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A McCall-type culdeplasty appears to be the most effective surgical technique for preventing an enterocele in women who have had a vaginal hysterectomy. After a vaginal hysterectomy, part of the rectum can herniate into the vagina because some of the connective tissue that separates the two body parts is removed during the hysterectomy. This herniation is called an enterocele. Compared to peritoneal closure and a vaginal Moschcowitz-type operation, the McCall-type culdeplasty was more effective in preventing enterocele in a study of 100 women who had a vaginal hysterectomy.

The pubourethral ligaments and muscular attachments appear to play a role in holding the urethra in proper position. This information has suggested a surgical technique that may improve the success of surgery for urinary incontinence. Researchers dissected cadavers to confirm the exact anatomy of these ligaments. They also compared urethral stability in 30 women with stress incontinence and 30 problem-free women. All 30 women with stress incontinence displayed urethral instability when holding their breath and bearing down versus none of the problem-free women.

The ability to see the ovaries and move them down appear to be the primary criteria for removal of the ovaries during a hysterectomy using the transvaginal approach. The ovaries may be successfully removed by the vaginal route in most patients. In a group of 966 women having a hysterectomy via the vaginal route, 30% of them had the ovaries removed as well. Moreover, in 99.9% of cases overall, the ovaries could be visualized and brought down to where they could have been removed vaginally. Vaginal hysterectomy reduces the incidence of injuries to the ureters.

Byline: Stephen H. Cruikshank, S.Robert Kovac Keywords: Uterosacral-cardinal ligaments; pubocervical fascia; anterior vaginal segment Abstract: OBJECTIVE: The purpose of our study was to evaluate a surgical technique we have developed that, when used at vaginal hysterectomy, helps prevent posthysterectomy anterior vaginal segment (wall) prolapse. STUDY DESIGN: This modified surgical procedure was used in 966 consecutive vaginal hysterectomies performed from January 1989 through December 1994. Patients returned at 1, 3, and 12 months and annually thereafter for follow-up. The longest follow-up period to date is 5.5 years. RESULTS: Of the 925 patients in our study followed up for [greater than or equal to]1 year, 908 (98.1%) retained excellent anterior vaginal support. Symptomatic anterior vaginal segment prolapse occurred in 12 patients (1.3%), and asymptomatic prolapse, with the anterior vaginal wall descending less than halfway from the ischial spines to the hymen, occurred in 5 (0.5%). None of the 42 patients followed up for Author Affiliation: Dayton, Ohio, and St. Louis, Missouri Article Note: (footnote) [star] From the Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Wright State University School of Medicine, and St. John's Mercy Medical Center., [star][star] Reprint requests: Stephen H. Cruikshank, MD, Department of Obstetrics and Gynecology, Wright State University School of Medicine, 128 Apple St., Suite 3800 CHE, Dayton, OH 45409-2793., a 0002-9378/96 $5.00 + 0 6/6/72913

Women treated for uterine prolapse by attaching the ligaments supporting the uterus to the sacrospinous ligament were able to later bear children and deliver vaginally. Uterine prolapse occurs when the uterus slides from its normal position. The sacrospinous ligament attaches the end of the backbone to the pelvis. Nineteen women with uterine prolapse had sacrospinous fixation surgery. All of the patients had severely weakened uterosacral ligaments as determined by pelvic exam prior to surgery. The surgical procedure took approximately 15 minutes and was performed vaginally, without abdominal incision. The average hospital stay was 2.4 days. Five women were able to become pregnant and deliver vaginally after surgery. One of the five became pregnant twice and delivered vaginally both times. One woman who was unable to become pregnant had a second surgery for prolapse, but has had no problems since. Of the 11 other women who did not become pregnant, none needed additional surgery more than three years after their initial surgery.

Rh factor incompatibilities occur when the blood of a mother that does not contain the factor (Rh negative) mixes with blood of the fetus that does contain the factor (Rh positive) to cause the production of destructive antibodies. Although the incompatibility does not affect the current pregnancy, subsequent pregnancies are at risk for fetal red blood cell destruction. Potential blood mixing can occur during a threatened spontaneous abortion. Although one half of the patients who have bleeding in the first three months of pregnancy miscarry, the remainder maintain the pregnancy. It is not clear whether all women who have first trimester bleeding should undergo Rh immune globulin prophylaxis, an injection to prevent antibody reactions from occurring in subsequent pregnancies. It is recommended that all Rh-negative women have the immune globulin injection by the 28th week of pregnancy. A case is presented of a 35-year-old woman who was RH negative and had had a previous child with an Rh-negative father. She had four abortions and received Rh immune globulin after each procedure. No antibodies were detected before the first abortion or the first delivery. She came to the hospital complaining of cramping and bleeding. A pelvic ultrasound revealed a viable 8.5-week-old fetus. The father of this child was Rh positive. She was not given Rh immune globulin and was told to visit with an obstetrician. The patient's antibody screen was negative at the prenatal visit. Amniocentesis was performed at another institution at 15 weeks of pregnancy and 300 micrograms of Rh immune globulin were given. When the patient transferred to another facility, antibody testing was positive, which was thought to be caused by passive antibodies; Rh immune globulin was given. However, analysis of the fetus' blood at delivery was strongly positive. The mother's blood was analyzed and found to have an extremely high antibody concentration. This is the first reported case of a missed maternal sensitization developing after bleeding in the first three months of pregnancy. Although an obstetrician would probably have given the immune globulin, emergency personnel did not. It is recommended that Rh immune globulin should be given to all Rh-negative women who experience first-trimester bleeding. (Consumer Summary produced by Reliance Medical Information, Inc.)