Spinal epidural abscess--a rare complication after epidural analgesia for labour and delivery.

We report a case of spinal epidural abscess formation after short-term epidural catheter placement for analgesia during labour and delivery. The patient was previously healthy and did not have any predisposing factors. Increasing back pain was the only complaint. A contrast-enhanced CT study on day 5 was inconclusive. Magnetic resonance imaging was performed and showed a large triangular-shaped abscess with adjacent inflammation of the paravertebral muscles. One day later, the patient developed a sensory deficit in the left lower limb. The neurological deficit completely resolved after surgical decompression and debridement, which was followed by antibiotic treatment.

[Condylomata acuminata in pregnancy. Is there an indication for Cesarean section?]. / Condylomata acuminata in der Schwangerschaft. Besteht eine Sektioindikation?

Condylomata acuminata are very rare in children, although the prevalence of clinically or cytologically visible human papilloma virus infections is high. We report on a 28-year old G IV, P II with genital warts at the time of delivery, who had a baby boy without any signs of HPV-infection. The condylomata of the mother persisted, and subsequently laser vaporisation was performed one year after delivery. One year after laser therapy, a recurrent HPV-infection in the mother was detected. At this time, her two year old son had condylomata on his scrotum. The same serotypes, HPV 6 and 11, could be identified in the mother and child. With this case report, we discuss the possible ways of transmission and consequent clinical management of HPV infections in pregnancy.

[Laser therapy of the vulva, perineal area and uterine cervix]. / Lasertherapie an der Vulva, im Perianalbereich und an der Portio.

Within a period of two years 205 patients of our colposcopy-laser-outpatient department have been treated with a 40 Watt CO2-laser. 97 patients had dysplastic or condylomatous lesions of the portio, 85 ones condylomas in the vulvar, vaginal or perianal regions. 70 per cent of laser vaporisations had been done ambulatoryly. Complication rate following laser conisation was 12 per cent, following laser vaporisation 0 per cent. The rate of recurrent or persistent dysplasias was 12 per cent, of condylomas 18 per cent on an average observation time of 16 months.

[Colposcopy, histology, cytology and HPV findings in patients with condylomata of the vulva]. / Kolposkopie, Histologie, Zytologie und HPV-Befunde bei Patientinnen mit Kondylomen der Vulva.

The presence of vulvar condylomata acuminata shows evidence HPV infection of the vulva. 49 patients with such lesions came to our hospital for laser treatment. At that time, none of the patients were aware of their cervical disease. Colposcopy and biopsy of the cervix revealed in eight (16%) of the 49 patients CIN I and CIN II in one patient (2%). Condylomata or other HPV-associated lesions were found in seven patients (14%) and cervicitis in two (4%). HPV were detected in the cervix in 23 patients (46%). HPV types 16 and 18 were found in seven patients (14%) and HPV types 31, 33 and 35 in four patients (8%). It is concluded, that patients with condylomata acuminata of the vulva have a high risk of developing CIN and should undergo colposcopy.

[Prevention of vaginal prolapse in hysterectomy by suspension of the vaginal stump]. / Prophylaxe des Scheidenvorfalls bei der Hysterektomie durch Suspension des Vaginalstumpfes.

For prophylaxis of enterocele and of prolapse of the vagina following hysterectomy, the vaginal stump is fixed in at-risk patients to the sacro-uterine ligaments (known as McCall's suture) or to the sacro-spinal ligament (Amreich-Richter method). We report on the indications and results obtained in 101 sacro-spinal fixations and 211 McCall sutures in vaginal hysterectomy and 118 McCall sutures in abdominal hysterectomy. From 1975 to 1981 sacro-spinal fixation was only occasionally employed in prophylaxis of enterocele. After introduction of the McCall suture in 1982, the use of this method has been steadily increasing and has largely replaced sacrospinal fixation for prophylactic purposes. Nevertheless we are still using this often in cases of total prolapse, since in that situation, the fixation of the vaginal stump to the sacrouterine ligaments (in most cases weakly developed) is insufficient and does not offer enough support. Of a total of 350 McCall sutures performed to date, postrenal anuria occurred twice after kinking of the ureters, a typical complication that requires removal of the McCall suture. In a total of 174 sacro-spinal fixations of the vaginal stump for prophylactic or therapeutic indications, pronounced intraoperative haemorrhage took place in about 5% of the cases, whereas in one case, there was an abscess formation due to an infected haematoma. Technical details on both methods and on avoiding complications are discussed.

