Intracavitary radiotherapy for refractory dysfunctional uterine bleeding. A case report.

BACKGROUND: Pelvic irradiation was once a common treatment for dysfunctional uterine bleeding (DUB). Today the majority of women with DUB are successfully treated with hormonal therapy; patients unresponsive to hormonal therapy may require endometrial ablation or hysterectomy. We present a patient with severe, intractable DUB and contraindications to surgery who was treated with intracavitary radiotherapy. CASE: A 39-year-old, 150-cm-tall, 310-kg woman was referred for management of severe DUB refractory to medical management. The bleeding was successfully treated with intracavitary cesium. Hysterectomy was not recommended due to the operative risks posed by the patient's massive obesity. Because of technical difficulties during a previous dilation and curettage and the expense of long-term GnRH agonist therapy, the patient elected to undergo intracavitary radiotherapy. CONCLUSION: In selected patients, intracavitary radiotherapy can be used to treat DUB when conventional therapy fails or is contraindicated.

Shoulder dystocia: an obstetric emergency.

Shoulder dystocia is one of the most dreaded complications of vaginal delivery encountered by the obstetrician. Although risk factors for shoulder dystocia exist, approximately 50% of cases do not demonstrate the classic predisposing signs. Obstetricians can help patients decrease their risk for fetal macrosomia by frequent attention to weight gain, nutrition, and exercise during pregnancy and by aggressive management of diabetes. All obstetricians must be familiar with the maneuvers used to effect delivery of impacted shoulders and must be prepared to institute these maneuvers immediately in a crisis situation.

Do qualifiers of ASCUS distinguish between low- and high-risk patients?

OBJECTIVE: To evaluate the qualification of a Pap smear classified as atypical squamous cells of undetermined significance (ASCUS) favor reactive or neoplasia as recommended by the Bethesda System. STUDY DESIGN: The smears from 105 concurrent patients with a cytologic diagnosis of ASCUS not otherwise qualified were reviewed and subclassified as ASCUS favor reactive, low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL) based on the Bethesda System criteria. The cervical biopsy diagnoses were correlated. RESULTS: Of the 105 cases classified as ASCUS, 37 were subclassified as favor reactive, 51 as favor LSIL and 17 as favor HSIL on cytologic review. In the ASCUS favor reactive group, 19 (51%) had reactive changes on biopsy, 17 (46%) had cervical intraepithelial neoplasia (CIN) 1, and 1 (2%) had CIN 3. A total of 48% patients had CIN. In the favor LSIL group, there was CIN 1 in 28 cases (55%), CIN 2 or 3 in 12 (23%) and benign changes in 11 (22%) on biopsy. Seventy-eight percent had CIN. In the 17 cases classified as ASCUS favor HSIL group, all had CIN. CONCLUSION: Of the total 105 cases of ASCUS, 71% had CIN, 29% had reactive changes on follow-up biopsies, and 48% of patients in the ASCUS favor reactive group had CIN. Qualifiers of ASCUS have questionable utility in patient management.

Prenatal ultrasound diagnosis of massive subchorionic thrombohematoma.

Massive subchorionic thrombohematoma is a rare condition in which a large maternal blood clot separates the chorionic plate from the villous chorion. This condition is usually complicated by intrauterine growth restriction, and is often associated with fetal distress and perinatal death. We present a case in which the diagnosis of massive subchorionic thrombohematoma was made at 24 weeks' gestation. Doppler ultrasound helped to confirm the diagnosis and demonstrated severely abnormal umbilical blood flow. Two days after the diagnosis, fetal distress prompted emergency Cesarean delivery of a growth-restricted infant.

Atypical glandular cells of undetermined significance and other glandular cell abnormalities in a high-risk population.

OBJECTIVES: We set out to determine our rate of atypical glandular cells of undetermined significance (AGUS) classification, to compare our AGUS rate to rates reported by others, and to determine the correlation between AGUS and histological abnormalities in our population. MATERIALS AND METHODS: Reports from all Papanicolaou (Pap) smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. RESULTS: A total of 462 (1.2%) of 39,484 Pap smears were classified as epithelial cell abnormality-glandular cell, with 328 (0.83%) AGUS, 102 (0.26%) endometrial cells out of phase or in a postmenopausal woman, and 32 (0.08%) adenocarcinoma. A total of 146 (45%) of the AGUS cases had timely biopsies: 95 (65.1%) had benign findings, 27 (18.5%) had cervical intraepithelial neoplasia, 14 (9.6%) had adenocarcinoma (10 endometrial, 2 endocervical, 2 extrauterine), 9 (6%) had endometrial hyperplasia, and 1 (0.7%) showed endocervical glandular cell dysplasia. CONCLUSIONS: AGUS on Pap is associated with a clinically significant histological abnormality in a moderate percentage of patients. Both squamous and glandular lesions are seen, supporting the need for aggressive evaluation of the cervix, endocervix, and endometrium when AGUS is reported.

