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Objective: To compare the proficiency of novices in acquiring laparoscopic suturing skills following training in a virtual reality simulator or box trainer compared to no training., Methods: This was a RCT in a university-affiliated teaching hospital recruiting participants who had no laparoscopic suturing experience to have suturing skill training in the virtual reality simulator, box trainer, or no training as control. Trainees were allowed to terminate training when they perceived competence in the procedure. Suturing skills were tested in the box trainer and scored using a modified Global Operative Assessment of Laparoscopic Skills questionnaire by their own self-evaluation and two experienced gynaecological laparoscopists., Results: Of the 36 participants recruited, 27 (75%) had no laparoscopic experience. Participants with no laparoscopic experience took longer to complete training than those with experience (median 90 minutes [interquartile range (IQR) 80-115] vs. 55 min [IQR 40-65], respectively; P = 0.044). There were no differences in successful completion of the task (7/12 [58.3%], 10/12 [83.3%], 7/12 [58.3%]; P = 0.325), median suturing time in seconds (628 [IQR 460-835], 611 [IQR 434-691], 609 [IQR 540-837]; P = 0.702), mean subjective (mean ± SD 9.8 ± 1.8, 10.4 ± 2.8, 9.3 ± 2.4; P = 0.710), and objective (7.2 ± 1.8, 8.2 ± 2.1, 7.6 ± 1.7; P = 0.426) modified Global Operative Assessment of Laparoscopic Skills score in the simulator, pelvic trainer, and control groups, respectively. The intraclass correlation coefficient of the two reviewers was 0.422 (95% CI 0.159-0.717)., Conclusion: Trainees were unable to accurately assess themselves as to skill level in laparoscopic suturing. A longer training time is required for novices to master laparoscopic suturing using a simulator or box trainer., (Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate the positive predictive value of Pipelle endometrial sampling in detecting the presence of an underlying endometrial polyp. The secondary objective is to examine the histologic features that can predict the presence of endometrial polyps., Study Design: This is a retrospective case review study. 195 women who had undergone diagnostic hysteroscopy and/or polypectomy were identified in a University teaching hospital. All patients had a prior polyp diagnosis in the Pipelle endometrial sample. The histology of these samples were compared and analyzed with subsequent DH findings and final hysteroscopic biopsies. Slides were reviewed by 2 gynaecological pathologists., Results: 162 women were premenopausal (mean age 46.1, SD=4.6) and 33 were postmenopausal (mean age 57.2, SD=8.1). The commonest indication for a Pipelle endometrial sampling was abnormal uterine bleeding. Presence of polyp was confirmed by DH in 56.3% (111/195) cases. Of these, 81.1% (90/111) were confirmed histologically. The positive predictive value of detection of polyps in Pipelle endometrial samples for premenopausal and postmenopausal women was 53.7% and 72.7%, respectively (p=.05). The most reliable histologic features that can predict the presence of an underlying polyp was fibrous stroma (p=.01) and focal glandular clustering (p=.03). The prevalence of endometrial hyperplasia and carcinoma in women who was confirmed to have polyp was 11.7% (13/111)., Conclusion: The positive predictive value of Pipelle endometrial samples in detecting endometrial polyps was 56.3%. It was higher in the postmenopausal women (72.7%) compared to premenopausal women (53.7%). The prevalence of endometrial hyperplasia and carcinoma in women who was confirmed to have polyp was consistent with the rate reported in the literature. Using ultrasonography as an adjunct maybe helpful in diagnosing endometrial polyps., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To determine the prevalence of domestic violence and its risk factors in women presenting with urinary symptoms., Methods: The study was carried out in the urogynecology clinic and general gynecology clinic, Department of Obstetrics and Gynecology, Queen Mary Hospital, Hong Kong from 1st May 2013 till 31st October 2014. Two hundred and twenty-five women presenting to the urogynecology clinic with urinary symptoms were categorized according to their symptoms and were asked to complete the Modified Abuse Assessment Screen. Demographic data of the subjects and their partners were collected. Mann-Whitney U test were used for analysis of continuous variables, while Chi-square test and Fisher Exact test were used for analysis of categorical variables between the abused and non-abused group. Prevalence of domestic violence were calculated and compared., Results: The prevalence of domestic violence among this group of patients (7.6%) was found to be lower when compared with other studies. Verbal abuse was the commonest form of violence in our locality. The median age of the abused group and the non-abused group were both 56 years old, with the age ranging from 40 to 64 and 29 to 70 years old respectively. The prevalence of domestic violence among patients with overactive bladder syndrome, stress urinary incontinence and mixed urinary incontinence were 19.5%, 4.2% and 5.5% respectively (Fisher Exact test for whole group, P<0.05)., Conclusion: The prevalence and nature of abuse in our locality was different from the quoted figures worldwide. Patients with overactive bladder syndrome were more likely to be victims of abuse than patients with other urinary symptoms. The difference in the prevalence of domestic violence among patients with different urinary symptoms could be related to their underlying pathophysiology. When encountering patients with overactive bladder syndrome, clinicians should consider this high incidence of domestic violence and provide prompt referral whenever necessary.

