETHISTERONE ACETATE HRT (ESTALISâ) COMPAREDWITH ESTRADIOL ALONE ON QUALITY OF LIFE INPOSTMENOPAUSAL WOMENA.A. Licata (1), S. Shumaker (2), D.F. Archer (3), E.G. Luftkin (4)(1) Cleveland Foundation Clinic, Cleveland, Ohio, USA.(2) The Bowman Gray School of Medicine, Wake Forest University,Winston-Salem, North Carolina, USA.(3) Dept. OB/GYN, Eastern Virginia Medical School, Norfolk, Virginia,USA.(4) Dept. Endocrinology, Mayo Clinic, Rochester, Minnesota, USA.
Objectives: To compare continuous combined or sequential transdermalestradiol 50mg/day (E2 50) together with one of three doses ofnorethisterone acetate (NETA) 140, 250 or 400mg/day (50/140, 50/250or 50/400) versus E2 50 alone on quality of life (QoL) in healthypostmenopausal women aged 40 – 70 years with an intact uterus.Study methods: An overview of two 1-year, multicenter, double-blind,randomized, parallel-group studies. In the first study, women receivedeither a patch releasing E2 50 or sequential therapy consisting of an E2patch for days 1 to 14 of each cycle and a combination patch releasingE2 50 plus, NETA 140, 250, or 400mg/day for days 15 to 28 of eachcycle. In the other study, women received either an E2 50 patch ortransdermal continuous combined E2/NETA delivering E2 50 andNETA 140, 250, 400mg/day. End-points for the two studies wereselected QoL parameters measured on a point index scale.Results: QoL improved in all treatment groups from baseline to studyendpoint. However, the E2/NETA 50/250 and 50/400 groups showedgreater improvement than E2 alone in terms of sleep disturbance, urinaryincontinence, cognitive function, sexual arousal and overall health-related QoL.Conclusions: A combination HRT patch* administering eithercontinuous combined or sequential E2 50mg/day, together with eitherNETA 140, 250, or 400mg/day improved QoL in postmenopausalwomen. Transdermal E2/NETA appears to have greater benefits oncertain parameters, such as urinary incontinence, cognitive function andsexual arousal than E2 alone.*Trademark: Estalisâ - continuous combined, Estalisâ Sequi -sequential
P3.13.06EFFECTS OF HORMONE REPLACEMENT THERAPY ONAPOPTOSIS AND BCL-2 AND P53 EXPRESSION IN THE SKIN OFPOSTMENOPAUSAL WOMENAssis, JS ; Fonseca, AM; Sauerbronn, AVD; Sandoval, MP; Schivartche,PL; Bagnoli, VR & Pinotti, JA Dept. OB/GYN, São Paulo UniversityMedical School, São Paulo, Brazil
Objective: To quantify apoptotic cells and the presence of proteins bcl-2and p53 in the skin of postmenopausal women.Subjects and method: A total of 19 patients were included in this study.Patients were randomly allocated to either hormone replacement therapy(n = 10) or placebo pill (n = 9). Skin biopsies were performed before and6 months after initiation of therapy. The tunnel reaction was employedto characterize apoptotic cells, and the immunohistochemical reactionfor bcl-2 and p53 expression in the epidermis.Results: There was no difference in either group regarding to age, race,and duration of menopause. Hormone replacement therapy given for sixmonths did not substantially interfere in the quantity of apoptotic cells.The reactions for the expression of proteins bcl-2 and p53 provednegative in both groups.Conclusions: We concluded that: (1) there were no statisticallydifferences in apoptotic rates before and after treatment between groups;(2) there were no statistically differences in the apoptotic rates by theend of the 6th month of treatment between groups; (3) the expression ofproteins bcl-2 and p53 proved to be negative in all aspects analyzed.
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P3.13.07EFFECTS OF LONG-TERM HORMONE REPLACEMENTTHERAPY (HRT) ON LUMBER BONE MINERAL DENSITY (BMD)N.H. Nagata , M. Nozaki, R. Egami, K. Koera, Dept. OB/GYN, GraduateSchool of Medical Sciences, Kyushu University, Fukuoka, Japan.
Objectives: This study was designed to investigate whether it is possibleto predict the effect of HRT on menopausal osteoporosis at thebeginning of therapy utilizing retrospective data on the change in L2-4BMD over eight years of HRT.Study Methods: 37 subjects who were on HRT (CEE 0.625 mg/dayalone or combined MPA 2.5 mg/day) over 8 years were enrolled and hadBMD measured every 6 months. The average HRT duration was 8.6years (8 – 10 years). BMD was measured by DEXA (Hologic QDR-1000W) before and during HRT (CV<1.0%). The correlation between anincrease and decrease in BMD after long term HRT and 9 related factorswere examined. We focused on the closest correlation of changes inBMD after one-year HRT and divided the subjects into three groups toexamine the effects on BMD after long-term HRT. Group A: BMDincreased more than 1% compared to pre-treatment value. Group B:Increase was less than 1%. Group C: BMD decreased more than 1%.Results: There was a significant correlation between the increase anddecrease of BMD after long-term HRT and those changes of after oneyear of HRT, BMD before HRT and the period when BMD reaches amaximum. BMD increased significantly in both group A and B (22 outof 23 and 3 out of 4 cases, respectively, p<0.05). However the BMD ofseven out of ten subjects in Group C decreased significantly compared topre-treatment values (p<0.05). In Groups A and B, BMD wasmaintained by long-term HRT but not in group C.Conclusions: It may be possible to select the optimum duration of HRTby observing changes in BMD after one year of HRT in menopausalpatients of osteoporosis.
P3.13.08EFFECTS OF PROGESTIN DOSE AND TIME SINCE MENOPAUSEON ENDOMETRIAL BLEEDING WITH CONTINUOUSCOMBINED HORMONE REPLACEMENT THERAPYD.F. Archer , J.H. Pickar, Clinical Research Center, Jones Institute forReproductive Medicine, Norfolk, VA, USA.
Objective: To analyze the effects of progestin dose and time since lastspontaneous menstrual period (LMP) on bleeding profiles with twocontinuous combined hormone replacement regimens in postmenopausalwomen.Methods: A randomized, double-blind, multi-center trial was conductedwith 553 women recruited form 99 sites. Women received a continuousoral regimen of 0.625 mg/d conjugated equine estrogens (CEE)combined with either 2.5 mg/d or 5.0 mg/d medroxyprogesterone acetate(MPA) for 1 year (12 cycles).Results: After 1 year, more women in the 5.0 mg MPA group reportedno bleeding (94%) compared with women in the 2.5 mg group MPA(90%; P<0.001). After 3 cycles for women 3 years or less from theirLMP, 72.4% of women in the 5.0 mg MPA group did not experiencebleeding compared to 59.0% in the 2.5mg MPA group (P<0.001). Thistrend was also noted after 6 months and 1 year; however, thosedifferences were not statistically significant. For women more than 3years since their LMP, 95% of women in the 5.0 mg MPA group and91% in the 2.5 mg MPA group reported no bleeding after 1 year.Conclusions: The continuous combined regimen of CEE plus 5.0 mgMPA may be more suitable for women closer to the onset of menopause,or for women irritating therapy who are more likely to discontinue dueto irregular bleeding. Thus the improved bleeding profile with thisregimen may enhance HRT compliance particularly in the early cyclesof therapy.
P3.13.09EFFETCS OF RALOXIFENE VS. PLACEBO ON DEPRESSIVESYMPTOMS IN NON-OSTEOPOROTIC POSTMENOPAUSALWOMENI. Pavo (1), F. Martenyi (1), D. Masanauskaite (1), N.B. Zharkova (2), S.Metcalfe (1), D.B. Muchmore (3)(1) Lilly Area Medical Center, Vienna, Austria.(2) Mental Health Research Center of the Russian Academy of Medical
Sciences, Moscow, Russia.(3) Lilly Research Laboratories, Eli Lilly and Company, Indianapolis,
Indiana, USA.
Objectives: The aim of this study was to assess the effects of raloxifene(RLX) 60 mg/d on depressive symptoms in healthy, postmenopausalwomen enrolled in a 1-year osteoporosis prevention trial.Study Methods: One hundred and twenty eight healthy, postmenopausalwomen were enrolled in a phase 3, multi-center, randomized, double-blind trial designed to compare the effects of RLX 60 mg/d vs. placebo(PL) on the bone mineral density. In a sub-study, 36 randomly chosen,clinically non-depressed patients were assessed for effective symptomsby an independent, blinded psychiatrist using the Hamilton DepressionRating Scale (HAMD) at study entry (baseline) and after 12 months(endpoint). The changes from baseline to endpoint were initiallyassessed using the paired t-test. When it was concluded that the data didnot follow a normal distribution (Shapiro-Wilk test), the Wilcoxonsigned-rank test was performed.Results: There was no significant differences in HAMD scores betweentreatment groups at baseline. In the PL group (mean age, 59.3; n=18), nosignificant changes from baseline to endpoint were observed in the totalHAMD score (-2.0±4.14) and in the Depression (-0.44±1.38), Sleep (-0.50±0.99), and General/Somatic (-0.06±1.43) sub-scores; a significantdecrease in the Anxiety (-1.06±2.07; p=0.045) sub-score was observedfor PL. Women in the RLX treatment arm (mean age 58.4, n=18)showed a statistically significant improvement in the total HAMD score(-3.22±4.39; p=0.006), as well as in their Depression (-1.00±1.88;p=0.037) and Anxiety (-1.39±1.65; p=0.002) subs-cores; no significantchanges were observed in the Sleep (-0.56±1.65) and General/Somatic (-0.28±1.36) sub-scores with RLX. The between group differences in eachrating were not statistically significant.Conclusions: Results of this pilot study suggest that RLX may havebeneficial effects on affective symptoms in postmenopausal women.
P3.13.10EFFICACY AND TOLERABILITY OF PREMARIN CREAM FORATROPHIC VAGINITIS IN ASIAN WOMENM.F. Rhoa , (1), N. Raymundo (2), Y-C Bi (3), C-H Lai (4), S.L. Yu (5),S. Raman (6), K.Y. Leung (4),(1) Wyeth-Ayerst Global Pharm., St. Davids, PA, USA.(2) Manila Central Univ, Philippines.(3) Nanjing Jiangsu Provincial Hospital, P.R., China.(4) Chang Gung Memorial Hospital, Taipei, Taiwan.(5) Queen Elizabeth Hospital, Hong Kong.
Objectives: To assess the subjective, cytological and clinical effects,tolerabilty and acceptability of Premarin Cream for the treatment ofpostmenopausal atrophic vaginitis in Asian women.Design: 151 postmenopausal women with clinical and cytologicalevidence of vaginal atrophy were enrolled at 9 centers in P.R. China,Philippines, Hong Kong, Taiwan, Malaysia and Singapore. Patients eretreated with 1 gram of Premarin Cream [0.625 mg conjugatedestrogens/gram] applied intravaginally on cycle days 1-21 of a 28-daycycle, for 2 cycles. Gynecological evaluations and vaginal cytologysmears were performed at baseline (BL) and on study days 21 and 49.Symptoms and patient acceptability were evaluated from daily diarycards kept by patients prior to, and throughout, treatment. Tolerabilitywas assessed through physical exams, vital signs, adverse events, andstudy withdrawals.Results: Statistical analysis of the study is ongoing. Changes from BL todays 21 and 49 in vaginal cytology and the clinical gynecological examare reported. Changes in the subjective signs and symptoms of atrophyfrom the diary cards are also reported, as well as changes in the totalsymptom score. Treatment acceptability and tolerability form BL to day49 are performed and reported.Conclusions: This study provides data in Asian women about theefficacy of therapy for atrophic vaginitis. This trial not only yields data
WEDNESDAY, SEPTEMBER 6 121
concerning pre and post-treatment clinical findings in a large number ofAsian women, but also renders descriptive data bout the specificsubjective symptoms they report, and their tolerance and acceptance oflocal therapy for atrophic vaginitis.
P3.13.11ESTROGEN THERAPY DID NOT IMPROVE CARBOHYDRATEMETABOLISM (CHO) IN POSTMENOPAUSAL WOMEN WITHTYPE 2 DIABETES MELLITUS (DM).C Sztejnsznajd, MER Silva, NR M elo , A Nussbacher, RT Fukui, MRSCorreia, RF Santos, OE Gebara, M Weingarten, S Lage, TRF Rocha, ED’Amico, BL Wajchenberg, DM Rocha, MJM UrsichMedicine School of São Paulo University, São Paulo, Brasil
Estrogen replacement therapy decreases the risk of cardiovasculardisease (CVD) in healthy postmenopausal women, but there are fewreports on diabetic women, known to have a greater prevalence of(CVD).Methods: The effect of CE on the CHO metabolism and lipid profile wasassessed in 13 postmenopausal women with type 2 DM treated withsulfonylurea. Clinical data: age, 48-63yr; BMI, 24.7-32.2kg/m2;postmenopausal for 4-10yr; duration of diabetes, 3-16yr; hypertension,4-10yr. After adequate metabolic control, a 4-month period of placeboand an equal period of conjugated estrogens 0.625 mg/d (CE) wasperformed. At the end of each phase, a lipid (fast) and an OGTT (75g)was done. Weight and blood pressure remained stable .No significantdifferences were seen on the levels of triglycerides, total cholesterol andLDL- cholesterol .On estrogen therapy there was a significantimprovement (table) on HDL-Cholesterol and glycated hemoglobin.However, on the GTTO, the glucose response remained unchanged,although, significant higher insulin levels were seen at 90 and 120 min.Conclusion: Estrogen therapy had no benefit on glucose levels fast orafter the glucose load, despite improvement on glycated hemoglobin.The results could suggest a worsening on insulin resistance.
HDL-
Cholesterol
Glycated
Hemoglobin
Insulin -90’ Insulin-120’
mg/dl % mU/ml mU/ml
Placebo 39 ±8 8.6±1.4 43±28 61±45
CE 52 ±16* 7.5±1.2* 56±9* 73±41*
* p=0,02.
P3.13.12FIBRINOLYSIS AND CARBOHYDRATE METABOLISM (CHO)WERE NOT IMPROVED WITH ESTROGEN THERAPY INPOSTMENOPAUSAL WOMEN WITH TYPE 2 DIABETESMELLITUS (DM).C Sztejnsznajd, MER Silva, NR M elo , A Nussbacher, RT Fukui, MRSCorreia, RF Santos, OE Gebara, M Weingarten, S Lage, TRF Rocha, ED’Amico, BL Wajchenberg, DM Rocha, MJM UrsichMedicine School of São Paulo University, Brasil
There are few reports on the effects of estrogen replacement therapy ondiabetic women, known to have a greater prevalence of cardiovasculardisease (CVD), but it decreases the risk of CVD in healthypostmenopausal women.Methods: The effect of CE on the CHO metabolism, lipid profile and thehemostatic system, was assessed in 13 postmenopausal women with type2 DM treated with sulfonylurea. Clinical data: age, 48-63yr; BMI: 24.7-32.2kg/m2; postmenopausal for 4-10yr; duration of diabetes, 3-16yr;hypertension, 4-10yr. After adequate metabolic control, a 4-monthperiod of placebo and an equal period of conjugated estrogens 0.625mg/d (CE) was performed. At the end of each phase, a lipid, ahaemostatic profile (fast) and an OGTT (75g) was done. Weight andblood pressure remained stable.Results: No significant differences were seen on the levels oftriglycerides, total cholesterol, factors V, VII and VIII, fibrinogen, PAI-1, t-PA antigen, plasminogen, C-protein and anti-thrombin -III .Onestrogen therapy, there was a significant improvement (table) on HDL-Cholesterol and glycated hemoglobin, although on the OGTT, theglucose response remained unchanged, but significant higher insulinlevels were seen at 90 and 120 min.
Conclusion: Estrogen therapy had no effect on clotting factors and nobenefit on fibrinolysis, despite adequate metabolic control. The resultscould suggest a worsening on insulin resistance.
HDL-
Cholesterol
Glycated
Hemoglobin
Insulin -90’ Insulin-120’
mg/dl % mU/ml mU/ml
Placebo 39 ±8 8.6±1.4 43±28 61±45
CE 52 ±16* 7.5±1.2* 56±9* 73±41*
* p<0.02
P3.13.13HORMONE REPLACEMENT THERAPY IN THE PATIENTTREATED FOR ENDOMETRIAL CANCERM. Nozaki , H. Nagata, R. Egami, K. Koera, H. Nakano, Dept. OB/GYN,Graduate School of Medical Sciences, Kyushu University, Fukuoka,Japan.
Objectives: Adenocarcinoma of the endometrium is considered to be anestrogen-dependent neoplasm and hormone replacement therapy (HRT)for patients even after surgical treatment has been contraindicated.However, various conditions due to estrogen lack, such ashyperlipidemia, osteoporosis and vasomotor symptoms, should betreated for quality of life.Study Methods: 176 patients undergoing primary treatment for surgicalstage 1 and 2 after a one-year close observation were evaluated between1986 and 1998. Their histological grades were G1 and G2. 23 patientsreceived HRT (0.625 mg/day of conjugated equine estrogen wereadministered) and 158 patients had no HRT. In the group receivingHRT, the median age was 49 years (range 38 to 62 years) and 8 of thesepatients had received radiation therapy after surgery. None receivedchemotherapy. The duration of HRT was 12-78 months. All patientsgave their informed consent to participate in this study.Results: In the group receiving HRT, cancer recurrence has not beenseen. In the group without HRT, however, there have been 11recurrences. The two groups are not significantly different (p<0.05). Thegroup receiving HRT have improved symptoms of lack of estrogen, suchas hot flush, night sweats, vasomotor symptom, vaginal atrophy,hyperlipidemia and osteoporosis.Conclusions: HRT appears to have been used safely after surgicallytreated stage 1, 2 and histological grade G1, 2 endometrial cancer.
P3.13.14IMPLICATIONS OF TISSUE FACTOR IN MENOPAUSE ANDEFFECTS OF HORMONE REPLACEMENT THERAPYA. Vilar iñ no , A. Scazziotta, A. Tempone, G. Jacquier, L. Penalba, S.Pns, R. Wikinski, O. Contreras Ortiz, Dept. Climaterio, Bioquímica.Hospital Clinic, University of Buenos Aires, Argentina.
Objectives: Tissue Factor (TF) exposure after arterial damage plays arole in the pathogenesis of acute ischemic coronary syndrome byinitiating intravascular thrombosis formation.Study Methods: We studied 62 patients. Characteristics: PerimenopausalWomen (PMW) (17), Age 45, 9±3, 3 BMI under 25. Postmenopausalwomen (PostW) (45) 55 ±6,5 under 25Twenty patients received 17 Bestradiol 0, 05 two months and 17Bestradiol 0.05 plus noretisterone acetate 0.025 for two months, crossover design. TF and Tissue factor pathway inhibitor (TFPI) weredetermined by Inubind from American Diagnostic.Results:
PMW PostW Pvalue
TF 14, 27±13, 54 27, 16±18, 77 0.0344
TFPI 69, 40±29, 48 92, 55±57,09 0.025
PMW PI PII Pvalue
TF 34, 33±27, 91 7, 78±9, 04 5, 44±9, 4 0.046, 0.029
TFPI 108, 4±41, 08 64, 43±24, 67 88, 4±20, 8 0.073
Conclusions: The increase in tissue factor might be a predisponent factorfor the development of thrombogenic disease.
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P3.13.15INTERACTION BETWEEN RALOXIFENE AND VAGINALPREMARINâ OR REPLENSâ IN WOMEN WITH PRE-EXISTINGVAGINAL ATROPHY – EFFECTS ON SEXUAL ACTIVITYB. Kessel (1), R. Basson (2), A.V. Ciaccia (2), S. Siddhanti (2), L.Plouffe (2)(1) University if Hawaii, John A. Burns School of Medicine, Honolulu,Hawaii, USA.(2) Lilly Research Laboratories, Indianapolis, Indiana, USA.
Objective: Determine the effects of raloxifene HCI 60mg/d (Evistaâ, EliLilly and Company), indicated for the treatment and prevention ofpostmenopausal osteoporosis, on sexual activity in women with pre-existing vaginal atrophy who are taking vaginal Premarinâ cream orReplensâ vaginal moisturizer.Design: 187 naturally postmenopausal women with at least 2 signs ofgenitourinary atrophy were randomly assigned to one of four treatmentgroups: double-blind oral placebo or raloxifene 60 mg/day (RLX) withopen-label vaginal Premarin cream (0.5 g/day; PRM) or Replens (REP).A 10 question Sexual Activity Questionnaire (SAQ; Thirlaway et al.Quality Life Res 1996; 5:81), which assesses sexual function of womenwith respect to activity, pleasure, and discomfort, was administered atbaseline and at 3 month endpoint.Results: Mean age and years postmenopause at entry were 59 and 9.5,respectively, 104 women acknowledged being sexually active. Therewere no baseline treatment–group differences in the mean scores for anyquestion. For most questions, the effects were small relative to thestandard deviations, preventing detection of meaningful, consistentchanges. For two questions relating to coital discomfort, both PRM andREP improved vaginal dryness and dyspareunia over the course of thestudy. Improvements in coital discomfort were as notable for raloxifenetreatment as for placebo.Conclusion: Both PRM and REP are associated with improved SAQscores for discomfort. RLX did not modify treatment response to PRMor REP.
P3.13.16MAMMOGRAPHIC PATTERN IN THAI CLIMACTERIC WOMENR. Wattanayingcharoenchai , U. Theppisai, U. Udomsubpayakul, Dept.OB/GYN, Research Center, Ramathibodi Hospital, Bangkok, Thailand.
Objectives: To study the breast imaging reporting and data system(BIRADS) mammographic category in climacteric women and itsrelation to age, menopausal status and parity.Study Methods: 1,001 climacteric women without hormonalreplacement therapy, who had attended menopause clinic from March1994 to November 1998, were included in this study. A screeningmammogram and breast ultrasound that performed in all subjects werestandard technique. The mammogram finding was interpreted using therecommendation of the American College of Radiology Breast ImagingReporting and Data Systems (BIRADS). Chi-square test was used toanalyze relationship of mammogram finding to age, menaopausal statusand parity.Results: The age range of climacteric women were 40-75 years, whichconsisted of 22% premenopause, 33.8% perimenopause and 44.1%postmenopausal women. By using BIRADS category, 58.4% were incategory 1, 36.5% in category 2, 2.8%, 2.0% and 0.3% in category 3, 4and 5 respectively. Most cases of mammographic category 2 were densebreast, benign calcification, benign axillary lymph nodes, simple cysts,fibrocystic disease and fibroadenoma. All cases in mammographiccategory 3 had undergone mammogram and found no evidence ofmalignancy. The biopsy which was performed in 50% of cases incategory 4 showed fibroadenoma and fibrocystic disease. 15% ofwomen in category 4 underwent clinical examination and mammogramand the rest had lost follow-up. Only 1 in 3 cases in category 5 wasintraductal carcinoma. The study had shown statistically relationshipbetween mammographic category and parity, but no relation with ageand menopausal status.Conclusions: In clinical practice, screening mammogram, usingBIRADS category, can divide women into 2 groups: (1) category 1 and2, whose mammograms are clearly normal and benign, require annualscreening only; and (2) category 3, 4 and 5 need further managementdepending on the results of the mammogram. Moreover, the BIRADScategory can help reduce unnecessary invasive procedure.
P3.13.17MENOPAUSE AS A DEMOGRAPHIC VARIABLE OF THE LOW-BIRTH RATE ENVIRONMENTAL AREAM. Mirkovic (1), M. Bogavac (1), V. Grujic (2)(1) Dept. OB/GYN, Clinical Center of Novi Sad, Novi Sad, Yugoslavia.(2) Institute of Health Protection, Novi Sad, Yugoslavia.
Objective: The aim of this study was to collect the data on the timing ofmenopause in the low-birth rate environmental area of the YugoslavProvince of Vojvodina.Study Methods: There were 175 women comprised in the study. Thedata on menopause was obtained by an inquiry introduced during adirect contact with the women.Results: The menopause in our materials occurs at 47 + 4.48 years. Itmost often occurs in the age group of 50.5 years. The menarchealmedian is presented with 45.65 + 0.42. There are no significantdifferences in menarche timing between the native and newcomerpopulations in Vojvodina. Relative to the occupation, the menopauseoccurs later in the housewives (48.45 years) than in the workers (46.33years). The longer length of service – the later menopause timing (thelength of service 0 - 10 years: the menopause occurring at 45 years; thelength of service of more than 31 years: the menopause occurring at47.11 years). Increased number of abortions affects earlier menopause: 5and more than 5 abortions give menopause at 46.50 years. According toour data, the number of deliveries does not significantly influence themenopause timing. Earlier menarche gives later menopause: menarche atthe age of 12 – menopause at 49.42 years versus menarche timing at 18years with the following menopause at the age of 45.Conclusion:1. There are initial signs of postponing menopause timing in theProvince of Vojvodina.2. There is also a phenomenon of menarche acceleration.3. Since 1989 the birth rate in Vojvodina has been negative. The specificfertility rates in the population over 34 years of age are irrelevant.Prolongation of the fertile period can, beside other factors, be of vitalsignificance for Vojvodina – the low-birthrate region in Yugoslavia.
P3.13.18NATURAL ESTROGENS: A WAY TO IMPROVE WELFARE OFWOMEN IN POSTMENOPAUSAL PERIODW. Kurach , C. Poduszczak, Dept. GYN, University Teaching Hospital,The Foundation for the Development of MMA, Warsaw, Poland.
Objectives: The objective of the research was the evaluation of theinfluence natural estrogens on well being women in postmenopausalperiod.Study Methods: Forty women 58.2 years of age on average, at least 12months after menopause. All patients underwent a continuous treatmentwithout bleeding with Oestrofeminal from Mack – oral pills containing0.3 mg of estriol per pill. In order to assess the symptoms of climactericsyndrome five-group Green’s scale was used.The intensity of complaints was assessed subjectively by the patient inthe scale from 0 to 3 in six categories.Results: Within the six categories of climacteric symptoms the followingresults were obtained.(1) Psychological symptoms were diminished by 37%(2) Somatic symptoms were diminished by 42%(3) Vegetative symptoms were diminished by 37%(4) Anxiety and nervousness were diminished by 29%(5) Depression was diminished by 21%(6) The total point index in Green’s scale decreased by 36%Conclusions: Natural estrogens dosed 0.3 mg per day is affective remedydiminishing climacteric symptoms by the 36% during the first threemonths of treatment. It seems to be particularly effective in treatment ofpsychological and somatic symptoms which accompany menopause.
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P3.13.19PREVALENCE OF CLASSIC RISK FACTORS IN CLIMACTERICWOMEN WITH CORONARY ARTERY DISEASE.E.R.G. Alexandre ; D. Armaganijan, Department of Coronary HeartDisease, Dante Pazzanese of Cardiology Institute, São Paulo, Brazil.S.M.R. Rolim-Lima; J.M. Aldrighi, Department of Maternal-InfantileHealth, Public Health School of São Paulo University, São Paulo, Brazil
Objective: The incidence of coronary artery disease (CAD) increasesduring climacteric period. The aim of the study was to investigate thepreval ence of the classic risk factors.Study Methods: Sixty-five patients (pts) were included for a period offifteen months(98/10 to 2000/01), aged 37-64 years (mean = 51,69 + 7,13 years). Theywere divided into three age groups: Group I (GI) > 35 < 45 years; GII > 45 < 55 and GIII > 55 < 65. All of them have confirmed CAD byangiography.Results: The prevalence of the risk factors in the different groups are: GI(n = 13 pts): Familiar Antecedents = 61,5%, Hypertension = 92,3%,Hyperlipidemia = 69,2%, Tabagism = 84,6% and Diabetes = 38,5%; GII(n = 31 pts) Familiar Antecedents = 64,5%, Hypertension = 80,6%,Hyperlipidemia =74,1%,Tabagism=67,7% and Diabetes = 35,4%; GIII(n = 21 pts) Familiar Antecedents = 66,6%, Hypertension = 85,7%,Hyperlipidemia = 76,2%, Tabagism = 47,6% and Diabetes = 19%.Conclusions: The prevalence of familiar antecedents from CAD andhyperlipidemia was the same in the three age groups. The hypertensionwas the most prevalent in all groups, followed by tabagism and diabetes.There was a significant statistical difference in the prevalence oftabagism: in the group I.
P3.13.20RECOVERY OF MASS AND OF MUSCULAR TONE INMENOPAUSE WITH HRT: PROSPECTIVE STUDYG.R. Lai , M.F. Careddu, F. Dore, B. Gigliotti
The Authors have wanted study the modifications of the mass, of thetone, of the standard strength and of that specifies, of the femoralquadriceps in women in menopause in transdermal substitutivehormonal therapy versus that oral.I had selected 2 croups of 60 [ oral: A ] and 30 [ transdermal: B ]patients observed for 12 monthes across ultrasaund monitoring,isochinetics electromyography and isometric, electromyography againstleg, test of Kotz. In the evaluation to 6 monthes the muscular mass, thetone, forces you/it and the ability of electrical transmission were grownof the 58-66% [group A] and of the 20-23% [group B ]: _>3.841.Thecheck to 12 monthes the result were of the 85-91% [group A] and ofthe 30-33% [ group B ]: _>6.635. In conclusion the therapies havestatistically meaningful differences in the comparison of themaintenance and of the possible recover of the muscular performance,important element in the woman life quality in young menopause, of tallsociocultural level with life expectations of great quality.
P3.13.21SKIN THICKNESS IN DIFFERENT MENOPAUSAL STATUSK. Panyakhamlerd , P. Chotnopparatpattara, N. Taechakraichana, A.Kukulprasong, S. Chaikittisilpa, K. Limpaphayom, Dept. OB/GYN,Chulalongkorn University, Bangkok, Thailand.
Objectives: This study was performed to compare the skin thickness ofThai women in their premenopause, perimenopause and earlymenopause.Study Methods: 112 women between 40 and 60 years of age, visiting themenopause clinic, King Chulalongkorn Memorial Hospital, were dividedinto 3 groups: premenopause (N=31), perimenopause (N=35) and earlypostmenopause (N=46). Skin thickness was measured byultrasonography using an Acuson 128 with a linear 7.5 MHz probe at theright great trochanter area. All tests were performed by the sameradiologist. Each measurement was made six times before the mean wascalculated.Results: The mean skin thickness in each group was 2.28 ± 0.39 mm,2.18 ± 0.35 m, and 2.02 ± 0.36 mm respectively. The skin thickness ofwomen in the early postmenopausal group was significantly lower thanthose in the premenopausal group, but no difference was found betweenpremenopausal and perimenopausal group nor between perimenopausal
and early postmenopausal group. Furthermore, we found no correlationbetween skin thickness and chronological age.Conclusions: The decline in skin thickness of women enteringmenopause requires a period of time to undergo significant alterationsand the study revealed a significant reduction of skin thickness as earlyas in the course of the early postmenopausal period.
