Metastatic uterine leiomyosarcoma presenting as a primary sarcoma of the parotid gland.

BACKGROUND: Leiomyosarcoma of the uterus has a high metastatic potential to distant sites due to its tendency for hematogenous spread. CASE: A 49-year-old woman presented with an enlarging parotid mass, diagnosed originally as a primary fibrosarcoma. Six years later, she developed pulmonary metastases and heavy, abnormal uterine bleeding. At hysterectomy, a uterine leiomyosarcoma, identical morphologically to the previous lesions, was identified. All tumors showed similar immunohistochemical staining, suggesting the metastatic nature of the original parotid tumor. CONCLUSION: This rare case of uterine leiomyosarcoma, presenting as a primary parotid sarcoma, underscores the importance of considering the possibility of a uterine primary tumor when a sarcoma arises in an organ in which these tumors are unusual.

Wide-band transabdominal cerclage for a foreshortened, incompetent cervix.

BACKGROUND: The role of cervical cerclage in the prevention of fetal wastage due to cervical incompetence is well established. The transvaginal approach and, failing that, the transabdominal approach, provide sufficient treatment in most cases. However, the traditional techniques require adequate cervical length for placement and maintenance of the suture. CASE: We report a new technique used for a patient with a markedly foreshortened cervix and a history of multiple second-trimester pregnancy losses despite placement of McDonald cerclages. To improve the performance of the cervix, we included the lower portion of the uterus in a 3-cm-wide Prolene mesh cerclage. During the patient's subsequent pregnancy, the mesh band funneled the lower uterine segment, creating a functionally longer cervix. The patient successfully carried the pregnancy to term and was delivered by cesarean. CONCLUSION: This variation on the transabdominal approach is useful in the management of patients with cervical incompetence who demonstrate a foreshortened cervix incapable of maintaining a traditional cervical suture.

The effect of placenta previa on blood loss in second-trimester pregnancy termination.

OBJECTIVE: To determine whether placenta previa increases bleeding during second-trimester pregnancy termination. METHODS: The records of 131 consecutive women undergoing elective pregnancy termination at 13-24 weeks' gestation were reviewed and divided into those with and without placenta previa based on an ultrasound examination before the procedure. These two groups were then compared for differences in maternal characteristics, estimated blood loss, operative time, infection, and hospital admission. RESULTS: Twenty-three of 131 women (17.6%) had placenta previa. Sixty-seven percent of the previa patients smoked, versus 37% in the control group, a statistically significant difference. A statistical difference was noted with respect to placenta previa in intraoperative blood loss (P < .05), but not operative time, time to discharge, infection, hemorrhage, or other complications. CONCLUSION: Second-trimester pregnancy terminations in the presence of placenta previa are associated with a higher estimated blood loss, but no apparent increase in abortion-related infection, postoperative transfusion requirements, hysterectomy, or other complications.

Cystometric evaluation of vesical endometriosis before and after hormonal or surgical treatment.

Subjective patient complaints as they relate to bladder endometriosis have been well reported. Objective findings have been lacking. The case reported on demonstrates the cystometric finding of a small-capacity irritable bladder in a patient with vesical endometriosis. It further demonstrates the improvement of these findings following surgical resection of endometriosises and hormonal therapy using danazol.

Transvaginal small-bowel evisceration: a case report.

Transvaginal small-bowel evisceration is rare. Only 47 case reports appear in the literature in English. Review of this literature shows that vaginal evisceration occurs mainly in women who are older, multiparous, and have undergone vaginal surgery. The immediate cause of evisceration is either sudden, increased intraabdominal pressure, trauma, or a spontaneous event. The small bowel and omentum are most commonly involved. Surgical repair is performed vaginally, abdominally, or by both methods. We present a case of transvaginal small bowel evisceration caused by inadvertent self-induced trauma, a heretofore unreported cause of this complication, in a 79-year-old woman with known weakness of her pelvic structural support. She experienced sudden evisceration of small bowel following manual decompression of her cystocele during voiding. We used a combined abdominal and vaginal approach to examine the small and large intestines and mesentery for trauma, attach the vaginal vault to the shortened uterosacral ligament, obliterate the cul-de-sac using the Moschowitz procedure, and repair the defect in the levator plate. To limit risk, patients should be evaluated for predisposing conditions. We recommend a combined abdominal and vaginal surgical approach to adequately evaluate the involved tissues and to effect repair.

