Acute promyelocytic leukemia and pregnancy. A case report.

BACKGROUND: Acute promyelocytic leukemia (APL) is an uncommon form of acute myeloid leukemia usually associated with disseminated intravascular coagulation (DIC). Pregnancy in patients with APL requires special consideration to maximize the probability of survival of both mother and fetus. METHODS: A patient with APL diagnosed during pregnancy who developed DIC is described. Obstetric and oncologic management of this difficult patient is discussed, and a pertinent literature review of pregnancy in APL is presented. RESULTS: Of 23 pregnancies in patients with APL reported in the literature (including the present patient), 19 yielded live births, including 8 of 12 who received chemotherapy during late pregnancy and all 3 patients who received all-trans-retinoic acid (ATRA) during late pregnancy. Chemotherapy or ATRA induced complete remission in 72% of treated patients. CONCLUSIONS: Proper management of pregnant patients with APL usually results in a live birth and complete remission of the mother's leukemia, despite the potentially devastating consequences of DIC, which is present at diagnosis in most patients.

Postgraduate internship in gynecology and obstetrics for physician assistants: a 4-year experience.

Changes in the Hospital Code (405 Regulations) to limit the number of hours worked by residents have been implemented in New York state and may soon become a nation-wide policy. Although their goal is to guarantee quality of patient care and assure education for residents, the limitation of hours worked has increased manpower shortages, some of which could be resolved by using physician assistants with specialty training. To provide this training, a Postgraduate Internship in Gynecology and Obstetrics for Physician Assistants has been developed at the North Central Bronx Hospital and the Montefiore Medical Center. It is the first program of its kind at the postgraduate level to educate physician assistants specifically for practice in obstetrics and gynecology. The program consists of 3 months of didactic lectures to review and update knowledge on topics in medicine, surgery, gynecology, preoperative and postoperative care, cardiac and trauma life support, and critical care, followed by a clinical year similar to that of a rotating physician intern. We believe that such postgraduate educational opportunities in gynecology and obstetrics benefit both the individual physician assistant's growth and development and the level of care delivered, and may be an answer to staffing needs.

Abnormal cervical cytology leading to the diagnosis of gastric cancer.

There have been nine cases reported in the English literature in which the finding of malignant cells on cervical/vaginal cytology led to the diagnosis of primary gastric cancer. We report on a patient with gastric carcinoma, metastatic to the cervix, in which the diagnosis was suspected by the finding of signet ring cells on a Papanicolaou smear of the cervix. Prior to treatment of this patient, concordance of signet ring carcinoma on cervical and ascitic fluid cytology and on cervical and gastric biopsies was documented; this has not been reported previously. Thirty-four additional cases of gastric carcinoma metastatic to the cervix are reviewed. This paper is presented to remind the clinician that, however rare, metastases from the gastrointestinal tract to the uterine cervix do occur.

Primary ovarian pregnancy two years after bilateral tubal ligation. A case report.

This is the first documented case of intrafollicular ovarian pregnancy following bilateral tubal ligation. The patency of the previously ligated tube was demonstrated by hysterosalpinography. It appears that the incidence of ovarian pregnancy is not related to the rising incidence of tubal pregnancy.

Spontaneous clostridia gas gangrene of uterus associated with endometrial malignancy.

Only four patients with clostridia sepsis in association with gynecologic malignancy have been reported, all of whom had prior diagnostic or therapeutic intervention. Our patient is the first documented case of such clostridium sepsis that occurred spontaneously, i.e., without previous trauma, instrumentation, radiation or chemotherapy. The value of aggressive management is reviewed.

Cystic papillary hidradenoma of the vulva: case report and review of the literature.

Papillary hidradenoma of the vulva is a rare, benign neoplasm arising from apocrine sweat glands of the skin. Frequently, this lesion has been mistaken for carcinoma. The treatment of choice is local excision. The prognosis for patients with this tumor is excellent. We present a patient who is unique because she had a lesion which was the largest ever recorded, and which existed over twice as long as any previously described. This case is also presented to remind the clinician that, despite the gross appearance of the tumor which resembles carcinoma on sectioning, biopsy and histological diagnosis should guide the ultimate management of patients with such lesions. The findings in our patient support the view that no matter how large or how long in existence, hidradenoma remains benign.

Retroperitoneal hematoma from a ruptured tubal pregnancy as an unusual cause of a pelvic mass. A case report.

Retroperitoneal hematoma can result from a ruptured tubal pregnancy and present as a pelvic mass. Such a case has not been described previously.

Abdominal wall actinomycosis associated with an IUD. A case report.

