Sixty-four Women Research Articles

Effects of Closed Suction Drainage in Reducing Pain after Laparoscopic-Assisted Vaginal Hysterectomy

Study Objective To estimate whether closed suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy (LAVH) reduces the frequency and intensity of shoulder-tip, abdominal, and back pain. Design Prospective, randomized study (Canadian Task Force classification 1). Setting Teaching medical center. Patients One hundred sixty-four women. Intervention LAVH. Measurements and Main Results For group 1 (80 women), closed suction (Jackson–Pratt) drains were inserted into the peritoneal cavity and cul-de-sac, whereas for group 2 (84), no drains were placed. Shoulder-tip, abdominal, and back pain were evaluated by visual analog scores (VAS) 3, 24, and 48 hours after surgery. The frequency of shoulder-tip pain was significantly lower in group 1 at 24 hours (23% vs 40%, p = 0.013) and 48 hours (9% vs 21%, p = 0.024; VAS scores at 24 hrs 2.2 ± 1.1 vs 3.8 ± 1.3, p = 0.010; VAS scores at 48 hours 1.5 ± 1.0 vs 2.5 ± 1.2, p = 0.018). At 48 hours fewer women in group 1 experienced abdominal pain (31% vs 50%, p = 0.039; VAS scores 2.0 ± 1.1 vs 4.0 ± 1.3, p = 0.007). No statistically significant differences in frequency and VAS scores for back pain were found at any time. The quantity of oral analgesics was greater for group 2 than for group 1 (12.4 ± 1.6 vs 9.0 ± 1.4, p <0.001). Economic evaluation of analgesic requirements and material costs for the two groups showed that simple analgesics were more cost-effective than closed suction drainage in the treatment of pain. Conclusion Closed suction drains may reduce the frequency and intensity of shoulder-tip and abdominal pain and postoperative analgesia requirements after LAVH, but simple oral analgesics are more cost effective.

Upper extremity deep vein thrombosis associated with indwelling peripheral venous catheters in gynecology oncology patients

Objective The goal of this study was to review the clinical presentation, management, and outcome of upper extremity deep vein thrombosis (UEDVT) in women with gynecologic malignancies who had indwelling peripheral venous access catheters. Methods From a retrospective review of medical records, we identified 13 patients with various gynecologic malignancies who were diagnosed with UEDVT during their disease course. We obtained tumor data, detailed information regarding the indwelling catheters used, and the diagnosis and management of UEDVT. Results Two hundred sixty-four women with gynecologic malignancies underwent insertion of an indwelling peripheral catheter by interventional radiology over a 5-year period. A total of 325 catheters were placed in these patients. Thirteen patients developed UEDVTs, and all had a catheter in situ at the time of DVT diagnosis. Eleven of thirteen patients had Peripheral Access System (PAS) Ports and two had peripheral indwelling central catheters (PICCs). The mean age of the patients was 53 years (range, 32–70). At the time of UEDVT diagnosis patients had the following: progressive cancer ( n = 8), stable disease ( n = 1), no evaluable disease ( n = 4), and actively receiving chemotherapy ( n = 7). Clinical signs/symptoms at the time of diagnosis included: catheter occlusion ( n = 2), arm swelling and pain ( n = 10), and superior vena cava syndrome ( n = 1). Diagnosis of thrombosis was confirmed using Doppler ultrasound ( n = 4), venography ( n = 5), and both modalities ( n = 4). Management of UEDVT consisted of anticoagulation with warfarin (2–6 months) ( n = 9), urokinase infusion ( n = 2), intravenous antibiotics for 21 days and heparin for 10 days ( n = 1), arm elevation only ( n = 1), Lovenox for 60 days ( n = 1), and no therapy ( n = 1). There were no complications associated with anticoagulation. No patient had a pulmonary embolism. The incidence of UEDVT among our patients with indwelling venous catheters was 5.7%. Conclusion Symptomatic UEDVT is an uncommon complication of indwelling peripheral venous catheters in women with gynecologic malignancies. The risk of pulmonary embolism is low in this patient population.

