Cervical dysplasia in pregnancy: progression versus regression post-partum.

OBJECTIVE: To assess the natural history of cervical dysplasia during pregnancy and determine the rates for progression or regression post-partum by the severity of the lesion. METHOD: This was a retrospective study of 100 patients screened by PAP smear. Lesions were graded by colposcopy and biopsy, and followed post-partum. RESULTS: Lesions were graded as ASCUS, LGSIL, and HGSIL. The majority of lesions showed a tendency to regress post-partum (approximately 64%), a trend that was statistically significant (P < .003). A substantial minority (approximately 34%) showed no change in severity of the lesion. The tendency for lesions to progress in severity was very low (approximately 3%). No patient had microinvasive disease. Of patients who had CIS, persistence of this lesion post-partum was present in 67%. CONCLUSION: Patients with cervical dysplasia in pregnancy may be followed conservatively with colposcopy and biopsy.

Serum creatine kinase is not a reliable indicator of ectopic pregnancy.

OBJECTIVE: It has been reported that elevation in creatine kinase may be used as an indicator of ectopic pregnancy as a consequence of trophoblast invasion of the smooth muscle layer of the Fallopian tube. In this study, we attempt to verify this observation and establish the sensitivity and positive predictive value of the test. METHODS: Serum creatine kinase (MM-fraction) was obtained from patients presenting with possible ectopic pregnancy prior to surgical intervention. Ectopic pregnancies were confirmed by laparoscopy. Noted was whether the gestation was ruptured or unruptured, its location in the tube, and estimated cross-sectional tubal distention. Controls consisted of patients with first-trimester pregnancies simulating ectopic pregnancy, i.e., patients having a positive pregnancy test, complicated by vaginal bleeding and/or abdominal pain. RESULTS: The distribution of creatine kinase values for both patients with ectopics versus control are positively skewed, with a mode of 10-19 U/L. The mean creatine kinase for ectopic pregnancies was 62.3 U/L, S.D. = 63.1 U/L. For controls, the mean creatine kinase = 40.8 U/L, S.D. = 30.1 U/L. The difference in these means is significant (p = 0.04), but weakly so. In addition, for ectopic gestations there was no significant difference in creatine kinase values with regard to degree of tubal distention, gestation location, or whether rupture had occurred, thereby limiting the clinical value of this test. CONCLUSIONS: Although the mean value of serum creatine kinase is statistically significantly higher in ectopic pregnancy relative to controls, the distribution curve for creatine kinase values for ectopics is broad, with much overlap with the control curve. Hence, the sensitivity and positive predictive value for this test is poor.

Twin entanglement revisited.

A fear of interlocking twins is one factor that has led to a high Cesarean section (C/S) rate in breech (A)/vertex (B) (Br(a)/Vtx(b)) twins. We sought to estimate the frequency of occurrence of twin entanglement, and of interlocking Br(a)/Vtx(b) twins in vaginal deliveries. 541 twins and 48,195 deliveries were retrospectively studied for the period 1987-1995. The incidence of Br(a)/Vtx(b) deliveries was noted, and the number of deliveries marked by interlocking and collision of fetuses. The mode of delivery, reason for C/S, and sources of perinatal mortality were noted. Only 43 deliveries were Br(a)/Vtx(b) (7.9% of all twins) and of these only 14 (32.6%) were delivered vaginally. One case of interlocking (2.3% of all Br(a)/Vtx(b) pairs) and five cases of collision of twins (ie competition for entry into the pelvic inlet with obstruction) were noted. All cases mentioned were delivered by C/S. No perinatal mortality resulted from these cases. In recent years the trend has been for greater use of C/S and ultrasound in managing twin deliveries. In this study 67.4% of Br(a)/Vtx(b) twins were delivered by C/S. Although there are fewer vaginal deliveries of these twins and the rate for interlocking (2.3%; 95% CI: 0.06-12.3%) for the whole group has remained about the same, we found the rate in those twins allowed vaginal delivery was 6.7% (95% CI: 0.2-31.9%). The presentation at greatest risk for entanglement was found to be Br(a)/Vtx(b).

Cesarean section for the second twin.

