Chromosome findings in 2,500 second trimester amniocenteses.

We have analyzed the chromosome abnormalities found in 2,500 amniocenteses for prenatal diagnosis; 1,887 (75%) were performed because the maternal age was 34 years or more. Chromosome abnormalities were detected in 1.80% of those referred for advanced maternal age, 1.2% between ages 34 and 39 years and 4.6% 40 years and over. Of these, four occurred in women who would have been 34 years at delivery (2.9%). Trisomy 21 accounted for 50% of the chromosome abnormalities; sex chromosome abnormalities, for 25%; the remaining 25% was divided equally between trisomy 18 and partial trisomies and mosaics. Unexpected translocations were found in 0.4%, of which two-thirds were balanced and identified in one parent. The accuracy was 99.6%.

Pessaries in the geriatric patient.

Pessaries have been used for centuries in the management of uterine prolapse. Although surgical repair has been popularized by surgeons and gynecologists for younger women with pelvic relaxation, pessaries remain a useful palliative strategy for patients who refuse surgery or represent higher operative risks. Despite the fact that pessaries are commonly used today, there is scant geriatric literature to describe their use among elderly patients. This article will review the indications and management of pessaries among elderly women with the goal of preventing complications and promoting investigation for their clinical application.

Modified Pereyra procedure under local anesthesia.

The modified Pereyra procedure, a retropubic urethropexy for the correction of anatomic stress urinary incontinence represents a safe, rapid, and well-tolerated technique for restoration of the normal retropubic position of the urethrovesical junction in selected patients. When general or regional anesthesia seem contraindicated due to age, medical risk, or anatomic factors, the procedure may be performed satisfactorily under local anesthesia. Of ten patients who underwent this procedure, nine reported excellent tolerance of the local technique. The postoperative hospital stay averaged three days. The average time from the injection of anesthesia to the termination of the surgical procedure was 45 minutes. Results were successful in 90%. This dependable surgical procedure for the correction of anatomic stress urinary incontinence may be performed in selected patients under local anesthesia with a high degree of patient tolerance.

Prenatal genetic diagnosis in 350 amniocenteses.

Three hundred and fifty second trimester amniocenteses performed for prenatal diagnosis of genetic disorders are reported. One hundred and ninety-three of these were performed because maternal age was greater than 35 years, and 6 fetuses with unbalanced chromosomal abnormalities (3%) were identified. Thirteen procedures were performed because a previous child had had a neural tube defect; 1 anencephalic fetus was identified. Ninety-six percent of the initial taps were cultured successfully; we failed to obtain amniotic fluid in 3% of patients. The risk of a spontaneous abortion occurring at some time after the amniocentesis was 0.85%, and no cases of fetal injury were identified.

The modified Pereyra procedure in recurrent stress urinary incontinence: a 15-year review.

OBJECTIVE: To assess the effectiveness and perioperative morbidity of the modified Pereyra procedure in the treatment of recurrent stress urinary incontinence. METHODS: Data of 54 patients who underwent a modified Pereyra procedure for the treatment of recurrent stress urinary incontinence between January 1, 1978, and August 1, 1992, were analyzed retrospectively regarding presenting symptoms, preoperative evaluation, surgical procedure, complications, and cure and failure rates. The patients were divided into two groups depending on the preoperative absence (group I) or presence (group II) of risk factors for repeated failure (detrusor instability, low-pressure urethra, fibrotic urethra, negative Q-tip test, and neurogenic incontinence). RESULTS: After a mean follow-up of 36.3 months, the cure rate of 81.6% in group I (N = 38) was significantly (P = .005) higher than that in group II (N = 16; 43.8% cured). The mean time of occurrence of failure was 11.9 months for group I and 6.8 months for group II. The incidence of intraoperative complications (Pereyra suture in bladder, hemorrhage) for both groups was 7.4%. Immediate postoperative complications were found in 25.9% of all patients; these were mainly infectious processes. Late postoperative complications occurred in 33.3%, with the most prevalent being new-onset urge incontinence and de novo detrusor instability (11.1%) and obstructive voiding dysfunction (9.3%). The rates of perioperative morbidity were not significantly different between the groups. CONCLUSION: The modified Pereyra procedure is well suited for the treatment of uncomplicated recurrent stress urinary incontinence, with a long-term cure rate of over 80%. However, success rates are significantly lower for recurrent stress incontinence in association with persistent risk factors for failure. In either instance, the procedure is associated with appreciable perioperative morbidity.

Genetic amniocentesis in twin pregnancy.

Fifty-three patients with twin gestation were seen at the University of California, Los Angeles, between January 1, 1977 and June 30, 1983 for antenatal genetic studies. The diagnosis of twins was successfully made in 52 patients using ultrasound. Forty-eight patients with viable fetuses requested sampling of both sacs. Amniotic fluid was successfully obtained from both sacs in 47 patients. There was only one spontaneous abortion six weeks after the amniocentesis. In five patients, one of the fetuses was delivered alive, whereas another was delivered as a stillborn without any apparent reason. Eleven sets were delivered prematurely at less than 36 weeks. There were two neonatal deaths, one from prematurity and one with multiple congenital anomalies. This study showed that differential amniocentesis can be used safely to obtain reliable information about each fetus in twin gestation.

