Experience with the routine use of an abbreviated crossmatch.

Three years' experience with the routine use of an abbreviated crossmatch procedure is reported. If a patient had no known history of and/or no currently demonstrable unexpected antibodies, ABO and Rh type specific blood was crossmatched at the time of need by using an immediate spin saline abbreviated crossmatch. Once blood was issued, both a 37 degrees C incubation and an antiglobulin crossmatch were done using the same tube employed for the abbreviated crossmatch. This served as a check that clinically significant antibodies were not overlooked. None of the 19,818 patients transfused following an abbreviated crossmatch suffered an acute hemolytic transfusion reaction as a result of this strategy; however, two patients may have manifested asymptomatic hemolysis. This approach to compatibility testing might be appealing to hospitals faced with fiscal limitations and new regulations affecting hospital reimbursement.

Effects of prostaglandin E2 analogue suppository on blood loss in suction abortion.

The purpose of the present clinical investigation was to determine the effect of preoperative treatment with a long-acting prostaglandin suppository containing 9-deoxo-16,16-dimethyl-9-methylene prostaglandin E2 on uterine blood loss in patients undergoing preoperative cervical dilatation before transcervical abortion. Ninety-five young women in the ninth to 14th week of gestation were randomly assigned to one of two groups. Patients in group 1 were treated with a long-acting prostaglandin suppository and group 2 patients acted as control subjects. At the end of three hours, patients in both groups underwent abortion with careful intraoperative measurement of blood loss in both groups. The blood loss in the prostaglandin-treated group was significantly lower than that in the control group (69.0 +/- 14.1 mL versus 151.1 +/- 26.6 mL). The difference in intraoperative blood loss was observed at all gestations between nine and 14 weeks. There was significantly greater dilation of the cervix after prostaglandin treatment (mean difference, 4.58 mm; P less than .005).

Prostaglandin E2 induction of labor for fetal demise.

Intrauterine fetal demise is a source of anxiety to both patient and physician. Heretofore, the standard treatment was either careful observation until the patient went into labor or attempt at induction of labor with oxytocin. Unfortunately, oxytocin stimulation has not proven to be uniformly successful for this problem. Prostaglandin E2 suppositories have been shown to be effective in inducing uterine evacuation after intrauterine fetal demise. In the opinion of the authors, this approach will in the future replace the sometimes dangerous and emotionally laden convention of watchful delayed therapy.

Liver tumors and oral contraceptives.

Benign hepatocellular neoplasia has been found in 23 patients receiving oral contraceptives of various types. Because primary liver tumors are rare, this marked increase in incidence within 5 years suggests a cause-and-effect relationship. Since progestogens are enzyme inducers it is possible that they accelerate oncogenesis by increasing toxic metabolites which cannot be excreted due to the cholestatic effect of estrogens. Vascular changes and the hypercoagulation state of pill users may act synergistically to produce hemorrhagic necrosis and tumor rupture. Liver scans, celiac arteriography, and standard liver function tests are impractical and ineffective in the identification of the patient at risk. Management of the suspect patient with an intact liver should consist of biopsy at laparotomy so that the entire liver can be inspected. Observation, discontinuance of oral contraceptives, avoidance of similar steroids, and pregnancy should provide adequate prophylaxis against liver rupture. However, if a large blood-filled sinus lake or an area of coagulation necrosis is encountered, resection is imperative to prevent later rupture.

Prenatal diagnosis of chromosomal and enzymatic defects.

Second trimester amniocentesis is a valuable procedure to detect chromosomal and enzymatic defects. A brief review of the current literature and the author's experience is presented.

Association of liver tumors with oral contraceptives.

Benign hepatocellular neoplasia occurring in 22 women receiving oral contraceptive steroids but no other known hepatotoxins is reported for the first time from a registry for liver tumors associated with oral contraceptives. A review of recent literature has yielded 45 cases including 3 previously reported by the authors. This striking increase in what were formerly rare primary liver tumors in young women strongly suggests a cause and effect of relationship. Eighteen patients presented with intrahepatic or extrahepatic rupture and hemoperitoneum with hemorrhagic shock due to vascular changes within their liver tumors. Five died as a direct or indirect result of preoperative or postoperative blood loss. The predominant lesions were focal nodular hyperplasia, hepatic adenoma, and hamartoma. Multiple synonymous nomenclature used to describe the histopathology of these tumors is disquieting and requires clarification. For diagnosis, enzyme determinations are not helpful. However, radionucleide liver scans, sonography, and celiac arteriography may be of value. Clinical surveillance must be the primary means for identification of this potentially lethal adverse phenomenon among 50,000,000 oral contraceptive users.

