Complication of laparoscopic detorsion of adnexal mass.

Detorsion of an ischemic adnexal mass has recently been advocated for most cases of twisted adnexa. Usually, the affected ovary regains some or all of its vitality and function. However, when the ovary is completely necrotic, it may form an abscess if it contains tissue components that cannot be eliminated by the peritoneal immune system. We report a case of pelvic abscess formation in a detorsed ovary that previously contained an unsuspected dermoid cyst. We call for an extensive inspection of the detorsed ovary before ending the laparoscopic operation, and if it remains necrotic and is suspected of containing a dermoid cyst, it should be removed promptly.

Second trimester abortion by laminaria followed by vaginal misoprostol or intrauterine prostaglandin F2alpha: a randomized trial.

Intra-amniotic injection, as well as intravaginal application of prostaglandins, have been used to terminate second trimester pregnancies. There is as yet no consensus as to the most efficient protocol of such late abortions. Our goal was to compare the efficacy of intra-amniotic injection of prostaglandin F2 alpha (PGF2alpha) and intravaginal application of misoprostol in terminating second trimester pregnancies after pretreatment with intracervical laminaria. Women with live fetuses and requesting second trimester abortions were randomized into two groups. Eighteen hours following the insertion of intracervical laminaria, women were treated with either intra-amniotic injection of 40 mg PGF2alpha, or 12 hourly doses (to a maximum of 4 doses) of 200 mcg misoprostol. Fifty women were randomly assigned to each group. Failure to abort within 24 h of initiation of treatment occurred in 6 patients (12%) in the misoprostol group and 14 (28%) of the PGF2alpha group (p = 0.04). Mean time of induction of pharmacologic treatment to abortion was 13.6 h in the misoprostol group and 10.7 h in the PGF2alpha group (p = 0.03). The mean number of analgesic injections given were 0.8 in the misoprostol group and 1.6 in the PGF2alpha group (p = 0.0001). Only the method of abortion was predictive of abortion success and not other variables such as patient age, gestational age, gravidity, or parity. Following intracervical laminaria, vaginal misoprostol has been found to be more effective and less painful, compared with intra-amniotic PGF2alpha, for the termination of second trimester pregnancies with live fetuses.

Prospective randomized comparison between an open and closed vaginal cuff in abdominal hysterectomy.

OBJECTIVE: To compare an operative and postoperative course of open vaginal cuff hysterectomy and closed vaginal cuff hysterectomy, and to correlate the length of stay, febrile morbidity and the incidence of pelvic fluid collections to the type of surgery. PARTICIPANTS: One-hundred women scheduled for hysterectomy were prospectively randomized into two groups that underwent either a closed or an open vaginal cuff technique. RESULTS: The open vaginal cuff technique took on average 19% more time than the closed vaginal cuff operation (P < 0.05, t-test). The incidence and size of pelvic fluid collections was significantly higher after the closed vaginal cuff hysterectomy than after the open technique (P < 0.01, t-test). However, the postoperative length of stay, febrile morbidity and the rate of complications were similar. CONCLUSIONS: Both techniques of hysterectomy produced a similar postoperative course despite the fact that the closed vaginal cuff technique resulted in a higher incidence of pelvic fluid collections. Therefore considering a shorter operation time for the closed vaginal cuff hysterectomy, this technique seems slightly preferable.

Advanced squamous cell carcinoma of the vulva after treatment for verrucous carcinoma. A case report.

Verrucous carcinoma of the vulva, a rare variant of squamous cell carcinoma, is a locally destructive, nonmetastasizing tumor. While controversy surrounds the choice of treatment for this lesion, which frequently recurs, it is generally accepted that a recurrence is almost always local, with histologic characteristics and biologic behavior the same as those of the primary tumor. A case of squamous cell carcinoma of the vulva with involvement of the regional lymph nodes after treatment of verrucous carcinoma is reported to increase awareness of the potential biologic behavior of this uncommon tumor.

Cervical cerclage in uterine malformations.

This retrospective study represents our experience with cervical cerclage (suture) in pregnancies with uterine malformation. Seventeen patients with uterine malformations were involved. In these patients, the outcome of 31 gestations with cervical cerclage was evaluated. Uterine malformation was associated with cervical incompetence in 41% of the patients. Term delivery rate and fetal loss were observed in 56% and 26% of pregnancies, respectively. Infant salvage was not significantly different regardless of whether cervical incompetence was present or absent. A prolonged hospital stay and frequent use of tocolysis were noted during gestations with cerclage. Our data suggest that the outcome of pregnancies with uterine malformation was not improved by cervical cerclage when the indication for cerclage was the malformation itself.

Postpartum maternal group B streptococcal meningitis.