Abdominal wall actinomycosis without pelvic organ involvement in users of intrauterine contraceptive devices (IUDs) has not been reported on previously. We encountered one such patient, whose uterine cervix was colonized superficially with Actinomyces. We suggest that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Papanicolaou smears or in endocervical curettings. Such patients should be treated with appropriate antibiotic therapy, especially prior to any surgical intervention.

PIP: This paper presents the 1st reported case of actinomycosis of the subcutaneous tissues and abdominal wall without pelvic organ involvement in an IUD user. The patient, a 39-year old woman, para 4-0-1-4, presented with lower abdominal pain. Pap smear findings were reported as cervical intraepithelial neoplasia, grade I-II, and endocervical curettage showed colonies of Actinomyces species. A subsequent cone biopsy revealed carcinoma in situ but no evidence of Actinomyces. The final diagnosis was cervical intraepithelial neoplasia, leiomyomata, and actinomycotic abscesses of the abdominal wall. It is suggested that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Pap smears or in endocervical curettings. Treatment of actinomycosis generally involves intravenous aqueous penicillin, 10-20 million units/day for 4-5 days, followed by 2-15 million units/day of oral penicillin for 3 weeks-1 year. Longterm antibiotic therapy is particularly important prior to any surgical intervention. If left untreated, actinomycosis can lead to infection, brain abscess, or death.

Paraganglioma complicating pregnancy and the puerperium.

A rare case of a paraganglioma (extraadrenal pheochromocytoma) that complicated both pregnancy and the puerperium is described. The patient presented a confusing clinical picture simulating pregnancy-induced hypertension, which, after delivery, masqueraded as intractable fever of unknown origin. Computed tomography precisely identified the presence and location of the mass, which had eluded detection despite exhaustive testing. Pheochromocytoma should be considered in the differential diagnosis of postpartum fever of unknown origin, especially if associated with paroxysmal hypertension.

Current concepts of defibrination in the pregnant woman.

The possible predisposing causes of difibrination in the pregnant woman are discussed. Coagulation profiles and qualitative and quantitative assessment of fibrinolytic activity during labor, delivery and the early puerperium in normal pregnancies are presented. These factors were also studied in patients with abruptio placentae and prolonged intrauterine fetal death and in women whose pregnancies were terminated with intraamniotic infusion of hypertonic saline or prostaglandin F2alpha. The findings suggest that a minor degree of physiologic defibrination develops during normal labor that is qualitatively similar to, but of much lesser magnitude than, the pathologic defibrination syndrome commonly associated with abruptio placentae or prolonged intrauterine fetal death. Some degree of defibrination occurs in women undergoing saline abortion, similar to that of women during normal parturition, but does not usually reach clinically significant levels. The coagulation changes seen during prostaglandin abortion suggest that a minor degree of defibrination occurs that is substantially less than that seen during saline abortion. The findings presented form a basis for the rational management of defibrination in the pregnant woman.

Defibrination in obstetrics. Modern concepts.

Coagulation profiles of serum fibrinogen, factors V and VIII and haemoglobin in normal pregnancies during labour, delivery and the early puerperium are presented. These factors were also studied in patients with abruptio placentae, in intra-uterine death, and in patients whose pregnancies were terminated with intra-amniotic saline and prostaglandin F2alpha. An assessment of fibrinolytic activity in these patients was made using qualitative (euglobulin lysis time) and quantitative (FR-antigen) tests. The coagulation findings presented form a basis for the rational management of defibrination in obstetrics.

Factors responsible for delay in obtaining interruption of pregnancy.

PIP: A sample of 132 women undergoing early abortion by suction curettage or late abortion (after the twelfth week of gestation) by intrauterine saline instillation at the Hospital of the Albert Einstein College of Medicine between January 1 and March 31, 1971, were interviewed to explore why there are so many late abortions. Women having late abortions tended to be younger (mean age 22.2 compared to mean age 26.6 for women having early abortions) single and nulliparous and were less likely to use contraception than women seeking early abortions (only 26% under age 25 had used contraception compared to 71% of the same age group who had early abortions). The majority (55%) of the patients delayed abortions for personal reasons, but 26% of the abortions were delayed because of reasons related to the medical care system. Women from outside of New York experienced greater difficulty in obtaining abortions than residents as evidenced by the fact that almost 1/2 of the nonresidents had decided on abortion before the twelfth week and still had late abortions. In both the early and late groups nearly 14% had to wait longer than necessary to obtain abortions. The study suggests that both physicians and patients be made aware of the advantages of early abortion. Over 40% of the women in the study had never used contraception, a result which stresses the need for health education and counseling with emphasis on contraception, particularly among the inexperienced and younger women. Until a major shift is seen from late to early abortion however, saline abortions must be provided safely and with consideration for the woman.^ieng