Accuracy of colposcopically directed biopsy in patients with cervical neoplasia.

The histologic diagnoses of premalignant and malignant lesions of the cervix obtained by examining the colposcopically directed biopsy material from 643 patients were compared with those of the surgical material subsequently obtained. The procedures during which samples were acquired included hysterectomy (370), cervical conization (263), cervical amputation (2), and removal of a retained cervical stump (8). The diagnostic accuracy of colposcopically directed biopsy was 93.0% in those patients with satisfactory colposcopy, ie, the final diagnosis did not differ by more than 1 grade from that of the directed biopsy diagnosis. Two patients with widespread stage III cervical intraepithelial neoplasia on directed biopsy had microinvasive carcinoma in the therapeutic cone specimen. All invasive carcinomas (stage IB, occult) were diagnosed by directed biopsy and confirmed by subsequent examination of the surgical specimen.

Abdominal pregnancy: review of current management and addition of 10 cases.

Ten cases of abdominal pregnancy managed at the Brookdale Hospital Medical Center over a 17-year period are presented. An incidence of 1 abdominal pregnancy in 7095 deliveries occurred in this series; another institution reported 1 in 7931. A perinatal mortality rate of 80% and no maternal mortality in the study are contrasted to rates of 75 to 95% and 2 to 18%, respectively, from the world literature. Recurrent abdominal pain in the gravid patient with a prior history of infertility, tubal pregnancy, and/or surgery may signal abdominal pregnancy. Similarly, the management of fetal death should include consideration of the presence of abdominal pregnancy. The role of ultrasonography in diagnosis and the importance of immediate surgical intervention with minimal disturbance of the placenta are stressed.

Vaginal epithelialization with human amnion.

Human amnion is a readily available and inexpensive allograft with low antigenicity, high antimicrobial potential, and the ability to foster epithelialization. It has been used to reconstruct the vagina in 2 patients following vaginectomy for diffuse carcinoma in situ (CIS) and in 1 patient following severe, corrosive, vulvovaginal burns. It was also used to construct the vagina in 1 patient with müllerian agenesis. In all 4 cases, epithelialization was complete within 8 weeks.

Reproductive performance of DES-exposed female progeny.

The reproductive performance of 106 patients exposed in utero to diethylstilbestrol by maternal ingestion is described. Fetal wastage is high, apparently because of spontaneous abortion during the first and second trimesters. Recommendations are made for preconception counseling of exposed progeny to increase fetal salvage.

Squamous cell carcinoma in situ of the vagina and cervix after intrauterine DES exposure.

Two patients exposed in utero to maternal DES ingestion presented with adenosis. Each developed intraepithelial neoplasia in an area of active metaplastic change. The question is raised whether a continuum exists beginning with DES exposure and proceeding through the occurrence of adenosis and active squamous metaplasia to dysplastic alteration and finally squamous neoplasia. Since the cytologic smear is negative in 50% of cases during the dysplastic phase, it is recommened that all cases of adenosis be followed by colposcopy.

Sweet syndrome with involvement of the female genital tract.

Acute febrile neutrophilic dermatosis, otherwise known as Sweet syndrome, usually occurs in women after prior respiratory infections. The first case of Sweet syndrome with involvement of the female genital tract is reported here. The woman recovered completely, and no evidence of other underlying disease has appeared.

Delayed onset of clear cell adenocarcinoma of the vagina in DES-exposed progeny.

Clear cell adenocarcinoma of the vagina occurred in a diethylstilbestrol (DES)-exposed patient in the fourth year of continuous observation for adenosis. Diagnosis was suspected by digital and colposcopic examination and confirmed by target biopsy. Cytology was negative. The development of malignancy in a patient who has been known to have adenosis has been previously described but is very rare. The necessity for careful regular follow-up using cytology, digital palpation, and colposcopy at 6-month intervals is emphasized.

Gender-related behavior development in females exposed to diethylstilbestrol (DES) in utero: an attempted replication.

This report concerns the role of prenatal hormones in normal and abnormal psychosexual differentiation. Several studies indicate that perinatal treatment of infrahuman female mammals with diethylstilbestrol (DES) masculinizes certain features of their brain and behavior. Accordingly, the authors have hypothesized that prenatal exposure to DES may also masculinize the gender-role behavior of girls and women. A previous study suggested that prenatally DES-exposed women show decreased interest in parenting. The authors failed to replicate these findings in a different sample despite the use of similar methodology. Post-hoc analysis shows that the assessment devices would have detected masculinization if it were present. The implications of these findings for an understanding of psychosexual development are discussed.

Genital fistulas secondary to diverticular disease of the colon: a review.

