Adnexal torsion with a paraovarian cyst in a teenage girl

Adnexal torsion with a paraovarian cyst in adolescent or premenarchal girls is extremely rare and very difficult to diagnose before surgery. We identified three published cases of the disorder in adolescent or premenarchal girls. Our patient, a 12.5-year-old girl, is the fourth. The cyst was excised and the adnexa untwisted at laparoscopy. High awareness and timely laparoscopy contributed to conservation of the adnexa in our young patient.

Red blood cell survival and kinetics during pregnancy

Profound changes occur during pregnancy in the maternal hematopoietic system in order to meet the needs of the developing fetus and of the mother. By presenting the available data in one review, this review links all known hematopoietic events that occur during normal and certain abnormal pregnancies. Erythropoietin and erythrocyte production are increased during normal pregnancy while erythrocyte mass per unit of body weight remains constant throughout the entire pregnancy, and hemoglobin and hematocrit continuously decrease into the third trimester. Erythrocyte life span is decreased during normal pregnancy due to 'emergency hemopoiesis' in response to elevated erythropoietin levels. In preeclampsia, maternal erythrocytes are of similar to non-pregnant state age distribution, while fetal erythrocytes are of younger age distribution than in normal pregnancy. In gestational diabetes, maternal erythrocyte age distribution is similar to that of normal pregnancy. In multifetal pregnancy, maternal erythrocyte age distribution is younger than that of normal pregnancy.

Continuous-flow vaginoscopy in children and adolescents

STUDY OBJECTIVE

To assess the role of continuous-flow vaginoscopy in the management of gynecologic problems in pediatric and adolescent patients.

DESIGN

Prospective, observational study (Canadian Task Force classification II-3). Setting. University-affiliated teaching hospital.

PATIENTS

Twenty-two consecutive children and adolescents evaluated for vulvovaginitis (15), vaginal trauma (4), bleeding (2), and genital malformation (1).

INTERVENTION

Continuous-flow vaginoscopy with a 4-mm hysteroscope under general anesthesia.

MEASUREMENTS AND MAIN RESULTS

Vaginal walls, fornices, and cervices were well visualized in all patients. No pathologic findings were found in 16, a foreign body was present in 3, and vaginal lacerations in 3. Foreign material was removed with long straight forceps, bleeding spots were coagulated, and lacerations sutured. No complications occurred. The patients were discharged 4 to 24 hours after the procedure.

CONCLUSION

Diagnosis of gynecologic problems in children and adolescents should include vaginoscopy. Continuous-flow vaginoscopy is quick and easy to perform in these patients.

Comparison of the differential distribution of leukocytes in preeclampsia versus uncomplicated pregnancy

OBJECTIVE

To describe leukocyte count and differential distribution in preeclampsia and uncomplicated pregnancy.

STUDY DESIGN

Blood samples were obtained from 46 consecutive preeclamptic patients and 46 controls with uncomplicated pregnancy. Thirty met the criteria for mild preeclampsia and 16 for severe. The blood was tested within 1 h of venepuncture. An aliquot of the blood was tested in the Cell-Dyn 2000 for complete blood cell count.

MAIN RESULTS

The absolute neutrophil count was significantly elevated in preeclamptic patients as compared with that of controls with uncomplicated pregnancy (9,410.1+/-3,066.9 vs. 7,498.6+/-2,354.0 x 10(6)/l, p < 0.05). In neutrophils, the elevation was more prominent in severe preeclamptic patients as compared with mild preeclamptic patients (10,658.8+/-3520.4 vs. 8,694.4+/-2,561.9 x 10(6)/l, p < 0.05). The absolute lymphocyte and eosinophil counts declined in patients with preeclampsia as compared with uncomplicated pregnancy, whereas monocyte and basophil counts did not differ.

CONCLUSION

Our results suggest that preeclampsia is associated with an increase in the absolute neutrophil count.

Meigs' syndrome: the history of the eponym

Meigs' syndrome is defined as presence of ascites with hydrothorax in association with benign ovarian tumor. The syndrome is named after Joe Vincent Meigs (1892-1963), a Harvard Medical School Professor of Gynecology. However, it was described by several authors in the 19th and the beginning of 20th centuries. Meigs and Cass deserve the credit for awakening the medical profession to the importance of the syndrome in 1937. At the end, the syndrome was coined Meigs' syndrome by Rhodes and Terrell in 1937.

