Diaa M. El-Mowafi, MD

Department         of Obstetrics and Gynecology, Benha Faculty of Medicine

Correspond Author: Diaa El-Mowafi,M.D. 4 Ghazza St.,         El-Hossania, El-Mansoura 35111, Egypt. Tel. +2-050-363308 Fax         +2-050-332771

Transperineal and transabdominal sonography were done         for 180 patients attending Benha University Hospitals at 28-40 weeks         gestational age with an antepartum hemorrhage in the period between         July, 1995 and October, 1996.

Transabdomianl sonograms (TAS) were not conclusive         for detection or exclusion of placenta praevia (PP) in 128 patients         (71.1%) due to unsatisfactory visualization of the cervix. Four patients         of those were found to have PP during delivery. The remaining 52         patients (28.9%) were diagnosed by (TAS) as having PP which confirmed at         delivery.

Transperineal sonography (TPS) successfully         visualized the internal surface of the cervix in all our 180 patients,         allowing exclusion of PP in 122 cases (67.8%), none of them showed         evidence of PP at delivery. TPS showed PP in 58 patients (32.2%), where         it was confirmed in 56 patients only at delivery. TAS showed 92.8%         sensitivity, 94.3% specificity, 88.1% positive predictive value,96.6%         negative predictive value, with an overall accuracy of 93.8%. TPS showed         98.5% sensitivity, 97.5% specificity, 94.8% positive predictive value,         99.1% negative predictive value with an overall accuracy of 97.7%. 

Although sonography is the method of choice for         evaluating patients with antepartum hemorrhage, still it gives false         positive results due to distortion of the lower uterine segment by         uterine contraction, an over distended urinary bladder or the presence         of subchorionic hematoma overlying the cervix simulating placental         tissue ( Bowie et al., 1978, Artis et al., 1985, Townsend et al., 1986         and Gallagher et al., 1987). To avoid false positive interpretation,         both the lower edge of the placenta and the cervix must be visualized         (Barbara et al., 1992).

Although TAS is usually successful in depicting the         cervix during the first and second trimester of pregnancy, an additional         technique is needed to complement TAS during the third trimester ( Brown         et al., 1986). Techniques had been developed to evaluate the presenting         part of the foots from the pelvis but this can be uncomfortable for the         patient and are often unsuccessful late in the third trimester ( Jeffry         and Laing, 1981).

Another approach was to use endovaginal sonography.         Initial studies were promising, but endovaginal probe must be inserted         and adjusted cautiously to avoid evoking an attack of bleeding in a         patient with possible PP (Robert et al., 1990). TPS seems to be more         convenient and possibly safer in imaging the cervix and lower uterine         segment as vaginal penetration is avoided (Barbara et al., 1991).

This study was carried out on 200 patients attending         with antepartum hemorrhage in the maternity clinic or emergency         department in Benha University Hospitals. Twenty patients were missed         during follow up and/or labor, so they have been excluded from the study         and 180 patients were included in the results.

All patients were subjected to complete history         taking, full general and abdominal examination. TAS and TPS were done         for every patient using 3.5 MHz mechanical sector real-time scanner (Aloka,         SSD 720 - Japan).

The examination was performed while the mother in the         supine position with her urinary bladder partially filled so as not to         distort the configuration of the cervix or lower uterine segment.

The gestational age was determined by measurement of         the biparietal diameter (BPD) and femur length (FL) according to the         criteria described by Handlock (1990).

The placenta was localized and considered praevia if         placental tissue was overlying any part of the cervix. It is complete PP         if placental tissues are covering the entire surface of the internal os,         marginal when covering part of the cervix without encroaching on the         internal os and partial when covering a portion of the internal os         without covering the entire os. The last two grades were grouped         together in data analysis as they are difficult to distinguish from each         other by sonography. TAS was considered inadequate to exclude PP if the         inferior edge of the placenta could not be imaged or the cervix could         not be visualized.

Abruptio placenta was diagnosed if there is placental         infarction, marginal necrosis or retroplacental blood clot as described         by Nyberg et al., (1987).

