Cesarean delivery and severe idiopathic thrombocytopenic purpura. A case report.

A postsplenectomy patient had idiopathic thrombocytopenic purpura (ITP) that was exacerbated with both her pregnancies. She failed to have sustained platelet counts in her previous pregnancy in spite of receiving steroids and chemotherapy. She underwent elective cesarean section with a platelet count of 7,000 but did not receive platelet transfusions. No unusual bleeding occurred, and an improvement in the ITP was noted postpartum.

Triplet pregnancies.

Fifteen triplet gestations delivered over 23 years beginning with 1954 are reviewed. The mortality rate was 7.1% in the gestation period of 28 weeks or more. This mortality rate compares favorably with the 15% to 50% rate reported in the literature. Among the third babies of each set, there was a mortality rate of 14.3%, again confirming the high mortality rate reported in the literature. Morbidity in triplet gestations was equally elevated. Although the data do not suggest what the best method of delivery is, the increased morbidity and mortality for the third baby of the set delivered vaginally implies that a more liberal use of cesarean section may reduce the potential risks for that baby. Also, among the eight cesarean sections performed in pregnancies at 28 weeks of gestation or more that have been reported in the literature, none of the babies died during the neonatal period.

The value of endocervical curettage as part of the standard colposcopic evaluation.

Whether to perform endocervical curettage (ECC) as part of a routine colposcopic examination in patients with an abnormal Papanicolaou smear remains controversial. Some studies consider ECC an essential part of a colposcopic examination regardless of the level of the squamocolumnar junction (SCJ); others consider it superfluous in cases where the SCJ can be visualized. Between January 1980 and December 1982, 278 new patients with abnormal Papanicolaou smears underwent colposcopy. Directed biopsies established the degree of cervical intraepithelial neoplasia (CIN) and ruled out invasive disease. ECC was done on every patient. A total of 51 patients (18%) had a positive ECC. Seven patients could not be evaluated because their records were incomplete. Of the 44 evaluable patients, 32 (73%) had satisfactory colposcopy. In the remaining 12 (27%) the upper limit of the transformation zone could not be seen clearly; in that group the degrees of CIN on colposcopic biopsy and ECC were in agreement in two cases; ECC revealed the degree to be less severe in four cases and more severe in six (50%). In the group with satisfactory examinations, 15 had the same degree of CIN on colposcopic biopsy and ECC; ten had less severe and seven (22%), more severe degrees of CIN on ECC. Of greatest clinical importance was that, overall, 11.5% had a positive ECC despite a satisfactory colposcopic examination. This study indicated that ECC provides unique and important information, justifying its inclusion as part of the standard evaluation of every patient undergoing colposcopy for abnormal cervical cytology.

Cytodiagnosis of endometrial malignant mixed mesodermal tumor.

The accuracy of endometrial aspiration smears obtained with the Isaacs cell sampler in the diagnosis of malignant mixed mesodermal tumors (MMMT) was compared to the results obtained with routine cervical and vaginal smears in five cases of MMMT found in a series of 220 endometrial aspirations. Cervical and vaginal smears previously taken on these patients were positive for adenocarcinoma or MMMT in two cases and suspicious for adenocarcinoma in the remaining three cases. Endometrial aspirates were positive for MMMT in three cases and positive for adenocarcinoma or MMMT in two cases. The endometrial aspiration smears contained a variety of cells: malignant glandular, squamous, spindly stromal, undifferentiated, osteoid and tumor giant cells; chondrocytes and free psammoma bodies were also observed. These cases indicated that endometrial aspiration can accurately detect the heterologous cellular elements found in MMMT and is an effective technique in its diagnosis.

Endometrial aspiration studies on Isaacs cell sampler with cytohistologic correlation.

Endometrial aspiration material obtained with the Isaacs cell sampler from 220 patients was studied and correlated with tissue biopsy from 172 of these patients. Of 52 endometrial carcinomas, there were two false-negative readings. In addition, five cases thought to be malignancies by cytologic criteria were not confirmed by histology. Therefore, the endometrial cell sampler showed a specificity of 96.85%, sensitivity of 96.15% and predictive value of 90.90%. Only nine cases of unsatisfactory cellular samples were obtained as compared to 13 cases of insufficient material by dilatation and curettage.

Treatment of vaginitis.

The physiology and flora of the normal vagina and the more common causes and associated treatments of vaginitis are reviewed. Vaginitis encompasses a group of diseases causing inflammatory changes in the vagina and vulva. Treatment of the various vaginitides requires accurate diagnosis, which is hampered by difficulties in culturing pathogens and in resolving the pathogenicity of various organisms. The ability of the body to withstand vaginitis is affected by physiologic changes within the vagina. The vaginitides and associated treatments reviewed include candidiasis and trichomoniasis; Hemophilus vaginalis and other bacterial vaginitis; and Herpes hominis, chlamydial, and atropic vaginitis.

Intractable bleeding managed with Foley catheter tamponade after dilation and evacuation.

Hemorrhage is one of the most frequent complications after dilation and evacuation. A small fraction of patients with hemorrhage will not respond to standard therapies. We discuss a case where both reaspiration and standard pharmacologic therapy failed to control hemorrhage and where hemorrhage was ultimately controlled by tamponade with two Foley catheters. We propose this method as an additional alternative for controlling hemorrhage after dilation and evacuation before resorting to angiographic embolization or surgery.

The prenatal sonographic diagnosis of lethal multiple pterygium syndrome: a heritable cause of recurrent abortion.

Presumably, a large number of recurrent abortions are caused by lethal recessive syndromes whose diagnosis depends either on a known family history or on the identification of characteristic fetal phenotypic features on pathologic examination. Because these conditions are rare, family histories are seldom helpful, and nondirected postmortem examinations on degenerating samples are seldom enlightening. Serial ultrasonography beginning early in pregnancy may provide important information in the evaluation of recurrent abortion caused by lethal recessive disorders. Reported is the accurate prenatal sonographic diagnosis of lethal multiple pterygium syndrome in a patient with a history of recurrent abortions. This syndrome is characterized by multiple limb contractures with pterygia, facial clefting, intracranial abnormalities, cystic hygroma, progressive fetal edema, and fetal death by midgestation. Inheritance may be X-linked recessive. Lethal multiple pterygium syndrome should be considered in patients with a history of recurrent midtrimester losses.

Trisomy 12 mosaicism in phenotypically normal fetuses following prenatal detection.

We report three cases of amniocentesis in which mosaicism for trisomy 12 was detected in two or more independent cultures. The parents elected to terminate the pregnancy in all three cases. Follow-up studies in two of the cases confirmed the mosaicism in fetal tissues (in subcutaneous tissue in one case; in fetal lung in the other), but not in blood. No fetal anomalies were evident by ultrasound or at autopsy. These results along with other reported cases demonstrate the difficulty in counselling for mosaic trisomy 12.