Transvaginal approach for repair of rectovaginal fistulae complicating Crohn's disease.

The management of rectovaginal fistulae complicating Crohn's disease is difficult and often unsatisfactory. Between December 1983 and November 1988, 13 patients with Crohn's disease underwent repair of rectovaginal fistulae via a transvaginal approach. All patients had a diverting intestinal stoma either as part of the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. Each of the patients had low or mid septal fistulae; high fistulae generally are treated transabdominally and are not the focus of this discussion. Fistulae were eradicated in 12 of the 13 women and did not recur during the follow-up period, which averaged 50 months (range, 9 to 68 months). The only treatment failure was a patient who had a markedly diseased colon from the cecum to the rectum and a very low-lying fistula. It is concluded that a modified transvaginal approach is an effective method for repair of rectovaginal fistulae secondary to Crohn's disease.

Babesiosis in pregnancy.

Babesiosis is a malaria-like illness due to intraerythrocytic protozoan parasites. To the authors' knowledge, this unusual disease has not previously been described in a pregnant woman. Herein is reported the case of a gravid woman with an intact spleen who developed infection with Babesia microti in the fifth month of gestation. Her illness resolved following supportive care only, and evidence of transmission of disease to the fetus was not found.

Eisenmenger's syndrome and pregnancy.

Two additional cases of successfully managed Eisenmenger's syndrome (ES) during pregnancy are described. A review of the literature on this subject revealed 115 reported cases, of which only 44 (including our two cases) were felt to be adequately documented, representing 70 pregnancies. These formed the material for statistical evaluation. Fifty-two per cent of all patients died in connection with pregnancy. Thirty and three-tenths per cent of all pregnancies results in maternal death. Maternal mortality in first, second, and third pregnancies was not significantly different. A high incidence of maternal death was assoicated with hypovolemia, thromboembolic phenomena and preeclampsia, but mortality was not higher in the toxemia than in the non-toxemia group. Cesarean sections and other operations are associated with extremely high maternal mortality during pregnancy. Thirty-four per cent of all vaginal deliveries, three out of four cesarean sections, and only 1 out of 14 pregnancy interruptions (the only one by hysterotomy) resulted in maternal death. Abortions are significantly safer than any kind of delivery (p less than 0.05). Ventricular septal defect (VSD) is the most frequent underlying shunt defect. Maternal mortality in association with VSD is higher (60%) than in association with atrial septal defect (ASD) (44%) and patent ductus arteriosus (PDA) (41.7%). The majority of maternal deaths occurred during or within the first week after delivery. Only 25.6 per cent of all pregnancies reached term. At least 54.9 per cent of all deliveries occurred prematurely. Thirty and two-tenths per cent of all infants showed intrauterine growth retardation. This represented almost half of all new borns with available information. Perinatal mortality reached 28.3 per cent and was significantly associated with prematurity (p less than 0.001). Pregnancy is contraindicated in patients with ES. Abortion is the treatment of choice, once pregnancy has occurred. Where interruption of pregnancy is refused, utmost care must be taken to assure maternal and fetal survival. A protocol for the management of such pregnancies is discussed on the basis of available information.

Shunt flow and pulmonary hemodynamics during labor and delivery in the Eisenmenger syndrome.

The Eisenmenger syndrome carries a high mortality rate in a women during delivery and the immediate postpartum period. It has been suggested that marked changes in shunt flow and pulmonary hemodynamics may be responsible. These functions were studied under various physiologic and pharmacologic conditions during labor and delivery in a patient with the Eisenmenger syndrome. Uterine contractions were associated with a decrease in the ratio of pulmonary to systemic blood flow (Qp/Qs) from 1.58 to 1.05. The Qp/Qs ratio also decreased (to 0.83) when forceps were applied during uterine contractions. Epidural anesthesia, oxytocin and the supine position did not adversely affect pulmonary hemodynamics or shunt flow. On the basis of these results, if pregnancy cannot be terminated in a patient with the Eisenmenger syndrome, it is recommended that the patient be given high concentration of oxygen and epidural anesthesia and that serial arterial blood gas determinations be performed to detect changes in shunt flow.