Ultrasound gel was placed on the head of the same         abdominal transducer. A disposable condom was used as a protective         covering applied to the transducer head secured with a rubber band and         an ultrasound gel was applied to the other surface of to the protective         covering. The examination was carried out while the patient lied supine         with the thighs abducted sufficiently to allow placement and lateral         angulation of the transducer. The transducer was placed directly over         the perineum in a sagital orientation between the labia majora, usually         directly over the labia minora, but occasionally between them. The         center of the transducer was located posterior to the urethra and         anterior to the vagina (Fig. 1). When the cervix and lower uterine         segment were visualized, the transducer was slowly angled medially and         laterally to image the entire internal surface of the cervix. Criteria         for diagnosis of PP were the same as in transabdominal scanning.

PP was excluded if at least one of the following was         present:

(1) The lower edge of the placenta seen separate from         the cervix.

(2) Amniotic fluid between the presenting part and         the cervix without interposed placental tissue.

(3) The presenting part immediately overlying the         cervix without intervening placental tissue.

One hundred and fifteen cases were delivered at 36-40         weeks gestation either by cesarean section (48) or by normal vaginal         delivery (67). The indication for caesarian section was severe attack of         vaginal bleeding either because of PP (40) or abruptio placentae (8)         cases. The other 65 patients were followed up by conservative management         and repeated ultrasonography till delivery. Sixteen of those patients         were delivered by cesarean section and 49 by vaginal delivery. The         indication for cesarean section was PP. Absence of PP was confirmed at         delivery by absence of placental tissue overlying the cervix at cesarean         section or if successful vaginal delivery was accomplished without         abnormal vaginal bleeding attributable to PP ( Barbara et al., 1992).

The study included 180 patients of mean age 28± 4.2         (S.D) years and of mean gestational age 36.8± 5.5 (S.D.) weeks.         Fifty-six patients had PP (G

) while the remaining 124         patients had no PP at delivery (G

). Data analysis of the         later group revealed that 68 patients had abruptio placentae diagnosed         by TAS only as TPS has afield limited to the lower uterine segment,         cervix and vagina. Eight patients had a local cause of bleeding detected         by speculum examination after exclusion of PP, while in 47 patients no         definite cause of bleeding could be identified. 

         shows no significant difference in the clinical criteria of both groups         (G

TPS successfully depicted the internal surface of the         cervix in all our 180 patients, allowing determination of the presence         or absence of overlying placental tissue. While TAS was inconclusive for         PP in 128 patients (71.1%), because the cervix was obscured by the         presenting part of the foots. The difference between the two methods in         visualization of the internal surface of the cervix was statistically         very highly significant (P<0.001) (

The inferior edge of the placenta was seen in 164         patients (91.1%) by TAS versus 57 patients (31.6%) by TPS. The         difference was statistically highly significant (P<0.01) (

TPS excluded PP in 122 patients (67.6%) and showed it         in the remaining 58 patients (32.3%) (

). The         exclusion of PP was based upon : (1) No intervening placental tissue         between the presenting part and the cervix in 69 patients (56.5%). (5)         Visualization of amniotic fluid between the presenting part and the         cervix without interposed placental tissues in 53 patients (43.5%).         Delivery records confirmed the absence of PP in the all-122 patients.

Twenty-nine of the 58 patients in whom TPS showed PP         had complete PP and 29 had marginal partial PP. There was no significant         difference (P>0.05) between delivery outcome and TPS diagnosis of PP         (

TAS was suggestive of PP in 59 patients, 33 (18.3%)         of them had a complete PP and 26 (14.4) had marginal or partial PP.         There was no significant difference (P>0.05) between delivery outcome         and TAS diagnosis (

The overall accuracy of TPS was 97.7% versus 93.8%         for TAS (

Sonography for patients with third trimester vaginal         bleeding requires sufficient visualization of both the inferior edge of         the placenta and the cervix to exclude or verify PP as a cause of such         bleeding ( Barbara et al,. 1992). In this study, the internal surface of         the cervix was clearly visualized in all cases (100%) by the perineal         approach while it was seen in only 20% (36/180) of cases by the         abdominal approach. Many authors agree with these results (Barbara et         al., 1991, Barbara et al., 1992 and Ricky et al., 1995 ). Although         Barbara et al., (1991), reported a potential difficulty with TPS that is         the presence of rectal gas obscuring the region of the internal os.         However, this dose not pose a significant problem when evaluating our         patients because it is the internal surface of the cervix which is         important when imaging is looking for overlying placental tissue.

