Inpatients with menometrorrhagia: etiologies, treatments, and outcomes.

BACKGROUND: Abnormal uterine bleeding is commonly seen in emergency departments and gynecologic clinics. In a southern, inner-city hospital, a seemingly large number of women are admitted with life-threatening anemia of benign gynecologic origin. We examine its causes, review treatments and outcomes, and discuss optimization of therapy. METHODS: A chart review of patients requiring emergency admission for anemia of gynecologic origin yielded 48 patients from July 1, 1994, through April 30, 1998. Patients with known or obvious gynecologic malignancies were excluded. RESULTS: Of 48 patients, 69% were black. Mean age was 41 years. Sixty-three percent had had no previous treatment. Almost one fourth had a history of mental illness and/or substance abuse. Two thirds had uterine leiomyomata. Most (81%) required transfusion; 25% had surgery during initial hospitalization. Of those who did not receive definitive therapy (hysterectomy), 13% were subsequently readmitted for active bleeding and/or symptomatic anemia. CONCLUSIONS: Our study patients were admitted with potentially life-threatening anemia. All were adequately resuscitated using a variety of measures, including high-dose estrogen therapy and transfusion. Optimal therapy for those requiring emergency treatment should include hormonal therapy and transfusion if necessary, early surgical intervention unless otherwise contraindicated, and close follow-up until definitive therapy is achieved.

Before Kubler-Ross: lessons about grief from the book of Job.

Medicine is as old as the human species, and medical literature is among the earliest writing. Current research is of great help in identifying new interventions, but a great deal of the art of medicine is showcased in ancient works. The 20th century saw a plethora of books, articles, and monographs on the subjects of grief, death and dying, and suffering, but none of these has provided greater insight than the biblical book of Job. Excerpts from Job illustrate both the nature of grief and appropriate intervention when it is confronted.

Postoperative febrile morbidity in the benign gynecologic patient. Identification and management.

OBJECTIVE: To identify a useful temperature threshold and occurrence frequency that might represent genuine morbidity and to identify elements of the fever evaluation that were most useful in discriminating ill patients from those with transient and inconsequential temperature elevations. STUDY DESIGN: A retrospective chart review of postoperative gynecologic patients was undertaken for a one-year period. Data regarding temperatures, frequencies and workup were collected, as were descriptive data regarding the patient and case. RESULTS: Some of the previously reported associations, such as menopausal status and insurance coverage, failed to materialize as associated with temperature increases in this study. Other associations, such as blood loss and length of surgery, were confirmed. The commonly used threshold for "fever" of 38 degrees C was not as discriminatory as a threshold of 38.3 degrees C. Frequency, as well as absolute degree of elevation, did appear to relate to level of morbidity. The most useful studies in assessing temperature elevations were the white blood cell count and chest radiography. CONCLUSION: Although prospective evaluation is difficult and much work remains to be done, our data are sufficiently compelling to suggest a minimum temperature and frequency at which the otherwise-well-appearing postoperative patient should be assessed for infection. We also found the yield sufficient to make routine ordering useful only in the case of the white blood cell count and possibly the chest radiograph. Other tests should be reserved for use if directed by the physical examination or patient history.

Predicting style-of-care preferences of obstetric patients. Medical vs. midwifery model.

OBJECTIVE: To identify patient populations preferring more medically oriented vs. more midwifery-oriented medical care in order to provide an institutional resourcing model. STUDY DESIGN: Questionnaires were distributed to pregnant women regarding possible concerns related to style of care and length of hospitalization for obstetric delivery. Responses from the 135 usable surveys were analyzed by cluster analysis to search for common demographic or ideologic concerns that might distinguish two or more groups of patients according to style-of-care preferences. RESULTS: Four clusters were identified and categorized based on the initial hypothesis as midwifery preference, medical preference, passive and wanting both. Cluster membership could not be predicted by any demographic or historical variable studied, and the most significant style-of-care discriminator was related to preferred length of postpartum hospital stay, with 80% of the midwifery preference cluster desiring a short (< 24 hour) stay as compared to a single patient (2%) in the medical preference cluster. CONCLUSION: While obstetric care is often offered in distinctly stylized packages according to the training of the provider, our study suggests that patient preferences are much more complex and may contain many elements of both midwifery and medical styles of care. Broadening access to obstetric care will involve moving from our own preconceived notions of appropriate packaging into a patient-based and multi-option setting for delivery of these services.