Pruritic vulvar squamous papillomatosis: evidence for human papillomavirus etiology.

The origin of squamous papillae of the vulvar vestibule is controversial. Although some are considered as asymptomatic normal variants of pelvic anatomy, a review of 12 cases of vulvar squamous papillae in patients visiting the Infectious Diseases Clinic at UCLA reveals a distinctly symptomatic variety. A syndrome complex of premonitory vulvar vestibular pruritus, pain or burning, dyspareunia, and progressive development of squamous papillae was noted. Microscopic examination of tissue specimens of the areas of squamous papillae reveals the presence of koilocytic change suggestive of viral infection with human papillomavirus. Furthermore, immunoperoxidase stain revealed human papillomavirus capsid antigen in two cases, which has heretofore not been reported in the literature to the authors' knowledge. Evidence of partner infection on physical examination of sexual partners of these women revealed changes consistent with human papillomavirus in four of six partners who were available for examination. Treatment with podophyllin, cryotherapy, laser, or a combination seems to give predictable resolution of the condition and associated symptoms.

Follow-up of 2000 second-trimester amniocenteses.

The authors analyzed the outcome of 2000 consecutive second-trimester amniocenteses. Seventy-three percent were performed for maternal age of 34 years or more. The risk of spontaneous abortion before 28 weeks' gestation was 1.3% and for stillbirth or neonatal death, 1.4%. Total fetal loss was 2.7%, compared with 2.2% in a control population. Congenital malformations were found in 1.6% of the study group and in 1.9% of controls; no increase in skeletal problems was observed. Prematurity, defined as a birth weight of less than 2500 g, was noted in 3.6%, compared with 3.7% and 3.9% in 2 control populations. Respiratory difficulties persisting for more than 24 hours were observed in 0.8% of patients, compared with 0.7% of controls. Analyses of the outcome of amniocenteses performed at a single large center do not show an increase in perinatal complications or malformations.

Pubourethral supports in perspective: modified pereyra procedure for urinary incontinence.

The present study supports the thesis that failures in urethral suspensory-type operations in women with anatomic stress urinary incontinence often are caused by pull-out of suspensory sutures attached to attenuated endopelvic fascia around the urethrovesical junction. Thickening of this fascia helps impede suture pull-out. Such thickening is facilitated by detaching the fascia from the pubis to enfold it. Freeing the fascia from the inferior pubis exposes the posterior pubourethral ligaments to direct view. Binding the much stronger posterior pubourethral ligaments and enfolded fascia together with the suspensory sutures provides maximum resistance to suture pull-out. Of 54 women treated with this modified Pereyra procedure as a primary operation for anatomic stress urinary incontinence, 94.5% showed complete cure or marked improvement 4 to 6 years postoperatively.

A comparison of a three-day and seven-day clotrimazole regimen for vulvovaginal candidiasis.

Patients with mycologically proven symptomatic fungal infections of the vagina were treated ina double-blind trial with either one 100-mg clotrimazole vaginal tablet daily for seven days (group I) or two tablets daily for three days (group II). Patients were evaluated at one and four weeks after therapy. The investigator's evaluation of treatment efficacy showed 85% (22/26) success in group II compared with 75% (21/28) in group I (P = 0.46). Both groups had improvement itching, discharge, and vaginal and vulval irritation. No significant (P less than 0.10) differences were seen between groups after therapy. Only three side effects were seen. It is concluded that a three-day course of two clotrimazole vaginal tablet daily is as effective and safe as the previously recommended one tablet daily for seven days, and the shorter therapy is likely to improve patient compliance.

A comparison of the efficacy of two vaginal creams for vulvovaginal candidiasis, and correlations with the presence of Candida species in the perianal area and oral contraceptive use.

In a double-blind clinical study, 93 patients with vulvovaginal candidiasis were randomly assigned to treatment with either clotrimazole (1%) or miconazole (2%) vaginal cream for seven days. The treatments were comparable in reducing the severity of presenting signs and symptoms. At one and four weeks posttherapy, negative vaginal cultures were found in 84.4% and 75.0%, respectively, of the clotrimazole-treated patients and in 85.4% and 74.5%, respectively, of the miconazole-treated patients. The incidences of recurrence/reinfection and treatment failures were comparable in the two groups. Treatment failures and recurrences/reinfections were not correlated with positive perianal cultures for Candida species. Patients using oral contraceptives had a higher incidence of positive vaginal cultures at four weeks posttherapy than did patients not using oral contraceptives or using other methods.

Laparoscopic tubal sterilization: long-term postoperative follow-up.

