Hemothorax after Lupron therapy of a patient with pleural endometriosis--a case report and literature review.

BACKGROUND: Pulmonary endometrial implants, although uncommon, have been well described in the literature. Symptoms occur with menses and may include recurrent pleuritic chest pain, pneumothorax, hemoptysis, or hemothorax. Exacerbation of pulmonary symptoms by Lupron therapy has not been previously described. CASE REPORT: A 38-year-old African-American female with known endometriosis but no history of pulmonary disease was evaluated for a 2-year history of severe dysmenorrhea. A trial of hormonal suppression was unsuccessful, and she was offered Lupron therapy. Three weeks after its initiation, and shortly after the onset of menses, she came to the emergency room with pleuritic chest pain and shortness of breath and was found to have a right-sided hemopneumothorax. Thoracentesis treatment was successful in eliminating this symptom. CONCLUSION: Although pulmonary endometriosis is rare, physicians should be aware that Lupron therapy can exacerbate pulmonary symptoms during the initial phase of therapy.

Asymptomatic endometrial carcinoma after endometrial ablation.

Endometrial ablation has been recently introduced as a surgical alternative to hysterectomy for the treatment of dysfunctional uterine bleeding. The procedure itself is reasonably safe. However, if occult endometrial cancer is present before the procedure and is not detected, it may be more difficult to diagnose later. Endometrial cancer may also arise de novo from missed endometrial tissue. Two cases of endometrial cancer following endometrial ablation have been reported, but its overall incidence is unknown. A 58-year-old woman was treated with endometrial ablation for dysfunctional uterine bleeding. Three years later she underwent hysterectomy and Marshall-Marchetti-Krantz procedure for urinary incontinence; incidental, asymptomatic endometrial adenocarcinoma was discovered. The final pathology was grade 1 adenocarcinoma, invading more than 50% of the myometrium (FIGO stage Ic). Endometrial cancer may occur following endometrial ablation and it may be asymptomatic. Careful patient selection and close follow-up are essential.

Incisional bowel herniations after operative laparoscopy: a series of nineteen cases and review of the literature.

OBJECTIVES: The objectives of this report were (1) to identify all cases of incisional bowel herniations noted after operative laparoscopy in 11 participating institutions and (2) to report the clinical details of such patients. STUDY DESIGN: A retrospective case review was performed. RESULTS: Nineteen cases of incisional bowel herniation were identified. The average age of the patients was 50.5 years. Initial laparoscopic procedures varied and included laparoscopically assisted vaginal hysterectomy (six patients), laparoscopically assisted vaginal hysterectomy with lymphadenectomy (five patients), oophorectomy (two patients), adhesiolysis (two patients), myomectomy (two patients), lymphadenectomy alone (one patient), and ovarian cystectomy (one patient). The average time to reoperation was 8.5 days. CONCLUSIONS: Incisional bowel herniation is a serious complication of operative laparoscopy. Herniations occur through ports > or = mm in size at both umbilical and extraumbilical sites. New techniques are needed to avoid this serious complication.

Rabbit fallopian tube reanastomosis using a microvascular stapling device.

The 3M Precise Microvascular Anastomotic System (MAS), a microvascular stapling device, was compared with microsurgery for the reanastomosis of rabbit fallopian tubes. Differences in operative time, tubal patency, adhesion formation, and fertility rate were studied in 18 rabbits. Only 17% of tubes repaired by MAS were subsequently patent by chromopertubation, compared with 72% with microsurgery. Mean nidation indices were 0.05 for MAS and 0.22 for microsurgery. Sixty-one percent of adnexae repaired by MAS were adhesion stage I, whereas 83% of microsurgically repaired adnexae were stage I. Mean operative time was 28.2 min for MAS vs 21.6 min for microsurgery. Only the differences in patency rate and operative time were statistically significant, but the trends suggest that fallopian tube reanastomosis by MAS offers no advantage over conventional microsurgical technique.

Vesicovaginal fistula.

