Squamous intraepithelial neoplasia in an ovarian cyst, cervical intraepithelial neoplasia, and human papillomavirus.

A case of squamous intraepithelial neoplasia in an ovarian cyst in association with cervical intraepithelial neoplasia (CIN) III is described. In view of the association of human papillomavirus (HPV) and CIN, the possibility that HPV infection could be associated with similar changes in the ovary was postulated. The HPV genome was shown in formalin-fixed tissue of the cervical lesion by nonisotopic in situ hybridization (NISH) and by the polymerase chain reaction (PCR). However, HPV could not be shown in the ovarian lesion by NISH or PCR. On the basis of these findings there appears to be no association between HPV infection and squamous intraepithelial neoplasia in an ovarian cyst.

Laparoscopy or minilaparotomy for sterilization of women.

A prospective randomly controlled study was conducted on 200 women undergoing sterilization by application of clips to the fallopian tubes. Laparotomy or laparoscopy was used, and the patients' response to the procedure was evaluated. There were few surgical complications. Postoperative pain and discomfort were experienced for a mean of 2.7 and 2.4 days in the those undergoing minilaparotomy and laparoscopy, respectively. The patients' response indicates a marginal benefit from the laparoscopic approach to application of clips to the fallopian tubes.

Laparoscopic sterilization with spring-loaded clips: double-puncture technique.

The application of a spring-loaded clip to each fallopian tube using a second-incision clip applicator is a safe and effective method of laparoscopic sterilization. The operation is quick and easy to perform and is suitable for use with local anesthesia. The method avoids the dangers of hemorrhage, for the clip only alters 3 mm of the fallopian tube and does not transect the tube or mesosalpinx. No pregnancies have followed the sterilization procedure. An intrauterine pregnancy has occurred after a reversal procedure in one patient.

PIP: 533 women undergoing laparoscopic sterilization were studied in an effort to determine the feasibility and safety of a second-puncture clip applicator. The operation was done on an outpatient or overnight basis and a choice of general or local anesthesia was offered. Results indicated that 97.7% of the cases were uncomplicated while 1.2% resulted in bowel perforation; .4% in hematoma and .7% in tubal ligation. None of the complications were due to clip or applicator design. 85% of the cases had no complaints while 5% of the patients experienced abdominal discomfort lasting 48 to 72 hours. This was the only side effect related to the procedure with a spring-loaded clip. No pregnancies occurred at the 6-month follow-up and 1 reanastomosis occurred supporting existing evidence about successful reversal after sterilization with a spring-loaded clip.

Treatment of endometriosis: a study of medical management.

Fifty patients with endometriosis were treated with hormones: 27 with danazol and 23 with Enavid (mestranol 75 micrograms and norethynodrel 5 mg). Side effects were more common and potentially more serious in the group treated with Enavid. Fewer women completed treatment with Enavid and their physical signs showed little improvement. Danazol was better tolerated and the results of treatment, as judged by improvement of symptoms or signs and in future fertility rates, were superior to those recorded in the Enavid treated group. Patients with large endometriotic cysts or severe fibrosis did not benefit from medical treatment. Danazol treatment appeared helpful for women who had mild or moderate endometriotic disease. It may be used alone or as a complimentary treatment after conservative surgical operations.

PIP: The results of treatment with the hormones danazol and Enovid were compared in 50 patients with endometriosis. The patients had presented with infertility, or with symptoms or signs of endometriosis. The diagnosis was confirmed either at laparotomy or laparoscopy. In the group treated with danazol, only 6 of the 27 patients needed a dose that exceeded 400 mg daily. Side effects were a significant problem. The side effects were both more common and potentially more serious in the group treated with Enovid. 7 of the 23 patients treated with Enovid failed to complete treatment because of side effects suggesting vascular or clotting dangers. Danazol was better tolerated and the treatment results, as judged by improvement of symptoms or signs and in future fertility rates, were superior to those recorded in the Enovid treated group. The patients with large endometriotic cysts or severe fibrosis failed to benefit from medical treatment. The danazol treatment appeared helpful for those women who had mild or moderate endometriotic disease. It maybe used either alone or as a complementary treatment following conservative surgical operations.

