Vulvar pyoderma gangrenosum.

Pyoderma gangrenosum is an idiopathic dermatologic disease manifested by painful cutaneous ulceration. The ulcers are characterized by their undermined, violaceous borders and necrotic tissue at the ulcer base. The lesions may have an unusual response to physical manipulation known as pathergy, a phenomenon that is manifested by rapid progression following debridement. Pyoderma gangrenosum is frequently associated with systemic diseases such as inflammatory bowel disease, rheumatoid arthritis, chronic active hepatitis and hematologic malignancies. Conservative wound care and systemic corticosteroids are usually effective therapy. We report the second case in the gynecologic literature of a patient with vulvar pyoderma gangrenosum.

MRI findings of sciatic endometriosis.

Endometriosis is a rare cause of sciatic mononeuropathy. We report a woman with cyclic, menstruation-related hip pain associated with right leg weakness and sensory loss. Examination and electrodiagnostic studies suggested sciatic nerve dysfunction. Magnetic resonance imaging (MRI) revealed abnormal signal consistent with endometriotic tissue in the region of the right sciatic nerve. The abnormal signal partially regressed after treatment of the endometriosis. This case further illustrates the utility of MRI in the assessment of rare pelvic disorders.

Maternal mortality in North Carolina: a forty-year experience.

An analysis of 67 maternal deaths from January 1, 1981, through December 31, 1985, are reported in detail and in the perspective of 3780 maternal deaths previously reviewed in North Carolina since January 1, 1946. Although the direct obstetric mortality rate has decreased 95% over the 40 years, within causal mortality groups the rates have changed variably during the past 5 years. For the first time, no deaths from obstetric infection occurred. Whereas deaths from toxemia continue to decline, those from hemorrhage, embolism, and anesthetic complications remain unchanged. Within the hemorrhage causal group, deaths from ectopic pregnancy have risen to 70%. The maternal death rate after 20 weeks' gestation is almost 10 times that associated with pregnancy interruptions. Of particular concern is the relative risk of death between the nonwhite and white patients. The North Carolina data are reviewed in the light of those in the South Atlantic region and in the nation as a whole.

PIP: An analysis of 67 maternal deaths from January 1, 1981, through December 31, 1985, are reported in detail and in the perspective of 3780 maternal deaths previously reviewed in North Carolina since January 1, 1946. During the 5-year study period, 428,891 live births and 155,498 elective abortions occurred. A total of 54 direct and indirect maternal deaths were unrelated to elective abortion (12.6: 100,000 live births) and 2 deaths succeeded 1 elective and 1 indicated abortion (1.3: 100,000 abortions). Although the direct obstetric mortality rate has decreased 95% over the 40 years, within causal mortality groups the rates have changed variably during the past 5 years. For the 1st time, no deaths from obstetric infection occurred. Whereas deaths from toxemia continue to decline, those from hemorrhage, embolism, and anesthetic complications remain unchanged. Within the hemorrhage causal group, deaths from ectopic pregnancy have risen to 70%. The maternal death rate after 20 weeks' gestation is almost 10 times that associated with pregnancy interruptions. Data from North Carolina, as well as regional and national data indicate at least a 3-fold to 4-fold greater risk of death in nonwhite women. Significant risk variations, such as the increased frequency of cardiovascular disease in the black race, are present in causal groups that cannot be explained specifically.

The effect of placental location on uterine artery flow velocity waveforms.

We examined the effect of placental location with regard to flow velocity waveforms in the uterine arteries in 84 control and 28 hypertensive women during the third trimester of pregnancy. The ratio of systolic peak to end-diastolic frequency was obtained with a continuous-wave Doppler device and the placental location was determined by real-time ultrasonography. In both normal and hypertensive pregnancies with unilateral placental location the systolic/diastolic ratio of the ipsilateral uterine artery was significantly lower than the contralateral artery ratio [1.73 +/- 0.35 (systolic/diastolic ratio) versus 2.46 +/- 0.73, p less than 0.001, and 2.38 +/- 1.01 versus 4.04 +/- 1.77, p = 0.0012, respectively]. The physiologic and clinical significance of this finding is discussed.

Temporal and receptor correlates of the estrogen response in sheep.

Uterine blood flow and uterine cytosol and nuclear estrogen receptors were measured at critical times during estradiol-induced vasodilatation in acute anesthetized and chronic conscious sheep preparations at estradiol bolus injection frequencies from 1 to 24 hours. During acute experiments, the uterine blood flow response was muted and cytosol estrogen receptor replenishment did not occur whereas full replenishment occurred in 12 hours in conscious ewes. In ewes treated with daily estradiol that had a stable daily uterine blood flow response, the uterine blood flow response 24 hours after uterine biopsy was similar to the preoperative one. Analysis of the duration of peak uterine blood flow levels and the rate of uterine blood flow descent from peak levels showed that an interval of 18 hours between estradiol injections was necessary for the uterine blood flow response to approximate that observed after 24 hours. These observations suggest: (1) that uterine vascular receptor replenishment is delayed compared with that of the total uterus; (2) that operative stress compromises cytosol estrogen receptor metabolism and possibly nuclear estrogen receptor function; (3) that the delayed maximum uterine blood flow response to estradiol in ewes previously untreated with estradiol is due to a trophic uterine effect of daily estradiol stimulation.

