Digital examination compared to trans-perineal ultrasound for the evaluation of anal sphincter repair.

OBJECTIVE: To assess the adequacy of a third- or a fourth-degree laceration repair by comparing digital and trans-perineal ultrasound measurements. METHOD: During a 4-year period, 34 subjects without prior history of anal sphincter injury or fecal incontinence underwent ultrasound measurements of external anal sphincter muscle diameter and perineal length, which were compared to measurements obtained by digital examination. RESULTS: Pearson's correlation coefficients for comparing the digital external sphincter examination to trans-perineal ultrasonography, and the digital perineal examination to trans-perineal ultrasonography were 0.88 and 0.40, respectively. Patients (n=4/34) whose external sphincter was identified as less than 1 cm by digital examination were found to have an external sphincter diameter of less than 1 cm by trans-perineal ultrasound. CONCLUSION: The digital perineum examination is a reliable method of measuring the external sphincter thickness and perineal body length immediately after primary repair.

Case-control study of antenatal cocaine use and platelet levels.

OBJECTIVE: Our aim was to determine the prevalence of thrombocytopenia in pregnant patients who did and did not use cocaine. STUDY DESIGN: A 1:1 case-control study of 326 patients attending an inner-city, neighborhood-based antenatal program between January 1992 and December 1998 is presented. Data concerning cocaine use (history and urine toxicology study) and platelet count, along with gestational age, were compared by nonparametric techniques (chi2 test, Fisher exact test, Wilcoxon rank sums, and receiver operating characteristic curve). RESULTS: The prevalence of thrombocytopenia during pregnancy was not different between cocaine-using patients (13/160; 8.1%) and nonusing patients (11/160; 6.9%; difference not significant). In patients who abused cocaine and for whom both positive and negative urine screening results were obtained concomitantly with platelet levels, no difference in platelet counts was evident. Overall, thrombocytopenia occurred more often in the third trimester than earlier in pregnancy for both control and cocaine-using pregnant women. CONCLUSION: Cocaine use among pregnant women was not associated with thrombocytopenia. A low platelet count was found more often later in pregnancy.

Postpartum acquired hemophilia (factor VIII inhibitors): a case report and review of the literature.

Pathologic inhibitors of blood coagulation as a cause of postpartum acquired hemostatic failure are rare. Since 1937, 96 cases of postpartum factor VIII (FVIII) inhibitors, including the current case, have been reported. Suspicion for the diagnosis of this condition is often low. We report a case of postpartum FVIII inhibitor formation in a 24-year-old woman who developed intermittent postpartum bleeding that resulted from the inhibitors she formed to FVIII. A unique form of therapy was used in treatment of her disorder. She did not respond to conventional surgical or medical management of her bleeding until Autoplex T (Baxter Healthcare, Glendale, CA), an activated prothrombin complex concentrate (aPCC) was used. The literature concerning acquired hemophilia is reviewed, and new therapeutic medical advances are emphasized.

Pregnancy after adjustable gastric banding.

OBJECTIVE: To determine outcomes of pregnancies of obese women who had surgical placement of an adjustable gastric band to treat obesity. METHODS: We conducted two clinical trials to evaluate adjustable gastric banding that involved 359 obese women of reproductive potential (age 18-51 years), of whom 20 conceived resulting in 23 pregnancies. Specific information about pregnancies and fetal outcomes was collected from medical records and direct patient contact. RESULTS: Eighteen pregnancies were full term, one was an ectopic gestation, two ended in elective abortions, and two in spontaneous abortions unrelated to the womens' medical conditions. Of the 18 full-term pregnancies, 14 delivered vaginally and four by cesarean (one for prolonged fetal bradycardia, two for cephalopelvic disproportion, and one repeat cesarean for twins). The mean birth weight was 3676 g (range 2381-3912 g). Five women lost weight (range 1.8-17.6 kg) during pregnancy without obvious fetal and neonatal effects. Three women had fluid removed from their gastric bands (decreasing the mechanical constriction) to treat nausea and vomiting. Two women who had no fluid in their bands eliminated the effectiveness of the obesity treatment, resulting in excessive weight gain. CONCLUSION: Morbidly obese women who became pregnant soon after receiving an adjustable gastric band had uncomplicated pregnancies. Adjustment of the gastric band to decrease the amount of mechanical obstruction decreased nausea and vomiting, but led to excessive weight gain in two women when it was done prophylactically. Obese women at risk of pregnancy should be counseled that it might occur unexpectedly after weight loss from gastric banding unless birth control is promptly instituted.

