Cholecystectomy during pregnancy without fetal loss.

Cholecystectomy in the pregnant patient has been generally avoided because of the reported high incidence of associated fetal loss that has been linked to spontaneous and elective abortion during the first trimester and premature labor during the third trimester. Recent developments relating to diagnostic and anesthetic management and the use of tocolytic agents have altered the over-all approach to patients. We have, therefore, retrospectively reviewed the medical records of all women discharged from four area hospitals during 1982 to 1987 with a concurrent diagnosis of cholelithiasis and pregnancy. Twenty-two patients met the review criteria. The incidence of biliary stone disease among gravid patients during the time interval was 0.05 per cent. Of 22 patients, none underwent radiation for diagnosis. Nine patients underwent cholecystectomy while pregnant; two were operated upon during the first trimester, four during the second and three during the third. Three required common bile duct exploration and three had intraoperative cholangiograms. Elective abortion was not recommended to the six patients because of radiation exposure. Two of nine had premature contractions develop that were controlled with tocolytic agents. There were no spontaneous abortions. The mean Apgar scores for neonates born subsequent to cholecystectomy was virtually identical to neonates born to patients in whom cholecystectomy was deferred. It is concluded that the diagnosis and surgical treatment of cholelithiasis can be safely undertaken in the pregnant patient without fetal loss. Delaying appropriate surgical therapy no longer seems warranted.

Starch peritonitis. A case report and clinicopathologic review.

A case of starch peritonitis is presented with a review of the history of this continuing problem. The syndrome's presentation, diagnosis, histopathology and treatment are discussed. The rarity of starch peritonitis today may be due to more attention to glove washing by surgeons, fewer impurities in the glove powder or lack of recognition of the syndrome. In order to prevent a resurgence of the starch peritonitis syndrome we must continue to emphasize the importance of washing gloves, maintain the quality control and purity of the powder used, and be cognizant of the signs and symptoms so that such cases may be managed nonoperatively.

Severe intracranial hemorrhage and hydrocephalus in low-birthweight infants treated with CSF shunts.

The high-risk low-birth-weight newborn not uncommonly develops intracranial hemorrhage and intraventricular hemorrhage (ICH/IVH) from the immature state of the germinal matrix. Posthemorrhagic hydrocephalus may develop. Infants with small hemorrhages (grades I, II of Papile), with or without hydrocephalus have been shown to develop normally in 80%-90% of cases. There is limited information in the literature about the management and outcome of infants with more severe hemorrhages (grades III, IV of Papile), due to the dismal outlook as to their outcome in most centers. The current status and concerns as to the management of these infants is reviewed, and the aspects of neurosurgical and neonatal follow-up and outcome are described. A significant number of these infants have severe handicaps, which are primarily motor. However, a group of infants is noted who have normal intellectual performance despite varying degrees of motor handicaps: 18% have normal intellectual and motor development. In the current series predictors of poorest outcome are the presence of grade IV hemorrhage and/or seizures. The vast majority of the grades III and IV hemorrhages develop hydrocephalus that is a complex management issue for the neurosurgeon.

Ventriculoperitoneal shunts in low birth weight infants with intracranial hemorrhage: neurodevelopmental outcome.

Fifty preterm infants (mean birth weight, 1266 +/- 303 g; mean gestational age, 30 +/- 2 weeks) who required a ventriculoperitoneal (VP) shunt for posthemorrhagic hydrocephalus (92% with Grade III or IV hemorrhage) were followed for neurodevelopmental problems. VP shunts were placed at a median age of 29 days (range, 18 to 87 days) after serial lumbar punctures failed to control progressive and symptomatic ventriculomegaly. A total of 34 infants (68%) required one shunt revision or more, and the overall infection rate per patient was 50%. Seven infants died, 2 from shunt infections. The infants were evaluated with audiological, ophthalmological, and neurodevelopmental examinations. Of the survivors, 11 (28%) have severe visual loss and 10 (24%) have hearing impairment. Of the infants, 21 (49%) have severe motor handicaps and 19 (38%) have seizure disorders. Developmental and motor scores were obtained using the Bayley or Knobloch-Gesell scales. Seven infants (18%) have normal developmental outcomes; 26 (60%) have multiple handicaps. Grade IV hemorrhage or the occurrence of seizures was a predictor of poor neurodevelopmental outcome. We conclude that progressive posthemorrhagic hydrocephalus in low birth weight infants is associated with multiple handicaps despite early VP shunt placement.