Hysteroscopic treatment of the septate uterus.

Twelve patients with symptomatic septate uteri underwent hysteroscopic division of the uterine septum, monitored by concomitant laparoscopy, over a six-year period. The preoperative reproductive performance included 42 pregnancies, with only three viable deliveries. Ten of the 12 patients conceived within one year after therapy, and eight of these patients delivered a live infant at term. Two patients had a spontaneous abortion at six and eight weeks after therapy, respectively, but in each, a subsequent pregnancy was carried to term. Three patients are currently pregnant (eight, 12, and 18 weeks). Two patients have not as yet conceived. Two patients required a second hysteroscopic operation because a partial residual septum was observed on the posttreatment hysterogram.

Hysteroscopic removal of intrauterine devices with missing filaments.

Ninety-one patients using intrauterine devices (IUD with nonvisible filaments on examination underwent hysterscopy for location and retrieval of the devices. These were among 320 patients who underwent hysterscopy for a variety of indications. All but 6 patients for whom additional surgery was planned were given local anesthesia. In 78 patients, the device was found within the uterine cavity and removed under hysterscopic control. In the remaining 13, no intrauterine device was observed. Six of these 13 patients had a translocated device which was removed either by laparoscopy or laparotomy. Hysteroscopy is proposed as a useful and effective method of diagnosis and management in ambulatory patients when the filaments of the IUD are absent.

Substance abuse in pregnant women: recent experience at the Perinatal Center for Chemical Dependence of Northwestern Memorial Hospital.

Drug abuse during pregnancy is associated with adverse perinatal outcome. Patterns of abuse have changed in recent years with the increasing popularity of cocaine. We compared pregnancy outcome data from 137 women receiving prenatal care in the Perinatal Center for Chemical Dependence of Northwestern Memorial Hospital with those of matched controls. Among drug-using women, the mean gestational age at delivery and mean birth weight were significantly lower than those of controls. In addition, study pregnancies were more frequently complicated by the need for antenatal hospitalization, preterm delivery, low birth weight (less than 2500 g), and abruptio placentae.

Innovative community-based postgraduate training for obstetrics and gynecology in west Africa.

OBJECTIVE: To describe a unique international effort to develop a training program in West Africa that would be of similar quality to any other in the world (but with sensitivity to cross-cultural needs) and would retain physicians in West Africa to improve women's health in that part of the world. METHODS: Step-by-step formulation of a program included initial trainee recruitment, the inclusion of foreign guest faculty, and the establishment of institutional libraries. This was followed by a phase of curriculum development, recruitment of West African faculty, and organization of an innovative, community-based fourth year. RESULTS: Between ten and 12 postgraduates will have completed the program by January 1996, and will be placed in Ghana. More than 60% of Ghanaian postgraduates have passed the relevant regional examinations, compared with less than 25% of candidates from other countries. Nine Ghanaian specialists have returned to Ghana to become faculty members in the program. Over 20 published peer-reviewed articles have resulted from this program since 1989. The number of residents being trained has increased from three to 28. Seven new residents joined the program in 1994. An early reduction in maternal mortality from 9.9 deaths per 1000 births in 1991 to 4.2 deaths per 1000 births in 1992 was noted when senior postgraduates took over labor and delivery at the teaching hospital in Accra, Ghana, where approximately 10,000 deliveries occur per year. CONCLUSION: Specialty training in obstetrics and gynecology that is specifically aimed at meeting the needs of West Africa has been initiated successfully. Long-range success will require support from regional governments and continued long-term commitments from the international community of obstetricians and gynecologists.

Current status of hysteroscopy in gynecologic practice.

During the past century hysteroscopy has developed into a highly sophisticated and effective technique with increasing applicability. Hysteroscopic instruments have been refined with fiberoptics, allowing light to be introduced into the uterine cavity with high intensity but without danger of thermal injury. Safe methods for uterine distention provide an undistorted panoramic view of the uterine cavity. As a diagnostic technique, hysteroscopy affords accuracy in detecting intrauterine conditions which may not be revealed by traditional methods of exploration. As an operative technique, hysteroscopy increases the precision of surgery and minimizes trauma to the endometrial lining, and may, on some occasions, preclude major surgical intervention. In addition, hysterscopy is potentially useful for female sterilization and offers promise as an investigative tool for studies of the intratubal milieu.

Simulated respiratory system for in vitro evaluation of two inhalation delivery systems using selected steroids.

