Endometrial stripe thickness in tubal and intrauterine pregnancies.

OBJECTIVE: To evaluate endometrial stripe thickness (EST) among patients with tubal pregnancy (TP) and intrauterine pregnancy (IUP). DESIGN: Historical cohort. SETTING: City hospital. PATIENT(S): Ninety-four women suspected to have TP. INTERVENTION(S): Serum betaHCG and sonographic EST measurements. MAIN OUTCOME MEASURE(S): Comparison of age, gestational age (GA), EST, and log beta HCG. RESULT(S): The two groups of women, 65 with TP and 29 with IUP, had similar mean ages (+/-SD) of 28.6 +/- 5.7 and 28.6 +/- 6.1, respectively. The median values of GA in the 2 groups were similar, 46.6 and 44.6 d, respectively. The mean values for EST (+/-SD), adjusted for GA, were significantly different: 9.9 +/- 5.9 mm in the TP group and 12.6 +/- 5.3 mm in the IUP group. The mean values (+/-SD) of log beta HCG in the 2 groups also differed significantly: 6.90 +/- 1.29 and 7.52 +/- 0.97, respectively. No correlation was found between EST and GA or log beta HCG within either group. CONCLUSION(S): The mean EST in women with TP was significantly smaller than in women with IUP. The wide range of EST values and their overlap precludes the utilization of EST as a single feature in the diagnosis of a tubal pregnancy.

Adenomyosis: symptoms, histology, and pregnancy terminations.

OBJECTIVE: To correlate symptoms of uterine adenomyosis with histopathologic features. METHODS: One hundred eleven specimens of uteri and cervices that weighed under 280 g were reevaluated. When adenomyosis was identified, assessment included depth of adenomyotic foci, graded as deep (above 80%), intermediate (40-80%), and superficial (under 40%), and number of adenomyotic foci. Clinical data were collected from patient records. RESULTS: Specimens were categorized in four groups, 17 with adenomyosis alone, 19 with adenomyosis with leiomyomas, 39 with leiomyomas alone, and 36 with neither. Among women with adenomyosis alone, 58.8% had pregnancy terminations and 47.4% of women with adenomyosis and leiomyomas had terminations, compared with 20.5% of women with leiomyomas alone (P <.01) and 22.2% in those with neither (P <.01). The number of foci correlated significantly with depth within the myometrium in specimens with adenomyosis alone (r =.46, P =.05) or combined with leiomyomas (r =.66, P <.001). The median number of foci associated with dysmenorrhea was 10 compared with 4.5 without it (P <.003); in menorrhagia the respective median numbers were 7 and 7 (P =.25). Menorrhagia and dysmenorrhea presented in 36.8% and 77.8% of deep, compared with 13.3% (P <.001) and 12.5% (P <.001) of intermediate depths, respectively. Superficial depth was not associated with menorrhagia or dysmenorrhea. CONCLUSION: Pregnancy termination might affect the pathogenesis of adenomyosis. The number of foci and their myometrial depths correlated to each other and to dysmenorrhea, but only myometrial depth correlated to menorrhagia.

Pelvic inflammatory disease after tubal sterilization: a review.

Exceptions ot the common notion that tubal occlusion protects from recurrent pelvic inflammatory disease (PID) do exist. Since 1975, 71 cases of salpingitis and 38 tubo-ovarian abscesses (TOA) in sterilized women have been published. The majority of cases of salpingitis after previous tubal occlusion (SPOT) developed more than a year after either laparoscopic or laparotomy sterilization procedures. For tubo-ovarian abscess after previous tubal occlusion (TOAPOT), this time interval ranged from several weeks to almost two decades. Most cases of salpingitis showed inflammation of both tubal segments. When only one segment was involved, it was generally the proximal segment. The appearance of the TOAPOT at the time of surgery was typical to TOA. The symptoms of salpingitis were not different from symptoms in any other case of PID, and those associated with TOAPOT were typical of TOA. Laboratory findings included leucocytosis and growth of Neisseria gonorrohoea and Chlamydia trachomatis from the cervix, the infected tube, and the peritoneal fluid. Pus cultures obtained from cases of TOAPOT grew mixed or single organisms. Detailed histopathologic studies in tubal specimens after the failure of an occlusion procedure are available from cases with no infection. They have demonstrated distortion, loss of musculature, and loss of lumen configuration, all of which may have been the result of compromised blood supply to the tube. These findings may be extrapolated to cases of SPOT and TOAPOT, assuming similar changes may be present before the development of infection. The mechanisms by which infection may develop in previously occluded tubes are divided into three groups: The first group consists of situations where there is persistence of free passage between the proximal and distal portions of the tube. These include toboperitoneal fistula, spontaneous anastomosis at the occlusion site, recanalization of the occluded site, incomplete tubal occlusion due to a faulty surgical technique or rupture of the weakened tubal wall. The second group consists of infections initiated by the surgical procedure itself, such as introduction of pathogens at surgery, exacerbation of chronic PID, and ascending infection secondary to surgical manipulation. In the third group, the infection is initiated systemically by hematogeneous spread, lymphatic spread, or change in immunologic status.

