Ovarian fibroma in the era of laparoscopic surgery: a general surgeon's experience.

The ovarian fibroma is a rare benign tumor originating from the connective tissue of the ovarian cortex. On occasion, the general surgeon may encounter ovarian fibroma while operating an acute abdomen. We present a series of 15 ovarian fibromas encountered in 13 patients over 11 years experience in our general surgical ward. Only four cases required emergency operations due to either tumors or adnexal torsion. High-resolution ultrasound scan with color Doppler suggested an ovarian fibroma in only ten cases, while CT and MRI were suggestive for the diagnosis in three other cases. Surgical treatment consisted of five ovarectomies, three adnexal resections and five total hysterectomies with bilateral salpingo-oophorectomy. Seven patients underwent laparoscopic surgery, four of them for an ovarian resection and in three for an adnexectomy. Laparoscopic approach has significant advantages by limiting parietal aggression with better cosmetic results, short hospital admission, lower costs, few postoperative adhesions and rapid recovery.

Premature rupture of membranes, placenta increta, and hysterectomy in a pregnancy following endometrial ablation.

Endometrial ablation has become a popular method of managing menorrhagia. Pregnancy after endometrial ablation has a high rate of complications. We present the case of a parous woman with a history of endometrial ablation with preterm premature rupture of membranes. Despite the absence of established sonographic markers for abnormal placentation, placenta accreta was noted at the time of cesarean delivery. In women with history of endometrial ablation, the endometrium is not normal and may allow for more aggressive placental invasion or adherence. Consequently, the sonographic indices described for evaluating placenta accreta may not be present. We believe that placentation in women with prior endometrial ablations should be considered extremely high risk for placenta accreta or increta and managed accordingly when preparing for delivery.

Effects of colchicine on pelvic adhesions associated with the intrauterine inoculation of Neisseria gonorrhoeae in rabbits.

OBJECTIVE: To determine whether colchicine, an anti-inflammatory drug, is effective in reducing adhesion formation in a rabbit model in which pelvic inflammation was produced by injection of a suspension of Neisseria gonorrhoeae into the uterine horn. METHODS: Following inoculation, the rabbits were divided into four groups of 11 animals each. The control group received 1 mL saline intramuscularly (IM) for 14 days. Another group received one 100-mg dose of ceftriaxone IM 2-4 hours after inoculation. The third group received one 100-mg dose of ceftriaxone IM 2-4 hours after inoculation and 1 mg colchicine IM daily for 14 days. The fourth group received 1 mg colchicine IM daily for 14 days. The day after the last injection of colchicine, the rabbits were sacrificed and the abdominal cavities were explored to determine the number and grade of adhesions. RESULTS: The incidence of adhesions in the control group was similar to that in the antibiotic-treated group, suggesting that antibiotics do not prevent adhesions in this model. Similarly, the incidence of adhesions in the colchicine and antibiotic group was not different from that in the group receiving colchicine alone. However, the colchicine-treated groups had significantly fewer adhesions than the groups not treated with colchicine (P < .0005). CONCLUSIONS: In this model, antibiotics alone did not prevent the formation of adhesions. Colchicine, alone or in combination with antibiotics, was effective in preventing bacteria-induced pelvic adhesions. Therefore, colchicine may offer a novel approach to the prevention of adhesions associated with pelvic inflammatory disease in women.

Colchicine and post-inflammatory adhesions in a rabbit model: a dose-response study.

OBJECTIVE: To determine the dose-response relationship of colchicine in reducing inflammatory adhesive disease secondary to Neisseria gonorrhoeae in the rabbit. METHODS: Following intrauterine inoculation of a suspension of N gonorrhoeae, the rabbits were divided into five groups of 11 rabbits each. The control group received no medications. The remaining four groups received 0.1, 0.5, 1, and 2 mg, respectively, of colchicine intramuscularly daily for 14 days. The day after the last injection of colchicine, the peritoneal cavity was explored and assessed for the presence, number, and grade of adhesions. RESULTS: With increasing doses of colchicine, the incidence of adhesions decreased. A linear model (log [dose + 0.5]) showed, however, that as the dose of colchicine increased, the response tended to plateau (P < .05). CONCLUSION: In this model, colchicine was effective in preventing inflammatory adhesions in the rabbit. Increasing doses produced a greater effect in reducing adhesion formation. However, there was a plateau of the response at the 1-mg dose.

Cervical pregnancy: case reports and a current literature review.

The increasing number of reports of successful conservative treatment of cervical pregnancy, such as using the folinic acid antagonist methotrexate, constitutes a breakthrough in the management of this unusual but potentially life-threatening complication of pregnancy. We are reporting two cases of cervical pregnancy, both diagnosed in the first trimester of pregnancy. The first one was successfully treated by transvaginal ultrasound-guided administration of 2 mEq KCI intraamniotically in order to stop the fetal heart activity, followed by administration of 84 mg of methotrexate intraaminiotically (1 mg/kg); whereas in the second case, we encountered a technical failure of the above method. Both patients expressed desire to maintain their reproductive capability. These two cases gave us the opportunity to review the recent literature on cervical pregnancy.

Histology and fertility effects of polydioxanone on rat reproductive tissue.