Vesicovaginal fistulas are often the result of obstetric trauma in third world countries and gynecologic surgery in developed countries. Improvement in obstetric care and the increased use of cesarean section has resulted in a decrease in the incidence of obstetric fistulas in the United States. However, the incidence of fistulas as a result of surgery has remained relatively unchanged for years. Most postoperative fistulas occur under very normal operative circumstances. The keys to prevention of postoperative fistulas are wide dissection of the bladder from the cervix and vagina in the correct plane during surgery and recognition of bladder damage intraoperatively with appropriate repair. More than 90 percent of vesicovaginal fistulas can and should be repaired vaginally. The procedures available for repair are the flap splitting and Latzko techniques. On occasion an abdominal approach is indicated, particularly for vesicouterine fistulas. Requirements for successful repair include adequate surgical exposure, wide mobilization of the vagina, nonexcision of the fistula tract, tension-free closure of the bladder, and grafting when indicated.

CA-125 in peritoneal fluid from patients with nonmalignant gynecologic disorders.

To assess the diagnostic value of measuring CA-125 levels in peritoneal fluid from women with nonmalignant gynecologic disorders, we determined CA-125 levels in peritoneal fluid and in serum collected simultaneously from 46 women undergoing gynecologic surgery. Patients with benign ovarian disease, non-ovarian gynecologic pathology and severe endometriosis had, on average, higher CA-125 levels in peritoneal fluid than did patients with a normal pelvis and those with mild endometriosis. There was no obvious correlation between peritoneal fluid and serum levels of CA-125. Our data show that (1) measurement of serum CA-125 levels is not useful for distinguishing between different benign gynecologic disorders, and (2) levels of CA-125 in peritoneal fluid in benign gynecologic disorders are comparable to the reported lower range of levels observed in women with intraperitoneal malignancies.

Adenoma malignum presenting as urinary incontinence.

A woman diagnosed with adenoma malignum (minimal-deviation adenocarcinoma) of the cervix with an ovarian metastasis is described. The highly malignant potential and diagnostic difficulty makes recognition of this neoplasm and the use of recent techniques to assist in diagnosis important to the practicing gynecologist.

Biodistribution, with high uptake by the reproductive tract, of an intraperitoneally infused radiohalogenated steroidal estrogen-receptor ligand.

We infused [123I]16 alpha-(123I)-iodo-estradiol ([123I]E2) intraperitoneally (i.p.) into swine to study its biodistribution and to explore the i.p. use of radiohalogenated steroid estrogen-receptor (ER) ligands as a potential option for diagnosing and treating intra-abdominal, retroperitoneal, and distant sites of advanced ER-rich malignancies. Fifty to 80% of the radiolabel was absorbed from the peritoneal cavity within 30 minutes, and 30 to 50% of the infused radiolabel was excreted in the urine within 2 hr. The rate of biliary clearance was maximal within 25 minutes. At 3 hr, the ER-rich reproductive tract had greater than 63 times the concentration of radiolabel in blood; the former was blocked by non-labeled competitors for ER. Uptake by non-ER-rich tissues, compared to blood, ranged from 0.7:1 (heart and lungs) to 16:1 (spleen); the omentum, however, exhibited a concentration as high as 64:1, which was not blocked by non-labeled ER ligands. Uptake by ER-rich target tissue remained high when charcoal was used to prevent reabsorption of radiolabel from the digestive tract after its biliary excretion, and when the products of biliary excretion were removed by catheterization of the common bile duct. Neither charcoal nor exteriorization of bile appeared to affect urinary clearance of the radiolabel over the time course of the experiments. Taken together with the recent development of syntheses that yield radiohalogenated sex steroid receptor ligands of high specific activity, our findings are encouraging for the potential application of radiolabeled ligands as i.p. administered pharmaceuticals. The advantage of the i.p. route is that it provides direct uptake of the pharmaceutical by free-floating clusters and individual cancer cells in ascitic fluid, as well as delivery via the circulation to vascularized intra- and/or extraperitoneal metastases.

Comparison of chemiluminescent DNA probe to cell culture for the screening of Chlamydia trachomatis in a gynecology clinic population.

Two hundred ninety-five endocervical swab specimens were obtained from patients presenting to a gynecology clinic in order to compare a nonradioactive chemiluminescent DNA probe with cell culture for detection of Chlamydia trachomatis. Discrepancies between cell culture and DNA probe were resolved by retesting and reculturing samples. In a population with a 10.8% prevalence, the corrected sensitivity, specificity, positive predictive value, and negative predictive value for the DNA probe were 80.6, 95.8, 71.4, and 97.3%, respectively. These results compare favorably to other non-culture methods such as direct fluorescent antibody and enzyme immunoassay tests for the detection of C trachomatis in populations with similar prevalence rates.

