Gas embolism in obstetrics and gynecology. A review.

OBJECTIVE: To review gas embolism in the field of obstetrics and gynecology, with an emphasis on the pathophysiology, clinical presentation and treatment options. STUDY DESIGN: A review of the world literature on gas embolism. CONCLUSION: Gas embolism is an unusual complication and has increased in frequency since the introduction of new invasive procedures. Since the clinical presentation of gas embolism has many faces, it is important to identify it as early as possible: timely treatment may be life saving, while a delay may have serious consequences.

Evaluation of prognostic factors for vaginal delivery after cesarean section.

Although the success rate of vaginal birth after cesarean section in selected patients is > 60%, most of these women elect the option of a planned repeat cesarean section. In this study our purpose was to evaluate the predictive value and relative importance of 15 prognostic factors by using univariate and multivariate analysis in order to refine the selection of patients for a trial of labor. The analyses were based on 261 patients with one prior cesarean section who were allowed a trial of labor. The final model resulted in six significant prognostic factors. The overall predictive value of the model was 68%. However, the predictive value for a successful vaginal delivery was excellent: 94.5% (139/147) of the women predicted to deliver vaginally actually did so. This group constituted 56% (147/261) of our candidates for vaginal delivery. The predictive value of the test for failure was only 33.3% (38/114); 66.6% of the women completed a vaginal delivery despite the prediction of failure. Because the chance of a successful vaginal delivery is > 60% in women with a prediction of failure, until a selection criterion with a better prognostic value can be identified, a liberal approach to vaginal birth after cesarean section is justified even in this group. A 60% chance is perceived by many women and physicians as too low to elect this option. Since we were able to predict a successful vaginal delivery in a large proportion of the candidates, it may encourage at least this group of patients to elect a trial of labor.

Premature ovarian failure--the prognostic application of autoimmunity on conception after ovulation induction.

OBJECTIVE: To assess whether the presence of autoimmune activity in patients with premature ovarian failure (POF) can predict the response to ovulation induction and conception. DESIGN: Assessment of autoimmune activity in patients with POF, correlating the response to ovulation induction with this autoreactivity. SETTING: Tertiary care academic center. PATIENTS: Forty women with POF, 15 of them treated by ovulation induction because of infertility. INTERVENTIONS: All patients were tested for the presence of autoimmune activity, antibodies against various tissues, and 15 of them were treated with combinations of hMG/hCG, glucocorticosteroids as immunosuppressant, and some of them also with a long-acting GnRH agonist. Those patients not interested in infertility were put on hormone replacement therapy (HRT). MAIN OUTCOME MEASURES: Serum E2 and P were measured during ovulation induction as well as follicular diameter monitoring by transvaginal sonography. Achievement of gestations and their outcome were monitored in the group in which ovulation induction was accomplished. RESULTS: Antibodies against thyroglobulin, nuclear antigens, heart, tissue gluten, or increased levels of immunoglobulin (Ig)M, or decreased levels of complement C3 and C4 were significantly different in the patients with POF than in the control population. Autoreactivity of at least one class of the tested antibodies was found in 31 of 40 patients (77%). In 15 patients with autoimmune activity who have undergone ovulation induction using hMG/hCG, 14 pregnancies were achieved in 8 patients. Two of the pregnancies were spontaneous, and 12 were generated by hMG/hCG and fluocortolone, with or without pretreatment with GnRH-a. Twelve healthy babies were generated by 10 gestations, 3 ended in spontaneous abortions (23%), and 1 is ongoing. All the nonspontaneous pregnancies were achieved in the first three cycles of ovulation induction. CONCLUSIONS: Patients with POF and autoimmune activity, suggesting an autoimmune etiology to the ovarian failure, may respond to ovulation induction and have a conception rate of approximately 40% in three cycles. Those who do not conceive in three treatment cycles have a very low probability to conceive; therefore, further attempts of ovulation induction should be discouraged. However, some patients may spontaneously conceive in association with HRT.

Evaluation of normal gestational sac growth: appearance of embryonic heartbeat and embryo body movements using the transvaginal technique.

