Melanosis of the vagina. A case report.

BACKGROUND: Melanosis is a term given to lesions in which melanin pigment is confined to the basal layer of squamous epithelium and on visual inspection may have an appearance similar to that of malignant melanoma. Although relatively common in the oral and gastrointestinal tract, melanosis is an uncommon finding in the female genital tract and especially rare in the vagina; most reported cases have been vulvar. CASE: A 43-year-old, nulliparous woman was noted to have a pigmented lesion at the vaginal cuff during a routine annual examination one year after a hysterectomy. On physical examination, the lesion appeared as a coalescence of several small, pigmented areas at the cuff. On palpation the lesion was flat, having the contour of normal vaginal mucosa, and was not indurated or tender. A biopsy revealed vaginal melanosis. The patient was followed conservatively, with annual examinations, which documented no change in color, size or contour of the lesion. At this writing the patient is six years from presentation and doing well. CONCLUSION: Vaginal melanosis may be difficult to distinguish clinically from malignant melanoma but carries a much different prognosis. A biopsy of any pigmented lesion is always indicated prior to determining the need for therapy versus observation.

Recurrence of dysplasia after loop electrosurgical excision procedures with long-term follow-up.

OBJECTIVE: The aim of this study was to determine the rates of recurrent dysplasia with longer follow-up durations and to determine whether margin status and other variables were associated with recurrence. STUDY DESIGN: A retrospective chart review was performed for all women who underwent a loop electrosurgical excision procedure at Wilford Hall Medical Center, Lackland Air Force Base, Texas, between January 1993 and December 1994. Extracted information included age, parity, indication for the loop electrosurgical excision procedure, histologic classification of the loop electrosurgical excision procedure specimen, margin status, and whether a "deep" (endocervical) pass had been performed. Follow-up data included findings of repeated cytologic examination, colposcopy, and biopsy if performed. RESULTS: The mean duration of follow-up for all women was 24 months. Margins were positive in 28%, with 73% of these being endocervical. The overall recurrent dysplasia rate was 31%, with a mean time to recurrence of 11.9 months. Participants with any positive margins had a higher recurrence rate than did those with negative margins (47% vs 26%; P = .009). High-grade lesions at the margin were more commonly associated with recurrence than were low-grade lesions relative to those with clear margins (high-grade lesion vs negative margins, 55% vs 26%; P = .003; low-grade lesion vs negative margins, 36% vs 26%; P = .34). Recurrence was not associated either with the performance of an endocervical pass or with the histologic diagnosis of the loop electrosurgical excision procedure specimen. CONCLUSION: With comprehensive long-term follow-up, positive margins on loop electrosurgical excision procedure specimens were shown to be a risk factor for recurrence of cervical dysplasia, particularly when high-grade lesions were seen at the margin. Recurrence was also considerable among women with negative margins. Women should be counseled regarding this risk, and the importance of follow-up should be emphasized.

Use of the GnRH agonist stimulation test in the diagnosis of ovarian remnant syndrome. A report of three cases.

Ovarian remnant syndrome is an uncommon problem that may follow bilateral oophorectomy. These patients may present with chronic pelvic pain or pelvic masses and may require surgery to confirm or exclude the diagnosis. In this report we describe the successful use of the gonadotropin releasing hormone agonist (GnRH-a) stimulation test to identify the presence of functioning ovarian tissue in three women with ovarian remnant syndrome who presented for evaluation of persistent chronic pelvic pain. In these cases the endogenous gonadotropin flare was able to stimulate the production of significant quantities of estradiol to confirm the diagnosis. The GnRH-a stimulation test may be a useful adjunct in the evaluation of women at risk for ovarian remnant syndrome prior to proceeding with surgery.

Evaluation of the impact of intraobserver variability on endometrial dating and the diagnosis of luteal phase defects.

OBJECTIVE: To determine the magnitude of intraobserver variation in dating endometrial biopsies and its impact on clinical management. DESIGN: Blinded histopathologic interpretation of endometrial biopsy specimens 1 year apart by five pathologists. SETTING: Large military tertiary care center. PATIENTS: Endometrial biopsy specimens from 51 patients undergoing evaluation for potential luteal phase defects. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Calculation of the magnitude of the individual and overall intraobserver variation in endometrial dating for the five pathologists and estimation of its potential impact on clinical management. RESULTS: The intraobserver variation was 0.69 +/- 0.05 days (means +/- SE). There was no significant difference in the magnitude of the variation for 1-day or 2-day dating ranges. The theoretical probability of altering clinical management by having the same pathologist redate a given specimen ranged from 15% to 28%. CONCLUSION: Histologic dating of endometrial biopsies is subject to a small but highly clinically significant intraobserver variability that may have a major impact on clinical management.