Regulation of gonadotropin-releasing hormone (GnRH) receptor gene expression in sheep: interaction of GnRH and estradiol.

GnRH and estradiol are important regulators of GnRH receptors. When delivered to the anterior pituitary gland continuously, GnRH decreases numbers of GnRH receptors on gonadotropes. Treatment with estradiol consistently increases numbers of GnRH receptors. Because estradiol acts via intracellular receptors while GnRH exerts its effects through a membrane receptor, it is likely that these hormones influence GnRH receptor expression via different mechanisms. In this experiment, we tested two hypotheses: 1) continuous infusion of GnRH will decrease expression of the GnRH receptor gene; and 2) estradiol will override the negative effects of continuous infusion of GnRH on GnRH receptor expression. Ovariectomized ewes were administered either GnRH (10 microg/h, n = 10) or saline (n = 10) continuously for 136 h. At 124 h, 5 ewes in each group were administered estradiol (25 microg i.m.) and anterior pituitary glands were collected 12 h later. Treatment with GnRH caused an abrupt increase in circulating concentrations of LH, and the maximal mean concentration was observed 4 h after the start of GnRH infusion. Following this increase, concentrations of LH in GnRH-treated ewes declined and were similar to those in saline-treated ewes from 8 h to 124 h. After injection of estradiol at 124 h, circulating concentrations of LH increased in both GnRH- and saline-treated ewes. However, this response occurred within 6 h in ewes treated with GnRH compared with 9 h in ewes treated with saline (P < 0.05). Compared with saline-treated controls, treatment with GnRH decreased mean steady-state amount of GnRH receptor messenger RNA (mRNA) (P < 0.01) and concentration of GnRH receptors (P < 0.05). Treatment with estradiol caused an increase in concentrations of GnRH receptor mRNA (P < 0.05) and GnRH receptors (P < 0.01). Amounts of GnRH receptor mRNA and numbers of GnRH receptors in ewes treated with both GnRH and estradiol were not different from those in the control group but were higher (P < 0.002) relative to ewes treated with GnRH alone. Treatment with GnRH and estradiol also influenced the expression of genes encoding the LHbeta and FSHbeta subunits. Compared with saline-treated controls, treatment with GnRH reduced steady-state amounts of mRNA encoding LHbeta subunit (P < 0.005) and FSHbeta subunit (P < 0.05). Treatment with estradiol caused a decrease in concentrations of FSHbeta subunit mRNA (P < 0.01) but did not affect amounts of LHbeta subunit mRNA. The combined treatment of GnRH and estradiol reduced concentrations of mRNA encoding LHbeta subunit (P < 0.01) and FSHbeta subunit (P < 0.005). From these data we conclude that 1) reduced numbers of GnRH receptors during continuous infusion of GnRH are mediated in part by decreased expression of the GnRH receptor gene; and 2) estradiol is able to override the negative effect of GnRH by stimulating an increase in GnRH receptor gene expression and GnRH receptor concentrations. Therefore, although the gonadotrope becomes refractory to GnRH during homologous desensitization, this desensitization does not affect the cell's ability to respond to estradiol.

Anxiety and depression. Diagnosis and treatment during pregnancy.

Anxiety and depression are common disorders that the obstetrician-gynecologist frequently encounters, and they often require consultation with mental health care professionals. Pregnancy offers an unusual challenge because many of the decisions made about the safety of certain drugs are educated guesses. Common sense dictates that no drug should be used unless a serious threat to the mother exists such as suicide. Preconceptional counseling and early referral to and from colleagues in mental health should help the obstetrician guide mother and fetus to a successful pregnancy outcome.

Characteristics of patients with rapidly growing cervical cancer.

Between April 1983 and December 1990, 387 newly diagnosed cervical cancer cases were managed at our institution. We retrospectively reviewed 59 of those cases, which were identified as having developed within 3 years of the patients' last normal Pap smear. Squamous cell carcinoma was found in 45 patients, and 33 had poorly differentiated lesions. Six cases had typical histology. However, 27 cases (82%) had distinctive histologic features that have not been previously described in rapidly progressive cervical cancer. Thirty-seven patients had surgical treatment; 7 (19%) died of disease. Twenty-two patients had radiation; 10 (45%) died of disease. Patients who have invasive cervical cancer after a recent normal Pap smear may have unusual histologic types, and some with early-stage disease may have better outcome if treated with radical surgery.