Objective: To review the clinical profiles and management outcomes of patients with pyometra., Study Design: A retrospective review of all women admitted with a confirmed diagnosis of pyometra over an 8-year period (January 2003 to December 2010). The medical records, including operation notes, histological and microbiological results, were reviewed., Results: A total of 57 patients accounting for 76 admissions were identified. The mean patient age was 82.0 ± 11.3 years. The most common presenting symptom was postmenopausal bleeding (59.2%), followed by vaginal discharge (40.8%), fever (6.6%), and abdominal pain (5.3%). Drainage of pyometra was either by uterine Foley catheter insertion (48 patients [84.2%]) or repeated endometrial aspiration (2 patients [3.5%]). Antibiotics were prescribed to 49 patients (86.0%). Diagnostic hysteroscopy with mechanical cervical dilation was performed in 6 patients (10.5%). Gynecological malignancy was identified in only 1 patient, while colorectal cancer was identified in 2 patients. No patient had spontaneous uterine perforation or sepsis. Sixteen patients had recurrent pyometra within a mean follow-up period of 5.1 ± 5.8 months (range, 0.5-23 months)., Conclusion: Pyometra usually presents with postmenopausal bleeding and can be treated with drainage and antibiotics treatment. In contrast to previous reports, our study indicates that spontaneous uterine perforation and gynecological malignancies are not commonly associated with pyometra.

Background and Objectives: Our objective was to review the surgical management, surgical outcomes, and obstetric outcomes of adnexal masses in pregnancy., Methods: A retrospective review was performed of pregnant women before 20 weeks of gestation who underwent laparoscopy or laparotomy for management of an adnexal mass during the period of January 2005 to June 2012 at a university-affiliated hospital., Results: Thirty-five pregnant women underwent surgical removal of adnexal masses during the 7.5-year study period: 21 (60.0%) underwent laparoscopic surgery, and 14 (40.0%) underwent laparotomy. The left upper quadrant entry technique was used in 20 women. Conversion to laparotomy was required in 2 women because of extensive pelvic adhesions. The mean gestational age at surgery was 15.2 ± 1.9 weeks. All women had undergone ovarian cystectomy. A malignant mass was found in 3 (8.6%) women. The laparoscopy group had a significantly less blood loss (67.4 ± 55.8 vs 153.6 ± 181.0 mL, P = .048) and shorter mean hospital stay (2.8 ± 1.0 vs 3.8 ± 1.1 days, P = .006) than the laparotomy group. One woman miscarried soon after surgery. There was no significant difference in obstetric outcomes between the laparoscopy and laparotomy groups., Conclusion: Surgical management of adnexal masses during pregnancy appears to have favorable outcomes for the mother and the fetus.

Background: Medical abortion in women with the scar of a classical caesarean section (CS) and a large uterine leiomyoma is rarely attempted; it carries the risk of uterine rupture and haemorrhage., Case: A 34-year-old multiparous woman with prior classical CS and a 14 × 10 × 9 cm leiomyoma arising from the uterine isthmus had an induced abortion at 14 weeks' gestation. Mechanical cervical priming with Dilapan(®)-S followed by vaginal misoprostol administration resulted in the uncomplicated expulsion of the uterine contents., Conclusions: An early second trimester medical abortion with misoprostol was successfully performed in a woman with prior classical CS and a large uterine leiomyoma.

Objective: To review the use of the left upper quadrant approach in benign gynecologic laparoscopic surgery over a nine-year period., Design: Retrospective review. Setting. University-affiliated hospital., Population: Women who underwent laparoscopic gynecologic surgery the upper quadrant approach between January 2002 and December 2010., Methods: Medical records were reviewed., Main Outcome Measures: Demographic data, past surgical histories, indications for surgery and the use of the left upper quadrant approach, intraoperative findings, diagnosis and any complications., Results: 143 patients were identified, accounting for 4.9% of all gynecologic laparoscopic surgery. The indications for using the left upper quadrant approach were: previous open abdominal surgery (113, 79.0%), surgery in the second trimester of pregnancy (16, 11.1%), presence of large pelvic mass (9, 6.2%), previous transverse rectus abdominis myocutaneous flap for breast reconstruction (3, 2.0%), previous periumbilical hernia repair (1, 0.6%) and previous laparoscopic umbilical wound dehiscence (1, 0.6%). In women with previous abdominal surgery, the overall incidence of adhesions between omentum and/or bowel to the anterior abdominal wall in the umbilical region was 58.4%. Twelve (8.3%) patients required conversion to laparotomy. One patient had subcutaneous surgical emphysema over the left upper quadrant entry site., Conclusions: The left upper quadrant approach is an effective, safe and easy technique for peritoneal cavity access in women undergoing laparoscopic gynecologic surgery and should be considered in women with risk factors of periumbilical adhesions and in the presence of a large pelvic mass., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To investigate the effectiveness of a single pre-operative dose of sublingual misoprostol on reducing blood loss in abdominal hysterectomies performed for symptomatic uterine leiomyomas., Study Design: A cohort of 64 women undergoing total abdominal hysterectomy for symptomatic uterine leiomyomas were randomly assigned to receive a single dose of sublingual 400 mcg misoprostol (n=32) or placebo containing 20mg vitamin B(6) (n=32) 30 min before the operation. The primary outcome was the operative blood loss. The secondary outcomes were requirement for blood transfusion, change in haemoglobin level after operation, and the incidence of side effects., Results: Women who had misoprostol were found to have similar operative blood loss to those who had placebo (570.9 ± 361.3 ml versus 521.4 ± 297.4 ml, for misoprostol and placebo group respectively; P=0.803). This study with a sample size of 64 was sufficient to have 80% power at the 5% level of significance to detect a reduction of blood loss greater than or equal to 30%. There were no observed differences in the need for post-operative blood transfusion (25% versus 15.6%, for misoprostol and placebo group respectively; P=0.536), the change in haemoglobin level after the operation, and the side effects profiles between the two groups., Conclusion: A single pre-operative dose of sublingual misoprostol is not effective in reducing intra-operative blood loss and need for post-operative blood transfusion after total abdominal hysterectomies for symptomatic uterine leiomyomas., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess whether early or immediate removal of a 12F in-dwelling Foley catheter after total abdominal hysterectomy affects the level of subjective pain assessment postoperatively., Design: Randomized controlled trial., Setting: University Hospital., Population: Seventy women underwent total abdominal hysterectomies for various benign gynecological diseases., Methods: Women were randomized to have the urinary catheter removed in the operating room after the surgical procedure or to have it removed on postoperative day 1., Main Outcome Measures: The primary outcome was patients' pain assessment and the secondary outcomes were rate of re-catheterization and symptomatic urinary tract infection., Results: There was no difference in the pain assessment between the two groups. A significantly higher number of urinary retention episodes requiring re-catheterization were found in the immediate removal group compared with the delayed removal group (20 vs. 0%; p= 0.011). The incidence of symptomatic urinary tract infection did not differ between the two groups., Conclusions: There are pros and cons regarding the policy of one-day in-dwelling catheterization compared to immediate catheter removal., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