Maternal group B streptococcal (GBS) meningitis is rare, with only four cases previously reported in the literature. In this review a fifth case of postpartum GBS meningitis is presented. The five cases are compared with 34 cases of GBS meningitis in nonparturient adults. All cases of maternal GBS meningitis followed a vaginal delivery. The mean age of patients who had GBS meningitis outside the perinatal setting was 55 years, and most of these individuals had associated illnesses or frank immunosuppression; the mortality rate in this group was 23%. In contrast, all five patients with maternal GBS meningitis recovered. The case presented herein, like the four previous cases, illustrates the point that when patients with maternal GBS meningitis are treated immediately and have been healthy before the infection, the prognosis is good.

Survival after malignant pericardial effusion and cardiac tamponade in advanced ovarian cancer.

Malignant pericardial effusion and tamponade are rarely seen complications of epithelial ovarian cancer. With the use of multiagent chemotherapy these complications may be seen more frequently in the future. Therapy should be individualized, as long-term survival may be possible if the systemic manifestations of the cancer can be controlled.

Primary malignant melanoma of the vagina: report of four cases and review of the literature.

Four cases of malignant melanoma arising in the vagina are described, and the literature related to this unusual tumor is reviewed. The 2-year survival rate is better following radical surgery than after other treatment modalities; however, the 5-year survival rate is unrelated to type of therapy. Radical surgery appears to control local disease, but fails to address systemic spread of the tumor. Therefore, improvement in survival will require effective systemic therapy.

Broad spectrum antibiotics as short term prophylaxis for elective abdominal hysterectomy: comparison of mezlocillin, cefazolin and placebo.

A prospective randomized placebo controlled double-blind study was conducted in order to evaluate the effect of short term perioperative antibiotic prophylaxis on patients undergoing elective abdominal hysterectomy. Fifty-two patients received 3 doses of 0.5 g cefazolin, 54 patients received 3 doses of 1 g mezlocillin and 53 patients received placebo. Postoperative infectious morbidity and the rate of pelvic cellulitis were significantly lower in either antibiotic group in comparison to the placebo group, but neither drug proved to be superior in this respect. The fever index was significantly lower in the mezlocillin group in comparison to both cefazolin and placebo groups. It was thus concluded that antibiotic prophylaxis has a beneficial effect on patients undergoing abdominal hysterectomy and both drugs--cefazolin and mezlocillin--seem to be equally effective.

Effect of irrigation or intravenous antibiotic prophylaxis on infectious morbidity at cesarean section.

The efficacy of intraoperative irrigation with cefamandole nafate at cesarean section was evaluated in a prospective, randomized double-blind study. Two hundred and eight patients were treated with antibiotic irrigation and intravenous placebo or with perioperative intravenous cefamandole and irrigated with normal saline. The rate of endometritis was 10.9% in the irrigation group and 14% in the intravenous group, but the difference was not statistically significant. The rate of any infection, the number of days with fever, additional hospitalization days, and number of antibiotics used for treatment were similar in the two groups. It thus was concluded that irrigation with antibiotic is equal but not superior to perioperative intravenous antibiotics.

Short-term prophylactic antibiotic for elective abdominal hysterectomy: how short?

A prospective double-blind study was conducted in order to evaluate the effect of antibiotic prophylaxis on patients undergoing elective abdominal hysterectomy. In the first stage of the study, 116 patients received, on call to the operating room and subsequently 8 and 16 h post-operatively, cefazolin sodium or placebo. In the second stage of the study, 90 patients received the same antibiotics, but treatment was extended to 6 doses, 8 h apart. Of the 53 women who received placebo, 27 (50.9%) became morbid, while only 15 of the 63 (23.8%) who received 24 h prophylaxis were classified as morbid (p less than 0.005). By extending the prophylactic treatment to 48 h further reduction of the morbidity was achieved. Of the 90 patients only 11 (12.2%) became morbid (P less than 0.005). When morbidity rates were compared between different ethnic groups, over-weight and normal weight patients, pre- and post-menopausal women, it was not possible to define a group which is at a higher risk for post-operative morbidity. It was thus concluded that prophylactic antibiotics should be administered routinely to all patients undergoing abdominal hysterectomy, preferably for 48 h.

The value of laparoscopy in women with chronic pelvic pain and a "normal pelvis".

