Biodistribution, with high uptake by the reproductive tract, of an intraperitoneally infused radiohalogenated steroidal estrogen-receptor ligand.

We infused [123I]16 alpha-(123I)-iodo-estradiol ([123I]E2) intraperitoneally (i.p.) into swine to study its biodistribution and to explore the i.p. use of radiohalogenated steroid estrogen-receptor (ER) ligands as a potential option for diagnosing and treating intra-abdominal, retroperitoneal, and distant sites of advanced ER-rich malignancies. Fifty to 80% of the radiolabel was absorbed from the peritoneal cavity within 30 minutes, and 30 to 50% of the infused radiolabel was excreted in the urine within 2 hr. The rate of biliary clearance was maximal within 25 minutes. At 3 hr, the ER-rich reproductive tract had greater than 63 times the concentration of radiolabel in blood; the former was blocked by non-labeled competitors for ER. Uptake by non-ER-rich tissues, compared to blood, ranged from 0.7:1 (heart and lungs) to 16:1 (spleen); the omentum, however, exhibited a concentration as high as 64:1, which was not blocked by non-labeled ER ligands. Uptake by ER-rich target tissue remained high when charcoal was used to prevent reabsorption of radiolabel from the digestive tract after its biliary excretion, and when the products of biliary excretion were removed by catheterization of the common bile duct. Neither charcoal nor exteriorization of bile appeared to affect urinary clearance of the radiolabel over the time course of the experiments. Taken together with the recent development of syntheses that yield radiohalogenated sex steroid receptor ligands of high specific activity, our findings are encouraging for the potential application of radiolabeled ligands as i.p. administered pharmaceuticals. The advantage of the i.p. route is that it provides direct uptake of the pharmaceutical by free-floating clusters and individual cancer cells in ascitic fluid, as well as delivery via the circulation to vascularized intra- and/or extraperitoneal metastases.

Fetal outcome with oligohydramnios in the second trimester.

Thirty-four cases of oligohydramnios in the second trimester were diagnosed by ultrasonography. Nine of these pregnancies were associated with fetal anomalies including Potter syndrome (three), atrioventricular dissociation (two), congenital absence of thyroid (one), and multiple anomalies (three). There were ten unexplained stillbirths, one demise due to abruptio placentae, eight with perinatal morbidity after premature labor or abruptio placentae, and six with live-born term infants. Although oligohydramnios in the second trimester is associated with increased perinatal morbidity, this finding is not associated with a universally poor outcome.

External cephalic version with tocolysis: factors associated with success.

Data were collected prospectively on factors that might affect the success or failure of external cephalic version, using a protocol including fetal monitoring, ultrasound, tocolysis, and external version after 37 weeks' gestation. Patients were accepted into the protocol whether or not risk factors for failure were present. Sixty-seven patients were admitted to the study and 40 (60%) underwent successful version. Using chi 2 analysis, we found that failure of external version was significantly associated with obesity, descent of the breech into the pelvis, decreased fluid, and fetal back positioned posteriorly. Thirteen women were in active labor; this had no effect on the success rate providing that descent had not occurred. Two factors, descent of the breech into the pelvis and posterior position of the fetal back, had an independent effect on success after controlling for other variables.

Pregnancy complicated by intraamniotic infection by Salmonella typhi.

There are few reports of transplacental infection by Salmonella typhi. A case of a primagravida at 26 weeks' gestation with severe S typhi gastroenteritis, sepsis, and disseminated intravascular coagulation is presented. Shortly after institution of antibiotic therapy, she spontaneously aborted a previable infant. Amniotic fluid was turbid and subsequently grew S typhi.

Significance of endometrial cultures performed at cesarean section.

To determine the bacterial pathogenesis of postcesarean endomyometritis, swab endometrial cultures of the lower uterine segment were taken intraoperatively in 160 cases. Both aerobic and anaerobic cultures were obtained. Of all patients, 16.8% developed endomyometritis. There was a statistically significant relationship between positive cultures and the development of endomyometritis. The organisms isolated were those commonly found in other types of pelvic infection: pathogenic aerobes and anaerobes as well as commensals. An average of 1.3 organisms were recovered per patient with positive cultures. An analysis is provided for findings depending on the status of membranes and the influence of labor. The following risk factors were identified for the development of endomyometritis: primary cesarean section, labor, ruptured membranes, and postoperative hematocrit. Implications of these findings and a review of similar studies is provided.

Comparison of chemiluminescent DNA probe to cell culture for the screening of Chlamydia trachomatis in a gynecology clinic population.

Two hundred ninety-five endocervical swab specimens were obtained from patients presenting to a gynecology clinic in order to compare a nonradioactive chemiluminescent DNA probe with cell culture for detection of Chlamydia trachomatis. Discrepancies between cell culture and DNA probe were resolved by retesting and reculturing samples. In a population with a 10.8% prevalence, the corrected sensitivity, specificity, positive predictive value, and negative predictive value for the DNA probe were 80.6, 95.8, 71.4, and 97.3%, respectively. These results compare favorably to other non-culture methods such as direct fluorescent antibody and enzyme immunoassay tests for the detection of C trachomatis in populations with similar prevalence rates.

