Laser treatment of recurrent vulvar angiokeratoma associated with Noonan syndrome.

BACKGROUND: Vulvar angiokeratoma is often confused with other, more common perineal lesions. Chronically elevated venous pressures may contribute to this rare disorder. Laser treatment may lend palliation for several years. CASE: A woman with the characteristic cardiac abnormalities of Noonan syndrome initially responded to Argon laser treatment of vulvar angiokeratoma. Excessive recurrent disease was treated satisfactorily with the Nd:YAG laser. CONCLUSION: Recurrent vulvar angiokeratoma in Noonan syndrome supports the premise that increased persistent central venous pressure may be involved in the disease process.

Streptococcal toxic shock associated with septic abortion.

The group A streptococcus is capable of producing exotoxins that have been linked to a toxic shock-like syndrome. Streptococcal toxic shock is a rapidly progressive disease associated with injury to multiple organ systems and a 30-60% mortality rate. We present a case of a 40-year-old woman who developed group A streptococcal toxic shock following a spontaneous abortion. She required surgical debridement, pulmonary artery catheterization, mechanical ventilation, and massive transfusions. Clinicians must be aware of the presentation of this disease, as its incidence appears to be increasing.

Complications of uterine leiomyomas in pregnancy.

Uterine leiomyomas are found in approximately 2% of pregnant women. One of ten women with myomas will have complications related to myomas during pregnancy. The major complication is the syndrome of painful myomas of pregnancy, characterized by second- and early third-trimester pain and occasionally bleeding. In our population, fever, rebound tenderness, and elevated white blood cell count were not associated with pain. Short courses of ibuprofen were successful in controlling pain in these women. Other complications of myomas in pregnancy included preterm premature rupture of the membranes, malpresentation, increased cesarean delivery rate, and postpartum endomyometritis.

Distinguishing tubal metaplasia from endocervical dysplasia on cervical Papanicolaou smears.

Tubal metaplasia is a benign endocervical lesion. There may be confusion, however, in distinguishing tubal metaplasia from endocervical gland dysplasia on Papanicolaou smear. We present a case in which a cervical smear diagnosis initially reported as endocervical atypia was corrected to a diagnosis of tubal metaplasia upon cytologic review, thus altering patient management. The presence of terminal bars and cilia are the most helpful features in the cytologic recognition of tubal metaplasia. The evaluation of endocervical gland dysplasia suggested by Papanicolaou smear may include diagnostic conization; therefore, to prevent unnecessary intervention, it is important to distinguish endocervical gland dysplasia from tubal metaplasia.

Perimortem cesarean delivery.

Postmortem cesarean delivery is an operation that has been practiced since antiquity. In previous centuries low infant survival rates led to negative opinions regarding the operation's usefulness. A review of the past centuries' cases and a review of fetal physiology suggest that to obtain optimum infant survival, cesarean delivery should be initiated within four minutes of maternal cardiac arrest. The physiology of cardiopulmonary resuscitation during pregnancy is analyzed, and recent cases of maternal cardiac arrest with successful maternal resuscitation are reviewed. This data suggests that perimortem cesarean delivery initiated within four minutes of maternal cardiac arrest will yield the highest rates of maternal survival. Legal liability from the operation is minimal.

Toxic shock syndrome associated with vulvar necrotizing fasciitis.

BACKGROUND: Fifty percent of toxic shock syndrome is associated with nonmenstrual etiologies such as postoperative wound infection. CASE: A 44-year-old woman developed necrotizing vulvar fasciitis that was successfully treated with surgical debridement and broad-spectrum antibiotics. However, after improving for 3 days postoperatively, she developed fever, a generalized maculopapular rash, and renal and liver abnormalities. As her condition worsened, she developed hypotension and respiratory distress. After 5 days in the intensive care unit, she gradually improved. Her wound culture from admission grew multiple organisms, including Staphylococcus aureus that produced toxic shock syndrome toxin-1. CONCLUSION: Toxic shock may occur in varied gynecologic settings, including pelvic and perineal infection. Successful management requires a prompt and aggressive response to multi-organ system failure.

Argon laser therapy of vulvar angiokeratoma.

