Placenta accreta: Elective versus emergent delivery as a major predictor of blood loss

OBJECTIVE

To compare blood loss and the use for blood transfusion between elective (planned) and emergent cesarean hysterectomy performed for placenta accreta by a single, multidisciplinary team and to present the team's pre-operative evaluation and the surgical technique.

STUDY DESIGN

Prospective cohort study at a single tertiary care center. Maternal and neonatal outcomes were compared between elective and emergent delivery of pregnancies complicated by placenta accreta. The primary outcomes were the need for blood transfusion and the number of units transfused.

RESULTS

A total of 28 cases of confirmed placenta accreta underwent peripartum hysterectomy, including 22 as elective and 6 as emergent. Eleven out of 22 (50%) subjects in the elective group received blood transfusion, while all subjects in the emergency group required transfusion (p = 0.03). More importantly, the number of units of packed red blood cells transfused was only 1.90 (±2.20) units in the elective cases compared to 7.83 (±4.90) units in cases performed emergently (p = 0.03).

CONCLUSION

Elective cesarean hysterectomy for this indication using a clearly outlined surgical approach is associated with significantly lower blood loss and hence less need for transfusion, compared to its emergent counterpart.

Laparoscopic splenectomy for isolated parenchymal splenic metastasis of ovarian cancer

Metastatic carcinoma of the spleen occurs in a setting of widespread malignant disease. Solitary parenchymal splenic metastasis of ovarian carcinoma is rare. We report a case of a 59-year-old woman who presented with an elevated serum CA125 level due to a solitary splenic metastasis after a long disease-free period. She was treated with laparoscopic splenectomy followed by chemotherapy. The literature contains 16 cases of solitary parenchymal splenic metastasis of ovarian carcinoma. Our case is the third case that was treated with laparoscopic splenectomy. We review the literature, and we focus on the laparoscopic approach in managing these cases.

Biodegradation of naphthalene by free and alginate entrapped Pseudomonas sp

Naphthalene degradation by freely suspended and immobilized cells of Pseudomonas sp. isolated from contaminated effluents has been investigated in batch cultures and continuously in a packed bed reactor. Naphthalene concentration was varied from 25 mM to 75 mM, the temperature (30 degrees C) and pH (7.0) were kept constant. The results showed good acclimation of the strain to carbon source and degradation rate was highly affected by initial concentration. Alginate-entrapped cells have given good yields although initial rates were not as high as those encountered with free cells. A first order exponential decay kinetic model was proposed with values of parameters for each initial concentration. A laboratory scale packed-bed bioreactor was designed using parameters calculated above and continuous experiments were realized at different flow rates (100 to 200 ml/h), with different feed concentrations and operating during 30 days. The conversion at low feed concentrations and low flow rates was complete whereas at high flow rates and high concentrations it was less efficient because of diffusional limitations and short residence time.

Case report: endometrial cancer implanting in the laparotomy scar

A 58-year-old woman underwent abdominal hysterectomy and bilateral salpingo-oophorectomy for stage Ib, grade 2 endometrial adenocarcinoma followed by external pelvic irradiation. Five years later she presented with a 7 cm solitary infraumbilical incisional tumor recurrence that was resected. Histology of the tumor implant was similar to that of the primary cancer. The patient was then started on progestin therapy with no evidence of recurrence for four years. To our knowledge this is the fourth reported case of endometrial cancer implanting in an abdominal scar.

Giant cervical polyp. A case report

BACKGROUND

Very large cervical polyps are rarely reported.

CASE

A giant cervical polyp, 17 x 10 x 5 cm, protruded through the vaginal introitus in a 27-year-old, sexually inactive woman.

CONCLUSION

Although carcinomatous change occurs in 1.7% of cervical polyps, malignant degeneration did not occur in the six reported cases. Thus, biopsy of these tumors before excision may not be necessary.

Prolonged intake of chlorambucil for ovarian cancer

The use of alkylating agents has been reported to be a cause of secondary leukemia particularly in patients surviving for 2 years or more after treatment of ovarian carcinoma. The risk of developing leukemia is possibly related to the duration of treatment and the total dose of alkylating agents administered. We report a patient with epithelial ovarian carcinoma who received chlorambucil for 130 consecutive months with no clinical or laboratory evidence of leukemia.