Medical treatment of endometriosis: a comparative trial.

In a comparison of danazol, and mestranol with norethynodrel (Enavid, Searle) in the treatment of endometriosis danazol was shown to be superior. Danazol is however relatively ineffective when large tumours or extensive adhesions are present and such patients will usually need a surgical operation. Women who have completed their families and who have severe symptoms will be better treated by hysterectomy. Treatment with danazol is indicated for young women with mild or moderate endometriosis. Danazol treatment may also be given postoperatively after conservative operations.

Comparative trial of extra-amniotic and vaginal prostaglandin E2 in tylose gel for induction of labor.

Two hundred and sixty-one patients of varying parity and cervical "ripeness" were given Prostaglandin E2 (PCE2) in tylose gel either vaginally (2.0 mgm) or extraamniotically (0.3 mgm) prior to planned surgical induction. Surgical inductions was avoided in 52 per cent of the vaginal group and 40 per cent of the extra-amniotic group. When subdivided according to parity and cervical ripeness, both groups were comparable except in the multigravid patients with high cervical 'scores', when the vaginal route was significantly more likely to establish labor. Both groups were without significant ill-effects to the mother or fetus.

Effect of introduction of colposcopy into a district general hospital.

Management of cervical intra-epithelial neoplasia, in a district general hospital, was examined for two 22-month periods before and after the introduction of colposcopy. This technique enables the clinician to evaluate the extent and severity of pre-malignant change, and makes treatment, using less radical destructive techniques, possible. The method of conservative treatment in this hospital was diathermy, and the cure rate of cases so treated was 97%. The use of diathermy treatment resulted in a 75% reduction in the incidence of cone biopsy in women below the age of 40 years. A further advantage of colposcopy has been recognized, which is that some women with "mild or moderate changes" are discovered to have more severe lesions, and receive appropriate treatment without delay. It follows that all patients with an abnormal smear should be referred for colposcopy, unless there is an obvious local cause of the abnormality, such as easily treatable infection, and that the post-treatment smear reverts to normal. In this hospital the cost of establishing a colposcopic service was low, and the cost benefits, as well as the improved management of cervical intraepithelial neoplasia suggests that the service should be introduced in all district general hospitals.

Reversal of female sterilization.

Reversal of sterilization was attempted in 22 women without the use of an operating microscope. Fifty per cent became pregnant. Success was influenced by the site and extent of the tubal damage resulting from the sterilization procedure, mechanical occlusive sterilization techniques offering the best change of a successful reversal.

A comparison of Filshie and Hulka-Clemens clips used in sterilisation operations.

PIP: 289 women requesting sterilization were randomly assigned to 2 groups for a prospective study whose object was to compare the perioperative difficulties and morbidity associated with sterilization using either Filshie Mark VI or Hulka-Clemens clips. The Filshie clip was found to be superior to the Hulka-Clemens clip in ease of application and in its ability to occlude the tube in a satisfactory manner. The Filshie clip device was also easier to maintain. Significant perioperative pain occurred more frequently in the Hulka-Clemens group. The complication rate, both surgically and method related, was low. There were no pregnancies in either group after 12 months of follow-up.^ieng

Clinical application of human-placental-lactogen values in late pregnancy.

Human-placental-lactogen (H.P.L.) levels were measured in the blood of 1000 women in the third trimester of pregnancy to see how measurement of H.P.L. could help in the management of an obstetric population in Britain. It was found that in the 93% of the population with a mean H.P.L. level of 4.3 mg/l or above, only 1.1% would have a poor pregnancy and 4.8% a compromised pregnancy. Of the 7% with levels below 4.3 mg/l, 57% woul have a normal outcome and 43% a poor or indifferent outcome. The false-positive rate was considerable, but the results of the study indicate nevertheless that H.P.L. levels are useful in predicting the outcome of pregnancy and that their measurement should be included as part of routine screening in the third trimester.