P3.13.22SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) AND HORMONEREPLACEMENT THERAPY (HRT)Chuery, ACS; Fonseca, AM; Pádua, MAF; Bagnoli, VR; Sauerbronn,AVD; Burgos, RM & Halbe, HW. Dept. OB/GYN, São Paulo UniversityMedical School, São Paulo, Brazil.
Objective: To analyze clinical and laboratorial findings in patients withSystemic Lupus Erythematosus (SLE) submitted to hormonereplacement therapy (HRT).Methods: Sixty-five menopausal women with SLE were included in thisstudy. Age, initial complaint, Kuppermann Menopausal Index (KMI)and lipids screening were evaluated before and after 2 years of HRT.Patients were divided into 3 groups according to the HRT regimen used:Group A: association of estrogen and progestin (n = 31); Group B:estrogen therapy alone in patients submitted to hysterectomy (n = 7); andGroup C: progestin therapy alone (n = 27).Results: The mean patients’ age was 46,4 years. The main complaintwas hot flushes in 49,7%. No changes were found in the lipidsscreening. In Group A, 74,2% of the patients had clinical improvement,and 9,7% of cases had complications related to SLE. In Group B theclinical improvement was observed in 71,4% and no complicationrelated to SLE were found. In Group C 74,1% had clinical improvementand 7,4% had complications related to SLE.Conclusions: During the follow-up time analyzed the majority of womenhad important improvement in climacteric symptoms, without clinicalcomplications of Lupus with the introduction of HRT
P3.13.23THE DYNAMICS OF VEGETATIVE REGULATION OF THEHEART RATE IN PATIENTS WITH SURGICALLY INDUCEDMENOPAUSEB. Ventskovsky , N. Yarotsky, Yu. Sirenko, O. Kupnovitsky,V. Zhegulovich, A. Senchuk, National Medical University, Kiev,Ukraine
Objectives: To assess the changes of the blood pressure (BP) and heartrate variability after surgical menopause.Study Methods: 25 patients (average age 47±5 years) have beeninvestigated before and in the 6-months period after ovaryectomy. Two-functional 24-hours monitoring (ECG, BP) was performed with the useof system “Cardioteus” (“Meditech”, Hungary) before the operation andon days 3, 30 and 180 after operation. We have evaluated the daily BPprofile, its average value and variability, and the indices of heart ratevariability.Results: Vagotonic type of cardiac rhythm regulation was predominantbefore the operation together with the hypotension and low variability.From the 3rd day on after the surgery 55% of the patients have shown theincreasing sympathetic component (group 1), while the remainingpatients had vagotonic type (group 2). In 72% of group 1 this wasfollowed by the rising of average BP. On the day 180th of the follow-up45% of the patients from group 1 have developed the arterialhypertension.Conclusions: The investigation of the vegetative regulation of thecardiac rhythm makes possible the prediction of arterial hypertension onthe background of sympatheticotonia in the early postoperative period.
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P3.13.24THE EFFECT OF RALOXIFENE ON THE INCIDENCE OFSURGICAL INTERVENTION FOR PELVIC FLOOR RELAXATIONS. Goldstein (1), P. Neven (2), S. Eckert (3), Y.L. Taylor (3),A.V. Ciaccia (30, L Plouffe Jr. (3)(1) Dept. OB/GYN, NYU Medical Center, New York, New York, USA,(2) Dept. OB/GYN, Algemene Kliniek St Jan, Brussels, Belgium.(3) Lilly Research Laboratories, Indianapolis, Indiana, USA.
Objectives: Estrogen has been traditionally considered to have positiveeffects on pelvic floor relaxation, although no randomized, clinical trialshave validated this perception. Pelvic floor relaxation has beenassociated with two SERMs to date, levormeloxifene and idoxifene. Theobjective of this analysis was to determine whether raloxifene increasedthe incidence of pelvic floor relaxation requiring surgical intervention,as compared with placebo.Study Methods: Safety data from 3 double-blind, placebo-controlled,randomized clinical trials of osteoporosis, which enrolled a total of 6926postmenopausal women without prior hysterectomy treated for 36months, were pooled for this analysis. Studies 1 and 2 enrolled younger(mean age =54.8; n=969), healthy postmenopausal women randomizedto 30, 60, or 150 mg/day raloxifene or placebo. Study 3 enrolled older(mean age = 66.5; n=5957) osteoporotic, postmenopausal womenrandomized to raloxifene 60 or 120 mg/day or placebo. Indications forany reported pelvic surgeries were identified. Procedures performed forpelvic floor relaxation or urinary incontinence, including hysterectomies,were included in this analysis.Results: When considering all surgical procedures for pelvic floorrelaxation, including hysterectomies, a total of 34 (1.5%) patients in theplacebo group and 38 (0.8%) patients in the combined raloxifene groupsunderwent a surgical procedure for some type of pelvic floor repair. Therelative risk for pelvic floor repair was 0.51 (95%CI: 0.32, 0.80). Therewas an overall statistically significant reduction in the incidence ofprocedures indicated for the treatment of pelvic floor relaxation in thecombined raloxifene groups, as compared with the placebo group.(p=0.004).Conclusions: These findings suggest that raloxifene may help reduce theincidence of pelvic floor relaxation requiring surgery.
P3.13.25THE EFFECTS OF TIBOLONE ON PERIPHERAL VASCULARSYSTEMSüleyman Engin Akhan, Bülent Baysal, Esra Akgöz , Abdullah Turfanda Department of Obstetrics and Gynecology, Istanbul University Facultyof Medicine, Istanbul, Turkey.
Objective: The effect of tibolone, a synthetic steroid used in HRT, on thecardiovascular system and the biomolecular mechanism of this effect isnot exactly known. The aim of this study, is to evaluate the effect oftibolone on the vascular system by evaluating its action on endothelin-1(ET-1), the most potent vasoconstrictor agent, and its correlation withcarotid pulsatility index and lipid profile.Materials and Methods: Our study group was composed of 32 womenaged between 45 and 55 years with no systemic disease, who werepostmenopausal for at least a year, have FSH > 40 IU/ml and have bodymass index < 30 kg/m_.Initially, endothelin-1 and FSH levels, lipid profiles were measured andinternal carotid artery Doppler USG was performed in all patients. All ofthese parameters were repeated after 6 months of tibolone use. Resultswere expressed as p value, mean starting value±standart deviation vs.mean ending value±standard deviation, Z value. Wilcoxon signed ranktest was used during the statistical analysis and p value < 0.05 wasaccepted as statistically significant.Results: The average age of the patients was 49.5±3.5 years and theaverage postmenopausal age was 70.5±54.4 months. Twenty-five out of32 patients have completed the study. The BMI’s measured after thestudy was siginificantly increased (p=0.08, 26.36±3.73 vs. 27.06±3.3,Z= -2.66). After six months of tibolone treatment while HDL levels weresignificantly decreased (p=0.06, 48.32±7.3 vs.42.9±7.2, Z= -2.734), nosignificant change was observed in LDL levels (p=0.135, 158.2±19.98vs. 154.52±14.9, Z= -1.495). Although the decrease in ET-1 levels werenot significant (p=0.819, 10.25±1.92 vs. 9.6±1.91, Z= -0.229), internalcarotid pulsatility index measured after 6 months were significantllydecreased.
Conclusions: Although ET-1 levels were not statistically affected duringthe course of the study, we propose that the significant decrease noted oncarotid artery pulsatility index shows that tibolone has a positive effectindirectly on the peripheral vascular system in spite of significantlydecreased HDL levels.
P3.13.26THROMBOPHILIC PROFILE OF CLIMATERIC ANDMENOPAUSED WOMEN WITH VENOUS THROMBOEMBOLISMWHO ATTENDED THE GYNECOLOGY SERVICE OF SÃO PAULOUNIVERSITY HOSPITALMargarido, PFR .; Junqueira, PA; Bagnoli, VR; Fonseca, AM; Halbe,HW; Pinotti, JA Dept. OB/GYN, São Paulo University Medical School,São Paulo, Brazil
Objectives: Evaluate the thrombophilic profile and risk factorsassociated of climateric and menopaused women with history of venousthromboembolic disease who attended the Gynecologi Service of SãoPaulo University Hospital.Methods: Between January 1997 and December 1999, 18 women withpast history of venous thromboembolic disease were evaluated. The ageranged from 35 to 70 years. The diagnostic of the disease was based onmediacal history, past history of heparin and other anticoagulant use anddoppler of venous sistem from lower limbs. A research forthrombophilic states for eligible cases was conducted based on thequantification of antithrombin III, proteins C and S, lupic anticoagulantand anticardiolipin anti-bodies (IgG e IgM) seric levels. The womenwere questioned about tabagism, use of hormone replacement therapyduring the ocurrence of thromboembolism and other clinical conditionsassociated. The body mass index was calculated for all patients.Results: All 18 cases were considered as having a past history ofthromboembolic disease. The median age was 49,9 years. Patients werediveded in 3 groups according to the first episode of the disease: 66,7%had venous thombosis; 22,2% had pulmonary embolism; and 11,1% hadthrombophlebitis. The median age at the first episode was 43,6 (17-70years). In 7 cases (38,9%) at least one associated thrombophilic factorwas identified. Out of these cases, 4 (57,1%) were positive for lupicanticoagulant (1 was associated to protein S levels below the normalrange and other was associated to IgG anticardiolipin anti-body); 2 cases(28,6%) were positive for anticardiolipin anti-body only; 1 woman(14,3%) was identified as carrier of protein C deficience. In relation tothe associated risk factors 50% were found to be overweight(25>BMI<30); obesity (BMI>30) was found in 22,2%; and tabagism in27,8%. In 6 cases (33,3%) the thromboembolic episode ocurred duringhormone replacement therapy. In 3 of these cases there were found athrombophilic state in later investigationConclusions: As suggested by this study, BMI bigger than 25 and ageover 40 years are important risk factors for the developing oftromboembolic disease. Among the cases wich develop the diseaseduring hormone replacement therapy the prevalence of thrombophilicstate may (can?) be as high as 50%.
P3.13.27TRANSVAGINAL COLOR DOPPLER SONOGRAPHICEVALUATION OF THE UTERUS IN POSTMENOPAUSALWOMEN ON DAILY RALOXIFENE THERAPYA. Chittacharoen , U. Theppisai, Dept. OB/GYN, Faculty of Medicine,Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Objective: To evaluate the effect of raloxifene on the endometrium andthe uterus by transvaginal color Doppler sonography.Study Methods: The study group was composed of 33 asymptomaticpostmenopausal women. All had been treated with raloxifene (60mg/day) daily for 6 months. The patients underwent transvaginal colorDoppler sonography before starting raloxifene and after treatment. Theuterus was scanned by transvaginal ultrasound to evaluate endometrialthickness, echotexture and uterine volume. Color and pulsed Dopplerultrasound were used to evaluate the pulsatility (PI) and resistance (RI)indices of both uterine arteries. The mean values of the endometrialthickness, uterine volume and the PI and RI of the uterine arteries wereused for statistical analysis.Results: The mean endometrial thickness (3.63 ± 1.14 vs. 3.58 ± 0.97mm) and uterine volume (40.85 ± 18.61 vs 37.93 ± 19.76 ml) were notsignificantly different between starting treatment and after treatment
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(P>0.05). The mean value of the PI (3.42 ± 1.54 vs 3.84 ± 1.37) and RI(0.93 ± 0.11 vs 0.98 ± 0.10) of the uterine arteries were not significantlydifferent between before starting treatment and after treatment (p>0.05).Conclusion: Daily therapy with raloxifene does not stimulate theendometrium, the uterus and uterine blood flow.
P3.13.28TREATMENT OF DRY EYES IN POSTMENOPAUSAL WOMENWITH HORMONE REPLACEMENT THERAPYS. Chaikittisilpa (1), N. Taechakraichana (1), K. Panyakhamlerd (1), K.Limpaphayom (1), W. Tulvatana (2), Chulalongkorn University,Bangkok, Thailand.(1) Dept. OB/GYN(2) Dept. Ophthalmology
Objective: The aim of the study was to investigate the effects ofhormone replacement therapy on dry eyes in postmenopausal women.Study Methods: A prospective, randomized, placebo-controlled trial wasconducted in King Chulalongkorn Memorial Hospital to investigate theefficacy of conjugated equine estrogen 0.625 mg plusmedroxyprogesterone acetate 2.5 mg daily on tear volume inpostmenopausal women. A total of 27 postmenopausal women wererandomly assigned to receive the treatment, 13 cases with conjugatedequine estrogen plus medroxyprogesterone acetate, 14 cases withplacebo for 12 weeks. The tear volume was measured by Zone-QuickÒtest before and after the treatment. The symptoms of dry eyes wererecorded in visual analogue scale. The statistical analysis was unpaired t-test.Results: The two groups were not different in age, year sincemenopause, body mass index (BMI) or initial tear volume. The tearvolume was significantly increased in the hormonal group after 12weeks of treatment (P<0.05), but the placebo group was not. There wasno significant difference between groups in the tear volume after thetreatment. The eye symptoms were not significantly changed in bothgroups.Conclusions: The treatment of dry eyes in postmenopausal women withconjugated equine estrogen plus medroxyprogesterone acetate neitherincreased the tear volume nor improved eye symptoms within threemonths.
P3.14 MULTIPLE GESTATION
P3.14.01A CASE OF TRIPLET GESTATION COMPLICATED BY THEANTENATAL DEATH OF TWO FETUSES AND THE SURVIVALOF THE THIRD FETUSL. Zanotti , A. Contarini, A. De Rosi, Ospedale Civile S. Maria delleCroci, Ravenna, Italy.
Case Report: A case of triplet gestation complicated by the antenataldeath of two fetuses and the survival of the third fetus until the 32nd
week. The two fetuses had monochorionic placentation. One of themdied at the 22nd week, the second one at the 20th week. The survivingfetus had its own placenta.We adopted a conservative management until the fetal lung was maturewith cortisonic, antibiotic, heparin and ritodrine therapy. Cesareansection was performed on the 32nd week.
P3.14.02ABNORMALITY OF TWIN PREGNANCY: FETUS PAPYRACEUS –CASE REPORTN. Sulovic , M. Dunjic, S. Stanisic, L.J. Savic, Dept. OB/GYN,University Clinic, School of Medicine Pristina, Belgrade, Yugoslavia.
Objectives: The aim of the work is to study the development of a twinpregnancy after one of the twins died in early pregnancy and thepossible negative influence on the clotting system of pregnant women.Study Methods: Observation was done on patient DM, a 30 year-oldhousewife. She was observed from her first appearance at thedepartment. Personal and family anamnesis was regular. She had onedelivery three years ago with Cesarean section.Results: In the first ultrasonographic examination we found a twinpregnancy with obvious heartbeats of both twins. After two weeks on
control examination we found only one fetus, regularly developed, andin a separate amniotic cavity, a fetus without heartbeat with a smallquantity of amniotic fluid in a bizarre position. Patient was immediatelyadmitted in the hospital. Ultrasonographic examination, as well asroutine laboratory analyses were repeated every ten days. After the 28th
week of gestation we included a cardiotocographic (CTG) control everyfive days. In the 38th week the birth was finished by Cesarean section(indication for operation – previous Cesarean section). A female childwas born. After delivery, placenta was extracted with membranes whichcontained a dead fetus, 12 cm in length. After recovery which lastedseven days, the patient was dismissed in good condition with a healthybaby.Conclusions: An ultrasound examination proved to be of great help inmaking a diagnosis. It is very important to make a diagnosis in time,because if we do not do this, we will probably have great and heavycomplications.
P3.14.03ACTIVATED NITRIC OXIDE SYNTHASE EXPRESSION INRECIPIENT'S PLACENTA FROM MONOCHORIONIC TWINSWITH TTTSM. Nobunaga 1, M. Kanai1, T. Mizutani2, N. Suehara2, A. Nakajima3,R. Chin3, T. Nobunaga3, T. Kimura3, M. Koyama3, C. Azuma3,Y. Murata3
1Kanai Women's Clinic, Osaka, Japan, 536-0004, 2Dept. OB, OsakaMedical Center and Research Institute for Maternal and Child Health,Osaka, Japan, 594-1101, 3Dept. OB/GYN, Faculty of Medicine, OsakaUniversity, Osaka, Japan, 565-0871
Objectives; We investigated whether Nitric Oxide (NO), recognized tohave various biological effects on mammalian cells, contributes to thepathophysiology of TTTS, which has an extremely high perinatalmortality and morbidity.Study Methods; Ten MD twin pregnancies without TTTS and 6 MDtwin pregnancies with TTTS after 28 gestational weeks were studied._@The concentrations of NO2-+NO3-, stable metabolites of NO, inamniotic fluid and umbilical plasma were measured. Western blotanalysis and immunohistochemistory were also carried out to examinethe expression of NOS in the placenta.Results; The NO2-+NO3- concentrations of amniotic fluid (24.0 _M)and umbilical plasma (58.5 _M) in 10 twins with TTTS weresignificantly higher than those of amniotic fluid (11.5 _M; p<0.01) andumbilical plasma (27.0 _M; p<0.005) of 8 MD control twins. Westernblot analysis and immunohistochemistry revealed faint NOS I (ncNOS)protein in the syncytiotrophoblast of all of recipient, donor, and MDcontrol twins and the expression of NOS II (iNOS) in thesyncytiotrophoblast of MD twins with TTTS. NOS III (ecNOS)expressions in syncytiotrophoblast and endothelium of all of recipient,donor, and MD control twins were detected. The NOS III expressionwas three- to four-fold higher in donor's placenta compared with MDcontrol twins. On the other hand, the protein of placenta from recipienttwins expressed NOS III more than 10 times of MD control twins.Conclusions; We have demonstrated the elevated NO production in theplacenta of MD twins with TTTS, suggesting that NO contributes tokeep low vascular resistance and that the cytotoxicity of overproducedNO causes the high perinatal morbidity and mortality in TTTS twins.
P3.14.04ANTENATAL DIAGNOSIS OF TWIN-TWIN TRANSFUSIONSYNDROME BY DOPPLER ULTRASOUNDA. Hajric-Egic , Z. Mikovic, A. Cirovic, D. Filimonovic, V. Mandic,OB/GYN “Narodni Front” University Clinic, Belgrade,Yugoslavia.
Objectives: The present study used Doppler ultrasound to analyze theusefulness of umbilical arterial velocimetry for predicting the risk oftwin-twin transfusion syndrome.Study Methods: We studied 145 pairs of twins born at the “NarodniFront” OB/GYN University Clinic in Belgrade between January 1996and June 1998. Eight of 145 pairs of twins had twin-twin transfusionsyndrome. Using pulsed Doppler evaluation of the umbilical artery ofeach twin, the pulsatility index (PI) was used to evaluate the umbilicalarterial waveforms.Results: Eight cases of twin-twin transfusion syndrome were diagnosed(5.5%). Four cases resulted in spontaneous abortion between 23-26
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weeks and four in premature delivery between 28 and 35 weeks. Five ofsixteen fetuses survived (mortality 69%). The differences in the PI(above 0.5) from twin-twin transfusion syndrome cases between 23 and35 weeks, significantly exceeded those of the cases without thissyndrome (p<0.05).Conclusion: The difference in PI umbilical artery seemed to predict therisk and prognosis of twin-twin transfusion syndrome, even before theonset of severe discordant growth and severe amniotic fluid disparity.
P3.14.06CERVICAL LENGTH MEASURED BY TRANSVAGINALULTRASONOGRAPHY IN TWIN PREGNANCIESM. Kudela , M. Procházka, Dept OB/GYN, University Hospital,Olomouc, Czech Republic.
Objectives: The aim of the study was to evaluate cervical length in twinpregnancies by transvaginal ultrasonography as a predictor of prematurelabor.Study methods: Thirty-two women with twin pregnancies withoutpremature uterine contractions were evaluated by the means of vaginalultrasound every second week between the 16th and 34th week ofgestation. The length of the functional part of the cervix as well as theformation of “funnellling” was recorded. Signs of genital infection werealso searched for. In case of cervical shortening below 25 mm before the28th gestational week the patients were randomized for bed rest ofcerclage (as a part of the CIPRACT project).Results: The mean length of gestation in the whole group was 35.5weeks. Twenty-one pregnant women (66%) delivered after the 36th
week. In the 23rd week of gestation the average length of cervix in thosewho delivered after the 36th week was 33.5±6.8 mm. The mean cervicallength in the second group (delivery before the 36th week) was 21.6±5.5mm. The difference was statistically significant (p=0.01). Genitalinfection (increased CRP, WBC, HVS and pH) in the latter group wasfound in 27%. The results of conservative treatment (bed rest) versussurgical treatment (cerclage) will be evaluated according to theCOIPRACT protocol.Conclusions: Transvaginal ultrasonography seems to be a powerfuldiagnostic tool for assessing the risk of premature labor in twinpregnancies.
P3.14.07DICEPHALIC CONJOINED TWINS – A CASE REPORTF. Pricop , E. Crauciuc, M. Stavarache, D. Gafitanu, O. Masheh, 3rd
Clinic OB/GYN, University of Medicine and Pharmacy, Iasi, Romania.
Objectives: Presentation of one case of dicephalic conjoined twins, a aremalformation with a frequency of 1/50,000 births in the world.Material and Method: The patient D.M.E., 25 years old, of urbanmedium, was hospitalized with the diagnosis: VI pregnancies, II births –living infants, dicephalic fetus in complete pelvic presentation, activatedbirth, having 2 antecedent normal children and without a competentantenatal medical consultation. An emergency cesarean section wasperformed because of a fetus-pelvis disproportion, delivery departed,and the conception product was extracted: dicephalic conjoined twins,with a weight of 4100 g, size 46 cm, right cranial perimeter 35 cm, leftcranial perimeter 36 cm, thoracic perimeter 40 cm, abdominal perimeter35 cm, who lived for 30 minutes. The specimen has been investigatedradiologically and echographically before dissection through atomograph computer.Results: The anatomic examination showed: normality of cranialextremities (skull, soft parts and central nervous system); spines unitedin the oversacral lumbar segment; median lung aplasia in symmetry,lateral lungs were normal; heart with a sole ventricle and bifid at theatrial pole; aortic arch in symmetry, with right and left sub-claviculararteries retro-visceral; a sole trilobate thymus; sole liver and milt;digestive duct doubled in symmetry, but located latero-lateraly at thelevel of the medi-enteric intestine; double pancreas and biliary vesiclesin and two lateral kidneys, in normal position; sexual apparatus – femalesex with an important caudal appendage, located around a cavity withcloacal aspect. The hystologic examination did not show importantmodifications.Conclusions: The complex examination of the specimen allow us to statethat the diagnosis is: dicephalus dibrahii dipus conjoined twins, during
the last twenty years no other case was mentioned in Romania. There isno possibility to state an etiological diagnosis.Embriologically, we defend the fusion theory (Winslow), proved byO’Rahilly (1998): gemelarity trouble during the 1st week.
P3.14.08ONE CHANCE OF DIAGNOSIS AND TREATMENT FOR UTERUSDIDELPHYS WITH UNILATERAL IMPERFORATE VAGINACOMPLICATED BY TRIPLETS PREGNANCY: CASE REPORTChunping Jiang SheKou People's Hospital, Shenzhen, Guangdong,China (518067)
Object: To summarize the artificial abortion characteristic of uterusdidelphys with unilateral imperforate vigina complicated by pregnancyand learn more knowledge about the kind of cases.study methods: The clinical presentation of a case of uterus didelphyswith unilateral imperforate vagina complicated by triplets pregnancy isanalyzed and the literature from 1922 is reviewed.results: uterus didelphys with unilateral imperforate vagina is a kind ofgenitous anomaly.It includes a series of urogenital anomalies.So far itsetiology and pathogenesis are unknow.There is no identical name andclassification internationally.A lot of the kind of patients can't bediagnosed because its clinical presentation is not specific feature for theanomaly.It's artificial abortion process is more difficult and clinicalpesentation after abortion is special.It gives a chance to diagnoses andtreat.Conclusion: Artificial abortion is a chance of diagnosis and treatmentwhen the case is complicated by pregnancy.
P3.14.09OUTCOME OF TWIN PREGNANCIES IN NORTH JORDANS. Ziadeh , Dept. OB/GYN, Jordan University of Science andTechnology, Amman, Jordan.
Objective: The purpose of the study was to analyze the course ofpregnancy and perinatal outcome of 386 twins.Study Method: Retrospective analysis of maternal and neonatal medicalrecords of 386 twin pregnancies at Princess Badee’a Teaching Hospital,North Jordan from January, 1996 to June, 1999.Results: During the study period, there were 3305 deliveries of which386 were twin pregnancies (1/86). The gross perinatal mortality rate was178 per 1000 twin births. The perinatal mortality rate for singleton birthsduring the same period was 10 per 1000. Out of 772 twin babies, 108were breech. Breech presentation was associated with the highestperinatal mortality rate (278 per 1000). 184 out of 386 twin pregnancieswere preterm. The highest perinatal mortality rate occurred in thepreterm group (184.78 per 1000).The neonatal mortality rate fell with increasing birth weight from 532per 1000 at 1500g. to 16 per 1000 at 2500g.Regarding the association between modes of delivery and perinatalmortality, the highest mortality occurred with the babies whose birthswere by assisted vaginal delivery (144 per 1000).Conclusion: Prematurity and low birth weight were associated with highperinatal deaths. Various ways of reducing perinatal mortality associatedwith twin pregnancies, ranging from prophylactic use of beta-sympathomimetics to bed rest in prevention of preterm labor have beensuggested.In Jordan, emphasis must be placed on adequate antenatal care and theincreased use of ultrasound in modern obstetrics has resulted in earlierdetection of twin pregnancies and greater supervision. Perinataloutcomes may improve by proper management of complications such aspreterm labor, PIH, malpresentation.Keywords: Twin pregnancy, Neonatal outcome.
P3.14.10PERIPARTUM COMPLICATIONS OF UNDIAGNOSED TWINPREGNANCIESS.A. Obed , Dept. OB/GYN, University of Ghana Medical School,Accra, Ghana.
Objectives: The study was aimed at finding out why undiagnosed twinscontinue to be managed at delivery in a leading teaching hospital in
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Ghana, the associated maternal and perinatal morbidities and how toreduce the incidence.Study Methods: The details of age, parity, antenatal care, maternal andperinatal complications of all 806 twin deliveries managed at the KorleBu Teaching Hospital, Accra, Ghana in the two-year period from 1st Jan.1997 to 31st Dec. 1998 formed the database. One hundred and eighty-one of these undiagnosed twin cases at the time of delivery werematched against the 605 diagnosed for analysis.Results: The high incidence rate of 22.4% of twins delivered at thehospital were undetected before confinement was mainly due to poorantenatal care. There were significantly higher maternal and perinatalmorbidities in the undiagnosed twins compared to those detected beforedelivery.Conclusion: Improving the antenatal care of patients managed at thelevels A and B of the Primary Health Care System could enhance thedetection rates of twin pregnancies, and a better maternal and fetaloutcome.
P3.14.11TWINS AS A RISK FACTOR FOR GESTATIONAL OUTCOMER.A.M. Sá , R.B.R.G. Bornia, A.A. Cunha, N.R. Silva, M.J. Franco, J.E.Nejain, Dept. OB/GYN, Maternidade Escola, Faculdade de Medicina,Universidade Federal do Rio De Janeiro, RJ, Brazil.
Objective: To assess multiple gestation as a risk factor for pregnancyoutcome.Study Methods: The study design was a retrospective cohort. From Jan.1, 1996 to Oct. 31, 1999, 5555 pregnancies were observed at theMaternidade Escola da UFRL/RIO/BRASIL. The inclusion criteria wasgestational age >21 weeks. The study factor was a twin pregnancy. Theywere 172 (3.1%).Results: The multiple gestation, compared to singleton one, was a riskfactor for pre-eclampsia. (RR=2.28, CI=1.68-3.10), eclampsia(RR=12.52, CI=2.45-64.07), pre-term delivery threat (RR=4.43,CI=3.12-6.29), hemorrhage in the 3rd trimester of pregnancy (RR=2.85,CI=1.03-7.83), premature rupture of membranes (RR=1.35, CI=1.07-1.69), lower gestational age (34.9±3.3 vs 38.4±2.8, -3.5 weeks, p<0.001)and lower gestational birth weight (2238 ± 692 vs 3157 ± 614, -919 g,p<0.001).Conclusions: Twin pregnancy is a risk factor for gestational outcomesassociated with toxemia, pre-term delivery, premature rupture ofmembrane, lower gestational age and lower birth weight.
P3.15 NEONATALOGY
P3.15.02BRAIN CIRCULATION AT NEWBORNS WITH PERINATALPATHOLOGYN. Bashakin , A. Aksenow, I. Antipova, M. TroickayaMoscow Regional Scientific Research Institute OB/GYN, Moscow,Russia
Objective: The aim of the study was to investigate parameters cerebralcirculation (CC) at newborns with perinatal pathology.Study Methods: We used transcranial ultrasonic dopplerometrija arteriacerebri anterior (ACA) at 40 term infants in the age of 1-6 day (thescanner Aloka-650, transducer 5 MHz) at children with the complicatedcurrent of the perinatal period (basic group – 32 children with neurologydisease, hypotrophia, infants of diabetic mothers) and control group (8healthy newborn).Results: Maximal value of systolic cerebral blood flow velocity in ACAat all newborn control group changed from 25.6 up to 51 cm/s. In time,22 (71%) children of the basic group were lower 25.6 cm/s (p<0.001)and here have come 8 of 10 children of diabetic mothers. Minimal valueof diastolic cerebral blood flow velocity in ACA also was authenticallyabove at newborn control group (8.1 – 14.0 cm/s). The systolic-diastolicratio (S/D), index of resistance (RI) at children of the basic group hadthe greater disorder of meanings (in the control an index S/D has made2.71 – 3.92, RI o.63 – 0.74). At newborn with RI >0.75, it was markedmore expressed neurology diseases with prevalence of an oppression ofcerebral function , than at children with RI<0.75.Conclusions: Newborns with serious perinatal pathology need in thecorrection cerebral circulation diseases for decrease brain pathology.
P3.15.03CHOLESTEROL SIDE-CHAIN CLEAVAGE ACTIVITY IN HUMANUMBILICAL CORD BLOOD ERYTHROCYTES IN VITROK.L. Peh, A. Loganath, PCT Chew, YC Wong, SC Ng, University DeptOB/GYN, National University Hospital, Singapore, Republic ofSingapore.