Prenatal sonographic findings in trisomy 13, 18, 21 and 22. A review of 46 cases

A study of 46 patients with trisomic fetuses was performed to determine if there are one or more second-trimester ultrasonic findings predictive of aneuploidy. Videotapes of ultrasonography performed prior to amniocentesis on the 46 fetuses with autosomal trisomy and from a control group of 50 chromosomally normal fetuses were reviewed without knowledge of the karyotype. Fetuses with autosomal trisomies had short long bones, especially femurs, as well as high biparietal diameter/femur length ratios. In addition, a nuchal thickness of > 5 mm, abnormal heart anatomy, slight pyelectasis, increased bowel echogenicity and/or abnormal flexion of the hands were all predictive of autosomal trisomies.

Leiomyosarcoma of the vulva: report of a case

A 52-year-old female presented with a progressively enlarging vulvar mass. Pathological evaluation revealed a high-grade vulvar leiomyosarcoma. Immunohistochemical and ultrastructural studies were performed to support the diagnosis. In an effort to better understand the biology of this tumor additional immunohistochemical studies for the protein product of p53 tumor suppressor gene and estrogen receptor expression by tumor cells, as well as the type of immune cells infiltrating the tumor were performed. Tumor cells showed an overexpression of p53 protein and were estrogen receptor-positive. Macrophages and T and B lymphocytes infiltrated the tumor in moderate numbers with occasional lymphoid aggregate formation. This study is the first attempt to better understand the biology of these tumors.

Outcome of pregnancies complicated by sickle cell and sickle-C hemoglobinopathies

Retrospective analysis was made of office and hospital records of patients with sickle cell hemoglobinopathies. Blood products were transfused only when indicated for symptomatic anemia, severe anemia with a hematocrit less than 18%, sickle crisis, cardiovascular instability, and preoperatively. The Fisher exact test and the Student t test were used for statistical analysis; P < 0.05 was considered significant. All mean values are reported +/- 1 standard deviation. From 1981 to 1991, 40 patients with sickle cell hemoglobinopathies had a total of 61 singleton pregnancies: 36 were complicated by SS disease (SSD), 22 by sickle cell disease (SCD), two by sickle-thalassemia, and one had CC disease (CCD). Only patients with SSD and SCD are reported here. The mean maternal age was 24.3 +/- 5.3 and 19.5 +/- 0.6 years in patients with SSD and SCD, respectively. There was a high occurrence of preterm labor (45% and 20%), preeclampsia (20% and 8.7%), pain crisis (50% and 34.2%), pulmonary complications (25% and 16.7%), and cesarean sections (52.6% and 37.1%) in SSD and SCD, respectively. An average of two units of blood was required by 43.1% of the patients. Two patients with SSD had unpreventable deaths. The mean gestational age at delivery was 35.5 +/- 4.3 and 37.0 +/- 3.7 weeks (P < 0.05), and the mean birthweight was 2443 +/- 926 and 2997 +/- 807 g (P < 0.05), respectively. There were two intrauterine fetal deaths and one neonatal death in the SSD group and one neonatal death in the SCD group. The perinatal mortality was 10.5% and 2.9%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war

OBJECTIVE

To evaluate the value of selective laparotomy in pregnant women with penetrating abdominal injuries.

METHODS

A retrospective survey was carried out at our center over 16 years of civil war, extending from 1975 to 1991. Fourteen pregnant women had uterine injuries secondary to high-velocity abdominal penetrating trauma. The corresponding management was evaluated carefully with respect to maternal and fetal outcomes.

RESULTS

Two maternal deaths occurred, neither resulting solely from intra-abdominal injuries. Visceral injuries were present when the entrance of the missile was in either the upper abdomen or the back. When the entry site was anterior and below the uterine fundus, visceral injuries were absent in all six women upon surgical exploration. Perinatal deaths occurred in half of the cases and were due to maternal shock or uteroplacental or direct fetal injury. Immediate cesarean delivery was performed because of either limited surgical field exposure, fetal injury, or distress. Three patients explored were managed by delaying delivery. All later delivered vaginally with successful fetal outcomes in all three.

