Risk factors for rejection of synthetic suburethral slings for stress urinary incontinence: a case-control study.

OBJECTIVE:To identify variables associated with rejection of synthetic, suburethral slings used for female stress urinary incontinence.METHODS:Between 1991 and 1998, gynecologists at our department performed 428 operations for stress urinary incontinence by inserting expanded polytetrafluoroethylene or polyethylene suburethral slings. After suitable exclusions, 386 women followed for at least 24 months after surgery remained for analysis. Of the 386 women, 47 (12.2%) had graft rejection or symptoms associated with rejection within 24 months after surgery, which led to later removal. We compared cases and controls using logistic regression analyses with forward selection to identify independent risk factors and risk markers for rejection.RESULTS:The rejection rate declined sharply during the years 1993-1994 after introduction of routines that included preoperative prophylactic antibiotics active against anaerobes and repeated preoperative treatment of the vagina with chlorhexidine acetate. After adjusting for potentially confounding variables, surgery after 1993, the gynecologist performing the procedure, and adequate antibiotic prophylaxis remained significantly associated with a lower rejection rate. There was no significant association between rejection and sling material, age at surgery, year of surgery (in one year steps), or concomitant prolapse surgery.CONCLUSION:Rejection of suburethral slings might be associated with bacterial contamination of the graft, and the rate was decreased with prophylactic antibiotics a repeated and vaginal disinfection

Risk factors for acidemia at birth

OBJECTIVE: To identify risk factors for acidemia at birth. METHODS: From September 1988 to December 1996, cord arterial blood pH was measured in 23,016 of 27,064 live-born infants (85.0%). Values below 7.05 were observed in 264 newborns (1.1%), of whom 14 born by cesarean delivery before labor and one triplet infant were excluded from the study. The remaining 249 newborns with acidemia and their mothers were compared with 249 unmatched controls with normal pH (the first infant with umbilical arterial pH above 7.10 born after each case). Multivariate logistic regression was used to adjust for potentially confounding variables. RESULTS: Variables significantly and independently associated with acidemia at birth were labor with breech presentation (adjusted odds ratio [OR]2.9), oxytocin administration (OR 2.1), meperidine administration (OR 2.0), cord entanglement (OR 1.7), and male gender of the infant (OR 1.4). Clinical evidence of chorioamnionitis also was associated with acidemia, although after adjustment for prematurity, the association was not statistically significant (OR 3.9, 95% confidence interval 0.8, 19). CONCLUSION: Labor with breech presentation, administration of oxytocin and meperidine, cord entanglement, and male gender are associated with an increased risk for insufficient fetomaternal gas exchange

Risk factors for fever in labor

OBJECTIVE: To identify risk factors for fever in labor. METHODS: A retrospective case-control study was conducted. Maternal sublingual temperature was measured every 2-4 hours during labor in 3109 of 3860 consecutive term parturients presenting from September 1992 through December 1993. Women who had fever (at least one recorded temperature of 38C or more, n = 72) during labor were compared with those who remained afebrile (n = 3037). Furthermore, a matched-pair case-control study was conducted, involving 250 women at term who developed fever in labor and 250 controls matched for parity and duration of labor; all delivered between January 1989 and December 1993. A conditional multiple logistic regression analysis was used to identify independent risk factors for fever during labor. RESULTS: In the case-control study, fever was associated with epidural analgesia, nulliparity, and a long duration of labor. These three variables were also related among themselves. However, multiple regression analysis showed that all three variables were independently associated with maternal temperature. In the matched-pair study, epidural analgesia, rupture of membranes longer than 24 hours, latency phase exceeding 8 hours, and a temperature in the upper normal range (37.5-37.9C) at admission were independent risk factors for developing fever in labor. CONCLUSION: Epidural analgesia, duration of labor, and a long interval from rupture of membranes to delivery were independent risk factors for maternal fever in labor

Maternal fever in term labour in relation to fetal tachycardia, cord artery acidaemia and neonatal infection

