Mullerian adenosarcoma of uterine cervix: report of three cases and review of literature.

BACKGROUND: Mullerian adenosarcoma of the uterine cervix is a rare tumor seen in young women of reproductive age group. It presents as cervical polyps and is a low-grade malignancy with a tendency for local recurrence. Diagnosis can be difficult since it can easily be mistaken for benign polyps, both clinically and pathologically. CASE: We present three cases of adenosarcoma of the cervix presenting as cervical polyps and review the clinical and pathological features of these tumors. CONCLUSION: Adenosarcoma of the cervix should be ruled out especially in women presenting with recurrent cervical polyps. A careful histological examination is mandatory, important prognostic factors being myometrial invasion and sarcomatous overgrowth. Distant metastasis is very rare and therapy can be tailored to suit patient's needs but long term follow-up is essential.

Ovarian malignant melanoma: unusual presentation of a solitary metastasis.

BACKGROUND: Malignant melanomas of the ovary are rare with unpredictable clinical and biological behavior. We present this case report of a metastatic ovarian malignant melanoma, where the ovary was the first site of relapse after 10 years of remission. CASE: A 58-year-old postmenopausal woman was incidentally found to have an abdominal mass, 10 years after removal of a cutaneous malignant melanoma lesion. Ultrasound and CT scan revealed an adnexal mass, which was found to be a solitary ovarian tumor at laparotomy. Histology confirmed malignant melanoma metastasis. CONCLUSION: Relapse after a prolonged period of remission, presenting, as an isolated ovarian metastasis is an unusual presentation of malignant melanoma. As illustrated by this case report, a differential diagnosis of a metastatic malignant melanoma must be considered.

Laparoscopic extraperitoneal paraaortic lymphadenectomy: a study of its applications in gynecological malignancies.

OBJECTIVES: To describe our experience of laparoscopic extraperitoneal paraaortic lymphadenectomy and to study the feasibility, safety and applications of this technique in managing cervical, ovarian and endometrial carcinomas. METHODS: Our study included 32 women with cervical, ovarian or endometrial cancers undergoing laparoscopic extraperitoneal paraaortic lymphadenectomy between December 1997 and May 2002. The operating time, nodal yield, hospital stay and complications were recorded prospectively. The impact on the overall management was assessed by comparing the preoperative therapeutic plan with that following surgicopathological staging. RESULTS: The median nodal yield was 12 nodes, median-operating time was 80 min and the median hospital stay was 2 days. The median follow-up was 15.25 months. Lymphadenectomy was successful in all but one woman who had a peritoneal tear causing CO(2) gas leakage. Complications included one case each of pulmonary embolism, umbilical hernia, lymphocoele, pelvic collection and left-thigh cellulitis. In all women, the need for adjuvant chemotherapy or extended field radiotherapy (EFRT) was based on nodal histology. The primary plan of management was changed in 22.6% women. In the endometrial and cervical cancer group, 8.3% women deferred and 20.8% additionally received EFRT. All women with ovarian cancer (stage I) were completely staged and avoided chemotherapy. CONCLUSIONS: Laparoscopic extraperitoneal paraaortic lymphadenectomy is feasible with minimal complications, acceptable nodal yield and short hospital stay. It accurately identifies those cervical and endometrial cancers requiring extended field irradiation as part of their adjuvant therapy. It can be effectively applied in staging early ovarian cancers to determine the need for adjuvant chemotherapy.

Molecular quantification and mapping of lymph-node micrometastases in cervical cancer.