Women's perceptions of and experiences with medical student involvement in outpatient obstetric and gynecologic care in the United Arab Emirates

Objective: The purpose of this study was to determine the experiences, satisfaction, and comfort of women with medical student participation in outpatient care during obstetric and gynecology clerkships. Study Design: A consecutive sample of 303 women who attended the clinic were interviewed before consultation; a structured questionnaire was used. Results: Two hundred sixty-four women (87.1%) accepted student involvement; 158 women (59.8%) and 173 women (66.5%), respectively, preferred female students or preceptors. Comfort levels were significantly lower with male students or preceptors in all skills that were tested (P <.0001), particularly pelvic examination and the discussion of sexual problems. Acceptance was associated significantly with older age (P <.0001), higher parity (P <.0001), higher education (P =.002), husband's occupation (P =.006), obstetric consultation (P <.0001), previous teaching encounters (P =.0006), recognition of the students' roles (P =.004), and satisfaction with clinical service (P = 0.01). Reasons for nonacceptance (n = 39 women, 12.9%) were concern about privacy during examination (53.8%) or counseling (25.6%) and the extent of the students' involvement (20.5%). Conclusion: Most women agreed to participate in the teaching of obstetric and gynecologic skills to medical students. (Am J Obstet Gynecol 2002;187:1091-100.)

Adjuvant High Dose Rate Vaginal Brachytherapy as Treatment of Stage I and II Endometrial Carcinoma

In Brief OBJECTIVE To evaluate the efficacy of high dose rate vaginal brachytherapy in the treatment of International Federation of Gynecology and Obstetrics stage IB, IC, and II endometrial carcinoma after surgical staging and complete lymphadenectomy. METHODS All patients with stage IB, IC, or II adenocarcinoma or adenosquamous carcinoma of the endometrium who received postoperative high dose rate vaginal brachytherapy at our institution between June 1, 1989, and June 1, 1999, were eligible. High dose rate vaginal brachytherapy was delivered in three fractions of 700 cGy. Retrospective chart review was performed. Kaplan–Meier estimates were calculated for disease-free and overall survival. RESULTS One hundred sixty-four women were identified. Fifty-six percent had stage IB disease, 30% had stage IC disease, and 14% had stage II disease. Approximately one third of patients had high-grade lesions and nearly 40% had deep myometrial invasion. Median follow-up was 65 months (range 6–142 months). To date, 14 patients have had recurrence; 2 at the vaginal apex, 9 at distant sites, 1 at the pelvic sidewall, 1 simultaneously in the pelvis and at a distant site, and 1 at an unknown site. Both patients with vaginal apex recurrences had salvage therapy and are now free of disease. The overall 5-year survival and disease-free survival rates were 87% and 90%, respectively. There were no Radiation Therapy Oncology Group grade 3 or 4 toxicities. High dose rate vaginal brachytherapy was approximately $1,000 less expensive than external-beam whole-pelvic radiation. CONCLUSIONS Adjuvant high dose rate vaginal brachytherapy in thoroughly staged patients with intermediate-risk endometrial carcinoma provides excellent overall and disease-free survival with less toxicity and at less cost compared with whole-pelvic radiation. Adjuvant treatment with high dose rate vaginal brachytherapy is efficacious in patients with FIGO stage I and II endometrial carcinoma

Comparison of Two Procedures for Laparoscopic-Assisted Vaginal Hysterectomy of Large Myomatous Uteri

Study Objective To evaluate whether laparoscopic bipolar coagulation of uterine vessels (LBCUV) and supracervical amputation improve laparoscopic-assisted vaginal hysterectomy (LAVH). Design Prospective, randomized, longitudinal study (Canadian Task Force classification II-1). Setting Private practice, university-affiliated hospital. Patients Sixty-four women (age 31–52 yrs) with symptomatic myomatous uteri larger than 12 weeks on bimanual examination. Interventions LAVH with or without LBCUV and laparoscopic supracervical amputation followed by trachelectomy. Measurements and Main Results LBCUV and laparoscopic supracervical amputation followed by trachelectomy and removal of the specimen vaginally were performed successfully in 29 women (group A). Hysterectomy was performed successfully in 32 comparable patients (group B) with severing of the round ligament, ovarian ligament, or infundibulopelvic ligament, and preparation of the bladder flap in the laparoscopic phase, and severing of uterine vessels and cardinal-uterosacral ligament complex through the vagina. Average blood loss was 169.8 and 308.7 ml in groups A and B, respectively (p <0.05); average operating time was 126.4 and 152.8 minutes, respectively (p <0.05); hemoglobin decreased on average 0.9 and 1.7 g/100 ml, respectively (p <0.05). Conclusion LBCUV and laparoscopic supracervical amputation followed by trachelectomy reduce operating time and blood loss in LAVH, and allow conversion of many abdominal procedures to laparoscopy.