This prospective study compares the histology and fertility effects of the microsuture polydioxanone to nylon and polyglactin-910. Twelve rats underwent uterine horn microroeanatomoses with nylon (6 right horns), polyglactin-910 (6 right horns), and polydioxanone (12 left horns). After mating, there were no significant differences in gestational implantations or adhesions per uterine horn. Postoperative histologic evaluation of nylon showed persistent histiocytic reaction and fibrosis, occasional giant cells, and suture persistence at 100 days. Polyglactin-910 had initial histiocytic responses, no giant cells or fibrosis, and was resorbed by 60 days. Polydioxanone had initial histiocytic reaction and giant cells, no fibrosis, and was resorbed by 100 days. Our findings, and a review of the literature, confirmed mixed histologic reactions but no difference in fertility with these three microsutures. Because of its low reactivity and great strength, polydioxanone may be a good alternative suture material in reproductive microsurgery.

Postpartum hemorrhage and intrauterine balloon tamponade. A report of three cases.

BACKGROUND: Postpartum hemorrhage can become rapidly catastrophic. If medical management fails, then, according to recent reports, the use of an intrauterine inflated Foley catheter balloon for tamponade gives excellent results and can help avoid invasive procedures. CASE: We present one case of profuse hemorrhage following evacuation of the fetus after intrauterine fetal death at 17 weeks' gestation controlled with intrauterine balloon tamponade and two cases of severe postpartum hemorrhage (one immediate and one late) following normal vaginal deliveries, both controlled with Foley catheters. In either case the patient required no blood transfusions, and major surgery was avoided. CONCLUSION: Intrauterine balloon tamponade is highly effective. The catheter is readily available, is not expensive, does not require special training for insertion and, extremely important, can avoid major surgery.

Significant abdominal wall hematoma from an umbilical port insertion.

Laparoscopists consider the umbilical and ventral midline area to be "vascular safe." On occasion, however, the insertion of the first trocar at the umbilical port may result in severe abdominal wall hematoma.

Operative laparoscopy and vulvar hematoma: an unusual association.

Few cases of intraoperative or postoperative complications associated with laparoscopic adnexal surgery have been reported in the literature. We describe a case of laparoscopic abdominal vascular injury and persistent bleeding in the matrix of the ovary following laparoscopic cystectomy. During the first postsurgical day, the patient was syncopal. The physical examination showed a vulvar hematoma and minimal bleeding from a laparoscopic incision in the abdominal wall. Vulvar hematoma and an unstable patient may signal serious vascular bleeding.

Spontaneous bilateral tubal ectopic pregnancy and failed methotrexate therapy: a case report.

Spontaneous bilateral ectopic pregnancy is extremely rare. An unsuspected case of spontaneous bilateral ectopic pregnancy with failure of single-dose methotrexate is presented. We question whether the recommended dose of methotrexate for unilateral ectopic pregnancy is adequate for bilateral tubal pregnancy.

Ovarian vein thrombosis associated with Crohn's disease: a case report.

A nonpuerperal patient with Crohn's disease and pelvic pain was incidently diagnosed with ovarian vein thrombosis. The patient's laboratory data were negative for an inherited hypercoagulopathy state. Ovarian vein thrombosis is a possible cause of pelvic pain in patients with Crohn's disease. Modern imaging technology has made it easier to diagnose the once-elusive ovarian vein thrombosis.

Septic shock in pregnancy: a case report.

We present the clinical course of a pregnant woman in septic shock. While we were managing this case, an elevated pulmonary capillary wedge pressure was found, expressing left ventricular dysfunction. Therefore we question the widely accepted and recommended practice of loading the pregnant women in septic shock with 1 to 2 L of crystalloids before the institution of central monitoring. It is our belief that an aggressive and earlier central monitoring of the hemodynamic status can result in better treatment decisions.

Location and concentration of estrogen, progesterone, and androgen receptors in the bladder and urethra of the rabbit.

The objective of this study was to determine location and concentration of estrogen, androgen, and progesterone receptors in the bladder and urethra of the rabbit. Two urethral and two bladder specimens were obtained from four 12-week-old female New Zealand white rabbits. Rat monoclonal antibody (AN1-15) to human androgen receptor and (H222) to human estrogen receptor and mouse monoclonal antibody (PR6) to chicken progesterone receptor were used. Immunocytochemical staining was performed and specimens were evaluated for presence and location of steroid receptors. Androgen receptors were found in the highest concentrations in urethral and bladder epithelium. Low to low/moderate concentration were found in smooth muscle. Estrogen receptors were found in moderate to moderate/high concentrations in urethral epithelium and bladder and urethral smooth muscle. Progesterone receptors were not found in appreciable concentrations from any location, though the animals were not pretreated with estrogen. The rabbit model suggests a mechanism by which estrogen therapy can be effective in treating postmenopausal lower urinary tract symptoms. Progesterone receptors were not found in appreciable concentrations, suggesting progesterone therapy may not diminish the effectiveness of estrogen therapy by acting on urethral progesterone receptors. The effect of androgens on the lower urinary tract needs further investigation to determine if androgen therapy can alleviate lower urinary tract symptoms.