OBJECTIVE: To determine 1. whether maternal fever during term labour is associated with acidaemia at birth and neonatal infection and 2. whether fetal tachycardia precedes maternal fever and is associated with neonatal infection. DESIGN: Retrospective matched-pair case-control study. SUBJECTS: Two hundred and forty-eight newborn infants whose mothers developed fever during term labour (cases) and 248 control infants. The women were matched for parity and duration of labour. MAIN OUTCOME MEASURES: Cord artery acid-base status, Apgar scores, neonatal infections, and fetal heart rate before maternal fever. RESULTS: Mean pH, as well as the rate of cord artery acidaemia at birth (pH < 7.10) was equal in cases and controls (in both groups 7.24% and 6%, respectively). Signs of septicaemia and/or pneumonia were identified in 17 case newborns (7%) and in one control (0.4%; OR 17.0, P < 0.001). Of 212 pairs with complete heart rate data, fetal tachycardia preceded maternal fever in 39 cases (18%) and in 16 controls (8%) (OR 2.6, P = 0.003). Tachycardia before maternal fever was not associated with increased neonatal infectious morbidity. CONCLUSIONS: Maternal fever during term labour was associated with perinatal infection, but not with acidaemia at birth. Elevated fetal heart rate preceded maternal fever in a minority of cases and was not associated with perinatal infection

Prediction of post-operative pain after a laparoscopic tubal ligation procedure.

Background: Pre-operative identification of reliable predictors of post-operative pain may lead to improved pain management strategies. We investigated the correlation between pre-operative pain, psychometric variables, response to heat stimuli and post-operative pain following a laparoscopic tubal ligation procedure. Methods: Assessments of anxiety, mood, psychological vulnerability and pre-operative pain were made before surgery using the State-Trait Anxiety Inventory (STAI), the Hospital Anxiety Depression Scale (HADS), a psychological vulnerability test and the Short-Form McGill Pain Questionnaire (SF-MPQ), respectively. Pre-operative assessments of thermal thresholds and pain response to randomized series of heat stimuli (1 s, 44-48 degrees C) were made with quantitative sensory testing technique. Post-operative pain intensity was evaluated daily by a visual analogue scale during rest and during standardized dynamic conditions for 10 days following surgery. Univariate and multivariate regression analyses were used to construct prediction models. Results: Fifty-nine patients completed the study. Post-operative pain was significantly correlated with pre-operative pain (SF-MPQ), heat pain perception, psychological vulnerability, STAI and HADS. In the multiple regression model pre-operative pain and heat pain perception were significant predictive factors (R=0.537-0.609). Conclusion: The study indicates that pre-surgical pain and heat pain sensitivity are important pre-operative indicators of post-operative pain intensity, while psychological factors like vulnerability and anxiety seem to contribute to a lesser degree after laparoscopic tubal ligation. The prediction model accounted for 29-43% of the total variance in post-operative movement-related pain

Endometritis: The clinical-pathologic syndrome

OBJECTIVE: The purpose of this study was to evaluate histologically proved endometritis as a clinical syndrome that is distinct from laparoscopically confirmed salpingitis. STUDY DESIGN: This was a cross-sectional study of 152 women in an urban hospital with a suspected pelvic inflammatory disease. All women provided a standardized medical history and underwent physical examination, endometrial biopsy, and laparoscopy. We defined endometritis by the presence of plasma cells in endometrial stroma and neutrophils in the endometrial epithelium. RESULTS: Of 152 women who were enrolled, 43 women had neither endometritis nor salpingitis; 26 women had endometritis alone without salpingitis, and 83 women had salpingitis. Those women with endometritis alone more often had couched recently, had a current intrauterine device, and were in menstrual cycle day 1 to 7, compared with women with no endometritis or salpingitis (P = .007, .04, .005, respectively) or women with acute salpingitis (P = .03, .01, .02, respectively). Infection with Neisseria gonorrhoeae and/or Chlamydia trachomatis was found more frequently in women with endometritis alone than in women with no endometritis or salpingitis (P < .001) and less frequently than in women with salpingitis (P = .05). Lower quadrant, adnexal, cervical motion, rebound tenderness, peritonitis, tenderness score, fever, and laboratory abnormalities that indicated inflammation and detection of gonorrheal or chlamydial infection were significantly less common in women with endometritis alone than in women with salpingitis but were somewhat more common in women with endometritis alone than among women with no salpingitis or endometritis. CONCLUSION: Among women with suspected pelvic inflammatory disease, the histopathologic manifestations of endometritis were associated with clinical manifestations, infection, and specific risk factors that were intermediate in frequency between women with salpingitis and women with neither endometritis nor salpingitis