Randomized clinical trial comparing mitoxantrone with epirubicin and with doxorubicin, each combined with cyclophosphamide in the first-line treatment of patients with metastatic breast cancer.

Two hundred and twenty-four patients with advanced breast cancer were enrolled in a multicenter prospective randomized clinical study and received either doxorubicin (40 mg/m2), or epirubicin (40 mg/m2) or mitoxantrone (12 mg/m2) each combined with cyclophosphamide (600 mg/m2) i.v. In the patient collective the following response rates were observed: complete response 12.1%; partial response 30.6%; stable disease 40.5%; progressive disease 16.8%. A complete response was observed significantly less often in patients where more than one organ site was involved as compared to those patients with only one metastatic site. The mean time period required to reach a best response was 3.7 months. There was no significant difference between the response rates in the three arms. In comparing the observed toxicities in 1,434 treatment cycles, there was a significant difference with regard to leukocytopenia (mitoxantrone arm exhibiting more than either epirubicin and doxorubicin) although infections did not occur more frequently in the mitoxantrone arm; with regard to alopecia, mitoxantrone and epirubicin arms both exhibited less than doxorubicin. It is noteworthy that no patient who had previously received adjuvant chemotherapy achieved a complete response (p = 0.006). The overall significance of these findings can only be clearly evaluated when survival times can be measured.

[Fertility following tubal pregnancy: comparison of tube-saving surgery and salpingectomy]. / Fertilität nach Tubargravidität: Vergleich von tubenerhaltenden Operationen und Salpingektomien.

391 patients were operated during 1980 to 1987 at the Department of Gynaecology of the University of Tübingen for extrauterine pregnancy. A questionnaire was circulated to inquire, how many of these women wanted to become pregnant again. 176 answered positively, the return quota being 82%. After surgery, performed to preserve the Fallopian tubes, 64% of these patients had an intrauterine pregnancy, compared with only 41% after salpingectomy or segmental resection without anastomosis. In women without the characteristic factors which reduce fertility, such as primary sterility, surgery concerning sterility or refertilization, or other kinds of abdominal surgery, a greater proportion of intrauterine pregnancies was seen after surgery preserving the Fallopian tubes (79%), than in women with the above mentioned risk factors (53%). The incidence of repeat extrauterine pregnancies was approximately equal after Fallopian tube-preserving surgery and after salpingectomy (20% and 18%, respectively).

[Results of organ-saving therapy in tubal pregnancy]. / Ergebnisse der organerhaltenden Therapie der Eileiterschwangerschaft.

Worldwide, the incidence of nonruptured tubal pregnancy has increased, and so has the feasibility of conservative management of this condition. Following conservative surgery the rate of intrauterine pregnancy is significantly higher than after salpingectomy. The rate of ectopic pregnancy has not (or hardly) increased. For a surgeon skilled in this technique, the laparoscopic approach has advantages because it avoids laparotomy. For the time being, medical treatment of ectopic pregnancy with methotrexate, prostaglandins, and antiprogesterone should be confined to clinical studies. For nonviable, nonruptured tubal pregnancy with decreasing HCG titers expectant management seems possible; following conservative treatment, monitoring of HCG until it becomes undetectable is mandatory.

[Sonographic diagnosis of extrauterine pregnancy]. / Die sonographische Diagnostik der Extrauteringravidität.

Value of sonography in early diagnosis of ectopic pregnancy was investigated in a retrospective study. Frequency and value of different sonographic findings were analysed in 192 patients, who received laparotomy for ectopic pregnancy. In 171 patients (89%), the absence of an intrauterine sac in conjunction with a positive serum pregnancy test was the most reliable sign for ectopic pregnancy. A complex or cystic adnexal mass was found in 66 cases (32%). Hematocele or the presence of fluid in the cul-de-sac was observed in 61 patients (34%). Since an adnexal mass and retrouterine fluid or hematocele are rare sonographic findings in early ectopic pregnancy, the absence of an intrauterine sac in conjunction with a positive serum pregnancy test are of greatest significance. But correct diagnosis based on this sign is only possible considering the following conditions: 1. Evidence of pregnancy (beta-HCG in serum). 2. Gestational age more than 5 weeks. 3. Exclusion of intrauterine abortion .4. Consideration of differential diagnosis of pseudo-gestational sac and coexistence of an intra- and extrauterine pregnancy.

[Maternal morbidity following cesarean section. Comparison of isthmo-corpus longitudinal section and isthmian transverse section in premature labor]. / Mütterliche Morbidität nach Sectio. Vergleich von isthmokorporalem Längsschnitt und isthmischem Querschnitt bei Frühgeburten.