It has been advocated that placenta accreta/percreta should be managed conservatively to avoid massive pelvic bleeding and preserve fertility. Diagnosis of this condition with high-resolution imaging investigations performed during the antenatal period facilitates discussion of management plans with other clinical disciplines (eg interventional radiologists), the patient, and her family. Three cases of placenta praevia with accreta are presented. The three cases were managed by leaving the placenta in-utero after caesarean section, using uterine arterial embolisation to control postpartum haemorrhage only when needed. In all these cases, we succeeded in conserving the uterus without major complications. With improved imaging techniques, accurate antenatal diagnosis of placenta praevia with accreta is now possible. This new approach to conservative management can be considered in order to not only conserve the uterus but also to avoid uncontrolled pelvic haemorrhaging.

Objective: To examine the applicability of hysterofetoscopy and cord blood collection at first trimester termination of pregnancy for fetal abnormalities., Methods: From 2004 to 2007, transcervical hysterofetoscopy was performed in seven patients at the same operation setting of surgical termination of pregnancy. The findings were compared with prenatal diagnosis. Feasibility of cord blood collection was also examined., Results: Out of these seven patients, six of them had prenatal ultrasound diagnosis of cystic hygroma. All of them had chromosomal abnormalities. Subcutaneous oedema was confirmed by hysterofetoscopy with good view. Another pregnancy was complicated by homozygous alpha thalassaemia and the diagnosis was confirmed by electrophoresis of fetal haemoglobin collected from umbilical cord vessel. Cord blood collection was also attempted in two other patients yielding fetal blood with minimal maternal contamination., Conclusion: Transcervical hysterofetoscopy is a feasible tool in confirming external fetal structural abnormalities before surgical termination of pregnancy. It can be performed under either general anaesthesia or conscious sedation. Umbilical cord blood collection can facilitate confirmation of genetic diseases. It may also allow the potential of isolating fetal mesenchymal stem cell in first trimester., (Copyright (c) 2008 John Wiley & Sons, Ltd.)

Aims: Freshwater fish has been found to be the reservoir of Laribacter hongkongensis, a recently discovered bacterium associated with community-acquired gastroenteritis. However, little is known about the ecology of this bacterium in the aquatic environment. We carried out a surveillance study to investigate the presence of L. hongkongensis in water and freshwater fish from 10 drinking water reservoirs in Hong Kong., Methods and Results: Using membrane filtration, L. hongkongensis was isolated from the waters of six reservoirs, with numbers ranging from 1 to 12 CFU l(-1). Higher recovery rates were observed in summer and during days of higher water and ambient temperatures. Of 27 freshwater fish collected from the reservoirs, L. hongkongensis was recovered from the intestines of two fish, a Goldfish and a Nile tilapia. Overall, 35 different pulsed-field gel electrophoresis patterns are found among the 59 isolates recovered from water and the two isolates from freshwater fish., Conclusions: The present report represents the first to demonstrate the presence of L. hongkongensis in natural water environments., Significance and Impact of the Study: Although it is unlikely that treated, drinking water is an important source of L. hongkongensis-associated gastroenteritis, one should be aware of the possibility of other contaminated water as a source of human infection.

Introduction: Women with menorrhagia have increased levels of plasminogen activators in the endometrium. Tranexamic acid (cyklokapron), an antifibrinolytic agent, is commonly prescribed worldwide to women with menorrhagia, including those with fibroids. Necrosis in uterine leiomyomas may be associated with pregnancy, and progestogen or oral contraceptive use but its association with tranexamic acid has not been investigated. Four hundred ninety patients with uterine leiomyomas in 2004 and 2005 were reviewed. Their ages ranged from 22 to 86 (mean 47.2). One hundred forty-seven (30%) were treated with tranexamic acid., Results: Infarct-type necrosis was observed in the leiomyomas of 38 patients, 22 of whom had tranexamic acid (15%) whereas the remaining 16 had no drug exposure (4.7%) (odds ratio=3.60; 95% confidence interval: 1.83-6.07; P=0.0003). Two patients who took the drug less than 2 weeks before surgery had early infarcts with appearance resembled coagulative type necrosis. Eleven of the 22 cases of drug-induced necrotic leiomyoma (50%) also showed intralesional thrombus formation, and 4 showed organization of the thrombi., Conclusions: Infarct-type necrosis and thrombosis of leiomyoma was more commonly observed in patients treated with tranexamic acid. Although the drug is effective for menorrhagia, clinicians should be aware of the possible complications associated with leiomyoma necrosis such as pain and fever. Distinguishing between types of necrosis may not always be straightforward particularly in early infarcts when the reparative connective tissue reaction between the viable and necrotic cells is not well-developed, resulting in an appearance similar to coagulative necrosis. When the overall gross and microscopic features of a leiomyoma with coagulative necrosis favor a benign lesion, the drug history should be reviewed so that this type of early and healing infarct-type necrosis is considered as the underlying cause of the apparent coagulative necrosis. This may otherwise result in a diagnosis of smooth muscle tumor of uncertain malignant potential, leading to prolonged follow-up and unnecessary further surgical intervention.