Genital fistulas that complicate diverticular disease of the sigmoid colon may no longer be considered esoteric, or even rare phenomena. The vast majority of such lesions present with a foul, often fecal, sometimes purulent and occasionally blood-tinged, vaginal discharge for which patients customarily first seek relief from their gynecologists. Despite this fact, the topic is not mentioned in a single American textbook of gynecology. It is the purpose of this report to review the pertinent literature and to include the authors' experience with 13 additional cases in order to bring this topic to the attention of our gynecologic colleagues.

Antenatal diagnosis of acardiac, acephalic twin.

A case of acardiac, acephalic twin diagnosed by antenatal ultrasound is reported. The obstetrical significance of this condition is discussed.

Vaginal delivery after cesarean section.

We retrospectively analyzed 194 pregnancies in women with a history of previous cesarean section (CS) who were offered a trial of labor. We offered every woman a trial of labor as long as she did not have a known previous classical scar. One hundred fifty-one women delivered vaginally (79%), 24 women had multiple uterine scars. Multiple gestations and breech presentation were not considered a sole indication to perform CS. Fetal and maternal morbidity are presented. We conclude that women with multiple previous CS scars can safely deliver vaginally as can women with unknown uterine scars, with careful intrapartum surveillance. Although our numbers of women with breech presentation and multiple gestations are small, in the absence of significant morbidity, we continue to allow these women to labor and deliver vaginally.

Therapeutic conization under colposcopic guidance in the operating room.

One hundred eight patients with "satisfactory" colposcopy, a histologic diagnosis of cervical carcinoma in situ and a stated desire to maintain fertility were treated by therapeutic conization performed under colposcopic guidance in the operating room. One patient had a recurrence of carcinoma in situ at 8 months, and two patients had mild dysplasia at 18 and 24 months. Fifteen patients conceived.

Cervical sarcoma botryoides. A case report.

BACKGROUND: Sarcoma botryoides is a rare gynecologic malignancy. Reported treatment protocols range from localized resection of the tumor to radical surgery and adjuvant chemotherapy. Recently, limited excisional surgery combined with chemotherapy has contributed to excellent survival rates and preserved bladder and rectal function. CASE: We report a case of cervical sarcoma botryoides with minimal invasion. The patient had primary surgical treatment with complete resection of the tumor without adjuvant chemotherapy. Four months after surgery she presented with extensive metastatic retroperitoneal disease and died two weeks later. CONCLUSION: The clinical course of this patient suggests that complete surgical resection in cases of localized disease is not adequate therapy for sarcoma botryoides. Adjuvant chemotherapy should always be used, even at a very early stage.

Squamous cell carcinoma of the endometrium. A case report.

Invasive squamous cell carcinoma of the endometrium occurred secondary to squamous cell carcinoma in situ of the cervix. There have been 27 previous reports of secondary endometrial squamous cell carcinoma and 31 of primary.

Placenta percreta as a cause of uterine perforation during abortion. A case report.

Uterine perforation occurred during abortion in a patient with placenta percreta. The predisposing factor in the invasive placenta in this case was a uterine scar from a cesarean section.

Genital fistulas caused by diverticular disease of the sigmoid colon.

OBJECTIVE: Our purpose was to bring to the attention of gynecologists a subject not mentioned in a single textbook of gynecology, namely, genital fistulas resulting from diverticular disease of the sigmoid colon. STUDY DESIGN: We report our experience with 13 genital fistulas caused by sigmoid diverticulitis. RESULTS: Ten fistulas involved the vagina, one the vagina and bladder, one the tube, and one the uterus. Average age of the patients was 68.6 years (range 54 to 89 years). Presenting symptom in 12 patients was a malodorous vaginal discharge. All with vaginal lesions had previously undergone total hysterectomy. A barium enema failed to demonstrate a fistula in 8 of 11 patients. Colonoscopy failed in 8 of 8 patients. All fistulas were demonstrated by retrograde dye studies. Ten patients operated on were cured. Three patients refused surgery; of these, 1 had intestinal obstruction, 1 may have had spontaneous closure of the fistula, and 1 is being observed. Surgery involved staged procedures in 2 patients, fistulectomy in 4, and bowel resection and anastomosis in 4. CONCLUSIONS: Sigmoidovaginal fistulas are the most prevalent variety of cologenital fistula caused by sigmoid diverticulitis. The diagnosis should be considered in a patient > 50 years old who complains of a foul vaginal discharge and has a history of total hysterectomy. Its presence is best demonstrated by vaginogram. Surgical therapy is advised, the extent of which will rest on the surgeon's judgment of the severity of the inflammatory process found at exploration.