Early postpartum discharge versus traditional length of stay: patient preferences.

BACKGROUND: Despite a vast body of literature on postpartum safety issues, little has been written about patients' preferences for hospitalized versus home-based support and reasons for those choices. METHODS: A questionnaire was offered to obstetric patients at a prenatal class. Data were analyzed using chi-square analysis and logit modeling, searching for factors accounting for the patient's choice of discharge plan. RESULTS: Neither demographic nor style-of-care variables affected patient choice significantly. Personal issues like comfort with child care were highly correlated, both individually and as a group, with choice of length of stay. Less than 25% of the group studied expressed a desire for early discharge. CONCLUSIONS: Women with a high internal locus of control and/or distrust of the medical system expressed a desire for early postpartum discharge. Few women in our study exhibited those qualities; over 75% of those who had a preference wanted a longer period of hospitalization. Although our sample has both negative and positive skews in terms of other available social supports, it is a well-educated and economically well-supported group. We conclude that many women do not believe they would be ready to leave the hospital at less than 24 hours postpartum.

Where have all the young men gone? Keeping men in obstetrics and gynecology.

Some of the fears and myths of the gender-discrimination role-reversal in gynecology are explored. Women entered male-advantaged medicine by acquiring skills traditionally believed to be masculine strengths (such as mathematics, chemistry, and analytical skills); by the same token, men may be able to adapt to the current female-advantaged environment by acquiring some traditionally female skills such as good communication and empathy.

The effect of instituting an elective labor epidural program on the operative delivery rate.

OBJECTIVE: To evaluate labor outcome as well as maternal and neonatal morbidity before and after the initiation of elective labor epidural capability. METHODS: On October 1, 1993, a sudden change in military requirements mandated provision of elective labor epidural capability at our institution. Before this time, epidural provision had been primarily in response to urgent obstetrician requests. Pre-labor and labor characteristics and outcomes were reviewed for the year before this policy change (group 1, n = 373) and for the year after it (group 2, n = 421) in a population of nulliparous patients delivering singleton, vertex fetuses at 36-42 weeks' gestational age. In addition, the group of patients receiving labor epidurals before their ready availability (group 1E, n = 49) was compared with the group receiving them after ready availability (group 2E, n = 247). RESULTS: Maternal labor characteristics showed a slight (10 minutes on average) prolongation of the second stage of labor in group 2. The incidence of diagnosed chorioamnionitis was higher in group 2. Patients receiving epidurals in each time frame were analyzed to identify epidural-related findings, as opposed to findings associated with intrinsically more problematic labors. Epidural-related factors included the slightly prolonged second stage of labor, increased use of oxytocin, and a higher incidence of diagnosed chorioamnionitis. CONCLUSION: Our study demonstrated no increase in the rate of operative deliveries in a population that suddenly received access to on-request labor epidurals. We believe this option should be offered to parturients without making them feel that they must choose between comfort and safety.

Medical care of women deployed during Desert Storm.

The Desert Shield/Desert Storm troop deployment included record numbers of women and highlighted the vacuum of planning and information regarding medical care for women deployed to a theater of war. I review the retrievable literature from that conflict and discuss the data regarding resource management and clinical significance. The literature and my observations as an active-duty female gynecologist are presented to prompt a thorough systemwide evaluation of medical wartime readiness in light of the changing demographics of the military force.

Significance of atypical cervical cytology in pregnancy.