Objectives: Our recent study on the enzymic ability of human umbilicalcord blood erythrocytes to oxidize pregnenolone to progesterone raisedthe possibility whether these blood cells also possess the cholesterol C-20, 22-desmolase ability to cleave the side-chain of cholesterol toproduce pregnenolone and isocaproic acid, a rate-limiting step insteroidogenesis.Study Methods: Sonicated preparations of plasma-free erythrocytes atthe range of total numbers between 59.8x109 and 66.9x109 obtainedfrom umbilical arterial and venous blood collected from women (n=6;age 26 to 39 years) following spontaneous vaginal delivery fromuncomplicated pregnancies at term (37 to 41 weeks) were incubatedwith [26-14C] cholesterol as substrate. The content of leucocytes waspersistently very low (<0.0005%) in the incubates. The controls wereheat-denatured preparations of cord blood erythrocytes. Using thereverse-isotope dilution procedure, [14C] isocaproic acid wascharacterized from the incubates.Results: Radiochemically pure p-bromophenacyl ester of isocaproic acidwas obtained in all the 6 incubations with viable cord blood erythrocyteswith specific activities ranging between 7.3 and 50.2 dpm/mg. Such ametabolite was not evident in the controls. Characterization of [14C]isocaproic acid is a reflection of the fact that the multienzyme desmolasesystem specific for the oxidation of the terminal 6 carbon atoms of theside-chain of cholesterol exists in the viable preparations. The efficiencyof enzymic conversion spanned from 8.9x10-2 to 6.1x10-1%.Conclusions: The results reveal the presence of C-20, 22 desmolaseenzyme system capable of conversion of [26-14C] cholesterol to [14C]isocaproic acid and pregnenolone in the cord blood erythrocytes. Theevidence in vitro indicates that a potential for in situ production ofpregnenolone exists in these erthrocytes. The evidence in vitro indicatesthat a potential for in situ production of pregnenolone exists in theseerythrocytes during human pregnancy. An additional source ofpregnenolone supply for subsequent steroid biotransformation necessaryfor maintenance of pregnancy and development of the fetus isimplicated.
P3.15.04COMPLETE MATURE TERATOMA FETIFORMN. Kuno , Dept. OB/GYN, Japanese Red Cross Nagoya First Hospital,Nagoya, Japan.
Objectives: A virginal 25 year-old Japanese woman was refereed to ourinstitute with giant ovarian tumor. Tumor markers, X-ray, CT, MRIindicated the tumor is an ovarian mature cystic teratoma. The tumor wasresected and pathologically diagnosed as benign dermoid cyst. A solidfetiform mass was discovered in it. This is to investigate the degree ofdifferentiation of the fetiform mass and the limitation of developmentwithout paternal genome.Study Methods: The tumor was macro- and micro-scopicallyinvestigated.Results: The whole tumor was 110g with a smooth surface and in thetumor, buried deep in the fat and hair, was a small doll-like structure(10x7x7cm), weighing 150g, with distinguishable head, face upper andlower limbs and trunk. The whole structure was covered with thickwhite skin with coarse lanugo, but both cranial and caudal end werecovered with thick, long and dark hair. Eye, teeth, brain-tissue, nails,rudimentary ear, phallus-like structure, and omphalocele weredistinguishable in appearance. Intestinal tract, blood vessels, spinal cord,bone and bone marrow, peritoneal membrane, respiratory epithelium anddura mater were microscopially confirmed.Radiographic examination revealed the cranial bottom and occipitalbone, spine like structure, upper and lower limb bones and lowermetatarsal bones.Conclusion: This is an additional case of mature cystic teratoma fetiformand might be one of the biggest and most differentiated cases reported.The existence of cranio-caudal, antero-posterior and left-right axisindicate the primary developmental step of the axis formation mightoccur without the participation of paternal genes. The preciseobservation of this case may contribute to understand how much human
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parthenogenesis can be carried out only with maternal geneticinformation.
P3.15.05DETERMINING OBSTETRIC RISK FACTORS AND PREGNANCYOUTCOME OF FETUSES WITH TRUE KNOTS OF THEUMBILICAL CORDE. Sheiner 1, R. Hershkowitz1, T. Silberstein1, G. Holceberg1, I. Shoham-Vardi2, M. Katz1, M. Mazor1. Dept Ob/Gyn1 and Epidemiology2, SorokaUniversity Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
Objective: To determine the obstetric risk factors and pregnancyoutcome of fetuses with true knot of the umbilical cord.Study design: We analyzed 69139 singleton birth files. Deliveriesoccurred in the between the years 1990-1997. Fetuses withmalformations were excluded.Results: The incidence of true knots was 1.2% (841/69139). Thefollowing obstetric factors were found to be significantly correlated totrue knots of the umbilical cord in a multiple logistic regression model:Chronic hypertension (OR=1.7; 95%CI 1.2-2.5), patients afteramniocentesis (OR=1.2; 95%CI 1.1-1.5), male fetuses (OR=1.5; 95%CI1.3-1.7), prolapse of cord (OR=3.4; 95%CI 1.8-6.2) and cord around theneck (OR=1.9; 95%CI 1.6-2.3). The incidence of fetal distress andmeconium stained amniotic fluid was significantly higher amongpatients with true knots of cord [7.0% vs 3.6%; 22.4% vs. 16.2respectively, p<0.0001]. Moreover, there was a fourfold higher rate ofstillbirths among those fetuses [1.9% vs. 0.5% p<0.0001], and higherrates of cesarean sections [15.5% vs. 10.5%, p<0.0001].Conclusion: True knots of the umbilical cord are associated with ahigher rate of fetal distress and stillbirths than those without thiscondition. Thus, careful sonographic and Doppler examinations shouldbe performed in high-risk patients for the detection of anomalies of theumbilical cord.
P3.15.06EARLY ADAPTATION AT NEWBORN HIGH INFECTIOUS RISKI. Antipova , A. Aksenov, L. Kuzmenko, T. Tareeva, N. Bashakin,Moscow Regional Scientific Research Institute OB/GYN, Moscow,Russia
Objective: The aim of the study was to investigate the features of earlyadaptation newborn high infectious risk for optimization of tacticsconducting.Study Methods: We surveyed 156 newborn from the mothers withchronic infectious diseases (ChID) in the early neonatal period. Clinical,ultrasound and immunologycal methods were used.Results: It was established, that ChID of the mother renders seriousadverse influence on a condition of a fetus and current of earlyadaptation at newborn, resulting to development hypoxic, infectious andtoxic defeat of brain (49.6%), intrauterine hypotrophy (29.4%),intrauterine and postnatal infection (30.4%). Was established 4 variantsof current early neonatal of the period depending on a condition of thechild at birth and dynamics of a condition at the first hours o’clock. Fornewborn, high infectious risk (even clinically healthy) are characteristicto the infringements hemodynamics (later closing of fetalcommunications, decrease contractile activity of myocardium, highcommon peripheric vascular resistance, arterial hypertension), endocrineof adaptation (low level adrenocorticotrophin and cortisone),metabolism (decompensated metabolic and respiratory-metabolicacidosis, increase activity of blood enzyme), the change of the factors ofspecific and not specific protection (hypoimmunoglobulinaemia G isless 9.8 g/l, the decrease of a level scale gamma-interferon is less 8 ME,the increase of parameters activity peroxid oxidation of lipids – MDA ismore 6 ng/ml).Conclusion: Newborn from the mothers with ChID are the high riskchildren for disease in the early neonatal period. They need in thecorrection hemodynamics, metabolism and immunologycal disturbances.
P3.15.07EFFECTS OF INFERTILITY TREATMENTS ON THE NEONATALHEALTHF. Zarrinkoub , A. Beigi, Dept. OB/GYN/PED, Arash MaternityHospital, Tehran University of Medical Sciences, Tehran, IRAN.
Objectives: To evaluate health of newborns of women who conceived byinfertility treatments.Study methods: In a prospective study on the 4,460 newborns thatdelivered at Arash hospital, Tehran university of medical sciences, fromFeb 1996 to Jun 1999, the newborns of women who conceivedspontaneously compare to those who used infertility treatments.Infertility treatment group divided into two group 1-stimulation group 2-assisted reproductive technology (ART) group.Results: Infertility treatments were reported for 6.3% of pregnancies(283 women, 314 newborns) relative risk of low birth weight,prematurity, intrauterine growth retardation, morbidity, transfer toneonatal intensive care unit and birth defects were approximately 3times higher for the stimulation group and 4-6 times higher for the ARTgroup.Conclusions: We found an association between infertility treatments andneonatal morbidity, and most of this impact appeared to be mediated bymultiplicity and prematurity, therefore reducing the number of medicallyinduced multiple pregnancies is the most effective prevent ion ofneonatal morbidity related to infertility treatments.
P3.15.08FETAL RENAL ANOMALIES AND FETAL ULTRASOUNDG. Whincup , Dept. PED, The Conquest Hospital, The Ridge, StLeonards on Sea, East Sussex, UK.
Objectives: To identify within the fetal population infants likely to havelater true renal anomalies.Study Methods: A two year population sample (3,600 pregnancies) wereincluded in a prospective study and had antenatal ultrasound scans ontwo or more occasions during pregnancy. Further scans were performedpostnataly on infants where antenatal hydronephrosis was identified.Results: This study demonstrated an incidence of hydronephrosis of 10%with renal reflux of 1%. This is at odds with previously publishedfigures. Within the study period infants who presented with acoincidental urinary tract infection but had normal scans antenatal weredemonstrated reflux (20%).Conclusions: Antenatal ultrasound offers a safe and quick identificationof the basic anatomy of the fetal kidney. It does not exclude reflux inthis population. If neonatal scans at to and eight weeks with a fullbladder are normal subsequent scans at nine months will also be normal.It is not possible to reassure the mother of a fetus that reflux does notexist hoewever antenataly.
P3.15.09FREQUENCY AND STRUCTURE OF CONGENITAL MAJOR-MALFORMATIONS OF 10,000 NEWBORN INFANTSM. Josimovska , V. Mitevska, M. Mihajlovska, Medical Centre,Kumanovo, Republic of Macedonia.
The importance of congenital malformations in practical neonatalpediatrics illustrates the data that about 1% of newborn infants duringdelivery have clearly showed major-malformations, i.e.. those whichhave significant medical, surgical and estetic consequences and whichdisturb organism functions and development, or some parts of theorganism. Here, congenital malformations which are diagnosed later inchildhood (heart, kidney, lung malformations), are not included.Newborn infants were observed at Newborn Infants’ Division at theGYN/OB Dept. in Kumanovo Hospital from 119 to November 1996, orin total, 10,000 newborn infants. In 1992 there were 1.1%malformations, in 1993 – 2%; in 1994 – 0.8%; in 1995 – 0.7% and in1996 until November –0.9%. This shows that the frequency ofcongenital malformations is almost the same, and at 10,000 newborninfants that is 0.98%. In 1999 were 1880 newborn infants with 19 withwho had malformations. According frequency in the first place areextremity malformations – 52% (pes equinovarus polidactilia,sundactilia); body malformations – 20% (evisceracia, rashishizis with orwithout meningomielocele); multiple congenital anomalies – 10%(syndrome Becwit, syndrome Down); then face malformations – 8%
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(cheliognatoplantoshizis); then head malformations – 5%(microcephalia, hydrocephalia) and artrezio ani –5% from all majormalformations. The basic criterion for practical importance formalformations is their pathological significance for the organism.Surgical therapy is almost the only possible way for malformations.Education and help are necessary in family planning always when thereis a potential risk for posterity.
P3.15.10LEFT ATRIAL MYXOMA WITH ENDOCARDIACFIBROELASTOSIS ON A NEWBORN (HISTOPATHOLOGICALCONSIDERATIONS)F. Pricop (1), M. Pavaleanu (1), D. Gafitanu (1), C. Cotea (2),C. Asmarandei (2), C. Cotutiu (3), C. Amalinei (3); (1) Dept. OB/GYN,University Hospital “Elena Doamna”, Iasi, Romania. (2) Dept.Neonatology, University Hospital “Elena Doamna”, Iasi, Romania.(3) Dept. Morphopathology, University Hospital “Elena Doamna”, Iasi,Romania.
Objectives: The aim of the study was to correlate themorphopathological findings with the outcome of a new born with atrialmyxoma and endocardiac fibroelastosis. Cardiac tumors are extremelyrare in childhood (150 published cases) and at the newborn age areexceptionally diagnosticated. Myxomas represent 10 – 15% fromprimary cardiac tumors. Frequently they are benign, but the benignity ishistological, the evolution being usually grave.Study Methods: The lower case is the first in our 25 years of clinicalexistence. She is a girl, the seventh born naturally, breech presentation,Apgar 8, 3500 grams weight at 38 weeks of gestation. The family hadanother baby that died at 11 months with a cardiac malformation. Themother presented signs of premature labor, neglected urinary infectionand anemia during the pregnancy evolution and only two prenatalconsultations. The postpartum evolution of the child was favorable in thefirst two days. The third day, the general status was suddenly altered,with cyanosis, acute cardiobreathing distress, cardiogenesis shock, andthe child died after seven hours by irreversible heart failure. The thoracicX-ray showed acute cardiomegaly.Results: Histopathological exam presented a left atrial myxoma, with thesize of a cherry, gray white, with lean surface and thin tissue, placednext to the superior face of the mitrial valve. The parietal endocardiumwas thicker, and had a fibroelastosis aspect. Unfortunately the patienthad been diagnosed after death.Conclusions: In the future, use of the antepartum and postpartumscreening by echocardiography could improve the vital prognosticearlier diagnosis and effective surgical treatment.
P3.15.11LOW BIRTH WEIGHT INFANTS: DETERMINING OF GENITALTRACT INFECTION AS REASON FOR DELIVERY ANDESTIMATION OF MATERNAL-FETAL INFLAMMATORYRESPONSEK. Piperkova , Neonatology Dept., Clinic for Child Diseases, SkopjeUniversity, R. of MacedoniaM. Trajanova, D. Buljukova, Spec. Hosp. OB/GYN "Cair", Skopje,R. of Macedonia
Objective: In multifactorial etiology of preterm labor we determined theincidence of genital tract infections among mothers as reason forpreterm labor and preterm rupture of membranes (pPROM), as well asfor subsequent maternal-fetal inflammatory response.Study methods: We processed 164 preterm infants with birth weightbetween 500 and 1500 gm, and their respective mothers. The mother-infant pairs were grouped. Group 1 - includes preterm deliveries andpPROM caused by infection of the mother: vaginal, cervical, amniotic,and decidual. Group 2 - includes those who had a clear maternal or fetalindication for preterm delivery. Group 3 - included those with idiopathicpreterm labor.Results: Of the total 164 preterm deliveries, in 66 cases (40.2%) thereason for preterm labor and pPROM was infection of the reproductiontract of the mother. Of these mothers, 24 (36.4%) had proven bacterialvaginosis where therapy had just started; 7 (10.6%) hadchorioamnionitis; and 35 (53.0%) had asymptomatic untreated bacterialvaginosis. Maternal-fetal inflammatory response was detected in a very
early stage of 12 to 24 hours after delivery, by determining CRP,Elastase a1 proteinase inhibitor and hemoculture.Conclusion: The infection participates with a high percentage in earlypreterm births. Persistence in detecting infections in the lowerreproductive tract in this pregnancy or in earlier ones, as well assystematic treatment of bacterial vaginosis, reduced to a high degree therisk of preterm delivery and pPROM, and maternal-fetal morbidity,which is especially important for the prevention of high-risk prematureinfants.
P3.15.12MORBIDITY AND MORTALITY IN NEWBORDS OFADOLESCENT MOTHERS WITH ECLAMPSIAC. Ferrada , M. Molina, R. Perex, L. Cid, V. Casanueva, C. Aedo,Y. Farlas, P. Pyarzun, P. Paredes. B. Rosal, Faculty of Medicine,Physical Science & Mathematics, University of Conception, Chile.
Objectives: The aim of the study was to evaluate the perinatal morbidityand mortality in newborns of adolescent mothers with eclampsia.Study Methods: A retrospective study was conducted in 53 newborns ofadolescent mothers with eclampsia at the Clinical Hospital ofConception, Chile, from 1988 to 1998.Results: These newborns were born by caesarean section (90.4%). Thelow weight at birth was 54.7% and the very low weight was 9.4%. Theneonatal asphyxia was 29.4% and severe asphyxia (13.7%). 41.2% werepremature and 32.1% small for gestational age. The mains neonatalmorbidities were Respiratory Distress Syndrome (17.6%) and metabolicdiseases (11.8%). There was 2 fetal deaths (3.8%) and 1 early neonataldeath (1.9%). In this group Perinatal mortality was 5.7%.Conclusions: Eclampsia in adolescent mothers had a negative impact inperinatal morbidity and mortality.
P3.15.13PERINATAL MORTALITY SURVEY IN A TEACHINGINSTITUTION.N. Chavan , P.K. Shah, V.R. Badhwar, Dept. of Obgyn. & LokmanyaTilak Medical College & Hospital, Mumbai, India.
Objectives: The aim of the study was to calculate the Perinatal mortalityrate (PNMR), to study associated maternal & foetal factors affecting itand to suggest control measures to reduce PNMR.Study Methods: Total number of patients delivered from February 1999to July 1999 (Six Months) were 3490. The study was done according tofollowing associated factors of reproductive age, gravidity, ANC status,socio economic and educational status, related maternal medical andObstetric factors, condition of foetus and neonate at birth and presenceof any congenital malformations.Results: Perinatal mortality rate (PNMR) was 52.7 / 1000 live births,corrected PNMR 44.69 per 1000 live births, and extended PNMR 61.03per 1000 live births and early neonatal mortality rate 19.43 per 1000 livebirths. The study revealed that women less than 20 years and more than30 years of age, primi and grand multipara, patient with poor socioeconomic and educational status where at greater risk of having perinatalmortality. In addition to these factors unregistered patients with poorantenatal attendance, transfer cases from peripheral hospitals had greaterrisk of perinatal mortality. PIH, anaemia, diabetis, APH,polyhydramnios, oligohydramnios and preterm labor were importantmaternal factors in increasing PNMR while immaturity, infection,asphyxia, RDS, congenital anomalies were major foetal factorsConclusions: Improvement in referral systems, awareness in society ofantenatal registration and followup with better intrapartum foetalmonitoring facilities and improvement in management of sepsis andpreterm babies will reduce the PNMR in developing countries.
P3.15.14pH VALUES AND THE WAY OF ENDING THE DELIVERY INPREVENTION ON INTRAPARTAL INJURIES OF NEWBORNSS. Aleksic , M. Bogavac, N. Curcic, Dept. OB/GYN, School ofMedicine, University of Novi Sad, Novi Sad, Yugoslavia.
Objectives: The aim of the study is to investigate the influence of pHvalues on intrapartal injuries of newborns. We have analyzed theglycosis of fetal erythrocytes that depend on pH values of blood.
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Study methods: The pH values of the blood taken intrapartally from thepresenting part of fetus were analyzed in 300 deliveries. The analysiscomprised pH values of newborns born by cesarean section in which pHvalues were determined from the blood of the umbilical cord,immediately after birth. The authors also analyzed pH values innewborns born by vacuum extraction as well as in normal vaginaldeliveries, and pH values were determined from the blood of theumbilical cord, immediately after birth. A part of this paper deals withthe influence of pH values on glycolysis of human fetal erthrocytes (invitro).Results: Decease in pH values below 7.25 led to the slowing down of theglycolysis process which was two times of pH values on intrapartalinjuries of newborn were investigated in the application of vacuumextraction. These injuries were more frequent in newborns which areacidosis, i.e. with lower values of pH blood.Conclusion :These authors concluded that vacuum extraction itself didnot lead to injuries, but only augmented sensibility, i.e. there is aquestion of decreased. They believed that vacuum extraction was a goodmethod when applied on time in indicated cases. Summarizing theobtained results we can say that we decide for cesarean section at ratherearly stage, which may be good, but we decide for vacuum extractionrather late, in cases when pH of blood is not taken intrapartally from thepresenting part of the fetus.
P3.15.15PRESENCE OF PROLONGATED PREGNANCY AND PERINATALMORBIDITYD. Bulukova , K. Piperkova, L. Kirovski, M. Trajanova, T. Bojadziev,A. Sopova, Special Gynecology & Obstetrics Hospital “Cair”, Skopje,Macedonia,
Objectives: The aim of the study was to show the relationship betweenthe prolonged pregnancy and perinatal morbidity.Study Methods: The total number of births in our Hospital during 1999amounted 3352. Of these, 3319 (99,015 %) were live born, and 33 (0,98%) were stillborn. Of the live born, term newborn were 3010 (89,80 %),preterm were 342 (10,2 %), and newborn from PP were 78 (2,3 %). Wedetermined PP according to anamnestic (definition by FIGO), clinicaland ultrasonographic characteristics of the fetus.Results: Perinatal morbidity was encountered in 1136 cases (34,33 %) ofthe total number of term newborn, and in 57 cases (73, 08 %) of the totalnumber of newborn from PP. In regard to the encountered earlymorbidity, there is a high significance in the differences among thenewborn from PP (p<0,001) in relation to the ill term newborn. Thehighest percentage of prolonged pregnancy we determined amongmothers with first birth – 52 (66,66%), with second birth – 16 (20,05%),third birth – 8 (10,25%), and multiple births – 2 (2,56%). Of the womenwith PP, 8% had placental insufficiency, and the reasons in the othercases are unknown.Conclusion: Regular checkups during the pregnancy period andprogrammed delivery remain the most significant for reducing PPassociated with the higher percentage of perinatal morbidity.
P3.15.16QUANTITATION AND CORRELATION BETWEEN DIFFERENTUMBILICAL CORD BLOOD CELL COUNTS ISOLATED FOR USEIN TRANSPLANTATIONR. Czajka (1), P. Szolomicka-Kurzawa (1), W. Mikolajek (2)(1) Dept. Obstetrics and Perinatology, Pomeranian Medical University,Szczecin, Poland. (2) Dept. Biochemistry and Chemistry, PomeranianMedical University, Szczecin, Poland.
Objectives: The aim of the study was to investigate the percentagenumber of hematopoietic progenitor cells in different populations ofumbilical cord blood white cells. Hematopoietic stem cells andprogenitor cells were isolated from umbilical cord blood within thepopulation of mononuclear cells (MNC). MNC can be found among‘small’ lymphocytes, these in turn belong to white blood cells.Study Methods: Ten samples of the umbilical blood collected afterdelivery of the placenta were assessed. The concentrations of leukocytesand lymphocytes were evaluated. Numbers of mononuclear cells and CD34+ cells were analyzed after cell isolation. MNC were isolated inFicoll-Hypaque gradient and CD 34+ cells were isolated with magneticcolumn use.
Results: Only one statistically significant correlation was found, betweenMNC and CD34+ cell concentrations (p<0.05). The mean percentage ofCD34+ cells within MNC ranged 0.8%.Conclusions: On the basis of results, it was established that MNCconcentration indirectly allowed for estimation of hematopoietic stemcells concentration, which is not the case when leukocytosis andlymphocytosis are taken into consideration.
P3.15.17RATE OF NEWBORN ASPHYXIA AFTER SELECTIVEOPERATIVE DELIVERYV. Saprikin , I. Dragun, T. Gracheva, Dept. of Obstetrics, ResearchCenter of OB/GYN, Moscow, Russia.
Objective: To reveal the reason of asphyxia in term newborns afterselected cesarean section.Material: Fulfilled examination included cardiotocographia, ultrasoundand Doppler, biochemical blood analyses and O2 and CO2 levels andoxygen transport in fetus cord. First group consisted of 49 newbornsdelivered with asphyxia of different severity, the second one consisted of84 newborns delivered with Apgar score 8-9.Results: Analysis of cardiotocogramm revealed deviation from normalvalues in 28.6% in the first group. Utero-placental and fetus-placentalcirculation was reduced in 24.5% by Doppler made 1-2 days beforedelivery and cord loop around fetus neck was found in 50% byultrasound. Such changes in the second group were noted 3 times asrare.Time from the beginning of the operation to delivery was higher on 2.2min in the I group than in the II group. 29% of newborns from the Igroup suffered from intrauterine infectious disease, that was 2.5 timehigher than in the I group.Conclusions: Reasons for newborn asphyxia, firstly, were the result ofintrauterine fetus condition before the delivery and it could be suggestedthat anesthesia and/or operative procedure by itself breaks uterine-placental-fetus circulation because changes of fetal heart rate wasregistered only in £30% of cases.
P3.15.18REPETITION OF OSTEOCHONDRODYSPLASIA – A RAREHEREDITARY DISORDER OF BONESS.Sipos , T.Marton, A.Ujházy, J.Rigó Jr., I.Dept. OB/GYN SemmelweisUniversity Medical School, Budapest, Hungary
Background: Osteochondrodysplasia with defective bone mineralizationis a rare hereditary disorder. It is characterized by bone structure defectsand a deficiency of bone/liver/kidney alkaline phosphatase activity inserum and tissues.Case report: Type 2a osteochondrodysplasia was detected in the first andsecond pregnancies of a 28 year old woman. Fetal age was 20 and 17gestational weeks, respectively. Ultrasonographical findings showed asoft, dilatated spine, narrow chest and short ribs as well as deformedbones and skull.An additional fetopathological finding wshypomineralization of the skelet (diagnosed by hystopathology and X-Ray examination). The disorder proved to be Infantile Hypophosphatasia(congenital lethal type).Outcome: Both pregnancies were terminated after the diagnosis of thedisorder.Conclusion: In order to detect this disorder, careful, repeated ultrasoundexam should be performed in the first and second trimester. A Serumalkaline phosphatase level and elevated urinare phosphoethanolaminelevel of the family members may help to predict the disorder.
P3.15.19SUPPRESSION OF MEMBRANE PERMEABILITY TRANSITION INFETAL RAT LIVER MITOCHONDRIA AND ITS ROLE INOXIDATIVE STRESST. Yoshioka (1), T. Yoshida (1), J. Akiyama (2)Div. OB/GYN, Kurashiki Medical Center, Kurashiki, Japan.Akiyama Memorial Hospital, Hakodate, Japan.
Objectives: Because neonates are exposed to various hazards such asoxidative stress during and immediately after labor, protectivemechanisms should exist, but few have been identified so far. The aim
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of this paper is to clarify the role of the mitochondrial membranepermeability transition (MPT) for protection of the fetus and neonatesagainst the hazards arising during perinatal period.Study Methods: Mitochondria were isolated from livers of fetal (FM)and adult (AM) rats by the method of Hogeboom. Cytochrome contentand rates of oxidative phosphorylation were measured byspectorphotometric and polarographic methods. MPT and cytochrome c(Cyt.c) release from mitochondria were measured by absorption at 540nm and Western blot analysis, respectively. Caspase-3 activity wasmeasured I a cell free system using a fluorgenic peptide substrate.Results: No typical absorption spectrum of reduced Cyt.c was observedin FM although Cyt.c was detected by Western blotting. The rates ofoxidative phosphorylation and the respiratory control ratio were lower inFM compared to AM. Similarly, both mitochondrial MPT and Cyt.crelease from FM induced by Ca2+ yielded lower values than those ofAM. However, Triton treated FM supernatant activated caspase-3.Conclusions: The present results suggest that decreases in mitochondrialMPT and Cyt.c release and the consequent decrease in the activation ofcaspase-3 which induces chromosomal DNA fragmentation andapoptosis in liver cells might contribute to the protection of the tissues ofboth the fetus and the neonate against various hazards.
P3.15.20THE COMPARISON OF THE METABOLIC STAINS TOXICITYAGAINST HUMAN HAEMATOPOIETIC STEM CELLS ISOLATEDFROM UMBILICAL CORD BLOOD.W. Mikolajek1, P. Szolomicka-Kurzawa2, R. Czajka 2. 1Department of Biochemistry and Chemistry, 2Department of Obstetrics andPerinatology, Pomeranian Medical University, Szczecin, Poland
Objectives: The aim of this study was to compare the potential toxicityof metabolic stains: Hoechst 342, Pyronin Y and Rhodamin 123, whichwere used for isolation of human haematopoietic progenitor cells fromumbilical cord blood.Study methods: Twenty samples of the umbilical blood collected afterdelivery of placenta were assessed. The potential clonogenicity of theprogenitor cells, isolated with the use of studied stains, measured as anumber of BFU-E and CFU-GM colonies was evaluated to comparewith clonogenicity of progenitors from control samples.Results: Less colonies of BFU-E and CFU-GM were found in all studiedsamples against to control. In the group where Pyronine Y was used,only number of CFU-GM colonies was statistically decreased. Allstudied metabolic stains had much stronger influence on CFU-GMcolonies than on BFU-E.Conclusions: Based on the results, it was established that Rhodamin 123and Pyronin Y were relatively safe metabolic stains for isolation ofhaematopoietic stem cells. Hoechst had higher toxicity.
P3.15.21THE INFLUENCE OF CORTISOL AND MELATONIN ON THEEARLY ADAPTIVE CONDITIONS OF NEWBORNS FORMMOTHERS SUFFERING FROM GESTOSISI. T. Govorukha , V. K. Chaika, Donetsk State Regional Center ofMotherhood and Childhood Protection, Donetsk, Ukraine
Objectives: The aim of the study was to estimate the level of cortisol andmelatonin in blood serum in newborns from mothers suffering fromgestosis.Study Methods: Forty-six newborns were divided into 3 groups. The fistgroup consisted of 13 babies born from ladies with normal pregnancy,18 newborns were from mothers with preeclampsia, as a complication ofpregnancy, 15 newborns from mothers with eclampsia consisted thethird group. The level of cortisol and melatonin in serum were examinedin all babies.Results: Newborns from 2 group had a raised level of cortisol andmelatonin by 1.6 and 1.2 times compared to those of the control group.In the 3 group there was an increase in cortisol and melatonin by 2.1 and0.85 times.Conclusions: There was a definite stressful adaptive capacity ofnewborns from mothers in preeclampsia as a complication of pregnancyand the loss of adaptive capacity in newborns from mothers witheclampsia.
P3.15.22THE INFLUENCE OF UMBILICAL CORD BLOOD STORAGETEMPERATURE AND FREEZING METHOD OF ISOLATEDMONONUCLEAR CELLS ON THEIR CLONOGENICITY.R. Czajka 1, W. Mikolajek2, P. Szolomicka-Kurzawa1. 1Department of Obstetrics and Perinatology, 2Department of Biochemistry andChemistry, Pomeranian Medical University, Szczecin, Poland
Objectives: Temperature is the one of the most important parameter ofstorage of each biological material. The aim of the study was to find theoptimal storage temperature for umbilical cord blood (UCB) just aftercollection and optimal method of isolated mononuclear cells (MNC)freezing.Study material: Forty nine samples of UCB were assessed in the firstpart of study. The viability and clonogenicity (as a number of risenBFU-E and CFU-GM) of UCB isolated MNC were evaluated aftershort-term storage (0-24h) in studied temperatures (+4C and roomtemp.). In the second part of experiment (20 samples of blood), thenumber, viability and clonogenicity of MNC retrieved after freezing indry ice or in mechanical freezer with use of methanol bath wereestimated.Results: It was established, that temperature of short-term storage ofUCB had no influence on viability of MNC and clonogenicity measuredfor CFU-GM. But number of risen BFU-E colonies was higher aftershort-term storage in room temperature. Statistically significant decreaseof number, viability and clonogenicity of MNC was found after freezingin dry ice. After freezing in methanol bath, the number of MNCdecreased after two days and viability and clonogenicity after four daysof experiment.Conclusions: Room temperature is a choice for short-term storage ofUCB. The more effective method of isolated MNC freezing should beexpected when the methanol bath is used for that purpose.
