Trabalhos Originais Archives - Page 2 of 51 - Revista Brasileira de Ginecologia e Obstetrícia
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):513-519
DOI 10.1590/S0100-72032002000800003
Purpose: to study pregnancy in adolescent women as a possible risk factor for low birth weight. Material and Methods: a cross-wide study was performed on 562 adolescent and non-adolescent mothers who were interviewed during the first 24 h after delivery in the period from January 10,2002, to March 25, 2002, in a public maternity hospital located in Rio Branco, Acre State, Brazil. Those who delivered dead fetuses, whose babies died after being born, or had twins were excluded from the study. Results: among the 562 mothers who were studied, 37.0% (n=208) were teenagers (16±1.6 years), and 63.0% (n=354) were 20 or more years old (22.9±6.3 years). The average weight of the newborns was statistically higher (p<0.010) among the adult mothers (3,158.64±626.50 g) than among the adolescent mothers (3,019.93±587.43 g). When the 32 (5.7%) premature newborn babies (<37 week's pregnancy) were excluded, there was also a significantly greater proportion (p<0.007) of newborns with low weight (<2,500 g) among the adolescent mothers (11.9%) than among the non-adolescent ones (5.5%). The analysis of logistic regression showed an increased risk for newborns with low weight among the adolescent mothers (OR=2.99; 1.47-6.07), as well as for abortion (OR=2.78; 1.23-6.30) and pregnancy - induced hypertensive disorders (OR=5.16; 1.65-16.12). Conclusions: the present study shows that associated with the psychosocial, familial, and economic impact, already reported in the literature, pregnancy in adolescents is associated with deleterious effects on the conceptus, which requires a cohort study to assess the repercussions at both the medium- and long-term.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):513-519
DOI 10.1590/S0100-72032002000800003
Purpose: to study pregnancy in adolescent women as a possible risk factor for low birth weight. Material and Methods: a cross-wide study was performed on 562 adolescent and non-adolescent mothers who were interviewed during the first 24 h after delivery in the period from January 10,2002, to March 25, 2002, in a public maternity hospital located in Rio Branco, Acre State, Brazil. Those who delivered dead fetuses, whose babies died after being born, or had twins were excluded from the study. Results: among the 562 mothers who were studied, 37.0% (n=208) were teenagers (16±1.6 years), and 63.0% (n=354) were 20 or more years old (22.9±6.3 years). The average weight of the newborns was statistically higher (p<0.010) among the adult mothers (3,158.64±626.50 g) than among the adolescent mothers (3,019.93±587.43 g). When the 32 (5.7%) premature newborn babies (<37 week's pregnancy) were excluded, there was also a significantly greater proportion (p<0.007) of newborns with low weight (<2,500 g) among the adolescent mothers (11.9%) than among the non-adolescent ones (5.5%). The analysis of logistic regression showed an increased risk for newborns with low weight among the adolescent mothers (OR=2.99; 1.47-6.07), as well as for abortion (OR=2.78; 1.23-6.30) and pregnancy - induced hypertensive disorders (OR=5.16; 1.65-16.12). Conclusions: the present study shows that associated with the psychosocial, familial, and economic impact, already reported in the literature, pregnancy in adolescents is associated with deleterious effects on the conceptus, which requires a cohort study to assess the repercussions at both the medium- and long-term.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):521-526
DOI 10.1590/S0100-72032002000800004
Purpose: to assess the evolution of epileptic seizures during pregnancy and the occurrence of malformations in neonates born to epileptic mothers who used anticonvulsant drugs during pregnancy, as well as the perinatal characteristics of the newborns. Methods: a total of 126 medical records of epileptic patients seen at the high-risk pregnancy outpatient clinic were analyzed retrospectively in terms of the following variables: age, parity, diagnosis of the type of epileptic seizure, anticonvulsant drug used during the prenatal period, evolution of epileptic seizures during the prenatal period, type of delivery, gestational age at resolution, and perinatal characteristics of the newborns. Results: the incidence of pregnant women with epilepsy was 0.2% in relation to prenatal patients, with simple partial epilepsy being the most frequent type (40% of cases). Monotherapy was applied to 75% of the patients and carbamazepine was the most frequently used drug. Among