Unusual urethral diverticulum lined by colonic epithelium with Paneth cell metaplasia.

Diverticulum of the female urethra has an incidence of 1.4% to 4.7%. It is generally agreed that the majority of these are acquired lesions. There is, however, evidence that some are of congenital origin. Documented cases of diverticula with colon-type tissue are rare. A case of urethral diverticulum with colonic epithelium and features of Paneth cell metaplasia is presented. Causes, symptoms, diagnostic methods, and treatment are discussed.

Abortion hysterectomy for gynecologic pathology.

Abortion hysterectomy has been discredited as the method of performing simultaneous pregnancy termination and elective sterilization for women with undesired pregnancies who simultaneously wish to end their child-bearing potential. The procedure continues to be advocated, however, for cases in which there is an underlying gynecologic pathologic condition. The morbidity of this procedure has not been directly compared with that for indicated hysterectomy in nonpregnant women. Between January 1976 and January 1987, 50 patients underwent abortion hysterectomy at The University of Chicago. The morbidity and mortality rates of these patients were compared with those of 50 premenopausal nonpregnant women undergoing abdominal hysterectomy for gynecologic pathologic status. There was no statistically significant different between the groups in the duration of surgery, estimated blood loss, or infectious morbidity. No operative site infections or other adverse sequelae were noted at the time of final postoperative examination. These data support the relative safety of abdominal abortion hysterectomy for women with undesired pregnancy in whom hysterectomy is indicated for an underlying gynecologic pathologic condition.

Use of expanded spectrum cephalosporins for the treatment of obstetrical and gynecological infections.

The antianaerobic cephalosporins, cefoxitin, ceftizoxime, cefotetan, and moxalactam, are compared in the treatment of obstetric/gynecologic infections associated with mixed aerobic and anaerobic pathogens. All of the antianaerobic cephalosporins have demonstrated similar efficacy in the treatment of mixed female genital tract infections. Thus, antibiotic selection requires a comparison of the antimicrobial activity, pharmacokinetics, adverse effects, and overall cost of therapy. All agents have excellent activity against the Gram-negative bacilli, and recent comparative data show that ceftizoxime is highly active against the Bacteroides sp. Dosing frequency and drug toxicity contribute to the overall cost of drug therapy. Cefoxitin is the only antianaerobic cephalosporin that cannot be dosed on a 12-hour basis. Ceftizoxime and cefoxitin, unlike moxalactam and cefotetan, do not contain the MTT group that has been associated with bleeding abnormalities. Substantial cost savings can be realized by using an antianaerobic cephalosporin administered every 12 hours. The experience at the Chicago Lying-in Hospital is presented.

External cephalic version with tocolysis: factors associated with success.

Data were collected prospectively on factors that might affect the success or failure of external cephalic version, using a protocol including fetal monitoring, ultrasound, tocolysis, and external version after 37 weeks' gestation. Patients were accepted into the protocol whether or not risk factors for failure were present. Sixty-seven patients were admitted to the study and 40 (60%) underwent successful version. Using chi 2 analysis, we found that failure of external version was significantly associated with obesity, descent of the breech into the pelvis, decreased fluid, and fetal back positioned posteriorly. Thirteen women were in active labor; this had no effect on the success rate providing that descent had not occurred. Two factors, descent of the breech into the pelvis and posterior position of the fetal back, had an independent effect on success after controlling for other variables.

A comparison of cefonicid and cefoxitin for preventing infections after vaginal hysterectomy.

One hundred women who underwent vaginal hysterectomy were randomly and prospectively divided into two study groups, one to receive a single, 1-g preoperative dose of cefonicid and the other to receive 2 g of cefoxitin preoperatively and postoperatively for a total of four doses. There were no differences between the two groups in the rates of febrile morbidity, urinary tract infection, serious infection, noninfectious morbidity or duration of hospitalization. Both cefonicid and cefoxitin were equally effective in preventing postoperative infectious morbidity and demonstrated little difference in side effects. The single-dose regimen of cefonicid provides the advantages of decreased cost and prolonged therapeutic tissue levels when compared to cefoxitin. Perioperative antimicrobial prophylaxis with this single-dose cephalosporin provides a cost-effective regimen that is both safe and prophylactically effective.