Tuberculosis skin testing in pregnancy: trends in a population.

BACKGROUND: A change has recently been noted in the epidemiology of tuberculosis in the United States. Multiple factors, including human immunodeficiency virus (HIV) infection, increases in the homeless population, and immigration, are cited as causes for an increased prevalence. The population of pregnant women in New Orleans exhibits several of these risk factors and may be compared with a previous description of this group reported in 1983. METHODS: All patients requesting obstetric care at the Medical Center of Louisiana at New Orleans from January 1994 to April 1995, were offered tuberculosis skin testing during their initial outpatient clinic visit. A skin test was considered positive if there was 10 mm of induration (5 mm in HIV-positive patients) at 48 hours. Other information collected included HIV status and ethnic group. This group was compared with a group of patients tested in 1981 and 1982. RESULTS: The study included 1621 patients, who underwent testing and had available results. The only significant risk factor for a positive skin test in 1994 was Hispanic ethnicity. Hispanics are the most recent immigrants to the New Orleans area. In 1983 Asians were at highest risk and were the newest immigrants to the city. HIV status was insignificant as a predictor of skin test conversion. CONCLUSIONS: Pregnant women at highest risk for tuberculosis in this urban center are recent immigrants to the United States. This is consistent with data reported by the Centers for Disease Control and Prevention from other locales. Efforts should be made to ensure that recently immigrated pregnant women receive skin testing as part of their obstetric care.

Diagnosis of Helicobacter pylori infection in a colony of rhesus monkeys (Macaca mulatta).

Twenty-three young adult rhesus monkeys from China were evaluated for the presence of Helicobacter pylori. Gastric body and antral biopsy samples were tested for H. pylori by PCR analysis, culture, rapid urease testing, and histologic evaluation. Serologic testing to detect H. pylori immunoglobulin G (IgG) antibodies was performed by using a commercially available human-based enzyme-linked immunosorbent assay (ELISA) test and an ELISA test which utilized homologous H. pylori antigens and an anti-rhesus IgG conjugate. PCR analysis with H. pylori-specific 26-kDa protein primers detected H. pylori in 21 of the 23 rhesus monkeys (91%). Culture testing identified the organism in 12 of the 23 animals (52%). Rapid urease tests were positive for all animals. H. pylori was diagnosed by histological examination in 11 of 23 monkeys (48%). Of the 21 monkeys positive for H. pylori by PCR, only 3 (14%) had positive results by the commercial ELISA test, yielding a sensitivity of 14%, a specificity of 100%, and an accuracy of 22%. However, 19 of the 21 PCR-positive animals (90%) had positive results by the ELISA test with homologous rhesus H. pylori antigen and anti-monkey conjugate, with predicted index values greater than or equal to 0.7 considered positive and values between 0.5 and 0.7 considered equivocal. This test had a sensitivity of 90%, a specificity of 100%, and an accuracy of 91%. Therefore, the ELISA test with rhesus monkey origin components was more accurate for detecting infected animals than the human-based ELISA.

Venous thromboembolism during pregnancy: a current review of diagnosis and management.

Pregnancy is widely recognized to be a physiologic state with a markedly elevated risk for thromboembolic complications. The diagnosis and management of venous thromboembolic events during pregnancy, however, remains controversial because of the lack of prospective, randomized trials that have included pregnant women. Significant progress has been made in the last 10 years in the management of these conditions in the nonpregnant patient and strong clinical guidelines have been established recently. Obstetrician-gynecologists may modify these guidelines and apply them to the pregnant patient based on their knowledge of the physiologic changes in pregnancy. Objective diagnostic techniques should be used liberally when the diagnosis of deep vein thrombosis or pulmonary emboli is considered because early intervention may prevent serious maternal sequelae including death. Heparin remains the anticoagulant of choice during pregnancy because of its proven safety for both the patient and the fetus. It is likely that long-term anticoagulation is necessary when venous thromboembolism occurs antepartum, although the most efficacious regimen has yet to be established. There is some concern about the prolonged use of heparin during pregnancy, particularly regarding the risk of osteopenia.

Surgical landmarks of the ureter in the cadaveric female pelvis.

