The role of HPV DNA in the evaluation and follow-up of asymptomatic male sexual partners of females with CIN3.

PURPOSE: To determine whether and how asymptomatic sexual partners of females with high-grade cervical intraepithelial neoplasia (CIN3) lesions should be examined. METHODS: Sexual partners of females with CIN3 were evaluated for HPV-related lesions by scraping samples for high-risk HPV DNA and androscopy (colposcopic inspection of the penis, scrotum and peri-anal area). Abnormal androscopically detected lesions were sampled for cytology by Pap smears. RESULTS: 74 partners of 87 females were studied and underwent androscopy, and 17 (22.9%) had abnormal findings: 11/74 had clinical genital condyloma acuminata and 6/74 had aceto-white lesions on the penile shaft or scrotum. Cytology of the 17 abnormal androscopies showed that six smears were normal and 11 had atypia and koilocytosis. Positive high-risk HPV DNA indicated that 13/74 (17.5 %) were infected with HPV. Two partners (2/74, 2.8%) had concomitant HPV DNA 16. CONCLUSIONS: Male sexual partners of females with CIN3 should undergo androscopy and cytology of colposcopically detected abnormal areas.

Clinical and economic benefit of HPV-load testing in follow-up and management of women postcone biopsy for CIN2-3.

This study aimed to evaluate the clinical and economic implications of integrating human papilloma virus (HPV) load testing into the follow-up and management protocol of women postconisation for high-grade cervical intraepithelial neoplasia (CIN2-3). We evaluated 130 suitable women: 63 were screened biannually by Pap smears ('conventional approach') and 67 also had HPV-load testing ('HPV approach'). More stringent criteria for undergoing colposcopy or reconisation were observed by the former group compared to the latter. Both approaches were analysed for cost effectiveness. There were 33 out of 67 (49.2%) colposcopic referrals and 24 out of 67 (35.8%) reconisation/hysterectomies with the 'conventional approach' compared to 9 out of 63 (14.2%) and 7 out of 63 (11.1%) with the 'HPV approach'. Cervical intraepithelial neoplasia 2-3 residual disease was detected in 7 out of 67 (10.5%) and 7 out of 63 (11.1%) women. The 'conventional approach' had more negative colposcopic biopsies and more negative reconisation/hysterectomy histologies than the 'HPV approach'. The respective cost per detection of one case of residual disease was US$3573 and US$3485. The 'HPV approach' required fewer colposcopic and reconisation procedures to detect one case of residual CIN2-3. Its higher positive predictive value than that of cytology provided a significant decrease in false positive rates and a reduction of US$88 per detected case.

Morphologic and histopathologic characteristics of placentas from twin pregnancies spontaneously conceived and from reduced and nonreduced assisted reproductive technologies.

OBJECTIVE: To prospectively evaluate morphologic and histopathologic characteristics of placentas from twin pregnancies obtained by assisted reproductive technologies (ART) and non-ART and to evaluate the influence of previous fetal reduction on placental features. STUDY DESIGN: Fifty-five placentas from consecutive deliveries of ART-obtained and 50 placentas from consecutive deliveries of non-ART-conceived twin pregnancies were investigated by one pathologist, who was blinded to specimen origins. The patients' demographic and clinical data were also recorded. RESULTS: The mean maternal and gestational ages were similar in both groups. ART-obtained pregnancies were associated with an increased incidence of pregnancy complications and lower mean birth weight. Placentas from ART-obtained pregnancies were mostly of the dichorionic type and were thinner, weighed less and had more infarctions as compared to non-ART-conceived pregnancies. Placental characteristics of reduced ART-obtained twin pregnancies were comparable to those of nonreduced ones. The second twin's placenta in all groups weighed less and had a higher incidence of anomalous umbilical cord insertion. CONCLUSION: Placentas from ART-obtained twin pregnancies appear to have more pathologic features as compared to those of non-ART-conceived ones. Fetal reduction does not significantly affect the remaining placentas.