In an increasing number of cases of the Caesarean delivery of small premature babies (length of gestation less than 32 weeks or an estimated weight of less than 1501 g) between April 1983 and March 1987, the uterus was opened by an isthmo-corporeal longitudinal section if the lower uterine segment appeared too narrow for a gentle delivery via an isthmian transverse incision. A comparison of 67 Caesarean deliveries of this type with 116 Caesarean deliveries of the same small premature babies using an isthmian transverse incision did not reveal any difference with regard to postoperative infections, feverish standard morbidity, or other noninfectious complications. In comparison with Caesarean deliveries of older babies, the Caesarean deliveries of small premature babies had significantly more infectious and noninfectious complications, such as cases of phlebitis of the arm owing to intravenous application (2.7% as against 1.0%), posthemorrhaging and hematomas (3.8% as against 0.8%), and blood transfusions (3.3% as against 0.8%). The number of infectious complications was significantly reduced by a perioperative antibiotics prophylaxis. The question of late complications as a result of the isthmo-corporeal longitudinal section, especially the danger of rupture of the uterine scar in the event of a subsequent vaginal delivery, has not yet been resolved.

[Diagnostic and therapeutic interventions in extrauterine pregnancy]. / Diagnostische und therapeutische Eingriffe bei Extrauteringravidität.

Between 1969 and 1985 surgery was performed in 456 cases of extrauterine pregnancy (EUP) at Tübingen University Gynecological Clinic. The average number of such operations performed annually rose from 11 in the first six years to 61 in the last three years. As a result of early detection and treatment of EUP, tubal ruptures and severe intraabdominal hemorrhages have become increasingly rare. In the last six years, blood transfusions were only necessary in 6% of the patients who underwent surgery. In 28% no blood at all was found in the abdomen at surgery. For this reason, puncture of the pouch of Douglas was increasingly--and finally completely--supplanted by laparoscopy. Up to 1977 the affected tube was always removed; subsequently it was ever more frequently preserved. From 1983 to 1985 preservation of the tube was already being requested by 83% of the patients and it was possible to achieve this in 90% of them. In a total of 202 patients in whom the affected tube was preserved the following surgical procedures were employed: salpingotomies in 61%, salpingostomies in 4%, segmental resections with and without anastomoses in 22%, and expression or removal of a tubal abortion in 10%. The principal complications were continued growth of the tubal pregnancy following expression and salpingotomy in one case each, and occurrence of a hematosalpinx with the tentative diagnosis of continued pregnancy. Therefore, it is imperative to check the drop in the beta-HCG level after procedures in which the tube is preserved.

[Tubal pregnancy following tubal sterilization]. / Tubargravidität nach Tubensterilisation.

The present paper reports on 21 tubal pregnancies which have occurred after tubal sterilization in Tübingen or elsewhere since 1975. The proportion of tubal pregnancies amongst sterilization failures was 75%. The interval between sterilization and the occurrence of the tubal pregnancy ranged between 5 months and 7-3/4 years. The most frequent symptoms of the tubal pregnancies were pain (15/21), amenorrhea (11/21) and vaginal bleeding (5/21). Only 11 of the 21 patients were admitted to the clinic with the (suspected) diagnosis of an extra-uterine pregnancy. In 20 of the 21 patients the pregnancy was located in the distal (ampullar) segment of the tube; in 8 cases the tube was ruptured. Thirteen patients were treated by bilateral and 5 by unilateral salpingectomy, and a further 3 by unilateral adnexectomy. Summarizing, a considerable number of pregnancies occurring after unsuccessful tubal sterilization are extra-uterine. They are often not recognized, or only at a late stage. In the authors' view the patient should be informed of the possibility of a tubal pregnancy prior to sterilization.

[4 tubal pregnancies in the same patient: advantages and disadvantages of tube-saving operation]. / Vier Tubargraciditäten bei derselben Patientin: Vor- und Nachteile der tubenerhaltenden Operation.

In comparison with salpingectomy conservative procedures for the treatment of tubal pregnancy increase the chance for a living child, but also the risk of further tubal pregnancies. After unilateral salpingectomy the risk of the next pregnancy being tubal is 11%; after conservative surgery it is also 11%. If the patient has only one Fallopian tube, conservative surgery alone offers a chance of an intrauterine pregnancy. On average there is a 54% likelihood of this. In such cases the risk of a recurrence of tubal pregnancy is 16%. The advantages and disadvantages of conservative procedures are illustrated with reference to two patients, each of whom had altogether four tubal pregnancies. One of these patients, after two tubal pregnancies, conceived an intrauterine pregnancy through the remaining tube, from which a tubal pregnancy had also been eliminated; thus, conservative surgery provided the possibility of this further pregnancy resulting in the woman's only living child.