Manchester procedure vs. vaginal hysterectomy for uterine prolapse. A comparison.

The Manchester procedure (MP) was compared with vaginal hysterectomy (VH) to determine whether any differences regarding patient demographics or operative or postoperative outcome could be found between the two techniques. A retrospective chart analysis was done comparing data from 88 consecutive MP to 105 randomly selected VH patients. All the operations were performed for uterine prolapse at Mount Sinai Hospital between 1984 and 1988. MP patients, when compared to VH patients, were more likely to be older and postmenopausal at the time of surgery and to have a private physician. MP patients were less likely to have significant medical illnesses than were VH patients. Statistically significant differences between MP and VH were found for operative time (100 vs 130 minutes, respectively) and blood loss (200 vs. 300 mL, respectively) (P < .001). This difference was not dependent on the performance of anterior or posterior repair. MP was associated with shorter operative time and less blood loss when compared to VH. This, coupled with apparently similar operative outcomes, suggests the use of MP as an alternative to VH in the absence of uterine pathology in appropriate candidates with uterine prolapse. Prospective, controlled, long-term studies comparing the operative results of these two procedures are needed.

Perinatal outcome after embryo transfer in ovum recipients. A comparison with standard in vitro fertilization.

OBJECTIVE: To compare perinatal outcome after embryo transfer vs. standard in vitro fertilization (IVF) in ovum recipients. STUDY DESIGN: We reviewed 22 consecutive ovum donor pregnancies delivered at Mount Sinai Hospital between July 1989 and November 1992 and matched them for age, parity and order of gestation to a control group who underwent standard IVF-embryo transfer (ET) during that period. RESULTS: The two groups showed similar rates of maternal complications, including hypertensive disorders, gestational diabetes and puerperal complications. When compared to patients undergoing autologous IVF-ET, ovum recipients had a lower rate of preterm labor (22.7% vs. 54.6%, P < .05), a higher mean gestational age at delivery (38.7 vs. 36.1 weeks, P < .01) and increased mean birth weight of neonates (2,924 vs. 2,374 g, P < .005). Though infants born through traditional IVF-ET were more likely to be preterm, Apgar scores were similar at one and five minutes. Our data support the generally favorable outcome seen in pregnancies conceived through ovum donation despite the fact that many of these patients had prior poor prenatal outcomes, long intervals until conception, and coexisting medical conditions. CONCLUSION: Ovum donation in women of comparable ages has obstetric outcomes equal to or better than patients undergoing traditional IVF-ET. Obstetric and perinatal outcome do not seem to be impaired in patients receiving donated oocytes.

Ascending back pain and headache during attempted epidural placement.

A 30-year-old parturient requested epidural analgesia during labor. Immediately after the epidural space was presumably identified using the loss-of-resistance-to-air technique, she reported severe back pain, followed by neck pain, which progressed to severe unrelenting headache. An emergency computerized tomographic (CT) scan performed during labor showed air in the intracranial subarachnoid space.

Peribronchial electrical admittance measures lung edema and congestion in the dog.

A new method has been developed to detect interstitial pulmonary edema. This method utilizes the unique arrangement of air and interstitial fluid within the lung. A 1.3-mm-diam twin catheter electrode was wedged in a peripheral airway of the lung. The electrical impedance measured at 35 kHz between these catheter-tip electrodes was 1,540 +/- 240 omega (mean +/- SD; n = 10) in the anesthetized closed-chest dog. Intravenous infusion of 1-3 liters 0.154 M NaCl increased extravascular water per gram of dry lung from a control value of 3.54 +/- 0.27 to 4.1-5.14. Peribronchial electrical impedance decreased in proportion to the amount of saline infused reaching a minimum of 550 omega. No signs of alveolar flooding were present during the experiments. Linear regression performed on peribronchial electrical admittance (PEA) as a function of extravascular water per gram of dry lung (ELW) resulted in the following relationship: PEA = 0.72 ELW - 1.81; r = 0.95. It is concluded that this method is a sensitive quantitative measure of lung interstitial fluid and can detect pulmonary edema and congestion in the dog lung before alveolar flooding occurs.