Is salpingostomy the surgical treatment of choice for unruptured tubal pregnancy?

Salpingostomy has gradually replaced salpingectomy as the surgical procedure of choice for unruptured tubal pregnancy in women who wish to preserve fertility. There are no prospective studies and only a few retrospective reports comparing fertility rates after salpingostomy and salpingectomy. Three major retrospective studies found no significant difference in fertility or incidence of repeat ectopic pregnancy between the two procedures, but salpingostomy carries a 5-8% risk of persistent ectopic pregnancy, contributing to increased morbidity and cost. There are approximately 109,000 ectopic pregnancies per year in the United States. If half are treated by salpingostomy, 54,500 women will need serial beta-hCG testing after surgery. Approximately 3543 will have a persistent ectopic pregnancy requiring surgical or medical treatment. The additional direct costs created by persistent ectopic pregnancy is estimated to be almost $16,000,000. Fertility after ectopic pregnancy is affected much more by the status of the contralateral tube than by the procedure performed, with fertility rates exceeding 80% after salpingectomy when the opposite tube is normal. By performing salpingectomy when the contralateral tube is normal, half the additional cost and morbidity could be avoided without jeopardizing subsequent fertility.

Limitations of audiovisual aids and educational objectives in a clinical clerkship.

The several components of a clinical clerkship were analyzed and correlated with Part II National Board scores and career choice. No positive correlations could be made between fulfilling educational objectives, utilization of audiovisual aids, general satisfaction and the clerkship, and eventual career choice or performance on National Board Examinations.

Adnexal masses in postmenopausal women.

Adnexal masses in postmenopausal women were reviewed according to size, pathology, age of the patient, and accuracy of ultrasound versus pelvic examination. Only one of 32 masses less than 5 cm in diameter was malignant. Of 55 masses 5-10 cm in size, six were malignant, including one lymphoma and two borderline tumors. Forty of 63 tumors larger than 10 cm were malignant. The proportion of malignancies increased with age. Pelvic examination missed 10% of tumors less than 10 cm in diameter. Of those palpated, the examination predicted the size of the mass to within 2 cm in 68% of cases. Ultrasonic prediction of size was accurate in 87% of cases scanned. Our findings cast doubt on the concept that all postmenopausal women with minimally enlarged ovaries should undergo laparotomy.

Continuity of ambulatory care in an obstetrics and gynecology residency program.

Continuity of ambulatory care was instituted four years ago in a large residency training program serving private and clinic patients. Details of the program are described. Seventy-nine percent and 87% continuity of care was achieved for prenatal patients and women with gynecologic problems, respectively. Long-term continuity of care for preventive health maintenance was not attained. House officers and nurses believe that continuity of care fosters more efficient use of laboratory testing and physician time and results in better patient care.

Congenital atresia of the lower vagina with regular menses through a fistula: a therapeutic approach.

Presented is an unusual case of congenital atresia of the lower vagina with regular menses through a fistulous tract. Diagnostic ultrasound was very helpful in defining the problem and aiding in the determination of a therapeutic plan. Distention of the blind vaginal pouch with fluid greatly facilitated a surgical solution to the problem and has applicability to other forms of vaginal atresia.

Changes in menstrual symptoms among sterilized and comparison women: a prospective study.

Changes in menstrual parameters after tubal sterilization were analyzed in ethnically diverse, poor women from three geographic areas in the United States. Two large suitable comparison groups were similarly studied. Menstrual cycles, duration of menstrual flow, and bleeding between periods were unchanged in the sterilization and comparison groups. The prevalence of dysmenorrhea increased in 10.8% of sterilized women, compared with 2.1% in the comparison groups. This difference was even more significant--16.4 and -0.5%--when usage of oral contraceptives and intrauterine devices was discounted. There was a nonsignificant increase in noncyclic pelvic pain.

Long-term effect of tubal sterilization on menstrual indices and pelvic pain.