Objective: To review the results of vaginal hysterectomies in patients without uterine prolapse., Design: Retrospective chart review., Setting: University affiliated hospital, Hong Kong., Patients: Patients who had vaginal hysterectomies in the absence of uterine prolapse, from 1999 to 2005 inclusive., Main Outcome Measures: The number, indications, operative procedures, and complications of such hysterectomies., Results: A total of 94 patients who underwent vaginal hysterectomy fulfilled the inclusion criteria. They accounted for 4.3 to 8.2% of all hysterectomies performed annually for benign diseases in the department, over the inclusive period 2000 to 2004. The incidences of complications, except bladder injuries, were comparable to those reported in other studies. The incidence of vault haematoma decreased as each surgeon's experience increased and more attention was paid to 'bleeders' at the 'four and eight o'clock areas' and more cephalic regions of the vaginal incision. Increased size of the uterus was an important determinant of the risk of complications., Conclusions: Vaginal hysterectomy is an underutilised approach in Hong Kong. With more experience and better patient selection, complication rates can be further reduced. Further evaluation is suggested for the role of bleeders at 'four and eight o'clock regions' as potential causes of vault haematoma.

Background: The incidence of birth trauma and birth asphyxia related to instrumental deliveries in our obstetric unit was high (2.8%) in 1998-1999. A study was performed in 2000 to identify the risk factors. Unexpectedly, the incidence (0.6%) was reduced significantly during the study period. We attributed this phenomenon to the famous Hawthorne effect (tendency to improve performance because of awareness of being studied)., Objectives: The objectives were to study whether there is a continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period (2001-2003) and to investigate the presence of underlying confounding factors apart from the Hawthorne effect., Method: To compare the hospital obstetric statistics among the pre-study period (1998-1999), the study period (2000) and the post-study period (2001-2003), in particular the incidence of birth trauma and birth asphyxia related to instrumental deliveries, the instrumental delivery rate, the overall Caesarean section rate, the Caesarean section rate for no progress of labour, the incidence of failed instrumental delivery, the incidence of attempted instrumental delivery in the operating theatre, and incidence of direct second-stage Caesarean sections., Results: The incidence of birth trauma and birth asphyxia related to instrumental deliveries (0.6%) during the study period (2000) was significantly lower than that (2.8%) during the pre-study period (1998-1999; RR 0.27, 95% CI 0.11-0.70). This phenomenon continued into the post-study period (2001-2003) when the incidence of 1.0% was similarly lower than that in the pre-study period (RR 0.35, 95% CI 0.20-0.64). The instrumental delivery rate decreased further in the post-study period (13.5%) compared with those in the study (16.6%) and pre-study (19.5%) periods (RR 0.81, 95% CI 0.75-0.89 and RR 0.69, 95% CI 0.65-0.74, respectively). There was a marked increase in the direct second-stage Caesarean section rate in the post-study period (7.1%) compared to those in the study (0.4%) and pre-study (0.7%) periods (RR 15.9, 95% CI 5.05-49.73 and RR 9.77, 95% CI 5.28-18.08, respectively)., Conclusion: A change in obstetric practice was identified that may explain the continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period.

Study Objective: To review the operative outcomes among different types of laparoscopic total hysterectomy (LH) classified according to the Munro and Parker classification system., Design: Prospective observational cohort study (Canadian Task Force classification II)., Setting: 6 major public hospitals in Hong Kong., Patients: 143 patients underwent LH in a 6-month period., Interventions: Type I to type IV LH according to the Munro and Parker classification system., Measurements and Main Results: We studied 56 type I, 49 type II, 25 type III, and 13 type IV LH. The median operative time was 105 minutes, which was significantly longer in the type IV LH group (160 minutes). The median blood loss was significantly higher in the type I LH group (300 mL). The incidence of urinary tract infection in type I LH was 8.9%, which was significantly higher than other LH groups. The overall operative complication rate was 20.3%, which was highest in the type III hysterectomy group (36%), although the difference did not reach statistical significance among the various types of hysterectomy groups., Conclusion: There has been a change from abdominal hysterectomy to LH in the past decades, and it is time for us to explore the best type of LH. Our findings suggest that type I LH is associated with significantly more blood loss and urinary tract infection; whereas type IV LH is associated with significantly longer operating time. However, we still cannot conclude which is the best type of LH until results from a randomized controlled trial will become available.

Objective: To review the use of episiotomy during vaginal delivery in Hong Kong public hospitals., Design: Prospective observational survey., Setting: Public hospitals, Hong Kong., Participants: Women who underwent normal vaginal delivery of a singleton foetus with cephalic presentation., Main Outcome Measures: Number of women having an episiotomy, severe-degree (third- or fourth-degree) tear, other types of tear, blood loss at delivery, postpartum haemorrhage, need for blood transfusion, puerperal pyrexia, wound infection, gaping wound that required suture removal, and drainage or resuturing of a perineal wound., Results: Between 1 January and 31 March 2003, there were 6222 singleton spontaneous normal vaginal deliveries in the public hospitals of Hong Kong. Of the 6167 women in whom the status of the perineum was known, episiotomy was performed in 5274 (85.5%). Primiparous women were more likely to undergo episiotomy at delivery than multiparous women (97.9% vs 71.4%). Women with episiotomy had significantly less perineal tearing of any kind than those without. The occurrence of any type of perineal tear and severe-degree (third- or fourth-degree) tear was significantly lower in primiparous women who had an episiotomy than those without (P<0.05). Women with episiotomy had increased mean blood loss at delivery but other complications were not significantly increased., Conclusions: In Hong Kong, episiotomy is routinely performed during normal vaginal delivery. It is associated with a significantly lower overall rate of perineal tearing. This study was observational, nonetheless the occurrence of other complications was likely to increase when episiotomy was performed. Firm evidence from several randomised controlled studies shows that routine episiotomy is unjustified and possibly harmful. Routine episiotomy should not be promoted in Hong Kong without further randomised controlled study.