Acute hemodynamic and respiratory effects of amniotic fluid embolism in the pregnant goat model.

OBJECTIVE: Our purpose was to determine the acute-phase central hemodynamic and respiratory effects of raw, filtered, filtered and boiled, and meconium-containing amniotic fluid. STUDY DESIGN: Pregnant goats (Capra hircus) in the last one third of pregnancy were given freshly collected autologous amniotic fluid in a volume of 2.5 ml/kg of body weight. Observations were then made at 10, 30, 60, 120, and 180 minutes after amniotic fluid embolism. Pulmonary artery catheters and femoral artery lung water catheters were placed for specimen and data collection. RESULTS: Marked pressor responses were observed in both the pulmonary and systemic circulations with all amniotic fluid infusions. The pressor response was similar with raw, filtered, and filtered and boiled amniotic fluid. The pressor response seen with amniotic fluid containing meconium was significantly greater than that seen with the other forms. No significant effects were observed on cardiac or respiratory function except in the meconium group, where transient left ventricular dysfunction was accompanied by an acute increase in extravascular lung water and dysoxia. CONCLUSIONS: The Capra hircus model is appropriate for the further study of amniotic fluid embolism. The acute pressor effects are transient and involve both the systemic and pulmonary circulations. Left ventricular dysfunction and dysoxia were observed only with embolism of amniotic fluid containing meconium.

The "less than optimal" cytology: importance in obstetric patients and in a routine gynecologic population.

OBJECTIVE: To determine whether patients with less than optimal Papanicolaou tests constitute a low-risk group for developing subsequent abnormalities and thus do not need early repeat screening. METHODS: For the 10-month period October 1989 to August 1990, all screening Papanicolaou tests were classified by the 1988 Bethesda System. Tests designated as less than optimal solely on the basis of lack of an endocervical component were the subject of the study. Prenatal patients with less than optimal tests had repeat tests at the postpartum visit (delayed-repeat group), whereas gynecologic less than optimal tests were repeated within 4 weeks (early-repeat group). The frequency of cytologic abnormalities in our routine gynecologic population was compared with that for both the delayed- and early-repeat testing groups. RESULTS: The less than optimal rate in obstetric patients was 10.2% (153 of 1492), which was significantly higher than the 5.6% rate (473 of 8411) in the routine gynecologic population (P < .0001). The rates of dysplasia or combined abnormalities (dysplasia, human papillomavirus, or atypia) in the delayed-repeat group did not differ significantly from those in the routine gynecologic population (P = .69 and P = .33, respectively). However, the rates of dysplasia or combined abnormalities were significantly lower in the early-repeat group than in the routine gynecologic population (P = .02 and P = .003, respectively). CONCLUSIONS: Less than optimal cervical cytologies occurred almost twice as often in obstetric as in gynecologic patients. Prenatal less than optimal test results were not associated with important cervical pathology, and repeat testing may safely be deferred until postpartum. In addition, early repeat testing in gynecologic patients is a low-yield procedure.

Umbilical arterial and venous acid-base and blood gas values and the effect of chorioamnionitis on those values in a cohort of preterm infants.

Umbilical arterial and venous acid-base and blood gas values in uncomplicated premature births are similar to values that are reported in term infants and are unaffected by birth weight or gestational age. In this group of patients chorioamnionitis had no significant effects on umbilical arterial acid-base or blood gas values or on the percentage of patients that were born with acidemia. Apgar scores were significantly lower in the group with chorioamnionitis in spite of a virtual absence of acidemia, which again suggests that low Apgar scores alone do not confirm a diagnosis of birth asphyxia.

Cardiopulmonary reference standards in the pregnant sheep (Ovis aries): a comparative study of ovine and human physiology in obstetrics.

1. Complete blood counts, respiratory rate, tidal volume, arterial and mixed venous blood gases; heart rate, cardiac output, and arterial, pulmonary artery, central venous and pulmonary wedge pressures were determined in 10 pregnant adult sheep of 42.7-65.7 kg body weight. 2. Arithmetic means, standard deviations, and coefficients of variation were calculated to develop reference values; in addition, the 95% confidence limits for ranges were established. 3. Comparison of derived data with that from non-pregnant sheep shows changes similar to those seen when examining pregnant and non-pregnant humans. 4. These results indicate the pregnant sheep is an acceptable model for human obstetrical research.

Human papillomavirus associated with poor healing of episiotomy repairs.