Circulating levels of pregnancy-specific beta1-glycoprotein and human placental lactogen in the third trimester of pregnancy: their relationship to parity, birth weight, and placental weight.

Circulating levels of pregnancy-specific beta1-glycoprotein (SP1) and human placental lactogen (HPL) were measured in 153 normal subjects during the third trimester of pregnancy. The levels of SP1 and HPL showed a skewed distribution and rose progressively to reach a plateau by the 36th week. The normal range was calculated by ranking the data and division into centiles as well as by logarithmic transformation of the values. A low but significant correlation was observed between SP1 and HPL levels, SP1 and birth weight. There was also a correlation between HPL levels and placental weight.

Late complications of sterilisation by laparoscopy and tubal ligation. A controlled study.

The frequency of late sequelae in 454 patients sterilised by laparoscopy and diathermy or by abdominal tubal ligation was compared with that in 154 controls whose husbands had had a vasectomy. Results showed an increase in menstrual loss and pain with menstruation in the sterilised groups, especially if this had been done by diathermy and division under laparoscopic control.

Placental lactogen levels in rhesus isoimmunization.

A prospective study of the plasma levels of human placental lactogen (HPL) in pregnancies complicated by rhesus isoimmunization showed that in mild and moderately affected cases the levels were normal, while in severely affected cases they were raised. Serial levels of HPL before the 26th week provide a valuable indication of fetal outcome, and we suggest that this estimation should be used routinely as an adjunct to other tests in the management of rhesus isoimmunization.

Screening for fetal neural tube defects by maternal plasma alpha-fetoprotein determination.

A total of 5539 consecutive pregnant patients at three maternity units in the City and Hackney District of London were screened for fetal neural tube defect by measurement of maternal plasma alpha-fetoprotein (AFP) levels. Only 25-7% of women booked at 16 to 22 weeks, the optimum time for this screening test; 54-1% booked before 16 weeks and 20-2% after 22 weeks. Of the women tested before 23 weeks, 300 had elevated levels of AFP in plasma and 14 of them had fetuses with abnormalities known to cause a rise in AFP levels (12 fetuses had a neural tube defect and 2 had alimentary tract abnormalities). Of women examined before 23 weeks, half of those with twin pregnancies had elevated levels of plasma AFP as did 16-7% of those who ultimately had a spontaneous abortion.

Early ultrasound examination in antenatal care.

Ultrasound examination was done on 442 women early in pregnancy. If there was a discrepancy the date of delivery calculated from ultrasound readings was preferred to that calculated by traditional means. As a result of this policy induction for planned caesarean section was postponed or cancelled in 10.4% of cases. In 9.7% of women the menstrual history was unreliable and the ultrasound measurement was used to estimate the date of delivery. Thus in 21.1% of pregnancies the early ultrasound measurement decided when or whether labour was to be induced. In women induced for postmaturity there was no increase in prolonged labour or need for caesarean section. There were no cases of neonatal respiratory distress and neonatal jaundice was less common than it was when the onset of labour was spontaneous. This evidence suggests that neonatal jaundice is not caused by induction of labour or by the agents used. The low frequency of jaundice in this series is thought to be due to accurate prediction of the expected date of delivery and consequent exclusion of premature babies born to "postmature" women.

A glucose-controlled insulin infusion system for diabetic women during labour.

A glucose-controlled insulin infusion system was used to control blood glucose concentration during labour or caesarean section in six insulin-dependent diabetics. The mean blood glucose concentration during the four hours of labour immediately before delivery was 4.6-5.2 mmol/1 (82.9-93.7 mg/100 ml). Feedback control of insulin delivery by blood glucose concentration should decrease the risk of postpartum hypoglycaemia in the infant and allow normal obstetric management for the insulin-dependent diabetic in labour.