A 25-year-old woman with Noonan syndrome presented with painful, bleeding lesions of the vulva and perineum. The histologic diagnosis was angiokeratoma. Chronic increased central venous pressure from the patient's underlying cardiac disease was felt to be etiologic. The Argon laser was used for ablation, with minimal blood loss despite the extreme vascularity of these lesions.

Massive ovarian cyst: a comprehensive surgical approach.

The massive ovarian cyst (greater than 25 pounds) presents a challenging opportunity for surgical intervention and potential cure of a debilitating problem. Although infrequently seen, such a patient requires awareness of the unique problems removal of these large masses may cause. Successful management requires a comprehensive approach before, during, and after the operative procedure. There are three keys to optimal management: 1) a multisystem, team approach, 2) intact cyst removal, and 3) a special incision and reconstructive technique.

Cancer in pregnancy: a review of the literature. Part I.

Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.

Successful treatment of a cervical pregnancy with a single low dose methotrexate regimen.

Until very recently cervical pregnancies have been treated with surgery, usually hysterectomy. The development of endovaginal ultrasound, which allows early diagnosis, and methotrexate chemotherapy have opened up new therapeutic options. A 45-year-old multigravida presented at 8 weeks' gestation with vaginal bleeding. Endovaginal ultrasound demonstrated a cervical pregnancy with a fetal pole, 1.2 x 1.4 cm sac, no cardiac pulsations, and an empty uterus. After discussion with the patient, single low dose methotrexate 1.5 mg/m2 was given intramuscularly. The patient's hCG titre was 5882 IU-(Third International Standard). Over a 5-week period the hCG titres fell, and the gestational sac disappeared. The patient experienced intermittent vaginal bleeding and cramping but was managed as an outpatient. Single low dose methotrexate may be a successful management option in selected cases of cervical pregnancy.

Low dose dopamine in the treatment of persistent oliguria in pre-eclampsia.

Oliguria in pre-eclamptic women is most often a result of decreased intravascular volume. In a small number of patients, renal vascular spasm may be the cause of decreased urine output. Prolonged oliguria/anuria secondary to vasospasm may lead to permanent renal damage. When volume repletion is unsuccessful in restoring urine output, some authors have suggested the use of peripheral vasodilators such as hydralazine. Dopamine in low doses 2 micrograms/kg per min was used successfully to restore urine output within an hour in a pre-eclamptic patient who had been essentially anuric for 8 h. Volume administration and hydralazine were unsuccessful. In the rare instance of a patient who is unresponsive to conventional methods, low dose dopamine may provide an adjunctive therapy to restore urine output after delivery. Central monitoring is essential in following such patients.

Preoperative CA 125 in endometrial cancer: is it useful?

OBJECTIVE: We sought to determine the clinical utility of preoperative CA 125 measurement in determining the need for lymphadenectomy in patients with endometrial carcinoma. STUDY DESIGN: A prospective nonrandomized study was performed over a 2-year period. Patients referred with the diagnosis of endometrial carcinoma had CA 125 levels determined before surgical staging. Operative findings were then correlated with preoperative CA 125 values. Standard statistical calculations were used to determine sensitivity, specificity, positive predictive value, and false-positive and false-negative rates. The Student t test was used to determine differences between mean values. RESULTS: Either a CA 125 level of >20 U/mL or a grade 3 tumor or both of these correctly predicted 87% of patients requiring surgical staging. In patients with a preoperative diagnosis of stage I, grade 1 or 2 tumors, a CA 125 level of >20 U/mL correctly identified 75% (9/12) of patients requiring lymphadenectomy compared with only 50% (6/12) identified when a CA 125 level of >35 U/mL was used. Two of 16 low-risk patients with preoperative grade 1 tumors and CA 125 levels of <20 U/mL had occult extrauterine disease at surgery. CONCLUSION: Measurement of preoperative CA 125 is a clinically useful test in endometrial cancer. CA 125 levels of >35 U/mL strongly predicted extrauterine disease but lacked sensitivity in identifying patients needing staging. Either a CA 125 level of >20 U/mL or a grade 3 tumor or both of these correctly identified 75% to 87% of patients requiring lymphadenectomy. Until more data are collected, abdominal hysterectomy should be the procedure of choice for patients with grade 1 tumors and CA 125 levels of <20 U/mL.

Nylon brush improves collection of cervical cytologic specimens.