Pelvic inflammatory disease. Decision making in the pharmacy and therapeutics committee.

In today's environment of cost containment, the pharmacy and therapeutics committee plays an increasingly important role in determining the availability of antibiotics for the treatment of specific diseases. However, if the drug is not optimal for treatment and sequelae of a disease process develop, no true savings are gained. The goal of treating pelvic inflammatory disease should not be just reduction of morbidity but preservation of fertility and reduction of surgery after therapy. Multiple factors must be considered when choosing antibiotic therapy for pelvic inflammatory disease, including the spectrum of pathogenic organisms involved, the efficacy of the antibiotic chosen, the safety profile of the antibiotic, the pattern of resistance to the antibiotic in both the hospital and the community, the cost of administering the antibiotic and management of its side effects. This paper reviews the concepts used at the Chicago Lying-in Hospital, University of Chicago, in choosing the primary antibiotic, ceftizoxime, for the treatment of pelvic inflammatory disease. This antibiotic offers a broad spectrum of antimicrobial activity with little resistance, few side effects, evidence of penetration into the infected tissues and prolonged dosing intervals, which allow substantial cost savings as well as efficacious treatment of acute pelvic inflammatory disease.

Surgical approaches to pelvic infections in women.

Pelvic abscess is a complication of gynecologic disease or obstetric surgery. Tuboovarian complex is differentiated from abscesses because of the absence of a true abscess wall; treatment of a tuboovarian complex is conservative. The diagnosis of tuboovarian complex is made by history, pelvic examination and ultrasonography. Tuboovarian abscesses (TOAs) are sequelae of surgical procedures. Both conventional and novel surgical techniques can be used to manage them. Pelvic thrombophlebitis and ovarian vein thrombosis are late complications of pelvic infections that may be associated with significant morbidity and mortality.

Overview of therapeutic and prophylactic antibiotics in obstetrics and gynecology.

Infection in the obstetrics-gynecology patient remains an important source of concern. Advances in the identification of pathogenic organisms have led to improvements in the diagnosis of pelvic infections. Important considerations in the selection of antibiotics for established infections include prior hospitalization status, the size of the bacterial inoculum causing the infection, the etiologic organisms and, in the case of prophylaxis, the type of operative procedure. The antibiotic must also be cost effective.

Use of C-reactive protein to predict the outcome of medical management of tuboovarian abscesses.

Medical management of tuboovarian abscesses (TOAs) has been shown to be successful. However, the ability to predict which patients with TOA would respond to antibiotic therapy could shorten the hospital stay and decrease treatment costs. C-reactive protein (CRP), an acute-phase-reactant protein with a short half-life, was investigated as a possible predictor of response by TOA patients to medical therapy. Twenty-two patients with TOAs were admitted prospectively into this study, which included daily quantitative determinations of CRP. The patients had either resolution of the mass and symptoms (responders), increased evidence of systemic sepsis and acute peritonitis requiring surgery (failures) or continuation of the tender adnexal mass without evidence of peritoneal irritation (persisters). Twelve patients classified as responders showed a continued daily decrease in quantitative CRP levels of at least 20% per day below the previous day's value until the return to normal levels. The five failures showed a progressive rise in CRP levels as well as evidence of systemic sepsis. Persisters showed an initial decrease in the CRP level followed by a leveling off of the value to a decrease of less than 20% per day. The rate at which daily CRP determinations decline may be a useful predictor of the response to antibiotic therapy.

Tumors originating in supernumerary ovaries. A report of two cases.

The supernumerary ovary is a rare gynecologic anomaly; 13 cases have been reported on since 1890. Three were associated with tumors arising in the ectopic ovarian tissue. We encountered two cases of benign neoplasms discovered to have originated in supernumerary ovaries.

Retrograde dissection of the adnexa in residual ovary syndrome.

Injuries to the ureter in the course of gynecologic procedures can occur frequently. The usual histologic signs and symptoms of peri-oophoritis, adhesion and distorted anatomy encountered with residual ovaries make their ablation hazardous to the surrounding structures and the ureter in particular. A method is described and illustrated to facilitate surgical extirpation and render the procedure safe.