In our study, the inferior edge of the placenta was         visualized in 91% of cases using transabdominal technique, while it is         visualized in 31.6% only by transperineal approach. These agree with the         results of Barbara et al., (1992). Their explanation was that the lower         edge of the placenta is usually beyond the field of view of         transperineal approach.

Dietz et al., (1991), described a comparison between         TAS and TPS for localization of low-lying placenta. They found         significant (P<0.001) discrepancies between the two methods. Perineal         scanning showed a higher rate of diagnosis (32%) than abdominal scanning         (11%). They explained this difference by the influence of bladder         distention with the use of abdominal scanning. An analysis of pregnancy         outcome in their results yielded a positive predictive value of 78% with         abdominal ultra sound and 86% with perineal ultrasound. Our study showed         higher rates of accuracy with positive predictive value of 88.1% for         abdominal ultrasound and 94.8% for transperineal scanning. This may be         attributed to the fact that Dietz and his colleagues used a fall bladder         technique with abdominal scanning and the patients were examined during         the second and third trimesters.

Zilianti et al., (1991) described transperineal         sonographic findings in a variety of clinical conditions, only 20 of         their 184 patients were examined for possible PP. In addition, the         authors did not attempt to evaluate the various grades of PP as our         study did. In spite of that, we agreed with their conclusion in that TPS         is useful in evaluation of possible PP.

TPS is a safe, accurate and rapid technique to         complement TAS for evaluation of patients with third trimester bleeding.         It has patient’s acceptance and tolerance, without the need for         vaginal penetration or manipulation of the cervix, which is very         important in such cases.

This technique is important in obstetric practice and         needs further study to validate its potential application in other         obstetric problems as premature rupture of membranes, cord presentation         and cervical incompetence.

Clinical Criteria of         Placenta Praevia Group (G

Articles

Transperineal and transabdominal sonography were done for 180 patients attending Benha University Hospitals at 28-40 weeks gestational age with an antepartum hemorrhage in the period between July, 1995 and October, 1996.

Placental Localization by Transperineal Sonography in Antepartum Hemorrhage

 To evaluate the laparoscopically assisted vaginal  hysterectomy (LAVH) in terms of indications, uterine size that can be  operated upon, surgical     procedures and their safety, intraoperative complications and blood  loss, operative time,     concomitant surgical procedures, postoperative period and  complications, and average total cost.
 
     

 A total of 136 patients underwent LAVH between November 1996 and November 1997 at Hutzel Hospital, Detroit Medical Center,     Wayne State University, Michigan, USA.
 
     

 The mean age of our patients was 45.8± 0.7 years (range,  30-59). Thirty-one patients (22.8%) had previous abdomino-pelvic  surgery. The most common     indication for LAVH and postoperative pathological finding were  myoma(s). The mean length of the removed uteri was 11.8± 0.4 cm (range,  5.6-14). Their mean     weight was 235± 8 gm (range, 59-560). The bipolar cautery was used  in 96 cases (71%), Endo GIA alone in 4 cases (3%), and both in 36 cases  (26%). There     was no significant difference between these three modalities in  terms of operative time, estimated blood loss, intraoperative and  postoperative complications. The     mean estimated blood loss was 149± 7 ml (range, 75-750). The mean  operative time was 150± 4 min (range, 60-215). Interaoperative  complications included one     case of bladder injury due to thick adhesions, two cases of inferior  epigastric vessels injuries that were easily repaired. Two cases had to  be switched from     laparoscopic to laparotomy procedure due to bleeding from the  uterine artery in one case and from the infundibulopelvic ligament in  the other. No blood transfusion     was indicated in any of our patients. Postoperative complications  included two cases of cystitis, four cases of ileus, one case of pelvic  infection, and one case of     pelvic abscess. All our patients had a hospital stay of 1-2 days.  The estimated average total cost of LAVH was $ 7,500.
 
     

 LAVH is a true advance in gynecological surgery enables  the surgeon to convert most of the abdominal hysterectomies into vaginal  ones and hence
 decreases morbidity, postoperative pain and complications.
 