Pectin esterase, polygalacturonase and gel formation in peach pectin fractions

Peaches (Prunus persica cv. Hermoza) were stored at 0C in regular air (RA) or in controlled atmosphere (CA 10% CO2, 3% O2) for 4 weeks and then ripened for 4 days at 20 degrees C. Woolliness developed in the regular air stored fruit while the controlled atmosphere stored fruit ripened normally. In the woolly fruit symptoms of the disorder were greater in the inner mesocarp than in the outer. Polygalacturonase (PG) and pectin esterase (PE) activities differed in the outer and inner mesocarp of the affected fruit. PG activity was low and PE activity was high in the inner mesocarp of the woolly fruit during ripening relative to the outer mesocarp, while in the healthy fruit, activities were similar in both areas. Cell wall fractions of water-soluble, CDTA-soluble and carbonate-soluble pectins were prepared from freshly harvested peaches and incubated with PE and PG from ripe peaches at different ratios. Only the CDTA-soluble fraction formed a gel with peach enzymes, and the rate of gelation increased with increasing amounts of PE relative to PG. Both water-soluble and CDTA-soluble pectin fractions formed gels with commercial PE (extracted from orange peel). The PE extracted from peaches was stable when stored at 0 degrees C for 9 days, while PG activity was stable only for 1 day. We suggest that PE, acting on pectins in the cell wall in vivo may cause gel formation and that the CDTA-soluble polymers have the capacity to bind apoplastic water and create the dry appearance observed in woolly fruit.

Non-adherence in pediatric liver transplant recipients--an assessment of risk factors and natural history

Despite the fact that non-adherence to medical therapy is one of the major causes of late morbidity and mortality in pediatric liver transplant recipients, little is known of the risk factors involved in this behavior. Three cases of fatal non-adherence are reported. Factors associated with non-adherence were investigated by performing a retrospective chart review of a panel of 27 variables in an age-matched cohort of 15 pediatric liver transplant recipients. The most striking differences between the severely non-adherent group and the age-matched cohort included history of substance abuse, child abuse (physical or sexual), not having two parents at home, having received public assistance, having been diagnosed with a psychiatric disorder, and history of school dropout. In addition it appeared that a pretransplant diagnosis of autoimmune hepatitis was associated with more significant medical sequelae related to non-adherence. These findings are preliminary owing to the retrospective design of this study, but could be used as a starting point for a prospective study of this important phenomenon.

Transient myocardial ischemia may occur following subendometrial vasopressin infiltration

A case of transient myocardial ischemia following subendometrial vasopressin infiltration in intractable intra-operative postpartum bleeding due to placenta accreta is described. In our experience, the rate of this side effect is one in 14 patients (rate of 7.1%). We believe that the benefits of the treatment outweigh the risks, since the uterus was saved in all 14 patients. Nevertheless, this case emphasises that extreme precaution is needed with subendometrial vasopressin infiltration. It should be emphasised that the needle must not be within a blood vessel because intravascular injection of vasopressin solution can precipitate acute arterial hypertension, bradycardia and even death. We suggest that local vasopressin infiltration into the placental site is indicated in cases of intractable bleeding at cesarean section after other conventional obstetric and pharmacological maneuvers have failed.