the 111 patients evaluated in terms of course of the disease during pregnancy, 53% showed no change, 31% became worse and 16% improved. Normal delivery was performed in 62.5% of cases, with a satisfactory perinatal result in terms of Apgar score, and with a rate of low birth weight neonates above the values for low-risk populations. No fetal malformations were observed. Conclusion: epilepsy showed a favorable course during pregnancy and was not aggravated by the latter, with cases of worsening of signs and symptoms being associated with epilepsy of difficult control before pregnancy. Evaluation of the perinatal characteristics of the neonates showed satisfactory Apgar scores and evolution, indicating that epilepsy and anticonvulsant drugs do not cause severe impairment of intrapartum vitality. No cases of malformations or hemorrhagic complications were detected in the present study.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):521-526
DOI 10.1590/S0100-72032002000800004
Purpose: to assess the evolution of epileptic seizures during pregnancy and the occurrence of malformations in neonates born to epileptic mothers who used anticonvulsant drugs during pregnancy, as well as the perinatal characteristics of the newborns. Methods: a total of 126 medical records of epileptic patients seen at the high-risk pregnancy outpatient clinic were analyzed retrospectively in terms of the following variables: age, parity, diagnosis of the type of epileptic seizure, anticonvulsant drug used during the prenatal period, evolution of epileptic seizures during the prenatal period, type of delivery, gestational age at resolution, and perinatal characteristics of the newborns. Results: the incidence of pregnant women with epilepsy was 0.2% in relation to prenatal patients, with simple partial epilepsy being the most frequent type (40% of cases). Monotherapy was applied to 75% of the patients and carbamazepine was the most frequently used drug. Among the 111 patients evaluated in terms of course of the disease during pregnancy, 53% showed no change, 31% became worse and 16% improved. Normal delivery was performed in 62.5% of cases, with a satisfactory perinatal result in terms of Apgar score, and with a rate of low birth weight neonates above the values for low-risk populations. No fetal malformations were observed. Conclusion: epilepsy showed a favorable course during pregnancy and was not aggravated by the latter, with cases of worsening of signs and symptoms being associated with epilepsy of difficult control before pregnancy. Evaluation of the perinatal characteristics of the neonates showed satisfactory Apgar scores and evolution, indicating that epilepsy and anticonvulsant drugs do not cause severe impairment of intrapartum vitality. No cases of malformations or hemorrhagic complications were detected in the present study.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):527-533
DOI 10.1590/S0100-72032002000800005
Purpose: to analyze the perinatal results of patients submitted to a 100 g oral glucose tolerance test (OGTT) during prenatal care at the Instituto Materno-Infantil de Pernambuco (IMIP), according to three different criteria. Methods: a cross-sectional study was conducted involving 210 pregnant patients attended at the IMIP, who were tested by a 100 g OGTT and had a singleton, topic pregnancy, without history of diabetes or glucose intolerance before pregnancy, and who delivered at the IMIP. The patients were classified into one of the following categories according to the levels found by OGTT: controls, mild hyperglycemia, Bertini's group, Carpenter's group and the National Diabetes Data Group (NDDG). These classes were then compared and association between the categories and preeclampsia, large for gestational age (LGA) newborns, rate of cesarean delivery, stillbirth, and mean birth weight was investigated. Results: the frequency of gestational diabetes was 48.1, 18.1, and 9% according to Bertini's, Carpenter and Coustan's and NDDG criteria, respectively, and mild hyperglycemia was present in 10.5%. Age of patients increased with a higher degree of carbohydrate intolerance. The groups did not differ regarding frequency of LGA, C-section, stillbirths, and birth weight. There was an increased frequency of preeclampsia among women with hyperglycemia and gestational diabetes according to Carpenter and Coustan's criteria. Conclusions: prevalence of gestational diabetes varied between 9 and 48% according to the different criteria, but maternal and perinatal results did not differ significantly among the groups. Strict diagnostic criteria can determine overdiagnosis without improvement of perinatal outcome.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):527-533