Lactobacillemia of amniotic fluid origin.

Four cases of amnionitis due to Lactobacillus sp and three cases of bacteremia are reported. Postpartum endometritis developed in all four cases. Lactobacillus bacteremia occurred in two infants. A review of the literature on serious infections due to Lactobacillus sp is also presented. The importance of considering the clinical role of any microorganism isolated in pure culture from symptomatic patients is discussed.

Measurement of C-reactive protein to compare ceftizoxime versus cefoxitin/doxycycline therapy for septic pelvis: a preliminary report.

C-reactive protein (CRP), a biological marker of inflammation, may be a useful indicator of therapeutic response in patients with septic pelvis. In a study comparing ceftizoxime and cefoxitin/doxycycline in patients with septic pelvis, quantitative CRP levels were closely correlated with the responses and failures of therapy. The results of this study showed the two antibiotic regimens to be equally effective, with 23 of 25 patients in each treatment group achieving a satisfactory response. The fact that ceftizoxime was effective in four of five patients with Chlamydia trachomatis in cervical isolates suggests that intravenous therapy for the acute infection can be accomplished without the addition of an antichlamydial agent. Upon discharge from the hospital, patients can continue therapy with an oral drug that is specifically active against Chlamydia.

Use of expanded spectrum cephalosporins for the treatment of obstetrical and gynecological infections.

The antianaerobic cephalosporins, cefoxitin, ceftizoxime, cefotetan, and moxalactam, are compared in the treatment of obstetric/gynecologic infections associated with mixed aerobic and anaerobic pathogens. All of the antianaerobic cephalosporins have demonstrated similar efficacy in the treatment of mixed female genital tract infections. Thus, antibiotic selection requires a comparison of the antimicrobial activity, pharmacokinetics, adverse effects, and overall cost of therapy. All agents have excellent activity against the Gram-negative bacilli, and recent comparative data show that ceftizoxime is highly active against the Bacteroides sp. Dosing frequency and drug toxicity contribute to the overall cost of drug therapy. Cefoxitin is the only antianaerobic cephalosporin that cannot be dosed on a 12-hour basis. Ceftizoxime and cefoxitin, unlike moxalactam and cefotetan, do not contain the MTT group that has been associated with bleeding abnormalities. Substantial cost savings can be realized by using an antianaerobic cephalosporin administered every 12 hours. The experience at the Chicago Lying-in Hospital is presented.

Vesicovaginal fistula.

Vesicovaginal fistulas are often the result of obstetric trauma in third world countries and gynecologic surgery in developed countries. Improvement in obstetric care and the increased use of cesarean section has resulted in a decrease in the incidence of obstetric fistulas in the United States. However, the incidence of fistulas as a result of surgery has remained relatively unchanged for years. Most postoperative fistulas occur under very normal operative circumstances. The keys to prevention of postoperative fistulas are wide dissection of the bladder from the cervix and vagina in the correct plane during surgery and recognition of bladder damage intraoperatively with appropriate repair. More than 90 percent of vesicovaginal fistulas can and should be repaired vaginally. The procedures available for repair are the flap splitting and Latzko techniques. On occasion an abdominal approach is indicated, particularly for vesicouterine fistulas. Requirements for successful repair include adequate surgical exposure, wide mobilization of the vagina, nonexcision of the fistula tract, tension-free closure of the bladder, and grafting when indicated.

Adenoma malignum presenting as urinary incontinence.

A woman diagnosed with adenoma malignum (minimal-deviation adenocarcinoma) of the cervix with an ovarian metastasis is described. The highly malignant potential and diagnostic difficulty makes recognition of this neoplasm and the use of recent techniques to assist in diagnosis important to the practicing gynecologist.

Urethral prolapse in the premenarcheal female.

Urethral prolapse in the premenarcheal female manifests as vaginal bleeding and a periurethral mass. In the past, the recommended management was surgical excision or cautery. However, conservative management has been shown to have excellent results. Five premenarcheal patients with urethral prolapse treated by conservative therapy are presented. Treatment regimen consisted of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine and estrogen cream. There were no complications or recurrences. Surgery is not warranted in the treatment of urethral prolapse in the premenarcheal female. Medical management is equally effective and less traumatic in this age group.

Asymptomatic endometrial carcinoma after endometrial ablation.

Endometrial ablation has been recently introduced as a surgical alternative to hysterectomy for the treatment of dysfunctional uterine bleeding. The procedure itself is reasonably safe. However, if occult endometrial cancer is present before the procedure and is not detected, it may be more difficult to diagnose later. Endometrial cancer may also arise de novo from missed endometrial tissue. Two cases of endometrial cancer following endometrial ablation have been reported, but its overall incidence is unknown. A 58-year-old woman was treated with endometrial ablation for dysfunctional uterine bleeding. Three years later she underwent hysterectomy and Marshall-Marchetti-Krantz procedure for urinary incontinence; incidental, asymptomatic endometrial adenocarcinoma was discovered. The final pathology was grade 1 adenocarcinoma, invading more than 50% of the myometrium (FIGO stage Ic). Endometrial cancer may occur following endometrial ablation and it may be asymptomatic. Careful patient selection and close follow-up are essential.