Our purpose was to delineate the course of the ureter in the female pelvis in relationship to several important surgical landmarks. Ten female cadavers with undissected pelves were used. The ureter was identified at the pelvic brim and traced inferiorly to the bladder. Sets of measurements (+/- 0.1 cm) that help define the location of the ureter were obtained at the three landmarks; the ischial spine, the obturator canal and the insertion of the arcus tendineus on the pubic bone. The mean distances from the ureter to the pelvic floor were ischial spine, 3.2 +/- 0.1 cm; obturator canal, 3.2 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 1.6 +/- 0.1 cm. The mean distances from the arcus tendineus to the pelvic floor were ischial spine, 1.9 +/- 0.1 cm; obturator canal, 2.8 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 3.2 +/- 0.1 cm. This study defines the relationship of the ureter to the pelvic floor through measurements taken at three landmarks. The data should be useful to pelvic surgeons and are important for the development of future surgical techniques.

Endometrial sarcoidosis as a cause of postmenopausal bleeding. A case report.

BACKGROUND: Sarcoidosis is a multisystem disease that rarely affects the female genital tract. It has been found the endometrium but has never been reported as a cause of postmenopausal bleeding. CASE: A 53-year-old, postmenopausal women presented complaining of a single, five-day episode of vaginal bleeding. An endometrial biopsy revealed many noncaseating granulomas with sarcoid-type asteroid bodies. The remainder of the work-up was negative, and the symptoms spontaneously resolved. CONCLUSION: Sarcoidosis can present as a focal disease and should be considered in the differential diagnosis of granulomatous disease of the endometrium.

Cytopathological findings on vaginal Papanicolaou smears after hysterectomy for benign gynecologic disease.

BACKGROUND: Periodic, routine Papanicolaou smears of cells from the vagina are commonly examined in women who have undergone a hysterectomy for benign gynecologic disease. The benefits of this method of screening are not known. METHODS: We analyzed Papanicolaou smears obtained from the vaginal apex (cuff) in 6265 women at Charity Hospital in New Orleans between January 1, 1992, and December 31, 1994. Of the 10,595 vaginal smears, an estimated 9610 were obtained during follow-up examinations of 5682 women who had undergone hysterectomy for benign gynecologic disease. RESULTS: Among these 9610 vaginal smears, 104, from 79 women, were abnormal. The abnormal smears were categorized according to the findings, as follows: atypical squamous cells of undetermined significance, 52 (0.5 percent of all smears); low-grade squamous intraepithelial lesion, 44 (0.5 percent); high-grade squamous intraepithelial lesion, 6 (0.1 percent); and squamous-cell carcinoma, 2 (0.02 percent). In five women, biopsies revealed vaginal intraepithelial neoplasia type I or II; there were no biopsy-proved cases of vaginal cancer. The probability of an abnormal Papanicolaou smear in this group of women was 1.1 percent, and the positive predictive value of the Papanicolaou test for detecting vaginal cancer was 0 percent (95 percent confidence interval, 0 to 33 percent). CONCLUSIONS: The prevalence of abnormal findings on cytopathological examination of vaginal Papanicolaou smears after hysterectomy for benign gynecologic disease is extremely low.

Use of a subcutaneous closed drainage system and antibiotics in obese gynecologic patients.

OBJECTIVE: The purpose of this study was to evaluate the effect of subcutaneous closed drainage systems and prophylactic antibiotics on the wound breakdown rate in obese patients undergoing gynecologic surgery. STUDY DESIGN: A prospective study was performed on 197 obese patients who were randomly selected to have a subcutaneous drain. Incision closure technique was standardized. Antibiotic usage was not randomized. Demographic data, perioperative data, and postoperative complications were noted and analyzed by X2 test and 2 x 2 contingency tables. RESULTS: The overall complication rate was 25%, with 20% (22/109) among the group receiving a drain versus 31% (27/88) without a drain. Seventeen patients (8.6%) had wound breakdowns: 7 of 109 (6.4%) with drains and 10 of 88 (11.4%) without drains. Prophylactic antibiotics were given to 46% (50/109) in the drain group and 51% (45/88) without a drain. Fewer patients (2%) with a drain receiving antibiotics had wound breakdowns. The group with the most breakdowns had neither a drain nor antibiotics (14%). CONCLUSION: We suggest the use of subcutaneous drains plus prophylactic antibiotics may decrease morbidity when operating on obese gynecologic patients.

Military pregnancies and adverse perinatal outcome.