DOI 10.1590/S0100-72032002000800005
Purpose: to analyze the perinatal results of patients submitted to a 100 g oral glucose tolerance test (OGTT) during prenatal care at the Instituto Materno-Infantil de Pernambuco (IMIP), according to three different criteria. Methods: a cross-sectional study was conducted involving 210 pregnant patients attended at the IMIP, who were tested by a 100 g OGTT and had a singleton, topic pregnancy, without history of diabetes or glucose intolerance before pregnancy, and who delivered at the IMIP. The patients were classified into one of the following categories according to the levels found by OGTT: controls, mild hyperglycemia, Bertini's group, Carpenter's group and the National Diabetes Data Group (NDDG). These classes were then compared and association between the categories and preeclampsia, large for gestational age (LGA) newborns, rate of cesarean delivery, stillbirth, and mean birth weight was investigated. Results: the frequency of gestational diabetes was 48.1, 18.1, and 9% according to Bertini's, Carpenter and Coustan's and NDDG criteria, respectively, and mild hyperglycemia was present in 10.5%. Age of patients increased with a higher degree of carbohydrate intolerance. The groups did not differ regarding frequency of LGA, C-section, stillbirths, and birth weight. There was an increased frequency of preeclampsia among women with hyperglycemia and gestational diabetes according to Carpenter and Coustan's criteria. Conclusions: prevalence of gestational diabetes varied between 9 and 48% according to the different criteria, but maternal and perinatal results did not differ significantly among the groups. Strict diagnostic criteria can determine overdiagnosis without improvement of perinatal outcome.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):535-539
DOI 10.1590/S0100-72032002000800006
Purpose: to study the association between long-standing type 1 diabetes with bad glycemic control and breast inflammatory lesions which can simulate inflammatory carcinoma. Patients and Methods: eighteen patients were studied, retrospectively, in a mastology reference center from January 1998 to December 2001, presenting with breast inflammatory lesion with or without palpable mass. They were submitted to serum glucose and glycosylated hemoglobin determination, as well as image examination and histopathologic analysis, and diabetic mastopathy was diagnosed. Results: the patients' average age was 50.2 years, and all had insulin-dependent diabetes mellitus, with average disease time of 14.9 years. All patients, with no exception, had a bad glycemic control; the average blood glucose was 329.6 mg/dL and the glycosilated hemoglobin average was 9.7%. NPH insulin dose being applied per day was 37.2 units. Patients underwent a clinical treatment with antibiotics and control of the glycemic levels with NPH insulin and had resolution of the symptoms in about five weeks. Conclusion: the professionals involved in women health care must be aware of this inflammatory pathology of the breast and its benign characteristics to avoid unnecessary procedures sometimes with patient injury.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):535-539
DOI 10.1590/S0100-72032002000800006
Purpose: to study the association between long-standing type 1 diabetes with bad glycemic control and breast inflammatory lesions which can simulate inflammatory carcinoma. Patients and Methods: eighteen patients were studied, retrospectively, in a mastology reference center from January 1998 to December 2001, presenting with breast inflammatory lesion with or without palpable mass. They were submitted to serum glucose and glycosylated hemoglobin determination, as well as image examination and histopathologic analysis, and diabetic mastopathy was diagnosed. Results: the patients' average age was 50.2 years, and all had insulin-dependent diabetes mellitus, with average disease time of 14.9 years. All patients, with no exception, had a bad glycemic control; the average blood glucose was 329.6 mg/dL and the glycosilated hemoglobin average was 9.7%. NPH insulin dose being applied per day was 37.2 units. Patients underwent a clinical treatment with antibiotics and control of the glycemic levels with NPH insulin and had resolution of the symptoms in about five weeks. Conclusion: the professionals involved in women health care must be aware of this inflammatory pathology of the breast and its benign characteristics to avoid unnecessary procedures sometimes with patient injury.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):541-545