During the period January 1976--December 1982 laparoscopy was performed on 186 women complaining of pelvic pain of at least 6 months' duration. In all these cases, the routine pelvic examination and other medical and laboratory tests were negative. Laparoscopy revealed pelvic pathology in only 8.2%: in the vast majority (91.8%) entirely normal pelvic organs were seen. Evidence from the literature is compiling as to the psychogenic origin of most cases of chronic pelvic pain. Recently, it has been shown that laparoscopically negative pelvic pain can be relieved or abolished by psychological intervention. Since pathological findings on laparoscopy are of very low percentage and since the pain is psychogenic in most cases, the value of routine laparoscopy in chronic pelvic pain is very low. We propose that all women with chronic pelvic pain and normal pelvic examination should undergo psychological assessment and treatment if necessary. Laparoscopy should then be reserved for only those cases who show no amelioration on psychological intervention. Our estimation is that this approach would reduce the rate of laparoscopies performed for chronic pelvic pain by about 90%.

Hormonal profile of endometrial cancer.

Out of all the risk factors of endometrial carcinoma, the 'Oestrone Theory' is especially fascinating. This theory assumes that prolonged uninterrupted stimulation of the endometrial cell by oestrone, without the competition of oestradiol and oestriol, brings about neoplasia. There is also some evidence of a protective effect of androgens and progesterone. In order to verify this theory in vivo, oestrone (E1), oestradiol (E2), testosterone (T) and progestogen levels were examined from the serum of 36 post-menopausal women suffering from endometrial carcinoma, and compared with a healthy group of women. Oestrone levels were found to be significantly higher in patients with endometrial carcinoma. A correlation was also found between oestrone levels and previous infertility. With the intention of tracking the origin of oestrone in those suffering from endometrial cancer, hormone levels were checked before and after total hysterectomy and oophorectomy. The high oestrone values dropped to normal after the operation, except in those who had previously suffered from infertility. In those patients, high oestrone values were found a year after the operation. No significant differences of testosterone or progesterone were found between the cancer patients and the healthy women. The operation did not have any influence on these values.

Ovarian pregnancy in association with an intrauterine device.

Within a 1-year period, two cases of primary ovarian pregnancy associated with an intrauterine device (IUD) occurred in our institution. The clinical signs and symptoms were similar to those in any other ectopic pregnancy. Both cases satisfied the criteria of Spiegelberg. The final diagnosis was based on the histopathological findings. A review of the literature is presented summarizing the 53 cases reported until now. The association between IUD, ectopic pregnancy in general, and ovarian pregnancy in particular is discussed.

PIP: 2 cases of primary ovarian pregnancy associated with an IUD occurred at the Rothschild University Hospital (Haifa, Israel) within a 1-year period. This report describes the 2 cases and summarized the 53 cases that were reported until now. In case 1, a 23-year old woman, gravida 1, para 1, abortus 0, presented with lower abdominal pain and faintness 1 hour after a curettage. Her past history revealed no pelvic inflammations or operations. Her period was reported to be regular every 28 days. She had been using a Cu-7 IUD for 24 months. A curettage to terminate the pregnancy had been performed outside the hospital, revealing no gross pregnancy tissue. At the same time the Cu-7 IUD had been removed. 1 hour later the patient had urgently been sent to the hospital because of fainting and severe abdominal pain. Pelvic examination revealed slight vaginal bleeding, external os open to the tip of a finger, a normal sized uterus, normal adnexa, and a tender bulging cul-de-sac. A culdocentesis was performed and revealed blood with clots. The suspected diagnosis was perforation of the uterus. On laparotomy the uterus was found to be of normal size with no signs of perforation. On the right ovary a bleeding mass of 2 x 2 cm was seen. A wedge resection of the right ovary was performed, with preservation of most of the ovarian tissue, and the patient received 1000 ml of whole blood. The postoperative course was uneventful. Histological examination revealed an ovarian pregnancy: within ovarian tissue a large corpus luteum was found with blood clots, and trophoblasts. A decidual reaction of the ovarian stromal tissue was diagnosed. The tissue from the curettage was diagnosed to be endometrium with decidual changes, without chorionic villi or trophoblasts. The 2nd patient, a 34-year old woman, gravida 4, para 3, abortus 1, presented with abdominal pain and vaginal bleeding for 7 days. She had carried a Lippes loop IUD for 18 months. The IUD had been removed on the 3rd day of the bleeding because of abdominal pain and her desire for another child. Culdocentesis revealed dark blood with clots. On laparotomy about 100 ml of blood were found in the peritoneal cavity. The uterus, both tubes, and the left ovary were normal. The right ovary was a 6 x 6 x 6 cm enlarged cystic hemorrhagic mass. A right oophorectomy was performed. The postoperative course was uneventful. Histologic examination revealed an ovarian pregnancy: within ovarian tissue blood clots, chorionic villi and corpus luteum were found. There are no specific clinical signs of ovarian pregnancy. Abdominal pain, irregular vaginal bleeding, and faintness are similar to those of other ectopic pregnancy. The type of IUD associated with ovarian pregnancy varies. The increasing association of ovarian pregnancies with copper IUDs seems simply to be related to the increasing prevalence of this type of IUD in recent years.