Objective: To compare preemptive analgesia and preclosure analgesia in reducing wound pain after laparoscopic operation., Design: Randomised, double-blind and placebo control., Setting: University referral centre., Population: Infertile women undergoing diagnostic laparoscopy with or without additional procedures., Methods: One hundred and forty-four women were randomised to receive 10 mL of 1% lignocaine at the surgical sites before incision and 10 mL of normal saline before closure of incision (the preemptive group), saline before incision and lignocaine before closure of incision (the preclosure group) and saline at the surgical sites both before incision and closure of incision (the placebo group)., Main Outcome Measures: Post-operative wound pain measured by linear visual analogue scale and amount of analgesic use., Results: The women in the preclosure group had significantly lower pain scores at 2, 4 and 24 hours than those in the placebo group, whereas the women in the preemptive group only showed significantly lower pain scores at 2 hours than the placebo group. The pain score at 24 hours in the preclosure group was significantly lower than that in the preemptive group. There was no significant difference in the post-operative analgesic requirement among the three groups., Conclusion: The preclosure analgesia is better than preemptive analgesia and no analgesia in reducing post-operative wound pain.

This study investigated the acceptability of the levonorgestrel-releasing intrauterine device (LNG-IUS) as contraception among young, single women after termination of pregnancy. Twenty subjects, with a median age of 21 years, had LNG-IUS inserted immediately after suction termination of first-trimester pregnancy. The subjects were followed-up at 6 weeks, 3 months, 6 months and 12 months. Fifteen subjects (75%) had other pregnancies terminated in the past. There were no serious complications or pregnancies. The acceptability of the LNG-IUS was generally above 86% during each follow-up visit. A total of seven (35%) subjects were lost to follow-up at different periods of the study. Overall, four subjects (22%) had the LNG-IUS removed. Nine subjects were seen at the end of the 1-year study period and all continued with the LNG-IUS for contraception. Side effects were commonly observed and irregular vaginal bleeding was the most common. We conclude that the LNG-IUS may be an acceptable method among selective young, single, nulliparous clients after termination of pregnancy and could be offered as an option of contraception to them. However, the small sample size and the high lost-to-follow-up rate are the major limitations of this study.

Objective: The Bethesda system for reporting cervicovaginal cytologic diagnoses was recently revised in 2001. Pathologists are required to report not only whether the smear favors neoplastic changes, but also the origin of the abnormal cells. In this study, archival smears were reviewed to evaluate the usefulness of the new classification., Methods: Smears having atypical glandular cells taken between January 1995 and December 1997 were reviewed and subclassified according to the revised Bethesda classification. Case records were then reviewed and cases with discrepancies between the cytological evaluation and corresponding final histological diagnoses were further reviewed., Results: There were 138 smears reviewed. The mean age of the patients was 47 (range, 18 to 78). Thirty-four smears favored neoplasia and 104 favored "NOS" ("not otherwise specified"). Sixty smears favored endocervical origin and 78 endometrial origin. Forty-three patients (31%) had significant pathologies, including 12 (8.7%) patients with high-grade CIN, 2 (1.4%) with low-grade CIN, 5 (3.6%) with HPV infection, 7 (5.1%) with carcinoma of the corpus, 1 (0.7%) with cervical adenocarcinoma in situ, 4 (2.9%) with adenocarcinoma of the cervix, 3 (2.2%) with endometrial hyperplasia, and 5 (3.6%) with carcinoma of the ovary. Two (1.4%) patients had double primary female genital malignancies and 2 patients (1.4%) had extragenital malignancies. Significant correlation was found between smears "favor neoplasia" and a final diagnosis with significant pathology (chi(2) test, P < 0.05). Significant association was found between AGC favored endocervical origin and a final diagnosis with cervical diseases (chi(2) test, P < 0.05). Four of the 43 patients who had significant pathologies had lesions found during their subsequent visits and all of them had cervical smears classified as AGC "favor neoplasia"., Conclusion: AGC found on cervical smears are an indication for early and intensive investigation.

Background: Uterine arteriovenous malformation is a rare condition. Uterine artery embolization offers the possibility of conservative management as opposed to the traditional hysterectomy. We report a case with recurrent uterine arteriovenous malformation confirmed by angiography and successfully treated with a second embolization procedure., Case: A 33-year-old woman presented with heavy vaginal bleeding. The diagnosis of uterine arteriovenous malformation was suspected on Doppler ultrasonography and confirmed by angiography. The first embolization procedure was performed using polyvinyl alcohol and steel coils. Recurrence was diagnosed 1 year later with the same imaging techniques. The second embolization procedure was performed using histoacryl. The patient remained asymptomatic at 1-year of follow-up., Conclusion: Minimally invasive management is an option in recurrent uterine arteriovenous malformation.

