Recombinant activated factor VII (NovoSeven): addition to replacement therapy in acute, uncontrolled and life-threatening bleeding.

BACKGROUND AND OBJECTIVES: Recombinant activated factor VII (rFVIIa, NovoSeven) has been used off-label for various conditions. A protocol for its use in acute, uncontrolled life-threatening bleeding, was devised and employed. A haematologist/transfusion specialist was assigned as a member of the team. MATERIALS AND METHODS: The clinical data were reviewed and summarized. A scoring system for the assessment and monitoring of coagulopathy was employed. Each parameter of prothrombin time (PT), activated partial thromboplastin time (aPTT), platelet number and fibrinogen level was allocated points according to the degree of abnormality. Three scoring levels emerged. RESULTS: Between April 2001 and April 2003, 13 patients received rFVIIa for acute, uncontrolled life-threatening bleeding. Nine of 13 patients remained alive for 15 days or longer after rFVIIa infusion. All patients who experienced a reduction or cessation of bleeding after rFVIIa infusion, also had a lower coagulopathy score after replacement therapy, prior to rFVIIa infusion, compared with their score at rFVIIa request. There was a reduction in the average use of blood products after rFVIIa infusion. The coagulopathy score was statistically predictive of response to rFVIIa and survival. CONCLUSIONS: In an area where very little data exists, we report the usefulness of rFVIIa. We propose that transfusion replacement should aim to correct coagulopathy before infusion of rFVIIa and that a haematologist/transfusion specialist should be involved in the management of these patients. A prognostically significant coagulopathy scoring system is offered.

Clinical evaluation of atypical glandular cells of undetermined significance upon cervical cytologic examination in Israeli Jewish women.

The adjusted incidence of cervical carcinoma among Israeli Jewish women is approximately 5 out of 100 000. This retrospective study sought to determine the clinical implications of finding atypical glandular cells of undetermined significance (AGUS) in cervical cytologic specimens in this population. Cervical cytologic examinations during January 2001-June 2003 diagnosed as AGUS were identified by a computerised database. Medical records were reviewed to determine the presence or absence of associated significant pathologic conditions of the cervix and identified 45 out of 11 800 patients (0.38%) with AGUS. AGUS was the only cytologic diagnosis in 14 patients, while 31 patients had both AGUS and an additional atypical squamous cell of undetermined significance (ASCUS). All subjects underwent colposcopy, endocervical curettage, and cervical biopsy. A clinically significant diagnosis (cervical intraepithelial neoplasia (CIN) II, CIN III, or carcinoma) was made in 24 patients (53.3%), including cancer in three (6.7%): one had microinvasive adenocarcinoma and two had microinvasive squamous cell carcinoma. Squamous carcinoma coexisting with a clinically significant lesion carried a risk of 61.3%, compared with a risk of 35.7% for AGUS alone (P=0.20). Detection of AGUS during cervical cytologic screening, especially with a coexisting ASCUS, indicates the existence of serious pathologic processes; management by cervical colposcopy, endocervical curettage, and cervical biopsy is recommended.

Role of urethrocystoscopy in the evaluation of refractory idiopathic detrusor instability.

OBJECTIVES: To assess the role of diagnostic urethrocystoscopy in the evaluation of women with idiopathic detrusor instability (DI) refractory to conventional pharmacologic management. METHODS: One hundred consecutive women (mean age 62.1 +/- 15.1 years) with idiopathic DI refractory to conventional pharmacologic management were prospectively enrolled. All patients underwent a meticulous evaluation, including a detailed history, urogynecologic questionnaire, micturition diary and pad test, urinalysis and culture, physical examination, and urodynamic studies. Refractory DI was defined as the lack of clinical improvement after at least 6 months of conventional drug therapy. These patients underwent additional evaluation with diagnostic urethrocystoscopy. RESULTS: All patients had a normal urinalysis and negative cytologic findings. Diagnostic urethrocystoscopy revealed isolated bladder tuberculosis in one and transitional cell carcinoma in another. Seven other patients had bladder diverticula (only one of which was also diagnosed by sonographic examination) and 22 had mild-to-moderate bladder trabeculations. CONCLUSIONS: The absence of other alarming signs (ie, recurrent urinary tract infection, hematuria, significant residual urinary volume, positive cytologic findings, or suspicious sonographic findings) cannot confirm the lack of significant lower urinary tract abnormalities among patients with refractory DI. Diagnostic urethrocystoscopy, a simple and safe office procedure, facilitates timely diagnosis and appropriate treatment for these patients.

Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence: preliminary results.

OBJECTIVES: Continent patients with a positive stress test demonstrated on repositioning of severe genitourinary prolapse are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence (SUI). Our aim was to evaluate in a prospective study whether a prophylactic, tension-free vaginal tape (TVT) procedure, performed during prolapse repair, may prevent the development of postoperative SUI in these women. METHODS: Thirty consecutive, clinically continent women (mean age 64.5 +/- 9.04 years) with severe genitourinary prolapse and occult SUI were prospectively enrolled. Occult SUI was defined as a positive stress test with repositioning of the prolapse during the preoperative urodynamic studies. All patients had urethral hypermobility; none had intrinsic sphincter deficiency. In addition to genitourinary prolapse repair, these patients underwent concomitant TVT to prevent postoperative SUI. Patients were followed up for at least 1 year. Repeated urodynamic studies were performed at 3 to 6 months postoperatively. The main outcome measures were postoperative SUI, persistent or de novo detrusor instability, and recurrence of prolapse. RESULTS: The mean duration of follow-up was 14.25 +/- 3.08 months (range 12 to 24). None of the patients developed postoperative symptomatic SUI. However, three asymptomatic patients (10%) had a positive stress test during their postoperative urodynamic evaluation. Nine patients (30%) had detrusor instability before surgery, which persisted in six (66%) postoperatively. Postoperative de novo detrusor instability was diagnosed in four other patients (13.33%). None of the patients had recurrent urogenital prolapse, nor did they have clinical evidence of bladder outlet obstruction. CONCLUSIONS: The preliminary results of TVT as a prophylactic procedure in clinically continent women with severe prolapse and occult SUI are encouraging. Long-term follow-up is required to confirm the durability of these results.

The effect of betamethasone versus dexamethasone on fetal biophysical parameters.

BACKGROUND: Clinical observations suggest that betamethasone reduces maternal perception of fetal movements and short term variability, but that this dose not occur after treatment with dexamethasone. OBJECTIVES: To compare the effect of betamethasone and dexamethasone on fetal biophysical parameters. METHODS: In a randomized, prospective, double blind study, 20 courses of betamethasone and 20 courses of dexamethasone were given in random sequence to patients with imminent preterm labor. During the first 32h after initiation of treatment, fetal movements were counted by the mothers and recorded by ultrasound, and a nonstress test was performed. RESULTS: Betamethasone induced a significant decrease in fetal movements as perceived by the mother and observed by ultrasound. Fetal breathing movements also decreased. Dexamethasone did not change fetal body movements. Neither drug changed the short term variability. CONCLUSIONS: Unlike betamethasone, dexamethasone does not induce a decrease in fetal movements. Dexamethasone might, therefore, be preferred for enhancement of lung maturation in imminent preterm labor.

Pemphigus vulgaris in pregnancy: a case report and review of literature.

Pemphigus vulgaris (PV) is an uncommon, immune-mediated bullous dermatosis, which, during its active phase, has been associated with infertility. Pemphigus vulgaris during pregnancy is exceedingly rare-only 26 cases with immunopathological confirmation have been reported. The disease may be associated with adverse neonatal outcome, including prematurity and fetal death. Transient skin lesions may occasionally appear in the neonate. We report a patient who conceived during the active phase of PV, required high doses of corticosteroids to control the disease, and was delivered of a pre-term, appropriate-for-gestational age newborn.