BACKGROUND: A proportion of patients with cancer and lymph nodes negative on histology will develop recurrence. Reverse-transcriptase PCR (RT-PCR) is a highly sensitive method for detection of lymph-node micrometastases, but accurate quantitative assessment has been difficult. METHODS: We studied primary tumours and 156 lymph nodes from 32 patients with cervical cancer (stage IA2, IB1, and IB2) and 32 lymph nodes from nine patients with benign disease. A fully quantitative, real-time RT-PCR assay was used to document absolute copy numbers of the epithelial marker cytokeratin 19. Primers and probe were designed not to amplify either of the two cytokeratin 19 pseudogenes. FINDINGS: All primary tumours and histologically involved lymph nodes (six) had more than 106 copies of cytokeratin 19 mRNA per microg total RNA. Expression of cytokeratin 19 (up to 1.1 x 10(5) copies per microg RNA) was detected in 66 (44%) of 150 histologically uninvolved lymph nodes, and in nodes from 16 of 32 patients with cervical cancer. 15 of these 16 patients with evidence of micrometastases had the highest cytokeratin 19 transcription level in a first lymph-node drainage station (three obturator, six internal, and six external iliac node). Transcription of cytokeratin 19 was found at a low level in just one of 32 lymph nodes obtained from nine patients with benign disease. Median copy number of cytokeratin 19 transcription was significantly higher (>10(3) copies) in association with adverse prognostic features. INTERPRETATION: The results suggest that about 50% of early-stage cervical cancers shed tumour cells to the pelvic lymph nodes. The amount of cytokeratin 19 expression was related to clinicopathological features. Further studies are required to document the clinical implications of molecular micrometastases.

Treating heartburn in pregnancy: comparison of acid and alkali mixtures.

A randomised crossover trial was performed in 55 pregnant women who complained of heartburn to see whether alkali or acid treatment alleviated it. Each woman was given a week's treatment with an acid mixture, an alkali mixture, and a placebo in randomised order. Both acid and alkali mixtures were better than placebo, but there was no significant difference between the acid and alkali treatments. Together with the inconsistent reports of some patients, these findings suggest that both acid reflux and bile regurgitation may cause heartburn in pregnant women and that other factors may also play a part. Because the cause of heartburn may be difficult to determine, treatment should be empirical. If the patient does not respond to seven days' acid treatment an alkali mixture should be prescribed; there is a 98% chance that one of these treatments will relieve symptoms.

Lumbar epidural analgesia in labour in twin pregnancy.

Fifty twin pregnancies in which the mother received epidural analgesia in labour were compared with 92 in which the mother received standard parenteral analgesia. The duration of the first and second stages of labour; the incidence of assisted deliveries when the head presented; the proportion of breech extractions when either the first or second twin presented by the breech; the incidence of low Apgar scores; and the perinatal mortality were not significantly different in the two groups. These findings suggest that lumbar epidural analgesia is safe for providing pain relief in labour for patients with a twin pregnancy. Moreover, an epidural block is preferable to conventional analgesia in these cases as it allows prompt intervention to effect delivery of the second twin.

Spontaneous premature birth in twin pregnancy.

Factors associated with spontaneous premature birth were investigated in 459 consecutive twin deliveries at this hospital. Low maternal age, low parity, and zygosity were significantly related to the incidence of this complication. The number of previous abortions, sex combinations and related birth order, and mode of presentation of the first twin were not related to the incidence of spontaneous premature delivery. We conclude that apart from low maternal age and low parity there are no obvious factors that would permit early identification of twin pregnancies at risk from spontaneous premature birth.

The relative efficacy of bed rest, cervical suture, and no treatment in the management of twin pregnancy.

We compared 60 twin pregnancies treated by bed rest, 37 treated by cervical suture and 36 receiving no active treatment. The incidence of the spontaneous onset of labour before 36 weeks of gestation, the mean gestational age at delivery, mean birth weights of the first and second twins and the incidence of 'small-for-dates babies' were similar in all three groups.

Umbilical vein cortisol after spontaneous and induced labour and at elective Caesarean section.

Umbilical vein (UV) plasma cortisol levels were assayed at delivery after spontaneous labour, oxytocin-induced labour, prostaglandin E2-induced labour and after delivery by elective Caesarean section. Higher mean UV cortisol levels were observed after vaginal delivery than after delivery by elective Caesarean section. The highest mean UV cortisol level was observed in the PGE2 group which accords with the known ability of prostaglandins to increase steroid production. The significance of these findings is discussed.

Relation of umbilical vein cortisol to neonatal bilirubin concentrations.

Umbilical vein cortisol levels were assayed following spontaneous labour in 30 patients. Serum bilirubin was measured in the infants born at three days after delivery. No correlation was demonstrated between third day bilirubin concentration and the cord blood cortisol. The implications of this finding are discussed.