A simulated respiratory system was developed for the in vitro evaluation of two differently designed oral inhalation delivery systems. The deposition properties of a newly designed delivery system used for triamcinolone acetonide were compared to the more conventional, commercially available adapter utilized for an aerosol containing beclomethasone dipropionate. The simulated respiratory system was constructed so that the delivered dose of active ingredient could be classified into two fractions: the fraction that would be deposited in the oral cavity and throat and the fraction that would reach the desired site of activity in the respiratory tract. Based on this method, the newly designed system delivered more than 95% of the labeled dose to the desired site. The beclomethasone dipropionate aerosol system, which was observed to discharge the active ingredient with a greater intensity, delivered approximately 40% of the labeled dose. The particle-size distribution of the dose dispensed from the newly designed delivery system attached to the triamcinolone acetonide aerosol was determined using an impactor technique. No effort was made to correlate these results with an in vivo response.

Development and evaluation of a dexamethasone timed-release aerosol formulation.

Dexamethasone microcapcules were prepared and in vitro parameters were determined by sieve analysis which yielded materials retained on Nos. 80-, 100-, 200-, and 270-mesh sieves. Release rate and direct total determinations indicated that some measure of timed release appeared in all four sieve samples. The pH-release rate profiles of the microcapsules indicated that dissoution was pH independent. Colloidal silica and isopropyl myristate formulations provided the best suspending characteristics of all aerosol formulations evaluated. Delivery rate, pressure, and evacuation testing demonstrated the usability and functionality of the aerosol. An evaluation was made on the effect on urinary excretion levels of 17-hydroxycorticosteroid when a physical admixture of the drug and timed-release microcapsules were sprayed on rabbits. The significantly higher 17-hydroxycorticosteroid levels obtained in urine of animals treated with the admixture after 1 day may have been attributed to both an immediate suppression of the endogenous steroid and the "spilling over" of excess dexamethasone. A significant difference also was found at the 90% confidence level among the 24, 48, and 72-hr 17-hydroxycorticosteroid levels in the admixture and the microcapsules, which substantiated the delayed effect of the latter.

In vitro release of therapeutically active ingredients from polymer matrixes.

Several therapeutically active ingredients including benzocaine, cyclomethycaine, and methapyrilene hydrochloride were incorporated into ethylcellulose and polyamide films. The effect of cetyl alcohol and tributyl citrate upon the release of these ingredients was studied. The films containing the active ingredient and plasticizer were cast upon a mercury substrate, and the in vitro release of these drugs from each film into a desorbing medium of distilled water was measured. The results indicated that the film-forming agent and plasticizer affected the drug release rate and that the release followed first-order kinetics. Benzocaine was slowly released from polyamide-cetyl alcohol films and polyamide-cetyl alcohol-tributyl citrate films. Polyamide-tributyl citrate films showed enhanced release of benzoacaine and cyclomethycaine. Ethylcellulose films plasticized with tributyl citrate produced a fast drug release. Based upon these results, a water-soluble, highly polar, noncomplexing additive would tend to increase the drug release from the film. When the amount of benzocaine released from ethylcellulose was plotted as a function of the square root of time, a linear plot was obtained. Since this linear plot passed through the origin, ethylcellulose should be an ideal matrix for benzocaine according to the Higuchi diffusion-controlled model. These studies demonstrated the in vitro release of thf the solubility of the active agent in both the polymer film as a function of the solubility of the active agent in both the polymer matrix and the desorbing medium.

Determination of 17-hydroxycorticosteroids in human urine.

A study was undertaken to develop a method that could be used an an indication of the absorption of steroids. It was demonstrated that 17-hydroxycorticosteroids in urine could be quantitatively determined via absorptivity values obtained through the use of standard hydrocortisone-alcohol solutions or standard solutions of hydrocortisone in urine utilizing the blue tetrazolium assay method. This method is dependent upon the hydrolysis of conjugated urinary steroids by beef liver glucuronidase. The resultant concentration of 17-hydroxycorticosteroids is determined colorimetrically using blue tetrazolium.

Development of an aerosol dosage form containing insulin.

An aerosol dosage form containing insulin was developed by suspending insulin zinc crystals in fluorocarbon propellant and using oleyl alcohol to improve the insulin suspension and to prevent valve clogging. A metered valve was used to control the amount of insulin delivered per actuation. The dose dispensed, sedimentation rate, and particle-size distribution of the aerosol formulation were evaluated. The potency of the insulin delivered from the aerosol containers stored at various temperatures and time intervals was determined using a radioimmunoassay. Based upon preliminary stability data, which were treated kinetically, it was noted that insulin aerosols stored in a refrigerator at 7 degrees would have a predicted shelflife of approximately 19 years, whereas samples stored at 25 and 37 degrees would have shelflives of 11 and 2 months, respectively. Long-term stability studies are indicated to establish this conclusion. On the basis of this study, it was concluded that an insulin-containing aerosol dosage form can be formulated and that a suitable dose of insulin can be dispensed using commercially available metered dose valves. The actual dose of insulin dispensed would have to be related to the degree of absorption of insulin one would normally expect when insulin is administered by the inhalation route.

