Characteristics of patients with rapidly growing cervical cancer.

Between April 1983 and December 1990, 387 newly diagnosed cervical cancer cases were managed at our institution. We retrospectively reviewed 59 of those cases, which were identified as having developed within 3 years of the patients' last normal Pap smear. Squamous cell carcinoma was found in 45 patients, and 33 had poorly differentiated lesions. Six cases had typical histology. However, 27 cases (82%) had distinctive histologic features that have not been previously described in rapidly progressive cervical cancer. Thirty-seven patients had surgical treatment; 7 (19%) died of disease. Twenty-two patients had radiation; 10 (45%) died of disease. Patients who have invasive cervical cancer after a recent normal Pap smear may have unusual histologic types, and some with early-stage disease may have better outcome if treated with radical surgery.

Use of a subcutaneous closed drainage system and antibiotics in obese gynecologic patients.

OBJECTIVE: The purpose of this study was to evaluate the effect of subcutaneous closed drainage systems and prophylactic antibiotics on the wound breakdown rate in obese patients undergoing gynecologic surgery. STUDY DESIGN: A prospective study was performed on 197 obese patients who were randomly selected to have a subcutaneous drain. Incision closure technique was standardized. Antibiotic usage was not randomized. Demographic data, perioperative data, and postoperative complications were noted and analyzed by X2 test and 2 x 2 contingency tables. RESULTS: The overall complication rate was 25%, with 20% (22/109) among the group receiving a drain versus 31% (27/88) without a drain. Seventeen patients (8.6%) had wound breakdowns: 7 of 109 (6.4%) with drains and 10 of 88 (11.4%) without drains. Prophylactic antibiotics were given to 46% (50/109) in the drain group and 51% (45/88) without a drain. Fewer patients (2%) with a drain receiving antibiotics had wound breakdowns. The group with the most breakdowns had neither a drain nor antibiotics (14%). CONCLUSION: We suggest the use of subcutaneous drains plus prophylactic antibiotics may decrease morbidity when operating on obese gynecologic patients.

Necrotizing surgical infection and necrotizing fasciitis in obstetric and gynecologic patients.

Necrotizing fasciitis (NF) is a rapidly progressive disease characterized by extensive necrosis of the skin, fascia, and subcutaneous tissue, with sparing of the underlying muscle. Diabetes mellitus, Bartholin's gland abscess, and recent surgical procedures (including episiotomy) are factors often found in obstetric and gynecologic patients. Mortality in this group of patients is higher than in the general surgical population. Death is usually due to overwhelming sepsis, renal and respiratory failure, and multiple organ failure. The infections are usually polymicrobial, with alpha-hemolytic streptococci, gram-negative coliforms, and anaerobic bacteria. Lower survival has been reported in large series when the groin is involved or when the general nutritional state is poor. From October 1988 to August 1990, we treated five patients with necrotizing fasciitis. Certain important characteristics of such patients have not been discussed in the obstetric and gynecologic literature. Nutritional status, with special emphasis on total protein, albumin, and the effects of alcoholism, has a significant impact on mortality. Nutritional support of these patients may improve survival. To limit the impact of secondary infections, surgical approaches should be modified by the anatomic location of the initial lesions. More frequent debriding in the operating room and early fecal diversion are recommended.

A prospective evaluation of an endometrial suction curette.

The object of this study was to assess the reliability of a technique using an endometrial suction curette to obtain tissue for diagnosis. A prospective study was performed. One hundred sequential outpatient biopsies using the Z-Sampler were studied. All samples were reviewed a second time by a single pathologist for adequacy. In 75% of samples, a histologic diagnosis could be determined. The remaining 25% were inadequate for diagnosis--4 identified at the time of sampling and completed with a Novak curette and 21 in which the sample would not support the histologic diagnosis. Analysis of the inadequate samples found that 12 of the 25 (48%) inadequate samples came from patients with the clinical diagnosis of postmenopausal or climacteric bleeding. This diagnosis was represented in only 18 of the 75 successful biopsies (24%, p less than 0.001). The findings suggest that endometrial sampling using disposable endometrial curettes provides adequate tissue for histologic interpretation in most patients. Although patients with postmenopausal or climacteric bleeding made up one half of all patients with an inadequate sample, 60% of these patients did have interpretable tissue obtained. In these patients, use of other or adjunctive sampling methods should be entertained based on clinical or other considerations.

Thrombotic thrombocytopenic purpura first seen as massive vaginal necrosis.

Thrombotic thrombocytopenic purpura is a hematologic disorder that affects the microcirculation. A 38-year-old woman was first seen with fever, thrombocytopenia, and vaginal bleeding. Pelvic examination revealed massive vaginal necrosis. Hematology consultation resulted in agreement with the diagnosis of thrombotic thrombocytopenic purpura. This is the first reported case of thrombotic thrombocytopenic purpura first seen as vaginal necrosis of which we are aware.