Study Objective: To determine the usefulness of the left upper quadrant approach in gynecologic laparoscopic surgery., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: University referral center., Patients: Twenty-four women with longitudinal scars from previous laparotomy through or close to the umbilicus., Intervention: Left upper quadrant was chosen as the site of primary entry of the reusable Veress needle (ninth or tenth left intercostal space) and reusable primary cannula (left upper quadrant just below the left subcostal margin)., Measurements and Main Results: Intraabdominal adhesions between old longitudinal scars and underlying bowel or omentum were present in 14 patients. Adhesions involving omentum only were present in 10 patients, bowel only in 2, and both omentum and bowel in 2. The only intraoperative complication was emphysema in one woman. All operative procedures were completed laparoscopically., Conclusion: The left upper quadrant approach is a safe entry point for reusable instruments at laparoscopic surgery in patients with midline incisions close to the umbilicus.

Objective: To determine whether maternal height has a significant effect on the length of gestation or the incidence of preterm birth in Asian women with singleton gestations., Methods: We retrospectively studied a cohort of consecutive adult Asian women with singleton gestations who delivered in a 2-year period, to determine the relationship between maternal height, expressed in quartiles, and the mean gestational age and incidence of preterm birth., Results: Of the 9819 deliveries during that period, 449 were excluded from analysis because of multiple gestation, maternal age less than 20 years, or incomplete data because of no antenatal care in our hospital. The 25th, 50th, and 75th percentile values of maternal height were 152, 156, and 160 cm, respectively. Significant differences were found in the maternal age, weight and body mass index (BMI), birth weight, and birth weight as a percentage of maternal weight, among the four quartiles, but the trend for age, BMI, and birth weight percentage was opposite to that of maternal weight and birth weight. However, there was no significant difference in the mean gestational age or incidence of preterm birth at less than 28, 28-31, or 32-36 weeks' gestation. There was no difference in the incidence of pregnancies beyond 41 weeks' gestation., Conclusion: Maternal stature does not have a significant influence on the mean gestational age or incidence of preterm birth in adult Asian women with singleton gestations.

In a randomized, double-blind study, the antiemetic efficacy of a single bolus of tropisetron 5 mg (group T, 37 patients), ondansetron 4 mg (group O, 39 patients) or saline (group C, 45 patients) given at induction was compared in a homogeneous group of 121 patients undergoing gynaecological laparotomy and receiving postoperative patient-controlled intravenous morphine for 24 to 48 hours. Fewer group T and group O patients developed severe nausea compared to group C (P < 0.01, log rank test in Kaplan-Meier analysis). Group T patients also had lower nausea scores than group O at 8 to 16h (P < 0.05). The overall incidences of severe nausea in groups T, O, and C were 5.4%, 17.9%, and 44.4% respectively (P < 0.001, group T vs group C; P < 0.05 group O vs group C). In conclusion, the 5-hydroxytryptamine 3 receptor antagonists tropisetron and ondansetron were superior to placebo in preventing PONV.

The synthetic steroid 7alpha-methyl-19-nortestosterone (MENT) is a potent androgen that is resistant to 5alpha-reductase. It thus has decreased activity at the prostate and may have advantages over testosterone-based regimens in long term treatment or as part of a male contraceptive. Administration to eugonadal men results in suppression of gonadotropins, but its ability to support androgen-dependent behavior has not been investigated. For sustained release administration, MENT acetate was used, because its diffusion characteristics were more suitable for use in implants. However, upon release the acetate is rapidly hydrolyzed, and MENT is the biologically active moiety in circulation. We studied the effects of MENT on sexual interest and activity, spontaneous erection, and mood states in comparison with testosterone enanthate (TE) in 20 Caucasian and Chinese hypogonadal men recruited in Edinburgh and Hong Kong (n = 10 in each center). Outcomes were measured using a combination of daily diaries, semistructured interviews, and questionnaires. Nocturnal penile tumescence (NPT) was also recorded in the Edinburgh group. After withdrawal of androgen replacement treatment (wash-out phase) for a minimum of 6 weeks, subjects were randomized to two groups in a cross-over design. Drug treatment regimens were of 6-week duration and consisted of two implants, each containing 115 mg MENT acetate, inserted s.c. into the upper arm and removed after 6 weeks and two injections of TE (200 mg, i.m.) 3 weeks apart. MENT treatment resulted in stable plasma MENT concentrations of 1.4 +/- 0.1 nmol/L after 3 weeks and 1.3 +/- 0.1 nmol/L after 6 weeks (mean +/- SEM; all men). Nadir testosterone concentrations were 3.6 +/- 0.6 nmol/L at the end of the wash-out phase and 9.4 +/- 0.6 nmol/L 3 weeks after each injection. There were no differences in hormone concentrations between centers. There were no adverse toxicological effects. There were only minor differences between the two treatments. Both MENT and TE treatment resulted in significant increases in sexual interest and activity, spontaneous erection (both by self-report and NPT measurement), and increases in positive moods, with decreases in negative moods in the Edinburgh group. In the Hong Kong group, both treatments increased waking erection, with a trend toward increased sexual interest and activity. Mood states appeared to be less affected during the wash-out phase than in Edinburgh men and showed no significant response to either treatment. These results demonstrate that MENT has similar effects on sexual activity and mood states as testosterone in hypogonadal men. As NPT is a physiological androgen-dependant outcome, these data provide further evidence for the androgenicity of MENT. The lack of detected effect of either androgen in Hong Kong men other than on waking erection illustrates the importance of the cultural context of symptomatology and its measurement. The appropriate dose of MENT remains to be determined, but these results support its development as a potential androgen replacement therapy.