The effect of early epidural block administration on the progression and outcome of labor.

This study was undertaken to prospectively evaluate the effect of early administration of epidural bupivacaine (0.25%) on the progression and outcome of labor in 60 nulliparous patients. Patients were randomly divided into two groups. In group 1 (30 patients, early administration), the epidural catheter was sited and the first epidural injection of 0.25% bupivacaine administered at a cervical dilatation of <4 cm; group 2 (30 patients, late administration) received the epidural catheter and first epidural injection of 0.25% bupivacaine at a cervical dilatation of >or=4 cm. The progression and outcome of labor were compared between the two groups. There were no statistically significant differences between the two groups in rate of cervical dilatation, duration of the second stage, numbers of instrumental deliveries or cesarean sections or Apgar scores at 1 and 5 min. We conclude that there is no need to restrict epidural top-ups until cervical dilatation of 4 cm, when active management of labor is advocated.

Transvaginal sonohysterography for the early diagnosis of residual trophoblastic tissue.

We prospectively evaluated 29 patients with early postabortion or postpartum bleeding, suspected of having possible retained trophoblastic tissue by transvaginal sonography and transvaginal sonohysterography. All patients received methyl-ergometrine maleate (Sandoz) and amoxicillin and clavulinic acid (Pharmascope) orally for 5 days and were then reevaluated. Ten patients (34.5%) had a normal uterine cavity on both transvaginal sonography and sonohysterography. Nineteen patients (65.5%) were suspected of having residual trophoblastic tissue by transvaginal sonography. Of these, five (26%) showed normal uterine cavity by sonohysterography. One patient (8.3%) reported heavy bleeding with clots after the conservative treatment. Repeated examination revealed normal uterine cavity. The remaining patients underwent curettage, and histopathologic examination revealed trophoblastic tissue. Transvaginal sonohysterography is more accurate than transvaginal sonography for diagnosing residual trophoblastic tissue in patients with postpartum and postabortion bleeding. Its use may eliminate unnecessary curettage procedures.

Transvaginal sonohysterography: a new aid in the diagnosis of residual trophoblastic tissue.

OBJECTIVE: The study was undertaken to evaluate the diagnostic accuracy of transvaginal sonohysterography in postabortion and postpartum patients suspected of having residual trophoblastic tissue. METHODS: Twenty two women with late postabortion and postpartum bleeding were evaluated by transvaginal sonography and transvaginal sonohysterography. The patients were prospectively divided into two groups according to the sonohysterographic findings. Women with an empty uterine cavity or with free-floating masses received conservative treatment. Those with suspected attached residual trophoblastic tissue underwent curettage. RESULTS: Sonohysterography confirmed the findings of two-dimensional sonography of an empty uterus in 8 patients; however, a free floating endometrial mass was found in 4 patients and that of an empty uterine cavity in another 2 of 14 patients suspected of having residual trophoblastic tissue by the two-dimensional ultrasound. All 14 patients who were treated conservatively ceased bleeding. The 4 patients with a free-floating mass reported ejection of a vaginal mass within 6 days of treatment. Eight patients underwent curettage. Residual trophoblastic tissue was found in all of them. CONCLUSION: Transvaginal sonohysterography is a simple and effective method for the evaluation of residual trophoblastic tissue in patients with postpartum and post-abortion bleeding. Its use may eliminate unnecessary curettage procedures.

Effect of second-stage 0.25% epidural bupivacaine on the outcome of labor.

OBJECTIVE: To evaluate the effect of second-stage epidural bupivacaine on the outcome of labor. METHODS: Two groups of 35 patients each were randomly allocated to receive continuous epidural bupivacaine throughout labor (group 1) or until an 8-cm dilatation of the cervix (group 2). RESULTS: There was no significant difference between the 2 groups in the rates of instrument deliveries and in their Apgar scores. CONCLUSIONS: The administration of continuous epidural bupivacaine (0.25%) throughout labor and delivery does not seem to affect the outcome of labor.