Ectopic pregnancy: a five year review.

PIP: A survey of all women between the ages of 15-50 who underwent laparotomy at the Women's Hospital, Liverpool, from January 1970 to December 1974, was performed to identify etiological factors in ectopic pregnancy. There were 49 ectopic pregnancies during this peirod. The majority of patients were 30-35 years of age (20), 16 were in the 25-29 group. 63.3% had a previous viable pregnancy, 16.3% had a previous abortion, and 3 patients had a previous ectopic pregnancy. The major sysmptoms were vaginal bleeding followed by abdominal pain. Only 16.3% gave a history of previous pelvic infection. However, 53.5% were found to have evidence of previous pelvic infection. 4 patients. Results indicate that pelvic inflammatory disease is still the greatest cause of ectopic pregancy.^ieng

Comparison of intravenous oxytocin and prostaglandin E2 for accelerating labour.

In a prospective study of 52 consecutive women who required acceleration of labour intravenous prostaglandin E2 (PGE2) was used as the oxytocic agent. These mothers were matched for age, parity, height, gestational age, initial cervical dilatation, and station and position of the fetal head with 52 women whose labours were accelerated with oxytocin; both drugs were equally effective. Acceleration to delivery intervals, second-stage durations, the number of assisted deliveries, and Apgar scores were similar regardless of the oxytocic used. Although PGE2 compares well with oxytocin, it offers no further advantages and is more expensive and less well tried than oxytocin.

The retroverted gravid uterus and its effect on the outcome of pregnancy.

Among 1954 pregnant women who booked before the end of the 14th week of gestation the uterus was retroverted in 220 (11.2%). The incidence of bleeding in early pregnancy and spontaneous abortion was significantly higher in the retroverted group. Only three patients (1.4%) with a retroverted gravid uterus developed acute retention of urine. Patients with retroverted uteri did not have a higher incidence of previous infertility, nor any increase in the incidence of common obstetric abnormalities.

Neonatal hyperbilirubinaemia following the use of prostaglandin E2 in labour.

A prospective study of 447 labours and the resulting newborn failed to reveal any significant difference between the incidence of neonatal hyperbilirubinaemia, defined as a level of at least 205 mumol/l (12 mg/100 ml), following spontaneous labour and after labour induced or accelerated with prostaglandin E2 (PGE2). The incidence of unexplained neonatal hyperbilirubinaemia after spontaneous labour was 4-5 per cent. There was no significant association between the incidence of neonatal hyperbilirubinaemia and the total dose of PGE2 used for induction. None of the babies of the six mothers who required more than 1-5 mg of PGE2 to induce labour developed hyperbilirubinaemia. No association was demonstrated between neonatal hyperbilirubinaemia and birth weight or the duration of labour. The implications of these findings are discussed.

Neonatal serum bilirubin levels following the use of prostaglandin E2 in labour.

A prospective study of 447 labours and the resulting neonates failed to reveal a significant difference between the mean serum bilirubin concentrations on the third and sixth day following spontaneous, accelerated or induced labour. A similar incidence of neonatal jaundice (bilirubin concentrations of 10 mg/100 or more) was found in the studied groups. However, there was a tendency for neonates born after accelerated or induced labour to have slightly higher bilirubin levels than those born after spontaneous labour. No strong dose dependent effect on the level of bilirubin concentration following Prostaglandin E2 induced labour was demonstrated.

Engagement of the fetal head in primigravidae and its relationship to duration of gestation and time of onset of labour.

In a retrospective survey on the time of engagement of the fetal head in 462 unselected consecutive primigravidae it was seen that by the end of the 37th week of gestation (259 days), engagement had occurred in only 23 per cent of them. The highest rate of engagement was from 39 to 40 weeks of gestation (273 to 280 days) and in 50 per cent of patients, engagement occurred between 38 and 42 weeks (266 to 294 days). The mean interval between engagement and delivery was 1.39 weeks (9.7 days), the median was 7 days, and the mode was less than 7 days. In 80 per cent of patients the engagement-delivery interval was less than 14 days. These findings strongly suggest that in the majority of primigravid patients the fetal head does not engage between 36 and 38 weeks of gestation (252 to 266 days) as is commonly believed.