Trauma in the obstetric patient.

Trauma is the leading nonobstetric cause of maternal death. Penetrating trauma during pregnancy primarily involves gunshot and stab wounds. The incidence of visceral injury in pregnant women with penetrating abdominal trauma is 16% to 38% versus 80% to 90% in the general population. Management of pelvic trauma in pregnancy involves assessment of two individuals and decision making that is by necessity centered around preservation of the mother, avoiding ill-advised premature delivery of the fetus except in certain situations.

Atlas of obstetric and gynecologic emergencies.

Obstetric emergencies are rarely photographed. They often occur late at night when all personnel are involved in life-saving maneuvers, precluding the opportunity to record graphic representation of the pathology. Included in this atlas are several such cases.

Peritoneal fluid cytokine and eicosanoid levels and their relation to the incidence of peritoneal adhesion.

OBJECTIVE: To determine the peritoneal fluid content of several cytokines and eicosanoids with inflammatory, anti-inflammatory, anti-fibrotic, and fibrotic activities, and to assess the relationship of these levels with the incidence of peritoneal adhesions. METHODS: Peritoneal fluids were collected from 30 subjects with adhesions (n = 22) or with normal pelvic anatomy (n = 8), and the level of interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF-alpha), interleukin-10 (IL-10), interferon gamma (IFN-gamma), transforming growth factor beta-1 (TGF-beta 1), granulocyte macrophage-colony stimulating factor (GM-CSF), prostaglandin E2 (PGE2), leukotriene B4 (LTB4), and thromboxane B2 (TXB2) were determined by enzyme-linked immunosorbent assay (ELISA) and radioreceptor assay. RESULTS: The peritoneal fluid content of these factors varied considerably, with low levels of IL-1 beta, TNF-alpha, IL-10, IFN-gamma, and GM-CSF. Only IFN-gamma levels were significantly lower in subjects with adhesions compared with the normal group (P < .05). The levels of total (latent + active) and active TGF-beta 1 were higher than those of other cytokines assayed and were significantly higher in subjects with adhesions compared with the normal group (P < .05). The peritoneal fluid content of PGE2, TXB2, and LTB4 was significantly higher than that of the cytokines and was higher, but not significantly so, in subjects with adhesions compared with normal subjects (P = .06). CONCLUSION: Although the effect of length of time since the adhesions were formed is not known, the results indicate that peritoneal fluid content of these cytokines and eicosanoids, with the exception of IFN-gamma and TGF-beta 1, does not correlate with the presence of peritoneal adhesions.

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.

Human papillomavirus DNA in LEEP plume.

OBJECTIVE: This study was undertaken to determine the prevalence of human papillomavirus (HPV) in loop electrosurgical excision procedure (LEEP) plumes. METHODS: Forty-nine consecutive patients with colposcopic and cytologic evidence of cervical intraepithelial neoplasia (CIN) were tested. Smoke plumes were collected through a filter placed in the suction tubing. DNA was harvested by proteinase K digest of the filters and prepared for polymerase chain reaction (PCR) by L1 consensus primers. RESULTS: Thirty-nine (80%) tissue samples were positive for HPV, with types 6/11 in 4, 16/18 in 19, 31/33/35 in 2, and other types in 6 patients. The tissue sample was inadequate for typing in 8 patients. HPV DNA was detected in 18 (37%) filters. CONCLUSIONS: Although the consequences of HPV in LEEP plume are unknown, it would be prudent to adopt stringent control procedures.

Quality, access, and clinical issues in a nurse practitioner colposcopy outreach program.

From 8/89 to 7/92 a NP-colposcopist performed 593 colposcopy examinations including cervical biopsies, endocervical curettages, and Pap smears. Procedures were performed in selected health departments in north-central Florida. This portable outreach program expanded services to a primarily rural, medically indigent population. Specimen results were 21.1% negative, 5.6% human papilloma virus (HPV) only, 37.3% CIN I, 17.4% CIN II, 11.9% CIN III, 2.4% CIS, 0.3% carcinoma, and 4% other. Many CIN lesions also included HPV, yielding an overall incidence of HPV at 62.7%. Using the Bethesda system, 42.8% were low grade lesions, 32.1% high grade. Fourteen cases of CIS and two of carcinoma (one invasive, one microinvasive) were found. An 87.7% colposcopic diagnostic acumen level is favorable compared with published physician studies. One third of undercalls were due to occult canal lesions. Significant risk factors were smoking (48.6%), first coitus at < 18 years old (74%), history of HPV (49.6%), and life-time sexual partners > 2 (61.3%). Holistic prevention enabled 209 non-colposcopy problems.