P3.15.23ULTRA-VIOLET INTRAVASCULAR LASER IN COMPLEXTREATMENT OF LUNG PATHOLOGY IN NEWBORNST. Shestakova, A. Zelynsky, M. Korsakova, V. Artyomenko, Dept.Perinatal Medicine, Child and Adolescent Gynecology, Odessa StateMedical University, Odessa, Ukraine.
Objectives: The aim of our research was to study the effectiveness ofultra-violet laser therapy in newborns suffering from lung pathology.During 1996 – 1998 intravascular laser therapy was performed in 122newborns (81 with pneumopathy and 41 with congenital pneumonia).Study Methods: Clinical, paraclinical, biochemical, radioimmune,rentgenological and instrumental methods were used to determine theroutine blood and urine data, partial O2 and CO2 blood pressure and itsoxygenation, lungs RÖ-graphy in 122 newborns of the main group (laser+ traditional therapy) in comparison with 102 newborns of the controlgroup (traditional therapy only). Laser irradiation was performedintravascularly daily (exposure 30 sec.) by means of “ALOU-2” laser(wave length 0.63 mcm, continuous beam, up to 2 mVt capacity) during7 days.Results: In newborns with pneumopathy the laser therapy leads tosignificant decrease of oxygen-dependent days quantity (4.5±0.34 days)in comparison with newborns of the control group (8.4±0.75 days) andsignificant increase of blood oxygen saturation (P<0.001 and P<0.005respectively). After the intravascular laser application in newborns withcongenital pneumonia the significant clinical condition improvementwas observed along with blood and urine data normalization which wasquicker in comparison with the same parameters in newborns of thecontrol group.Conclusions: The ultra-violet intravascular laser therapy in newbornswith pneumopathy and congenital pneumonia is very effective, leadingto mortality and morbidity decrease and good far-reaching results.
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P3.16 OVARIAN CANCER
P3.16.01A NOVEL TUMOR-ASSOCIATED ANTIGEN "RCAS1"EXPRESSION IN THE OVARIAN CANCERT.Kaku , K.Sonoda, S.Ogawa, H.Nakano, Kyushu University School ofHealth Sciences, Maidashi 3-1-1, Fukuoka, Japan, 812-8582.
Objectives: The aim of the study was to investigate the expression of anovel antigen "RCAS1" generated from a mouse immunized with ahuman uterine adenocarcinoma cell line, SiSo in the ovarian cancer.Study Methods: The expression of RCAS1 was immunohistochemicallyinvestigated in ovarian cancer (54 cases). Tissue specimens used in thisstudy included 26 cases of ovarian mucinous adenocarcinoma, 11 ofserous adenocarcinoma, 11 of clear cell carcinoma and 6 ofendometrioid adenocarcinoma.Results: The RCAS1 was positive in all 26 cases (100%) of mucinousadenocarcinoma, and expressed diffusely and strongly in the cytoplasmand membrane, and often in supranuclei areas. The RCAS1 was alsofound weakly in 72.7% (8/11) of serous adenocarcinoma, 66.7% (4/6) ofendometrioid adenocarcinoma, and 54.5% (6/11) of clear cell carcinoma.Conclusions: These data indicate that RCAS1 expression in ovarianepithelial tumor, especially in mucinous
P3.16.02A RETROSPECTIVE STUDY OF 102 BORDERLINE TUMORS OFTHE OVARY: CLINICAL FEATURES AND PROGNOSTICFACTORJ.W. Kim , M.H. Kim, J.W. Roh, N.H. Park, Y.S. Song, S.B. Kang, H.P.Lee, Seoul National University Hospital, 28 Yungun-Dong Chongno-Ku, Seoul, Korea, Korea, South, 110-744.
Objectives: To clarify the clinicopathologic features of borderlinetumors of the ovary and analyze the treatment and survivalcharacteristics through the study of our cases.Study Methods: One hundred two patients with borderline tumors of theovary, aged from 14 to 79 years, treated between 1982 and 1999 at SeoulNational University Hospital, were analyzed retrospectively forclinicopathologic features. Most informations about stage, treatmentmodality and prognosis were obtained by hospital record or contactingpatient with telephone.Results: There were 77 patients (75.5%) with stage Ia, 5 stage Ib, 11stage Ic, 4 with stage II and 5 with stage III by the classification ofFIGO. Seventy three patients (71.6%) were mucinous type and theremainder (28.4%) were serous type. Thirty seven (44.0%) out of 84patients showed morphologic malignancy by gray-scale sonography, and19 (44.2%) out of 43 patients by CT or MRI scan. Tumor marker wasabnormally increased in 27 (30.7%) out of 88 patients. Total abdominalhysterectomy, bilateral adnexectomy, and omentectomy were performedin 54 (52.9%) patients and fertility saving surgery in the others. Amongthem, enucleation of tumor and biopsy of contralateral ovary wasperformed in 11 (10.8%) patients. Twenty two patients (21.6%) weretreated with postoperative adjuvant chemotherapy. The median durationof follow up was 52.0 months (5-204 months) and 6 patients developedrecurrence several years after operation. The 10-year cumulativesurvival rate was 92.2% by Kaplan-Meier method and the onlyindependent prognostic factors evaluated by Cox analysis in regards tocorrected survival were the FIGO stage (p=0.0197).Conclusions: Most of the patients with borderline ovarian tumors wereat the early stage of disease at initial diagnosis. The slow clinical course,low recurrence rate and good prognosis in our patients explained againthe reason for therapeutic approach relying on surgery alone.
P3.16.03ACCURACY OF TISSUE POLYPEPTIDE SPECIFIC ANTIGEN(TPS) IN THE DIAGNOSIS OF OVARIAN MALIGNANCYP. Padungsutt , C. Thirapagawong, I. Suphanit, S. Neungton, S. Senapad,GYN/ONC Unit, Dept. OB/GYN, Faculty of Medicine, Siriraj Hospital,Mahiodol University, Bangkok, Thailand.
Objectives: To evaluate the accuracy of serum tissue polypeptidespecific antigen (TPS) by TPSä ELISA in diagnosis of ovarianmalignancies in comparison with histological results of ovaries.
Study Methods: The study was performed in the gynecologic patientsward, operating room and pathological division, Dept. OB/GYN, SirirajHospital.92 patients clinically diagnosed of ovarian tumors by history, physicalexamination, pelvic examination and/or pelvic ultrasonography wereenrolled. All of them underwent surgical treatment by exploratorylaparotomy in Siriraj Hospital. All patients had not been treated bychemotherapy, hormonal therapy and previously diagnosed anymalignancies.Determination of serum TPS (TPSä ELISA) level and comparison withthe histopathological results. Statistical methods were used to analyzethe accuracy of this tumor markers in ovarian malignancy diagnosis.Results: Tissue Polypeptide Specific Antigen was measured by ELISAin serum from 92 patients who were preoperatively diagnosed ovariantumor: 52 benign pelvic mass patients and 40 malignant ovarian tumorspatients. According to TPS positivity criteria by manufacturer (80 U/L),TPS level were evaluated in 28.8% benign pelvic mass patients and in90% malignant ovarian tumor patients. However, in statistical analysisby two by two table at every cut off TPS level and receiver operatingcharacteristic (ROC) curve, the optimal accuracy, sensitivity, specificity,positive predictive value, negative predictive value, false positive andfalse negative rate were 79.35, 90, 71.15, 70.59, 82.93, 28.85 and 10%respectively at positivity criteria 80 U/L by TPSä ELISA in diagnosisof ovarian malignancies.Conclusions: The accuracy of serum TPS by TPSä ELISA in diagnosisof ovarian malignancies is good and clinically acceptable. In a TPS levelgreater than 80 U/L is a useful positivity criteria for screening malignantovarian tumor. And TPS level greater than 180 U/L is a positivitycriteria for differentiating malignant ovarian tumor for benign pelvicmass. Because of its high false positive rate, any patients with TPSgreater than 80U/L should be further evaluated or investigated formalignant ovarian tumor.
P3.16.04ADULT GRANULOSA CELL TUMORS OF THE OVARY:HISTOPATHOLOGICAL PROGNOSTIC FACTORS ANDOUTCOMET.Fujimoto , N.Sakuragi, S.Fujimoto, Hokkaido University School ofMedicine, North 14 West 5, Sapporo, Hokkaido, Japan, 060-8638.
The prognostic factos of adult granulosa cell tumor (AGCT) have notbeen well defined. The aim of this study was to determinehistopathological prognostic factors of AGCT.In 27 AGCT patients, we examined clinical stage, microscopic patterns,mitotic index (MI), and lymph-vascular space invasion (LVSI) todetermine whether these factors were related to patient outcome. Wealso performed immunohistochemical examination for p53.Seventeen cases represented stage I, 3 stageII, 6 stage III, and 1 stageIV. There was no statistical difference between the stage I/II diseasesand stage III/IV diseases in terms of the disease-free survival (DFS) rate(p=0.0811). There was no relation between the microscopic pattern andthe DFS rate (p=0.8251). The DFS time for patients with aMI>=4/10HPF was significantly shorter than that for patients withMI<=3/10HPF (p<0.0005). The DFS time for patients with moderate orprominent LVSI was significantly shorter than that for patients with noor minimum LVSI (p<0.0001). The survival of patients depended onblood vessel invasion although lymphatic space involvement had weakerimpact on prognosis of patients with AGCT. As regards theimmunohistcemical staning for p53 protein, no overexpression of thep53 protein was observed in the majority of cases (24/25).The results of this study suggest that prognosis for patients with AGCTdepends on the MI and LVSI (especially blood vessel invasion). It wasalso suggested that p53 gene alterations
P3.16.05ADVANCED OVARIAN CANCER WITH ASCITES AND PLEURALEFFUSIONH. Nakachi , and T. Kinjo*, Dept. of OB/GYN, *Dept. of Surgery,Okinawa Prefectural Nanbu Hospital, 870 Aza Maezato, Itoman-City,Okinawa, Prefecture, Japan, 901-0362
A 69 year-old female, gravida 6, para 3, presented with the chiefcomplaints of cough and lower abdominal pain of several months’
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duration. Computed tomography revealed a huge abdominal tumor withascites and chest X-ray showed a pleural effusion on the right. Fineneedle aspiration of the pleural effusion for cytology demonstratedcancer cells, suggestive of adenocarcinoma. Her preoperative serum CA125 level was 6000 U/mL. She was diagnosed as having stage IVovarian cancer with pleural metastasis.The following operative findings were found: Bloody ascites waspresent. Left ovary (primary tumor) was enlarged to 16 X 10 X 9 cmand the tumor capsule was ruptured. The uterus and right ovary wereatrophic. She underwent total abdominal hysterectomy, bilateralsalpingo-oophorectomy and omentectomy. Pathological diagnosis in alloperative specimens was serous papillary cystadenocarcinoma.Following surgery she was started on combination chemotherapy withcarboplatin 500mg day 1, and etoposide 100mg days 1-3, repeated at 4week intervals. After the first course of chemotherapy, ascites andpleural effusion disappeared and the serum CA 125 level normalized(<35U/mL). She is now free of disease after completion of three coursesof this chemotherapy. She has tolerated the chemotherapy treatmentwell. Three more courses of chemotherapy are planned.We would like to present the therapy, clinical course, and laboratorydata of this stage IV ovarian cancer.
P3.16.06CHARACTERIZATION OF HUMAN OVARIAN CANCER CELLLINES BY INFRARED SPECTROSCOPYI. Symonds (1), E. Dickerson (1), A. Wilson (2), M. Pearson (3)(1) School of Human Development, University of Nottingham, Derby
City Hospital, Derby, UK.(2) Oncology Research Laboratory, Derby City Hospital, Derby, UK.(3) School of Chemistry, University of Nottingham, Nottingham, UK.
Objectives: The aim of the study was to determine if infraredspectroscopy could detect differences between human epithelial ovariancancer cell lines.Study Methods: 8 cell lines derived from 5 patients with epithelialovarian cancer were analyzed by transmission Fourier-transform infraredspectroscopy and the resulting spectra compared to those obtained from3 mesothelial cell lines. Cell lines were characterized by peakabsorbances at 9 different frequencies in the mid-infrared, normalized tothe 1540 cm-1 (amide II) band and by the ratio between the bandscorresponding to cytoplasmic and nuclear proteins.Results: Cell lines derived from 4/5 patients studies showed significantdifferences in peak absorbance at one or more frequencies from the othercell lines tested. The greatest variation occurred in the C-O vibrationalbands at 1050 cm-1 and 1152 cm-1 and the symmetric PO2
- band at 1085cm-1. Cell lines derived from solid tissue and those from ascites takenfrom the same patient showed no significant differences in IR spectra.All of the tumor cell lines demonstrated a significantly higher ratio ofnuclear to cytoplasmic absorbance as measured by the ratio of the bandsoccurring at 1085 cm-1 and 1456 cm-1 than mesothelial cells.Conclusions: Infrared spectroscopy can be used to characterize ovariancancer cell lines. Cell lines derived from different tumors show differentpatterns of IR absorbance.
P3.16.07CLINICAL ASSESSMENT OF NEOADJUVANT CHEMOTHERAPYAND INTERVAL CYTOREDUCTIVE SURGERY FORUNRESECTABLE ADVANCED OVARIAN CANCERK. Ushijima , T. Nishida, T. Sugiyama, T. Kamura, Dept. OB/GYN,Kurume University Scholl of Medicine, Kurume, Japan
Objectives: In spite of recent progress of medical technology, five yearssurvival of unresectable advanced ovarian cancer still remains about30%. The aim of the study was to investigate the clinical significance ofneoadjuvant chemotherapy (NAC) followed by interval cytoreductivesurgery (IRS) for unresectable advanced ovarian cancer.Study Methods: Between 1986 and 1998, one hundred and twentypatients with stage IIIc and IV epithelial ovarian cancer were treated inKurume University Hospital. Forty-two patients who underwentexploratory laparotomy and NAC and IRS (group A), and 78 patientswho had resectable tumor and underwent conventional primarydebulking surgery with having more than 1cm residuals (group B) werecompared with clinical courses after treatment, chemotherapeuticresponse, and surgical morbidity.
Results: In group A, 38 of 42 patients received 3.8 courses of NAC and79% (30/38) were successfully debulked at IRS and73% (22/30) of them achieved clinical remission. Among of severalregimens of NAC, TAXOL and CPT-11 including regimens wereeffective. Patients who underwent NAC plus IRS showed betterprognosis than those who did not under go IRS. Median survival intervalof group A patients was 29 months. No statistical difference wasobserved in overall survival or surgical morbidity between group A andB.Conclusions: NAC plus IRS would offer unresectable ovarian cancer thesame survival as the resectable tumor undergone primary debulking.This new strategy was beneficial for the patients with unresectableadvanced ovarian cancer who were unable to receive standard treatment.
P3.16.08CLINICAL EVALUATION OF SQUAMOUS CELL CARCINOMAARISING FROM MATURE CYSTIC TERATOMA OF THE OVARYK. Yoneyama , T. Takeshita, K. Okino, S. Suzuki, H. Kobayashi, M.Arai, D. Doi, Y. Ohta, T. Araki, Dept. OB/GYN, Nippon MedicalSchool Main Hospital, Tokyo, Japan.
Objectives: The aim of the study was to evaluate the value of tumormarkers and clinical characteristics in making a differential diagnosisbetween mature cystic teratoma (MCT) and squamous cell carcinomaarising form MCT.Study Methods: Between September 1985 and January 2000, 19 patientswith ovarian squamous cell carcinoma arising from MCT was treated byNippon Medical School Gynecologic Oncology Group in Japan. Weanalyzed with respect to tumor markers, tumor size and patient age asparameters for differentiation between MCT and malignanttransformation.Results: There were significant differences in age, tumor size (p<0.0001)and levels of SCC, CA125, CA19-9 and CEA (p<0.022) between MCTand squamous cell carcinoma arising from MCT. Diagnostic efficiencywas highest for SCC (62.0%), followed by CA125 (50%). Receiveroperating characteristic (ROC) curves demonstrated that tumor size(AUC; 0.91) was the best screening marker for squamous cell carcinomaarising form MCT, followed by SCC (AUC;0.82). The optimal cutoffvalues for age, tumor size, SCC, CA125, CA19-9 and CEA were 40years, 9.1 cm, 2.8 ng/ml, 32.0 U/ml, 80.0 U/ml and 4.8 ng/mlrespectively, according to ROC analysis. The combination assay, whichcombines SCC with CEA using the optimal cutoff values was the bestscreening marker for squamous cell carcinoma arising from MCT.Conclusions: These results demonstrated that the combination assay,which combines SCC with CEA using the optimal cutoff values was thebest screening marker for squamous cell carcinoma arising form MCT.In addition, SCC and CEA levels should be measured in patients withage 40 years or older who have an MCT-like ovarian tumor larger than9.1 cm in greatest dimension.
P3.16.09CYCLIN-DEPENDENT KINASE INHIBITOR p27 ISUNDEREXPRESSED DURING OVARIAN CARCINOGENESISPROCESSK. Shigemasa (1), Y. Shiroyama (1), T. Sawasaki (2), T. Fujii (2), N.Nagai (1), K. Ohama (1)(1) Dept. OB/GYN, Hiroshima University, Hiroshima, Japan.(2) Dept. OB/GYN, Kure National Hospital, Kure, Japan.
Objectives: The aim of this study was to investigate the potential role ofp27 in ovarian tumor development and progression.Study Methods: P27 protein expression was investigated byimmunohistochemistry in 117 epithelial ovarian tumor tissues (15adenomas, 23 borderline tumors, and 79 adenocarcinomas) and 8 normalovaries. Immunohistochemical staining was performed by using theavidin-biotin peroxidase complex technique. p27 mRNA expressionlevel was examined by semi-quantitative PCR technique. mRNA wasisolated and cDNA was prepared from 32 ovarian tumor samples and 5normal ovaries. p27 sequences were amplified in parallel with the b-tubulin gene as an internal control. p27 mRNA expression level relativeto b-tubulin was determined by densitometry. All material was collectedwith informed consent. The c2 test of significance was used forstatistical analysis.
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Results: Nuclear staining of p27 protein was observed in the normalovarian surface epithelium. The epithelial cells of germinal inclusioncyst also showed positive p27 staining. The positive rates of p27 proteinby immunohistochemistry in ovarian adenomas, borderline tumors, andadenocarcinomas were 60%, 35%, and 13% respectively. There weresignificant differences in the positive rates of p27 between benign andmalignant tumors (p<0.01) and between borderline and malignanttumors (p=0.01). Semi-quantitative PCR analysis showed that p27mRNA levels were under-expressed in 19 of 32 (81%) ovarian tumorscompared to those in normal ovaries.
P3.16.10EFFECT OF CARBOPLATIN BASED CHEMOTHERAPY ONPATIENTS WITH EPITHELIAL OVARIAN CANCERC. Xiaojun , F. Youji, Obstetrics and Gynecology Hospital, ShanghaiMedical University, Shanghai, China.
Objective: To investigate the effect of progestins in combination withcarboplatin based cytotoxic chemotherapy on patients with epithelialovarian carcinoma.Materials and methods: 82 patients with Stage I~IV Grade I~IIIepithelial ovarian carcinoma participated in this trial. All patientsreceived cytoreductive surgery and standard carboplatin basedchemotherapy. 45 patients received injections of progestin(Hydroxyprogesteroni Caproas 250 mg im Biw x 1 month; 500 mg imQ2w x 3 years). These patients were considered as the progestin group.The remaining 37 patients receiving standard chemotherapy were only inthe control group. Life table was used to calculate the survival rate andrecurrence rate.Results: The 3-year survival rate of the progestin group and the controlgroup was:Stage I: 100%, 100%; Stage Ib~Ic: 92.0%, 87.5%; Stage III: 78.4%,48.5%; Grade I: 100%, 100%; Grade II: 88.9%, 68.6%; Grade III:92.9%, 83.0%. The 3-year recurrence rate of the progestin group and thecontrol group was: Stage I: 0%, 0%; Stage Ib~Ic: 16.0%, 27.1%; StageIII: 39.7%, 73.0%; Grade I: 0%, 0%; Grade II: 52.0%, 65.7%; Grade III:14.9%, 25.0%.Conclusions: Progestins in combination with carboplatin basedchemotherapy may improve the long-term survival rate and reduce therecurrence rate in patients with epithelial ovarian carcinoma.
P3.16.11ESTABLISHMENT AND CHARACTERIZATION OF OVARIANCLEAR CELL ADENOCARCINOMA LINEI. Fukasawa , T. Sakamoto, A. Yoshinaka, M. Tanaka, Y. Ota, N. Inaba,Dept. OB/GYN, S. Yasuda, Dept. Molecular Biology, DokkyoUniversity, Tochigi, Japan.
Objectives: The aim of the study was to establish a new cell line derivedfrom a clear cell carcinoma of the ovary, and to investigate thecharacterization of this cell line.Study Methods: Primary cells were obtained from the fresh ascitic fluidof a patient with a FIGO stage a ovarian clear cell adenocarcinoma.These cells, designated KY, were maintained in culture at 37 C withinan atmosphere of 5% CO2/95% air. RPMI 1640 supplemented with 10%fetal bovine serum was used as the growth medium. Cultured cells werestained with periodic acid-Schiff(PAS) for glycogen and oil red O forlipid. The levels of vascular endothelial growth factor(VEGF), tumornecrosis factor- (TNF- ) and triglyceride in conditioned media weremeasured. Expression of VEGF mRNA was examined by reversetranscriptase-polymerase chain reaction.Results: The KY cell line has been successively subcultured more than60 times over 25 months. The growth curve at the 20th generationindicated the population doubling time to be 33 hours. Aftersubcutaneous heterotransplantation into nude mice, the KY cells wereobserved to produce tumors histologically similar to the originalcarcinoma. The volume doubling time of the tumor was estimated to beabout 3.5 days. PAS positive and oil red O positive staining was foundin the cytoplasm. VEGF and TNF- protein levels in the conditionedmedia were 34,500 and 0.5 pg/ml, respectively. Triglyceride was notdetected. Expression of VEGF mRNA was observed in the cultured KYcells.
Conclusions: The KY cell line was found to be a useful experimentalmodel to investigate the characteristics of ovarian clear celladenocarcinoma.
P3.16.12EVALUATION OF CARCINOEMBRYONIC ANTIGEN (CEA)LEVEL IN FEMALE GENITAL TRACT TUMORSM.H. Makarem , A.A. Youssef, M.M. Anwar and M.A. Bedaiwy, Deptof OB/GYN, Faculty of Medicine, Assiut University, Assiut, Egypt.
Objectives: The aim of the study was to evaluate the level of CEA inserum in different genital tract neoplasm.Study Methods: Ninety-one patients with genital tract tumor and acontrol group of 30 healthy females were studied. Two samples of 10 ccblood were taken from patients; one in the immediate preoperativeperiod and the second after 2 weeks postoperatively. One sample wastaken from the controls. All samples taken were separated and stored at–20oC. The CEA level was measured by fluoroimmunoassay technique.Results: The preoperative serum level of CEA in the patients wasstatistically higher than in the controls. The level of CEA in ovarian andcervical malignancy was statistically higher than in the control, while thelevel of CEA in endometrial carcinoma, vulvovaginal malignancies andbenign tumors was not different. Also it was observed that there wassignificant lowering of CEA in the patients postoperatively.Conclusions: CEA level is higher in special types of ovarianmalignancies. Radical surgery; in the management of ovarianmalignancy; resulted in much lowering in CEA in blood postoperatively.The CEA level can be used as a predictor for early recurrence of ovarianmucinous cystadenocarcinoma.
P3.16.13EVALUATION OF TWO THERAPY MODALITIES OF OVARYCARCINOMAA. Dörr , O. Bláha, Z. Malo, Dept. OB/GYN,Masaryk University, OB/GYN University Hospital, Brno-Bohunice,Czech Republic, 639 00.
Objectives: The goal of our study is to evaluate the results of ovarycarcinoma treatment in group withouth and with using Platinum drugs aswere carried out in a six years periodStudy Methods: Standard therapy method consisted in radical operationand subsequent chemotherapy. In group A (45 patients) followedchemotherapy withouth Platinum drugs and in group B (47 patients)followed chemotherapy with Platinum drugs, C A P combinationussually.We observed 5 years survival rates, disease free interval and side effectsor complications.Results: 92 observed patients were stratified according to the stage ofdisease and by the size of residual tumour.Entire time of 5 years survived were found out for about 39% in group Aand 43 % in group B(p<0,02). Prolongation of remision was observed ingroup B from 9,1 to 14,9 months (p< 0,05)Conclusions: Prolongation of 5 years survival rate and disease freeinterval was observed in patients with Platinum therapy and no moredifferent side effects were observed.
P3.16.14EXPRESSION OF CARBONYL REDUCTASE IN EPITHELIALOVARIAN CANCER AND ITS CLINICAL SIGNIFICANCEM. Umemoto , Y. Yokoyama, S. Sato, Y. Saito, Dept. OB/GYN,Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
Objectives: The expression of carbonyl reductase (CR) in epithelialovarian cancer and its clinical significance were examined.Study Methods: Using an anti-CR antibody, immunohistochemicalstaining (immunostaining) via the LSAB method was performed on 73primary epithelial ovarian cancers, 24 intraabdominal disseminations(ID), 13 retroperitoneal lymph node (RLN) metastases, 12 recurrenttumors (RT), 13 borderline malignant tumors, and 25 benign ovariantumors for a total of 160 specimens resected after patients’s consent hadbeen obtained. The degree of CR expression in the tissue of the tumorwas divided into three grades of negative, weakly positive and strongly
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positive for evaluation based on the proportion of positive cells and thestaining intensity.Results: The rate of specimens in which CR was positive was 30% forbenign tumor, 38% for a borderline malignant tumor, and 62% forovarian cancer, with a significant difference in CR expression betweenovarian cancer and benign tumor (p<0.01).(1) The degree of CR expression was not significantly different between
the primary cancer and ID, and between the primary cancer and RT.(2) Among primary cancers, the CR positive rate was 38% for those
with RLN metastasis (n=13) and 67% for those without RLNmetastasis (n=60), the former being significantly lower than thelatter (p<0.05).
(3) The 5-year survival rate was 62.7% for the ovarian cancer patientswith negative CR (n=27) and 86.1% for the positive CR group(n=46) (p=0.078).
Conclusions: The results suggest that decreased CR expression inovarian cancer is involved in RLN metastasis and that CR is a usefulnegative marker in determining the prognosis of epithelial ovariancancer.
P3.16.15FINAL STAGING OF OVARIAN CANCER CLASSIFIED AS STAGEI ( FIGO) DURING SURGERYAndrzej Bienkiewicz , Leszek Gottwald, Jacek Suzin, Dept. ofGynecological Oncology, Inst. of Obst. and Gynecol., MedicalUniversity, 37 Wilenska st., 94-029 Lódz, Poland
Background.Ovarian cancer is one of the most common and difficultdiagnostic and therapeutic problems in gynecological oncology. Surgicalprocedure together with chemotherapy is recommended even in latestages of disease. The precise evaluation of staging during surgerycombined with frozen section is of critical importance in furthermanagement.Aim of study. We compared intraoperative clinical staging of ovariancancer with the final histopathological examination in stages estimatedas Ia-Ic during surgery.Material and methods. 50 women who underwent surgical procedurebetween 1994-1999 in our department due to the ovarian cancerinvolving one or both ovaries were included into the study.Results. In 34 cases the tumor was unilateral and in 16 cases bothovaries were involved. In 18 cases (36%) the ascites was observed.However the histopathological examination of removed tissues in 3 (6%)cases demonstrated the involvement of the uterus and the tubes, in 11(22%) cases microimplants in the omentum were found. 2 out of those11 patients were below 30. In 2 cases the microimplants were detected inthe appendix. The cytologic examination of the peritoneal fluid waspositive in 8 cases. The microimplants of neoplasmatic cells to thesecond ovary were detected in 2 cases. In 2 cases ovarian cancercoexisted with endometrial cancer of different histological type and withcervical preinvasive cancer. Among the clinical factors the adhesions ofthe tumor to the peritoneum and bowels correlated with higher stages ofovarian cancer estimated in histopathological examination.Conclusions. Due to the high rate of late stages of ovarian cancer amongthose which were classified initially as stage I, all those patients shouldbe reffered to the Gynecological Oncology Departments, where theadequate procedures can be performed. In all cases of diagnosed ovariancancer despite of clinically early stages in women below 30, the radicalsurgery should be recommended.
P3.16.16FOLLOW UP OF OVARIAN CANCER – WHICH EXAMINATIONSARE NECESSARY?F. Heller , T. Fehm, S. Ackermann, W. Jäger, N. LangDept. OB/Gyn, University Erlangen-Nuremberg, Germany
Objectives: The aim of the retrospective study was to investigate whichexaminations are necessary for detection of a relapse in ovarian cancerpatients.Study Methods: Over the first two years after primary surgery follow upcheck ups were performed in 3 month intervals by interview, physicalexamination and CA 125 determination. During the following threeyears follow up checks were performed every 6 month and later onlyonce a year. Dependent on a pathological finding further diagnosticmethods were performed (e. g.: CT, sonography, local biopsy). Between
1984 and 1999 62 patients with a completely documented follow-up, nosecondary cancer and a complete remission for more than twelve monthswere included in the study.Results: In 25 (40%) patients all three methods resulted in a pathologicalfinding. 11 (18%) patients reported well being, but a palpable abdominalmass was found and the CA 125 was elevated. Only an elevatedtumormarker CA 125 could be measured in 9 (14%) cases. Elevated CA125 value and patients´discomforts characterized 6 cases (10%) withovarian cancer relapses. A normal CA 125 level was measured in 11cases (18%), but with one exception, the women reported disorders or atumor was palpable. After the suspected diagnosis without positivetumor evidence a CT was performed in 83% (n=52) and a sonography in77% (n=48). Both imaging techniques showed false negative results in10% (n=5) and 21% (n=10) respectively.Conclusions: Interview, physical examination and the determination ofserum CA 125 level together detected 98% of ovarian cancer relapses.At that time the tumormarker CA 125 was normal in 18%. Imagingtechniques (CT, Sonography) should only be used when a suspicionbased on these parameters is raised.