Objectives: To study the incidence of undiagnosed breech and to compare the obstetric outcome with those diagnosed before the onset of labour in a local teaching hospital where external cephalic version at term is routinely offered., Design: A retrospective casenote analysis., Setting: Tsan Yuk Hospital, a teaching hospital in Hong Kong., Participants: One hundred and thirty-one women with a singleton breech presentation at term, delivered in a local teaching hospital from 1 January 1997 to 31 December 1997. The group of 22 women who had successful external cephalic version performed was included., Results: Breech presentation was diagnosed at the antenatal clinic in 103 women (79%). In the remaining 28 women (21%), breech presentation was diagnosed for the first time after the onset of labour. Undiagnosed breech presentations were more likely to deliver vaginally (42%) than those diagnosed at the antenatal clinic (11%) (P < 0.001). Vaginal delivery was still more common in the undiagnosed group (46%) than the diagnosed group (26%), even when the group with successful external cephalic version was included (P < 0.05), although the difference became less obvious. The demographic characteristics, birthweight, type of breech and short term neonatal outcomes were comparable between the two groups., Conclusion: It is important to include women who had successful external cephalic version when comparing the obstetric outcome of undiagnosed and diagnosed breeches. Careful assessment for vaginal delivery is still very useful even when breech presentations are first diagnosed after the onset of labour because the infants are even more likely to deliver vaginally with no great excess of neonatal morbidity.

We performed a prospective nonrandomized multicentre study to compare laparoscopic surgery and laparotomy in the immediate surgical outcome of tubal ectopic pregnancy (TEP), at 9 teaching hospitals in Hong Kong with a laparoscopic surgical service, on all patients with the operative diagnosis of tubal ectopic pregnancy between July 1, 1996 and June 30, 1997. In the period studied, 630 patients were recruited of which 614 were suitable for analysis. In them, 382 (62.2%) had laparoscopic surgery while the rest had laparotomy with or without diagnostic laparoscopy. Significantly more cases of shock ended in laparotomy (86.1% versus 13.9%). After exclusion of patients with shock, laparoscopic surgery offered a significantly shorter postoperative hospital stay (mean 2.7 days versus 5.3 days), a slightly lower perioperative complication rate (8.1% versus 13.9%) and more conservative surgery (90.1% of all salpingotomies) than laparotomy. A longer operating time was needed for laparoscopic surgery (1.2 hours versus 1.01 hours).

Background: The evolution of myomectomy 'scars' has not been reported. This prospective study was carried out to determine the evolution of the myomectomy 'scars' following conventional open myomectomy., Methods: Ten patients admitted for myomectomy were recruited. The sizes of the leiomyomata were determined with ultrasonography. Serial sonographic examinations were performed following the open myomectomy so as to determine the morphology and volume of the scars. The volumes of the uterus were also measured to document the postoperative remodeling of the uterus., Results: The myomectomy 'scars' were represented by an area with mixed echogenic echoes in the immediate postoperative period. In one month, their volumes decreased to less than 5% of the preoperative volumes and were reduced to vague areas marked by short echogenic lines at 6 months. Most of the remodeling of the uterus occurred in the first month postoperatively., Conclusions: The mixed echogenic areas probably represented the approximated myometrial walls of the leiomyomata. Detection of such in postoperative sonography should not cause undue alarm.

Trauma to abdominal wall blood vessels occurs following 0.2-2% of laparoscopic operations. This prospective observational study assessed the possible role of sonographic localization of abdominal blood vessels prior to laparoscopic surgery in Chinese women and compared the findings reported in a Western group. The inferior epigastric and superficial circumflex iliac vessels were located by color Doppler imaging. Ultrasonography was 100% and 80% successful in locating the inferior epigastric and the superficial circumflex iliac vessels, respectively. The positions of the inferior epigastric vessels were similar to those reported in the Western population whilst the superficial circumflex iliac vessels were found to be situated 1 cm more medially. In our study population, a safe area for entry of lateral ports appeared to be 7 cm from the midline and 5 cm above the pubic symphysis. Sonographic localization of abdominal blood vessels is a potentially useful clinical tool in the prevention of blood vessel trauma.

Objective: To assess the accuracy of the cervical smear and colposcopy in diagnosing low grade squamous intraepithelial lesions (LSIL), and the natural history of LSIL., Method: The cytological, colposcopic and histological findings of 145 patients with a smear diagnosis of LSIL were compared, and the final outcome studied., Results: The diagnosis of LSIL either by cytology alone or in combination with colposcopy was associated with a rate of overdiagnosis of 11.7% and 6.9%, respectively, and a rate of underdiagnosis of 31.0% and 26.2%, respectively. Spontaneous regression of lesions occurred in 81.1% of patients with proven LSIL, with regression within 24 months in 4/5 of cases., Conclusions: The degree of dysplasia shown in the cervical smear correlated poorly with histology. All patients with cervical smear showing LSIL should have colposcopy and colposcopic-directed biopsy to exclude the presence of more advanced lesions. In the absence of some serious lesions, it is then acceptable to observe the patient for 24 months before adopting definite treatment, as spontaneous regression is common.

A retrospective review was made of patients who underwent day surgery at a gynaecological day practice in Hong Kong from October 1993 to June 1994. The first three months of practice, which involved 326 patients, was analysed separately. During the initial period, 49.5% of patients who had gynaecological operations were managed as day patients. The rates for patients with prolonged hospital stay and cancelled operations were 15.6% and 3.0%, respectively. In the subsequent period, the incidence of prolonged hospital stay decreased to 7.4%, while the cancellation rate was similar, at 3.6%. Patients with a prolonged hospital stay were less likely to be Chinese, were more likely to have other medical problems, to be of American Society of Anesthesiologists Class II, and to have procedures that involved opening of the peritoneal cavity. Non-medical problems were an important reason for prolonged hospital stay (37.4%). The stay rate could be reduced by provision of a separate operating facility and by improved counselling and selection of patients.