Pyomyoma after uterine instrumentation. A case report.

BACKGROUND: Since 1945, only 10 cases of pyomyoma have been described in the literature. Four were related to pregnancy but none to elective abortion or uterine instrumentation. CASE: A 32-year-old woman was admitted to the hospital with a history of lower abdominal pain, nausea, vomiting and low grade fever with a past medical history significant for uterine leiomyomata and a second-trimester elective abortion 10 weeks prior to admission. Pelvic sonography demonstrated an enlarged uterus with a mass consisting of cystic and solid components. Uterine curettage revealed blood clots and scanty endometrial tissue. After no improvement following antibiotic therapy and nondiagnostic uterine curettage, an exploratory laparotomy was performed. It revealed peritonitis with multiple pyomyomas draining purulent material. CONCLUSION: Although rarely reported, pyomyoma should be considered in the setting of a recent history of uterine instrumentation, signs of infection and a uterine myoma.

The enlarged uterus. Relation of uterine size to symptoms and histopathologic findings.

OBJECTIVE: To determine the association between the weight of an enlarged uterus and it clinical and histopathologic pictures. STUDY DESIGN: Forty-three patients with symptoms related to uterine enlargement of < 280 g who underwent total abdominal hysterectomy were compared to 73 patients with uteri weighing > or = 280 g. RESULTS: The mean age, parity, duration of disease and incident of past myomectomy were not different. All symptoms except low abdominal pressure were similarly distributed. The incidences of leiomyomata combined with adenomyosis were similar. A leiomyoma alone was more frequent in patients with a uterus of > or = 280 g (P < .001) while adenomyosis alone was more commonly associated with a smaller uterus (P < .001). CONCLUSION: Symptoms were not related to uterine weight except for low abdominal pressure, which was absent from smaller uteri. The diagnosis of leiomyomata was confirmed in all uteri > or = 280 g and in 62.8% of smaller uteri. Adenomyosis alone was present in smaller uteri only.

The myomatous erythrocytosis syndrome: a review.

OBJECTIVE: To review the literature regarding the association of erythrocytosis and uterine myomas, because of the lack of anemia in many women with menorrhagia and fibroids. DATA SOURCES: We searched the MEDLINE English-language data base and reference lists to find articles referring to the myomatous erythrocytosis syndrome. METHODS OF STUDY SELECTION: All case reports of the myomatous erythrocytosis syndrome were included in this review. DATA EXTRACTION AND SYNTHESIS: Symptoms, laboratory studies, histopathologic findings, and possible etiologies for each of 31 cases were extracted. The symptoms described were most commonly related to the presence of a myomatous uterus with occasional manifestations of erythrocytosis. A routine complete blood count was used to diagnose erythrocytosis in all cases. Evaluation of the bone marrow, blood volume, erythrocyte life span, and erythropoietin activity have all been used to help confirm the diagnosis. The histopathologic findings were similar to those commonly seen in myomas. Possible factors in the etiology of this syndrome include: vascular shunts within the myoma, large uterine size, myoma site, change in red cell life span, alteration in erythropoietin production by the kidney, and autonomous secretion of erythropoietin or an erythropoietin-like substrate by the myomatous uterus. CONCLUSION: Elevated levels of erythropoietin accompany the myomatous erythrocytosis syndrome. All myomas may alter erythropoietin production, causing varying degrees of erythrocytosis, which could explain the lack of anticipated anemia despite the presence of menorrhagia. Use of the currently available, highly sensitive radioimmunoassay for erythropoietin should help in our understanding of the role uterine myomas play in erythropoiesis.