The classic approach to diagnosis of vulvovaginitis: a critical analysis.

OBJECTIVE: To correlate the symptoms, signs and clinical diagnosis in women with vaginal discharge, based on the combined weight of the character of the vaginal discharge and bedside tests, with the laboratory diagnosis. METHODS: Women presenting consecutively to the women's health center with vaginal discharge were interviewed and examined for assessment of the quantity and color of the discharge. One drop of the material was then examined for pH and the whiff test was done; a wet mount in saline and in 10% KOH was examined microscopically. The clinical diagnosis was based on the results of these assessments. Gram stain and cultures of the discharge were sent to the microbiology laboratory. RESULTS: One hundred and fifty-three women with vaginal discharge with a clinical diagnosis of vulvovaginitis participated in the study. Fifty-five (35.9%) had normal flora and the other 98 (64.1%) had true infectious vulvovaginitis (kappa agreement = 18%). According to the laboratory, the principal infectious micro-organism causing the vulvovaginitis was Candida species. Candida infection was associated with pH levels of less than 4.5 (p < 0.0001, odds ratio = 4.74, 95% confidence interval: 2.35-9.5, positive predictive value 68.4%). The whiff test was positive in only a small percentage of bacterial vaginosis (BV) (p = not significant (NS)). Clue cells were documented in 53.3% of patients with a laboratory diagnosis of BV (p < 0.02, positive predictive value 26.7%). CONCLUSIONS: The current approach to the diagnosis of vulvovaginitis should be further studied. The classical and time-consuming assessments were shown not to be reliable diagnostic measures.

Soluble endothelial and platelet selectins in serum and ascitic fluid of women with ovarian hyperstimulation syndrome.

PROBLEM: The selectins, a group of cell adhesion molecules, are major mediators of inflammatory, immunologic, and angiogenic reactions. Their possible involvement and levels of the soluble isoform in serum and ascitic fluid of women with ovarian hyperstimulation syndrome (OHSS) were not previously evaluated. METHOD OF STUDY: This prospective, case-control study involved 16 women with OHSS. Ten matched women treated by controlled ovarian stimulation and eight healthy women with normal diagnostic laparoscopy served as controls. Serum and peritoneal fluid samples obtained from all subjects were assayed for soluble endothelial selectin (sES) and soluble platelet selectin (sPS) by specific enzyme-linked immunosorbent assay. RESULTS: Significantly higher levels of sES (median, 17.1 [9-41] vs 9.3 [2.4 21.3] ng/mL [P = 0.03]) and sPS (median, 23 [13-277] vs 6.5 [1.6-28.7] ng/mL [P = 0.001]) were observed in the peritoneal fluid of women with OHSS than the basal levels of healthy, non-stimulated women. Women with OHSS had significantly lower sES serum levels than those treated by controlled ovarian hyperstimulation without OHSS, while their sPS serum levels were comparable. CONCLUSIONS: Ascitic fluid of women with OHSS contains appreciable amounts of soluble selectins, suggesting their ovarian origin and possible involvement in the syndrome.

Low-molecular-weight heparin for the prevention of obstetric complications in women with thrombophilias.

OBJECTIVE: To evaluate the benefit of combined low-molecular-weight (LMW) heparin and aspirin for prophylaxis in women carriers of thrombophilia who had previously suffered from severe obstetric complications. METHODS: The 33 studied women had an earlier pregnancy complicated by severe preeclampsia, abruptio placentae, intrauterine growth retardation, or intrauterine fetal death. All were subsequently diagnosed as carrying inherited thrombophilias. In their subsequent pregnancy, prophylactic therapy consisting of LMW heparin 40 mg/day (Enoxaparin, Rhone-Poulenc-Rorer, France) and aspirin was administered. Patients who were found to be homozygotes for the methylenetetrahydrofolate reductase mutation also received folic acid supplementation throughout their pregnancy. RESULTS: Low-molecular-weight heparin was well tolerated and none of the women or the newborns developed any hemorrhagic complications. Only three (9.1%) of the women developed pregnancy complications. The mean gestational age and the mean birth weight at delivery in the previously complicated pregnancies were 32.1 +/- 5.0 weeks and 1175 +/- 590 g, respectively, compared to 37.6 +/- 2.3 weeks and 2719 +/- 526 g, respectively, in the treated pregnancies (p < 0.001). CONCLUSIONS: This uncontrolled trial suggests that patients with obstetric complications and an inherited thrombophilia may benefit from treatment with combined LMW heparin and aspirin in subsequent pregnancies. However, this needs to be verified by controlled trials before considering clinical application.