CONCLUSION

Selective laparotomy may be considered in pregnant women with anterior penetrating abdominal trauma, as the likelihood of intra-abdominal injuries may be predicted based on the location of the penetrating wound.

Peritoneal papillary serous carcinoma in a woman with a history of utero DES exposure

Antenatal exposure to diethylstilbestrol (DES) has been implicated in the development of clear-cell adenocarcinoma of the vagina and cervix. In addition, there are a handful of case reports of gram cell tumors and other benign ovarian tumors in the offspring of women treated with DES during pregnancy. This the first report of a papillary serous carcinoma of the peritoneum following in utero exposure to DES. As the population of women with a history of in utero exposure to DES is reaching into the fourth decade, these patients need to be closely monitored for the development of gynecologic malignancies, especially epithelial and germ cell ovarian tumors. We also encourage the reporting of these tumors of the DES registry to document the exact incidence of these malignancies.

Gynecologic tumors in tamoxifen-treated women with breast cancer

OBJECTIVES

To present six additional cases of gynecologic tumors in tamoxifen-treated breast cancer patients, review the literature, and recommend measures for surveillance.

METHODS

The hospital and office records of patients treated with tamoxifen at the University of Kansas Medical Center and Research Medical Center were analyzed. A comprehensive review of tamoxifen in the English and European literature was performed using MEDLINE and the bibliographies of various articles.

RESULTS

From 1985-1992 at our institutions, six tamoxifen-treated breast cancer patients developed gynecologic tumors: three endometrial adenocarcinomas, a mixed müllerian sarcoma, a fallopian tube carcinoma with adenofibroma of the endometrium, and recurrent hyperplastic endometrial polyps. The literature contained 61 cases of adenocarcinoma of the endometrium and possibly four cases of uterine sarcomas in tamoxifen-treated breast cancer patients. The number of gynecologic malignancies reported is now 70. In 35 of the patients, the mean age (+/- standard deviation) was 63.9 +/- 12.0 years, and 61 of 66 patients (92.4%) were postmenopausal. Of the endometrial adenocarcinomas, 25 of 27 (92.6%) were stage I, and 11 of 27 (40.7%) were grade 1. The dose of tamoxifen was 20 mg/day in 15 (23.4%), 30 mg/day in 11 (17.2%), and 40 mg or higher in 38 (59.4%); 57% were treated with tamoxifen for less than 2 years.

CONCLUSIONS

Tamoxifen is a safe and reliable treatment of breast cancer, but data suggest an association with endometrial cancer. We propose close monitoring of patients taking tamoxifen and prompt evaluation of any uterine bleeding or pelvic complaint.

Electrical breast stimulation. Oxytocin, prolactin and uterine response

Electrical breast stimulation using a modified electromyograph was performed on 10 pregnant women between 38 and 42 weeks of gestation. An adequate uterine contraction pattern (at least three contractions lasting > or = 30 seconds in a 10-minute interval either recorded by external tochodynamometry, palpated and/or felt by the patient) was obtained in 8 of the 10. Two patients, however, had uterine hyperstimulation (contractions lasting > 90 seconds). In contrast to previous reports, serum oxytocin levels increased significantly in 7 of the 10 patients. Moreover, this increase preceded or was concomitant with the uterine contractions. Serum prolactin varied unpredictably following electrical breast stimulation. The stimulation was well tolerated, without any discomfort, by all the patients. Electrical breast stimulation can thus be used for the stimulation of uterine contractions.