Adjuvant high dose rate vaginal brachytherapy as treatment of stage I and II endometrial carcinoma

OBJECTIVE: To evaluate the efficacy of high dose rate vaginal brachytherapy in the treatment of International Federation of Gynecology and Obstetrics stage IB, IC, and II endometrial carcinoma after surgical staging and complete lymphadenectomy.METHODS: All patients with stage IB, IC, or II adenocarcinoma or adenosquamous carcinoma of the endometrium who received postoperative high dose rate vaginal brachytherapy at our institution between June 1, 1989, and June 1, 1999, were eligible. High dose rate vaginal brachytherapy was delivered in three fractions of 700 cGy. Retrospective chart review was performed. Kaplan-Meier estimates were calculated for disease-free and overall survival.RESULTS: One hundred sixty-four women were identified. Fifty-six percent had stage IB disease, 30% had stage IC disease, and 14% had stage II disease. Approximately one third of patients had high-grade lesions and nearly 40% had deep myometrial invasion. Median follow-up was 65 months (range 6–142 months). To date, 14 patients have had recurrence; 2 at the vaginal apex, 9 at distant sites, 1 at the pelvic sidewall, 1 simultaneously in the pelvis and at a distant site, and 1 at an unknown site. Both patients with vaginal apex recurrences had salvage therapy and are now free of disease. The overall 5-year survival and disease-free survival rates were 87% and 90%, respectively. There were no Radiation Therapy Oncology Group grade 3 or 4 toxicities. High dose rate vaginal brachytherapy was approximately $1,000 less expensive than external-beam whole-pelvic radiation.CONCLUSIONS: Adjuvant high dose rate vaginal brachytherapy in thoroughly staged patients with intermediate-risk endometrial carcinoma provides excellent overall and disease-free survival with less toxicity and at less cost compared with whole-pelvic radiation.

A Randomized Controlled Trial Comparing Three Invitation Strategies in a Breast Cancer Screening Program

Background. The objective of this study was to compare the response received by a population-based breast cancer screening program, according to three different invitation strategies: letters sent by mail from the program (program group), letters sent by mail from the Primary Health Care Team (PHT group), and direct contact through a trained professional (direct contact group).Methods. We used a cluster-randomized controlled trial with assignment to invitation group using home address. Nine hundred eighty-six women of Barcelona (Spain), ages 50 to 64 years, were invited to participate in the program. The main outcome used was the response rate after the first invitation.Results. Five hundred sixty-four women accepted the invitation (57.2%). The highest response rate was achieved in the direct contact group (63.5%), followed by the PHT group (55.6%), the program group being the one that attained the lowest response rate (52.1%). The direct contact group had a higher probability of participating than the PHT group (RR = 1.14, P = 0.037) or the program group (RR = 1.22, P = 0.003). The response rate in the direct contact group was 72.1% when the letter was received by the subject herself. The increase in response occurred particularly among women of lower educational level.Conclusions. Inviting women to participate in a breast cancer screening program through direct contact by trained personnel increased participation rate compared with mailed-letter methods. The positive effect appeared restricted to women with lower educational levels.

Self-reported zidovudine adherence among pregnant women with human immunodeficiency virus infection in four US states

Objective: Our purpose was to identify clinical and psychosocial factors associated with rates of prenatal zidovudine use and adherence among human immunodeficiency virus–infected pregnant women. Study Design: Two hundred sixty-four women completed 2 interviews between October 1996 and November 1998 at prenatal clinics in Miami, Florida; Brooklyn, New York; Connecticut; and North Carolina. Interviews took place after 24 weeks’ gestation and then between 32 weeks and delivery. Results: Prenatal zidovudine had been prescribed for 94% of the women, 37% of whom received monotherapy. Among women taking zidovudine, 20% reported incomplete adherence. In multivariate analyses having missed zidovudine doses was positively associated with prenatal illicit drug use (odds ratio, 3.49; 95% confidence interval, 1.30-9.42; P < .05) and missing prenatal vitamins (odds ratio, 2.71; 95% confidence interval, 1.30-5.67; P < .01). Conclusions: Zidovudine therapies have been successfully implemented in prenatal care settings in the United States. The success of these therapies may be limited among some patients by incomplete regimen adherence, particularly among illicit drug users. (Am J Obstet Gynecol 2001;184:1235-40.)