Contribution of human papillomavirus testing by hybrid capture in the triage of women with repeated abnormal pap smears before colposcopy referral.

OBJECTIVE: The purpose of this work was to evaluate the ability of testing for high-risk human papillomavirus (HPV) types using the hybrid capture technique to predict the presence of cervical intraepithelial neoplasia (CIN) II,III in patients with repeated atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LGSIL) on Pap smears. METHODS: Hybrid capture testing and tissue biopsy were performed on 503 consecutive women with ASCUS or LGSIL on repeated Pap smears who were referred for colposcopy. RESULTS: A highly significant association (P < 0.0001) was found between a positive test for high-risk HPV types and CIN II,III, with an 87.0% positive predictive value and a 95.7% negative predictive value. In 226 women with ASCUS on repeated Pap smears, a positive test for high-risk HPV types had a 85.7% sensitivity and a 97% specificity for CIN II,III. In 277 patients with LGSIL on repeated Pap smears, a positive test for high-risk HPV types had an 88.2% sensitivity and a 94.7% specificity for CIN I,II. Reserving colposcopy examination for women who were positive for high-risk HPV types would have reduced the number of referrals for colposcopy to 24.6% and maintained a sensitivity of 87.0% for CIN II,III. CONCLUSIONS: A positive hybrid capture test for high-risk HPV types was highly sensitive and specific for the presence of CIN II,III in patients with ASCUS and LGSIL on repeated Pap smears. We believe that improved methodology will eventually enable more selective colposcopy referrals without affecting patient safety among these women.

Analysis of 104 twin pregnancies conceived with assisted reproductive technologies and 193 spontaneously conceived twin pregnancies.

OBJECTIVE: To evaluate pregnancy outcome of assisted reproductive technology (ART)-conceived twin pregnancies. DESIGN: Retrospective study. SETTING: A tertiary obstetric care center. PATIENT(S): All twin pregnancies delivered > or = 24 weeks of gestation from January 1, 1996, to December 31, 1997. INTERVENTION(S): Maternal and neonatal record review. MAIN OUTCOME MEASURE(S): Pregnancy and perinatal outcome. RESULT(S): The study group comprised 104 ART-conceived twin pregnancies, and 193 non-ART-conceived pregnancies served as controls. Mean maternal age, the proportion of nulliparae, and the percentage of women who delivered before 34 weeks' gestation was higher among the study women, whereas mean gestational age was younger. The incidences of pregnancy-induced hypertension, uterine bleeding, premature contractions, intrauterine growth retardation, fetal death, discordance, and cesarean section were significantly higher in the study group. Correspondingly, in the study group, the mean birth weight of both twins was lower; more neonates weighed < 1, 500 g, more had Apgar scores of < 7 at 5 minutes, more were admitted to the intensive care unit, and more second twin neonates died. The outcome of twin pregnancies conceived spontaneously was comparable with those conceived by ovulation induction. CONCLUSION(S): Assisted reproductive technology-conceived twin pregnancies are at greater risk than non-ART-conceived ones for pregnancy complications and adverse perinatal outcome.

Patients with double primary tumors in the breast and ovary- clinical characteristics and BRCA1-2 mutations status.