A prospective, randomized study was performed to compare the efficacy of a combined endocervical and ectocervical nylon brush with the cotton-tipped swab and wooden spatula for obtaining cervical cytologic specimens. Strict objective criteria were used to determine the adequacy of Papanicolaou smears on the basis of the number of cells present. The two methods were equally effective in collecting ectocervical smears. However, 96% of endocervical smears obtained with the nylon brush contained greater than 50 cells, compared with 58% of swab and spatula smears. Only 1.4% of brush samples contained no endocervical cells, versus 19% of swab and spatula smears. The presence of endocervical cells confirms adequate sampling of the transitional zone. Use of the cytologic Papanicolaou brush may result in fewer false negative and inadequate Papanicolaou smears.

Computed tomography: does it really improve the treatment of cervical carcinoma?

OBJECTIVE: The purpose of this study was to determine if computed tomography in cervical cancer staging resulted in treatment modifications leading to improved survival. STUDY DESIGN: Medical records of 246 consecutive women treated over a 3-year period for primary cervical cancer were reviewed. Frequency of recurrence was the outcome measure of interest and subjected to chi 2 analysis. RESULTS: Only eight patients had improved survival from treatment modifications based on computed tomography findings. Eight patients underwent additional surgical procedures because of computed tomography findings that proved to be erroneous. CONCLUSIONS: Considering the high cost and limited benefit, computed tomography for cervical cancer staging is not recommended.

Necrotizing fasciitis of the vulva.

OBJECTIVE: We attempted to characterize the natural history of necrotizing fasciitis of the vulva. STUDY DESIGN: The records of 29 nonpregnant women with necrotizing fasciitis of the vulva were evaluated. RESULTS: These women experienced a rapidly progressing polymicrobial infection. Initially, the infections in many women were thought to be labial cellulitis, appearing mild and innocuous. Delays in recognition and aggressive surgical management were associated with increased morbidity and mortality. Of 15 women with a delay greater than 48 hours between presentation and treatment, 11 died. Twenty of 29 (69%) were diabetic, accounting for 11 of the 14 deaths. CONCLUSION: Early diagnosis and aggressive surgical debridement in spite of mild symptoms will improve outcome in this serious disease process.

Methotrexate and angiographic embolization for conservative treatment of cervical pregnancy.

Cervical pregnancy has traditionally been treated by hysterectomy. Recent reports of the use of methotrexate have been encouraging as a potential conservative approach. We present a case of a cervical pregnancy diagnosed at 8 weeks' gestation in a woman who greatly desired fertility. She was treated successfully with a combination of multidose intramuscular methotrexate (1 mg/kg/day) and citrovorum rescue. When profuse bleeding developed on day 8, angiographic embolization was used to obviate surgery. The beta-hCG titer peaked at 58,362 IU/mL and was undetectable by postchemotherapy day 30. No blood transfusion was required, and reproductive capacity was spared. Four months after the cervical pregnancy, the patient became pregnant and had a healthy infant. Medical management of cervical pregnancy is an option when reproductive capacity is desired in selected patients with appropriate counseling.

Clostridium difficile infection in obstetric and gynecologic patients.

We reviewed hospital records of women on the obstetrics and gynecologic services with a diagnosis of antibiotic-associated diarrhea, pseudomembranous colitis, or Clostridium difficile infection to better characterize the incidence and course of women with C difficile infection. Cases were included if there was identification of C difficile by culture or toxin or endoscopic verification of pseudomembranous colitis. Between January 1985 and June 1995, there were 74,120 admissions to the obstetrics and gynecology services at two tertiary level hospitals. Eighteen women were found to have documented C difficile infection (0.02%)--3 from the obstetric services, 10 from the benign gynecologic services, and 5 from the gynecologic/oncology services. Diarrhea developed from 2 days to 30 days after antibiotics had been given (mean, 10 days). Nine patients had fever, six had nausea and vomiting, and five had abdominal pain. Antimicrobial agents given before infection included cephalexin, cefoxitin, imipenem, ciprofloxacin, trimethoprim/sulfamethoxazole, ampicillin, gentamicin, and clindamycin. All patients were treated successfully with inpatient antimicrobial agents-15 with metronidazole and 3 with vancomycin. There was one possible recurrence.