P3.16.17GIANT PYOMYOMA AND ENDOCARDITIS MIMICKINGOVARIAN CANCERJ.P. Carvalho , M.L.N. Dias, P.R. Genta, T.A. Janiszewski, F.M.Carvalho, J.S. Souen, Dept. OB/GYN and International Medicine,Hospital das Clinicas, University of Sao Paulo School of Medicine, SaoPaulo, Brazil.
Introduction: Diagnosis of ovarian cancer can be difficult because manydiseases may mimic this neoplasm clinically, radiologically or by anincrease in CA-125 levels.Case Report: A 60 year old female diabetic patient was admittedcomplaining of an abdominal mass, malaise and loss of 32kg in 3months, and fever for the past two weeks. A systolic murmur could beheard along the left sternal border. A large pelvic mass extending to theepigastrium could be seen. Blood cultures grew Streptococcusagalactiae. Transesophageal echocardiogram showed a filamentarylesion at the tricuspid valve, suggestive of vegetation. IntravenousPenicillin was started and Amikacin was added later due to persistenceof fever. Computed tomography showed a large mass with signs ofnecrosis extending from the pelvis to the hepatic hilum and deep venousthrombosis of the femoral and external iliac veins. CA-125 was109.7U/mL. Ovarian cancer was suspected and the patient underwentsurgery one month after admission when the infection and diabetes werecontrolled. A giant suppurated uterine mass was found and totalabdominal hysterectomy with bilateral salpingooforectomy wasperformed. Culture of the uterine suppuration also grew S. agalactiae.Histopathological examination revealed an 18cm leiomyoma with cysticdegeneration and abscess formation (pyomyoma). The patient recoveredwell and gained weight. She is doing well 6 months after surgery.Conclusion: Pyomyoma is a rare complication of uterine leiomyoma,only 12 cases being reported since 1945. Pyomyoma was never reportedto be associated with endocarditis and with elevated CA – 125, althoughelevated CA-125 had been related to uterine leiomyoma.
P3.16.18INSULIN-LIKE GROWTH FACTOR-i/GROWTH HORMONE AXIS,C-ERB B-2 ONCOPROTEIN LEVELS, CATHEPSIN-D ANDPEROXIDASE IN OVARIAN CARCINOMAM. Zakhary (a), A. Sabra (b), T. El-Deep (a), A. Mustafa (c), H.Mahfouz (d), (a) Dept. OB/GYN, (b) Biochemistry, (c) ClinicalPathology, (d) Radiotherapy, Dept. Faculty of Medicine, AssiutUniversity, Egypt.
Objectives: To investigate the insulin like growth factor 1 (IGF-1)/growth hormone axis, c-erb B-2 oncoprotein levels, activities ofcathepsin-D and peroxidase in ovarian carcinoma.Study Methods: Serum and tissue samples of 48 patients with malignnatovarian tumors, ovarian tissues of 10 patients with fibroids or DUB toobtain control and serum samples of 15 healthy females (control). Serumand tissue levels of IGF-1, c-erb B-2 oncoprotein, cathepsin-D, serumlevels of growth hormone and tissue activity levels of peroxidase werestudied.
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Results: Significant increase of IGF-1, c-erb B-2 oncoprotein, cathepsin-D mean levels in patients compared with controls. Levels of serumgrowth hormone and tissue peroxidase increased significantly in patientswith ovarian tumors compared with controls. Significant positivecorrelations existed between serum and tissue c-erb B-2 oncoproteinlevels as well as serum growth hormone and serum IGF-1 levels. Levelsof tissue IGF-1 correlated significantly with tissue activity. The changesin the bioindices studied reflected the biological behavior of the tumorbeing higher in advanced stage and high burden tumors.Conclusions: IGF-1/growth hormone axis seems to play an importantrole in the biological behavior of ovarian carcinoma, regulating theirgrowth and spread. The use of IGF-1 antagonists would represent newtherapeutic lines. Over-expression of c-erb B-2 oncogene is anotherimportant level in ovarian carcinoma. In addition cathepsin-D plays animportant role in spread and advancement of ovarian tumors. The use ofspecific inhibitors to these enzymes would provide important adjuvanttherapeutic lines.
P3.16.19INTERLEUKIN-8 SERUM LEVEL SHIFT IN PATIENTS WITHOVARIAN CANCER UNDER A PACLITAXEL CONTAININGCHEMOTHERAPYK. Mayerhofer (1), K. Bodner-Adler (1), M. Schindl (1), A. Kaider (2),L. Hefler (1), R. Zeillinger (1), S. Leodolter (1) and C. Kainz (1)(1) Dept. OB/GYN, University of Vienna Medical School, Vienna,
Austria.(2) Dept. Medical Computer Sciences, University of Vienna Medical
School, Vienna, Austria.
Objectives: Paclitaxel was descried to induce interleukin-8 (IL-8)transcription and secretion in human ovarian cancer cells. Aim of thisstudy was to investigate possible clinical implication of the effect ofpaclitaxel on Il-8 serum levels in patients suffering from ovarian cancer.Study Methods: Thirty-one patients with ovarian cancer, treated with acombination chemotherapy consisting of paclitaxel and carboplatin,entered the study. Il-8 serum levels and CA-125 serum levels weredetected three times per patient, directly before, after 3 cycles and after 6cycles of the chemotherapy. Additionally, serum samples of 59 healthage-matched women were obtained. A quantitative human IL-8immunoassay was used to determine the IL-8 serum levels.Results: 78% of patients responded to chemotherapy, with 62% ofcomplete responses and 16% of partial responses. The median IL-8serum level before chemotherapy was 75pg/mL (range: 2.7 – 903.3),during chemotherapy 23.75 pg/mL (range:0.5-248.2) and afterchemotherapy 17.65 pg/ml (range: 0.6-377), The median IL-8 serumlevel in controls was 15.6 pg/mL (range: 1.4 – 106.3). We found astatistically significant decrease in both of IL-8 serum levels (p<0.05;p<0.05) and of CA-125 serum levels (p<0.05; p<0.05) from the first ofthe second measurement and from the first to the third measurement. Wefound no correlation between the shifts of IL-8 serum levels and CA-125serum levels during chemotherapy. We observed no statisticallysignificant correlation between IL-8 serum levels and anyclinicopathological parameter.Conclusions: We found elevated IL-8 serum in patients with ovariancancer and a decrease of IL-8 serum levels under a paclitaxel-containingchemotherapy. The results of this study may indicate that IL-8 probablyacts as a useful monitoring marker in patients with ovarian cancerindependent to CA-125.
P3.16.20INTRA-ARTERIAL INJECTION OF CARBOPLATIN ANDINTRAVENOUS DRIP INFUSION OF PACLITAXEL IN PATIENTSWITH INOPERABLE ADVANCED OVARIAN CANCERT. Yamazaki (1), H. Hatano (1), N. Matsubara (1), Y. Yamaguchi (2), Y.Shigemori (2), I. Konishi (3)(1) Dept. OB/GYN, Iida Municipal Hospital, Iida, Nagano, Japan.(2) Dept. Radiology, Iida Municipal Hospital, Iida, Nagano, Japan.(3) Dept. OB/GYN, Shinshu University School of Medicine, Nagano,
Japan.
Objectives: Preoperative chemotherapy by intra-arterial injection hasbeen reported in only a few patients with ovarian cancer. Therefore, weconcurrently conducted intra-arterial injection of carboplatin (CBDCA)
and intravenous drip infusion of paclitaxel (TXL) in patients withinoperable advanced ovarian cancer and evaluated their clinical efficacy.Study Methods: 2 patients (Case No.1:46 years old, No.2: 69 years old)had an inoperable giant ovarian cancer and showed dyspnea due toaccumulation of a large amount of pleural effusion and ascites. Intra-arterial injection of CBDCA (AUC=5) was conducted through a 4 Frpigtail catheter inserted into the abdominal aorta directly beneath therenal artery. Concurrently, TXL was administered at 175mg/m2 byintravenous drip infusion. This treatment was repeated every 4 weeksbefore surgery. Case No. 1 and No. 2 received 2 and 3 cycles,respectively.Results: In both patients, pleural effusion and ascites disappeared. Imagediagnosis also showed almost complete disappearance of the gianttumors. High blood tumor marker values rapidly returned to normal.Complete operation could be conducted after completion of thechemotherapy. Pathological diagnosis of resected tumor samples showedslight serous papillary adenocarcinoma in both left and right ovaries inboth patients, but most tumor tissues showed necrosis. The clinicalcourse of both patients has been monitored following surgery. Theclinical course of both patients has been monitored following surgery.The clinical course of both patients has been monitored followingsurgery. No evidence of recurrence has been observed.Conclusions: Combination of intra-arterial injection of CBDCA andintravenous drip infusion of TXL was thought to be very effective beforesurgery in patients with inoperable advanced ovarian cancer.
P3.16.21INVOLVEMENT OF VASCULAR ENDOTHELIAL GROWTHFACTOR IN ASCITES FORMATION OF OVARIAN CANCERCELLS AND ITS REGULATION BY GnRH AGONISTN. Akutagawa , A. Nishikawa, M. Iwasaki, T. Fujimoto, Y. Kitajima, K.Manase, H. Henmi, T. Endo, R. Kudo, Dept. OB/GYN, SapporoMedical University, School of Medicine, S1-W16, Chuo-ku, Sapporo,JAPAN, 060-8543
Objectives: The aim of the experiment is to elucidate the molecularmechanism of ascites formation in ovarian cancer cells and to assesswhether GnRH agonist (GnRHa) can regulate the ascites in GnRHreceptor (GnRH-R)-positive cells.Study Methods: We used two human ovarian cancer cell lines (HTBOAand AMOC-2). Expression of VEGF and GnRH-R was analyzed byNorthern blot or the RT-PCR method. We utilized human a ovariancancer ascites model by using nude mice. We administered GnRHa(leuprorelin acetate, 60mg/mouse) daily from 14 days after inoculationof cancer cells. Mice were sacrificed 3 weeks after GnRHaadministration and the formation of tumor, ascites and peritonealdissemination were evaluated.Results: HTBOA (poorly differentiated carcinoma) expressed bothVEGF and GnRH-R mRNA, and presented peritoneal dissemination andascites formation. AMOC-2 (serous cyst adenocarcinoma) did notexpress VEGF mRNA but presented solid tumors without ascitesformation. The frequency of ascites formation was significantlydecreased in the group of mice treated with GnRHa compared with thecontrol group.Conclusions: VEGF plays an important role in ascites formation. It issuggested that GnRHa might regulate the ascites formation in ovariancancer cells.
P3.16.22MALIGNANT OVARIAN GERM CELL TUMOR; 208 CASES:OUTCOMES AND PROGNOSTIC STUDYP. Padungsutt , C. Thirapakawong, S. Therasakvichaya, P. Inthasorn, P.Tanmahasamut, I. Suphanit, S. Neungton, S. Senapad, GYN/ONC Unit,Dept. OB/GYN, Faculty of Medicine Siriraj Hospital, MahidolUniversity, Bangkok, Thailand.
Objectives: To study outcomes of malignant ovarian germ cell tumor(MOGCT).Study Methods: The authors performed a retrospective analysis ofwomen with MOGCT managed in gynecologic oncology unit, Dept.OB/GYN, during the period 1975-1997. We analyzed patients & tumordata by using Kaplan-Meier survival analysis and Cox regressionanalysis.
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Results: 208 patients were included. The mean age was 24 years (range7-64), median age was 23 years, median follow up time was 39 months(range 1-288). Histology were confirmed MOGCT includeddysgerminoma for 62 patients, non-dysgerminoma for 146 patients. Allpatients underwent operation: radical surgery for 118 patients (56.73%)and fertility sparing surgery for 90 patients (43.27%).According to FIGO 1987 staging system; 89, 25, 67 and 27 patientswere classified in stage I, II, III and IV respectively. 195 patients weretreated by chemotherapy but evaluable patients were achieved in 167patients. Outcomes of these patients were complete response 133patients (79.6%). Failure to fist line chemotherapy occurred in 44patients (29.3%) mostly in non-dysgerminoma but only 10 of 44(22.7%) were completely responded to second line chemotherapy andstill free of disease. Recurrence occurred in 11 patients (6.4%) but 7 outof 11 patients (63.6%) who relapsed were successful salvaged.Overall 5-year survival rate was 80.77%. The 5-year survival rate fordysgerminoma and non-dysgerminoma were 93.8 and 72.9%respectively. The 5-year survival rate for radical and conservativesurgery were 77 and 81% (P>0.05). In analysis of prognostic factors forsurvival showed that advanced stage and non-dysgerminoma wereindependent prognostic factors (P<0.05).Conclusions: This retrospective review is one of a large series tounderstand natural history, outcomes and prognostic factors. Advancedstage and non-dysgerminoma remained the most significantly adverseprognostic factors. Conservative surgery or fertility sparing surgery mustbe considered and did not affect overall survival outcome in malignantovarian germ cell tumors.
P3.16.23MALIGNANT TRANSFORMATION OF MATURE TERATOMAS –REPORT OF TWO CASESA. Pregal , D. Costa, N. Afonso, J.M. Furtado, P. Vieira de Castro,D. Pereira, J. Pinto de Oliveira, M. Osório, (1) Dept OB\GYN; SraOliveira Hospital, Guimaràes, Portugal, (2) Dept of Medical Oncology,Instituto Portugues Oncologia, Oporto, Portugal
Malignant transformation of mature teratomas is rare (1,8%) withsquamous cell carcinoma being the most frequent histological type(80%).These tumors carry a worse prognosis than all other types ofepithelial ovarian cancer and grade of differentiation and vascularinvasion represent the most important prognostic factors.Surgical extirpation seems to be the procedure of choice butradiotherapy and combined multi-agent chemotherapy are being furtherevaluated especially in those cases with pelvic and peritoneal metastasis,associated with poor prognosis.The authors describe the cases of two patients aged 70 and 49 yearsdiagnosed with mature teratoma with squamous cell malignization. Bothpatients’ first complaint was abdominal enlargement and diagnosis wasmade at laparotomy. The older of the patients (staged Ic GII) has a veryshort follow up time. The other patient was staged IIIc GII, receivedadjuvant chemotherapy and is alive and disease free nine months afterdiagnosis.Review of the literature concerning this pathology was made anddiscussion about diagnosis, treatment and prognosis is presented.
P3.16.24MANAGEMENT OF ENDODERMAL SINUS TUMORS OF OVARYWITH ALPHAFETOPROTEINT. Hoshino , Y. Taguchi, T. Okamoto, S. Hamada, H. Kuroda, K.Nakamura, T. Komatsu, M. Shiotani, H. Shimada, Y. Ihara, Dept.OB.GYN, Kobe City General Hospital, Kobe, Hyogo, Japan.
Objectives: The aim of the study is to improve the management ofpatients with endodermal sinus tumors (EST) of the ovary, monitoringserum alphafetoprotein (AFP) level.Study Methods: Preoperative and postoperative AFP were examinedserially. Four patients now have no evidence of disease (NED), but 3died from the disease. The half time of AFP was calculated in thepostoperative course. In NED cases (long survivors), mean and standarddeviation (M and SD) of SFP were calculated.Results: The half time of AFP was relevant to the prognosis. In NEDcases, AFP values were changing within the very small range and Mwere different to each other in statistically significant level.
Conclusions: AFP was found to be a useful tumor marker for themanagement of patients with EST. The individual normal range of AFPwas very small and different to each other.
P3.16.25PACLITAXEL INDUCES MDR1-GENE EXPRESSION IN OVARIANCARCINOMAST. Schöndorf a, C. Benzb, R. Neumannb, H. Kolhagena, C. M. Kurbachera, P. Mallmanna, U.-J. Göhringa
aDept. Gynecol / Obstet, University of Cologne, D-50924 Cologne,GermanybBayer AG, ZF-BTD, D-47812 Krefeld, Germany
Objectives Resistance to antineoplastics (multidrug resistance, MDR) isa major concern in ovarian cancer therapy. Clinical MDR is oftenassociated with overexpression of the mdr1-gene. Our aim was toinvestigate the involvement of anticancer drugs in mdr1-gene induction.Study Methods We cultivated tumor cells of 7 different ovarian cancercell lines for three days. Addition of either no supplement (control) orthe commonly applied therapeutics adriamycin, paclitaxel or cisplatin,respectively, simulated the clinical situation. Total RNA was extractedusing the Rneasy kit (Qiagen). RNA yields were adjusted to 75 ng/PCR.The mdr1 transcripts were amplified in a 25ml quantitative RT-PCRusing TaqMan technology. Levels of the target sequence and the internalGAPDH reference were determined simultaneously.Results In 6/7 ovarian carcinoma cell lines, drug application inducedincreasing transcription of the mdr1-gene to varying extent ranging from1.3 to 2-fold. Particularly, in all six cell lines, the most strikingaugmentation was induced by paclitaxel treatment.Conclusions In summary, the quRT-PCR enables detection of mdr1-expression even at low transcript levels. In future, detection of mdr1-expression could be incorporated into ovarian cancer staging and mayserve as a helpful marker in decision of an individual therapy.
P3.16.26PELVIC ADNEXAL MASS – MANAGEMENT AND OPERATIVEFINDINGSE. Bajalaski , B. Boskovski, N. Bakalova, Ginekoloska Bolnica Cair,Skopje, Republic of Macedonia.
Objectives: The aim of this article is to make analyses between theclinical and operative findings including the final histological diagnosis.Study Methods: In this study object of observation are patients that havebeen operated between 1995-1999 because of adnexal mass as a leadingindication or as additional diagnosis for other benign disorder of theuterus. There were 132 such an operated cases, among 1320gynecological operation or 10%.Results: The patohistological results shows that 93% of the operatedcases were benign ovarian tumors and 9 cases or 7% were malignant.The leading three diagnosis of the benign ovarian tumors were cystaendometroides 20 cases, cystadenoma serosum 17, teratoma srosumbenignum 16, and cysta symplex ovarii 15. The other type of benigntumors presented in very small number of cases. There were very rareovarian tumors like Brener tumor ovarii, thecoma, leomioma ovarii as asingle case in this study group. The malignant tumors presented in 9cases or 7%. The major number (4) were cystadenocarcinoma serosumovarii. The age of the patients was between 45-60 years.Conclusions: The conclusion from the presented facts is that the pelvicadnexal masses must be treated very seriously, especially those in themiddle age (45-60) because of the high percentage of malignancy.
P3.16.27PHENOTYPE OF TUMOR INFILTRATING LYMPHOCYTES (TIL)IN PATIENTS WITH MALIGNANT ASCITESJ. Tosner , M. Touskova, B. Melichar, I. Ditetova, J. Krejsek,O. Kopecky, Charles University Medical School, Hradec Kralove,Czech Republic
Objectives: To compare the phenotype of TIL in ascites of patients (pts)with ovarian carcinoma (OC) and different primary tumors.Study methods: The phenotype of TIL was examined by two-color flowcytometry in ascites of 51 patients [OC:21pts; pancreatic cancer(PC):9pts; gastrointestinal cancers (GIC)-colorectal cancer 8pts, gastric
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cancer 4pts; malignant melanoma (MM) 4pts; other primary 5pts].Interleukin-10 (IL-10) and neopterin (NEO) were determined in asciticfluid by enzyme-linked immunosorbent assay.Results: Most of the TIL (OC 74 + 12%; PC 69 + 8 %; GIC 70 + 14 %; MM89 + 5 %; other 78 + 12%) had CD3+ phenotype. The majority of CD3+
cells expressed CD4 antigen. Compared to OC, pts with PC had higherNK cells (22 + 9 vs 12 + 8%, p0.01), and lower CD3+CD45RO (38 + 11vs54 + 12%, p0.01), CD8+CD28+ (9 + 2% vs 14 + 6%, p0.01), CD19+CD86+
(0.3 + 0.3 vs 0.8 + 0.7%, p0.05), and CD3+CD152+ cells (0.4 + 0.3 vs1.2 + 1.1%, p0.025). Patients with GIC had lower CD19+ (4 + 3 vs 7 + 4%,p0.025) and CD19+CD86+ (0.4 + 0.3 vs 0.8 + 0.7%, p0.05) cells.Percentages of other TIL subsets as well as concentrations of IL-10 andNEO were similar among patients with different primaries, and were forthe whole cohort CD3+CD4+: 40 + 14%, CD3+CD8+: 32 + 13 %,CD3+CD25+: 5 + 6%, CD3+HLA-DR+: 7 + 11%, CD3+RA: 13 + 9%,CD3+CD80+: 2 + 2%, CD+CD57+: 3 + 4%, CD3+CD95+ 32 + 14%, IL-10: 114 + 86 pg/ml, NEO: 14.6 + 13.1 nM. A substantial number of allcells in the ascites exhibited dendritic cell (DC) phenotype (1.2 + 1.6%).A significant correlation was observed between the concentrations of IL-10 in ascitic fluid and percentages of CD3+CD25+ cells (Spearman rankcorrel. coeff., rs=0.29, p0.05), DC (0.36, p 0.05), and NEO andCD8+CD28+ cells (rs = - 0.32, p 0.05).Conclusions: Most of the TIL are CD3+ with memory cell phenotype. Asubstantial minority of cells express activation markers, costimulatorymolecules, or naive cell phenotype. Differences were observed in TILphenotype of pts with different primaries with lower NK cells and higherCD8+CD28+ in OC. Increased ascitic IL-10 is associated with higherDC numbers. (Supported by IGA grants 5196-3 and 4676-3).
P3.16.28PLASMA UROKINASE PLASMINOGEN ACTIVATOR AND ITSRECEPTOR IN OVARIAN AND CERVICAL NEOPLASIAD. Contreras , C. Lox and S. Chavez, Dept. OB/GYN, Texas TechSchool of Medicine, Lubbock, Texas, USA.
Objectives: Advanced ovarian and cervical cancer has a poor prognosis.Therefore, we examined components of the fibrinolytic mechanism tosee if any of these might serve as a tumor marker.Study Methods: Menopausal controls and patients with either benignovarian cyst or cervical dysplasia or ovarian cystadenocarcinoma orsquamous cell cervical carcinoma were included in this study. Plasmawas collected prior to surgery and during the course of chemotherapy.Surgery was either oopherectomy and/or hysterectomy. Therapy wastaxol and cisplastin for ovarian and cisplastin plus radiation for cervical.The therapy was continued for up to a year as required for the ovarian.Plasma samples were evaluated by enzyme-linked immunoabsorbantassays (ELISA) for circulating levels of urokinase plasminogen activator(uPA), and urokinase plasminogen activator receptor (uPAR).Results: The levels of uPA were elevated during chemotherapy, whilethe receptor for uPA was markedly elevated in both types of cancer andduring chemotherapy, while the ratio of uPA/uPAR was significantlydepressed in both cancer groups. A major evaluation in both uPA anduPAR occurred prior to metastatic recurrence in 2 patients with ovariancarcinoma. The ratio of uPA/uPAR markedly increased in 2 patientswith cervical carcinoma following chemotherapy, a positive indicator ofresponse.Conclusions: It appears that uPA, uPAR and their ratio are indicative oftumor mediated induction of alterations of fibrinolysis in both benignand malignant tumors of the ovary and cervix, and may be a viabletumor marker. It has been suggested that these factors may directly aidin tumor cell migration and metastasis. The activation of these factorsmay help explain the poor survival of patients with advanced ovarianand cervical cancer.
P3.16.29POTENTIAL ANGIOGENESIS BIOMARKERS IN OVARIANCARCINOMAA.Sabra (1), M. Zakhary (2), A. Kamel (3), Faculty of Medicine, AssiutUniversity, Assiut, Egypt.(1) Dept. OB/GYN(2) Dept. of Biochemistry(3) Dept. of Clinical Pathology
Objectives: To investigate the role of antiangiogenic drugs in treatingovarian carcinoma.Study Methods: Serum and tissue levels of angiogenic stimulators,vascular endothelial cell growth factor (VEGF), basic fibroblast growthfactor (b-FGF), nitric oxide (NO), gangliosides and hyaluronan weredetermined in 48 patients with ovarian carcinoma together with 11samples obtained from patients undergoing hysterectomy for fibroid ordysfunctional uterine bleeding.Results: The study revealed significant increase in the levels ofangiogenic stimulators in either sera or tissue homogenates of patientswith ovarian carcinoma compared with controls (P<0.001). The levels ofthese angiogenic stimulators reflected tumor stage as well as tumorburden. Patients with serous cystadenocarcinomas showed higher levelsof serum and tissue angiogenic stimulators, compared with mucinouscystadenocarcinoma and undifferentiated tumors. No relationship couldbe detected between any of these angiogenic stimulators and patients ageor menopausal status. The source(s) of these angiogenic stimulators aremultifactorial, originating from the tumor cells themselves, connectivetissue cells and the recruited inflammatory cells invading the tumormass.Conclusion: From these data, it could be concluded that antiangiogenicdrugs could be valuable in treating ovarian carcinoma.
P3.16.30PREDICTIVE VALUE OF RISK OF MALIGNANCY INDEX IN THEEVALUATION OF PELVIC MASSESA.P. Manjunath, Pratapkumar, K. Sujatha, R.Vani, Kasturba MedicalCollege & Hospital, Manipal, Karnataka State, India, 380016.
Objectives: To evaluate the ability of Risk of malignancy index (RMI)incorporating menopausal status, serum CA 125 levels and ultrasoundfeatures to discriminate benign from malignant pelvic masses.Study methods: A retrospective study of one hundred and fifty twowomen admitted between January 1997 and August 1999 for surgicalexploration of pelvic masses was conducted at Kasturba Hospital,Manipal. Risk of malignancy index is the product of menopausal score,ultrasound score and serum CA 125 levels, was calculated for allpatients. The sensitivity specificity and positive predictive value ofserum CA 125 levels, ultrasound findings and menopausal status weretaken separately and combined in to the RMI to diagnose ovarian cancer.Results: The Risk of malignancy index is more accurate than themenopausal status, serum CA 125 levels and ultrasound featuresseparately in diagnosing malignancy. The Risk of malignancy index at acut off level of 200 gave a sensitivity of 74%, specificity of 91% andpositive predictive value of 93%.Conclusions: The risk of malignancy index identified women withmalignant pelvic masses efficiently. The risk of malignancy index is asimple scoring system, which can be used in less specialized gynecologycenters. We recommend the risk of malignancy index to facilitate theselection of patients for referral to an oncological unit for adequatestaging and optimal debulking.
P3.16.31PREGNANCY FOLLOWING CONSERVATIVE SURGICALTREATMENT OF THE MALIGNANT GERM-CELL TUMORL. Tasic , N. Prokic, S. Runic, N. Antic, V. Rajkovic, M. Dzinic, M.Pantic, R. Lukic, M. Zamurovic, OB/GYN Clinic, Narodni Front,School of Medicine, University of Belgrade, Yugoslavia.
Objectives: The aim of this study is to demonstrate that by theapplication of the conservative surgical treatment, the complete healingof the malignant germ-cell tumor stage I-a according to the FIGOclassification is possible, as well as the conservation of the reproductivefunction of the young women.
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Study Methods: In one patient, nulligravid, the color-doppler revealedthe presence of a solid-cystic tumor sized 15 cm. With adequatevascularization and lower Resistance index (Ri 0.4-0.44). The tumormarkers HCG and AFP were increased. This was the case of themalignant germ-cell tumor, histopathalogically of the mixed type (75%embrional carcinoma and 25% dysgerminoma) which belonged to the eI-a stage according to the FIGO classification. The treatment consisted ofthe unilateral ovariectomy and biopsy of another ovary, with thelymphadenectomy along the external illiac artery, interilliacally andfrom the paraaortal space.Results: Following the conservative operative treatment, completed bythe hemotherapy scheduled for the malignant germ-cell tumors (BEP:Bleomycin, Etoposid, Cysplatine, three to four treatments in 21 dayintervals), the patients had the control check up monthly in thebeginning and afterwards every 3 or 6 months by the method of color-doppler ultrasound and the control of the tumor makers (HCG, AFP).Our patient conceived spontaneously two years following the operationand brought the pregnancy to the term without major complications.Even five years following the operation all the laboratory analyses arewithin the normal range.Conclusion: The malignant germ-cell tumors belonging to the I-a stageaccording to the FIGO classification can be treated successfully by theconservative surgical method which does not interfere upon thereproductive function of these women.
P3.16.32PRIMARY ADENOCARCINOMA OF A FALLOPIAN TUBE OF 3CASEST. Saito , T. Yano, K. Otaka, T. Kinoshita, and M. Ito. Dept. OB/GYN,And Group of K. Hiruta, and N. Kameda, Dept. (Cytopathology), SakuraHospital, Toho University, Sakura, Chiba, Japan
Objective: The primary fallopian tube carcinoma is one of the leastfrequent tumors of the female genital tract. Our research has beencompleted including reviewing of the worldwide and national literature.Methods: Three patients with primary cancer of the fallopian tubetreated at the Sakura Hospital of Toho University, between 1993 and1999 was retrospectively evaluated for stage, histopathology, treatmentand results.Results: Median age was 61 (range 55-69 years old).Two (2) patients had vaginal bleeding and One (1) patient had sense ofabdominal fullness.All patients had 104-1600U/ml of Serum levels of CA125.All cases were diagnosed after surgery. There was a doubt of ovarycancer before surgery for vaginal bleeding in case of two patients. Incase of patient with abdominal fullness, accumulation of abdominaldropsy with malignant cell was only found. Therefore, diagnosticsurgery has been taken. All cases were adenocarcinoma according withcytological diagnosis. All patients had surgery, both total abdominalhysterectomy and bilateral salpingo-oophorectomy. In additionrertroperitoneal lymphadenectomy had done for 2 cases. According toFIGO staging, 2 cases were evaluated as stage I, 1 case as stage III.Relapse was found 1 year after this surgery, however both removal andCAP6 Treatment was applied. At result relapse was not found anymore.CBDCA was dosed before surgery. As result accumulation ofabdominal dropsy has decreased.Conclusions:1. Preoperative diagnosis is very much difficult in fallopian tube
carcinoma.2. With tumor marker, high level of CA125 was observed.3. As a part of treatment, there is a possibility of platinum and it may be
effective.
P3.16.33RESIDUAL OVARY SYNDROME - CLINICAL MANAGEMENT OFPOST-OPERATIVE ADHESIVE RETENTION CYST OF ADNEXAY. Tamaki , K. Kotake, Y. Izawa, S. Kaneko, Dept. OB/GYN, MatsudoMunicipal Hospital, Matsudo Chiba, Japan.
Objectives: Residual ovary syndrome (ROS) has become recognized as acause of lower abdominal pain, dyspareunia and pelvic mass. Thepurpose of this study is to investigate clinical management of post-operative adhesive retention cyst originating from preserved ovary at thetime of hysterectomy.