OBJECTIVE: The aim of this study was to define the prevalence, clinical characteristics, and BRCA1-2 mutation carrier status of ovarian cancer (OvC) patients with a previous primary malignancy in the breast (PPMBr). METHODS: The study population comprised 1240 consecutive Jewish Israeli women with pathologically confirmed epithelial OvC diagnosed between March 1, 1994, and December 31, 1997. Demographic and clinical data were obtained from medical files and from a detailed questionnaire taken through a nationwide epidemiological case-control study on OvC. Blood samples and tumor tissues were collected for analysis of the three predominant germline BRCA1-2 Jewish founder mutations (185delAG, 5382insC, and 6174delT). RESULTS: Fifty nine (4.7%) patients with OvC had a PPMBr. The median age at diagnosis of OvC was 60 years. The mean interval between the two diagnoses was 104 months (range 0-363 months). In the majority of the patients (n = 53), the diagnosis of breast cancer (BrC) preceded the OvC by more than 1 year. The ovarian tumors were diagnosed in 47% of the cases following investigation of patients' symptoms. In 41%, diagnosis was made as a consequence of check-up exams performed during the routine follow-up of BrC survivors. Patients with PPMBr were more likely to present with FIGO ovarian stage III-IV, compared to women with solitary OvC (73% vs 60. 3%, P < 0.05), and less likely to have borderline tumors (3.4% vs 17. 9%, P = 0.007). Family history of OvC/BrC was recorded in 26% of this group of patients compared to 10.5% among patients with solitary OvC (P = 0.003). Patients with PPMBr had an exceptionally high prevalence of BRCA1-2 mutations (57%), irrespective of family history. CONCLUSIONS: Patients with PPMBr present with more advanced disease and invasive-type epithelial ovarian tumors when compared to cases associated with solitary OvC. The rate of BRCA1-2 mutations in Jewish women with OvC who had PPMBr is at least twice as high as in Jewish women with OvC as the solitary disease.

p53 and WAF1 polymorphisms in Jewish-Israeli women with epithelial ovarian cancer and its association with BRCA mutations.

OBJECTIVE: To investigate whether polymorphic p53 and WAF1 alleles are associated with clinical, demographic and histopathological features and BRCA mutation in women with ovarian cancer. DESIGN: A cross-sectional study. POPULATION: Two hundred and twenty-one nonselected Israeli women with epithelial ovarian cancer. METHODS: DNA was analysed for known polymorphisms in intron 3 (a 16 nucleotide single repeat) and intron 6 (a G to A change at nucleotide 13,494) of the p53 gene, the S31R polymorphism in the WAF1 gene, and for three predominant Jewish mutations in the BRCA genes (185delAG and 5382insC in BRCA1, and 6174delT in BRCA2). MAIN OUTCOME MEASURE: The rate of polymorphic p53 and WAF1 alleles and their association with BRCA mutation, ethnic origin, age and stage at diagnosis, and family history of cancer. RESULTS: Of the tested women, 72 (32.6%) were either BRCA1 (n = 57) or BRCA2 (n = 15) mutation carriers. Sixty-eight of 213 (31.9%) were heterozygous for intron 3 polymorphism, 67/193 (34.7%) for intron 6 polymorphism, and 22/154 (14.3%) for S31R of the WAF1 gene. The p53 and WAF1 polymorphism rate did not differ between BRCA mutation carriers and noncarriers. No significant association between specific p53 or WAF1 genotypes, and clinical, histopathological or demographic variables was observed. CONCLUSION: In Jewish-Israeli women with sporadic and familial ovarian cancer, p53 or WAF1 polymorphisms do not seem to affect the phenotype.

Vertebral osteomyelitis: a rare complication of transvaginal ultrasound-guided oocyte retrieval.

