Clinical outcome following vaginal drainage of pelvic abscess.

Fifty-nine women treated by colpotomy drainage for pelvic abscess over a 20-year period (January 1961 to July 1981) were studied. Mean age was 27.3 years (+/- 9.5 SD). Mean parity was 2.0 (+/- 2.3 SD). The abscess was secondary to pelvic inflammatory disease in 37 cases, abortion in four, cesarean section in six, other surgery in two, intrauterine device in four, appendicitis in four, and followed term vaginal delivery in two. The mean stay in the hospital was 14.4 (+/- 10.7) days. There were two deaths, both related to septic abortion with diffuse peritonitis. Further surgery during the same admission was performed in 13 instances (seven hysterectomies); additional surgery at a later admission was carried out in 11 patients (10 hysterectomies). Fourteen of these procedures were emergencies. Two patients were readmitted with pelvic inflammatory disease. Five of 40 potentially fertile patients (12.5%) had successful pregnancies at a later date.

Ruptured tuboovarian abscess. Is hysterectomy necessary?

The use of conservative pelvic surgery combined with intra- and postoperative antibiotic peritoneal lavage has been evaluated in 113 women with generalized peritonitis due to ruptured tuboovarian abscess. Mortality was 7.1% and hysterectomy was only required in 3% of cases. Hormonal and menstrual functions were retained in 73.5% and the potential for future pregnancy in 42.5%. Further surgery was required in 17.5% of the patients. These results are contrasted with recent series of comparable size in which the mortality and morbidity were similar but the frequency of hysterectomy ranged from 70--100%. It is concluded that hysterectomy is not necessary in the management of ruptured tuboovarian abscess if the major source of sepsis is removed and adequate peritoneal drainage is provided by the use of lavage.

Surgical management of diffuse peritonitis complicating obstetric/gynecologic infections.

A retrospective review of 176 women undergoing surgery for diffuse peritonitis secondary to pelvic infections from 1972 to 1976 was conducted. Mortality with septic abortion was 27.3% (12 of 44), with pelvic inflammatory disease 7.1% (eight of 113), and with puerperal sepsis 6.7% (one of 15). Overall mortality was 13.1% (23 of 176). Mortality was lower (P less than .05) with surgery within 24 hours (7.5%, six of 80) than after 24 hours (17.7%, 17 of 96). Mortality was lower (P less than .01) with specific antianaerobic antibiotics (zero of 36) than without (16.4%, 23 of 140). Mortality was 21.3% with hysterectomy (ten of 47) and 10.1% (13 of 129) with conservative surgery, however hysterectomy was usually performed in the more severe cases (septic abortion 75%, puerperal sepsis 66%, pelvic inflammatory disease 3%). Mortality declined from 17.6% in 1972 to 1974 (21 of 119) to 3.5% in 1975 to 1976 (two of 57). Significant differences between the two periods included an increased use of specific antianaerobic antibiotics (8.4%/45.5%) and an increased incidence of early surgery (35.3%/66.6%) in the latter years. This series emphasizes the overriding importance of early surgery and the need for the inclusion of specific antianaerobic antibiotic agents in the chemotherapeutic regimen.

Diagnosis of chlamydial infection in pregnant women using the Testpack Chlamydia diagnostic kit.

We compared the performance of Testpack Chlamydia to tissue culture isolation for detection of endocervical chlamydia in an obstetric clinic population at high risk for infection. Among 227 evaluable patients, 30 tissue culture-confirmed chlamydial infections were found (13.2%). The sensitivity, specificity, and positive and negative predictive values of Testpack compared with tissue culture isolation were 66.7, 95.4, 69.0, and 94.9%, respectively. This test can be performed on a desktop within 30 minutes by staff with limited laboratory experience and no special equipment. Based upon our preliminary experience, we believe that Testpack Chlamydia offers promise as a screening device for the detection of endocervical chlamydial infections in high-risk obstetric populations.

Leuprolide acetate in the management of cesarean scar endometriosis.

BACKGROUND: Progestin or estrogen-progestin combination therapy has not proven useful in the treatment of endometriosis of the abdominal scar after cesarean delivery. We report our experience in managing this condition with a gonadotropin agonist. CASE: A 22-year-old black woman with a history of two previous cesareans developed endometriosis of the abdominal scar. The extent of the lesion was estimated by computed tomographic (CT) scan, and a 6-month preoperative course of leuprolide acetate was administered. The patient exhibited prompt symptomatic response to the gonadotropin agonist, but the physical examination and CT scan findings were unchanged. Pathologic examination after surgical removal of the lesion confirmed the clinical diagnosis. CONCLUSION: Leuprolide acetate administered to a patient with cesarean scar endometriosis was associated with an improvement in symptoms, but there was no change in lesion size.

