Bilateral torsion of the adnexa: a case report and a review of the world literature.

The 15th case of bilateral adnexal torsion, or the fifth case in which the bilateral adnexal torsion did not occur simultaneously, is presented. A review of the cases reported in the world literature reveals that fever (82%), nausea and/or vomiting (73%), and abdominal pain (93%) were the most common symptoms. Previous recurrent attacks of abdominal pain occurred in 53% of patients and may be the one finding that is highly suggestive of this entity. The adnexa were histologically normal in 50% of the specimens, with the remaining adnexal tissues manifesting evidence of tubal infection (ie, hydrosalpinx and pyosalpinx). The diagnosis was suspected preoperatively in only 38% of the cases.

The effect of oral contraceptive steroids on branches of the uterine artery.

Uteri from 38 patients exposed to oral contraceptive steroids and from 7 unexposed controls were examined for lesions in small branches of the uterine artery. Moderate or severe cellular proliferation of the intimal layer was found in 82% of patients exposed to exogenous steroids, but minimal or no involvement was found in the remaining 18% and in unexposed patients. The severity of involvement correlated with duration of exposure to contraceptive steroids but decreased in those patients who had stopped medication prior to surgery. This lesion has been reported previously in autopsy studies of women receiving contraceptive steroids and dying from vascular disease, but is now shown to be common in asymptomatic women receiving oral contraceptive pills.

A spinal cord neurolemmoma in pregnancy.

A case of spinal cord neurolemmoma (Schwanoma) in pregnancy is described. A review of the literature fails to reveal any similar tumors in association with pregnancy. Diagnosis, treatment, and pathogenesis of spinal cord tumors in pregnancy are reviewed.

An evaluation of uterine scar integrity after cesarean section in rabbits.

Cesarean sections were performed on 30 rabbits at term pregnancy. Two incisions were made in each of the two uterine horns, and each incision was closed according to a predetermined method (continuous, everted; continuous, inverted; interrupted, everted; or interrupted, inverted). Tissue from the uterine scar region was sampled at three different time periods (5-8 days, 12-15 days, or 28-30 days) post-surgery to evaluate the degree of uterine healing by a variety of histologic criteria. The initial healing response in the scarred region occurred around 28-30 days post-surgery. The different uterine closure techniques did not appreciably influence the healing response in this study. We evaluated tensile strength in 36 uterine muscle specimens containing the scar obtained from nine animals in the 28-32-days post-surgery group. Of these 36 specimens, 86.1% tore through the muscle instead of through the scar when tension was applied to the muscle.

Snake bite poisoning in pregnancy. A review of the literature.

With our 2 cases, there are 30 reported cases in English of snake bite poisoning in pregnancy with some details presented and 20 cases without details, for a total of 50 cases. We reviewed the maternal and fetal outcomes in the 30 cases that had such information. Poisoning by members of the Crotalidae family (rattlesnakes, cotton-mouths [water moccasins] and copperheads) during pregnancy carries with it a fetal wastage rate of 43% and a maternal mortality rate of 10%. Pit viper bites cause a bleeding diathesis from the fact that the venom of these snakes contains a procoagulant that defibrinates the blood and leads to bleeding throughout the body.

Clomiphene-dexamethasone treatment of clomiphene-resistant women with and without the polycystic ovary syndrome.

We used clomiphene and dexamethasone in 40 infertile women to treat chronic anovulation resistant to the use of clomiphene alone. Eighteen (45%) of the women had the polycystic ovary (PCO) syndrome; the remaining 22 (55%) had clomiphene-resistant anovulation from idiopathic causes. Both groups of women were similar in regard to age, parity, duration of infertility and absence of other causes of infertility besides chronic anovulation. Ovulation could be induced in approximately 90% of the women in each group. Altogether, 19 of 36 women (52.8%) conceived without any side effects or complications. The cumulative probability of conception at nine months of treatment was 87.5% in PCO patients and 46% in the non-PCO group. Clomiphene plus dexamethasone was highly effective in the treatment of clomiphene-resistant anovulation associated with infertility in women with and without the PCO syndrome.

Labor in the gravida with 10 or more years between pregnancies.

It has been suggested that women who have had a pregnancy interval of 10 or more years would have prolonged labor in pregnancies after the first, as do primigravidas. In a series of 94 multiparas with 10 or more years between pregnancies and 63 age-matched, multiparous controls, there was no significant difference in the length of the latent phase of labor or of the first, second and third stages of active labor in the two groups. The concept of a "physiologic primigravida" in these cases should be abandoned.

Characteristics of indigent women with ruptured and unruptured tubal pregnancies.

The diagnosis of tubal pregnancy, whether ruptured or unruptured, often requires a surgical procedure, such as laparoscopy or laparotomy, for confirmation. We compared women with ruptured and unruptured tubal pregnancies to determine whether the clinical presentations, morbidity and surgical complications in the two groups were significantly different. We compared the demographic characteristics, clinical presentations, laboratory findings, morbidity and complications from surgical management in the two groups. Women with ruptured tubal pregnancies had a higher incidence of abdominal pain lasting less than 24 hours, adnexal tenderness and positive culdocentesis from hemoperitoneum as compared to women with unruptured tubal gestations. Abnormal uterine bleeding was observed less frequently in women with ruptured tubal pregnancies as compared to women with unruptured ones despite similar gestational ages at presentation. All the patients with a tubal pregnancy were managed surgically. The morbidity and surgical complication rates in the two groups were not significantly different.

Long-term sterilization failure: twenty-three years.