Effect of pregnancy on liver tumor associated with oral contraceptives.

Four cases of liver adenoma associated with oral contraceptives complicating pregnancy are reported. All patients were symptomatic during pregnancy and 2 were admitted with rupture of the adenoma. One subsequently died. Increased growth and vascularity of adenomas during pregnancy is highly likely. The potential for development of lethal complications is considerable.

Effect of oral contraceptives on leukocyte phagocytic activity and plasma levels of prostaglandin E2 and thromboxane B2 in normal menstruating women.

Mononuclear and polymorphonuclear cells were isolated from the peripheral blood of normal menstruating women. Four of the subjects were not using oral contraceptives and five were taking various formulations. The women were tested once a week for 12 consecutive weeks. Plasma levels of 6-keto-prostaglandin F2 alpha (6-KF), prostaglandin E2 (PGE2), thromboxane B2 (TxB2), estrogen, and progesterone were measured by specific radioimmunoassays. The phagocytic activity of the mononuclear and polymorphonuclear cells isolated from the peripheral blood was measured with a bacterial phagocytosis and killing assay. The phagocytic activity of both types of cells was depressed perimenstrually in both groups of women. However, examination of individuals showed that those subjects not taking oral contraceptives had a worsening of phagocytic activities with approaching menses while the oral contraceptive subjects generally had an improving of these activities at this time. We were unable to correlate the phagocytic activities with either hormone or prostaglandin levels in the plasma of these subjects. However, the subjects on oral contraceptives had significantly lower levels of PGE2 and TxB2 than those women who were not using oral contraceptives.

Live tumors and oral contraceptives.

Data on 78 cases of benign hepatic neoplasia among women with a history of oral contraceptive (OC) use are analyzed. Data for the study were collected by the Liver Tumor Registry of the University of California Irvine Medical Center. Factors considered in the analyses include the patient's age and duration of OC therapy, histopathology of the tumors, and their symptoms, findings, and prognosis. The pathogenesis and treatment of the tumors are also discussed.

Preoperative cervical dilatation with a single long-acting prostaglandin analog suppository. An alternative to traumatic mechanical dilatation before surgical evacuation.

A single vaginal suppository containing 1 mg of 15-methyl prostaglandin F2 alpha methyl ester induced cervical dilatation in 60 patients requesting surgical termination of pregnancy. Forty-two percent of the patients required no further dilatation. Even when further dilatation was required, it was performed with considerable ease due to the softening effects of the prostaglandin on the cervix. The use of this agent may be of value in preventing complications resulting from mechanical dilatation of the cervix.

Prostaglandin E2 vaginal suppositories in the treatment of intractable late-onset postpartum hemorrhage. A case report.

Late-onset postpartum hemorrhage may sometimes be refractory to conventional methods of treatment. Prostaglandin E2 vaginal suppositories have been described as effective in arresting immediate postpartum hemorrhage secondary to uterine atony. This is the first report of the use of this treatment in a patient with massive hemorrhage three weeks after delivery.

Oral contraceptives and hepatic vein thrombosis.

The purpose of this paper is to report on three cases of the Budd-Chiari syndrome in young women who were taking oral contraceptives. Two patients survived, with gradual resolution of hepatomegaly and ascites following discontinuance of the birth control pills. One death occurred soon after the patient's admission to the hospital. The pathophysiology of this phenomenon involves two major aspects. Oral contraceptives are known to cause a hypercoagulation state as well as a direct effect on the blood vessels. In this series the combination of hypercoagulation and progressive occlusion of the vessels in patients on oral contraceptives appeared to lead to the development of thrombosis of the liver vessels.

Unilateral renal agenesis associated with vaginal or cervical fistula and anomalous uterine development.

Two patients with unexplained profuse vaginal discharge were noted to have anomalous uterine development associated with renal agenesis. Fistulous communication between a mesonephric duct remnant and the vagina or cervix was noted as the cause of the discharge. A previous report by one of the authors described two similar cases. Physicians should be alert to this syndrome as a cause of leukorrhea.