OBJECTIVE: To present a case of vertebral osteomyelitis as a complication of transvaginal oocyte retrieval. DESIGN: Case report. SETTING: The IVF unit of a university-affiliated hospital. PATIENT(S): A 41-year-old woman who underwent IVF-ET treatment. INTERVENTION(S): Standard IVF-ET treatment cycles with the use of transvaginal ultrasound for oocyte retrieval and computed tomography-guided needle aspiration. MAIN OUTCOME MEASURE(S): Recovery of the patient, sequelae, and recurrence. RESULT(S): Vertebral osteomyelitis was diagnosed and treated with antibiotics. CONCLUSION(S): When severe low back pain occurs after ovum retrieval, vertebral osteomyelitis should be considered. Early diagnosis requires a high index of suspicion.

Combined colposcopy, loop conization, and laser vaporization reduces recurrent abnormal cytology and residual disease in cervical dysplasia.

OBJECTIVES: Loop electrosurgical excision of the transformation zone (LEETZ) was recently associated with relatively high failure rates. We evaluated whether the combination of LEETZ with laser vaporization is superior to LEETZ alone in reducing the rates of recurrent abnormal cytology and residual disease. METHODS: The study population included 426 women with histologic diagnosis of cervical intraepithelial neoplasia (CIN) 2-3, of whom 289 (study group) were treated by LEETZ followed by laser vaporization of the crater base and walls and 137 (control group) were treated by LEETZ alone. All women were followed scrupulously at regular intervals for recurrent abnormal cytology and residual disease. The mean follow-up periods were 43 and 59 months for the study and control groups, respectively. RESULTS: Both groups were derived from the same community and were similar in epidemiologic characteristics and disease severity. Although the incidence of positive surgical margins was similar in both groups (10.4 and 9.5% for the study and control groups, respectively), recurrent abnormal cytology (10.2% vs 5.5%, P = 0.07) and histologic residual disease (21.4% vs 0%, P = 0.05) were more frequent among women in the control group. This applied to women with both negative and positive surgical margins. Both study and control women with positive surgical margins, especially at the endocervix, were at higher risk for recurrence. CONCLUSION: The addition of laser vaporization to LEETZ may improve outcome of both women with positive margins and women with negative margins. Our results support conservative management for all treated women, regardless of cone margin status.

Vascular cell adhesion molecule-1 in normal, failed, and ectopic pregnancy.

PROBLEM: Vascular cell adhesion molecule-1 (VCAM-1) is involved in early pregnancy establishment. This study sought to determine whether soluble VCAM-1 (sVCAM-1) serum levels differ among normal, failed, and ectopic pregnancy, its capacity to serve as a marker for pregnancy viability or ectopic pregnancy, and its correlation with serum progesterone and beta human chorionic gonadotrophin (PHCG) levels. METHOD OF STUDY: Maternal serum samples were obtained from 20 women with ectopic, 10 with normal, and 10 with failed intra-uterine pregnancy, all of comparable gestational age. Samples were assayed for sVCAM-1, progesterone, and betaHCG by specific assays. RESULTS: The median serum level of sVCAM-1 was comparable between the three pregnancy types (normal: 578.3 ng/mL, range 434.4-699.5 ng/mL; failed: 567.8 ng/mL, range 401.9 669.5 ng/mL; and ectopic: 470.7ng/mL range, 328.2-1151.1 ng/mL). Serum levels sVCAM-1 were not significantly correlated with betaHCG or progesterone levels. CONCLUSION: sVCAM-1 is not appropriate to serve as a marker for pregnancy viability or ectopic pregnancy.

Levels of vascular endothelial growth factor are elevated in patients with ectopic pregnancy: is this a novel marker?