Perineal Crohn's disease.

Crohn's disease has frequent perineal manifestations, including rectovaginal fistulas. This association is not widely recognized, especially in the gynecologic literature. Six cases of presumptive or documented Crohn's disease associated with rectovaginal fistulas and a review of the literature are presented. The need for a high degree of suspicion and a gastroenterologic evaluation is emphasized. Conservative management is stressed in view of the poor healing characteristics of perineal tissue in these patients. Alternative surgical approaches, including local repair, proximal diversion, and curative total proctocolectomy/ileostomy, are presented. Local repair is fraught with problems including postoperative breakdown and recurrence, yet proctocolectomy is a radical, but curative, procedure. An understanding of the ramifications of surgical intervention along with thorough patient counseling are required in managing these patients.

Subhourly variability of circulating norepinephrine and epinephrine in the pregnant ewe and fetal and newborn lamb.

Circulating norepinephrine and epinephrine were determined nine times over a 1-hour period in chronically instrumented ewes (n = 4), their fetuses (n = 4), and lambs (n = 4). In an apparent resting state, assessed by subjective and biophysical parameters, marked fluctuations were demonstrated in the mean norepinephrine and epinephrine values between animals and in the range of the concentrations of each individual animal. The significance of the fluctuations in resting plasma norepinephrine and epinephrine concentrations is discussed.

Glycosaminoglycans: their distribution and potential vasoactive action in the nonpregnant and pregnant ovine uterus.

The effects of direct uterine artery infusions of glucosamine-hydrochloric acid, dextrose, and mannitol were evaluated in ewes that had undergone oophorectomy. Glucosamine-hydrochloric acid caused a prompt dose-related increase in uterine blood flow which approximated uterine blood flow rates induced by estradiol. Infusions of dextrose caused similar but transient vasodilatation, whereas infusions of mannitol had no effect. The glycosaminoglycans content of endometrium, myometrium, and caruncles/cotyledons (placentomes) was measured in nonpregnant and early pregnant ewes between 19 and 45 days' gestation. In endometrium and myometrium, total hexosamine levels were similar in nonpregnant and pregnant ewes. In the placentomes, total hexosamine levels increased steadily after 20 to 25 days' gestation. The hyaluronic acid fraction of total glycosaminoglycans hexosamine increased similarly and paralleled the total hexosamine levels. Galactosamine levels were unchanged in all tissues. It is postulated that a function of Wharton's jelly may be to provide the mechanism for shunting of uterine blood flow to the ovine placentomes.

The effect of labor on maternal and fetal circulating catecholamines.

Maternal circulating catecholamines were determined in nonpregnant (n = 15) and antepartum (n = 15) subjects and at spontaneous vaginal (n = 20) and repeat cesarean section (n = 20) deliveries. Newborn levels of catecholamines were determined prior to the onset of respiration in the vaginal delivery (n = 20) and cesarean section (n = 20) groups. Maternal levels of norepinephrine at 36 to 38 weeks' gestation were lower than values in nonpregnant individuals, and did not increase at cesarean section but rose to nonpregnant levels at vaginal delivery. Antepartum levels of epinephrine were lower than levels in nonpregnant subjects and rose above nonpregnant levels in both delivery groups (P less than 0.02). Maternal levels of dopamine followed a similar pregnancy decline and rose above nonpregnant levels at delivery in both groups (P less than 0.02). Maternal levels of dopamine in the cesarean section group were significantly higher than those in vaginal delivery (P less than 0.05). Newborn levels of catecholamines demonstrated significant newborn secretion of norepinephrine, epinephrine, and dopamine at delivery in both groups. Umbilical arterial levels of norepinephrine and epinephrine were significantly greater after vaginal delivery than those after abdominal delivery (P less than 0.01). The significance of circulating catecholamines to, and their possible roles in, the parturient women and fetus are discussed.

In vivo evidence for increased adrenal sensitivity to adrenocorticotropin-(1-24) in the lamb fetus late in gestation.