     


 
 Hysterectomy is one of the most common gynecological surgical  procedures. The advantages of vaginal hysterectomy include no visible  scar, less postoperative pain,     reduced postoperative complications, shorter hospitalization, and  more rapid recovery.1-3 In spite of these advantages, vaginal  hysterectomy accounts only for 30%     of hysterectomies due to many restrictions. These restrictions are  absolute or relative contraindications include significant uterine  enlargement, fixation of the uterus by     adhesions, previous pelvic surgery, endometriosis, restricted  uterine mobility, and adnexael pathology.2,4 In fact, most of these  contraindications depend upon     surgeon’s experience.
 
 The main aim of laparoscopically assisted vaginal hysterectomy (LAVH) is  to enable the surgeon to overcome as many as possible from these  contraindications, and     hence converting most of the abdominal hysterectomies into vaginal  ones.
 
     


 
 This study included 136 patients who underwent LAVH in the period  between November 1996 and November 1997 at Hutzel Hospital, Detroit  Medical Center,     Wayne State University, Michigan, USA. The inclusion criteria for  our patients were indications for abdominal hysterectomy such as  symptomatic liomyoma(s), abnormal uterine bleeding, pelvic pain,     endometriosis, endometrial hyperplasia, ovarian cyst, and/or  cervical intraepithelial neoplasm. The exclusion criteria for our study  were a uterine size ³ 16 weeks and     patients who are candidates for vaginal hysterectomy i.e. having  uterine prolapsed.
 
 The LAVH procedure, with its advantages and possible complications, was  explained to the patient in the office before deciding on surgery.  Videotapes were usually     used to facilitate this. The other alternative procedures were also  discussed with her. Patients who chose the option of LAVH were admitted  on the morning of     surgery and signed her informed consent. As a routine, every patient  received 2gm cefotenan IV, 1-2 h before the operation or 100 mg  Vibramycin if she is allergic     to cefotenan. No other antibiotics were given either intra- or  postoperatively unless indicated. Under general endotracheal anesthesia,  the patient was prepared and     draped in the normal sterile fashion in the dorsal lithotomy  position. A Foley catheter was placed into the bladder. Patient was  examined under anesthesia to verify     the pre-recorded clinical data. Mobilization of the uterus during  surgery was accomplished by one of three methods. 

The first method was to grasp the cervix with     two single-toothed tenaculum at twelve and six o’clock and joined by  sterile rubber bands to a uterine sound placed inside the uterus. The  second method is by using     HUMI cannula. The third method was utilizing the Rumi & Koh  colpotomizer. 

An infraumbilical vertical skin incision or curve-linear (in  patients with previous     curve-linear laparoscopic incision) was made with a number 11 knife.  Verres needle was inserted through this incision. Its intraperitoneal  placement is verified by     suction with a plastic syringe and negative suction of saline drop  when instilled in its outer tip. Carbon dioxide gas was used to obtain  pneumoperitoneum, after which     Verres needle was removed and a 10-mm reusable or disposable trocar  was inserted after enlarging the incision to accommodate it. The  secondary 5-mm punctures     were made as one suprapubic and the other two in both iliac fossae  or in both hypochondria regions if the uterus is more than 12 weeks  size. 

Placement of secondary trocars were done under direct  visualization of the laparoscope after transabdominal illumination to  guard against injury of the anterior abdominal wall     vessels particularly the inferior epigastric artery. Thorough  exploration was performed for the abdominal and pelvic viscera including  appendix, bowel, liver, gall     bladder, diaphragm, in addition to genital organs. 

Special attention was made to the course of the ureters before  starting any surgical procedure and throughout its     performance. If there were adhesions, lysis was done using unipolar  scissors or bipolar coagulation followed by scissors for thick  adhesions. The thin filmy avascular     adhesions could be cut without electrocautery. Using Kleppinger  bipolar forceps, the round ligaments were coagulated about 1-1.5 cm from  the uterine cornua then     cut by unipolar scissors. For cutting of the infundibulopelvic and  broad ligaments either bipolar followed by unipolar cautery, Endo GIA 30  (United States Surgical     Corp., Norwalk, Connecticut) or both were used. If the ovary was to  be preserved, the proximal part of the ovarian ligament, fallopian tube  and mesosalpinx were     desiccated on both sides down to the vesicouterine space. 