Hysteroscopic sterilization.

Despite the numerous painstaking evaluative trials that were conducted for more than two decades, hysteroscopic sterilization techniques remain more of a concept than a reality. However, it is likely that transcervical methods will continue to attract the investigator who is interested in simple, inexpensive outpatient office or female sterilization procedures in the clinic. Regardless, the cost of clinical trials, required follow-up, and preclinical toxicologic evaluations may continue to inhibit further research in this area.

PIP: Hysteroscopic sterilization remains more of a concept than a practical reality despite an approach which seemed to offer minimal intervention, low cost, potential reversibility, a high effectiveness rate, and a low rate of complication. Clinical experience has, however, been lacking on the approach's effectiveness and rate of complication. The initial enthusiasm for hysteroscopic operations was based in part on a set of circumstances which have made hysteroscopy increasingly popular worldwide for diagnostic and surgical interventions. It is simple, requires minimal if any anesthesia, is adaptable to the outpatient setting, and has an operative risk substantially lower than that of laparotomy. This paper surveys the destructive and occlusive methods of hysteroscopic sterilization, problems common to hysteroscopic sterilization operations, and the future.

Sexually transmitted diseases: global importance.

The worldwide incidence of sexually transmitted diseases (STDs) including the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) continues to increase and represents a major public health problem especially in the developing world causing infertility and ectopic pregnancy. Prevention of the spread of STDs, along with early detection and appropriate therapy has the potential to minimize the reproductive tract damage of these infections and simultaneously improve the health of women in all areas of the world.

Prevalence of marijuana use during pregnancy. A pilot study.

We examined the prevalence of marijuana use in a group of pregnant women using a qualitative, rapid urine screen to detect marijuana metabolites. Between July 1, 1987, and Aug 15, 1987, 322 consecutive patients underwent an anonymous urine toxicology screen at the time of admission to the labor-and-delivery unit. Patients were identified only by a consecutive number and by their age, race, marital status, gravidity, parity and obstetric service (clinic vs. private). The prevalence of positive urine toxicologic screens for marijuana was 19.9% among the study population (64 positive tests among 322 women screened). The prevalence was greater among the clinic patients than the private patients (52 of 161, or 32.3%, vs. 12 of 161, or 7.5%, respectively). The distribution of race and marital status among the marijuana-positive and -negative groups were also significantly different. Specifically, the proportions of black and single women were higher among the marijuana-positive group. Our findings suggest that marijuana use is common in our obstetric patients. The possible association between marijuana use during pregnancy and perinatal morbidity, as well as the unreliable nature of patient drug histories, may support the use of rapid, inexpensive screening techniques, especially if general screening is considered.

Economic considerations in the use of laparoscopy for diagnosing pelvic inflammatory disease.

The clinical diagnosis of pelvic inflammatory disease (PID) is associated with an average accuracy rate of 65% when preoperative impressions are confirmed or rejected with laparoscopy. The cost of this error rate should be evaluated when considering the cost and risks of immediate laparoscopy in patients suspected of having PID. This study reviewed selected patient admissions for PID from Northwestern Memorial Hospital for the years 1981-1985. The costs of hospitalization and treatment and the inherent diagnostic error rate were considered concurrently. No significant additional expense would have been incurred if all the women admitted with a clinical diagnosis of PID had had laparoscopic verification of their clinical diagnoses as compared to the cost of treatment with intravenous antibiotics for three to five days. We recommend the early use of laparoscopy in establishing the diagnosis of PID because it ensures a more accurate and definitive diagnosis and does not add significantly to costs.

Study and treatment of gestational trophoblastic diseases at the John I. Brewer Trophoblastic Disease Center, 1962-1990.

From 1962 through 1989, 5063 patients were referred to the John I. Brewer Trophoblastic Disease Center of the Northwestern University Medical School. Among these were 564 patients treated with chemotherapy for gestational trophoblastic tumors (choriocarcinoma and invasive mole). The overall cure rate was 94%, 100% for 323 patients without evidence of metastases and 85% for 241 patients with metastatic disease. Four factors were determined to significantly influence treatment response: (1) clinicopathologic diagnosis of choriocarcinoma, (2) metastases to sites other than the lung or vagina, (3) number of metastases, and (4) previous failed chemotherapy.