Direct laparoscopic entry using a sharp and dull trocar technique.

For direct laparoscopic entry using a sharp and dull trocar technique, the sharp trocar is inserted with a twisting motion under constant pressure, then replaced with a dull trocar when a slight loss of resistance is felt. A slow, gradual entry into the peritoneal cavity is accomplished by twisting the dull trocar under constant pressure. Previous major abdominal or pelvic surgery is not a contraindication to this procedure, and use of these trocars, which can be resterilized for every use, may reduce surgical costs by decreasing the need for disposable trocars. This technique has been used in 1655 patients without complication or failure.

Transient blindness in a preeclamptic patient secondary to cerebral edema.

Blindness associated with a cerebral lesion has been described as cortical blindness. This is the first reported case in which computerized tomography has documented cerebral edema to be the cause of cortical blindness in a preeclamptic patient.

The effect of peritoneal fluid from patients with endometriosis on human sperm function in vitro.

OBJECTIVE: Our purpose was to evaluate the effect of peritoneal fluid from women with endometriosis on sperm motility and function in an in vitro model. STUDY DESIGN: Peritoneal fluid was collected at laparoscopy from patients with and without endometriosis. Human donor sperm was diluted with this fluid, and its effect on sperm function and motility was measured was measured with the zona-free hamster egg sperm penetration assay and computer-assisted semen analysis. RESULTS: The mean number of eggs penetrated by the sperm mixed with peritoneal fluid from patients with endometriosis was significantly fewer than the number penetrated by the sperm mixed with fluid from control patients (22.9 +/- 5.31 vs 44.4 +/- 4.96, p < 0.01, Student t test, n = 20). When evaluated by computer-assisted semen analysis, sperm mixed with peritoneal fluid from patients with endometriosis showed a significant decrease in mean swimming velocity compared with sperm mixed with peritoneal fluid from control patients (54.0 +/- 1.77 vs 59.2 +/- 1.05, p = 0.02, Student t test, n = 20). A significant increase in the fraction of sperm swimming at slower velocities was also found. A trend toward a positive correlation between eggs penetrated and sperm velocity was seen, but statistical significance was not achieved (correlation coefficient 0.4392, p = 0.053, n = 20). CONCLUSION: These data suggest that substances found in the peritoneal fluid of patients with endometriosis could contribute to infertility through impairment of both sperm function and motion kinematics.

Long-term tocolysis with combined intravenous terbutaline and magnesium sulfate: a 10-year study of 1000 patients.

OBJECTIVE: To determine whether long-term intravenous (IV) tocolysis using combined terbutaline and magnesium sulfate is safe and effective. METHODS: One thousand consecutive women in preterm labor were treated with combination IV tocolytic therapy. Terbutaline was initiated with an infusion rate of 1.75 micrograms/minute and increased to a maximum of 80 micrograms/minute. Magnesium sulfate was infused at 2 g/hour without any bolus and increased to maintain a serum level of 6.5-7.5 mg/dL. Tocolysis was continued until fetal lung maturity was achieved or delivery occurred. RESULTS: Combination tocolytic therapy prolonged pregnancy by a mean (+/- standard deviation) of 61 +/- 23.6 days in 751 women with intact membranes and by 20.5 +/- 17.4 days in 249 with ruptured membranes. The longest durations of continuous IV tocolysis were 123 days in a patient with intact membranes and 77 days in one with ruptured membranes. The most common side effects were nausea and vomiting, followed by chest tightness and shortness of breath. CONCLUSION: Long-term IV tocolysis appeared to be safe and to have acceptable side effects, allowing patients to receive combined terbutaline and magnesium sulfate until delivery.

The incidence of meconium-aspiration in Hawaii.

Meconium in the amniotic fluid was found in 2,633 obstetrical patients and meconium-aspiration occurred in 77 cases out of 14,527 deliveries. Although the incidence of meconium in the amniotic fluid increased significantly at 39 weeks, a corresponding significant increase in meconium-aspiration did not occur until 41 weeks gestation. All deaths associated with meconium, as well as 84% of the cases of severe meconium-aspiration syndrome, occurred in infants born of patients with oligohydramnios and a gestational age of 41 weeks or greater.

Massive fetomaternal hemorrhage preceded by decreased fetal movement and a nonreactive fetal heart rate pattern.

BACKGROUND: Massive fetomaternal hemorrhage occurs in one in 1000 deliveries and has been associated with decreased fetal movements and a sinusoidal fetal heart rate (FHR) pattern. CASES: Three women presented with decreased fetal movements, nonreactive FHR patterns, and positive Kleihauer-Betke tests. All three were at a viable gestational age and were immediately delivered by cesarean. The three infants were severely anemic, with hemoglobin levels of 6.5, 5.3, and 5.1 g/dL, respectively. CONCLUSION: A patient who presents with decreased fetal movement associated with a nonreactive FHR pattern and a positive Kleihauer-Betke test of more than 140 mL should be considered for immediate delivery if the gestational age is consistent with neonatal viability.

Vaginal birth after cesarean section in Hawaii. Experience at Kapiolani Medical Center for Women and Children.

Medical records at Kapiolani Medical Center for Women and Children were reviewed for cases that had a trial of labor subsequent to prior cesarean section during the period January 1990 to July 1991. All cases were > or = delivered 36 weeks' gestation. During the 19-month period, 356/483 or 73.5% cases with a trial of labor had successful vaginal births after previous cesarean sections (VBAC). The majority of the others that did not were due to failure of progression in labor. The incidence of scar separation was 5/483 (1.04%). There were 5/483 neonates with Apgar scores of < or = 6 at 5 minutes, giving a perinatal morbidity rate of 1.04%. There were no maternal deaths. Oxytocin induction resulted in successful VBAC in 30/47 (63.8%) cases. This study concludes that a trial of labor for vaginal birth after cesarean section is well established at our institution. In addition, the rates of successful VBAC, its complications and outcomes, are comparable to national averages.

Ritodrine and terbutaline compared for the treatment of preterm labor.

A prospective study comparing intravenous ritodrine and terbutaline was initiated to assess the efficacy of each drug in arresting preterm labor. Delivery was delayed for 25.8 days in patients treated with terbutaline and 13.0 days in patients treated with ritodrine. Patients treated with terbutaline gave birth to infants with a mean birthweight of 2 588 grams and 60% achieved a gestation of 36 weeks. Patients treated with ritodrine gave birth to infants with a mean birthweight of 2 392 grams and 39% achieved a gestation of 36 weeks. From this study it is evident that parturition was more effectively delayed in women treated with terbutaline than in a similar group of women treated with ritodrine.

Office termination of pregnancy by "menstrual aspiration".

A program of office menstrual aspiration was initiated in our institution in 1972. Since that time 1,443 patients have been admitted into the study. These patients were evaluated by age, marital status, gravidity, repeat pregnancy terminations, complications, and detailed tissue analysis as well as contraception utilized at the time of conception and following counseling after the procedure. A majority of these patients were less than 25 years old and single; 28% had had a previous termination and 51% a previous pregnancy. Pathologic evaluations revealed Arias-Stella reaction in 78%. When these data were compared to those of a similar group of women whose pregnancies were terminated in the hospital by suction curettage, it was found that the office procedure is comparatively safe and should therefore be the therapy of choice.