Pelvic inflammatory disease. Decision making in the pharmacy and therapeutics committee.

In today's environment of cost containment, the pharmacy and therapeutics committee plays an increasingly important role in determining the availability of antibiotics for the treatment of specific diseases. However, if the drug is not optimal for treatment and sequelae of a disease process develop, no true savings are gained. The goal of treating pelvic inflammatory disease should not be just reduction of morbidity but preservation of fertility and reduction of surgery after therapy. Multiple factors must be considered when choosing antibiotic therapy for pelvic inflammatory disease, including the spectrum of pathogenic organisms involved, the efficacy of the antibiotic chosen, the safety profile of the antibiotic, the pattern of resistance to the antibiotic in both the hospital and the community, the cost of administering the antibiotic and management of its side effects. This paper reviews the concepts used at the Chicago Lying-in Hospital, University of Chicago, in choosing the primary antibiotic, ceftizoxime, for the treatment of pelvic inflammatory disease. This antibiotic offers a broad spectrum of antimicrobial activity with little resistance, few side effects, evidence of penetration into the infected tissues and prolonged dosing intervals, which allow substantial cost savings as well as efficacious treatment of acute pelvic inflammatory disease.

Capnocytophaga isolated from the endometrium as a cause of neonatal sepsis. A case report.

Capnocytophaga, a genus of gram-negative, anaerobic organisms, was isolated from the endometrium of a postpartum woman and the blood of the neonate. This unusual organism, usually isolated from the oral cavity, is sensitive to most antibiotics except the aminoglycosides.

Overview of therapeutic and prophylactic antibiotics in obstetrics and gynecology.

Infection in the obstetrics-gynecology patient remains an important source of concern. Advances in the identification of pathogenic organisms have led to improvements in the diagnosis of pelvic infections. Important considerations in the selection of antibiotics for established infections include prior hospitalization status, the size of the bacterial inoculum causing the infection, the etiologic organisms and, in the case of prophylaxis, the type of operative procedure. The antibiotic must also be cost effective.

Atrial myxoma as a complication of tocolytic therapy. A case report.

A 27-year-old woman who presented with premature labor was given ritodrine for tocolysis. During the administration of the beta-sympathomimetics she developed cardiac changes, including subendocardial ischemia on EKG and an intermittent early diastolic sound. Echocardiography revealed a large left atrial myxoma. It was removed during pregnancy, and the patient tolerated the procedure well. The mechanism of the ischemia was believed to result from the space-occupying mass of the myxoma, preventing adequate atrial filling and subsequent congestive failure. It is recommended that patients who develop cardiac symptoms during tocolysis with beta-sympathomimetics undergo further investigation to rule out under-lying pathology.

Tumors originating in supernumerary ovaries. A report of two cases.

The supernumerary ovary is a rare gynecologic anomaly; 13 cases have been reported on since 1890. Three were associated with tumors arising in the ectopic ovarian tissue. We encountered two cases of benign neoplasms discovered to have originated in supernumerary ovaries.

Surgical approaches to pelvic infections in women.

Pelvic abscess is a complication of gynecologic disease or obstetric surgery. Tuboovarian complex is differentiated from abscesses because of the absence of a true abscess wall; treatment of a tuboovarian complex is conservative. The diagnosis of tuboovarian complex is made by history, pelvic examination and ultrasonography. Tuboovarian abscesses (TOAs) are sequelae of surgical procedures. Both conventional and novel surgical techniques can be used to manage them. Pelvic thrombophlebitis and ovarian vein thrombosis are late complications of pelvic infections that may be associated with significant morbidity and mortality.

Use of C-reactive protein to predict the outcome of medical management of tuboovarian abscesses.

Medical management of tuboovarian abscesses (TOAs) has been shown to be successful. However, the ability to predict which patients with TOA would respond to antibiotic therapy could shorten the hospital stay and decrease treatment costs. C-reactive protein (CRP), an acute-phase-reactant protein with a short half-life, was investigated as a possible predictor of response by TOA patients to medical therapy. Twenty-two patients with TOAs were admitted prospectively into this study, which included daily quantitative determinations of CRP. The patients had either resolution of the mass and symptoms (responders), increased evidence of systemic sepsis and acute peritonitis requiring surgery (failures) or continuation of the tender adnexal mass without evidence of peritoneal irritation (persisters). Twelve patients classified as responders showed a continued daily decrease in quantitative CRP levels of at least 20% per day below the previous day's value until the return to normal levels. The five failures showed a progressive rise in CRP levels as well as evidence of systemic sepsis. Persisters showed an initial decrease in the CRP level followed by a leveling off of the value to a decrease of less than 20% per day. The rate at which daily CRP determinations decline may be a useful predictor of the response to antibiotic therapy.