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Final journal vol.1 no.1 2012

Journal of Rashid Latif Medical College 1 (2012) 4-7 Original
Journal of Rashid Latif Medical College
j o u r n a l h o m e p a g e : w w w . j r l m c . o r g Incidence of Hysterectomy After Transcervical Resection of Endometrium- A
Five Years Audit

Talha Abdul Halim¹, Barry Gaughan², Paul Byrne² 1 Department of Obstetrics & Gynaecology, RLMC, 35 Km Ferozpur Road Lahore2 Department of Gynaecology, Beaumont Hospital, Dublin KEY WORDS:
Objective: Menorrhagia is a major debilitating condition, constituting 33% of
all gynaecological consultations. The management of heavy menstrual flow with endometrial resection is widely used. Aim of this study was to assess the long term effects of this surgical procedure on women health. Methods:
During a period of 62 months 60 women underwent Transcervical Resection
of Endometrium (TCRE) and procedure was successfully completed in 59
patients. Results: Menstrual loss was significantly decreased in 70.17%,
but only 51.66% patients were satisfied. Amenorrhea rate was 29.82%,
28.07% were hypomenorrhic, 12.08% women experienced normal flow and
29.82% found no improvement in menorrhagia. Repeat procedure was
performed in 10% of cases and hysterectomy rate was 25%. Complication
rate was 11.66%. Conclusion: Considering a high subsequent operative
treatment rate cost effectiveness of endometrial resection is questioned.
However it is an effective surgical procedure in carfully selected women with
resection in the management of abnormal uterine Menorrhagia is a significant debilitating condition which presents a major physical, financial and personal burden in today's health care . It comprises 3.1% of Patients and Methods:
general practitioner consultation and thirty three Between June 1991 and August 1996 sixty patients percent of all gynaecological consultations and this at Beaumont Hospital, Dublin were treated with proportion rises to 70% when investigating peri or post endometrial resection for abnormal uterine bleeding by menopausal women and 60% of these women will two surgeons. The age of the patients varied from 31 years to 53 years. The indication for surgery in all have a hysterectomy in the next five years , which is not patients was abnormal uterine bleeding. Most of the only associated with high operative morbidity of 25- patients were healthy and opted endometrial resection but also increased financial burdens on as an alternative to hysterectomy. In 10 ( 16.66%) hospitals. Minimally invasive surgery in the form of patients procedure was offered on medical grounds for hysteroscopic endometrial ablation, resection or uterine whom it was considered that conventional surgery may balloon therapy is indispensable in the management of be hazardous such as renal transplant (2), haemepresis abnormal uterine bleeding as these procedures appear (1) extreme obesity (4) chronic asthma (1) ischemic to be much more rapid, simpler, cause limited disability heart disease (1) and ileo-cystoplasty (1).
to the patient with shorter hospital stay and cheaper All patients were explained about the detail of the form of surgical treatment of abnormal uterine bleeding. operation, complications, failure rate and warned that Further more, it appears to be associated with sterility could not be guaranteed , simultaneously considerably fewer complications. The aim of this article laparoscopic sterilization was offered to all patients at is to assess the efficacy and safety of endometrial Correspondence to: Halim TA, Department of Obstetrics & Gynaecology, RLMC, 35 Km Ferozpur Road Lahore, Pakistan. Talha Abdul Halim¹, Barry Gaughan², Paul Byrne² risk of pregnancy and 16 (26.66%) patients were cutting and at 80-120W during coagulation on blend 1. A undergone sterilization at the time of endometrial 6mm cutting loop was used during endometrial resection and 4mm rollerball during endometrial Women with uterine size more than 12 weeks' ablation. Patients were kept overnight in hospital and pregnancy were not offered this procedure. For discharged the next day and reviewed in the out patient histological examination, endometrial specimen prior to endometrial resection was obtained either by pipple, Case notes were reviewed and all patients were dilatation and curettage or hysteroscopy. Danazol contacted by a postal questionnaire, in outpatient clinic (50%), Gonadotrophin releasing hormone analogues or on telephone; asking about menstruation, (43.33%) or medroxy progesterone (6.66%) were used dysmenorrhea, the need for further treatment and overall satisfaction; 59 patients responded. Microsoft Procedures were carried out under general Access data base programme was used to evaluate the anaesthesia and video monitoring with continuous flow resectoscope fitted with 4mm telescope and 30 fore oblique lens. 1.5% glycine was used to keep the uterine Results:
cavity distended and to maintain good visibility. A strict Endometrial resection was completed successfully record of inflow and outflow of glycine was kept by a in 59 patients. Follow up examination showed that member of the staff. The mean fluid deficit during the 29.82% had amenorrhea, 28.07 hypomenorrhea, procedure was 280ml (100-1300ml) . Valleylab, 12.28% normal flow and in 29.82% patients, no diathermy machine was pre-set at 100-120W during improvement was noticed in menstrual flow.
Table 1: Improvement in menstrual flow after the TCRE.
a. One patient had endometrial resection twice, and 08 (40%) respectively. Dysmenorrhea was not a new symptom in any patient who was dissatisfied with b. One patient remained amenorrhic for 3 years, now endometrial resection because of pain.
Although symptomatic menorrhagia was treated One patient lost to follow up and two patients had successfully in 70.17% patients, 18.51% patients were hysterectomy within 02 weeks of endometrial resection.