Transperineal sonography has been described as being useful in assessing patients in special clinical situations such as posterior placenta previa, preterm labor, stress incontinence, and vaginal atresia. We explored the feasibility of this approach in assessing the uterine circulation in 54 subjects, of whom 36 were postmenopausal. We found that visualization of the uterine artery by the transperineal approach was satisfactory in most patients. The uterine arterial Doppler indices obtained from this approach were compared with those obtained by the transvaginal route. Highly significant correlations were found (correlation coefficient tau for pulsatility index = 0.74, p < 0.0001). No significant differences in results between the two approaches were detected using the Wilcoxon Matched-Pairs Signed-Rank test. We conclude that transperineal Doppler studies of the uterine circulation are possible and may be useful in certain patient groups.

An observational study on the role of Doppler sonography in the assessment of patients with malignant trophoblastic disease was performed in an Oncology Unit of a University teaching hospital. A total of 32 consecutive patients referred for chemotherapy were recruited. Twenty-three non-pregnant and 18 women in the first trimester of pregnancy acted as controls. The patients were prospectively followed-up for 2 years. It was found that the uterine arterial resistance index and pulsatility index in patients who required chemotherapy were significantly lower when compared with the non-pregnant and pregnant controls; (Student t-test; P < 0.001 and P < 0.01, respectively). Stepwise regression analysis of beta-hCG titres on uterine artery resistance index showed significant correlation, after controlling for uterine volume (adjusted multiple R = 0.71, P < 0.00001). There were, however, no significant independent associations between the initial uterine artery resistance index and the need for chemotherapy, number of courses of chemotherapy required, duration required for the beta-hCG titre to return to normal, presence of metastatic disease, or the subsequent development of drug resistance or relapse. It was concluded that uterine arterial Doppler indices are significantly correlated with trophoblastic activity (beta-hCG titres) in malignant trophoblastic disease. However, their role in the prediction of subsequent tumour behaviour need to be assessed in larger series.

Objective: To determine if the current definition of antenatal anaemia (haemoglobin < 10 g/dl) has any clinical significance., Study Design: A retrospective study on all singleton deliveries over a 3-year period in two teaching hospitals under one university department was conducted by the extraction of data from a computer database. The major pregnancy complications and perinatal outcome were compared between mothers with and without anaemia and adjusted for parity., Results: The incidence of multiparity was significantly higher in the 817 anaemia patients compared to the 10125 non-anaemia patients, but there was no difference in the incidence of other major antenatal complications, type of labour or mode of delivery, incidence of preterm delivery, or perinatal mortality or morbidity, after adjusting for parity. Among the anaemia patients, those with thalassaemia trait (54.8%) had a significantly higher incidence of gestational glucose intolerance but the incidences of other complications and the perinatal outcome were similar to the iron deficiency patients., Conclusion: Antenatal anaemia, defined as a maternal haemoglobin of < 10 g/dl, does not adversely affect pregnancy outcome. This raises the question of whether the diagnosis of anaemia should be redefined.

Objective: To study the use of middle cerebral arterial Doppler findings in a group of high-risk fetuses as a predictor of adverse perinatal outcome, including subsequent neurologic handicap., Methods: A group of very high-risk fetuses was recruited over a 2-year period for study. Weekly fetal biometries and Doppler studies of the umbilical artery and middle cerebral arteries were carried out until delivery. Main outcome indices analyzed included birth weight ratio (ratio of observed birth weight to mean birth weight for gestation), days of ventilator requirement, neonatal intracranial hemorrhage or periventricular leukomalacia, necrotizing enterocolitis, and follow-up data on major neurologic handicap and death., Results: Seventy-four patients were recruited. One hundred thirty-four sets of examinations were made and prospective follow-up data were available for up to 2 years. The ratio of the umbilical and middle cerebral arterial resistance index was found to be inversely proportional to the birth weight ratio. Fetuses who had a high prenatal umbilical-cerebral Doppler ratio had significantly lower birth weight ratios than those with normal findings (0.72 versus 0.92; P < .001). The ratio was a more sensitive marker for growth restriction (sensitivity 78%) than conventional fetal biometry and umbilical arterial systolic-diastolic ratio. However, fetuses with high ratios did not have higher incidences of perinatal complications or subsequent neurologic handicap., Conclusion: Prenatal cerebral vasodilation is a sensitive marker for growth restriction and it seems to be a physiologic response to hypoxia. Fetuses with intrauterine cerebral vasodilation do not have increased risk for subsequent gross neurologic damage.

Objective: To assess whether colour Doppler sonography can replace pelvic arteriography in the assessment of patients with gestational trophoblastic disease., Design: An observational study in which patients with gestational trophoblastic disease were assessed with both pelvic arteriography and colour Doppler sonography., Setting: The oncology unit of the Department of Obstetrics and Gynaecology, University of Hong Kong. The unit is the main tertiary referral centre for treatment of trophoblastic diseases in Hong Kong., Subjects: Thirty-two consecutive women referred over an 18 month period., Main Outcome Measures: The site of localisation of the tumour and the size of the tumour as assessed by both methods., Results: Eleven patients had a spontaneous fall of beta-hCG titres and did not have pelvic arteriograms performed. The remaining 21 patients had both investigations performed. Four patients had no evidence of abnormal pelvic vessels either on colour Doppler sonography or on pelvic arteriography. Their raised beta hCG titres were due to metastatic disease elsewhere. In the remaining patients the location of the tumour vessels was found to be concordant between the two methods of imaging. Measurements of the mean diameter of tumour bulk by the two methods also agreed well (r = 0.93, P < 0.0001). Pelvic arteriogram over-estimated the size of the tumour in two patients by 2 and 3 cm, respectively, but this did not alter the risk categories of the patients., Conclusion: Colour Doppler sonography is a noninvasive technique that can replace pelvic arteriography in the assessment of patients with trophoblastic diseases.