A cross-sectional transvaginal ultrasound study was conducted in 137 normal pregnancies with gestational ages ranging from 5-12 weeks. Several biometric measurements were obtained throughout pregnancy, including the three diameters of the gestational sac, the crown-rump length, and the yolk sac. In addition, the appearance of the embryo heartbeat and embryo body movements were evaluated. Linear relationships were found between the mean gestational sac diameters and gestational age (r = 0.911; P less than .00001) and between mean gestational sac growth and crown-rump length growth (r = 0.926; P less than .0001). A gestational sac could be identified at 5 weeks' gestation; embryo heartbeat was imaged when the mean gestational sac diameter measured 2 cm, and embryo body movements could be seen when the mean gestational sac diameter reached 3 cm. In the present study, embryo heartbeat was identifiable after 6 weeks and 4 days with a sensitivity of 100%, specificity of 93.1%, positive predictive value of 96.9%, and negative predictive value of 100%. The embryo body movements, which were absent before 7 weeks' gestation, were observed after 8 weeks' gestation with a sensitivity of 100%, specificity of 92.8%, positive predictive value of 94.3%, and negative predictive value of 100%. With identification by transvaginal sonographic evaluation, the following can serve as markers of normal embryo growth: a mean gestational sac diameter greater than 2 cm in the presence of the embryo heartbeat, or a mean sac diameter measurement greater than 3 cm in the presence of embryo movement.

Intraamniotic infection in the very early phase of the second trimester.

A total of 157 consecutive patients were studied in an effort to examine prospectively the incidence of asymptomatic intraamniotic infection in the early phase of the second trimester. All patients were referred for amniotic fluid karyotyping. In addition, the amniotic fluids were examined for Gram stain and were directly cultured on blood agar and MacConkey agar as well as in thioglycollate broth. We found positive amniotic fluid cultures in eight cases (5.09%); however, results of Gram stain examinations were negative in all amniotic fluid samples. The data indicate that there is no correlation between white blood cells in the amniotic fluid and positive amniotic fluid culture results. Only one pregnancy with positive amniotic fluid culture resulted in a septic abortion. Therefore we can suggest that intraamniotic infection can exist early in pregnancy, even with intact membranes, and in most cases without any clinical symptoms.

Criteria for transvaginal sonographic diagnosis of ectopic pregnancy.

Transvaginal ultrasonography was performed in 1150 patients suspected of having an ectopic gestation. The criteria for transvaginal sonographic diagnosis of ectopic pregnancy were established by targeted scanning of the pelvic organs and spaces. Sonographic assessment of tubal pregnancy and its differential diagnosis were based on six criteria: (1) the presence or absence of gestational structures within the fallopian tube, (2) the presence or absence of amorphous material in a dilated fallopian tube, (3) the presence or absence of indirect signs of ectopic pregnancy within the pelvis, (4) the echogenicity of a suspected finding relative to the ovary, (5) the presence or absence of flow (of lacunar origin) within the suspected sonographic finding, and (6) the relationship of a suspected sonographic sign to an intentionally displaced ovary. The latter 3 criteria help differentiate between tubal gestation and a corpus luteum. We believe these diagnostic criteria should be applied when performing transvaginal sonographic scanning of patients suspected of having an ectopic gestation.

Air embolism following intra-uterine hypertonic saline instillation: treatment in a high-pressure chamber; a case report.

Air embolism was encountered in a patient following induced abortion by means of intra-amniotic hypertonic saline instillation. The only symptom present was isolated cortical blindness. The patient was treated in a high-pressure chamber and a nearly complete recovery was achieved.

PIP: Air embolism, diagnosed by clinical therapeutic trial in the Navy hyperbaric chamber, occurred in a woman having labor induced by hypertonic saline for intrauterine fetal death at 25 weeks' gestation. 20 hours after saline administration, and 2 hours after 2 mU/minute diluted oxytocin was started, she had a sudden cardiovascular collapse with cyanosis and dyspnea. She was resuscitated by ventilation by mask and iv fluids. When she regained consciousness she was cortically blind. During treatment by the Navy's protocol, 30 minutes of compression at 6 ATA alternating cycles of 100% oxygen and air after rapid decompression to 2.8 ATA for 5 hours 19 minutes, there was a dramatic improvement in vision. After treatment, she showed left hemianopsia with macular damage. A year later only slight loss of left visual field remained. Air embolism can only be differentiated from amniotic fluid embolism by demonstration of amniotic fluid or fetal components in the maternal central circulation, or a therapeutic trial in a hyperbaric chamber. It is safer to try the pressure chamber immediately.