A fifteen year experience with ectopic pregnancy.

The increasing importance of an ectopic pregnancy as a cause of maternal death presents a challenge that will be met when primary care physicians combine a high index of suspicion with the ability to recognize the patient most at risk. The major symptoms, abdominal pain, secondary amenorrhea and abnormal vaginal bleeding are well known, as are the major signs, abdominal tenderness, adnexal mass and tenderness on motion of the cervix. Less well known are factors in the clinical history which indicate the patient to be at high risk. These include primary or secondary infertility, previous abortion or ectopic pregnancy and previous tubal operation, either reconstructive or sterilizing. In addition, the use of an intrauterine contraceptive device or its recent removal because of abdominal pain or bleeding, or both, is highly significant. Of major importance is a history of recent uterine evacuation. Should the diagnosis of ectopic pregnancy be under consideration, procrastination by observation is no longer acceptable. An active effort must be made to confirm or deny the diagnosis, Culdocentesis should be performed in the emergency department or clinic. If positive, prompt laparotomy is indicated. Should the result of culdocentesis be unsatisfactory or negative, laparotomy should be undertaken with further delay.

PIP: Ectopic pregnancy is a serious complication of pregnancy accounting for 6-13% of all maternal deaths in the U.S. Early diagnosis and treatment is absolutely necessary to ensure a successful outcome. In the period from January 1, 1965-December 31, 1979, 556 consecutive cases of ectopic pregnancy were treated at The Brookdale Hospital Medical Center in Brooklyn, accounting for less than 1% of all pregnancies handled in that period. 3 of these cases had an ovarian pregnancy, 8 had an abdominal, and 545 a tubal pregnancy. Relevant personal characteristics and aspects of obstetric history of these cases were studied. 85% of them had used no contraception prior to the ectopic pregnancy. Maternal age was not a factor in the occurrence of the ectopic pregnancy. The following factors in the clinical history were found to put the patient in a high-risk category: 1) primary or secondary infertility; 2) previous abortion or ectopic pregnancy; 3) previous tubal operation, either reconstructive or sterilizing; 4) recent uterine evacuation; and 5) the use of an IUD or its recent removal due to abdominal pain and/or bleeding. Major symptoms were found to be abdominal pain, common symptoms or early pregnancy, abdominal tenderness, adnexal mass, and tenderness on motion of the cervix. Culdocentesis and laparoscopy are effective diagnostic aids. Procrastination by observation should not be followed.

[Reproductive performance of DES-exposed-female progeny. Consequences of diethylstilbestrol in women whose mothers ingested the substance during pregnancy]. / Consequences du diethyl stilbestrol chez des femmes dont la mere a ingere cette substance pendant la grosesse.

PIP: Between October 1973-October 1979, 613 women who had been exposed to diethylstilbestrol (DES) in utero were observed at the Brookdale Medical Center; 106 of these patients were observed for problems related to pregnancy. Most patients were between 17-27 years of age, and 39% were unmarried; 70 were in their 1st pregnancy. Results of the 1st pregnancy were 52 induced abortions, 3 pregnancies still ongoing at the time of the study; of the remaining 51 pregnancies, 32 terminated in delivery; there was a 37% of fetal wastage, mostly due to early delivery. 36 of the original 106 patients had a 2nd pregnancy; in this group there were 7 abortions and only 22 deliveries. 11 patients had a 3rd pregnancy, and 5 a 4th pregnancy; these patients were able to bring their pregnancy to term. In total there were 159 pregnancies, and a high percentage of fetal loss, mostly between the 13th and 28th week of pregnancy. It is well known that many women who have been exposed to DES in utero present modifications of the aspect, shape, and size of the uterine cavity, which causes difficulties in bringing a pregnancy to term. The article reviews the published literature on the subject.^ieng

Prenatal exposure to diethylstilbestrol (DES): childhood play behavior and adult gender-role behavior in women.

Data from lower mammals suggest a masculinizing or defeminizing influence of pre- or perinatal diethylstilbestrol (DES) exposure on various aspects of the sex-dimorphic behavior (including juvenile rough-and-tumble play) of genetic females. However, three previous studies on childhood play and adult gender-role behavior in human females have led to ambiguous results. In a follow-up study of 60 women with prenatal exposure to DES and 26 controls, we used psychometrically well-designed multi-item scales based on self-report inventories for the assessment of these aspects of behavior. No effects of DES could be demonstrated. We conclude that, at the doses studied, prenatal DES exposure in human females has not led to behavioral masculinization or defeminization of childhood play and adult gender-role behavior.