To ascertain the significance of squamous atypia encountered during routine Papanicolaou smear screening in pregnancy, we reviewed our experience with 76 pregnant women seen during a 4-year period. All were evaluated with repeat cytology and colposcopy during pregnancy and again postpartum. Colposcopic examination during pregnancy revealed a normal transformation zone without evidence of intraepithelial neoplasia in 46 women. In six of these women, repeat cytology was interpreted as cervical intraepithelial neoplasia (CIN) grade 1. In 30 women, an abnormal transformation zone was identified--14 with a negative repeat cytology. In five women, the transformation zone was interpreted as compatible with CIN 2 or CIN 3. Colposcopically directed biopsies were performed in 31 women, in all but two postpartum. Of the 76 women, human papilloma virus or CIN was identified on biopsy in 16 women (21%). We propose that an isolated report of atypical squamous cells on cervical cytology obtained at the initial prenatal visit does not warrant colposcopic evaluation during pregnancy, unless a repeat cytology suggests CIN. Repeat cytology and evaluation to exclude infections and inflammatory lesions is appropriate. However, if a subsequent cytology is abnormal, postpartum colposcopy and colposcopically directed biopsies seem appropriate, since the prevalence of HPV or CIN was 21%.

Implications of sampling the implantation site in the endometrial biopsy for infertility.

Endometrial sampling performed during the cycle of conception occurs uncommonly. Less frequent is inclusion of the implantation site in an endometrial specimen obtained late in the luteal phase during the course of an infertility evaluation. From 1984 to 1987 the implantation site was sampled in 3 of 520 (0.6%) endometrial biopsies for infertility. In each instance the pregnancy did not continue. Two women conceived again within a year; both delivered term infants. The third woman had not conceived after ten months of follow-up. When an infertility biopsy results in a diagnosis of intrauterine pregnancy, further evaluation of the patient should be determined by the clinical situation: even in couples with extremely compromised fertility the woman occasionally will become pregnant. The prognosis for that pregnancy may be poor; however, the prognosis for subsequently conceiving and carrying a pregnancy to term is encouraging. This study demonstrated the relative safety of endometrial sampling in the infertile woman. The use of barrier contraception during the cycle of sampling can further decrease the chance of interrupting an intrauterine pregnancy.

Significance of a positive Papanicolaou smear in a well screened population.

Of 35,937 gynecologic cytology specimens obtained from the cervix or vagina at our institution during a three-year period, 18 (0.05%) were reported as malignant; ten of these 18 (56%) positive results were due to carcinoma arising from sites other than the cervix or vagina. The site of the primary lesion was the endometrium in four patients, the ovary in three, the colon in one, and the breast in one; in one patient the site of the primary carcinoma was unknown. In our patient population a a positive Papanicolaou smear was more often indicative of a noncervical than a cervical malignancy. In addition to detecting preinvasive and invasive malignancies of the cervix and/or vagina, an annual cytologic smear may hasten the detection of extravaginal primary carcinomas.

Immunocytochemical evidence for a peroxisomal localization of manganese superoxide dismutase in leaf protoplasts from a higher plant.

The controversial question of the intracellular location of manganese-containing superoxide dismutase in higher plants was examined under a new experimental approach by applying the more rigorous and specific methods of immunocytochemistry to protoplasts isolated fromPisum sativum L. leaves. Manganese superoxide dismutase (EC 1.15.1.1) was purified to homogeneity from 15 kg of leaves ofPisum sativum L. Rabbits were immunized with the mangano enzyme and the antibody specific for pea manganese superoxide dismutase was purified and found not to contain antigenic sites in common with (i) human manganese superoxide dismutase, (ii) iron superoxide dismutase from eitherEscherichia coli or higher plants, or (iii) plant or animal cuprozinc-superoxide dismutase.Pisum sativum L. manganese superoxide dismutase only appears to have antigenic determinants similar to other manganese superoxide dismutases from higher land plants. The antibody to pea Mn-superoxide dismutase was used to locate the enzyme in protoplasts isolated from young pea leaves by indirect immunofluorescence, and by electron microscopy using the unlabelled antibody peroxidase-antiperoxidase method. Results from immunofluorescence showed that chloroplasts were devoid of specific fluorescence which appeared scattered over the cytosolic spaces among chloroplasts, and demonstrate the absence of manganese superoxide dismutase inside chloroplasts. The metalloenzyme was found to be localized only in peroxisomes, whereas mitochondria, the traditionally accepted site for this enzyme in many eukaryotic organisms, did not show any specific staining. The possible subcellular roles of manganese superoxide dismutase inPisum sativum L. leaves are discussed in the light of its peroxisomal location.