Study Methods: Uncontrolled, observational study. This study discussesthe presentation and management of twenty cases from 1985 through1997. The clinical background, ultrasonographic finding, and hormonalanalysis of contents in the cyst were evaluated.Results: Diagnoses at the time of hysterectomy are uterine myoma,endometriosis, carcinoma in situ, colon tumor. Symptoms occurredwithin 1 year to over 8 years. Each pelvic mass ranged from 5cm to14cm in size. Ultrasonographic finding is manifested by characteristicecho-free mass with irregular margin, in which ovarian follicles can bedetected. Hormonal analysis of the content was performed in 6 cases.The concentration of estradiol is between 22.6 and 4210 pg/ml, theconcentration of progesterone is between 1.6 to 16 ng/ml. Treatmentscarried out with GnRHa in 5 cases, oral contraceptives in 4 cases,puncture of the cysts in 6 cases, laparatomy in 2 cases, and observationin 5 cases.Conclusions: The diagnosis of ROS can be identified by characteristicultrasonographic findings and hormonal analysis of content in the cyst.Conservative treatment should be chosen.
P3.16.34RETROSPECTIVE STUDY OF 215 CASES OF OVARIAN CANCERE.C. Neagu , B. Marinescu, M. Neagu, L. Tasca, Dept. OB/GYN,University Hospital P. Sarbu, Bucharest, Romania.
Objectives: The aim of the study is to investigate retrospectively 215cases of ovarian cancer, concerning diagnosis, therapy and follow up.Study Methods: Two hundred and fifteen cases of ovarian cancer wereoperated from 1986 to 1999 (14 years), representing 17% of all cases ofgenital cancer operated. The middle age was 49.6 years, with limits of13 and 78 years. The greatest frequency was in the 5th and 6th decades(24.7% and 20.3%). The diagnosis was performed by clinical signs,echography, CT, laparotomy.Results: The distribution after the stage was: stage I – 49.9%; stage II –15.7%; stage III – 14% and stage IV – 20.2%. Ascitis was present in 54cases (25.3%). The lesion was bilateral in 52 cases (24.1%). From 163one side cancer cases, 48 (29%) presented borderline tumor in the otherside ovary. The histology showed: differentiated adenocarcinoma in80% of cases (papillary in 66% and mucinous in 13.8%), non-differentiated carcinoma in 9.2% of cases, sarcoma in 6.1%, malignantdisgerminoma in 3% of cases. Six cases were operated in emergency(3.6%). A radical resection, consisting in total hysterectomy withbilateral anexectomy and omenectomy was possible in 68% of cases. In23% of cases only partial resection was possible (debalking surgery) andin 9% of cases only the biopsy was performed. Intraperitonealchemotherapy was performed in all the cases. The postoperativepolychemotherapy was performed: 3 cycles for stages I and II and 6 – 12cycles for stages III and IV. The operative mortality was null. For 96cases operated before 1994 the survival at 5 years was 32% (31 cases).For the same period, 37% of the stage I cases and 28% of the stage IIcases developed mestastasis.Conclusion: In spite of an aggressive complex therapy, in absence of ascreening program, ovarian cancer continues to have a severe prognosis.
P3.16.35STUDY OF THROMBOPHILIAS MARKERS IN PATIENTS WITHBENIGN AND MALIGNANT OVARIAN MASSES AFTERSURGICAL TREATMENTA.M. Chabrov , A.G. Solopova, U.U. Tabakman, E. Luginina, A.D.Makatsaria, Dept. OB/GYN, Laboratory of Hemostasis Pathology,Sechenov Moscow Medical Academy, Moscow, Russia.
Objective: Thrombotic complications remain the leading cause of lethaloutcomes in patients with ovarian carcinoma. Appropriate anticoagulanttherapy pre- and post- surgical treatment can reduce thrombotic risk.Study Methods: We performed pilot study of 14 patients with benignovarian masses and 26 patients with ovarian carcinoma. Detection ofthrombin-antithrombin 111 complexes (TAT) and F1+2 was performedby ELISA (Behring, Germany), FDP by staphyl clamping test. Forstatistical analysis criteria of Willcoxon-Mann-Whitney was used.Results: Patients with ovarian carcinoma demonstrated initial high meanconcentration of TAT and F1+2 – 40.6mg/l and 3.02nmol/l respectively.In postoperative period significant decrease of TAT to 3.9mg/l (p<0.01)and F1+2 to 0.96nmol/l (p<0.05) was detected. The same tendency was
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mentioned in patients with benign processes with a lesser degree ofdecrease.Activation of intravascular coagulation was detected in 65% of patientswith ovarian carcinoma (FDP low concentration in 46%, moderate in15% and high concentration in 4%) with significant increase of FDP inpostoperative period (low – 27%, moderate – 62% and high in 8%).Conclusion: Close hemostasis monitoring pre- and post-operatively ismandatory for timely and appropriate anticoagulant management ofpatients with benign and malignant ovarian masses.
P3.16.36THE RESULTS OF THE TREATMENT OF OVARIAN CANCER -ESTONIAN EXPERIENCEInga Vaasna , University of Tartu, Clinic of Hematology and Oncology,7 Vallikraavi Str., Tartu 51003, Estonia.
Objectives: The aim of the study is to report our results and to makesome conclusions of our experience of treatment of ovarian cancer.Study Methods: This retrospective study analysed 290 patients withovarian cancer treated in our clinic between 1990- 1998.Results: As ovarian cancer is often asymptomatic in its early stage,70 % of patients have already reached stage III-IV at the timeof diagnosis.The main treatment regimen of ovarian cancer is surgicaltreatment combined with chemotherapy.The aim of the surgery is tooperate as radicaly as possible- the less the residual disease , the betterthe reaction on chemotherapy and the better are the results.The mostcommon chemotherapy for advanced disease is Taxol- Cisplatin orCisplatin- Cyclophosphamid. 17% of patients with ovarian cancer hadstage I, 6 % stage II, 54 % stage III, 23 % stage IV at the time ofdiagnosis. The most common histological type was serousadenocarcinoma - 74 %. 80 % of the patients with ovarian cancer werein menopause at the time of diagnosis.18 % of ovarian cancer patientshad had sterilitas primaria.The 5- year survival rate of ovarian cancerpatients is 27 %.Conclusions: The survival rate depends on the stage, histological type,differentiation,the residual disease, the age.The smaller the residualdisease the better the survival both for stage III alone and for allstages.The data suggest that further improvement in survival may beachived by aggressive debulking of stage III patients and confirm thesurvival benefit of Taxol and platinum based chemotherapy.
P3.16.37TRANSVAGINAL COLOR DOPPLER SONOGRAPHY INOVARIAN TUMORS WITH USE OF LEVOVISTÒ FOR IMPROVEDVISUALIZATION OF THE BLOOD FLOWE. Blanco , J. Carvalho, A. Fonseca, J. Pinotti, R. Pastore, Dept.OB/GYN, São Paulo University Medical School, São Paulo, Brazil.
Objective: The purpose of this study was to evaluate the potentialcontribution of color Doppler sonography to ultrasound diagnosis byincreasing Doppler signal intensities in small vessels of ovarian tumorswith injection of LevovistÒ.Study Methods: Thirty women were studied at the Department ofObstetrics and Gynecology, University of Sao Paulo (Brazil). Medicalhistory, physical examination and laboratory examination showed thatall of the patients were suitable for inclusion in this study, and none hada history of galactose intolerance. LevovistÒ is a specially manufacturedsuspension containing 99.9% galactose microparticles and 0.1% palmiticacid. Each vial contained 4 g of microparticles and after its suspension inwater it was administered intravenously via a peripheral vein. Dopplersonographic findings were compared before and after injection of 10 mlof LevovistÒ at a concentration of 400/ml.Results: The general tolerance of LevovistÒ was excellent. The baselineB mode scan revealed anechoic unilocular cysts in 6 cases, 9 wereunilocular of multilocular cysts with septa or papilas and 15, complexlesions with cystic and solid parts. In all patients we found an increase inDoppler signal intensity with a slight increase in 7 patients and aconsiderable to optimal increase in 17 cases. In 22 cases sonographyfindings were changed after injection of LevovistÒ, as color flowmapping showed increased vascularity either in the cystic wall or insolid structures within the tumor.Conclusions: Our results show that the injection of LevovistÒ facilitatesimaging of very small vessels with poor velocity patterns in ovariantumors. In 22 cases color flow mapping showed increased vascularity. In
addition, we found an enhancement of Doppler signal intensity in alllesions.
P3.16.38TROUSSEAU’S SYNDROME: A CASE OF SYSTEMICTHROMBOEMBOLIC EVENTS IN OVARIANCARCINOSARCOMAM. Nakayama , T. Iha, M. Tokashiki, K. Kanazawa, Dept. OB/GYN,University of the Ryukyus, Okinawa, Japan.
Objectives: Trousseau’s syndrome, thromboembolic disorders associatedwith neoplastic disease, was first recognized by Trousseau in 1865. Theaim of this report was to describe a case of the syndrome presented withsystemic manifestations of coagulopathic events in ovarian malignancy.Case Report: A 56-year old Japanese woman presented with thebenumbed arm and leg and visual disturbance. Examinations confirmeda huge irregular mass raising the possibility of underlying ovarianmalignancy. CT scan imaged low-density areas of the left occipital lobe,spleen and kidney, indicating thromboembolic lesions. Visualdisturbance was diagnosed to be a right homonymous hemianopsia dueto ischemic damage of the right optic area. Numbness of the arm and legwas suspected to be also due to transient ischemic brain damage becauseof no signs for venous thrombosis of the involved extremities.Furthermore, blood flow scintigraphy indicated multiple pulmonaryemboli. Inverted T-wave in ECG strongly suggested mild myocardialinfarction. No abnormalities were observed in bloodcoagulation/fibrinolysis analyses. Anti-coagulation therapy was initiatedwith intravenous injection of heparin. Two weeks later, the symptomswere almost improved with the exception of visual disturbance.Thereafter, she underwent radical surgery that explored Stage Ic ovariancarcinosarcoma, followed by cisplatin-based chemotherapy of 6-cycles.She has been free of disease with no relapse, but with visual disturbance,more than 5 years.Conclusions: To our knowledge, this is the first case of Trousseau’ssyndrome with intracranial thromboembolic event.
P3.16.39UTILITY OF MUCIN HISTOCHEMISTRY AND MORPHOMETRYIN THE EVALUATION OF SEROUS AND MUCINOUSEPITHELIAL TUMOURS OF THE OVARY.Karuna Rameshkumar , Department of Pathology, St.John’s MedicalCollege, Bangalore, India.
Background: Ovarian epithelial tumours form a morphologic continumfrom benign, borderline to malignant tumours. Mucin histochemistryand morphometry applied to such tumours may provide additionalinformation to light microscopy and clinical features.Objectives: To assess the incidence of serous and mucinous ovariantumours from 1988 to 1998 and to evaluate the utility of mucin histochemistry and morphometry.Material and Methods: The clinical data was accrued from archives. Inaddition to routine stains for basic morphology, mucin histochemistrywas done using 12 stains. Morphometry to measure height of theepithelium was done by visopan and eyepiece micrometry.Results: An incidence of 67.87% of epithelial tumours was observed,which on further categorisation showed 283 serous(s) and mucinous(m)tumours ( benign- 151s and 92m; Borderline- 8s and 14m; Malignant -6sand 14m). Mucin histochemistry showed a significant decrease of acidmucins from benign to borderline to malignant mucinous tumours.Nacetyl sialomucin which showed a decrease in malignant tumourparalleled with an increase in malignant potential of the tumour. Seroustumours showed predominantly neutral mucins which also showed asimilar trend. The height of the epithelium showed a similar decreasefrom benign to malignant mucinous tumours while such a distinctionwas not marked in serous tumours.Conclusions: The morphometry and mucin histochemistry showed adefinite change in relation to degree of malignancy and differentiation inmucinous tumours and hence may be of value in addition to cellularfeatures to assess the malignant potential .In serous tumours utility valueof such procedure is low.
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P3.17 PHYSIOLOGY OF REPRODUCTION
P3.17.01EFFECTS OF OXYTOCIN AND STAUROSPORINE ON THE CELLCYCLE IN MOUSE EARLY EMBRYON. Makimura , U. Fukui, T. Shibazaki, T. Tanaka, K. Kuroda, I. Nagata,Dept. OB/GYN, National Defense Medical College, Tokorozawa, Japan.
Objectives: We reported previously that protein kinase C (PKC) wasactivated by oxytocin (OT) in mouse early embryo, suggesting a closerelationship between PKC and embryo development. The purpose of thisstudy was to examine the influence of OT and an inhibitor of PKC,staurosporine (ST), on the embryo development and to clarify themechanism of cell cycle in early embryo.Study Methods:(1) One-cell stage embryos were incubated in mBWW mediumcontaining ST for 1h, transferred to the fresh medium containing OT,and incubated for 4 days to the blastocyst stage. (2) One-cell stageembryos (n=200) were incubated in mBWW alone, with ST or with OT.They were further divided into the following subgroups. They wereincubated from G1 phase to S phase (1-S), S/G2 phase (1-S/G2) in 1-cellstage embryos, and to S stage (2-S) in 2-cell stage embryo. Theexpression of cyclin D1, cyclin A2, cylcin-dependent kinase (cdk) 2 andp27 mRNA in embryos were analyzed by RT-PCR method.Results:(1) The embryo stopped developing at the 2-cell stage in the presence ofST. However, the stopped 2-cell embryo restarted developing by OT. (2)The low level of cyclin D1mRNA was detected in all groups. The highlevel of cyclin A2 mRNA was observed at the OT group in 1-S/G2 and2-S phase. The level of cdk2 mRNA increased with embryodevelopment in all groups. The high level of p27 mRNA was detected inthe OT group in 1-S/G2 phase.Conclusions: OT may restore the embryo development impaired bysome environmental factors. OT may promote the cell cycle of mouseembryo from G1 phase to S phase, since the appearance of cyclin A2mRNA expression was quickened by OT. Thus, OT may exert afavorable influence on the mechanism of cell cycle, and consequentlyactivate the viability of the embryo.
P3.17.02EFFECTS OF OXYTOCIN AND STAUROSPORINE ON THE CELLCYCLE IN MOUSE CUMULUS CELLU. Fukui , N. Makimura, T. Shibazaki, M. Murakami, K. Furuya,I. Nagata, Dept. OB/GYN, National Defense Medical College,Tokorozawa, Japan.
Objectives: We reported previously that protein kinase C (PKC) wasactivated by oxytocin (OT) in mouse embryo and OT was secreted frommouse cumulus cells surrounding ovum just after ovulation. The purposeof this study was to investigate the effects of OT and staurosporine (ST,PKC of inhibitor) on the progress of cell cycle in the cumulus cells.Study Methods: Mouse cumulus cells were removed from oocytes andseparated by hyaluronidase. Synchronized cumulus cells (1x105cells/ml)were incubated for 1, 3, 6 and 12h in the RPMI 1640 medium alone(control group), and with OT (OT group) or ST (ST group). Theexpressions of mRNAs of cyclin D1, cyclin A2 and cyclin-dependentkinase (cdk) 2 in culture cells were analyzed by RT-PCR method.Results: During culture, expression of cyclin D1 mRNA was detectedmarkedly in the ST group. The expression of cyclin A2 mRNA wasobserved earlier and higher in the OT group than in the other groups.Cdk2 mRNA was expressed constantly in all groups during theincubation.Conclusions: OT and ST act on the cumulus cells around the post-ovulated ooctye in the following ways. (1) ST may induce G1 cell cyclearrest since it expressed high levels of cyclin D1 mRNA, continuously.(2) OT may promote the step of cell cycle from G1 to S phase since itquickens the expression of cyclin A2 mRNA.
P3.17.03ESTIMATION OF THE BIOLOGIC VARIATION OF PRE ANDPOSTOVULATORY PARTS OF GESTATIONAL LENGTH ANDTHE VARIATION OF THE ERROR OF SECOND TRIMESTERULTRASOUND ASSESSMENT OF GESTATIONAL LENGTHB. Backe (1) , H. Buhaug (2), J. Nakling (3)(1) Dept. OB/GYN, University Hospital of Trondheim, Norway.Norwegian Institute for Hospital Research, SINTEF-UNIMED,Trondheim, Norway.(2) Dept. OB/GYN, Central Hospital, Lillehammer, Norway.
Objectives: To estimate the random error of ultrasound gestational ageassessment, the biologic variation in gestational length from conceptionto delivery, and the biologic variation of the interval from last menstrualperiod to conception.Study Methods: A cohort study of 9620 singleton pregnancies withspontaneous onset of labor was done. Routine ultrasound assessment ofgestational age was performed in second trimester, and all women had areliable last menstrual period. Combining the two estimated dates withthe observed day of delivery, the variance of the different proportions ofthe gestational time can be assessed.Results: The standard deviation of the period from conception tospontaneous delivery was 13.2 days and the time between first day oflast menstrual period and conception 7.1 days. The standard deviation ofthe difference between real and ultrasound estimated fetal age at the timeof second trimester routine ultrasound examination was 3.9 days.Conclusion: The naturally occurring or biologic variation of thepreovulatory part of gestation is substantially larger than the randomerror associated with the ultrasound method. Second trimester ultrasoundassessment of gestational age is more reliable than calculation based onlast menstrual period.
P3.17.04FRACTION OF CD4+ T CELLS CONTAINING IFN-g, BUT NOT IL-4IS EXPANDED IN WOMEN WITH PRE-ECLAMPSIA COMPAREDWITH NON-PREGNANT WOMENT. Aoya , A. Ohkuchi, H. Minakami, A. Izumi, R. Usui, I. Sato, Dept.OB/GYN, Jichi Medical School, Tochigi, Japan.
Objectives: Change in Th1/Th2 cells ratio may be involved in thedevelopment of pre-eclampsia. It is suggested that a fraction of Th1 cellsis expended in women with pre-eclampsia. However, it is not knownwhether the number of Th1 cells is actually increased in women withpre-eclampsia.Study Methods: 12 healthy non-pregnant women, 10 women withuncomplicated pregnancies in the third trimester, and 10 women withpre-eclampsia were examined. PBMCs were collected using Histopaque-1077. Three-color flow cytometric technique was used to analyzeintracellular cytokines. After treatment of the PBMCs with phorbolester, ionomycin and brefeldin A for 4 hours, individual cell wasclassified into CD4+ T cells or CD8+ T cells. These cells were treatedwith saponin and intracellular cytokines, IFN-g and IL-4, were stainedby specific antibodies.Results: Mean percentage (± SD) of cells that had intracellularsubstances reacted with anti-IFN-g antibody, but not with anti-IL-4antibody among CD4+ T cells was 13±5.8%, 10±5.8%, and 19±5.2% innon-pregnant, healthy pregnant, and pre-eclamptic women, respectively.Percentage of the cells that had intracellular substances reacted withanti-IFN-g antibody, but not with anti-IL-4 antibody among C8+ T cellswas 41±20%, 35±16%, and 48±18% in the 3 corresponding groups,respectively.Conclusions: These results suggested that a fraction of Th1 cellsappeared to be expanded in women with pre-eclampsia compared withnon-pregnant women and healthy pregnant women.
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P3.17.05HORMONAL CHANGES AND THEIR INFLUENCE ON LIPIDSMETABOLISM IN PHYSIOLOGICAL PREGNANCYE. Romejko , R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski, K.Czajkowski, J. Teliga, A. Malinowska, 2nd Dept. OB/GYN, WarsawMedical School, Warsaw, Poland.
Objective: The aim of the study was to investigate the influence of totalestrogens, human placental lactogen, estradiol and prolactine on lipids’metabolism in physiological pregnancy.Methods: One hundred thirty-six women in the third trimester (36.1±3.4weeks) of the physiological pregnancy entered the study. The followingserum parameters were measured: total lipids, total LDL fraction, totalcholesterol, free cholesterol, phospholipids, triglicerides, HDL-cholesterol, LDL-cholesterol, total estrogens, human placental lactogen,estradiol, prolactine. Methods generally accepted in clinicalbiochemistry were used. The statistical analysis and correlation wereperformed.Results: The following results were obtained: total estrogens and humanplacental lactogen create an increased of serum concentrations of: totallipids (p<0.001), total LDL fraction (p<0.001), phospholipids (p<0.001)and triglicerides (p<0.001) while total cholesterol, free cholesterol,HDL-cholesterol and LDL-cholesterol remain unchanged. Prolactinelowers the serum concentration of LDL-cholesterol (p<0.01) and doesnot alter any other of the lipids. Estradiol does not influence lipids’metabolism.Conclusions: The elevated concentrations of lipids in women withphysiological pregnancy are related to an increase of total estrogens andhuman placental lactogen. Prolactin has little effect on lipids also doesnot alter estradiol levels. This may suggest that the increase of the lipids’concentration in physiological pregnancy might be related mainly toestradiol activity.
P3.17.06HORMONAL CHANGES AND THEIR INFLUENCE ON LIPIDSMETABOLISM IN THE PREGNANCY COMPLICATED WITHPRIMARY HYPERTENSIONE. Romejko , R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski, K.Czajkowski, J. Teliga, A. Malinowska, 2nd Dept. OB/GYN, WarsawMedical School, Warsaw, Poland.
Objectives: The aim of the study was to investigate the influence of totalestrogens, human placental lactogen, estradiol and prolactine on lipids’metabolism in the third trimester of the pregnancy complicated withprimary hypertension.Methods: Twenty-eight pregnant women with primary hypertension(35.0±3.8 weeks, blood pressure 163±11/100±5.9 mmHg) entered thestudy. The following serum parameters were measured: total lipids, totalLDL fraction, total cholesterol, free cholesterol, phospholipids,triglicerides, HDL-cholesterol, LDL-cholesterol, total estrogens, humanplacental lactogen, estradiol, prolactine. Methods generally accepted inclinical biochemistry were used. The statistical analysis and correlationwere performed.Results: The following results were obtained: total estrogens (1753±774mmol/l, human placental lactogen 7841±1919 ng/ml, estradiol23,884±10,022 pg/ml, prolactine 200±51 ng/ml). The levels of totalestrogens, human placental lactogen and estradiol did not significantlydiffer form those in normal pregnancies while prolactine was decreased(p<0.001). Positive correlation occurred between total lipids and totalestrogens (p<0.01). Human placental lactogen and prolactine did notcorrelate with any of the lipids’ parameters whilst estradiol elevatedconcentration of triglicerides (p<0.03).Conclusions: The elevated concentrations of lipids in women withpregnancy complicated with primary hypertension are not related to thehormonal changes. The only positive correlation is between estradioland triglycerides. These observations are different form physiologicalpregnancy in which an increase in serum lipids’ concentration isstrongly related to total estrogen and human placental lactogen. Theelevated serum lipids’ concentration in pregnancy complicated withprimary hypertension may be related to the other yet unknownmechanism.
P3.17.07LIPIDS METABOLISM IN PREGNANCY COMPLICATED WITHPRIMARY HYPERTENSIONE. Romejko , R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski, K.Czajkowski, J. Teliga, A. Malinowska, 2nd Dept. OB/GYN, WarsawMedical School, Warsaw, Poland.
Objective: The aim of the study was to evaluate eight parameters oflipids’ metabolism in pregnant women with primary hypertension.Methods: Twenty-eight women with primary hypertension (the studiedgroup) and 136 healthy women (the control group) entered the study. Allwomen were in the third trimester of pregnancy and there was nosignificant difference in mean gestational age 35.0±3.8 vs. 36.1±3.4wks. Patients in the studied group presented blood pressure163±11/100±5.9 mmHg. The following parameters in blood serum weremeasured: total lipids, total LDL, total cholesterol, free cholesterol,phospholipids, triglicerides, HDL-cholesterol, LDL-cholesterol.Generally accepted clinical biochemistry methods were used.Results: Women in the studied group versus control group showedfollowing results: total lipids 777±195 vs. 692±122 mg%; p<0.03, totalLDL 562±207 vs. 465±100 mg%; p<0.01, total cholesterol 289±84 vs.264±40 mg%; NS, free cholesterol 83±27±vs. 77±14 mg%; NS,phospholipids 340±68 vs. 298±47 mg%; p<0.002, triglicerides 363±161vs. 232±73 mg%; p<0.0001, HDL-cholesterol 69±15 vs.69±20 mg%;NS, LDL-cholesterol 160±71 vs. 150±38.Conclusions: Women in the third trimester of pregnancy complicatedwith primary hypertension present significant alteration in lipids’metabolism manifesting in elevated serum concentrations of total lipids,triglicerides, phospholipids and total LDL. Primary hypertension doesnot change serum concentrations of total cholesterol, free cholesterol,HDL-cholesterol and LDL-cholesterol.
P3.17.08PHYSIOLOGICAL SIGNIFICANCE OF HYPERPOLARIZATION-ACTIVATED INWARD CURRENTS IN SMOOTH MUSCLE CELLSFROM THE CIRCULAR LAYERS OF PREGNANT RATMYOMETRIUMY. Inoue (1), K. Okabe (2), H. Soeda (2), T. Kawarabayashi (1)(1) Dept. OB/GYN, Fukuoka University, Fukuoka, Japan.(2) Dept. Physiol., Fukuoka Dental College, Fukuoka, Japan.
Objectives: The aim of this study was to clarify the properties ofhyperpolarization-activated current were investigated in pregnant ratuterus (17~ 19 days gestation).Study Methods: The microelectrode and patch-clamp techniques wereapplied to enzymatically-isolated rat myometrial cell and isometrictension recording was performed using myometrial strips.Results: The resting membrane potentials were –58.4 mV and –48.5 mVin longitudinal and circular muscle cells, respectively. Application ofhyperpolarizing current pulses produced a time-dependent anomalousinward rectification of membrane potential only in circular muscle cells.Under voltage-clamp conditions, inward currents (I h) were activated bylong hyperpolarizing pulses below –60 mV in circular but not inlongitudinal muscle cells. Application of Cs+
o but not Cs+I reduced the
amplitude of I h in a concentration-dependent manner (an IC50 of 0.15nM). The reversal potential for Ih was –26.2 mV and the slopeconductance was 5 nS/pF. Changes in the [K+]o and [Na+]o shifted thereversal potential, and Ih amplitude increased with excess [K+]o anddecreased with low [Na+]o. The steady-state activation of Ih was wellfitted by a Boltzmann equation with a half-activation potential of –84.3mV and a slope factor of 9.6 mV. Time courses of activation anddeactivation of the current strongly depended on membrane potential,and were well fitted by a single exponential function. In isometrictension recording, application of Cs+
o to the circular muscles reduced thefrequency, but not the amplitude of spontaneous contractions in aconcentration-dependent manner.Conclusions: It is concluded that in pregnant rat uterus Ih channels arepredominantly distributed in smooth muscle cells from the circular layer.Since Ih is activated at the resting membrane potential, it is likely thatthis current contributes to the maintenance of resting membranepotential and spontaneous activity in circular smooth muscle cells of latepregnant rats.
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P3.17.09PROTEIN EXPRESSION OF PLATELET-ACTIVATING FACTORACETYLHYDROLASE ISOFORMS I AND II IN HUMAN UTERINEMYOMETRIUM AND MYOMAK. Yasuda , H. Okada, T. Nakajima, H. KanzakiDept OB/GYN, Kansai Medical University, Osaka, Japan
Objectives: Platelet-activating factor(PAF), which induces myometrialcontraction, is inactivated by plasma and/or intracellular types ofplatelet-activating factor acetylhydrolase (PAF-AH). Intracellular PAF-AH isoform I is composed of a1, a2, and b sub-units, and isoform II ismonometric enzyme. The aim of the study is to investigate the proteinexpression of intracellular PAF-AH in human uterus during pregnancy.Study Methods: The protein expression of intracellular PAF-AHisoforms I and II in human uterine myometrium and myoma wasinvestigated by western blot analysis, and PAF-AH activities in thesetissues were assayed by radioactive tracer experiment.Results: PAF-AH isoform I and II were found in uterine myometriumand myoma. The a2 and b subunits of PAF-AH isoform I weremarkedly detected, but, the a1 subunit of PAF-AH isoform I and PAF-AH isoform II is negligible in these tissues. The levels of the a2 and bsubunit in pregnant uterus were significantly lower than those in non-pregnant uterus and myoma. Further, PAF-AH activity in pregnantuterus was significantly lower than that in non pregnant uterus andmyoma. In contrast, the level of b sub-unit in myoma was significantlyhigher than that in non-pregnant uterus, although no significantdifference in the level of a2 sub-unit was found between these tissues.PAF-AH activity in myoma was also significantly higher than that innon-pregnant uterus.Conclusions: These results indicate that the decrease of PAF-AHactivities in human pregnant uterine myometrium is due to relatively lowprotein expression of the a2 and b sub-units of PAF_AH isoform I,suggesting that the action of PAF increases in human uterus. Theincrease of PAF-AH activities in myoma may be due to relatively highprotein expression of b sub-unit, resulting in reduction of the PAFACTION.
P3.17.10TISSUE FACTOR PATHWAY INHIBITOR (TFPI) IN AMNIOTICFLUIDM. Uszynski , E. Zekanowska, J. Kuczynski, The Rydygier MedicalUniversity, Bydgoszcz, Poland.
Objectives: The question of the study was whether there is TFPI inamniotic fluid – an inhibitor of extrinsic pathway coagulation – whichmay modulate biological activity of major procoagulant of the amnioticfluid, i.e. tissue factor (TF).Study Methods: The study group consisted of 26 women withphysiological pregnancy who were giving birth at term. 10 non-pregnantwomen were the control group. The amniotic fluids were obtained firstin the 1st stage of labor by puncturing the lower pole of the amniotic sac,and then after the childbirth. The venous blood was also sampled. AnELISA method was used. A t-Student test was used in the statisticalanalysis.Results: A detectable amount of TFPI was found in the amniotic fluid –it appeared in the concentration 40.7 ± 20.4 ng/ml, while theconcentration in blood plasma was 71.4 ± 20.4 ng/ml (p<0.001). Theconcentration of TFPI in the blood plasma of non-pregnant women wasnot statistically significantly different from the concentration in pregnantwomen, and was 82.3 ± 12.3 ng/ml.Conclusion: Tissue factor pathway inhibitor (TFPI) appears in amnioticfluid in the concentration about 50% of that in blood plasma ofparturient women.
P3.17.11TRANSPLACENTAL PASSAGE OF TRACE ELEMENTS AND ITSREGULATORY MECHANISMH. Osada (1), K. Seki (1), Y. Watanabe (2), Y. Nishimura (2), M.Yukawa (2), S. Sekiya (1) - (1) Dept. OB/GYN, Chiba UniversitySchool of Medicine, Chiba, Japan. (2) Division of Human RadiationEnvironment, National Institute of Radiological Sciences, Chiba, Japan.