DOI 10.1590/S0100-72032002000800007
Purpose: to evaluate the diagnostic accuracy of sonohysterography as a diagnostic method for the evaluation of the uterine cavity in postmenopausal women with abnormal uterine cavity at conventional endovaginal sonography. Methods: this study consisted of the evaluation of 99 postmenopausal patients with abnormal uterine cavity on conventional endovaginal sonography, that was defined as endometrial thickness equal to or larger than 5 mm in a postmenopausal patient not on hormone replacement therapy, or endometrial thickness equal to or larger than 8 mm in patients on hormone replacement therapy, with irregular bleeding. These patients were subjected to sonohysterography, and specimens were obtained for pathologic examination by biopsy guided by histeroscopy in 92 patients, endometrial biopsy in four patientes and hysterectomy in three patients. The results of sonohysterography were compared with the pathologic findings, considered "gold standard". Results: there were eight cases of normal uterine cavity and 20 cases of atrophic endometrium and sonohysterography had high levels of specificity (97.8 and 97.5%) and low sensitivity (35 and 25%). There were high levels of sensitivity (92.3 and 75.0%) and specificity (94.1 and 97.9%) for polyps (65 cases) and submucous myomas (four cases). There were three cases of endometrial carcinoma and the sonohysterography had a sensitivity and specificity of 100%. Conclusions: sonohysterography showed to be accurate in the diagnostic of focal diseases (endometrial polyps and submucous myomas). There were three cases of endometrial cancer, and sonohysterography correctly diagnosed all of them. This method was also accurate to exclude endometrial abnormality. However, in the cases of diffusely thickened endometrium, the accuracy was low, because atrophic and normal endometrium on histopathology frequently appears as diffusely thickened endometrium at endovaginal sonography and sonohysterography. Sonohysterography did not lead to complications during and after the procedure.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):541-545
DOI 10.1590/S0100-72032002000800007
Purpose: to evaluate the diagnostic accuracy of sonohysterography as a diagnostic method for the evaluation of the uterine cavity in postmenopausal women with abnormal uterine cavity at conventional endovaginal sonography. Methods: this study consisted of the evaluation of 99 postmenopausal patients with abnormal uterine cavity on conventional endovaginal sonography, that was defined as endometrial thickness equal to or larger than 5 mm in a postmenopausal patient not on hormone replacement therapy, or endometrial thickness equal to or larger than 8 mm in patients on hormone replacement therapy, with irregular bleeding. These patients were subjected to sonohysterography, and specimens were obtained for pathologic examination by biopsy guided by histeroscopy in 92 patients, endometrial biopsy in four patientes and hysterectomy in three patients. The results of sonohysterography were compared with the pathologic findings, considered "gold standard". Results: there were eight cases of normal uterine cavity and 20 cases of atrophic endometrium and sonohysterography had high levels of specificity (97.8 and 97.5%) and low sensitivity (35 and 25%). There were high levels of sensitivity (92.3 and 75.0%) and specificity (94.1 and 97.9%) for polyps (65 cases) and submucous myomas (four cases). There were three cases of endometrial carcinoma and the sonohysterography had a sensitivity and specificity of 100%. Conclusions: sonohysterography showed to be accurate in the diagnostic of focal diseases (endometrial polyps and submucous myomas). There were three cases of endometrial cancer, and sonohysterography correctly diagnosed all of them. This method was also accurate to exclude endometrial abnormality. However, in the cases of diffusely thickened endometrium, the accuracy was low, because atrophic and normal endometrium on histopathology frequently appears as diffusely thickened endometrium at endovaginal sonography and sonohysterography. Sonohysterography did not lead to complications during and after the procedure.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):547-552
DOI 10.1590/S0100-72032002000800008
