Supracervical hysterectomy: back to the future?

Supracervical hysterectomy, commonly performed in the earlier decades of this century, is rarely performed in contemporary practice. The desire to prevent future cervical cancer initially underlay the advocacy of total hysterectomy. Cervical cytologic screening and effective outpatient treatment of preinvasive cervical disease are commonly available. Cancer of the cervical stump is an uncommon and largely preventable occurrence. Removal of the normal cervix reportedly may have adverse effects on bladder, bowel, and sexual function. Reduced operating time and a shorter recovery period may be associated with a supracervical procedure. The risk of subsequent cervical cancer may not outweigh the benefits of supracervical hysterectomy, which should be offered as an option to selected patients. Supracervical hysterectomy by minilaparotomy is within the capability of practicing gynecologists and may be adaptable to outpatient short-stay surgery, offering a cost-effective alternative for a variety of gynecologic conditions.

Selected use of midline episiotomy: effect on perineal trauma.

A prospective, nonrandomized controlled study was performed to determine the effect of using midline episiotomy only for mothers who experienced fetal distress and/or operative vaginal delivery. Such a policy resulted in a significant decline in third- and fourth-degree lacerations in nulliparous women. This reduction was most pronounced in nulliparous women delivering infants larger than 3400 g. No third- or fourth-degree laceration occurred without antecedent episiotomy in any woman. A policy of using episiotomy selectively appears to lower the incidence of perineal trauma.

Comparison of pharyngeal aspirate and amniotic fluid surfactant composition.

Amniotic fluid and oropharyngeal aspirate lung maturity profiles obtained simultaneously at delivery in 16 patients are compared. The lecithin/sphingomyelin ratio was greater in oropharyngeal aspirates than in amniotic fluid (p less than 0.02). The percent phosphatidylinositol was greater in oropharyngeal aspirates than in amniotic fluid (p less than 0.03). The mean differences between percent phosphatidylglycerol were not significant. These findings were uninfluenced by the time interval between amniotic fluid and oropharyngeal sampling, gestational age, or neonatal weight. These data could explain the lack of sensitivity of the amniotic fluid lung maturity profile.

Preeclampsia associated with hemolysis, elevated liver enzymes, and low platelets--an obstetric emergency?

A study was undertaken of 27 patients with severe preeclampsia who had hemolysis, liver enzyme elevation, and thrombocytopenia as described by Weinstein. In addition to this triad, all patients exhibited the symptoms and signs of pregnancy-induced hypertension by which the diagnosis is usually established. These patients were admitted to the hospital for strict bed rest. Patients who showed evidence of rapid maternal or fetal deterioration were delivered promptly. The remainder were managed without immediate delivery and with the institution of magnesium sulfate to prevent eclamptic seizures. Patients were monitored closely, and amniocentesis was performed to ascertain fetal lung status. If the lungs were mature, the infant was delivered. Attempting to delay delivery until a lecithin: sphingomyelin (L:S) ratio was mature resulted in only two infants developing respiratory distress syndrome (RDS); both had L:S ratios of less than 1.5 and were delivered for maternal indications. Maternal condition rapidly improved within 72 hours of delivery, and there was no persistence of thrombocytopenia or elevation of liver enzymes. Immediate delivery of preeclamptic patients who have thrombocytopenia and elevated liver enzymes may not be warranted. These findings suggest that the syndrome of hemolysis, elevated liver enzymes, and low platelets is not a separate entity, but merely a cluster of signs seen in some patients with hypertensive disorders in pregnancy.

Vaginal pool phospholipids in the management of premature rupture of membranes.

Clinical utility of vaginal pool amniotic fluid assessment in premature rupture of the membranes was prospectively studied in 214 patients between July 1, 1978, and June 30, 1981. We used a policy of nonintervention in patients with premature rupture of the membranes prior to 36 weeks' gestation. Vaginal samples collected on admission and daily thereafter were analyzed for phospholipids. Patients underwent delivery for any one of these conditions: (1) presence of phosphatidylglycerol, (2) spontaneous labor, or (3) sepsis. One hundred sixty-seven patients had no phosphatidylglycerol initially. Thirty-six of these acquired phosphatidylglycerol, and none had respiratory distress syndrome. Eight patients underwent delivery because of signs of sepsis in the mother, but all infants of septic mothers survived. The newborn infants of 49 patients developed the respiratory distress syndrome, and among these there were six deaths, with no maternal deaths. We believe that these results confirm the value of phosphatidylglycerol in patients with premature rupture of the membranes, and that delay in patients from premature rupture of the membranes results in few infections and a significant decrease in the respiratory distress syndrome.