Objectives: To examine the passage of trace elements from mother tofetus, and the role of the placenta that regulates both.
Study Methods: We enrolled 32 mother-and-infant pairs delivered after36 weeks of normal pregnancy and 13 pairs in whom the neonatesshowed IUGR of below -1.5 SD. Immediately after delivery, samples ofumbilical arterial and venous blood, maternal venous blood and placentawere collected. A panel of trace elements was determined preciselyusing inductively coupled plasma mass spectrometry or particle inducedX-ray emission method.Results: Fifteen trace elements: Na, Mg, K, Ca, Mn, Fe, Co, Cu, Zn, Se,Rb, Sr, Cd, Cs, and Ba were determined. K, Ca, Mn, Fe, Zn, Rb and Cslevels were higher, and Cu and Se levels were lower in umbilical serumthan in maternal serum. Zn, Sr and Cs levels in umbilical serumcorrelated positively with the maternal serum levels. In contrast,umbilical blood levels of Mg, Ca, Cu, and Se remained constantirrespective of the maternal levels. Within the [Mg, Ca, Fe, Cu, Se andSr] and [K and Rb] groups, correlations with respect to the ratios ofumbilical to maternal levels were found between elements. Inconcentrations expressed in dry weight, 3 patterns were observed:maternal blood < umbilical blood << placenta (Mn, Zn, Rb and Cs),maternal blood < umbilical blood < placenta (Mg, Sr and Ba), andmaternal blood > umbilical blood > placenta (Cu). Mg, Rb and Cs levelswere significantly higher in the placenta of IUGR neonates.Conclusion: The relation of trace element concentration betweenumbilical and maternal blood differs depending on element, suggestingthe presence of different trace element-specific regulatory mechanismsin the placenta.
P3.17.12VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) AND ITSRECEPTORS IN THE PLACENTAL BED OF HEALTHY AND PRE-ECLAMPTIC PREGNANCIES, AND THOSE COMPLICATED BYFETAL GROWTH RESTRICTIONP. Vuorela 1, O. Carpen2, E. Halmesmäki1 - 1Department of Obstetricsand Gynecology, Helsinki University Central Hospital, 1Department ofPathology, Helsinki University, Finland.
Objectives: In pre-eclamptic pregnancies (PE), as well as in pregnanciescomplicated with fetal growth restriction (FGR) with no hypertension orother symptoms, the physiological adaptation of the blood vessels in theplacental bed is inadequate. Vascular endothelial growth factor (VEGF)and its receptors play a crucial role in embryonic vascular development,and are expressed in the placenta. Therefore, we wanted to studywhether VEGF and its receptors VEGF receptor-1 (VEGFR-1) andVEGFR-2 are expressed in the placental bed, and whether PE or FGRare associated with changes in their expression.Study Methods: Placental bed samples from 5 women with PE, 5 womenwith FGR, and 5 healthy controls were collected following electiveCesarean delivery, and snap-frozen immediately. 5 mm tissue sectionswere analyzed by immunohistochemistry using polyclonal antibodiesagainst VEGF, VEGFR-1 and VEGFR-2 (Santa Cruz Biotechnology).Localization and intensity of staining were compared between thegroups.Results: VEGF, VEGFR-1 and VEGFR-2 were expressed in the vascularendothelium of the placental bed and, surprisingly, in the myometrialcells, but not in the decidualized stromal cells (Figure 1). No differencesbetween the different study groups were observed.Conclusion: VEGF, VEGFR-1 and VEGFR-2 may play a role in theuterine myometrium in term pregnancy. The localization or strength oftheir immunoreactivity in these cells is not affected by PE or FGR.
P3.18 PRE-CANCER, HPV
P3.18.01ANALYSIS OF WOMEN WHO FAIL TO ATTEND FORCOLPOSCOPY APPOINTMENTSS. McNeill , A. Hamilton, Craigavon Area Hospital, Portadown,Co. Armagh, N. Ireland, United Kingdom
Aim: We felt that our ‘did not attend’ (DNA) rate was excessively highfor the colposcopy clinics and we wished to identify why women failedto attend for these appointments. The concern was that these women arefailing to attend for what is a potentially serious but treatable condition.Methods: Over a 7 month period in 1998, 121 patients failed to attendwithout informing the clinic (DNA rate =13%). Charts were reviewedand a questionnaire was then sent out to each of these patients. Hospital
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records were reveiwed 6 months after completion of the study toascertain if these patients had subsequently attended.Results: 51% of all patients who DNA once fail to do so again. 35% hador had been treated for a diagnosis of moderate to severe dyskaryosis.The response to the questionnaire was poor (no=31). Commonestreasons for non-attendance were no appointment received, menstruation,pregnancy, and civil unrest. 42% said they had contacted the hospital tocancel their appointment. 80% said they would subsequently attend, and74% did. Of the group who did not reply, 43% did not subsequentlyattend. 25% of non-attendees were new patients. The estimated cost tothe trust was £3537.Conclusions: Patients with a history of non-attendance are likely to do soagain. A third of these patients had or had been treated for a potentiallyserious lesion. Anxiety regarding visits does not appear to be a majorcontributing factor.
P3.18.02ASSOCIATION BETWEEN NUMBER OF RECENT SEXUALPARTNERS AND THE RISK OF ACQUIRING CERVICAL HPV ISINFLUENCED BY YEARS SINCE FIRST INTERCOURSE.E.I.Svare 1, S. Krüger Kjaer2, J.E.Bock3 C.J.L.M.Meijer4,, J.M.M. Walboomers3,, A.J.C. van den Brule3,.1Dept. OB/GYN, Gentofte University Hospital, Denmark 2Institut ofCancer Epidemiology, Danish Cancer Society, Copenhagen,Denmark.3Dept. OB/GYN, University Hospital Rigshospitalet,Copenhagen, Denmark. 4Dept.of Pathology, University Hospital, VrijeUniversiteit, Amsterdam, The Netherlands.
Objectives: Genital infection with high-risk Human Papillomaviruses(HPV) is the most important risk factor for cervical cancer. Several dataindicate, however, that most women infected with HPV gain somedegree of immunity towards the infection. This implicates, that arepeated exposure should strengthen the immunity and, consequently,decrease the susceptibility to the virus.Study methods: Three hundred and sixty-one women attending STDclinics and 303 pregnant women (first trimester) were included.Presence of a wide range of genital HPV types was tested in cervicalswabs using PCR. Personal data were obtained in an interview using astandardized questionnaire. Adjusted prevalence odds ratios (PORs)were computed including adjustment for possible confounders.Results: In both study groups, the women who had been sexually activefor a relatively short time were significantly more likely to be HPVpositive, given the same number of recent sex partners than women whohad been sexually active for a longer time with adjusted POR of,respectively 4.9 (95% CI:1.8-13.3) and 2.5 (95% CI:1.0-6.3).Conclusions: Our data could support the hypothesis that some immunityto HPV is acquired over time and contributes to the opinion thatvaccination is a possibility in reducing risk of HPV infection.
P3.18.03ATYPICAL AND LOW GRADE SQUAMOUS INTRAEPITHELIAL(ASCUS/LSIL) LESIONS ON PAP: ASSOCIATION OF HUMANPAPILLOMA VIRUS (HPV), HUMAN IMMUNODEFICIENCYVIRUS (HIV) AND AGE WITH CERVICAL DYSPLASIA (CIN 1-3).S.E. Brooks , N. Khanna, G. Taylor; N. J. Gordon, A. Simsir, T. T.Chen,University of Maryland Medical Systems, 405 W. Redwood Street,Baltimore, MD, United States, 21201.
Objective: To evaluate the association of ASCUS, LSIL, HPV, HIV andage with cervical dysplasia.Method: Prospective study of 179 women attending urban Universitycolposcopy clinics. All underwent: questionnaire, colposcopy, HPVsubtyping (Hybrid Capture II) and biopsy, if indicated. HIV(+) statuswas by laboratory report. HIV(-) status was self reported. HPV high-riskand mixed-risk (HPV-HR) included oncogenic HPV subtypes. HPVlow-risk (HPV-LR) did not. Chi Square and multivariate analysis wasutilized.Results: The mean age of HIV(+) women was 41 and 26 in HIV(-)women (p=0.0001). Ninety- three per cent (38/41) of HIV(+) and69%(90/138) of HIV(-) patients were HPV(+). HIV(+) status(p=0.01)and HPV-HR(+) (p=0.0003)were associated with dysplasia.Fewer than 10% were HPV-LR(+). Overall, dysplasia was detected in18% (33/179), but was 23% (30/128) in HPV(+) women and 2% (1/51)in HPV(-) women. The rate of dysplasia in HIV(+) women was
34%(14/41) and 14%(19/138) in HIV(-) women. The negative predictivevalue of HPV typing was 97.8% (95% CI 88%-100%). The predictivepositive value was 24% (95% CI 16.6%-31.4%). The risk of dysplasiawas <1% in: HIV(-), HPV(-), or HPV-LR(+) <21 with an ASCUS Pap;and was 809 fold higher in: HIV(+), HPV-HR(+), >21 and LSIL.Conclusion: In a population with a high rate of HPV, cervical dysplasiawas uncommon (2%) in women with ASCUS/LSIL who were HPV(-) orHPV-LR(+). Colposcopy is of higher yield in older patients with LSILand HPV-HR, especially if HIV(+).
P3.18.04CERVICAL HUMAN PAPILLOMAVIRUS INFECTION INPERIMENOPAUSAL WOMEN WITH ABNORMAL COLPOSCOPICFINDINGSD. Jeremic , B. Stanimirovic, Gyn/Ob University Clinic “Narodni front”,Belgrade, Yugoslavia
Objectives: The aim of this study was to compare the prevalence of HPVinfection in cervical pathologic changes of perimenopausal women towomen of general reproductive age.Study methods: Twenty-nine women over 45 years of age with abnormalcolposcopic findings were undergone cervical biopsy forhystopathologic examination. HPV detection and typisation was donefrom cervical smears, using commercial kits based on RNA-DNAhybridization with probes against the six most common anogenital HPVtypes. The control was 60 women at any of reproductive age with sameabnormal colposcopic findings who underwent the same procedure.Results: The mean age of the studied patients was a little over 50 years(from 45 to 62). There was no difference between two groups innumbers of deliveries or abortion, numbers of sexual partners and age atfirst intercourse. Most common colposcopic findings (mosaic andacetowhite) were similarly found in both groups. Same was with benign,inflamatory hystopathology or LSIL. The only significance was shownwith HSIL (31% in studied group, 15.3% in control, p<0.05). Whendetected (65.5% in studied group and 71.7% in contro), HPV types 6/11alone, or in combination with other types were the most often in bothgroups (41% and 44.1%), followed by high-risk types 16/18 (38% and37%), while types 31/33 were detected at 21% of studied patients and22.7% of control. No significance was shown.Conclusion: Similar HPV presence in pathological cervical changes ofwomen of any age suggest that HPV detecting and typing should be apart of regular checking not only for young, but also for women in periand even postmenopausis
P3.18.05CLINICAL EVALUATION OF LOW GRADE SQUAMOUSINTRAEPITHELIAL LESION (LSIL) CYTOLOGYE. A. G. Pereyra, C. I. Parellada , A. C. S. Chuery, E. Narimatsu, L.Assoni, P. L. Schivartche, Dept. OB/GYN, São Paulo UniversityMedical School, São Paulo, Brazil.
Objectives: The aim of this study was the analysis of low gradesquamous intraepithelial lesion (LSIL) cytology correlating withcolposcopic findings and the histology of punch biopsy.Study Methods: In the period between January 1996 and July 1999,5779 women were referred to the Gynecology Ambulatory of cancerprevention of FMUSP and they all had Pap smear and colposcopy done.Patients presenting LSIL on Pap smear were selected which meant 333of them (5.7%). In the presence of abnormal colposcopic findings, thebiopsy was performed.Results: The colposcopic findings were normal in 150 patients (45%),abnormal in 149 (44.7%), miscellaneous in 11 (3.3%) and unsatisfactoryin 23 (6.9%). The histology of all abnormal findings and 2 cases ofulcers were negative in 68 cases (45%), low grade neoplasia in 55(36.4%), high grade neoplasia in 27 (17.8%) and vaginal intraephithelialneoplasia grade III in 1 (0.7%). The exact agreement between cytologyand punch biopsy was 36.4%.Conclusions: In LSIL approximately half of the cases had normalcolposcopy. In the presence of abnormal colposcopic findings almost50% did not confirm the cytology, 36.4% were agreed and 17.8% had amajor lesion.
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P3.18.06CYTOLOGIC FINDINGS IN LOW GRADE NEOPLASIAE. A. G. Pereyra, C. I. Parellada , A. C. S. Chuery, L. S. N. Pinto, P. L.Schivartche, F. Carvalho. Dept. OB/GYN, São Paulo University MedicalSchool, São Paulo, Brazil.
Objectives: The purpose of this study was to evaluate the cytologicresults in cases of low grade neoplasia histologically confirmed.Study Methods: In the period between July 1996 and July 1999, 4957women were submitted to Pap smear and colposcopy. In the presence ofabnormal findings, the biopsy was performed. Low grade squamousneoplasia was confirmed in 178 cases (3.6%).Results: In these 178 cases of low grade neoplasia, the Pap smearshowed normal results in 105 cases (59%), atypical squamous cells ofundetermined significance in 2 (1.1%), low grade squamousintraepithelial lesion in 43 (24.1%) and high grade squamousintraephithelial lesion in 28 (15.7%).Conclusions: The majority of the cases of low grade neoplasia hadnormal cytology. Pap smear is efficient as a screening method, but whenit is associated to colposcopic evaluation the sensibility to detectprecursor lesions is much improved.
P3.18.07CYTOLOGIC FINDINGS IN HIGH GRADE NEOPLASIAE.A.G. Pereyra , CI. Parellada , ACS Chuery, M. Tacla, P.L. Schivartche,J.A. Pinotti, Dept. OB/GYN, São Paulo University Medical School, SãoPaulo, Brazil.
Objectives: The goal of this paper was to determine the cytologicfindings in high grade neoplasia confirmed by histology.Study MethodsA total of 4957 women were examined with Pap smear and colposcopybetween July 1996 and July 1999. 117 (2.4%) women with histologicdiagnosis of high grade squamous neoplasia on colposcopically directedpunch biopsy were evaluated, correlating with cytology.Results: In these 117 cases of high grade neoplasia, the Pap smearshowed normal results in 19 cases (16.2%), atypical squamous cells ofundetermined significance in 4 (3.4%), low grade squamousintraepithelial lesion in 20 (17.1%), high grade squamousintraephithelial lesion in 66 (56.47%) and suggestive of invasive cancerin 8 (6.8%).Conclusions: The agreement between cytology and histology is greaterin the high grade neoplasia in comparison with low grade. However, thefalse negative of cytology is worrying. The colposcopy is a goodalternative to detect these missed cases.
P3.18.08CODON 72 POLYMORPHISM OF p53 AS A RISK FACTOR FORPATIENTS WITH HUMAN PAPILLOMAVIRUS ASSOCIATEDSQUAMOUS INTRAEPITHELIAL LESION AND INVASIVECANCER OF UTERINE CERVIXY.Tsuyoshi , W. Yukio, I. Hidetoshi, I. Mutsuo., Dept. OB/GYN,Asahikawa Medical College, Midorigaoka Higashi 2-1-1-1, Hokkaido,Asahikawa, Japan
Objectives: It has recently been reported that a patient homozygous forarginine (Arg) allele has about a seven times higher risk of developingcervical cancer than a patient homozygous for proline (Pro). To confirmthis result and elucidate whether this allelic deviation of Arg genotypeseen in invasive cervical cancer occurs in the premalignant lesion, SIL,we analyzed 219 SIL and 101 invasive cancer samples from Japanesepatients and 252 cytological samples as controls.Study Methods: Genomic DNA from cytological samples was extractedwith Isogen/Isogen-LS or DNA extractor WB kit. For paraffin-embedded tissues, DNA was extracted with DEXPAT. To detect HPVsDNA, two different consensus primer sets and type specific primerswere used for PCR amplification. For analysis of alleles with Arg or Proat codon 72 region, modified PCR-RFLP was applied.Results:Samples from 88 SIL and 76 invasive cancer were identified asHPV infected samples and used for further analyses; in these, thefrequency of Arg homozygotes was 31.8%, 33.0% and 36.8% incontrols, SIL and invasive cancer, respectively. The distributions ofallelic status of codon 72 (Pro/Pro, Pro/Arg and Arg/Arg) did not showsignificant differences between either control and SIL groups or control
and invasive cancer groups. Also no difference in the frequency ofArg/Arg genotype was detected even between control and HSIL groupsor control and invasive cancer infected with high risk HPVs groups.Conclusions:There was no obvious relationship between Arg genotypeat codon 72 of p53 and predisposition to HPV associated cervicalneoplasia.
P3.18.09GLANDULAR ATYPIA IN CERVICAL SMEAR:CYTOHISTOLOGIC AND CLINICAL CORRELATIONS. Swain , K. Elsapagh, S. Ghosh, H. Dunsmore, K. W McMullen, J. DSteven, K. D Morton* Dept. OB/GYN and Pathology*, Stirling RoyalInfirmary, Scotland, UK.
Objectives: To audit all the cases of cervical glandular atypia detectedby cervical cytology and to correlate with colposcopic and histologicdiagnosis and subsequent follow up these patientsStudy Methods: A retrospective case note based study over previousthree year period at a district general hospital in central Scotland.Results: Of the 38 women with cervical glandular atypia reported incervical smear; the mean age was 38 years, and 9 (24%) werenulliparous. Histopathologic examination showed 6(15.7%) cases tohave malignant lesions (3 cervical squamous cell carcinoma, 2endocervical adenocarcinoma, lendometrial adenocarcinoma). Theprecancerous lesions included 4(10.5%) cervical glandular intraepithelialneoplasia (GIN), 14(37%) cervical squamous intraepithelial neoplacia(CIN), 2 had both CIN and GIN. The benign pathology included 9(24%) chronic cervicitis, 2 cervical endometriosis and 2 cases of humanpapilloma virus infection. No pathology was identified in 1 case. Themedian follow up of these women was 20 months.Conclusions: The retrospective study suggests that a diagnosis ofcervical glandular atypia correlated with a clinically significant lesion inthe majority of cases. In addition to malignant lesions, cervicalsquamous intraepithelial neoplasia and cervical glandular intraepithelialneoplasia were the most common lesion identified. Cytological andcolposcopic follow up, including cytobrush endocervical cytologicalsampling and long term follow up, is recommended in these women.
P3.18.10HIGH PREVALENCE OF HIGH GRADE SQUAMOUSINTRAEPITHELIAL LESIONS (HSIL) AND MICROINVASIVECARCINOMA IN WOMEN WITH CYOLOGIC DIAGNOSIS OFLSILK.S. Law , T.C. Chang, C.H. Lai, F.P. Chen, Dept. OB/GYN, ChangGung Memorial Hospital, Keelung, Taiwan.
Objectives: To evaluate the histological nature of LSIL in a region withhigh prevalence of invasive cervical carcinoma and propose amanagement protocol.Study Methods: Eight hundred and seventy seven women with LSILwere compare with histological diagnosis through colposcopic biopsy,endocervical curettage, conization or hysterectomy during a studyperiosd from July 1994 to February 1998.Results: Among a total of 128, 925 Pap smear taken, there was 877(0.68%) diagnosed as LSIL. Among theses, 722 women with CIN-SILand 32 with HPV-SIL were enrolled in the final analysis.Of the 543 women with CIN-SIL, there were 145 (27%) cases of HSIL,as disclosed histologically with 16 (3%) cases of microinvasion. 32women with HPV-SIL revealed 18% of CIN 2/3 without microinvasionnoted. Among those followed up at an interval of 3 months with Papalone, the persistence rate was 46.8% with regression rate of 40%.Conclusions: A high percentage of cervical intraepithelial neoplasia 2/3as well as microinvasive lesions will go unnoticed if it were notevaluated with a colposcopic examination.
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P3.18.11HISTOLOGIC EVALUATION OF HUMAN PAPPILOMAVIRUS(HPV) INFECTION IN WOMEN WITH LOW AND HIGH GRADESQUAMOUS INTRAEPITHELIAL LESIONMassabki, JOP; Fonseca, AM; Assis, JS; Bagnoli, VR; Chnee, LH;Junqueira, PAA & Halbe, HW. Dept. OB/GYN, São Paulo UniversityMedical School, São Paulo, Brazil.
Objectives: To evaluate the HPV infection on cervical histology inwomen with low and high grade squamous intraepithelial lesion.Methods: Thirty women with low grade intraepithelial lesion (Group A)and 30 women with high grade squamous intraepithelial lesion (GroupB) were included in this study. Pap smear, colposcopy and biopsy wereperformed to identify the presence of HPV infection on histology.Results: The comparison between the 2 groups are shown in the tablebelow.Groups A BWith HPV 26 (86,7%) 11 (36,7%)Without HPV 4 (13,3%) 19 (63,3%)Total 30 30
Conclusions: The presence of cytopathic changes of HPV infection canbe seen mainly in low grade intraephitelial lesions (86,7%) whencompared with high grade lesions (36,7%). This could be explainedbecause the HPV-DNA is on the epissomal form causing cytopathicchanges on histology in low grade lesions, as long as in high gradelesions the HPV-DNA is on the integrated form, making the diagnosesdifficult.
P3.18.12LEEP VERSUS COLD KNIFE CONIZATION IN THE THERAPY OFCERVICAL INTRAEPITHELIAL NEOPLASIAC. Dannecker , R. Kimmig, C. J. Thaler, H. Hepp, P. HillemannsDept. of OB/GYN, Klinikum Grosshadern, University Munich,Germany
Objectives: This study was performed to evaluate the effectiveness andside effects of loop electrosurgical excision procedure (LEEP) incomparison to cold knife conization for the treatment of cervicalintraepithelial neoplasia (CIN).Study Methods: Between January 1996 and July 1998, 177 patientsunderwent conization. In a matched-pair setting, 50 cases with LEEPwere compared with 100 classical conization cases. LEEP wasperformed with ectocervical and endocervical excision.Results: Perioperative complications were less in the LEEP group (6%vs. 11%). The mean volume of the LEEP specimens (1,6 cm3) weresignificantly smaller than the volume of the cone specimens (2,6 cm3).Thermal artifacts were negligible. There were no significant differencesin the proportion of margin involvement (20% vs. 19%) andresidual/recurrent CIN. The endocervical excision contained dysplastictissue in 38% of the cases; more important, a positive endocervicalexcision was found in 11/12 CIN 3 cases (92%). The success rate wassimilar in both groups (96% vs. 97%). Hospitalization time was less forthe LEEP group.Conclusions: LEEP conization is a safe and cost effective procedurewith a lower complication rate providing a significantly smallerspecimen compared to cold knife conization. Therefore, LEEPconization may substitute cold knife conization. However, we dorecommend to perform LEEP conization with an endocervical excisionto reduce residual CIN.
P3.18.13OUTCOME OF TREATMENT RESULT OF CERVICAL ATYPIA BYLARGE LOOP EXCISION OF TRANSFORMATION ZONE OVERCRYOTHERAPY.K.J. Maula , Dept. of Gynaecological Oncology, National Institute ofCancer Research and Hospital, Dhaka 1212, BangladeshM.S. Flora, Dept of Epidemology, NIPSOM, Dhaka, BangladeshB. Islam, Dep of Cytopathology, NIRCH, Dhaka, Bangladesh
Objectives: The objective of the study was to compare the treatment outcome of cervical atypia between large loop excision of thetransformation zone of cervix and cryotherapy as an outpatientprocedure
Study methods: This study was undertaken among 80 patients ofcervical cytoabnormality attending in the outpatient department ofGynaecological Oncology of NIRCH Dhaka, Bangladesh over a periodof one year and six months(between July 98' to Dec 99'). The studypopulation were divided into two groups. One groups(40patients) weretreated by cryotherapy and the other group by large loop excisionalprocedure. Datas were wel matched in both groups.In both group 10 patients with severe inflamation with atypia, 9 patientsof chronic cervicitis with CIN I , 9 patients with CIN II, 12 patients ofCIN I with concomitant squamous metaplasia were treated byCryotherapy and large loop excissional procedure. All the cases werereviewed after 3 months with cervical smear.Results: On followup study at 3 months the group of patients weretreated with Cryo therapy shown to have persistence of the previouspathology in severe inflamation with atypia 3(7.5%)in CIN I 4(10%), inCIN I with squamous metaplasia 3(7.5%)and in CIN II 5 (12%)cases.On the other hand at 3 months review the group of patients treated withlarge loop excissional procedure had shown CIN II 2 (5%)and in CIN I 1(2.5%) cases.Conclusions: By large loop electrosurgical exicissional procedure gave amuch better results in cases of cervical cytoabnormalities overcryotherapy.
P3.18.14PREVALENCE OF CERVICAL INTRA-EPITHELIAL NEOPLASIAACCORDING TO THE CHRONOLOGICAL AGE AND THEINTERVAL SINCE FIRST SEXUAL INTERCOURSEL.C. Zeferino ; M.G.L. D'Ottaviano-Morelli; J.G.Cecatti; E.Z.Martinez,School of Medicine, Universidade Estadual de Campinas, CidadeUniversitaria, Rua Alexandre Fleming, 101, Campinas, Brazil, cep:13083-970.
Objectives: To analyze the association between cervical intra-epithelialneoplasia (CIN), chronological age and interval since first sexualintercourse (IFSI).Study Methods: The results of 120635 routine Pap tests, collected in thePublic Health System in the area of Campinas, Brazil, form September1998 through April 1999, performed at the Cytopathology Laboratory ofthe University. The prevalence , the prevalence ratio by chronologicalage and IFSI, with a 99% confidence interval, were estimated. A test fortrend and a logistic regression model were used.Results: Based on cytological diagnosis, 427 cases of CIN1,308 of CIN2and 170 of CIN3 were found. The prevalences of CIN1 and CIN2 tendedto decrease as the chronological age and IFSI increased. On the otherhand, the prevalence of CIN3 tended to increase. Using the logisticregression model, the odds ratio was 0.901 for age and 1.046 for IFSI,for CIN1; 0.886 for age and 1.083 for IFSI, for CIN2; 0.956 for age and1.176 for IFSI, for CIN3.Conclusion: The CIN1 and the CIN2 prevalences are more associatedwith the chronological age, than with the IFSI. The prevalence of CIN3is more associated with IFSI than with the chronological age.
P3.18.15SCREENING FOR CERVICAL CARCINOMA IN A HIGH RISKPOPULATION GROUP IN POKHARA VALLEY, NEPALS. Bajpai , Dept. OB/GYN, Manipal College of Medical Sciences,Pokhara, Nepal.
Objectives: To evaluate the results of cervical cytology screening usingBethseda system.Study Methods: Cytological evaluation of cervical smears was carriedout in 460 multiparous women (Parity 2 and above), over a period of oneyear, at their first visit to Manipal Teaching Hospital, Pokhara.Results: Cystopathology showed 36 (7.8%) Normal, 370 (80%)Inflammatory, of which 16 (4%) showed Trichomonas vaginalis; 4(0.8%) Reparative, 28 (6%) Squamous metaplasia, 8 (1.7%) AtypicalSquamous Cells of Undetermined Significance, 14 (3%) Low GradeSquamous Intraepithelial Lesion, 2 (0.4%) High Grade SquamousItraepitelial Lesion. LSIL and HSIL were present in women all of whomwere smokers, married at 17 years or below, of the low socio-economicstrata. In 60% cases, husbands were away from home for long periodsand multiple sexual contacts cannot be ruled out. Serology in theinflammatory group was positive for Chlamydia trachomatis in 38.5%.
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Conclusion: This study emphasizes the need for cytological screening inhigh risk women, in view of the prevailing custom of early marriage andyoung age at first coitus, smoking and a significant incidence of PelvicInflammatory Disease.
P3.18.16STUDY ON THE MANAGEMENT OF SIL OF THE UTERINECERVIXM.Oda (1) , M. Ohmura (1), Y. Ishii (2), N. Ishida (2), (1) TokyoMetropolitan Cancer Detection Center, 2-5 Kandasurugadai, Chiyoda-ku, Tokyo, Japan, 101-0062, (2) Tokyo Kenbikyou-In Foundation,Chiyoda-ku, Tokyo, Japan.
Objective: Establishment of a following-up system for squamousintraepithelial lesion (SIL) of the uterine cervix by retrospective study.Method: Between 1984 and 1994, we have been mass-screened 177,340subjects for uterine cervical cancer, and detected 798 cases of low SILand high SIL (excluding cases of CIS) of the uterine cervix at the TokyoMetropolitan Cancer Detection Center (detection rate 0.45%). Wefollowed 860 cases, including cases that were referred to us. Thefollowing criteria were used in evaluating the outcome of SIL. Cases inwhich both cytological and colposcopical results were negative at least 3times and continuously for at least 2 years were evaluated as regressing.Cases in which intraepithelial carcinoma or worse was confirmedhistologically were evaluated as progressing. Cases which did notprogress nor regress during at least 2 years of follow-up were evaluatedas persisting. The average follow-up period for SIL was 49.8 months.Results: 1) Out of 383 cases of low SIL, 12 cases (3.1%) progressed, 97cases (25.3%) persisted and 274 cases (71.4%) regressed.2) Out of 194 cases of high SIL, 39 cases (20.1%) progressed, 68 cases(35.1%) persisted and 87 cases (44.8%) regressed.3) Of the 361 cases that regressed, 301 did so within 2 years of follow-up.4) Of the 51 cases that progressed, the operative histologic diagnosiswas established in 44 cases. The breakdown was; CIS, 31 cases; MIC, 5cases; SCC 1b, 4cases.Conclusion: High SIL is a lesion that progresses at a rate ofapproximately six times that of low SIL.Closely controlled follow-up of high SIL is possible, but medicaltreatment is indicated if there is no regression within 2 years.
P3.19 ULTRASOUND
P3.19.01COMPARISON OF MATERNAL MIDDLE CEREBRAL ARTERYBLOOD FLOW VELOCITY AS MEASURED IN PREECLAMPTIC,HEALTHY PREGNANT AND NON-PREGNANT WOMEN BYTRANSCRANIAL DOPPLER SONOGRAPHY.J. Zatik (1) , J. Aranyosi(1), T. Major (1), L. Ovari(2), D. Pall (3),B. Fulesdi (1), (1) Dept. OB/GYN, (2) Dept. Int. Med. (3) Dept. Anesth.and Intensive Care, University Medical School of Debrecen, Hungary.
