Routine use of episiotomy in modern obstetrics. Should it be performed?

Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. Although episiotomy does decrease the occurrence of anterior lacerations, it fails to accomplish the majority of goals stated as reasons for its use. Episiotomy does not decrease damage to the perineum but rather increases it. The midline episiotomy increases the risk for third-degree and fourth-degree lacerations. Episiotomy fails to prevent the development of pelvic relaxation and its attendant complications. Rather than decreasing maternal morbidity, episiotomy increases blood loss and is related to greater initial postpartum pain and dyspareunia. It has been associated with a more difficult and lengthy repair as measured by the need for suture material and operating room time. The claims of a protective effect on the fetus in shortening the second stage of labor, improving Apgar scores, and preventing perinatal asphyxia have not been borne out. The value of episiotomy use on a routine basis bears scientific examination in prospective, randomized, controlled trials. These types of trials are certainly achievable, ethically correct, and much needed. Until these trials are completed and published, obstetricians should not routinely perform the procedure but rather determine the need for episiotomy on a case-by-case basis.

Retinoids and the eye.

Systemic retinoids are being used more frequently to treat various disorders of the skin, particularly disorders of keratinization. They are promising agents for chemoprevention of cancer and as such may be widely used in the future. Both natural and synthetic retinoids may affect the eye, both on the surface epithelium and the visual metabolism. Three basic effects of pharmacologic doses of synthetic retinoids have been seen. Blepharoconjunctivitis has been particularly prominent with isotretinoin use. Pseudotumor cerebri has been reported sporadically. Recently, night blindness has been reported with both isotretinoin and fenretinide. The greater use of isotretinoin may be more important in explaining the increased incidence of these side effects than is the individual metabolism of the different available synthetic retinoids. These three major side effects of the eye will be carefully evaluated as newer synthetic retinoids are proposed for further trials. Fortunately, it seems that all of these ocular manifestations are dose dependent and reversible, giving the clinician several alternatives to adjust the treatment regimen.

A system for variable aspiration of material dissected from the posterior chamber.

A beveled, coaxial irrigation/aspiration spatula is described for use with the linear suction control of the Ocutome.

6-hydroxydopamine in the treatment of open-angle glaucoma.

We evaluated the effectiveness of subconjunctival injections of 6-hydroxydopamine in conjunction with epinephrine in lowering ocular tension in 63 eyes of 61 patients with open-angle glaucoma. A single injection caused a peak median reduction in ocular tension of 6 mm Hg four weeks after the injection. Ten eyes (16%) showed no significant decrease in ocular tension. A single injection significantly decreased the ocular tension for 12 weeks in 40 (63%) and for 20 weeks in 21 (33%) of the eyes. The fellow control eyes showed a slight but not significant decrease in ocular tension.

Effect of plasma from cyclophosphamide-treated mice on CFU-S in an in vivo culture system.

Various studies suggest that humoral substances, capable of stimulating CFU-S proliferation, are released into the plasma in response to depletion of the CFU-S population by cytotoxic substances such as cyclophosphamide. To test this hypothesis, we placed 0.25 ml of a murine marrow cell suspension with an equal volume of plasma from either normal mice or from mice previously injected with 5 mg of cyclophosphamide into cellulose dialysis tubing. These tubes were then incubated in the peritoneal cavity of mice for 1-7 days. The CFU-S content of the tubes was then assayed. The CFu-S content of suspensions in normal mouse plasma declined to one-fourth of the initial value after 7 days, whereas those in plasma from mice that received cyclophosphamide 7 days previously were essentially unchanged in number. These data suggest that 7 days after injection of cyclophosphamide, the plasma contains a factor that either prevents death of CFU-S or stimulates them to proliferate. An alternative explanation is that normal plasma contains an inhibitor of CFU-S growth that is lacking in plasma of cyclophosphamide-treated mice.

Extraction of erythropoietin from kidneys.

Erythropoietin (Ep) in large amounts was detected in extracts of renal tissue from hypoxic rats. These extractions were performed by homogenization of kidney tissue in phosphate buffered saline, centrifugation at 3,000 g and collection of the supernate. Male kidneys contained more Ep than did females and the major portion of Ep is located in the renal cortex. Comparison of intrarenal and plasma Ep levels at various times following initiation and cessation of hypoxia appears to be a useful method for studying the kinetics of erythropoietin production and release, and also for studying feedback mechanisms that influence these functions.

The incidence of sickle trait in Blacks requiring filtering surgery.

Open-angle glaucoma in the blacks is generally thought to be a more malignant disease than in whites in terms of response to therapy and subsequent visual loss. An increased incidence of unsuspected sickle trait and undetected sickling may have contributed to these patients' optic nerve ischemia, progressive field loss and need for surgery. A homoglobin electrophoresis was done on 40 black patients who required filtering surgery for uncontrolled open-angle glaucoma. Only 2 of the 40 patients (5%) had sickle trait as determined by the hemoglobin electrophoresis. In a matched group of 40 controls, only 3 patients (7.5%) had sickle trait. Therefore, there does not appear to be an increased incidence of sickle trait in black patients requireing filtering surgery.