PIP: 93 women who underwent laparoscopic tubal coagulation during 1972-1973 were followed up for periods of 18 months to 3 years. Ages ranged from 17 to 47 years (mean 30.7) and 71% had 2-4 children. 8 requested sterilization prior to conception and 5 had pregnancy previously terminated by abortion. Most common postoperative complaints were tenderness at the incision site and shoulder or neck pain. In the 64 cases in which sterilization alone was performed average blood loss was less than 50 cc. In 8 cases it was associated with diagnositc dilatation and curettage, in 20 with therapeutic abortion, and in 1 with laparotomy. Complications included 1 case each of bleeding mesosalpinx controlled by cautery, wound hematoma, hematoma epiploic appendix, and peritoneal burn. A detailed menstrual history 18-36 months after operation found 73 of the 93 had regular periods with amount of bleeding and length of cycle generally unchanged. Of the 20 with menstrual changes, 2 developed amenorrhea within 1 year and 8 with preoperative menstrual irregularities were unchagned. 10 developed longer periods and/or shorter intervals. 5 related these changes to discontination of oral contraceptives. Of the remaining 1 had an abnormal Pap smear, 2 were 40-45 years of age (1 of whom refused vaginal hysterectomy for stress incontinence), and 2 were 35-40 with no previous history of cesarean sections or pelvic complaints. The majority (77%) of the women were satisfied with the procedure, 16% uncertain, and 5 patients expressed regret. 4 of the 5 who regretted the operation reported gynecological complaints. 5 required subsequent surgery. In 3 of the 5 the indication preexisted the sterilization and a more thorough screening might have prevented 2 surgical procedures. In this series the incidence of postoperative gynecological disease 18-36 months after laparoscopic tubal ligation is significantly lower than that reported in the literature for conventional tubal ligation.^ieng

Neural tube defects: maternal serum screening and prenatal diagnosis.

Neural tube defects represent some of the most common and serious of the congenital malformations. Although elevation of alpha-fetoprotein in amniotic fluid is not diagnostic, it does indicate an abnormality of the fetus in a very high proportion of cases. A normal level, however, does not exclude the possibility of a closed neural tube defect. It is therefore recommended that all amniocenteses performed between 15 and 20 weeks of gestation include measurement of alpha-fetoprotein. Maternal serum alpha-fetoprotein assay is a screening test and pilot studies will be necessary to determine its value as a routine prenatal blood test.

Childhood anogenital lichen sclerosus. A case report.

Childhood lichen sclerosus is a rare disorder. A 4-year-old girl with chronic vulvar pruritus who was initially suspected to be the victim of child abuse was treated. Vulvar biopsy was performed, confirming the diagnosis of lichen sclerosus. The child was treated with 2% progesterone cream, with complete resolution of her pruritic symptoms and signs of traumatic injury to the vulvar skin. The basic condition, lichen sclerosus, has persisted.

Endometrial cancer: rising incidence, detection and treatment.

PIP: This editorial consists of summaries of the discussions on incidence, pathogenesis, prognosis and patient follow-up, and transcripts of the discussions on detection and treatment of endometrial carcinoma, from a symposium held in Carefree, Arizona. 75% of the cancers occur in postmenopausal women; average age is 52 years, but is decreasing. Endometrial carcinoma rose from 20.3 to 46.3% of all uterine cancers in Cleveland University Hospitals from 1941-1970. Older patients are often diabetic, overweight, nulliparous, with anovulatory or familial history; young women frequently resemble mild Stein-Levinthal syndrome. Clinically, 20% of patients are assymptomatic, others may have softer or larger uterus, larger ovaries, irregular postmenopausal bleeding, or lengthy onset of menopause. The Gravlee jet wash is indicated for high risk patients and those about to take estrogen. Endometrial carcinoma first affects epithelium, then endometrial stroma, then upper myometrium, lower myometrium, then other organs, perhaps via lymphatics, vagina, tubes, but ascites is uncommon. Generally, U.S. physicians use intrauterine radium followed by surgery, British use surgery first, and Swedish use radiation only. Cases must be treated individually, e.g. surgery only for minimal cancer, radium and surgery for more serious cases, and preoperative external radiation also for advanced disease. Although radiation lessens chance of implantation during surgical trauma, insertion of intrauterine radium enhances spread of tumor cells. Injectable progestins sometimes control metastatic disease, although they require 8 weeks to act. Progestins may help those with late recurrence, squamous metaplasia, or who are under 50 years of age. Estrogens are rarely effective. Prognois for terminal patients often includes subjective improvement, bowel obstruction, lung complications, hemorrhage. Radiation side effects and menopausal symptoms are often problems for cured patients. In young cured patients the endometrium should be suppressed with progestins or oral contraceptives.^ieng

Constriction of the umbilical cord as a cause of fetal demise following midtrimester amniocentesis.

Two cases of constriction of the umbilical cord resulting in fetal demise following midtrimester amniocentesis are presented. In both cases, real-time ultrasonography prior to amniocentesis revealed a viable fetus. Fetal demise was identified immediately following the procedure in the first case and one month later in the other. A localized constriction at the fetal end of the umbilical cord in both, with torsion of the constricted segment in the second case, was observed. Wharton's jelly was noted to be deficient in this segment of the cord in the first case. The mechanism of fetal demise is discussed. It is suggested that this abnormality should be considered when fetal demise follows midtrimester amniocentesis.