Management of imperforate hymen with the carbon dioxide laser.

A method for the management of imperforate hymen using carbon dioxide laser is described. In four patients presenting with imperforate hymen, the hymen was excised by CO2 laser under local anesthesia. No bleeding or wound infection occurred, and healing was prompt and satisfactory. Two out of four patients became sexually active and experienced no introital dyspareunia. We conclude that the CO2 laser may be an alternative method of treatment for this rare congenital abnormality.

Mullerian adenosarcoma of the uterine cervix.

The management of cervical adenosarcoma in a 14-year-old girl is described. The tumor had an exceptionally violent biological nature and did not respond to a variety of customary and unorthodox therapeutic measures. These included conventional intravenous chemotherapy, radiation therapy, surgery, intraarterial chemotherapy, colostomy, and peritoneovenous shunt for untreatable ascites. The patient died within 16 months of diagnosis. This is the fifth case of cervical adenosarcoma in the English literature. This tumor usually has a better prognosis and none of the previous four cases succumbed to the disease. The unusual virulence of the present case is discussed and the literature reviewed.

The influence of maternal hypnosis on fetal movements in anxious pregnant women.

The influence of maternal hypnotherapy on fetal body movements in anxious parturients was studied in 25 patients at 35-37 weeks of gestation. There were two groups of patients. Group A consisted of 16 parturients who performed self-hypnosis. Group B consisted of 9 parturients in whom hypnosis was induced by a physician. When compared to a control period of 30 min there was a significant increase in the duration of fetal body movements recorded by ultrasound during 30 min of maternal hypnosis, p less than 0.005 for group A and p less than 0.01 for group B. It is suggested that in anxious parturients fetuses move into a more active state when maternal relaxation is achieved by hypnotherapy.

Steroidal binding sites in the ampulla of the human fallopian tube--autoradiographic and biochemical study.

Most of the morphological changes which occur during the different phases of the reproductive cycle are hormone-dependent. Thus, the aim of this work was to demonstrate the fluctuations in the availability of steroid binding sites in the ampullary segment of the tube during the menstrual cycle. Specimens were obtained during routine gynecological operations and were prepared for histological examination. In addition, determinations of specific binding of estradiol and progesterone (specific activity was about 100 Ci/mmol) were made in soluene-dissolved tissue of ampullary mucosa. Autoradiographic grain counts of tissues which were incubated with [3H]estradiol and [3H]progesterone were performed on histological sections. The epithelial cell binding capacity was higher than that of the cells in the underlying lamina propria and this was found throughout the cycle. Estrogen and progesterone binding capacity was higher during the proliferative phase and decreased markedly during the secretory phase. Tissue binding of steroids appears to be inversely related to serum levels, which are lower in the proliferative phase and rise during the secretory phase.

Tetra-amelia with multiple malformations in six male fetuses of one kindred.

An Arab Moslem kindred is reported in which six abnormal male fetuses were born in three closely related sibships. They had amelia, malformed head and other severe skeletal and visceral malformations. The similarities and differences between the developmental and inherent characteristics found in our patients and in families with Roberts syndrome are discussed.

The "grand multipara"--is it a problem? A review of 5785 cases.