OBJECTIVE: To determine the reasons for cesarean section (C/S) for the second twin following vaginal delivery of twin A, and causes of neonatal death (NND). STUDY DESIGN: Five hundred forty-one twin deliveries were studied retrospectively from 1987 to 1995. Deliveries were fractionated by fetal presentation for twin A and twin B (i.e., vertex A/vertex B, vertex A/breech B, vertex A/transverse lie B, breech A/vertex B, ... transverse lie A/transverse lie B, yielding nine groups). The variation in C/S rate was noted with respect to fetal presentation for twin A and twin B. The indications for C/S of twin B following successful delivery of twin A were noted, as were sources of NND. RESULTS: The C/S rate rose as the presentation of twin A changed from vertex to breech to transverse lie (13.8%, 67.4% and 100%, respectively, for twin B vertex). A similar trend was found for twin B as breech or transverse lie. The overall C/S rate was 34.6%, and of these, 27 were solely to deliver twin B, for 5.0% of all twins and 14.4% of all C/S. The risk for C/S for the second twin was increased 7.6x if twin A was vertex rather than breech. The prime reasons for C/S of twin B varied with the presentation of twin B. Cord prolapse of twin B was most common for vertex A/vertex B (7/8), whereas inability to turn and extract twin B was most common for vertex A/transverse lie B (back down) (9/14). The other two reasons for C/S were fetal distress of twin B (two) and abruption (two). Two cases of neonatal demise resulted from asphyxia: one due to cord prolapse (vertex A/vertex B), and one due to traumatic internal version and extraction (vertex A/transverse lie B). CONCLUSION: C/S delivery for the second twin is most common in vertex twin A pairs since it is these that are generally allowed to be delivered vaginally until an untoward event complicates the delivery of twin B. Hence, 96% of these C/S deliveries occur when twin A is vertex. The "safest" configuration (vertex A/vertex B) results in 26% of cases delivered by C/S for cord prolapse of twin B, while 52% of C/S deliveries are for change in presentation of twin B, with inability to perform internal podalic version and extraction. These two indications accounted for 81.5% of C/S and all the neonatal deaths.

Magnetic resonance imaging of peripartum rupture of the symphysis pubis.

BACKGROUND: Peripartum pubic symphyseal rupture is diagnosed on clinical grounds. Although the diagnosis may be supported by radiography, which shows diastasis of the pubic rami, magnetic resonance imaging (MRI) can visualize the nature of the soft tissue injury. CASE: Two puerperas thought clinically to have pubic symphyseal rupture were imaged with MRI. In addition to diastasis of the pubic rami, clefts were seen within the symphyseal cartilage, extending the entire breadth of the joint. The clefts were filled with fluid or hemorrhage, seen in T1- and T2-weighted images. The fluid was encapsulated within the joint by the surrounding ligaments. Four control normal puerperas, who had vaginal deliveries but were asymptomatic, showed none of the aforementioned findings. CONCLUSION: MRI can visualize the soft tissue injury seen in pubic symphyseal rupture and may be used to confirm the clinical diagnosis.

Vaginal hysterectomy by uterine morcellation: an efficient, non-morbid procedure.

OBJECTIVE: To evaluate the relationship between uterine size and a possible increase in operative morbidity and procedure failure rates in women undergoing total vaginal hysterectomy. METHODS: A retrospective chart analysis of all hysterectomies performed for histologically confirmed leiomyomata was completed. A total of 128 cases qualified. Patients were stratified into three groups: group I, patients undergoing vaginal hysterectomy with a uterine weight of 300 g or greater but less than 1000 g; group II, patients undergoing vaginal hysterectomy with a uterine weight of 100-299 g; and group III, patients undergoing abdominal hysterectomy with a uterine weight of 100-1000 g. The variables evaluated included the following: length of hospital stay, operative time, estimated blood loss, and operative complications. Data regarding failed vaginal hysterectomy requiring an abdominal approach were also obtained. RESULTS: Both vaginal hysterectomy groups had a significantly reduced length of stay compared with the total abdominal hysterectomy group. There was no significant difference in mean estimated blood loss between groups I and III. Similarly, there were no significant differences in complication rates among the three groups. Group I had an 84% (31 of 37) success rate versus 95% (40 of 42) for group II (not statistically significant). There were no significant differences in the mean uterine weight, estimated blood loss, and complication rate in unsuccessful versus successful vaginal hysterectomies. The estimated blood loss was significantly higher for unsuccessful vaginal hysterectomy. CONCLUSION: Uterine size alone is not an absolute contra-indication to vaginal hysterectomy. Large uterine size (greater than 300 g) was not related to a significant increase in failed vaginal hysterectomy. Conversely, failed vaginal hysterectomy was not size-dependent. Furthermore, there is no additional operative morbidity when vaginal hysterectomy is converted to a total abdominal hysterectomy because of a technical inability to complete the surgery vaginally.