A retrospective case-control investigation was conducted for risk factors in 47 parturients whose episiotomies dehisced in the immediate postpartum period. Data were extracted from the inpatient, outpatient, and pathology records of each of these 47 patients, as well as from the same records for each of the next two patients who delivered with the same type and degree of episiotomy. No difference between subjects and controls was found for age, parity, or medical history. Except for human papillomavirus (HPV), past or present history of sexually transmitted diseases was not a risk factor. However, active lesions, history thereof, or subsequent development of infection with HPV was found in 14 of 47 patients (29.8%) who had episiotomy breakdown, compared with 13 of 94 women (13.8%) who did not experience this complication, a statistically significant difference (P less than .023). Eleven subjects (23.4%) and nine controls (9.6%) gave a history of smoking during pregnancy, also a statistically significant difference (P less than .026).

Transvaginal-peritoneal migration of Trichomonas vaginalis as a cause of ascites. A report of two cases.

Genital tract colonization with Trichomonas vaginalis usually results in vaginitis without systemic manifestations. There are only four recorded cases of Trichomonas recovered from pelvic organs or peritoneal fluid. This report describes two additional women in whom motile flagellate organisms were recovered from abdominopelvic ascites. We hypothesize that an ascending trichomonal infection may have played an etiologic role in the development of their acute disease.

Early repair of episiotomy dehiscence.

Early repair of episiotomy dehiscence was performed in 22 women with an initial fourth-degree episiotomy, four with third-degree episiotomy, and five with a mediolateral episiotomy. Early complications were limited to development of a pinpoint rectovaginal fistula in two women, both subsequently repaired by a rectal mucosal flap procedure. Of the 27 women now 1 year or more post-repair, all are completely continent and report resumption of normal coital activity.

Magnesium sulfate pharmacokinetics: pregnant Capra hircus model.

A comparison of standard clinical regimens for the administration of magnesium sulfate for treatment of preeclampsia was performed in the pregnant goat model. The regimen of intravenous or intramuscular load and intramuscular maintenance championed by Pritchard was found to yield higher maternal serum levels through the first 4 hours of treatment compared with intravenous load with intravenous maintenance therapy (p less than 0.05); however, neither regimen affected the concentration of magnesium ion in the cerebrospinal fluid. Urinary excretion of magnesium and passage into the amniotic fluid were also evaluated for each route of administration and neither accounted for the disparity in serum concentrations noted during the first 4 hours of magnesium therapy.

The effect of hypermagnesemia on serum levels of osteocalcin in an animal model.

Using a pregnant goat (Capra hircus) model to study the in vivo effects of hypermagnesemia on serum osteocalcin concentration, magnesium sulfate infusion has been shown to increase circulating levels of osteocalcin. At 2 h after the administration of magnesium sulfate, a 98% increase in Mg2+ concentration over the basal level resulted in: a 38% increase in serum osteocalcin concentration over baseline; a 22% decrease in PTH concentration, and no change in total and ionized calcium concentrations. These in vivo data support previous in vitro results demonstrating that Mg2+ is a potent inhibitor of osteocalcin binding to hydroxyapatite.

Transverse lie.

To assess the impact of transverse lie on fetal and neonatal outcome, 14 mother and infant pairs with transverse lie were matched to 28 pairs with a vertex and 28 with a breech presentation. The control groups were matched for gestational age, route of delivery, type of anesthesia, and presence of labor. Infants in transverse lie were found to have a lower absolute arterial pH (7.21 versus 7.27, p less than 0.05) as well as more frequent severe acidosis (pH less than 7.1, 3 of 14 versus 0 of 56, p less than 0.04). Their birthweight was also less (2798 gm versus 3251 gm, p less than 0.05) and they sustained more birth trauma and long-term residual effects than either the breech (5 of 14 versus 1 of 28, p = 0.01) or vertex control groups (5 of 14 versus 2 of 28, p = 0.03). Based on these results, we recommend active intervention at 38 weeks' gestational age, via external version followed by labor induction, or failing this, cesarean delivery.

The effect of interobserver variation in dating endometrial histology on the diagnosis of luteal phase defects.

Endometrial biopsy specimens (n = 62) were evaluated by five pathologists to assess the effect of interobserver variation on histologic dating of the endometrium. The potential effect of this variation on the diagnosis of luteal phase defects (LPDs) and resulting clinical management was also determined. Mean (+/- standard error) interobserver variation was 0.96 +/- 0.08 days, comparable to results reported by other investigators. The magnitude of the variation was not affected by whether the biopsy specimen was obtained in the mid or late luteal phase, the degree of lag between the dating and subsequent menses, or the presence of an LPD. Redating of a specimen by another pathologist would have resulted in a change in the determination of "in" or "out" of phase in 22% of cases. The subsequent probability of changing patient management altered ranged from 22% to 39% depending on the clinical setting.