Vulvar vestibulitis is rarely associated with human papillomavirus infection types 6, 11, 16, or 18.

Vulvar vestibular biopsy specimens from 31 women with clinical and pathologic findings of vulvar vestibulitis were studied using polymerase chain reaction (PCR) for the identification of human papilloma virus (HPV). The PCR technique specifically probed for HPV types 6, 11, 16, and 18. Of the 31 subjects, three were found to have HPV within the biopsy specimens; two had HPV type 11 and one had HPV 16. Five of the 31 cases had histopathologic features of koilocytosis consistent with HPV effect; three of these five were found to have HPV. The findings support the hypothesis that HPV types 6, 11, 16, and 18 are rarely associated with vulvar vestibulitis. The frequencies identified were similar to those seen with control patients. True koilocytosis is the most useful pathologic feature distinguishing HPV-related cases; it is rarely identified in typical vulvar vestibulitis. Nonspecific changes in the vestibular epithelium associated with glycogen effect should not be interpreted as koilocytosis.

Serum lipids and lipoproteins in continuous or cyclic medroxyprogesterone acetate treatment in postmenopausal women treated with conjugated estrogens.

This study evaluates effects on serum lipids of continuous or sequential progestogens for hormonal replacement in women. Subjects received either a cyclic regimen of replacement (0.625 mg/d of conjugated equine estrogens (Es) for 25 days/month and 10 mg medroxyprogesterone acetate [MPA] for the last 13 days of E) or 0.625 mg/d E along with either 5 or 10 mg MPA (Provera, Upjohn Company, Kalamazoo, MI). Study parameters were measured over a 24-week period. No differences in total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, apolipoproteins I and II, sex hormone-binding globulin, or serum MPA levels were noted between the sequential and 5 mg continuous group. The 10 mg MPA group did not have an increase in HDL or decrease in low-density lipoprotein as did the other groups.

The use of nylon pouches to prevent cellular attachment to implanted materials.

A nylon pouch system has been developed to permit the in vivo exposure of implantable materials to tissue fluids without complications arising from cellular attachment or from the bacterial attack. SEM observations have indicated that the pouches were effective in reducing the ingress of bacteria as well as reducing, and in some cases eliminating, cell infiltration through their mesh structure. Over a 7 d implantation period, the exterior surfaces of the nylon pouches were heavily infested with microorganisms but there was minimal growth of bacteria within the pouches. Non-infected pouches that were implanted for up to 25 wk showed heavy deposits of cellular matter on the external surfaces of the pouches and minimal deposits within the pouches.

The biomechanical effects of tight suture closure upon fascia.

The biomechanical effect of tight suture closure of fascial incisions in male rats was evaluated. The incision of rats in group 1 was closed with maximum tension on the first throw of the approximating knot. The incision of rats in group 2 was closed in a similar manner, however a 3.14 squared millimeter rod was placed in the suture loop before securing the first throw. The rod was removed after the knot was formed and fascial edges were observed to be loosely approximated. All rats were sacrificed after seven days. The abdominal fascial and muscle unit was dissected and a 1 by 6 centimeter strip containing two suture loops was excised. Scanning electron microscopic examination of tissue specimens, tensile strength measurements and energy-to-failure under tensile loading studies were performed. Specimens for hydroxyproline assay were obtained from the tissue immediately surrounding the incision and between two suture loops. The scanning electron microphotographs of group 1 showed tissue overlap from the excessive force on the initial knot throws. Wounds loosely approximated had proper alignment of the wound edges and had greater proliferative activity in the clefts of the wounds. The tensile strength and energy-to-failure studies showed loosely approximated wounds to be far stronger (p less than 0.001). No statistically significant difference (p greater than 0.05) was found between hydroxyproline assays of the two groups.

A comparative study of suture materials: chromic gut and chromic gut treated with glycerin.

Histologic and mechanical properties of chromic gut and glycerin-treated chromic gut were evaluated. Zero gauges of both materials were implanted for 7 days to evaluate inflammatory response. No difference was found in the degree of inflammatory response. Scanning electron micrographs showed a more uniform surface for the glycerin-treated chromic gut. Regular chromic material was stronger in unknotted tensile strength and fracture load for all gauges. The 1-0 gauge glycerin-treated chromic gut stabilized with the knot configuration of 1 = 1 = 1 = 1; and the 1,2-0, and 3-0 gauges reached knot security at 1 = 1 = 1. The in vivo studies showed marked difference in the tensile strength of stable knots between the two materials. Only with five throws (1 = 1 = 1 = 1 = 1) did the strength of glycerin-treated chromic gut overlap that of regular chromic gut.