Value of the serum estradiol level on the day of human chorionic gonadotropin injection and on the day after in predicting the outcome in natural in vitro fertilization/intracytoplasmic sperm injection cycles

Objective: To predict the risk of premature ovulation and possibility of pregnancy in natural IVF/ICSI cycles on the basis of the estradiol (E 2) level on the day of hCG injection and on the day after. Design: A prospective study. Setting: Hospital research program. Patient(s): One hundred sixty-four women undergoing 305 IVF/ICSI natural cycles. Intervention(s): Serum E 2 levels were measured ∼12 h before (day 0) and 12–17 h after hCG administration (day 1). Main Outcome Measure(s): E 2 levels on day 0 and day 1, the ratio of the day 1 to day 0 levels, and cycle outcome. Result(s): In cycles with premature ovulation and in conception cycles, the average E 2 level on day 0 was statistically significantly higher than in other cycles, whereas the E 2 ratio was statistically significantly lower. Multiple logistic regression was used to determine the connection of the E 2 level on day 0 (B0 = −0.742, B = 2.147, P = .01) and the E 2 ratio (B0 = −0.742, B = −3.135, P<.001) with premature ovulation. Only the E 2 ratio (B0 = 0.659, B = −2.209, P = .0068) was significantly connected with conception. Conclusion(s): In predicting the outcome of natural IVF/ICSI cycles, the importance lies not in the E 2 level on the day of hCG administration or on the day after, but rather in the E 2 ratio. (Fertil Steril ® 2001; 75:000–00. © by American Society for Reproductive Medicine.)

Risk factors for cervical stenosis after loop electrocautery excision procedure

Objective: To assess frequency of and identify risk factors for the development of cervical stenosis after loop electrosurgical excision procedure. Methods: We reviewed outpatient charts of women treated by loop excision for cervical dysplasia between August 1996 and January 1998 in the colposcopy clinic at Massachusetts General Hospital. One hundred sixty-four women were evaluated for cervical stenosis during follow-up. Stenosis was considered present if manual dilation was required to allow endocervical sampling with an endocervical currette 3 mm wide. Multivariable analysis with stepwise logistic regression was used to evaluate age, parity, tobacco use, hormonal status, use of oral contraceptives, pathology, previous loop excision, performance of additional endocervical excision, and dimensions of excision specimens as predictors of cervical stenosis. Results: The average age was 32 years. Cervical stenosis occurred in ten of 164 women (6%, 95% CI 3%, 11%). Among factors analyzed, previous loop excision and volume of excision specimen were the only independent predictors of stenosis. Conclusion: Cervical stenosis correlated with history of loop excision and volume of tissue removed, suggesting that women who have second excisions or large excisions should be counseled that their risk of stenosis might be higher.

Long term follow-up of women treated with 16-week, dose-intensive adjuvant chemotherapy for high risk breast carcinoma

A Phase II study was performed evaluating the disease free and overall survival rates associated with a dose-intensive, 16-week, doxorubicin-based adjuvant chemotherapy regimen in women with breast carcinoma and > or = 10 involved axillary lymph nodes. Eligible patients underwent staging with computed tomography and bone scanning and were treated with a 16-week, dose-intensive chemotherapy regimen, comprised of 8 2-week courses of cyclophosphamide, 100 mg/m2 orally, on Days 1-7; doxorubicin, 40 mg/m2 intravenously (i.v.), on Day 1; methotrexate, 100 mg/m2 i.v., on Day 1 with leucovorin rescue, 10 mg/m2, every 6 hours for 6 doses orally on Day 2; vincristine, 1 mg i.v. on Day 1; 5-fluorouracil (5-FU), 600 mg/m2 i.v., on Day 2 over 2 hours; and 5-FU, 300 mg/m2/day continuous i.v. on Days 8 and 9. Tamoxifen, 20 mg daily, was administered to patients with estrogen receptor positive tumors treated after October 1988. All patients were offered locoregional radiation therapy. Sixty-four women were treated on protocol. The median follow-up of 27 surviving patients was > 8 years at last follow-up. Three patients were lost to follow-up. The median time to progression was 54 months, the Kaplan-Meier estimate of event free survival at 5 years was 44% (95% confidence interval [CI], 31-56%), and the Kaplan-Meier estimate of overall survival at 5 years was 57% (95% CI, 44-69%). At 98 months the Kaplan-Meier estimate of freedom from recurrence was 31% (95% CI, 19-43%) and the Kaplan-Meier estimate of survival at 111 months was 36% (95% CI, 23-49%). Despite the use of dose-intensive, doxorubicin-based, adjuvant chemotherapy, and intensive staging prior to study entry, the results of the current study are similar to those of previous reports for standard dose chemotherapy and appear inferior to those reported for high dose therapy.

Is epidural anesthesia in labor associated with chronic low back pain? A prospective cohort study.