OBJECTIVE: To evaluate the long-term effect of tubal sterilization on menstrual indices and pelvic pain. METHODS: Five hundred women undergoing sterilization were interviewed before sterilization, 6-10 months after surgery, and 3-4.5 years later. Four hundred sixty-six non-sterilized comparison women were interviewed in parallel. The study population consisted of low-income, ethnically and regionally diverse women from three participating institutions. RESULTS: When women who were taking oral contraceptives were excluded, no long-term differences was found between sterilized and nonsterilized women in terms of menstrual cycles, bleeding between periods, prolonged or heavy flow, dysmenorrhea, or noncyclic pelvic pain. Hysterectomy was uncommon (3.2%), but statistically more prevalent among sterilized women (4.55%) than nonsterilized women (2.17%) (P = .019). CONCLUSIONS: Tubal sterilization has no long-term effect on menstrual indices or pelvic pain. An increase in severe dysmenorrhea, which emerged as a disturbing but nonsignificant trend at 6-10 months, did not progress over the next 3-4.5 years. Reasons for an increased rate of hysterectomy are not clear, but may be related to a lower threshold for choosing hysterectomy as a treatment option once a woman has been sterilized.

Lack of resolution of ectopic pregnancy by intratubal injection of methotrexate.

Although reports of local injection of MTX in the treatment of EP appeared to be promising, our results do not confirm the efficacy of this approach. Our experience was sufficiently discouraging to prompt discontinuation of a randomized trail; our hope is that others will add to the accumulating data base so that the role of local injection of MTX can be clarified.

Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer.

OBJECTIVE: To evaluate the sensitivity of the Pipelle endometrial suction curette in the detection of endometrial carcinoma in patients with known endometrial cancer. STUDY DESIGN: A study was conducted using patients with known endometrial cancer undergoing a hysterectomy as part of a formal staging procedure. Endometrial biopsies were performed prior to each surgical procedure. Biopsy results were compared to the hysterectomy specimen for specimen adequacy and final histologic diagnosis. RESULTS: The Pipelle biopsy was adequate for analysis in 63 of 65 patients (97%). Malignancy was detected by biopsy in 54 of 65 patients, for a sensitivity of 83 +/- 5% (mean +/- SD). Of the 11 patients with false negative results, 5 had tumors present in only an endometrial polyp. Three of the 11 patients had disease localized to < 5% of the surface area of the endometrium. CONCLUSION: The Pipelle endometrial suction curette is an effective office device for evaluating patients at risk of endometrial cancer; however, tumors localized to a polyp or small area of endometrium may go undetected.

Acute vaginal bleeding in women undergoing liver transplantation.

OBJECTIVES: Our aim was to define the nature of acute vaginal bleeding problems in women undergoing liver transplantation and to determine the efficacy of treatments given. STUDY DESIGN: We performed a retrospective chart review of 24 patients undergoing liver transplantation in whom consultation was requested for vaginal bleeding. RESULTS: Twenty-four liver transplant patients were seen for evaluation of acute vaginal bleeding. Two patients were seen before transplantation, and 16 women were evaluated for bleeding after transplantation (8 within the first 15 postoperative days). In the other eight women abnormal uterine bleeding developed between 2 months and 5 years after transplantation. Five of these women had compromised liver function. In six other women vaginal bleeding originated from extrauterine sources. Six of seven endometrial biopsy specimens revealed proliferative endometrium, and the other showed adenomatous hyperplasia. Three of four patients had a response to progestational agents, bleeding stopped spontaneously in three patients, two required hysterectomy, and three died of other causes. The other five patients were not seen again by us before or after discharge from the hospital. CONCLUSIONS: Medical or surgical therapy can effectively control acute vaginal bleeding in liver transplant patients.

Compliance with depot medroxyprogesterone acetate: a randomized, controlled trial of intensive reminders.

We enrolled women in a prospective, randomized study to determine whether an intensive reminder system would improve compliance in women receiving depot medroxyprogesterone injections. Women selecting this treatment were assigned to a group that received both mail and telephone reminders or to a second group that received only a scheduled appointment at the time of the previous injection. The rate of continuation and the rate of on-time injections did not differ between groups. Women who had prolonged bleeding were more likely to discontinue depot medroxyprogesterone injections.