Characteristics of normal lochia

The objective of this paper is to determine the characteristics of each phase of lochia and how these may be influenced by a number of obstetric variables. Thirty-nine healthy women who had spontaneous vaginal delivery following uncomplicated pregnancy volunteered to complete a diary sheet immediately postpartum. The women were instructed to assess the color of their lochia by a color slide with differential gradation from dark red to white. The color was labeled as rubra (red, red-brown), serosa (brown-pink, brown), or alba (yellow, white). The overall duration of lochia was 36.0 +/- 7.5 days (range 17 to 51 days, median 37 days). Three types of lochia color patterns were identified: type 1--rubra-->serosa-->alba sequence (n = 20); type 2-rubra-->serosa-->alba sequence with prolonged rubra phase and short serosa and alba phases (n = 11); and type 3-with two rubra phases (rubra-->serosa/alba-->rubra-->serosa/alba sequence with near-equal duration of each phase) (n = 8). The rubra phase lasts 12.1 +/- 6.7 days in type 1, 24.8 +/- 5.0 days in type 2, and 5.5 +/- 2.5 days (the first rubra) in type 3 pattern (p < 0.05). There was a higher proportion of lactating women among women with type 1 pattern as compared with type 2 (11/20 and 2/11, p < 0.05, respectively). Women with type 2 pattern were of higher parity (2.8 +/- 1.3) as compared with those with type 1 (1.8 +/- 0.8) (p < 0.05). There were no significant differences in infants' birth weight between the various color types (3,276.0 +/- 379.8 g, 3,564.4 +/- 737.9 g, and 3,080.0 +/- 180.0 g for type 1, type 2, and type 3, respectively. There were no significant differences in overall duration of lochia or gestational age at delivery between the various color types. The results confirm the clinical impression that lochia persists longer than classically reported and is of diverse patterns. Three unique types of color patterns were identified. Type 1 is the most prevalent and is associated with prolonged breast feeding and thus can be considered as the classic type. Type 2 is associated with short or no breast feeding and higher parity. Type 3 may be a variant of type 2. We suggest that traditional teaching on lochia characteristics needs reappraisal.

A pilot study of posttraumatic stress and nonadherence in pediatric liver transplant recipients

BACKGROUND

Symptoms of posttraumatic stress disorder (PTSD) were described in survivors of life-threatening diseases, the trauma being the experiences associated with the disease or its treatment. Their prevalence in liver transplant recipients is unknown. Based on clinical observations, we hypothesize that a significant proportion of pediatric liver transplant recipients suffers from PTSD symptoms. We further hypothesize that nonadherence (noncompliance) to medical management may, in some cases, be associated with these symptoms. Traumatized patients, according to this hypothesis, will avoid taking their medications, because these serve as painful reminders of the disease.

OBJECTIVES

To determine the prevalence of PTSD symptoms in a sample of pediatric liver transplant recipients. To determine whether symptoms of PTSD are associated with nonadherence in these patients. To describe the clinical presentation of PTSD and the management of severe nonadherence in patients who suffer from this disorder.

METHODS

Nineteen pediatric liver transplant recipients and their caretakers were interviewed, using the UCLA Post Traumatic Stress Disorder Reaction Index (PTSRI). Data were obtained on a few demographic parameters and perception of disease threat. Adherence was evaluated by 2 methods: 1) a clinician panel (taking into account the clinical sequelae of severe nonadherence); and 2) computation of the standard deviations (SDs) of consecutive determinations of blood levels of Tacrolimus (a higher SD means higher variability between individual measures and is therefore an indicator of nonadherence). As an illustration of the general phenomenon, we describe 3 cases of liver transplant recipients who were nonadherent and who suffered from PTSD.

RESULTS

Six of 19 patients had positive scores on all 3 components of the PTSRI (PTSD patients). Three of these, and none of the others, were considered significantly nonadherent by the panel. Therefore, nonadherence was significantly associated with the existence of symptoms from all 3 domains of PTSD (Fisher's exact test) in our sample. In particular, a high avoidance score on the PTSRI was highly correlated with panel-determined nonadherence. Further, SD of medication levels were significantly higher in PTSD patients, compared with the rest of our sample. No significant differences were found in perception of disease threat or demographic variables between PTSD patients and the rest of our sample. The 3 cases that we describe became adherent to their medications when symptoms of PTSD subsided during the course of therapy.

CONCLUSIONS

Clinically significant nonadherence, determined by 2 different methods, was associated with the full spectrum of PTSD symptoms in this sample. It was especially associated with a high avoidance score, which suggests that avoidance of reminders of the disease (eg, medications) may be a mechanism of nonadherence. Screening for and management of these symptoms, therefore, may improve adherence. This novel concept may be applicable to other patient populations. However, more data are needed before any definite conclusions can be drawn.

Assisted internal autorotation with vacuum extractor. Description of an original maneuver

The traditional treatment of arrest of internal rotation of fetal head is forceps. We describe a maneuver for assisted internal autorotation of fetal head with vacuum extractor. We have used this approach in 30 parturients. No neonatal or maternal complications were noted.