OBJECTIVE: To determine serum levels of vascular endothelial growth factor (VEGF) and evaluate their capacity to serve as a marker for the diagnosis of ectopic pregnancy (EP). DESIGN: Prospective, case-controlled study. SETTING: A tertiary care center. PATIENT(S): Twenty women with EP, 10 women with normal intrauterine pregnancy, and 10 women with abnormal intrauterine pregnancy, all at comparable stages of gestation. INTERVENTION(S): Serum samples were obtained from all women. MAIN OUTCOME MEASURE(S): All samples were analyzed for VEGF, progesterone, and beta-hCG by specific methods. RESULT(S): Women with EP had higher serum levels of VEGF than women with normal intrauterine pregnancy and women with abnormal intrauterine pregnancy (median levels, 226.8 pg/mL, 24.4 pg/mL, and 59.4 pg/mL, respectively). With a cutoff level of 200 pg/mL, serum VEGF could distinguish intrauterine from extrauterine pregnancy with a sensitivity of 60%, specificity of 90%, and positive predictive value of 86%. CONCLUSION(S): The increased serum VEGF levels in women with EP may facilitate this challenging diagnosis and reduce maternal morbidity and mortality.

Phase II study of carboplatin and etoposide as salvage treatment for patients with metastatic breast cancer.

A phase II study of carboplatin and etoposide as salvage polychemotherapy in metastatic, infiltrating breast carcinoma was carried out with 25 multiply pretreated patients. Six of 25 patients (24%) had a partial response that lasted an average of 3.5 months; of the six responders, four had undergone either four or five previous chemotherapeutic treatments. Eight of 25 patients (32%) had stable disease, and 11 (44%) manifested disease progression. The median survival from time of entry to the salvage protocol was 8 months. There were treatment responses in lung, chest wall, liver, and skeleton. The most common side effects were leukopenia (68% of 25 patients), thrombocytopenia (56%), anemia (40%), fever (28%), and weakness (16%). Carboplatin combined with etoposide may be an effective and tolerable salvage regimen in advanced breast cancer.

Increased frequency of genetic thrombophilia in women with complications of pregnancy.

BACKGROUND: Obstetrical complications such as severe preeclampsia, abruptio placentae, fetal growth retardation, and stillbirth are associated with intervillous or spiral-artery thrombosis and inadequate placental perfusion. Whether these complications are associated with an increased frequency of thrombophilic mutations is not known. METHODS: We studied 110 women who had one of the above-mentioned obstetrical complications and 110 women who had one or more normal pregnancies. The women were tested several days after delivery for the mutation of guanine to adenine at nucleotide 1691 [corrected] in the factor V gene (factor V Leiden), the mutation of cytosine to thymine at nucleotide 677 in the gene encoding methylenetetrahydrofolate reductase, and the mutation of guanine to adenine at nucleotide 20210 in the prothrombin gene. Two to three months after delivery the women were tested for deficiency of protein C, protein S, or antithrombin III and for the presence of anticardiolipin antibodies. RESULTS: The mutation at nucleotide 1691 [corrected] in the factor V gene was detected in 22 of the women with obstetrical complications and in 7 of the women with normal pregnancies (20 percent and 6 percent, respectively; P=0.003). Twenty-four women with complications, as compared with nine women without complications, were homozygous for the C677T mutation in the gene encoding methylenetetrahydrofolate reductase (22 percent and 8 percent, respectively; P=0.005). The G20210A mutation in the prothrombin gene was found in 11 women with complications as compared with 3 women without complications (10 percent and 3 percent, respectively; P=0.03). Overall, 57 women with obstetrical complications had a thrombophilic mutation, as compared with 19 women with normal pregnancies (52 percent and 17 percent, respectively; P<0.001). Deficiency of protein S, protein C, or antithrombin III or anticardiolipin antibodies were detected in an additional 14 women with complications, as compared with 1 woman with a normal pregnancy (13 percent and 1 percent, respectively; P<0.001). CONCLUSIONS: Women with serious obstetrical complications have an increased incidence of mutations predisposing them to thrombosis and other inherited and acquired forms of thrombophilia.

Bone scan and bone biopsy in the detection of skeletal metastases.

This study provides the first quantitative indication of the limits of sensitivity of a bone scan with technetium (99Tc-MDP) in detecting skeletal metastases and thereby also helps to explain the fact that bone scans may be negative when metastases are present in the bone marrow. Since 99Tc-MDP remains the least noxious and most widely used isotope for bone scanning, these results have direct clinical relevance in the evaluation of patients with solid tumors and possible metastatic spread.