At this point, the bladder was filled with 250 ml of sterile  indigocarmine through the Foley catheter, which     is then clamped. This facilitates identification and desiccation of  the bladder as well as recognition of any accidental injury to it at  once. The bladder was grasped and     raised up during the incision of the vesicouterine peritoneum at its  reflection between the bladder and uterus. The bladder pillars were  coagulated by the bipolar     forceps then cut by scissors. The bladder was sharply dissected away  from the uterus using unipolar cautery scissors. The remainder of the  broad ligament was taken     down. Uterine arteries were skeletonized on both sides, cauterized  and transected. If this step was found to be an inaccessible one,  uterine vessels were ligated and     transected during the vaginal portion of the procedure as in usual  vaginal hysterectomy.
 
 With the use of the Rumi & Koh colpotomizer, it was easy to do  colpotomy during the laparoscopic portion of the procedure through the  abdomen. The visualization     of the blue plastic cup of the device indicated the accomplishment  of the colpotomy. This step was done with unipolar scissors. This makes  the use of Rumi & Koh     colpotomizer preferred from the technical standpoint. 
 
 After inspecting all the pedicles and ensuring good hemostasis, the  instruments except the trocars were removed from the abdomen. Attention  was now made to the     vaginal portion of the procedure.
 
 A circumferential incision was made around the cervix at the reflection  of the vagina with the Bovie electrocautery. The uterosacral and the  remainder of the cardinal     ligaments were clamped, bisected and ligated with 00 vicryl stitches  that left long to be attached later into the vaginal vault. The uterus  was then delivered as usual but     for bigger uteri, reduction of their size was carried out by making  an incision around the entire cervix and specimen was removed by  morcellation. Sometimes with
 delivering big myomas first, the remainder of the uterus came out  easily. The vagina was closed with 00 vicryl in a transverse manner with  attachment of the     uterosacral and cardinal ligaments stitches into it.
 
 Attention was turned again to the laparoscopy to ensure the final view  after completion of the procedure and guarantee complete hemostasis.  After evacuation of the     pneumoperitoneum, abdominal incisions were closed with  000-subcuticular vicryl. Incisions larger than 5 mm were closed first  with Corson-Thompson fascia closure     device.
 
 Patients were receiving two doses of 10 mg morphine IV, 8 h apart as a  postoperative analgesic, then continued with non-steroidal  anti-inflammatory agent as     Ibuprofen 400 mg t.d.s. When the patient was discharged, she was  instructed to avoid sexual intercourse for 4 weeks and to come for  follow up visit one week     postoperative unless she develops fever, persistent or increasing  pain, or vomiting. She was allowed to drive one week and to go back to  work two weeks after the     operation.
 
     


 
 The age range of our patients was 30-59 years, with a mean of 45.8± 0.7.  Thirty-one patients (22.8%) had undergone previous abdomino-pelvic  surgery. The most     common indication for LAVH in our patients, according to the  preoperative diagnosis, was fibroid uterus     (

). All specimens were sent as a routine for     pathological examination. The most common pathological finding was myoma(s)     (

).
 
 The mean estimated blood loss during operation as determined by the  anesthesiologist was 149± 7 ml (range, 75-750). The accurate blood loss  was calculated by     subtracting the volume of the irrigation fluid from the total amount  of the fluid in the suction apparatus. The mean operative time as  estimated by the anesthesiologist     was 150± 4 min ( range, 60-215 ). The time was shorter with getting  more experience with the procedure. The operations were done in a  teaching hospital allowing
 the residents and clinical fellows to observe, assisting, and actively  participating in the procedure under complete supervision of the  surgeon. This is, in fact,     prolonged the operative time to some extent.
 
 The bipolar cautery was used in 96 cases (71%), Endo GIA alone in 4  cases (3%), and both in 36 cases (26%). There was no significant  difference between these     three modalities in terms of the operative time, estimated blood  loss, intraoperative or postoperative complications.
 
 The mean length of the removed uteri was 11.8± 0.4 cm (range, 5.6-14).  The mean weight of the removed uteri, as estimated by the pathologist,  was 235± 8 gm     (range, 59-560).
 