Indications for in vitro fertilisation: changing trends: the Norfolk experience

From January 1987 to December 1990, 1,415 patients were enrolled for in vitro fertilisation (IVF), series 26-41, at the Jones Institute for Reproductive Medicine. They underwent 2,393 IVF cycles. The most common indications were tubal factor (57.3%), male infertility (22.0%), endometriosis (10.9%), and idiopathic infertility (5.2%). This represented a significant decrease in the proportion of cycles performed for tubal disease and an increase in the proportion of cycles performed for male infertility as compared with the earlier series 1-16, 1981-1984. Total pregnancy rates from fresh transfers remained stable for most indications, being the lowest for diethylstilbestrol (DES) exposure (16.7%), and highest for immunologic infertility (47.6%). In addition, patients with polycystic ovarian disease (PCOD) had a high pregnancy rate (47.2%) from fresh transfers but a high first trimester abortion rate as well (19.4%). The ongoing pregnancy rate from fresh transfers for the whole population was around 19.0%, being highest for patients with immunologic infertility (31.8%) and lowest for DES exposed patients (9.3%). The cumulative ongoing pregnancy rate to date for the whole population from fresh and cryopreserved embryos was 21.6% per embryo transfer (range from 13.3% for DES patients to 33.3% for immunologic infertility). The projected ongoing pregnancy rate as obtained from adding the number of cumulative pregnancies to date to the number of predicted ongoing pregnancies calculated from the remaining frozen embryos was 23.9% for the whole population (range 16.7% for DES patients to 33.3% for immunologic infertility).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of myomas or prior myomectomy on in vitro fertilization (IVF) performance

OBJECTIVE

The purpose of this study was to determine the effect of the presence of myomas and prior myomectomy on the pregnancy rate and pregnancy outcome in an in vitro fertilization (IVF) program.

DESIGN

Data collected from office and hospital records were analyzed retrospectively.

SETTING

Patients (all with private insurance carriers) were enrolled in an academic IVF program at The Jones Institute for Reproductive Medicine.

PATIENTS

All IVF patients enrolled in series 26-41, from 1987 to 1990, were reviewed. Only patients with well-documented myomas [by laparoscopy, laparotomy, hysteroscopy, or hysterosalpingography (HSG)] or prior myomectomy (confirmed by operative and pathology report) were included.

MAIN OUTCOME MEASURES

Pregnancy rates and pregnancy outcome were the main outcome measures. Pregnancy rates were calculated per preovulatory embryo transfer. Chi-square, Student t-test, and the Whitney-Mann test were used in the statistical analysis and P less than 0.05 was considered significant.

RESULTS

Among 1415 IVF patients, 11 had confirmed myomas present and 47 others had prior myomectomies. The mean age of patients with myomas and myomectomy was 37.1 +/- 4.1 and 36.1 +/- 1.9 years, respectively. Ten of the patients with myoma had normal endometrial cavities on HSG. Subserosal tumors were present in 10 of 11 patients with myomas. Ten of the 47 myomectomy patients had an abnormal cavity prior to surgery and all were corrected. About half of the patients with prior myomectomy had subserous myomas, while 10% were submucous in location. Two of the patients had hysteroscopic removal; all the rest were performed abdominally. The ongoing pregnancy rate from fresh embryo transfer for patients with myomas and myomectomy was 20.8 and 16.9%, respectively. This was comparable to the 19.0% ongoing pregnancy rate for all patients in these series. Despite the small number, and the fact that most had subserosal myomas, patients with myomas had a 50% abortion rate, while those postmyomectomy had a 34.2% abortion rate (statistically not significant). Moreover, if subdivided by their primary IVF indications, patients with prior myomectomy had similar ongoing pregnancy rates from fresh embryo transfer compared to the whole IVF population.

CONCLUSION

The incidence of myomas or prior myomectomy among infertility patients presenting for IVF was rather low. Myomectomy did not interfere with IVF performance in relation to overall and ongoing pregnancy rate.

Outcome of twin, triplet, and quadruplet in vitro fertilization pregnancies: the Norfolk experience

OBJECTIVE

To review the maternal morbidity and neonatal morbidity and mortality associated with in vitro fertilization (IVF) multiple pregnancies.

DESIGN

Retrospective analysis of data collected from office and hospital records and from questionnaires sent to patients, their obstetricians, and pediatricians.

SETTING

Patients (all with private insurance carriers) enrolled in an academic IVF program (The Jones Institute for Reproductive Medicine).

PATIENTS, PARTICIPANTS

All IVF pregnancies resulting in one or more gestational sacs on the initial ultrasound at 6 to 7 weeks were reviewed.