PIP: Depot-medroxyprogesterone acetate (DMPA) injection is an effective contraceptive that must be given within 14 weeks after previous injection to facilitate effective contraceptive action. This study investigated the effect of an intensive reminder system on the compliance and continuation of DMPA treatment. About 250 women (mean age, 20.7 years) who were not currently on DMPA treatment were enrolled in the study conducted in Pennsylvania between October 1993 and November 1994. These women were given DMPA injections and two groups were formed--those who came back for another treatment and those who came back after a year for 4 additional injections. One group of women received both mail and telephone reminders for treatment compliance, while another group received only a scheduled appointment at the time of the previous injection. Results revealed that the rate of continuation and rate of on-time injections was almost similar between the two groups. Presence of side effects, such as bleeding, would likely cause the discontinuation of the treatment.

The reliability of ultrasonography in the management of spontaneous abortion, clinically thought to be complete: a prospective study.

OBJECTIVE: The purpose of this study was to determine the reliability of ultrasonographic examination in the clinical management of spontaneous abortions thought to be complete. STUDY DESIGN: Patients with clinical findings suggestive of complete spontaneous abortion were managed prospectively on the basis of ultrasonographic results. Patients with an "empty uterus" were managed expectantly; those with a thickened endometrium or echoes consistent with retained tissue were subjected to curettage. RESULTS: Forty-eight of 49 (98%) patients with an "empty uterus" by ultrasonographic examination had an uneventful recovery without curettage. Nine of 13 (69%) patients with a thickened endometrium or evidence of retained tissue on ultrasonography had chorionic villi obtained by curettage. CONCLUSION: Ultrasonography is a highly reliable test in the management of women thought to have complete spontaneous abortion.

Post-tubal sterilization syndrome--a misnomer.

Menstrual parameters and gynecologic symptoms of 389 women who underwent laparoscopic tubal banding were studied prospectively and longitudinally. Previous oral contraceptive users exhibited an immediate increase in menstrual flow and dysmenorrhea, which declined slightly with time. No such changes occurred in women who used other methods of temporary contraception. A significant increase in noncyclic pelvic pain, independent of previous contraceptive usage, developed only in women greater than 38 years of age. Menstrual cycles and dyspareunia were not affected. A small control group of women whose husbands underwent vasectomy showed no significant changes in any of these parameters.

PIP: Menstrual parameters and gynecologic symptoms of 389 women who underwent laparoscopic tuabl banding were studied prospectively and longitudinally. Previous oral contraceptive (OC) users exhibited an immediate increase in menstrual flow and dysmenorrhea, which declined slightly with time. No such changes occurred in women who had used other methods of temporary contraception. A significant increase in noncyclic pelvin pain, independent of previous contraceptive usage, developed only in women 38 years of age. Menstrual cycles and dyspareunia were not affected. A small control group of women whose husbands underwent vasectomy showed no significant changes in any of these parameters.

Postpartum femoral neuropathy: relic of an earlier era?

Femoral neuropathy after childbirth is rarely encountered today, although around 1900 an incidence of up to 4.7% was found. A case of postpartum unilateral femoral neuropathy in a 29-year-old primigravida is described. The patient's labor was complicated by poor progression, a prolonged second stage (three hours), and midforceps delivery. The patient received both epidural anesthesia (requiring catheter manipulation) and spinal anesthesia. Total time in the dorsal lithotomy position was four hours; total duration of labor was 27 hours. After delivery, the patient experienced buckling at the right knee and numbness down the leg anteriorly. The electromyogram at one month was consistent with an acute femoral neuropathy. Information about other cases of postpartum lower extremity neuropathy was obtained by a retrospective review of all deliveries at a large maternity hospital between 1971 and 1987. Of 143,019 live births, there were three other cases of postpartum knee extensor weakness (2.8/100,000), five cases of postpartum footdrop (3.5/100,000), and two cases of meralgia paresthetica (1.4/100,000). Although the precise mechanism of injury remains unclear, the declining incidence of femoral neuropathy may reflect decreased duration of labor with modern obstetric practices, particularly more frequent Cesarean delivery.

The frequency of transplacental hemorrhage in patients with threatened abortions.

The frequency and volume of transplacental hemorrhage that occurs with threatened abortions is unknown. The use of Rh immune globulin for such patients is therefore undefined. We studied the incidence and quantity of transplacental hemorrhage in patients with threatened abortions and in a control population of patients presenting in the first 20 weeks of pregnancy without a history of bleeding. Using the Kleihauer-Betke test, the incidence of transplacental hemorrhage in our control and study population was not statistically different.