Plasma concentrations of immunoreactive ACTH and cortisol were monitored daily in chronically cannulated sheep fetuses during the last 3 weeks of gestation. A prepartum increase in fetal plasma cortisol occurred without a concomitant rise in fetal plasma ACTH. When fetal lambs were injected with various doses of ACTH-(1-24) and the plasma cortisol responses were integrated over time, the resulting changes in the log dose-response curves indicate that fetal adrenal sensitivity increases late in gestation. Thus, the marked rise in fetal plasma cortisol before birth can be explained, at least in part, by an increase in fetal adrenal sensitivity to ACTH.

Vascular and uterine responses to dobutamine and dopamine in the gravid ewe.

Dopamine, a naturally occurring catecholamine precursor of norepinephrine, has been used in the treatment of cardiogenic shock. Following intravenous administation it increases cardiac output, blood pressure, and renal blood flow. Dobutamine is a directly acting inotropic agent which increases myocardial contractility without significantly changing blood pressure. This study was devised to compare the effects of these two drugs on uterine blood flow (UBF), uterine tonus (UT), mean arterial blood pressure (MAP), and heart rate (HR). Chronically instrumented pregnant ewes near term were infused with differet concentrations of dopamine and dobutamine while HR, MAP, UT and UBF were recorded continuously. Dopamine produced a decrease in UBF and an increase in MAP and UT while the HR response was variable. Dobutamine administration resulted in a marked increase in HR and a decrease in UBF, while MAP and UT remained essentially unchanged. Uterine vascular resistance increased with both drugs during high-dosage administration, but the rise was more pronounced following dopamine infusion. Since dobutamine exhibits less alpha-adrenergic activity than dopamine this drug would seem to be preferred when an inotropic agent is required for treatment of the pregnant patient.

Effects of nitroglycerin and nitroprusside on the uterine vasculature of gravid ewes.

The effects of nitroglycerin (TNG) and sodium nitroprusside (SNP) on mean aortic pressure (MAP), uterine blood flow (UBF), uterine vascular conductance (UVC), and pulse rate (PR) were compared when the two agents were infused to prevent and treat hypertension induced by norepinephrine (NE) in gravid ewes. When infused alone, TNG, 19 microgram/kg/min, decreased MAP 19 per cent and increased PR 33 per cent from control values (P less than 0.05), but did not significantly change UBF or UVC. In comparison, SNP, 3 microgram/kg/min, decreased MAP 20 per cent and increased PR 43 per cent (P less than 0.05), and did not significantly change UBF or UVC. When given alone, four successive 2-min infusions of NE produced dose-related increase in MAP and decreases in UBF, UVC, and PR; values were significantly different from control with the two higher doses of NE. Although MAP, UBF, and UVC were still significantly changed from control levels when NE was given in the presence of the above infusions of TNG or SNP, MAP was lower and UBF and UVC were higher compared with when NE was given alone (P less than 0.05). When given to control hypertension induced by a continuous infusion of NE, TNG or SNP produced uterine vasodilatation and significantly increased UBF. Nitroglycerin and SNP were equally effective in counteracting the maternal hypertension and antagonizing the uterine vascular effect of NE. It is concluded that TNG and SNP counteract uterine vasoconstriction resulting from alpha-adrenergic stimulation and do not produce a shunt of blood flow away from the uterine vasculature when used to control hypertension in gravid ewes.

Relationship of lesion size to survival in patients with stage IB squamous cell carcinoma of the cervix uteri treated by radiation therapy.

Forty-five patients with Stage IB squamous cell carcinoma of the cervix uteri were treated with radiation therapy alone. The five year actuarial survival rate of the 22 patients in group 1 in whom the tumor was less than 4 centimeters in diameter was 95 per cent, which was significantly higher than the 67 per cent survival rate in the 23 patients in group 2 with bulky lesions greater than or equal to 4 centimeters in diameter, p less than 0.05. These results of radiation therapy are consistent with surgical results recently reported and indicate that patients with bulky lesions, especially those tumors greater than or equal to 4 centimeters in size, comprise a high risk subset within the Stage IB classification. A new classification is proposed in which bulky lesions are designated Stage IC, advanced overt, so that such high risk patients might be identified and more efficacious treatment regimens might be developed.

Responses of the gravid uterine vasculature to arterial levels of local anesthetic agents.

Responses of the uterine vasculature and myometrium to uterine arterial infusions of local anesthetic agents were evaluated in chronically prepared conscious ewes between 86 and 141 days of gestation. Decreases in uterine blood flow (UBF) with increasing levels of anesthetic drugs were similar to those previously observed in nonpregnant ewes. A 25% decrease in UBF occurred at 7 micrograms of bupivacaine, 11.5 micrograms of 2-chloroprocaine, and 19.5 micrograms of lidocaine per milliliter of control UBF. Myometrial tonus did not change significantly except with bupivacaine where an increase occurred (P less than 0.001). These data indicate that local anesthetic agents may lower gravid UBF by a direct vascular effect and by stimulation of myometrial contractility. The possible clinical implications of these observations are discussed.