The Grand Multipara (GM) has almost disappeared in the Western countries due to the advancement of family planning. Having a heterogeneous population, the problem of Grand Multiparity still exists in our country. This study is based on 5785 cases of GM which were treated in our Obstetrical Department during a period of 16 years (1960-1975). We have compared this group to the general obstetrical population in terms of pregnancy and delivery complications. Face and breech presentations as well as transverse lie were twice, brow presentations were three times as frequent in the GM group. Postpartum hemorrhage (P.P.H.) was four times and premature separation of the placenta twice as frequent. Rupture of the uterus was about 20 times more frequent. Forceps delivery and Cesarean section rate were twice, while the vacuum extraction 5-fold more frequent. Though there was no material mortality and perinatal mortality was not higher than in the general population. Even though the percentage of GM in our population has been decreased in the last 10 years, our results suggest that Grand Multiparity is still a high risk obstetrical problem.

PIP: The grand multipara (GM) has almost disappeared in the Western countries due to the advancement of family planning. Having a heterogenous population, the problem of grand multipara still exists in Israel. This study is based on 5785 cases of grand multipara, which were treated in the obstetrical department of the Rambam Medical Center, Technion during a period of 16 years (1960-75). The authors compared this group to the general obstetrical population in terms of pregnancy and delivery complications. Face and breech presentations as well as transverse lie were twice, brow presentations were 3 times as frequent in the GM group. Postpartum hemorrhage was 4 times and premature separation of the placenta twice as frequent. Rupture of the uterus was about 20 times more frequent. Forceps delivery and Cesarean section rate were twice, while the vacuum extraction 5-fold more frequent. There was no maternal mortality, and perinatal mortality was not higher than in the general population. Even though the percentage of GM in this population has decreased in the last 10 years, the results suggest that grand multiparity is still a high risk obstetrical problem.

Blood supply and innervation of the supermedial thigh flap employed in one-stage reconstruction of the scrotum and vulva--an anatomical study.

The supermedial thigh flap is an arterial and sensate flap. Anatomical studies reveal both large and small nutrient arteries. Its largest and most consistent artery is the superficial branch of the deep external pudendal artery, which constitutes the main circulation. The secondary blood supply to the base of the flaps is contributed by musculocutaneous perforators of the medial circumflex femoral artery. Subcutaneous branches of the superficial femoral artery, when present, are an additional source of arterial supply. Branches of the ilioinguinal nerve provide sensory innervation to the flaps.

[Measurement of the biparietal diameter before and after external version of the fetus]. / La mesure du diamètre bipariétal avant et après version externe du foetus.

In 52 cases of breech presentation, the biparietal diameter of the fetal head was measured before and after external version of the fetus. There was no significant statistical difference between these two measurements.

[Eisenmenger's syndrome in pregnancy. Controlled segmental epidural block for cesarean section]. / Eisenmenger-Syndrom und Schwangerschaft. Kontrollierte segmentäre Epiduralblockade zum Kaiserschnitt.

We present a case of Eisenmenger's Syndrome in which an elective Caesarean Section was carried out successfully under lumbar epidural anaesthesia, following adequate physiological and psychological preparation of the patient.

Ectopic pregnancy effects on the ipsilateral fallopian tube epithelium--an ultrastructural study.

Ectopic pregnancy specimens of 6 human Fallopian tube fimbrial epithelia were studied utilizing ultrastructural, cytochemical and morphometric methods. The observations were compared with those made on 12 intrauterine pregnancy specimens. The morphometric measurements indicate earlier onset of atrophic changes in ectopic pregnancy. Deciliation in Ectopic pregnancy preceded that observed in intrauterine pregnancy. Cell height also decreased earlier in ectopic pregnancy than in intrauterine pregnancy. In addition, during the 1st trimester, ultrastructural localization of calcium revealed that, in ectopic pregnancy, the mitochondrial calcium, which was observed in intrauterine specimens, was shifted into the cytoplasmic compartment of the ciliary cell. Consequently, cytoplasmic calcium was found in the ectopic specimens and was less evident in the intrauterine specimens. Thus, a local atrophic effect is evident in ectopic pregnancy, which appears earlier than the atrophic process found in intrauterine pregnancy.

Comprehensive fetal monitoring by microcomputer--a clinical approach.

An inexpensive microcomputer has been devised to analyze fetal heart signals and fetal activity which were simultaneously recorded. Digital techniques were used to provide quantitative analysis of each of these inputs, and the interrelations among them. A parallel graphical presentation of those inputs was also provided.