Leuprolide acetate in the management of ureteral obstruction caused by endometriosis.

Endometriotic ureteral obstruction is a serious event commonly diagnosed late and therefore associated with a major risk of hydronephrotic renal atrophy. The standard therapy is surgical. However, medical treatment has been reported using danazol, progestins, and estrogen-progestin combinations, although solid documentation of the effect of hormonal therapy against ureteral endometriosis is lacking. Gonadotropin-releasing hormone (GnRH) agonist treatment of endometriosis has yielded good results but has not been adequately reported in patients with ureteric involvement. We report three patients treated with a GnRH agonist, leuprolide acetate, for 6-9 months as a preoperative course. One patient had bilateral and two had unilateral obstruction. The preoperative course relieved the obstruction in the patient with bilateral disease and in one with unilateral changes. The failure occurred in a patient with intrinsic ureteric endometriosis. This early experience suggests a place for GnRH agonist therapy for patients with ureteric obstruction due to endometriosis, probably, but not necessarily, in conjunction with a planned surgical procedure. If medical therapy is attempted, close surveillance of renal function is mandatory.

Danazol in the management of ureteral obstruction secondary to endometriosis.

Ureteral obstruction caused by endometriosis is uncommon. It is, however, an important complication that imposes a 25% chance for permanent loss of renal function on the affected side. The standard management is surgical; however, three cases have been reported in which regression of obstruction followed medical therapy. This case report concerns a patient with long-standing partial ureteric obstruction due to endometriosis who was treated for 2 months with danazol. Clinical response of the endometriosis was excellent, but the obstruction persisted, a retroperitoneal ureteroneocystotomy was therefore performed. The ureter was found to be obstructed by dense fibrous tissue that contained endometrial glands. It seems therefore that a trial of danazol may be attempted in selected cases, but that the drug is unlikely to relieve endometriotic ureteric obstruction once dense fibrosis has occurred.

Conservative surgery for adnexal abscess.

Twenty-eight women were treated with conservative surgery for adnexal abscesses over a six-year period (1968-74). The mean age was 29.9 +/- 8.9 years (SD) and mean parity 1.2 +/- 1.1. Indications for surgery included failure to respond to medical therapy (16 cases) and exploration of a pelvic mass of uncertain etiology (12). The mean admission-operation interval was 8.7 +/- 9.9 days. The mean total hospital stay was 23.1 +/- 14.7 days. The most common procedures were unilateral adnexectomy (13 cases), simple drainage (6) and bilateral medial ligation (4). The intraoperative complications (one fatal cardiac arrest, two bladder lacerations and one bowel laceration) did not appear to be related to the conservative nature of the surgery. The postoperative complications, wound sepsis (six cases) and fecal fistula (one case), might have occurred equally with more radical operations. Menstrual function was retained in all the surviving patients and the potential for pregnancy in 18 (62%). Extrapolating these data from unselected cases in a developing nation, it seems likely that conservative procedures would afford an acceptable option in well-selected, fully informed women undergoing surgery for adnexal abscess in developed countries.

Continual postoperative antibiotic peritoneal lavage in diffuse peritonitis complicating cesarean section.

Nine women treated surgically for diffuse peritonitis complicating cesarean section underwent continual postoperative antibiotic peritoneal lavage as an adjunct to surgery. In all the patients the indication for surgery was failure to respond to standard medical therapy. Seven patients treated with hysterectomy recovered without evidence of continuing peritonitis or intraabdominal abscess formation. One of two patients in whom uterine conservation was attempted required an emergency hysterectomy three days later. In this series, continual postoperative antibiotic peritoneal lavage appeared to be an effective adjunctive treatment in the prevention of continuing peritonitis and abscess formation provided that hysterectomy was performed at the initial operation.

Diffuse peritoneal sepsis associated with colpotomy drainage of pelvic abscess.

The incidence of and mortality from diffuse peritoneal sepsis associated with the vaginal drainage of pelvic abscesses were retrospectively studied at two hospitals. During the 16-year period from 1961 through 1977 at the University of Mississippi Medical Center, 50 patients underwent colpotomy drainage of pelvic abscesses, diffuse peritoneal sepsis occurred in 5 cases (10%), and 2 of these 5 patients died (40%). During the five-year period from 1972 through 1976 at Baragwanath Hospital, 298 patients underwent colpotomy drainage of pelvic abscess, diffuse peritoneal spesis occurred in 18 cases (6%), and 4 of these 18 patients died (22%). By combining the two series, a total of 348 cases of colpotomy drainage yielded 23 instances of diffuse peritoneal sepsis (6.5%0, with six deaths attributable to this condition (26%). The overall mortality for the 348 cases was 2% (seven deaths), and diffuse peritoneal sepsis was the cause of six of the seven fatalities. It is concluded that colpotomy drainage of pelvic abscesses is a safe and most effective procedure provided that the cases are well selected and the postoperative course is closely followed. Neglect of these basic principles may result in the development of diffuse peritoneal sepsis in a small but important group of patients.