OBJECTIVE: To identify significant risk factors for an adverse outcome in active-duty military women. METHODS: A prospective study of 105 pregnancies and their outcome. RESULTS: The data revealed that: (1) single women more than married personnel had cesarean births when compared with forceps and vacuum (P < 0.03) or spontaneous vaginal delivery (P < 0.04); and (2) active-duty women who gained < 25 pounds during pregnancy developed preterm labor more often (P < 0.05). CONCLUSIONS: Risk factors for these adverse outcomes remain unknown.

Prospective survey of continuous versus single-injection spinal anesthesia in obstetrics.

Prior to the removal of spinal microcatheters from the market in 1992, these catheters were used extensively in the Obstetric Anesthesia Service at the Medical Center of Louisiana. We report on a prospective survey of the clinical application of single-injection versus continuous-catheter spinal anesthesia. Two hundred sixteen patients had single-injection anesthesia, and 218 had continuous-catheter anesthesia. No neurologic complications other than postdural puncture headache (PDPH) were encountered in either group. Five patients had PDPH after single-injection technique, and 8 patients had PDPH from continuous spinal anesthesia. Patients with diabetes were at higher risk for PDPH, and blacks were at lower risk (relative risks 4.35 and 0.31, respectively). Additionally, PDPH was associated with lower intraoperative urine output. No increased risk of complications was found after continuous spinal anesthesia with microcatheters.

Inherited disorders of coagulation in pregnancy.

Normal physiology has been reviewed to serve as a basis for understanding the abnormalities leading to the inherited coagulation disorders. These abnormalities involve each of the three arms of the coagulation process: platelets, the coagulation cascade, and the clot prevention/lysis pathways. Pregnancy presents a unique challenge to women with these disorders. However, with close attention to the natural course of the disorder and appropriate therapy instituted in a timely fashion, many of these women can achieve successful pregnancies.

Martial status and military occupational specialty: neither factor has a selective adverse effect on pregnancy outcome.

This investigation was undertaken to determine whether there is a relationship between martial status or military occupational specialty (MOS) and pregnancy outcome in and active-duty population. In this prospective, descriptive study 312 active-duty women were identified as married or single and stratified into four groups on the basis of MOS: group I (n = 144), mild to moderate mental stress; group II (n = 43), intensive mental stress; group III (n = 72), exposure to hazardous material; and group IV (n = 53), physical stress. Each patient group was evaluated to determine the incidence of medical complications. One hundred ninety-three of the service women were married and 70 were single. There was no significant difference between pregnancy complications and martial status. In spite of considerable stress and hazardous exposure the incidence of medical complications of pregnancy observed among groups (group I = 67%, group II = 58%, group III = 48% and group IV = 53%) was not significantly different. On the basis of the findings of this study we conclude that martial status and MOS did not significantly influence military pregnancy outcome.

A vaccine-elicited, single viral epitope-specific cytotoxic T lymphocyte response does not protect against intravenous, cell-free simian immunodeficiency virus challenge.

Protection against simian immunodeficiency virus (SIV) challenge was assessed in rhesus monkeys with a vaccine-elicited, single SIV epitope-specific cytotoxic T-lymphocyte (CTL) response in the absence of SIV-specific antibody. Strategies were first explored for eliciting an optimal SIV Gag epitope-specific CTL response. These studies were performed in rhesus monkeys expressing the major histocompatibility complex (MHC) class I gene Mamu-A*01, a haplotype associated with a predominant SIV CTL epitope mapped to residues 182 to 190 of the Gag protein (p11C). We demonstrated that a combined modality immunization strategy using a recombinant Mycobacterium bovis BCG-SIV Gag construct for priming, and peptide formulated in liposome for boosting, elicited a greater p11C-specific CTL response than did a single immunization with peptide-liposome alone. Vaccinated and control monkeys were then challenged with cell-free SIVmne by an intravenous route of inoculation. Despite a vigorous p11C-specific CTL response at the time of virus inoculation, all monkeys became infected with SIV. gag gene sequencing of the virus isolated from these monkeys demonstrated that the established viruses had no mutations in the p11C-coding region. Thus, the preexisting CTL response did not select for a viral variant that might escape T-cell immune recognition. These studies demonstrate that a potent SIV-specific CTL response can be elicited by combining live vector and peptide vaccine modalities. However, a single SIV Gag epitope-specific CTL response in the absence of SIV-specific antibody did not provide protection against a cell-free, intravenous SIV challenge.