Gigantomastia complicating pregnancy. Case report and review of the literature.

Gigantomastia, or Gravidic macromastia, during pregnancy is a diffuse increase in size of the breasts over and above their physiologic size. It is a rare disorder of undetermined etiology, that may be due to hormonal excess or to hypersensitivity of the target organ. The histologic appearance is of glandular hyperplasia with an increase in connective tissue. Treatment during pregnancy is supportive and pharmacologic; once the patient has delivered surgical treatment is usually indicated. We present herewith a case report of gigantomastia during pregnancy, with a discussion of the treatment and a review of the literature.

Transabdominal ultrasonographic evaluation of endometrial thickness in clomiphene citrate-stimulated cycles in relation to conception.

The possible antiestrogenic effect of clomiphene citrate on endometrial growth was assessed by serial transabdominal ultrasonographic measurements in 46 women with unexplained infertility. A significantly higher (p < 0.05) rate of endometrial growth was observed in the 8 women who conceived compared with the 38 women who failed to conceive. A thicker endometrium (4.6 +/- 0.3 mm) was observed from the third day before ovulation as well as a higher average growth rate in the three days prior to ovulation (0.7 +/- 0.1 mm/day) in the group that achieved pregnancy compared to a lower endometrium (2.1 +/- 0.2 mm) from the third day before ovulation and a slower growth rate in the three days prior to ovulation (0.2 +/- 0.0 mm/day) in the group that did not achieve pregnancy (p < 0.05). These data suggest that clomiphene citrate may exert an antiestrogenic effect on the endometrium, and thus interfere with implantation.

Epidural morphine bupivacaine combination for the control of autonomic hyperreflexia during labor.

The improvement in rehabilitation of young women with spinal cord lesions, combined with the fact that libido, fertility and child bearing remain intact, enables more such patients to conceive. The obstetric team is therefore bound to meet with such patients. Among the various complications of this condition during pregnancy is an acute life-threatening syndrome called autonomic hyperreflexia (AH), caused by an uncontrolled massive sympathetic discharge, which occurs in response to stimuli that reach the spinal cord below the lesion. Most authors agree that the best method of controlling AH during labor is by an epidural block which impends stimuli from reaching the spinal cord and thus provoking AH. Most authors could not completely abolish AH episodes using different medication epidurally. Herein we present a successful delivery using a combination of morphine bupivacaine epidurally.

Post-cesarean-section necrotizing fasciitis: report of a case and review of the literature.

Necrotizing fasciitis is a rare but potentially lethal, rapidly progressive, soft-tissue infection. Cure is dependent on early diagnosis and prompt surgical intervention. A case of necrotizing fasciitis in a patient after cesarean section is herein reported and the treatment and outcome discussed. An extensive review of the literature revealed a single case report of necrotizing fasciitis after cesarean section.

Hydrops-ectopic calcification-moth-eaten skeletal dysplasia (Greenberg dysplasia): prenatal diagnosis and further delineation of a rare genetic disorder.

An offspring of consanguineous parents of East-Indian origin was found prenatally to have hydrops fetalis, short limb dwarfism, polydactyly and chondro-osseous changes consistent with Greenberg hydrops-ectopic calcification-moth-eaten skeletal dysplasia (HEM) dysplasia. The radiological changes include platyspondyly with multiple extra ossification centers, extraneous calcification in the ribs, sternum, pelvis, and epiphysis, and moth-eaten long bones. The histopathological changes included chondrocytes with dilated rough endoplasmic reticulum and inclusion bodies with homogeneous material of intermediate electron density. These findings further delineate the spectrum of this rare autosomal recessive skeletal dysplasia.