Does typing of human papillomavirus assist in the triage of women with repeated low-grade, cervical cytologic abnormalities?

OBJECTIVE: To evaluate the ability of testing for high-risk human papillomavirus (HPV) using the hybrid capture technique to detect cervical intraepithelial neoplasia (CIN) in patients with repeated low-grade cervical cytologic abnormalities and an adequate and normal colposcopy. METHODS: Hybrid capture testing and LEETZ were performed on 166 women with repeated low-grade cervical cytologic abnormalities who were referred for colposcopy which was to be adequate and normal. RESULTS: A highly significant correlation (P < 0.0001) was found between a positive test for high-risk HPV types and the finding of CIN II,III. In 67 women with atypical squamous cells of undetermined significance on repeated cytologic studies, a positive test for high-risk HPV types had a sensitivity and specificity of 90 and 96.5%, respectively, for detecting CIN II,III. In 99 patients with low-grade squamous intraepithelial lesions found on repeated cytologic study, a positive test for high-risk HPV types identified all patients as having CIN II,III on cone biopsy (sensitivity, 100%), with a specificity of 86.4%. Restriction of tissue sampling to women who were positive for high-risk HPV types would have reduced the number of tissue samplings performed to 20.4%, while identifying 20 of 21 patients with biopsy-confirmed CIN II, III. CONCLUSION: A positive hybrid capture test for high-risk HPV types is highly sensitive and specific for detecting CIN II,III in patients with repeated low-grade cervical cytologic abnormalities and an adequate and normal colposcopy and may be used in the triage of these women before performing tissue sampling.

Can labor with breech presentation be induced?

Our objective was to evaluate the efficacy and safety of labor induction in women with a breech presentation, and an unripe cervix. We conducted a retrospective, matched-paired study on patients with breech presentation and an unripe cervix (n = 23), who underwent induction of labor using extra-amniotic saline instillation. The women were compared to three matched control groups: 46 women with vertex presentation and an unripe cervix, whose labor was induced by the same method, 23 with breech presentation who underwent a vaginal trial of labor, and 23 women with breech presentation who underwent a cesarean section without a trial of labor. In the study group, 12 women (52.2%) delivered vaginally. Rates of Apgar score, birth trauma, and maternal morbidity were similar in all groups. Induction of labor in patients with a breech presentation and an unripe cervix may be attempted in selected cases as it seems to be efficacious (vaginal delivery rate of 52.2%) and safe for both fetus and mother.

Intrauterine irrigation with prostaglandin F2-alpha for management of severe postpartum hemorrhage.

BACKGROUND: Severe postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. The use of prostaglandin F2-alpha to control severe postpartum hemorrhage may avert surgery for the control of bleeding. METHODS: After ruling out the possibility of genital tract injuries, 18 patients with severe postpartum hemorrhage caused by uterine atony were enrolled in the study. None of the patients responded to treatment with oxytocin, methylergonovine, or uterine massage. A Foley catheter was introduced into the uterine cavity and the balloon was inflated with 5 ml sterile saline solution. The catheter was connected to an infusion line of 500 ml saline solution containing 20 mg prostaglandin F2-alpha. The solution was infused at a rate of 3-4 ml/minute for the first 10 min, and then reduced to 1 ml/minute for a period of 12 24 hours. RESULTS: In 17 patients (94.4%) bleeding ceased within several minutes of initiation of intrauterine prostaglandin F2-alpha infusion, the uterus was firmly contracted and uterine bleeding did not recur. In one patient with placenta increta bleeding continued and hysterectomy was performed. None of the patients had any side effects. CONCLUSIONS: Intrauterine irrigation with low concentrations of prostaglandin F2-alpha is a simple, rapid and effective treatment for severe postpartum hemorrhage and facilitates constant and continuous hemostasis. Moreover, the minute dosage used eludes potentially complicating side effects.