Comparison of transvaginal ultrasound, hysteroscopy, and dilatation and curettage in the diagnosis of abnormal vaginal bleeding and intrauterine pathology in perimenopausal and postmenopausal women.

STUDY OBJECTIVE: To compare transvaginal ultrasound, hysteroscopy, and dilation and curettage (D&C) in the evaluation of women with perimenopausal and postmenopausal bleeding. DESIGN: Descriptive study (Canadian Task Force classification II-1). SETTING: Seven outpatient clinics. PATIENTS: One thousand two hundred eighty-six women. INTERVENTION: Transvaginal ultrasound, hysteroscopy, and D&C. MEASUREMENTS AND MAIN RESULTS: Of our patient population, 29 (2.26%) had a histologic diagnosis of endometrial carcinoma; in 2 of them (7.14%) endometrial thickness was 5 mm or less. In 10 women (34.5%), endometrial carcinoma was missed by hysteroscopy (sensitivity 65.52%, specificity 99.92%). Complication rate of D&C was 1.4%. CONCLUSION: In women with perimenopausal and postmenopausal bleeding neither transvaginal ultrasound nor hysteroscopy as a single diagnostic tool is suitable to rule out endometrial cancer.

Transcostal Access with the Veress Needle in Women with Several Previous Surgeries

Establishing pneumoperitoneum using the classic umbilical port in women who have had several previous surgeries is risky, life threatening, and a diabolic challenge for the surgeon. Open laparoscopy is one alternative, with a risk factor for bowel injury of 0.5%. Since 1992 we have preferred the transcostal approach. A stab incision is made between the ninth and tenth ribs in the left medioclavicular line and a disposable Veress needle is pushed into the coelomic cavity. Passing the needle only in this area of strongly attached peritoneum, the typical needle click is heard and its intraabdominal position is confirmed by an insufflation pressure below 5 mm Hg. After insufflation of 0.5 L, percussion in the right hypochondric quadrant ensures correct distribution of the gas. A contraindication for this port is a prior splenectomy. No complications occurred in our series of 64 patients.

[Benign increase of tumor marker Ca 12-5 in pelvic peritonitis with ascites]. / Nichtkarzinombedingte Erhöhung des Tumormarkers Ca 12-5 bei Pelveoperitonitis mit Aszites.

Two patients suffering from pelveoperitonitis had ascites and elevated CA 12-5 serum level mimicking epithelial ovarian cancer. Both were treated successfully with antibiotics, after laparoscopic confirmation.

[Fetomaternal macrotransfusion--a cause for decreased fetal movements. 2 cases]. / Die fetomaternale Makrotransfusion--eine Ursache für abnehmende Kindsbewegungen. Zwei Fälle.

Two cases of fetomaternal macrotransfusion in otherwise normal pregnancies are reported. In both cases the main symptoms observed by the patients were decreasing fetal movements. Cardiotocography revealed a highly pathologic pattern an immediate cesarean section was performed. The cause of massive fetomaternal hemorrhage (390 and 635 ml fetal blood) remains unclear. Delayed treatment leads to severe anemia followed by hypovolemic shock and ultimately to stillbirth. Pregnancies complicated by fetomaternal hemorrhage develop normally until signs of fetal decompensation begin to appear. Decreasing fetal movements in the most common symptom reported by the patients. In addition to a contraction-stress-test, blood from the pregnant women should be looked at for fetal erythrocytes, a test that can be performed very quickly and easily. If the fetus is viable, immediate delivery should be performed and blood transfusions to the newborn should be administered. In preterm pregnancies cordocentesis and intrauterine blood transfusion may be considered.

Polymerase chain reaction-assisted papillomavirus detection in cervicovaginal smears: stratification by clinical risk and cytology reports.

Seven hundred and twelve patients from cancer screening, pregnancy care, outpatient clinics for patients at risk for cervical dysplasia and human immunodeficiency virus (HIV) infection were tested simultaneously for cytological aberrations and human papillomavirus (HPV). Classification of these cases, and of all cytology records throughout 1991 and 1992 was performed according to the "Münchner Nomenklatur" and the Bethesda classification. HPV-directed polymerase chain reaction analysis was carried out with general primers, patients at risk for cervical dysplasia were tested by subsequent hybridization with HPV 16 and 18 probes. Patients from cancer screening and pregnancy care showed similar HPV prevalences ranging between 19.4%-24.6%. In contrast, patients from dysplasia and HIV units were infected in 56.2%-62.3% and 75.0%-76.9% respectively in centre of disease control stage III-IV, HPV detection rates in patients from dysplasia and HIV units increased gradually from 40.1%-52.9% in non-suspicious smears to 80.8%-100% in atypical smears. High risk HPV 16 and 18 infections were detected in 64% of smears with cytological evidence of HPV infection (koilocytosis) to 84.2% in severe dysplasia. Following the Bethesda guidelines, 2.9%-14.7% of all smears initially reported as Pap 2 K (suggestive of HPV infection) would be qualified as risk lesions (low grade squamous intraepithelial lesions), although they tested HPV negative in more than a third of cases. Thus, when using the Bethesda system, HPV analysis is needed to prevent overclassification and overtreatment. The "Münchner Nomenklatur" avoids this dilemma by not mixing morphological statements on infection, atypia and cancer risk.