Disseminated intravascular coagulopathy in pregnancy: thorough comprehension of etiology and management reduces obstetricians' stress

In pregnancy and puerperium disseminated intravascular coagulopathy may accompany abruptio placenta, intrauterine fetal demise with retained dead fetus, amniotic fluid embolism, endotoxin sepsis, preecalampsia with HELLP and massive transfusion. Clinical signs and symptoms of DIC can include oozing from venipuncture sites and/or mucous membranes, red cell lysis from activation of the complement system, hemorrhage from coagulopathy and possible uterine atony, hypotension from hemorrhage and/or bradykinin release, and oliguria from end-organ insult and hypovolemia/hypotension. Treatment of DIC consists of replacement of volume, blood products, and coagulation components and cardiovascular and respiratory support with elimination of underlying triggering mechanism.

Human fetal-placental weight ratio in normal singleton near-term pregnancies

OBJECTIVE

To determine the fetal-placental weight ratio in normal near-term singleton pregnancies.

PATIENTS AND METHODS

431 consecutive singleton near-term live deliveries following uncomplicated pregnancies were included in a prospective study. Mean maternal age was 28.6 years (range 17-50), mean parity was 2.9 (range 1-16). Mean gestation age at delivery was 39.7 weeks (range 33-42).

RESULTS

Mean newborn weight was 3,382.1 +/- 486.7 g (range 2,180-4,810). Mean placental weight was 613.0 +/- 123.8 g (range 319-1,266). Mean fetal-placental weight ratio was 5.6 +/- 0.96 (range 2.9-10.6) with kurtosis of 3.6 and skewness of 1.05. The ratio did not differ significantly between male (n = 253) and female (n = 176) infants, 5.7 +/- 0.89 and 5.6 +/- 1.04, respectively. There was a progressive increase in the fetal-placental weight ratio with gestational age (r = 0.87): from 5.3 +/- 0.90 at 33-36 weeks to 5.9 +/- 1.06 at the 41st week and 5.7 +/- 0.71 at the 42nd week (p < 0.05) and with birth weight distribution (r = 0.85) from 5.0 +/- 1. 06 in newborns weighing 2,000-2,499 g to 5.9 +/- 0.94 in newborns weighing >4,000 g (p < 0.05). There was a positive relationship between the fetal-placental weight ratio in teenage and elder parturients (r = 0.98): 5.2 +/- 0.98 (age 17-19), 5.7 +/- 0.88 (age 20-29), 5.6 +/- 1.08 (age 30-39), and 5.7 +/- 0.96 (age 41-50) (p < 0.05). The most contributing variable was birth weight.

CONCLUSIONS

The fetal-placental weight ratio tends to be low in teenage women, early near-term gestational age, and low fetal weight. There was a progressive increase in the fetal-placental weight ratio with gestational age and with birth weight distribution.

Uterine flora at cesarean and its relationship to postpartum endometritis

OBJECTIVE

To evaluate the relationship between the presence of microorganisms at the time of cesarean at different sites of the genital tract and the development of postpartum endometritus.

METHODS

One-hundred thirty-three healthy women who delivered by cesarean were enrolled in this prospective study. Cultures were obtained during the surgery and on days 3-5 postoperatively. Gram staining of uterine cavity fluid was done on days 3-5. Gram stains were examined under a high-power microscope for the presence of polymorphonuclear leukocytes.

RESULTS

Twenty patients (15.0%) met the criteria for postpartum endometritis. Forty-five patients (33.8%) had one or more positive cultures (n = 133) at the time of surgery, resulting in 93 positive cultures and 123 bacterial isolates. Forty-four patients had positive postoperative uterine cavity cultures at days 3-5 postpartum, resulting in 65 isolates. Of 44 patients with a positive postoperative culture, 26 (59.1%) also had Gram stain positive for polymorphonuclear leukocytes in the uterine cavity fluid, whereas only six of 89 patients (6.7%) with negative postoperative culture had a positive Gram stain (P < .05). The relative risk of having a positive culture on postoperative day 3-5 if the culture at surgery was positive at any site was 15.6 (95% confidence interval [CI] 5.9, 42.2), and it was 19.5 (95% CI 6.8, 57.8) if the culture was positive at the lower uterine segment.

CONCLUSION

The presence of bacteria in the lower uterine segment at the time of the surgery predicts their presence in the uterine cavity during puerperium. The Gram stain of uterine cavity fluid on postcesarean days 3-5 is another quick tool that can expedite the diagnosis of postpartum endometritis.