Comparison of amniotic fluid lung maturity profiles in paired vaginal and amniocentesis specimens.

Amniotic fluid was obtained by transvaginal amniocentesis from 27 pregnant women in the third trimester. Subsequent to amniocentesis, membranes were ruptured and vaginal pool amniotic fluid was taken by bulb aspiration. The samples were analyzed for lung maturity profile, consisting of the lecithin/sphingomyelin (L/S) ratio and the percentages of phosphatidylinositol and phosphatidylglycerol. The L/S ratio was higher in the vaginal pool than in the amniotic sac in 22% of the paired samples. Similarly, the percentage of phosphatidylinositol was greater in the vaginal pool than in the amniotic sac in 48%. Phosphatidylglycerol, however, is invariably present in the amniotic sac when it is detected in the vaginal pool. The possible usefulness of these results in the management of patients with premature rupture of membranes is discussed.

Clinical utility of fetal lung maturity profile.

The usefulness of the lung maturity profile in predicting the absence of respiratory distress syndrome (RDS) in the newborn was assessed in 356 patients with an obstetric indication for amniocentesis. Newborn infants delivered of mothers with a lecithin:sphingomyelin (L:S) ratio greater than 2.0, phosphatidylinositol at a level indicating maturity, and phosphatidylglycerol greater than 2% experienced no RDS. Twenty-six of 40 patients with studies indicating immaturity, in contrast, experienced RDS. Similarly, 20 infants who were predicted to be mature by L:S ratio but in whom no phosphatidylglycerol was present experienced a 40% incidence of RDS. In a small number of patients in whom the L:S ratio suggested that the fetal lung was immature, but in whom the phosphatidylglycerol level was greater than 2%, no RDS occurred. These results suggest that a mature lung profile is more valuable in predicting absence of RDS in the newborn than the L:S ratio alone. Certain conditions known to be associated with development of RDS in the newborn may be more accurately assessed by the presence or absence of phosphatidylglycerol in amniotic fluid. Although the series is small, it appears that the presence of phosphatidylglycerol even with an immature L:S ratio predicts that the newborn will be free of RDS.

Residency education in the 1980's.

It appears that great changes in residency education will be made in the 1980's. These changes not only portend excitement and improvement, but also predicate troublesome and trying times. Medical schools must take a more active part in residency training and may ultimately take full responsibility. Educational institutions will be asked to guarantee the intellectual and technical competence of their postgraduate trainees by tightly structuring the educational effort, and this obligation rightfully inures to the medical school rather than the hospital. Training programs must develop methods of using all private populations for postgraduate education that will reach at least the level of that achieved with nonprivate patients. Training programs must utilize community hospitals, and the desirable components of academia must be introduced into these institutions. As difficult to achieve as it is simple to state, new sources of funding must be found for postgraduate education. Finally, there eventually may be a need to devise entirely new concepts of training based on career goals, and the 1980's will provide fertile ground for those faculties that wish to be imaginative and innovative.

Choice of analgesia or anesthesia for pain relief in suction curettage.

One hundred and fifteen patients admitted to Duke University Medical Center from January 1, 1973, to December 31, 1974 inclusive, with the diagnosis of uncomplicated spontaneous incomplete or inevitable abortion were included in a randomized prospective study. All patients underwent suction curettage under either analgesia or general inhalation anesthesia. Patient response was adjudged regarding comfort and cooperativeness in the group receiving analgesia and postprocedure rehabilitation and discharge times in both groups. Fifteen of 59 patients receiving analgesia only were recorded unanimously as failures. Post-operative ambulation was no more rapid in patients receiving analgesia. Procedure-to-discharge intervals were unrelated to medication modality. There appears to be no advantage to analgesia as far as rehabilitation time, procedure-to-discharge time, and medical complications are concerned.

A computerized obstetric medical record.

Duke University has utilized computerized obstetric medical records since 1971. System evolution is described. Deficiencies in the current system appear to evolve from the computer/human interface rather than from basic system design. Critical elements in system success are physician acceptance of the appearance of data collection sheets and printed notes and continual rapid response in programing modification to allow for physician individuality and changes in medical practice. The limiting factor in the potential usefulness of such a system is the rate of incomplete data collection. It is suggested that if the physician were to enter data directly into the computer through a terminal, data collection would be more accurate and complete.