Safety and efficacy of vaginal prostaglandin E2 suppositories in the management of third-trimester fetal demise.

Prostaglandin E2 vaginal suppositories are well established in the management of intrauterine fetal demise in the second trimester of pregnancy. However, approval for their use in the third trimester has been withheld pending evaluation of safety and efficacy. In this study 46 patients with intrauterine fetal demise in the third trimester were managed in a similar fashion except that only a 10-mg dose of prostaglandin E2 was employed. Forty-four of the 46 patients were delivered successfully. One patient experienced a cervical laceration that necessitated a hysterectomy; in her, oxytocin was used to supplement the prostaglandin. It appears that prostaglandin E2 vaginal suppositories can be used safely in the management of fetal demise in the third trimester of pregnancy. Use of a lower dose of the medication as well as tocodynamometry is recommended because the absorption of and sensitivity to this medication vary from patient to patient. The frequency of administering the medication should depend on the patient's response rather than on any given formula.

PIP: Prostaglandin E2 (PGE2) vaginal suppositories are well established in the management of intrauterine fetal demise in the 2nd trimester of pregnancy. However, approval for their use in the 3rd trimester has been withheld pending evaluation of their safety and efficacy. In this study, 46 patients with intrauterine fetal demise in the 3rd trimester were managed in a similar fashion except that only a 10 mg dose of PGE2 was employed. 44 of the 46 patients were delivered successfully. 1 patient experienced a cervical laceration that necessitated a hysterectomy; in her, oxytocin was used to supplement the PG. It appears that PGE2 vaginal suppositories can use used safely in the management of fetal demise in the 3rd trimester. Use of a lower dose of the medication as well as tocodynamometry is recommended because of the absorption and sensitivity to this medication vary from patient to patient. The frequency of drug administration should depend on the patient's response rather than on any given formula.

Experience with the use of the Carboflator for establishing pneumoperitoneum.

Safe and adequate pneumoperitoneum is dependent upon intraperitoneal pressure and not upon the number of liters of gas insufflated. Volume of gas delivered depends upon the size of the patient and whether there is any possible leakage. The Carboflator is a useful instrument for establishing controlled insufflation of gas and fail-safe intraperitoneal pressure.

The making of a colposcopist. A safe and sensible approach.

A program was established to determine the accuracy of colposcopy at our institution. Forty-three patients with cytologic or histologic evidence of severe dysplasia or worse underwent diagnostic conization following satisfactory colposcopy. Thirty patients subsequently had either therapeutic conization or hysterectomy preceded by biopsy only. In all 73 cases, the surgical specimen did not reveal a more advanced lesion. However, when the colposcopy was unsatisfactory, the rate of error was 20.8%. It is our opinion that colposcopy is a safe and valuable technique as long as one recognizes the need for training and understands the indications for further diagnostic studies. The use of the colposcope for the evaluation of abnormal cervical cytology has increased steadily over the last few years, and several excellent courses are now offered throughout the United States. Armed with a certificate from such a course, many gynecologists then become self-proclaimed colposcopists in spite of warnings to the contrary by the instructors. In addition, supervision by experienced personnel is not always available. How, then, does one indeed become an accomplished colposcopist to the point that he or she can safely spare the patient the risk, inconvenience and expense of diagnostic cervical conization? Although several recent publications 2,5,6,9,11 document the diagnostic accuracy of colposcopically directly biopsies, we feel each individual should develop and evaluate his or her own skill before altering or abandoning conventional methods of diagnosis and management. The purpose of this report is to present our experience with colposcopy utilizing a program which can perhaps serve as a model to other clinicians.

Unilateral tuboovarian autoamputation.

Six cases of unilateral tuboovarian absence are reviewed. In four, the peritoneal cavity contained a separate ovoid structure. In two of these, the pathologist could identify the remnant as a phagocytized ovary. In a third patient, the ovoid body was seen fixed to the contralateral ovary during laparoscopy. Subsequently, it was identified radiologically as a calcific density. In the fourth case, an intact ovary was separated from the uterus and engulfed by omentum. If a total embryogenic error or selective dysgenesis of the urogenital fold occurs, ipsilateral anomalies usually involve adjacent structures of both the urinary and genital systems. Howerver, no anomalies of the uterus and urinary structures appeared evident in any reviewed case. Therefore, adnexal torsion with subsequent infarction necrosis and autoamputation represents the most likely explanation for this phenomenon.