Squamous intraepithelial lesions of the cervix in a high-risk population.

OBJECTIVES: We set out to examine our use of the squamous intraepithelial lesion (SIL) category, compare our SIL rate to rates reported by others, and determine the corre-lation between SIL and histologically proven cervical intraepithelial neoplasia (CIN) in our population. MATERIALS AND METHODS: Reports from all Papanicolaou smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. RESULTS: Of 39,484 Papanicolaou smears, 2,101 (5.3%) were classified as low-grade squamous intraepithelial lesion (LGSIL) and 1,366 (3.5%) were classified as high-grade (HGSIL). Of the LGSIL cases, 972 (46.3%) underwent timely biopsy: Findings were benign in 29.9%; 41.7% had CIN1,20.9% had CIN2, and 7.5% had CIN3. Of the HGSIL cases, 932 (68.2%) underwent timely biopsy: Findings were benign in 12.3%; 17.1% had CIN1, 26.7% had CIN2, 42.2% had CIN3, and 1.6% showed squamous cell carcinoma. Condusions. Our LGSIL rate is similar to reported rates, but our HGSIL rate of 3.5% is higher. We found good correlation between SIL on Papanicolaou smear and CIN on biopsy (70.1% for LGSIL and 86% for HGSIL).

Uterine rupture during induction of labor at term with intravaginal misoprostol.

BACKGROUND: Misoprostol (prostaglandin E1) compares favorably with dinoprostone (prostaglandin E2) and oxytocin for labor induction at term. Excessive uterine activity has been reported using high-dose regimens, but no negative effect on outcomes has been observed. CASE: Labor was induced in a 34-year-old multipara at 39 weeks' gestation using intravaginal misoprostol tablets. Five hours after administration of the second 25-microgram dose, fetal bradycardia prompted emergency cesarean delivery. Hysterectomy and left salpingo-oophorectomy were necessary to control bleeding from a 15-cm posterior uterine wall rupture. CONCLUSION: Misoprostol can cause excessive uterine activity and uterine rupture.

Deep loop excision for prehysterectomy endocervical evaluation.

OBJECTIVE: Our purpose was to determine whether office deep loop excision should replace cone biopsy for frozen-section endocervical evaluation before planned hysterectomy. STUDY DESIGN: This cohort study comprised 31 patients who underwent office deep loop excision with frozen-section analysis followed by hysterectomy and 50 historic controls who underwent cone biopsy with frozen-section analysis followed by hysterectomy. Diagnostic accuracy, margin status, presence of residual disease, morbidity, and cost were compared. RESULTS: Loop excision frozen sections had sensitivity (ectocervical specimen, 96%; deepest endocervical specimen, 93%), specificity (100%, 86%), and positive (100%, 88%) and negative (75%, 92%) predictive values similar to those of frozen cone biopsy (95%, 80%, 98%, and 67%, respectively. No differences in margin status, presence of residual dysplasia, or morbidity were observed. The shorter operating room time for vaginal hysterectomy after loop excision (p < 0.01) resulted in an approximate $2000 savings. CONCLUSION: Office loop excision is a cost-effective option for endocervical evaluation before planned hysterectomy.

Atypical squamous cells of undetermined significance in a high-risk population.

OBJECTIVES: We set out to develop a benchmark for our use of the term atypical squamous cells of undetermined significance (ASCUS), to compare our ASCUS rate to rates reported by others, and to determine the correlation between ASCUS and histologically-proved cervical intraepithelial neoplasia (CIN) in our population. MATERIALS AND METHODS: All Papanicolaou (Pap) smears and associated cervical biopsies or endocervical curettages interpreted by the University of Florida Department of Pathology between 1992 and 1995 were reviewed. RESULTS: Of 28,494 Pap smears; 17% were classified as "epithelial cell abnormality, squamous," with 7.4% ASCUS, 5.6% low-grade squamous intraepithelial lesion, and 4.0% high-grade squamous intraepithelial lesion. Of the 2,100 ASCUS cases, 753 had timely biopsies; 45.8% were benign, 53.8% showed CIN, and 0.4% showed carcinoma. Of the CIN cases, 39.2% were CIN1, 8.1% were CIN2, and 6.5% were CIN3. CONCLUSIONS: Our 7.4% ASCUS rate is similar to published rates. Our high rate of neoplasia associated with ASCUS (54.2%) and our low ASCUS-squamous intraepithelial lesion ratio (0.77) indicate that we do not overuse the ASCUS classification.