still unhappy either because of dysmenorrhea or Fifteen (25%) women had hysterectomy after persistence of menstruation despite improvement in previously been treated by endometrial resection. Thirty menstrual flow, so the overall satisfaction rate in our five (58.33%) patients had regular bleeding, 10 (66.67%) of them end up in hysterectomy in the follow In our study 87.93% women had more than 80% up period as compared to 25 (41.66%) women who had resection, satisfaction rate in these women was irregular bleeding and premenstrual dysmenorrhea in 56.86%, 25.49% found no change in menstrual flow and which only 05 (33.33%) had hysterectomy in the 23.52% eventually had hysterectomy as compared to subsequent period. Eleven (73.33%) hysterectomies 12.06% women who had less than 80% resection only were performed within a year after endometrial 28.57% were satisfied with the operation, 57.14 found resection. There were 06 (10%) cases of repeated no change in menorrhagia and 42.85% end up in procedures, only one (16.66%) of them was satisfied and one woman later on had hysterectomy.
Operating time was less than 30 minutes in 57 Indications for hysterectomy are given in Table III, (95%), 30-60 minute in 02 (3.33%) and 90 minutes in 01 four patients who had hysterectomy because of (1.66%) procedure. Return to normal activity was less dysmenorrhea, 03 (20%) were amenorrhic and 01 than 2 weeks in 55 (93.22%), 2-4 weeks in 02 (3.38%) and more than 06 weeks in 02 (3.38%) women. Twenty-five (41.66%) women had pre-menstrual Complications occurred in 07 (11.66%) patients and 20 (33.33%) had menstrual dysmenorrhea, the including two (3.33%) uterine perforations, one during overall improvement in dysmenorrhea was 09 (36%) cervical dilatation, procedure abandoned and second Incidence of Hysterectomy After Transcervical Resection of Endometrium- A Five Years Audit during endometrial resection, simultaneous priming agent as compared to Danazol users.
laparoscopy revealed no intra-abdominal organ injury, procedure completed under laparoscopic control. Two Dýscussýon:
(3.33%) patients developed post operative endometritis Conceptualizing the results of this study showed and there were two (3.33%) instances of post operative that endometrial resection is a simple and an effective bleeding, one patient who had auto immune procedure in the management of menorrhagia in thrombocytopenic purpra, bled heavily and did not carefully selected women. Although there was a respond on balloon tamponade and had hysterectomy significant improvement in menstrual flow in 70.17% of the next day of endometrial resection and second our patients, satisfaction rate was only 51.66% which patient had hysterectomy 10 days after the operation. One (1.66%) woman developed pulmonary embolism satisfaction in the range of 80-88%. However our results and was later on diagnosed with Anti phospho lipid are in agreement with other studies that complete syndrome. There was not a single instance of fluid resection is associated with higher success rate and patient satisfaction as compared to partial resection. Fifteen (57.69%) of GNRHa users and fifteen and Complication occurred in 11.66% of women as two (50%) of danazol and provera users respectively compared to other studies . We found no significant had amenorrhea or hypomenorrhea after endometrial difference in outcome concerning patient satisfaction resection. Adverse side effects of all these endometrial and age below or above 40 years. Although there was priming agents were within the expected pattern for improvement in pre-menstrual and menstrual these drugs. The incidence of hysterectomy was 10% dysmenorrhea in 36% and 40% patients respectively, more in women who used GNRHa as endometrial but it also become worse in 10.52% of women necessitating hysterectomy in 7.01% which is in agreement with other published data . A higher hysterectomy rate (25%) and lesser repeat procedure rate (10%) as compared to Scottish audit ( 11% and 13% respectively ) is not because of our lower threshold for hysterectomy but because of patient's own request.
Endometrial resection is a relatively safe procedure with high satisfaction rate in carefully selected women with history of heavy menstrual blood flow.
1. Lalonde A Evaluation of surgical options in
menorrhagia, Br J Obstet Gynaecol 1994; 101 (11) 8-14 2. Royal college of general practitioner and the office of population surveys (1986) Mortality statistic from general practice 1981-82 London HMSO.
3. Mencaglia L, Perino A, Hamou J . Hysteroscopy in perimenopausal and post menopausal women with abnormal uterine bleeding, J Reprod Med 1987; 32; 577-582.
4. Coulter A, Bradlow J, Agass M, Martin-Bates C, Tulloch A. Outcomes of referrals to gynaecology outpatient clinics for menstrual problems: an audit of general practice records. Br J Obstet Gynaecol 1991; 98; 789-796.
5. Clinch J. Length of hospital stay after vaginal hysterectomy. Br J Obstet Gynaecol 1994;101; 253-254 6. Dicker R.C, Greenspan J.R, Strauss L.T. et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynaecol 1982; 144; 841-848.
7. Goldberg J.M. Intrauterine pregnancy following endometrial ablation. Obstet Gynecol 1994;83; Talha Abdul Halim¹, Barry Gaughan², Paul Byrne² 8. Magos AL, Bauman R, Lockwood GM, Turnbull A 11. Maher PJ, Hill DJ. Transcervical resection for Experience with the first 250 endometrial resections abnormal uterine bleeding; report of 100 cases and for menorrhagia. Lancet 1991;337; 1074-78 review of the literature. Aust NZ J Obstet Gynaecol 9. A Scottish audit of hysteroscopic surgery for menorrhagia: Complication and follow up Scottish 12. Chullapram T, Song JY, Fraser IS. Medium term Hysteroscopic audit group. Br.J.Obstet Gynaecol follow-up of women with menorrhagia treated by rollerball endometrial ablation. Obstet Gynecol 10. Vilos GA, Pispidikis JT, Botzck. Economic evaluation of hysteroscopic endometrial ablation versus vaginal hysterectomy for menorrhagia.



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