Uncommon indications for laparoscopy.

Laparoscopy was used as an ancillary method for infrequently occurring or unconventional indications in 140 patients. Diagnostic laparoscopy was done if other clinical, laboratory and biophysical methods were inconclusive or not conclusive in due time. Under some conditions operative laparoscopy or a combined vaginal and laparoscopic approach eliminated the need for laparotomy. No special equipment is required for such diagnostic and operative laparoscopy.

[Psychological considerations in the wish for refertilization]. / Psychologische Uberlegungen zum Wunsch nach Refertilisierung.

51 women asking for refertilization were evaluated by means of a half-standardized questionnaire before laparoscopy. Special attention was directed towards the psychological situation at the time of sterilisation as well as the reasons for refertilization desired. In addition the Giessen-test was performed as standardized psychological personality inventory. In general, the sterilization was initiated by the women because of social, financial or marital difficulties. In 2/3 of the females sterilization was performed in association with other gynecological or obstetrical procedures. Most of the women did not have any kind of adequate psychological or social counseling. The desire for refertilization was mainly caused by changes in the personal situation. 29 of 51 women reported to have a new partner, 27 of them after divorce or separation, two after the previous partner's death. Ten women reported the loss of a child, however, 12 women desired refertilization without any obvious change in their private situation. In conclusion, it appeared that refertilization was desired and experienced as a real need as well as a result of a conflict in the women's self-understanding expressed by a tendency towards depression.

[Effectiveness of pre-operative antibiotic prevention in hysterectomies and cesarean section]. / Zur Wirksamkeit der perioperativen Antibiotikaprophylaxe bei Hysterektomien und abdominalen Schnittentbindungen.

All controlled studies which were available by computer search from the literature were evaluated regarding the efficiency of preventive antibiotics for post-operative infections following hysterectomies and Cesarian sections. All controlled studies were evaluated by identical criteria. In 41 out of 46 studies (89.1%) on vaginal hysterectomies, febrile morbidity showed a significant decrease. In abdominal hysterectomies, 15 of 26 studies (57.7%) and in Cesarian sections 47 of 53 studies (88.7%) showed a significant decrease. Following vaginal hysterectomies and Cesarian sections, the preventive antibiotics decreased the febrile morbidity by 26 or 26.9 percentage points and pelvic or uterine infections by about 20 percentage points. In abdominal hysterectomies, the decrease was only 10.4 or 4.4 percentage points. Cesarian sections after the onset of labour and or rupture of the membranes have a high risk of infection and show the best decrease of febrile morbidity following preventive antibiotics.

[Urinary tract infections as a cause for urge incontinence? (author's transl)]. / Harnweginfektionen als Ursache für eine Dranginkontinenz?

The clinical significance of urinary tract infections was investigated in a retrospective study in 160 patients with different types of urge-incontinence. The diagnosis of urge incontinence was entirely based on urethro-cystometry using the perfusion technique. Clinical signs of urgency were not necessarily evident. Motor urge incontinence was found in 83%, sensoric urge-incontinence in 17% of the patients. Urge-incontinence was rarely associated with urinary tract infection: significant bacteriuria was only found in 8.2%.

[The problem of documentation and quality control in operative gynaecology (author's transl)]. / Zum Problem der Dokumentation und Qualitätskontrolle in der operativen Gynäkologie.

A documentation system by punch card, key and program system was developed at the University Department for Women in Tübingen and used for operative gynaecology. From each patient 12 quantitative and 19 qualitative parameters were coded. Included in the code were the diagnosis or several diagnoses, the operation or several operations, previous operation or previous operations, risk factors, complications during the operation and following the operation and data on the anesthesia. 1,700 procedures with opening of the peritoneum were reviewed retrospectively. From these data 499 vaginal hysterectomies with anterior and posterior colporrhaphy and with/or without bilateral salpingo-oophorectomy were selected as well as 249 abdominal hysterectomies with Marshall Marchetti operation in the Tübingen modification with/or without bilateral salpingo-oophorectomy and with/or without colporhaphy. These two groups were compared regarding important parameters. It was confirmed that the morbidity in vaginal hysterectomy was much higher than in abdominal hysterectomy.