This case presents the longest time interval from tubal sterilization to failure by ectopic pregnancy of which we or our colleagues have ever heard. This multipara had a postpartum sterilization procedure performed at one University Hospital; 23 years later she was admitted to another University Hospital with a hemoperitoneum due to a ruptured ectopic pregnancy. Verification was affirmed by examination of the records of both hospitals.

A freestanding ambulatory surgical unit: a success or failure?

The concept of a freestanding ambulatory surgical center was to provide the patient with a more cost-effective, safe, and convenient service. A study of 5,369 surgical patients treated at the Northeast Louisiana Surgical Center, Inc., in Monroe, Louisiana, was carried out to determine whether these objectives had been met. The finding was that a freestanding ambulatory surgical center was more cost effective than either a hospital ambulatory unit or an in-hospital service. The infection rate was 0.06%, and the hospital transfer rate was 0.04%. The concept of freestanding ambulatory surgical center has fulfilled the expectations of safety, convenience, and cost effectiveness for the patients.

Antibiotic prophylactic uterine lavage in cesarean section: a double-blind comparison of saline, ticarcillin, and cefoxitin irrigation in indigent patients.

The purpose of this present study was to determine whether intraoperative antibiotic uterine irrigation was effective in reducing febrile morbidity (Part 1), and to determine whether ticarcillin disodium (Ticar) or cefoxitin sodium (Mefoxin) was the more effective solution (Part 2). The indications for cesarean section had an effect on febrile morbidity. In patients having nonelective cesarean section, febrile morbidity was high, occurring in 62.7% of the saline control group and 32.9% of those receiving ticarcillin disodium irrigation. In patients having elective cesarean section, febrile morbidity was lower (28% in the saline control group and 8.3% in the ticarcillin group [P less than or equal to .05]). Ticarcillin and cefoxitin were equal in reducing postoperative febrile morbidity. The use of prophylactic antibiotics, therefore, is indicated both in high-risk patients having nonelective cesarean section and in low-risk patients having elective repeat cesarean section.

Magnetic resonance imaging of defects in DeLancey's vaginal support levels I, II, and III.

OBJECTIVE: The aim was to demonstrate paravaginal defects at DeLancey's levels I, II, and III by pelvic magnetic resonance imaging scanning in patients with symptomatic pelvic relaxation preoperatively and to demonstrate the disappearance of such defects after surgical repair. STUDY DESIGN: Magnetic resonance imaging scans of the pelvis were performed in 12 patients exhibiting cystourethroceles and symptomatic urinary stress incontinence. RESULTS: Magnetic resonance imaging scans of bilateral fascial defects at the upper third of the vagina (level I) were unremarkable except for the constant "chevron sign," whereas the middle third of the vagina (level II) displayed the "saddlebags sign," and the lower third of the vagina (level III) displayed the "mustache sign." These defects disappeared postoperatively. CONCLUSIONS: Bilateral defects in the paracolpium at vaginal support levels I, II, and III may be found by magnetic resonance imaging scans before surgery in certain patients with symptomatic pelvic relaxation. Postoperative scans after paravaginal repair demonstrate the disappearance of these defects.

A comparison of magnesium sulfate and indomethacin to magnesium sulfate only for tocolysis in preterm labor with advanced cervical dilation.

Preterm labor becomes more difficult to inhibit as the degree of cervical dilation increases. Indeed, some physicians do not even attempt tocolysis with advanced cervical dilation. We compared single- versus double-agent tocolytic therapy when the cervix was dilated 3 cm or greater. We conducted a retrospective study of 44 patients with preterm labor of unknown etiology and with cervical dilation of greater than 3 cm. At the admitting physician's discretion, patients were treated with either magnesium sulfate or with magnesium sulfate and indomethacin in combination. Longer duration of successful tocolysis was noted in the group that received both magnesium sulfate and indomethacin (368.3 hours versus 70.9 hours). No maternal complications occurred in either group. These pilot data suggest that tocolysis with magnesium sulfate and indomethacin is a safe, effective method of tocolysis in patients with advanced cervical dilation.

Asymptomatic heterotopic ovarian pregnancy.

An unruptured heterotopic ovarian pregnancy was diagnosed and managed surgically. We believe this is the first such case in a woman who was asymptomatic at presentation for an unrelated complaint.

Small bowel obstruction and previous gynecologic surgery.

We reviewed the cases of women admitted to LSU Medical Center in Shreveport with the diagnosis of "small bowel obstruction" from Jan 1, 1975 to June 30, 1981. Review of the charts of patients who had exploratory laparotomy for relief of the obstruction showed that 83% of them had had previous abdominal surgery. Furthermore, 67% of the patients had had an abdominal hysterectomy. In 100% of the cases of obstruction after abdominal hysterectomy, there were adhesions to the site of reperitonealization or to the anterior abdominal wall. This study shows a higher incidence of small bowel obstruction after gynecologic surgery than has been previously reported.

Retrospective analysis of cervical cerclage procedures at the Louisiana State University, Shreveport (1980 to 1987).

We retrospectively reviewed 76 cerclage procedures done in 62 patients from January 1980 through October 1987 at the Louisiana State University Medical Center, Shreveport. The study showed a significant increase in fetal salvage after cerclage--from 23% to 72%. Emergency cerclage resulted in a fetal salvage rate of only 12%, in contrast to elective cerclage, which yielded a fetal salvage of 81%. Furthermore, fetal salvage was lower when the cerclage was done at less than 12 weeks' estimated gestational age (65%). The McDonald cerclage was done in 69 procedures, using a single suture in 49 patients and a double suture in 20. The fetal salvage rate was the same regardless of the number of sutures placed.