Endometrioid proliferative and low malignant potential tumors of the ovary. A clinicopathologic study of 46 cases.

We evaluated 41 endometroid neoplasms with features intermediate between a benign endometrioid tumor and endometrioid carcinoma. Although these tumors showed various degrees of epithelial proliferation, they lacked the destructive stromal invasion of carcinoma. Intermediate endometrioid tumors were subdivided into proliferative endometrioid tumors (PET), endometrioid tumors of low malignant potential (ETLMP), and ETLMP with microscopic areas of invasion. PET were adenofibromas with solid aggregates of epithelial proliferation not exceeding 5 mm in any dimension, whereas ETLMP either had noninvasive cytologically malignant epithelium or aggregates of atypical epithelium measuring at least 5 mm in any dimension uninterrupted by fibromatous stroma. Of the seven PET, five were purely adenofibromatous, while two were mixtures of adenofibromatous and papillary components. Of the 31 ETLMP, 12 were adenofibromatous and 19 were either purely papillary or had mixtures of papillary and adenofibromatous components. An additional three ETLMP had one or more areas of microscopic invasion of the stroma in the form of an irregular or cribriform infiltration by atypical glands, often with squamous differentiation. These three neoplasms were designated "ETLMP with microinvasive carcinoma." The only neoplasm with extraovarian implantation at presentation, however, was an ETLMP with mixed adenofibromatous and papillary features, without microinvasion. None of the other patients with ETLMP had a metastasis or developed one within a follow-up period of between 0.8 and 11.2 years. Because they are very low-grade neoplasms, ETLMP should be separated from endometrioid carcinoma and not confused with PET, because PET have no malignant potential.

Nuchal cords and neonatal outcome.

To assess the significance of nuchal cords, 110 affected woman-infant pairs at term gestation were compared with 110 control pairs. Newborns with a nuchal cord had an increased prevalence of umbilical artery acidemia (22 of 110 versus 13 of 110; P less than .05) and more variable fetal heart rate (FHR) decelerations in the first stage of labor (mild = 41 versus 20; P less than .0001; moderate-severe = 21 versus 5; P less than .0001) and the second stage of labor (moderate-severe = 46 versus 21; P less than .0001). In newborns with a nuchal cord, the umbilical artery acidemia was usually mixed (68%) or respiratory (23%) in origin, and pure metabolic acidemia was infrequent (9%). We conclude that nuchal cords are associated with an increased prevalence of variable FHR decelerations in the first and second stages of labor and with an increased incidence of umbilical artery acidemia.

Trophoblastic embolization during molar evacuation: central hemodynamic observations.

We evaluated prospectively the extent of trophoblastic embolization and its central hemodynamic effects during and after evacuation of large molar pregnancies in six women. A pulmonary artery catheter was inserted to obtain hemodynamic measurements as well as to obtain blood samples to identify trophoblasts before, during, and six hours after evacuation. Small numbers of both multinucleated giant cells and of large mononuclear cells with abundant cytoplasm were identified in the buffy coat of blood, aspirated in two cases before evacuation and for all six cases, during evacuation. There were no significant changes in heart rate or mean systemic arterial, pulmonary arterial, central venous, and pulmonary capillary wedge pressures; or cardiac output, stroke volume, and pulmonary or systemic vascular resistance when preevacuation preanesthetic values were compared with those six hours after evacuation. However, significant decreases in heart rate, mean arterial pressure, and pulmonary vascular resistance were observed during evacuation, which returned to preevacuation levels by completion of anesthesia.

Reference standards and the physiologic significance of the pregnant goat (Capra hircus) as a human model in obstetrical research.

1. Amniotic fluid, cerebrospinal fluid, serum, and urine chemistries; respiratory rate and arterial and mixed venous blood gases; heart rate, hematocrit, and cardiac output; and arterial, pulmonary artery, central venous and pulmonary wedge pressures were measured in 20 pregnant adult goats of 19.5-34 kg body weight. 2. Arithmetic means, standard deviations, and coefficients of variation were calculated to develop reference values; in addition, the 95% confidence limits for ranges were established. 3. Comparison of derived data with that from non-pregnant goats shows changes similar to those seen when examining pregnant and non-pregnant humans. 4. These results indicate the pregnant goat is an acceptable model for human obstetrical research.