 Intraoperative complications included one case of bladder perforation  due to thick dense adhesions to the lower uterine segment after two  previous cesarean     sections. It was easily repaired during the vaginal part of the  procedure. Two cases of accidental injury to the inferior epigastric  vessels were easily repaired by     Corson-Thompson fascia closure device. Two cases had to be switched  from laparoscopic to laparotomy procedure due to bleeding from the  uterine artery, in one     case, and from the infundibulopelvic ligament in the other case. No  blood transfusion was indicated in any of our patients.
 
 The cases of cystitis and pelvic infection were treated successfully  with antibiotics, while the pelvic abscess was evacuated and drained by a  second laparoscopic     procedure.
 
 All our patients had a hospital stay for 1-2 days. The estimated average  total cost of LAVH in our cases was $7,500. This is less than the cost  of abdominal     hysterectomy in the same hospital ($11,000).
 
     


 
 In spite of the dramatic increase of LAVH procedure since its first  description in 1989,5 its value remained controversial.6, 7,8 Advocates  encourage LAVH as a     procedure for conversion of abdominal hysterectomy into a vaginal  one. Indeed vaginal hysterectomy entails fewer complications, shortened  hospital stay, more     rapid recovery and return to normal activity. This is in addition to  the better cosmetic appearance of the laparoscopic scar if compared to  the laparotomy scar.     However, critics point out that LAVH requires longer operative time  and is more expensive.
 
 Our results showed that LAVH could be done in a wide variety of  indicated cases of hysterectomy. The indications were almost the same as  shown by other     surgeons.9,10,11 The pathological reports of the removed specimens  were confirmatory to our preoperative diagnosis. Reports added other  diagnoses that are     difficult to be diagnosed clinically such as adenomyosis,  endometriosis, endometrial hyperplasia, cervical intraepithelial  neoplasm, chronic cervicitis, and the nature of     the ovarian neoplasm.
 
 The concomitant surgical procedures that were done with our LAVHs didn’t  prolong the operative time except in cases of vaginal repair. The same  was noticed by     other surgeon.9,11 The average intraoperative blood loss of 150 ml  in our cases is fairly comparable to the 135 ml that reported in other  study,9 and still much lower     than the 390 ml that reported by another study.12 Our mean operative  time of 150 min is more than that reported by other studies (118 and  119.4 min) 13, 14 but our     study entailed a teaching and training goal for the residents and  clinical fellows which was not aimed in the other studies. The post  operative complication rate in our     study was 5.9% which is significantly lower than the 8.6% reported  by one study14, and the 22% reported by another study10 ( P< 0.0001  ). The average total     LAVH cost of $7,500 to our patients was significantly lower than  that reported by other studies.15 This may be attributed to the limited  use of disposable instruments     and the use of bipolar cautery in most of our cases instead of  sutures or Endo GIA that are more expensive.
 
     


 
 LAVH is a true advance in gynecological surgery that decreases  morbidity, postoperative pain and complications by converting most of  the abdominal     hysterectomies into vaginal ones. The short hospital stay, the rapid  return to work and normal activity, and the decrease in the cost of  treating complications, may     compensate for the claimed high cost of LAVH.

Table 1 Preoperative Diagnosis and Indications for Surgery 

The total number exceeds our patients number as most of the patients had more than one indication for surgery.

Table 2 Pathological Diagnosis for the Specimens

Cervical intraepithelial neoplasm (CIN I)

Cervical intraepithelial neoplasm (CIN II)

Cervical intraepithelial neoplasm (CIN III)

The total number exceeds our patients number as most of the patients had more than one pathological finding.

Table 3 Concomitant Surgical Procedures done with LAVH

More than one concomitant surgical procedure was done to some patients.

Table 4 The Encountered Postoperative Complications

Objective: To evaluate the laparoscopically assisted vaginal hysterectomy (LAVH) in terms of indications, uterine size that can be operated upon, surgical procedures and their safety, intraoperative complications and blood loss, operative time, concomitant surgical procedures, postoperative period and complications, and average total cost.

Diaa M. El-Mowafi, MD

Articles

Placental Localization by Transperineal Sonography in Antepartum Hemorrhage

Laparoscopically Assisted Vaginal Hysterectomy: A Gimmick or An Advance?