[Puerperal uterine inversion (report of 3 cases)]. / Inversio uteri puerperalis (Bericht über 3 Fälle).

The Inversio uteri puerperalis belongs to the obstetrical emergencies. Immediate reposition, treatment of shock and the use of beta-mimetics can reduce morbidity and mortality. Surgery for reposition should be used if manual reposition failed.

[Diagnostic problems in HELLP syndrome--presented with reference to 20 case reports]. / Diagnostische Probleme beim HELLP-Syndrom--Dargestellt anhand von 20 Fallbeispielen.

15 so-called "definite" cases and five so-called "questionable" cases of HELLP-Syndrome are reported and discussed. The cases demonstrate the chameleon-like behaviour of symptoms and how difficult it can be to avoid it's full manifestation even if careful attention is paid to liver enzymes or platelets. Elevated liver enzymes and low platelets are also found in normal pregnancies making differential diagnosis more difficult as the retrospective analysis of laboratory findings of more than 2000 normal pregnancies shows. Even though, careful attention should be paid to detect any early laboratory finding or clinical sign of HELLP-Syndrome in order to prevent dramatic outcomes. Any symptoms of gestosis should be reason to determine not only liver enzymes and platelets, but also haptoglobin as the latter seems to detect early hemolysis in a beginning HELLP-Syndrome.

[Detection of fibronectin for confirming the diagnosis of premature rupture of fetal membranes]. / Der Nachweis von Fibronectin zur Sicherung der Diagnose eines vorzeitigen Blasensprungs.

Diagnosis of premature rupture of membranes (PROM) usually leads to severe clinical consequences. Diagnostic tests for confirmation of suspected rupture of membranes are either unreliable or can adversely affect the pregnancy. Foetal fibronectin is synthesised by the foetoplacental membranes especially in the anchoring villus. Its concentration in the amniotic fluid is 5-10 times greater, than in the maternal plasma. An immunoassay has recently been developed, which detects fibronectin in vaginal secretions using monoclonal antibodies, thereby establishing the presence of amniotic fluid in the vagina. Vaginal specimens were collected from 133 pregnancies. 34 of 35 patients with clearly visible amniotic fluid in the vagina had a positive test result (97.1%), whereas the majority of the control group without any signs of ruptured membranes had negative test results (96.5%). 39 of 41 women with positive test results delivered within 48 hours (95%). A positive test result thus helps to confirm the diagnosis of PROM especially in equivocal cases or may indicate forthcoming labour.

Adenolymphoma: an immunohistochemical study with monoclonal antibodies against lymphocyte antigens.

Twenty-two adenolymphomas (Warthin's tumours) were investigated with respect to their lymphoid stroma; 4 were analyzed by monoclonal antibodies against B-cells and T-cells. A slight predominance of B-cells was found. In the T-cell fraction, the T-helper cells outnumbered the T-suppressor cells by a factor of 4. These and other cell types were found in the stroma and in the epithelium. Mast cells were associated with those adenolymphomas having a high proportion of epithelium.

Mast cells in cystadenolymphomas.

Cystadenolymphomas are a special kind of salivary gland tumours with an epithelial and a stromal part. Mast cells, which in this tumour were only rarely mentioned, were observed in large amounts in the stroma and in the epithelium. This type of cell is present especially in those cystadenolymphomas rich in epithelial parts. The possible significance of this observation is discussed.

[Immunodiagnostic findings in sera of patients with leishmaniasis, Chagas' disease, malaria and amebiasis in endemic regions of Venezuela (author's transl)]. / Immundiagnostische Befunde an Seren von Leishmaniose-, Chagas, Malaria- und Amöbiasis-Patienten in Endemiegebieten Venezuelas.

66 serum samples from patients suffering from mucocutaneous leishmaniasis (20), Chagas' disease (12), malaria (16) or amebiasis (18) were collected and examined with five different protozoic antigens (L. donovani, T. cruzi, P. fieldi, P. falciparum, E. histolytica) by means of the indirect fluorescent antibody test, the complement fixation test, the indirect hemagglutination test and the latex agglutination. Cross-reactions were observed only between the sera from patients with leishmaniasis and Chagas' disease, both groups, however, showed stronger reactions with the homologous antigen. There were no cross-reactions among the other antigens and antibodies. The results obtained in this study together with facts already proved by literature show the usefulness of the employed antigens for epidemiological surveys.