Imaging of pregnancy-related complications.

Thirty-six cases of pregnancy-related complications were studied with plain radiography, ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging alone or in combination. Among the complications diagnosed with these various techniques were venous thromboembolic disorders, deep vein thrombosis, ovarian vein thrombosis, endometritis and pyometra, HELLP syndrome (hemolysis, elevated liver enzyme levels, and low platelet counts), hepatic hematoma and rupture, fatty liver, uterine rupture, various hematomas and a foreign body, tubo-ovarian abscess, cerebral venous thrombosis, cerebral ischemia, and cerebral edema. Prompt detection and appropriate management of many of these complications could result in decreased maternal and fetal mortality and morbidity. Although US should be considered first because it can be performed bedside, does not require use of ionizing radiation, and is cost-effective, CT is superior in demonstrating the extent of the abnormality and MR imaging is best for detection of neurologic complications of pregnancy. The radiologist should select the best available method and tailor the examination according to the presumptive clinical diagnosis and the individual problem to be solved.

Cerclage, tocolysis and antibiotics for premature rupture of the membranes in previable twins. A case report.

Premature rupture of the membranes developed in a pregnancy with a previable twin gestation. In the absence of infection, aggressive management of premature rupture of the membranes, consisting of cerclage, tocolysis and antibiotics, salvaged the second twin by delaying delivery for five weeks.

Serum magnesium levels in pregnancy and preterm labor.

Pregnancy is marked by a state of hypomagnesemia. The serum magnesium level shows no gestational dependence (mean, 1.79 +/- 0.44 mg/dl) until 33 weeks, at which point it continuously declines. Serum magnesium is not depressed further with the onset of labor at term. Patients in preterm labor have a significantly depressed serum magnesium level (mean, 1.60 +/- 0.46 mg/dl; 21 to 33 weeks; p less than 0.0005). This level was not dependent on whether the etiology for the preterm labor was premature rupture of the membranes (PROM), twin gestation, abruption, placenta previa with bleeding, or chorioamnionitis. With PROM, the serum magnesium level was not depressed prior to the initiation of preterm labor. However, observation of hypomagnesemia for this and other etiologies just prior to the initiation of preterm labor were not available. Possible mechanisms by which hypomagnesemia induces uterine irritability are explored, including inhibition of adenyl cyclase with resultant increase in cytoplasmic calcium levels. Patients with diabetes mellitus appeared to have slightly reduced serum magnesium levels, but the results were not statistically significant. Magnesium levels in patients with preeclampsia were not significantly different from controls. Hypomagnesemia (magnesium 1.4 mg/dl or less) may be a marker for true preterm labor.

Use of thiazide diuretics to reduce the hypercalciuria of hypoparathyroidism during pregnancy.

A pregnant patient with idiopathic hypoparathyroidism is presented. Her hypomagnesemic hypocalcemia was unresponsive to conventional therapy, or magnesium supplementation. Sodium restriction with thiazide therapy successfully reduced her renal calcium wastage to control her symptoms and raise her serum calcium levels.

Can acetaminophen excess result in maternal and fetal toxicity?

This is the third case reported of maternal acetaminophen overdose during pregnancy. Such overdose may be associated with maternal liver toxicity. Fetal hepatotoxicity may be seen in association with maternal hepatotoxicity. As a result, the infant's blood coagulation times may be prolonged, and intracranial hemorrhage at delivery is a concern. Our case shows such a complication after chronic exposure to acetaminophen.

Pelvic ganglioneuroma during pregnancy. A case report.

Ganglioneuroma of the pelvis occurred in a pregnant woman. The tumor arose from the sympathetic chain. Obstruction of a vaginal delivery was considered likely, and cesarean delivery was elected. This is the first report of this tumor in pregnancy. Management of such tumors in women who desire further childbearing should be conservative due to the low malignant potential and slow growth of the neoplasm. On completion of childbearing, excision is the treatment of choice.