Pathfinder direct fluorescent antigen test for diagnosing maternal chlamydial infections. An evaluation.

Chlamydia trachomatis is a frequent cause of genital infections in young women. Chlamydial infections may adversely affect perinatal outcome. We compared the Pathfinder direct fluorescent antigen (DFA) test for chlamydial infections to tissue culture isolation in an obstetric population. Among 984 samples, 152 (15.4%) were inadequate for evaluation using the Pathfinder DFA test. Among 783 evaluable specimen pairs, the sensitivity, specificity, and positive and negative predictive values of the Pathfinder, as compared to tissue culture isolation, were 25%, 97.5%, 32.1% and 96.4%, respectively. On the basis of that experience, we do not recommend the Pathfinder DFA test as a clinical screening device for detecting chlamydial infections complicating pregnancy.

Leuprolide acetate depot for the treatment of uterine leiomyomas. Changes in bone density, uterine volume and uterine vascular resistive index.

This study measured the changes in uterine volume, uterine vascular resistive index and lumbar vertebral bone density before and after a six-month course of leuprolide acetate depot in women with uterine leiomyomas. All nine patients studied were black. The high baseline bone density of black women may provide a greater scope for the use of gonadotropin agonists as compared to women in the general population. A significant reduction in uterine volume was achieved in the patients with leuprolide therapy. Uterine vascular resistive indices were not altered consistently following leuprolide therapy in women with leiomyomas.

Comparison of cytobrush and cotton swab for Papanicolaou smears in pregnancy.

Papanicolaou smears obtained using cytobrush or cotton swabs were compared in 222 pregnant women. There were no complications attributable to the cytobrush. Endocervical cell yields obtained with the brush were 70.9% compared to 41.9% with the swab (P = .0001). There was no difference between use of the swab and the brush in the prevalence of dysplasia (19 cases) nor was there any difference in the prevalence of dysplasia in the smears that contained endocervical and/or metaplastic cells (17/181 = 8.6%) compared to those not containing these cell types (2/24 = 8.3%). This study suggests that use of the cytobrush in pregnancy warrants further study because of the frequency with which smears are reported as inadequate because they lack endocervical and/or metaplastic cells.

Comparison of pregnancy outcome between treated and untreated women with chlamydial cervicitis.

BACKGROUND: Maternal, fetal, neonatal, and infant outcome in treated versus untreated pregnant women with positive endocervical cultures for Chlamydia trachomatis is controversial. METHODS: One thousand three hundred fifty pregnant women registering consecutively on the staff clinic service were screened for chlamydia. The results of the antigen, but not the culture tests, were available for clinical management. RESULTS: Eighty one patients had positive chlamydia cultures, a prevalence rate of 5.1%. Fifty eight patients were not treated, 44 because of false-negative direct antigen tests. Twenty three patients were treated. Maternal complications including abortion, preterm rupture of membranes, preterm delivery, chorioamnionitis, and endometritis were similar in the two groups. Similarly, neonatal and infant complications including prematurity, conjunctivitis, and pneumonia were similar in the two groups. CONCLUSIONS: Our findings suggest that further prospective, controlled culture based studies are needed before recommending routine screening for chlamydia even in high risk populations.

Acute urinary retention due to a free-standing broad ligament leiomyoma.

A 38-year-old woman who had used oral contraceptives continuously since age 22 presented with acute urinary retention. Physical examination revealed a bladder outlet obstruction due to a large paravaginal/broad ligament mass. Magnetic resonance imaging (MRI) demonstrated that the mass was separate from the uterus which was confirmed at surgery when an isolated free-standing leiomyoma was removed.

Treatment of unruptured ectopic pregnancy with methotrexate.

Medical treatment is appropriate for patients with an unruptured tubal pregnancy who wish to preserve fertility or have medical problems associated with increased risk of anesthesia. Patients with persistent trophoblast after conservative surgery should be treated with methotrexate rather than undergo a repeat surgery. All nine of our patients with ectopic pregnancies who were treated with MTX were cured with one course of therapy. Little toxicity was observed and subsequent reproductive performance after medical treatment was comparable to that reported in the literature. Direct injection of MTX into an ectopic pregnancy under sonographic control provided an option for treatment which required little anesthesia, reduced the amount of drug and allowed the treatment of a gestation which would otherwise not be considered a candidate for the 3 dose intramuscular injection protocol (see Table 3).