Purpose: to evaluate the estrogenic effects of soy phytoestrogens in postmenopausal patients. Method: we selected postmenopausal patients from the Climacteric Service of the Gynecology Department of the Federal University of São Paulo - Escola Paulista de Medicina. The patients were divided into two groups: GI (n=40) received daily 100 mg isoflavone (3 x 33.3 mg/day); and GCtr (n=40) received daily placebo. We included in this study the Kuppermann menopausal index, physical examination and the biochemical determination of total and fractions of cholesterol, triglycerides, estradiol, FSH e LH. We also performed sonographic examination to measure endometrial thickness. To compare baseline and after treatment values of both groups, the nonparametric Kruskal-Wallis test was used for the Kuppermann index, while the t test was performed for other data. Results: evaluation of the Kupperman Menopausal Index, 80% patients of GI showed a decrease in the total score, while the improvement of symptoms in GCtr was 12,5%. The analysis of total cholesterol levels showed that 35 patients of GI had levels above 200 mg/dL, and only 13 of GCtr presented similar levels. The body mass index reduction occurred in GI and the control group showed no changes. We also verified that echo endometrial thickness and FSH levels were similar to baseline values. However the values of estrogen increased after isoflavone treatment. Conclusion: we concluded that 100 mg/day isoflavone may be an alternative treatment for attenuating the climacteric symptoms in 80% of isoflavone users and that it reduced total cholesterol.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(8):547-552
DOI 10.1590/S0100-72032002000800008
Purpose: to evaluate the estrogenic effects of soy phytoestrogens in postmenopausal patients. Method: we selected postmenopausal patients from the Climacteric Service of the Gynecology Department of the Federal University of São Paulo - Escola Paulista de Medicina. The patients were divided into two groups: GI (n=40) received daily 100 mg isoflavone (3 x 33.3 mg/day); and GCtr (n=40) received daily placebo. We included in this study the Kuppermann menopausal index, physical examination and the biochemical determination of total and fractions of cholesterol, triglycerides, estradiol, FSH e LH. We also performed sonographic examination to measure endometrial thickness. To compare baseline and after treatment values of both groups, the nonparametric Kruskal-Wallis test was used for the Kuppermann index, while the t test was performed for other data. Results: evaluation of the Kupperman Menopausal Index, 80% patients of GI showed a decrease in the total score, while the improvement of symptoms in GCtr was 12,5%. The analysis of total cholesterol levels showed that 35 patients of GI had levels above 200 mg/dL, and only 13 of GCtr presented similar levels. The body mass index reduction occurred in GI and the control group showed no changes. We also verified that echo endometrial thickness and FSH levels were similar to baseline values. However the values of estrogen increased after isoflavone treatment. Conclusion: we concluded that 100 mg/day isoflavone may be an alternative treatment for attenuating the climacteric symptoms in 80% of isoflavone users and that it reduced total cholesterol.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(7):433-438
DOI 10.1590/S0100-72032002000700002
Purpose: to analyze the correlation between Valsalva leak point pressure and maximum urethral closure pressure and clinical symptoms in women with stress urinary incontinence. Methods: we analyzed retrospectively 164 patients with urodynamic diagnosis of stress and mixed urinary incontinence established by the Urogynecology and Vaginal Surgery Sector of UNIFESP/EPM. All patients were submmited to medical interview, physical examination and urodynamic study. Patients were divided into groups according to the subjective degree of stress urinary incontinence. Valsalva leak point pressure (VLPP) was measured with a vesical volume of 200 mL. Urethral profile was determined using a flow catheter number 8 with measurement of maximum urethral closure pressure (MUCP). Data were compared by chi², ANOVA and Tukey tests. Results: mean age was 51.2 years (19-82), 76 women (47.2%) were in menacme and 85 (52.8%) in postmenopausal status. Mean parity was 3.9 (0-18). The exact test for trend demonstrated a statistically significant (p<0.0001) correlation between the number of patients with VLPP of 60 cmH2O or less and clinical complaints. The group with severe leakage had mean VLPP of 69.1 cmH2O. The group with moderated leakage had mean VLPP of 84.6 cmH2O and the group with mild leakage had mean VLPP of 90.6 cmH2O. Conclusions: VLPP correlated with the subjective degree of stress urinary incontinence. Higher grades of stress urinary incontinence had a higher likelyhood of a low VLPP. MUCP did not correlate with clinical complaints.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(7):433-438