Objectives: The aim of the study was to test the hypothesis that cerebralblood flow velocity is altered in preeclamptic pregnant women ascompared to healthy pregnant and non-pregnant women.Study Methods: Preeclamptic (n=21) and healthy pregnant (n=17), aswell as non-pregnant (n=29) women had undergone transcranial Dopplerblood flow velocity measurements of the middle cerebral artery. Meanblood flow velocities of the middle cerebral artery (MCAV) werecompared between the different groups.Results: MCAV values was significantly higher in non-pregnant womenas compared to healthy pregnant women. Preeclamptic women showedsignificantly higher MCAV values compared to non-pregnant females.Same to the non-pregnant women, healthy pregnant patients showedlower MCAV values compared with preeclamptic women.Conclusions: We detected increased resting cerebral flow velocities inthe middle cerebral arteries of pregnant patients with preeclampsia. Inour opinion this finding refers to arteriolar dilation of the resistancevessels of the brain.
P3.19.02A CASE OF EVENTRATION OF THE DIAPHRAGMS. Watababe , T. Maemura, C. Aoki, M. Shiokawa, K. Itou, Y, Yao,K. Masaki, M. Tanaka, H. Kubo, S, Hirakawa Dept OB/GYN, TohoSchool of Medicine, Tokyo, Japan
Eventration of the diaphragm is relatively rare to diaphragmatic hernia.The prenatal diagnosis is very difficult, because of the similarity ofdiaphragmatic hernia. We present a case that diagnosed diaphragmatichernia at preterm but was eventration eventually. A 39-year-old female,GOPO, performed amniocentesis for high age pregnancy and familyhistory of Down syndrome of her husband’s sister. But no chromosomalabnormalities revealed. Ultrasonography that performed at 28 weeksrevealed the fetal stomach to be at the level of the back of the heart andcolon gas of the left side of the heart. Diagnosis considered werediaphragmatic hernia at that time. Emergency Cesarean section wasdone for premature rupture of membrane at 37 weeks, and 2017 g, maleinfant that was slept by the anesthesia delivered and respiration wascontrolled by the ventilation at once. He had no malformation. On day 6,open surgery was done and excess diaphragm visualized under theoperation. This was considered eventration. Post operative day 4,respiratory function improved and the tube was removed.
P3.19.03AN ASSESSMENT OF GESTATION SPECIFIC AMNIOTIC FLUIDINDEX AMONGST INDIAN WOMENS. Khadilkar , S. Desai, C. Purandare, S. Tayade, M. Patel, Cama andAlbless Hospital [University teaching Hospital], A2 Aparna Vaibhav,B.W. Pathare Road, Mumbai, Maharashtra, India, 400028.
Objectives: To obtain a gestational reference range for the amniotic fluidindex amongst the Indian women and to compare the study with thosefrom other countries.Study Methods: An analysis of AFI estimations was undertaken in 1000Indian patients with normal pregnancy between 16 to 40 weeks ofgestation.Patients with fetal anomalies, PIH, diabetes mellitus and othermaternal complications were excluded from the study.The median ,the5th and the 95th percentile values were calculated for each gestationalweek and these values were compared with other studies.Results: The median value of AFI reached its peak at 28 weeks and allgestation specific medians were significantly lower in studied populationof Indian women as compared to other studies.Conclusion: We standardized the reference value for normal AFI inIndian women and AFI values differ with different population andgeographical distribution.
P3.19.04CLINICAL VALUE OF PLACENTAL LOCALISATION ATTHE 18-20 WEEKS SCANS G Toh , B Ahmed, A Hildreth, K Hinshaw, Department of Obstetrics &Gynaecology, Sunderland Royal Hospital, Sunderland, United Kingdom.
Objective: To determine the significance of ultrasound location ofplacental site at the 18-20 weeks anomaly scan.Study design: A retrospective analysis of 517 consecutive anomaly scansperformed between 18 – 20 weeks gestation at Sunderland RoyalHospital, between January to March 1998. A low implantation of theplacenta at anomaly scan was arbitrarily defined as lower placental edgesituated within 20mm from the internal cervical os. Subsequent antenatalcourses and outcomes of these pregnancies were ascertained from thecase notes. The Minitab statistic programme was used to assist dataanalysis.Results: At 20 weeks scans, 96 (18.6%) were reported to have low-lyingplacenta. Among these, 14 (14.6%) were reported to cover the internalos and within this group, 5 (35.7%) were posteriorly sited. There was nosignificant difference in the incidence of bleeding (8%) whether theplacenta was low-lying or normally sited at 20 weeks scan (p=1.00). Atdelivery, there were 3 cases of major placenta praevia giving afrequency of 0.6%. Two of these cases were reported to have low-lyingand posteriorly sited placenta at 20 weeks. In the remaining case, theplacenta was actually normally sited at 20 weeks scan. Therefore, thePPV of low-lying placenta was only 2.1% (95% CI 0.2-7.3) but the PPVof placenta covering os was 14.3% (95% CI 1.8-42.8). However, thePPV of posterior placenta covering os for major praevia was 40% (95%
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CI 13.6-77.2). In addition, the NPV of normally sited placenta was99.8% (95% CI 98.7-99.9).Conclusions: The placental site does not seem to have any influence onthe subsequent admission rates for antepartum haemorrahge. A low-lying placenta at 20 weeks scan does not warrant a routine repeat scan inthird trimester, but rescanning those with placenta covering os,particularly if posteriorly sited, appears to be more cost effective.Furthermore, an apparently normal placentation at 20 weeks scan is veryreassuring indeed, but it still does not absolutely exclude major placentapraevia in later pregnancy.
P3.19.05COMPARING THE VAGINAL AND RECTAL APPROACH FORMEASURING THE FEMALE URETHRA WITH THREE-DIMENSIONAL ULTRASOUNDD. Stutterecker , W. Umek, O. Preyer, E. Hanzal, Urogynecology Unit,Department of Gynecology and Obstetrics, University Hospital, Vienna,Austria
Objectives: The aim of this study was to assess differences in urethralmeasurements by comparing transvaginally and transrectally acquiredimages of urethral and periurethral tissues.Study methods: We examined 68 women (mean age 51,3±18,4 years)using a mechanical sector probe (7,5 MHz) with real-time and three-dimensional (3D) facilities on a Combison 530D (Kretztechnik,Austria). The probe was applied both vaginally and transrectally. Thestored images allowed detailed morphologic assessment of the urethraincluding the measurement of volumes in three perpendicular planes.Length of the urethra, length, maximum thickness and volume of therhabdosphincter, maximum thickness of the inner part of the urethra(consisting of smooth muscle, submucous vascular plexus andurothelium) were measured. SPSS statistical software system was usedfor calculation.Results: Both vaginal and rectal scans were tolerated well. Values forlength of the urethra (27,8±3,6 mm vaginally vs. 27,7±5,0 rectally),length (16,5±4,3 vs. 15,7±3,3), thickness (6,1±1,4 vs. 6,3±1,8) andvolume (0,7±0,3 ml vs. 0,8±0,4) of the rhabdosphincter did not differbetween the two methods. The inner layer of the urethra wassignificantly thicker when examined vaginally (11,5±2,3 vs. 8,8±1,5;p<0,001).Conclusion: Vaginal and rectal approaches of 3D-ultrasound provideequal values for most female urethral structures. However, the part ofthe urethra consisting of smooth muscle and vascular plexus appears tobe compressed on vaginal scans.
P3.19.06DOPPLER VELOCIMETRY IN THE ADRENAL ARTERY IN THEHUMAN FETUS FOR THE DETECTION OF FETAL STRESSY. Fujita , S. Satoh, S. Yanai, K. Tsukimori, H. Nakano, Dept. OB/GYB,Graduate School of Medical Sciences, Kyushu University, Fukuoka,Japan
Objectives: The aim of the study is to clarify the age-relatedchronological changes and hemodynamic aberrations in complicatedpregnancies in the velocity of waveforms of the fetal adrenal artery.Study Methods: A total of 125 cases between 24 and 41 weeks’gestation are included in this study. In these , 108 cases had normalpregnant course with reactive NST, no structural or growth abnormality,and no neonatal asphyxia. Other 17 cases had fetal complications; 4cases with suspected IUGR, 10 with structural abnormality, 2 with non-reactive NST and 1 with oligoamnios. After detecting the middle adrenalartery by color Doppler flow imaging, velocity waveforms are recordedin condition without fetal movements. The RI value was calculated asthe average from 2 consecutive cardiac cycles in each case. Using thedata obtained in normal cases, the regression analysis was made forevery 2-week interval from 24 to 41 weeks’ gestation. The deviation ofRI values was investigated as for cases with fetal complications.Results: In normal cases, RI values in fetal adrenal artery decreasedgradually with advancing gestational age. The means values ad 24 and41 weeks are 0.74 and 0.66 respectively (RI=-0.0006wk2+0.034wk-0.0259, R2=0.964). In cases with fetal complication, 7 cases had RIvalues below the mean-2SD. Out of 7, 3 cases (3/7;42.9%) had fetalhypoxia, fetal anemia and insufficient feto-placental circulation.
Conclusion: In normal pregnancy, it was found that vascular resistancetoward fetal adrenal gland gradually decreases with advancinggestational age, reflecting developing vascular network, and that itchanges in lower values in fetuses with hypoxia, anemia and insufficientfeto-placental circulation, indicating dominant blood flow in the adrenalgland under hypoxic and/or anemic condition.
P3.19.07DOWN’S SYNDROME RISK ASSESSMENT – COMBINEDSECOND TRIMESTER SERUM SCREENING ANDULTRASONOGRAPHYV. Dimitrova , T. Chernev, V. Mazneikova, I.Kremensky, StateUniversity Hospital “Maichin Dom”, Sofia, Bulgaria
Objectives: To assess sensitivity and necessity for invasive testing insecond trimester Down’s syndrome [DS] screening based on serum testsalone and on serum tests combined with genetic sonogram [GS].Study Methods: Two methods for second trimester DS risk assessmentwere compared in a group of 1150 patients, 227 (19,7%) of them abovethe age of 37. Serum screening [SS] with two markers - AFP and freehCG - was going on prospectively. The cut-off risk value for invasivetesting was 1:250 at birth. Parallel with that DS risk obtained from theSS was recalculated depending on the results from the GS. In theabsence of fetal anomalies or sonographic markers for chromosomaldefects risk was reduced by 40%. In the presence of specific ultrasoundmarkers (increased nuchal fold thickness, short femur, echogenic bowel,pyelectasis) risk was corrected by specific factors proposed in literature.Fetal anomalies were considered an indication for amniocentesis despitethe results from the SS.Results: There were 183 abnormal SS test results in the group studied(15,9%) and 11 (0,95%) chromosomally abnormal fetuses (8-DS, 3 –other aneuploidies). Nine of them were in patients older than 37 and 2 –in younger ones. SS alone detected 8 out of the 11 chromosomallyabnormal fetuses (sensitivity 72,7%) and 7 of the 8 DS ones (sensitivity87,5%). If only the results from the SS were considered 3 cases withchromosomal defects would have been missed – one DS fetus, one withtrisomy 18 and one with unbalanced translocation. Abnormal sonogramswere found in 34 out of 1150 fetuses (2,9%). 19 of them were in thelow-risk SS group (1,97%) and 15 were in the high-risk SS group(8,2%). Five of the DS fetuses had one or more sonographic markers but3 of them had none. The three fetuses with other but DS chromosomaldefects had easily detectable sonographic markers. Risk recalculationbased on data from the SS and the GS resulted in overall reduction of thenumber of high-risk results and amniocenteses required by 37 (20%).Detection rate was 100% for both DS fetuses and the ones with otherchromosomal defects with 12,7% invasive testing. In the 3 cases of DSfetuses without sonographic markers SS risk was so high that itwarranted amniocentesis even after risk recalculation.Conclusions: Combined second trimester SS and GS can reduce thenumber of amniocenteses required because of positive SS results in apredominantly high-risk population. Detection rate for DS is not affectedand the detection rate for other chromosomal defects is increased.
P3.19.08HYDATIC CYST OF THE BREASTD. Zeghal , A. Souki, M.B. Chennouffi, M.S. Hendaoui, E. Sfar, H.Chelli, Centre de Maternité et de Néonatologie de Tunis, Tunis, Tunisia
Objectives: In Tunisia, the hydatic cyst is an endemic disease but thebreast localisation is exceptionally reported. In this poster, a new case isdescribed.Study Methods: Case report and review of the litterature.Results: We colleged one case of hydatic cyst of the breast. The womanwas 52 years old and lived in a rural area. The systematic examination ofthe breast founded a 3 cm nodule. The mammography practiced showeda calcified image of 30 mm. The breast ultrasound showed a well-haitedformation of 30 mm, having an heterogeneous echostructure with somemembranes that evoked a breast hydatic cyst.In this case, we found another hydatic localisation in the VII th segmentof the liver. The X-ray investigation of the thorax was normal.The treatment was surgical; it consisted in a simple resection of the cystallowing a recovery without complications. The histological study gavea confirmation of the diagnostic.
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Conclusion: Mammary hydatic disease is a benign and harmlessaffection caused by ecchinococcus granulosus. In a country where thisdisease in endemic breast localisation should be considered..
P3.19.09MORPHOLOGIC OBSTETRIC ULTRASOUND INDICATIONS ANDDIAGNOSTIC FINDINGS OF EXAMINATIONS PERFORMED IN AREFERENCE HOSPITAL.F.Dib , A.Berezowski, G.Duarte, R.Yano, F.Costa, S.Cunha. Universityof São Paulo, Ribeirão Preto City, São Paulo State, Brazil, 14049-900.
Objectives: To establish the profile of fetal abnormalities that exists inthe population assisted at an Universitary Hospital.Study Methods: From January to December, 1998, 176 pregnants werereferred to an Universitary Hospital to be submitted to a morphologicalobstetric ultrasound examination.Results: Most of fetuses were anatomically normal. The most commonabnormalities were from central nervous system, followed by genito-urinary tract abnormalities and multiple malformations. A completetable listing all diagnostics is available for presentations.Conclusions: Most of fetuses were anatomically normal. The mostcommon abnormalities were from central nervous system, followed bygenito-urinary tract abnormalities and multiple malformations acomplete table listing all diagnostics is available for presentations.Under any suspected abnormality detected by a routine ultrasoundexaminations the patient must be referred to a specialized center toconfirm the diagnostic. Most of indications for morphological ultrasoundhad revealed normal fetuses, so this exam must be performed by welltrained professionals only. According to many reports the centralnervous system and the genito-urinary tract abnormalities were the mostfrequent.
P3.19.10NECESSITY OF BREAST ULTRASOUND IN ROUTINEGYNECOLOGICAL EXAMINATIONSM. Gojnic , M. Pervulov, S. Petkovic, T. Mostic, University of Belgrade,Clinical Centre of Serbia, Institute for Gynecology and Obstetrics,Belgrade, Yugoslavia.
Objectives: The aim of this study was to present the necessity of makingultrasound examinations in routine gynecological screening andintroducing that diagnosis in gynecology, not only in oncology.Study MethodsLast year, we started to make routine ultrasonography in examinedgroup of gynecological patients, with no significant breast problems.Making ultrasound examinations of breast in 570 women, aged 20 to 40years, without problems, we wanted to point out necessity ofexaminations.Results: During routine control of women with no significant problems,we have found that:- 62% have microcystic diplasia, needed frequent controls21% have cystic tumors for further necessary punctions14% of fibroadenom tumors2.6% exactly 15 women with first signs of ductal carcinomasConclusions: We wanted to suggest that routine ultrasonography of thebreast must be in the first step of diagnosis together with palpatoryexaminations and ultrasonography of genital organs, Papanicolau,vaginal secretion, colposcopy. Giving women the first chance of havingexaminations in oncology department makes our first health step moredistant and much scaring to ordinary people.
P3.19.11PATIENTS’ PERCEPTION OF TRANSVAGINAL ULTRASOUNDSCANNING (TVS)C. Absi , K. Reddy, N. Amso, Dept. OB/GYN, University Hospital ofWales, Cardiff, UK
Objectives: Trasvaginal Ultrasound Scanning is a routine investigationfor women presenting with gynecological complications. However, verylittle research has been undertaken into the women’s perception to thisvery intimate and embarrassing procedure. The aims of this study wereto seek the patient’s view to the service provided and women’sexperiences before and after the vaginal scan.
Study Methods: One hundred and fifty seven consecutive patients whoattended the Outpatient “One-Stop” clinic for trasvaginal scanning wereincluded I the study. Following the procedure, each patient was asked tocomplete an anonymous questionnaire relating to their views on theinformation leaflet sent prior to the appointment, the procedure itself inrelation to pain, anxiety (using 10-point visual analogue scale) and theclinical environment.Results: One hundred and forty patients completed the questionnaires(89% response). Of those patients, 128 (91.4%) found the writteninformation regarding the procedure, which were sent prior to theirappointment, clear to understand and helped in reducing their anxieties.All patients described the procedure as acceptable with preserveddignity, 139 (99%) experienced slight to mild pain/discomfort only withone reported no pain at all. One hundred and sixteen (82.8%) watchedthe monitor during scanning; 100 patients (86.2%) found this helpful inreducing their anxieties.Conclusions: All patients in this sample found TVS acceptable, withbearable mild to moderate pain experience. The study highlightedseveral areas for improvement.
P3.19.12SPECIAL CHARACTERISTICS OF ULTRASOUND DETECTIONOF LEVONORGESTREL IUS (MIRENA®) IN THE UTERUSA. Soder, Zehntwiesenstraße 5, D-76275 Ettlingen, Germany
Objectives: Ultrasound control of intrauterine devices is a commonprocedure in gynaecological practice. The hormonal LNG IUS is not aseasily detectable as a Copper IUD because it does not contain echogeniccopper wire. The aim of this case study was to define typical features ofthe LNG IUS in longitudinal and transverse view.Study Methods: In this case study 420 women using LNG-IUS wereexamined by transvaginal sonography (Sonoscope 3, Kranzbühlerdevice).Results: In all cases LNG IUS could be detected in the uterus.Thehormone cylinder shows a typical trapezoid dorsal shadow in thelongitudinal sonografic view. The caudal and cranial ends of thehormone cylinder body are clearly identified by echo-rich spots. Thedistance between the uterine fundus and the cranial end of the LNG IUScorresponds to half the uterus diameter, and thus shows optimal positionof LNG IUS in the uterus. In transverse view the expanded arms showstrong echogenicity while the tips of the arms and the hormone cylinderare identified by shadows.Conclusions: The LNG IUS shows typical features in ultrasound,different from those of the Copper IUDs. Transvaginal ultrasound is asuitable method to control the position of the LNG IUS in utero.
P3.19.13THE USE OF ENDOLUMINAL SONOGRAPHY AT DELIVERY INPRIMIPAROUS WOMEN.A. Baxter , K. Phillips, G. Duthie, A. Gardiner, Castle Hill Hospital,Hull, United Kingdom
Objectives: To establish the accuracy, practicality, reliability andreproducibility of endoluminal ultrasonography (ELUS) immediatelyafter delivery in nulliparous women.The incidence of anal sphincter tears after vaginal delivery is 0.5-2%.ELUS has been shown to be more sensitive at identifying women withsubclinical injuries than digital examination. Using ELUS it has beenshown that anal sphincter injury can occur in up to 35% of womendelivering for the first time. We have used ELUS to detect tearsimmediately after delivery with a view to immediate repair.Method: All primiparous women were offered an EAS immediately afterdelivery. Using a B&K 360 degree scanner with 10Mz probe the imageswere recorded at 1cm and 2cm from the anal margin and just belowpubo-rectalis. These were scored independently as ‘intact’, ‘thinned’ or‘disrupted’ by four assessors. The assessment of the senior team memberwas taken as the ‘gold standard’ against which the other assessmentswould be compared.Results: 62 primigravidae were scanned. External anal sphincter defectswere identified in 31% and internal sphincter defects in 6%. Agreementin the assessments was reached in 80% of cases with defects and 97%with none. The quality of the hard copy image was deemed adequate foranalysis in 100% of cases.
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Conclusion: Satisfactory images were obtained in all cases, indicatingthat EAS is a practical tool for use in the immediate postpartum period.Images were acquired in 3-4 minutes causing only minimal discomfort.The technique is reproducible and importantly, interpretation of theimages is highly consistent. The high anal sphincter damage incidence inthe group reflects higher scan acceptance rates when there was concernof sphincter damage.
P3.19.14TRANSVAGINAL ULTRASONOGRAPHY IN EARLYDIAGNOSTIC OF ENDOMETRIAL HYPERPLASIAT.F. Tatarchuk , T.D. Zadorognaya, E.V. Burlaka, J.P. SolskyInstitute of Pediatrics, Obstetrics and Gyneacology, Ukraine
Objectives: We aimed to detect the early ultrasonic signs of endometrialhyperplasia.Study Methods: The study included 84 peri- and postmenopausal womenat the age of 45-55 in period, which had the indication for dialation andcurettage of uterine cavity. In order to receive more objective results ofinvestigation the endometrium/myometrium coefficient was estimated,that is the ratio of the endometrium thickness to anteroposterior diameterof uterus.The control group consisted of 75 peri- and postmenopausal women whounderwent transvaginal sonography and had none pathological changesin the endometrium and the values of the TE (the thickness of theendometrium) and EUC (Enometrium - Uterus coefficient) were withinnormal range of the age.Results: During the first year of Menopause we revealed only in 6 of 52women hyperplasia with atypia has been revealed and was accompaniedby abnormal bleeding. In postmenopausal women during the secondyear of Menopause the hyperplasia with atypia has been found in 8 casesof 32 women (25%). It should be stressed that 4 of these women hadnome of the clinical symptoms. This proves the importance ofsubclinical diagnostic criteria for hyperplasia with atypia and theestimation of the EUC may be one of these criteria. The results of ET inwomen during the second year of postmenopause have demonstratedthat values in women with atipical hyperplasia (6,3 + 2,13) were notsignificantly different compared to control group (5,9 + 1,76) and weresignificantly lower than in women with hyperplasia (12,8 + 2,57) andpolyposis (14,1 + 1,93).Concerning the results of EUC it was revealed that in women withatipical hyperlasia the values (0,29 + 0,07) were significantly higher thanin control group (0,11 + 0,02) and did not reliably differ from thecomplex hyperplasia (0,31 + 0,04) and polyposis of endometrium(0,31 + 0,08). The increase of echogenecity and the increase ofconduction of the sound in the hyperplastic endometrium testify thehyperplasia with atypia.Conclusions: The results indicate the expediency of measuring EUC andET in postmenopausal women.
P3.19.15ULTRASOUND DIAGNOSIS OF MALIGNANT TUMORS OFOVARYN.V. Vedernicova , M.N. Zholobova, L.S. Aleksandrov, N.V.Vinogradskya, E.V. Nachodkina, G.B. Saakyan, E.B. Savinova, MoscowMedical Academy, Urgent Medical Aid Hospital, Moscow, Russia.
The problem of the diagnosis of the tumors in the genital tract is farfrom decision in gynecology. Among all neoplasia of the genital tract,25% are malignant tumors. The ultrasound diagnosis allows us todetermine tumors in pelvis in 95-98% and establish its topical location in85-98% of cases. Any solid mass, thickening of the capsule or septumsupposes malignancy. Diagnostic accuracy of ultrasound picture wasdetermined in comparison with the results of morphologicalinvestigations. Under the comparison the indicator of sensitivity was93% and the indicator of specificity was 47%. We considered the tumorto be benign if the pulsative index was more than 1.00 and malignantwhen it was less or equal to 1.00. Velocities curves, taken from differentareas of tumor have wide spectrum results from low to high. In 61.6% ofinvestigated patients with the tumors of ovary, we did not receive datefor the existence malignant processes. Among earlier operated patients,in 16 we diagnosed the relapse of tumor. The ultrasound investigationimproved the diagnosis of malignant tumors of ovary on 17.7% incomparison with clinical data. Among patients with ascites, ascitic fluid
was found in 91% under ultrasound investigation. In single cases, ascitiswas in quantity 200-300 ml. In 77% of cases, our investigation provedthe damage of the omentum. In other cases, the tumor changes inomentum did not find. Key difficulties in determination of localizationof the tumor, sizes and nature of process, condition of the other ovarywere depended on marked adhesive process in pelvis and abdomencavity. The main cause of hypodiagnosis of damage of omentum was theabsence ascitis in abdomen cavity that made special acoustic medium.Receiving additional data in the conditions of gynecological departmentcontributed to more rapid moving of patients in oncological hospitalwith the following composite treatment, that undoubtedly was affectedto the final result of therapy.
P3.19.16ULTRASOUND EVALUATION OF THE UTERINE CAVITY INTHE EARLY PUERPERIUMB. Ahmed , A. Fayyad, N. Christoforidis, T. Hildreth, K. Hinshaw, Dept.OB/GYN, Sunderland Royal Hospital, Newcastle-Upon-Tyne, UK.
Objective: To evaluate the size and contents of the uterine cavity with 24– 48 hours following normal vaginal delivery using transabdominalultrasound.Aims:1. To describe the size and contents of the uterine cavity in the early
puerperium.2. To compare findings in primiparous and multiparous women.3. To define the clinical significance of heterogenous echoes in the
uterine cavity.Study Methods: 100 women following normal singleton vaginal deliveryat term were evaluated sonographically within 48 hours of delivery,using transabdominal real-time ultrasound. The amount of lochia in allwomen was normal. The uterine cavity was measured in two planes. Themaximum length and anteroposterior diameter were measured in themid-sagittal plane. The maximum transverse diameter was measured inthe true axial plane of the uterus. The internal appearance of theendometrial cavity and any echoes within it were evaluated. All womenwere followed up to eight weeks post-partum for any significant vaginalbleeding or infection.Results: 37% had mixed heterogenous echoes with the uterine cavity.None of these women had abnormal symptoms. The only scan parameterthat was significantly different between the groups with heterogenous orhomogenous echoes was the antero-posterior diameter of the cavity:9.2(3.2-30.7) mm vs. 5/8(3.2-15.1) mm [median range] p=0.0003(Mann-Whitney). There were no significant differences between the AP,length or transverse cavity measurements related to parity. Only onewoman presented with “secondary PPH”; she had originally been in thegroup with a homgenous (empty) cavity in the early puerperium.Conclusions: In the early puerperium, the ultrasound finding of mixedechogenic shadowing in the uterine cavity is common (37%). In thepresence of normal lochia, it does not seem to imply pathology (i.e.retained products of conception). We suggest that the ultrasoundappearances we have described should be regarded as normal at thatstage. In future studies, women with heterogenous echoes in the uterinecavity in the early puerperium will be evaluated longitudinally in orderto define how quickly they resolve.
P3.19.17ULTRASOUND GUIDED PUNCTURES OF PELVIC CYSTICMASSES: 8 YEARS EXPERIENCEZ. Puzigaca , T. Starovic-Medan, Z. Sretenovic, V. Ivanovski, M. Savic,R. Nikolic, G. Bunjevacki, Center for Family Planning and HumanReproduction, Mother and Child Heath Care Institute of Serbia,Belgrade, Yugoslavia.
Objectives: The objective was to evaluate the role of ultrasound guidedpunctures in the management of pelvic cystic masses.Study Methods: Thirty patients, aged 5-68, with pelvic cystic massesultrasonographically determined as unilocular, anechoic, withoutpapillary projections, and with a diameter over 5 cm, were subjected topuncture.Results: Recidives appeared in six patients (20%) within an intervalranging from two months to five years.Conclusions: Ultrasonography is an efficient method for diagnosingpelvic cystic masses, and can assist us in deciding on the accurate
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treatment. Further studies are required to re-evaluate our criteriaindicating cysts puncture, since the rate of recidives is high.
P3.20 VAGINAL CANCER
P3.20.01MANAGEMENT OF MALIGNANT MELANOMA OF THEVAGINA: A REPORT OF 15 CASESRazvi K , Selo-Ojeme D, Lowe D, Nasir N, Blake PM, Gore ME, BartonDPJ, Shepherd JH. St Bartholomew’s Hospital and the Royal MarsdenHospital, London, UK.
Objective: To review the management and results of treatment ofmalignant melanoma of the vagina in 2 gynaecological cancer centres inLondon.Methodology: A retrospective review of a computerised databaserecords as well as case-notes over a 25-year period ending December1999.Results: Completed data for 15 patients were available for review.Abnormal vaginal bleeding was the principal complaint in most caseswith the lower third of the vagina being the most common site ofoccurrence. Of the 10 patients who had initial surgery, 7 had a widelocal excision and 3 had radical surgery. The other 5 patients had pelvicradiotherapy as primary treatment. Five surgical patients had post-opadjuvant radiotherapy and a further 2 had radiotherapy within a year ofsurgery for recurrent disease. Of the 5 patients given systemic therapy orchemotherapy, 3 had it for recurrent disease and 2 as adjuvant treatment.The survival period ranged from 2 to 78 months (mean 20.9 months)with only 2 patients surviving at least 5 years.Discussion: This study confirms the extremely poor prognosis of vaginalmelanomas regardless of the type of primary or adjuvant treatment.Thus, conservative procedures should be recommended as the primarytreatment. There is an urgent need to identify novel therapeutic strategiesin order to improve survival of this condition.
P3.20.02VAGINAL SARCOMA: UNUSUAL PRESENTATION ANDDILEMMA OF MANAGEMENTK. Gupta , N.R. Mondol, S.K.Banerjee, Dept. GYN, Cancer CenterWelfare Home & Research Institute and Child Care Center,Thakurpukur, Calcutta, India.
Objectives: To share an unusual presentation of vaginal sarcoma in aprimipara within seven months of a normal vaginal delivery and theensuing dilemma of its management.Study Methods: In addition to the routine hematological and radiologicalscreening, special investigations like CT scan of the whole abdomen wasperformed. Examination under anesthesia followed by excision biopsyof the vaginal nodule and subsequent panhysterectomy was performed.Histopathological examination (HPE) of the excised vaginal nodulerevealed low grade endometrial stromal sarcoma, while HPE of theuterus, cervix, fallopian tubes and ovaries were free from anymalignancy.Results: Following surgery, she was followed up monthly. In the fourthpost-operative month, she suddenly presented with unilateral inguinallymph node enlargement. Fine needle aspiration cytology (FNAC) of theswelling was negative for malignancy. On the sixth postoperative month,she presented with bilateral inguinal lymph node enlargement. Sincebilateral inguinal lympgh node dissection was not feasible, externalradiation (5500 cGY in 25 fractions over six weeks) was administered.Despite such aggressive treatment, in the fifteenth post-operative month,she was found to have extensive unilateral pleural effusion and lungmetastasis. Pleural tapping was done and intrapleural chemotherapyadvised. She is still under follow-up as of December 23, 1999.Conclusions: Unusual presentations of rare malignancies make itextremely difficult to plan a definitive protocol for effective andpredictable treatment.