MAIN OUTCOME MEASURES

The frequency and severity of obstetrical and neonatal complications and the perinatal mortality of IVF twins, triplets, and quadruplets were compared. These were also compared with non-IVF multiple pregnancies.

RESULTS

From 1982 to 1990, 629 IVF pregnancies progressed beyond 20 weeks; 115 twins (18.3%), 15 triplets (2.4%), and 4 quadruplets (0.6%). There was a high incidence of antenatal complications such as abortions (30.3%, 42%, and 20%), premature labor (41.5%, 92.3%, and 75%), pregnancy-induced hypertension (17.0%, 38.6%, and 50%), and gestational diabetes mellitus (3.1%, 38.5%, and 25%) for twins, triplets, and quadruplets, respectively. The mean gestational age at delivery was 35.5 +/- 3.7, 31.8 +/- 2.7, and 31.0 +/- 1.7 weeks, respectively. There was also a proportionate progressive increase in neonatal complications. The mean weights were 2,473 +/- 745, 1,666 +/- 441 and 1,414 +/- 368 g, respectively. Twins (22.7%), 64.1% of triplets, and 75% of quadruplets needed admission to the neonatal intensive care unit and remained for an average of 12.0 +/- 2.3, 17.4 +/- 14.0, and 57.8 +/- 17.9 days, respectively. There was no difference in the mean Apgar scores or the incidence of congenital malformations in the three groups. The corrected perinatal mortality rates were 38.5, 0.0, and 0.0 per thousand live births, respectively.

CONCLUSION

Triplet and quadruplet IVF pregnancies have increased obstetrical and neonatal complications compared with IVF twins. The perinatal mortality and the incidence of congenital malformations are, however, comparable in all three groups.

Outcome of triplet and quadruplet pregnancies resulting from in vitro fertilization

Analysis of the outcome of 26 sets of triplet and five sets of quadruplet pregnancies resulting from in vitro fertilization (IVF) shows an high incidence of antenatal complications including first trimester bleeding (53.3 and 80%), premature onset of labour (92.3 and 67%), pregnancy-induced hypertension (28.6 and 67%) and gestational diabetes mellitus (38.5 and 33%), respectively. Intra-uterine growth retardation occurred in 7.6 and 0%, while third trimester bleeding complicated 7.6 and 0% of triplet and quadruplet pregnancies, respectively. These patients were hospitalized for a mean of 22.9 +/- 19.4 and 56.0 +/- 30.5 days, respectively. The mean gestational age at delivery for triplet and quadruplet pregnancies was 31.8 +/- 2.7 and 30.3 +/- 0.6 weeks, while the mean birth weight was 1663 +/- 423 and 1232 +/- 181 g, respectively. These neonates stayed in the hospital for a mean of 28.1 +/- 16.2 and 69.6 +/- 15.5 days, respectively. The corrected perinatal mortality was 2.2% for triplets and 0% for quadruplets. These data can be used in counseling patients with triplet and quadruplet pregnancies especially those resulting from IVF.

Pregnancy in a non-communication rudimentary uterine horn

A case of pregnancy in a rudimentary uterine horn is presented. The pregnancy ended in fetal demise at the end of the second trimester. The diagnosis was missed by ultrasonography on two occasions and was made only at laparotomy following failure to initiate uterine contractions. Histologic examination of the myometrium of the rudimentary horn revealed extensive interstitial fibrosis. A high index of suspicion of pregnancy in a rudimentary horn is recommended whenever adequate ecbolic infusions fail to induce myometrial contractions.

Superfetation secondary to ovulation induction with clomiphene citrate: a case report

In conclusion, CC has been associated with an increased rate of multifetal pregnancy; however, after each induction cycle, pregnancy should be ruled out before start of a new induction cycle. This would prevent misinterpretations of the gestational age at delivery, and hence of maturity, and would also help prevent any potential malformation that may be caused by a yet undetected teratogenic effect of CC.

Ectopic pregnancy in an undescended fallopian tube: an unusual presentation

A case of a ruptured ectopic pregnancy in an undescended fallopian tube is presented. The tube and its ipsilateral ovary were located near the splenic flexure of the colon. The embryology and the differential diagnosis of this potentially fatal condition are discussed.