DOI 10.1590/S0100-72032002000700002
Purpose: to analyze the correlation between Valsalva leak point pressure and maximum urethral closure pressure and clinical symptoms in women with stress urinary incontinence. Methods: we analyzed retrospectively 164 patients with urodynamic diagnosis of stress and mixed urinary incontinence established by the Urogynecology and Vaginal Surgery Sector of UNIFESP/EPM. All patients were submmited to medical interview, physical examination and urodynamic study. Patients were divided into groups according to the subjective degree of stress urinary incontinence. Valsalva leak point pressure (VLPP) was measured with a vesical volume of 200 mL. Urethral profile was determined using a flow catheter number 8 with measurement of maximum urethral closure pressure (MUCP). Data were compared by chi², ANOVA and Tukey tests. Results: mean age was 51.2 years (19-82), 76 women (47.2%) were in menacme and 85 (52.8%) in postmenopausal status. Mean parity was 3.9 (0-18). The exact test for trend demonstrated a statistically significant (p<0.0001) correlation between the number of patients with VLPP of 60 cmH2O or less and clinical complaints. The group with severe leakage had mean VLPP of 69.1 cmH2O. The group with moderated leakage had mean VLPP of 84.6 cmH2O and the group with mild leakage had mean VLPP of 90.6 cmH2O. Conclusions: VLPP correlated with the subjective degree of stress urinary incontinence. Higher grades of stress urinary incontinence had a higher likelyhood of a low VLPP. MUCP did not correlate with clinical complaints.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(7):441-446
DOI 10.1590/S0100-72032002000700003
Purpose: to evaluate the reproductive aspects in climacteric women of the Family Health Program in Cuiabá. Methods: it was a cross-sectional study including 354 women, with ages between 40 and 65 years, attended at the Central-Western District Family Health Program of Cuiabá. A pretested questionnaire with specific questions regarding the present study was used. Data were analyzed using the Z test and chi² test for trend. The mean age of the 354 women was 49.7±7 years and the median 48 years. A total of 243 (68.6%) were born in Mato Grosso, and the others were migrants from different states. Most were married (65.8%), white (48.0%), catholic (73.4%), and had low schooling: 62.4% did not finish the elementary school and 19.2% were illiterate. About 84% were occupied only in domestic activities, and more than a half (58.2%) belonged to a lower social class. Results: the average number of pregnancies was 5.4±3.3. Nearly 5% were nulliparous and 7% had more than ten children. Almost 50% had the first pregnancy in adolescence and 14% after the age of 40 years. A total of 229 women (65%) were submitted to pelvic surgery: 78% to tubal sterilization, 20% to hysterectomy, and 7% to bilateral oophorectomy. Menopause was due to hysterectomy/oophorectomy in 25% of the women. Conclusion: almost 65% of the women were submitted to a pelvic surgery. The most frequent surgery was tubal sterilization followed by total hysterectomy.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2002;24(7):441-446
DOI 10.1590/S0100-72032002000700003
Purpose: to evaluate the reproductive aspects in climacteric women of the Family Health Program in Cuiabá. Methods: it was a cross-sectional study including 354 women, with ages between 40 and 65 years, attended at the Central-Western District Family Health Program of Cuiabá. A pretested questionnaire with specific questions regarding the present study was used. Data were analyzed using the Z test and chi² test for trend. The mean age of the 354 women was 49.7±7 years and the median 48 years. A total of 243 (68.6%) were born in Mato Grosso, and the others were migrants from different states. Most were married (65.8%), white (48.0%), catholic (73.4%), and had low schooling: 62.4% did not finish the elementary school and 19.2% were illiterate. About 84% were occupied only in domestic activities, and more than a half (58.2%) belonged to a lower social class. Results: the average number of pregnancies was 5.4±3.3. Nearly 5% were nulliparous and 7% had more than ten children. Almost 50% had the first pregnancy in adolescence and 14% after the age of 40 years. A total of 229 women (65%) were submitted to pelvic surgery: 78% to tubal sterilization, 20% to hysterectomy, and 7% to bilateral oophorectomy. Menopause was due to hysterectomy/oophorectomy in 25% of the women. Conclusion: almost 65% of the women were submitted to a pelvic surgery. The most frequent surgery was tubal sterilization followed by total hysterectomy.