Effect of Sibutramine on Weight Reduction in Women With Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial

Objective: To examine the efficacy of sibutramine together with brief lifestyle modification for weight reduction in obese women with polycystic ovary syndrome (PCOS). Design: Investigator-initiated, multicenter, double-blind, randomized, parallel-group clinical trial. Setting: Departments of Obstetrics and Gynecology in primary care, referral centers, and private practice. Patient(s): Forty-two patients with confirmed PCOS were included in the study, and 34 patients completed the study. Intervention: Sibutramine 15 mg once daily together with brief lifestyle modification was compare with placebo together with brief lifestyle modification. Main Outcome Measure(s): The primary endpoint was to assess weight loss. Secondary endpoints included the efficacy of sibutramine for treatment of menstrual pattern and cardiovascular risk factors. Result(s): After 6 months the sibutramine group had lost 7.8 +/- 5.1 kg compared with a weight loss of 2.8 +/- 6.2 kg in the placebo group. Sibutramine treatment resulted in significant decreases in apolipoprotein B, apolipoprotein B/apolipoprotein A ratio, triglycerides, and cystatin C levels. Conclusion(s): Sibutramine in combination with lifestyle intervention results in significant weight reduction in obese patients with PCOS. In addition to the weight loss, sibutramine seems to have beneficial effects on metabolic and cardiovascular risk factors

Variability in diagnosis of clue cells, lactobacillary grading and white blood cells in vaginal wet smears with conventional bright light and phase contrast microscopy

Objective: Study the reproducibility of wet smear interpretation of clue cells, lactobacillary grades and leukocyte dominance with conventional bright light and phase contrast microscopy. Study design: Sets of vaginal specimens were taken from unselected consecutive women attending an outpatient gynaecology clinic. Air-dried vaginal fluid on a microscope slide was rehydrated with isotonic saline before examination by six independent international investigators. Some investigators initially used a conventional bright light microscope, followed by phase contrast technique. Results: Using phase contrast microscopy, an excellent inter-observer agreement was obtained among all investigators for clue cells detection (Kappa values from 0.69 to 0.94) and lactobacillary grades (Kappa 0.73-0.93). When conventional light microscopes were used, poor agreement was obtained for these criteria (Kappa index 0.37-0.72 and 0.80, respectively), but switching to phase contrast microscopy by the same investigators, improved Kappa to 0.83-0.85 and 0.88, respectively. The inter-observer agreement for estimation of the leukocyte/epithelial cell ratio (Kappa index 0.17-0.67) was poor, irrespective of the type of microscopy applied. Intra-observer agreement of clue cell detection and lactobacillary grading was also found to be excellent if phase contrast microscopy was used (Kappa 0.87-0.93), and poor with conventional bright light microscopy (Kappa 0.45-0.66). Conclusion: Clue cells and the lactobacillary grades are reliably identified by phase contrast microscopy in wet smears, with excellent intra- and inter-observer reproducibility agreement, and better than when simple bright light microscopy was used. Evaluation of leukocyte grading, on the other hand, was inconsistent among the different microscopists, irrespective of the type of microscope used. We propose to grade the leukocytes in a different way than searching for leukocyte dominance over epithelial cells, namely by counting them per high power field and per epithelial cell. (c) 2009 Elsevier Ireland Ltd. All rights reserved