The association between epidural anesthesia during labor and subsequent postpartum low back pain remains unclear. The objective of this follow-up cohort study was to determine whether epidural anesthesia was associated with chronic back pain 1 yr after delivery. We contacted 329 women by telephone and asked them to complete a standardized questionnaire 1 yr (+/-1 mo) after delivery. One hundred sixty-four women had received epidural analgesia for labor and delivery, and 165 had not. Subjects were asked to quantify their back pain (yes/no, numeric rating score, and interference with daily activities). Differences between the two groups were tested by using the chi2 test and the Mann-Whitney U-test, and logistic regression was used to control for confounding variables. The response rate was 244 of 329 (74%). Responders and nonresponders were similar in their demographic and clinical characteristics. There was no difference in the prevalence of back pain between women who had received epidural anesthesia (12 of 121, 10%) and those who had not (17 of 123, 14%). The adjusted relative risk of low back pain at 1 yr (epidural versus nonepidural) was 0.63 (95% confidence interval 0.25, 1.56). There were also no differences between the two groups on numeric rating scores or level of interference with activities. This prospective follow-up study demonstrated no association between epidural anesthesia for labor and delivery and chronic back pain 1 yr after delivery. We evaluated the presence of low back pain 1 yr after delivery in two groups of women-those who chose epidural analgesia for labor and those who did not. There was no increased risk of back pain in women who had used epidural analgesia. This finding is consistent with those of other North American studies.

Is Epidural Anesthesia in Labor Associated with Chronic Low Back Pain? A Prospective Cohort Study

The association between epidural anesthesia during labor and subsequent postpartum low back pain remains unclear.The objective of this follow-up cohort study was to determine whether epidural anesthesia was associated with chronic back pain 1 yr after delivery. We contacted 329 women by telephone and asked them to complete a standardized questionnaire 1 yr (+/- 1 mo) after delivery. One hundred sixty-four women had received epidural analgesia for labor and delivery, and 165 had not. Subjects were asked to quantify their back pain (yes/no, numeric rating score, and interference with daily activities). Differences between the two groups were tested by using the chi squared test and the Mann-Whitney U-test, and logistic regression was used to control for confounding variables. The response rate was 244 of 329 (74%). Responders and nonresponders were similar in their demographic and clinical characteristics. There was no difference in the prevalence of back pain between women who had received epidural anesthesia (12 of 121, 10%) and those who had not (17 of 123, 14%). The adjusted relative risk of low back pain at 1 yr (epidural versus nonepidural) was 0.63 (95% confidence interval 0.25, 1.56). There were also no differences between the two groups on numeric rating scores or level of interference with activities. This prospective follow-up study demonstrated no association between epidural anesthesia for labor and delivery and chronic back pain 1 yr after delivery. Implications: We evaluated the presence of low back pain 1 yr after delivery in two groups of women-those who chose epidural analgesia for labor and those who did not. There was no increased risk of back pain in women who had used epidural analgesia. This finding is consistent with those of other North American studies. (Anesth Analg 1997;85:1066-70)

One- versus two-layer closure of a low transverse cesarean: The next pregnancy

To determine whether a low transverse cesarean closure method in one or two layers affects subsequent pregnancy outcome. In a prospective trial reported previously, 906 women were assigned randomly to either one- or two-layer uterine closure. One hundred sixty-four women had a subsequent pregnancy and delivery (18 weeks' gestation or longer) at our institution. Maternal and neonatal outcomes were ascertained by medical chart review and compared between the one- and two-layer closure groups. Of the 164 subsequent deliveries, 83 had previous closure in one layer, whereas 81 had involved a two-layer closure. The demographic characteristics of these two groups were similar. Nineteen women (12%) underwent elective repeat cesareans without labor, and the remaining 145 experienced labor. Length of labor, mode of delivery, duration of hospital stay, gestation at delivery, and the incidences of uterine scar dehiscence, chorioamnionitis, postpartum metritis, hemorrhage, transfusion, and abnormal placentation did not differ significantly between the groups. Selected neonatal outcomes, including Apgar scores, cord pH, birth weight, and perinatal death, were similar between groups as well. These findings suggest that the type of low transverse cesarean closure does not significantly affect the outcome of the next pregnancy.

Women's Career Aspirations and Achievements

This report describes the educational, occupational, and familial behavior a panel of sixty-four women exhibited during the first seven yearsfollowing their college gradua tion. Their career patterns are compared with the aspirations they held as seniors in college. The findings reveal high consistency between senior aspirations and actual behavior on some items, e.g., mariage and graduate school, but less consistency on others, including occupational choice. Generally the women worked more often and had children less frequently than they had anticipated. The actual life style patterns of these women and their aspirations for the future result from the fact that women pursue a contingency strategy in organizing their adult lives.