Vaginal delivery and serum markers of ischemia/reperfusion injury.

OBJECTIVE: Vaginal deliveries have been associated with pelvic organ prolapse and incontinence. The objective was to show whether markers of ischemia/reperfusion injury are dependent upon the mode of delivery and length of labor. METHOD: Complete venipuncture sets were obtained on 62 subjects. All samples collected were analyzed for serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH). Lipid peroxidation was analyzed, using thiobarbituric acid reactive substances (TBARS), on a subset of 37 patients. RESULTS: There was a significant increase in CPK from admission to 1 h postpartum and postpartum day 1 in vaginal delivery versus cesarean delivery. Longer second stages were associated with significant increases in CPK. There were no significant changes in either LDH or TBARS from admission to any other time point regardless of mode of delivery. CONCLUSION: Vaginal delivery and longer second stages were associated with a much greater increase in one of these injury markers.

Simple ultrasound evaluation of the anal sphincter in female patients using a transvaginal transducer.

OBJECTIVE: Fecal incontinence affects 0.2% of women aged 15-64 years and about 1.3% of women over 64 years. Most cases are related to instrumental deliveries affecting the anal sphincter complex. We propose a simple technique using the generally available transvaginal transducer to evaluate the anal sphincter complex. METHODS: Ninety-two patients underwent ultrasound examination. Group I consisted of 53 nulliparous patients. In Group II there were six patients with normal spontaneous vaginal deliveries without episiotomies. In Group III there were 14 patients with vaginal deliveries and one to three episiotomies but no lacerations. In Group IV there were nine postpartum patients with recently repaired (48 h to 3 weeks) third- and fourth-degree lacerations. All women in Groups I-IV were asymptomatic. Group V consisted of 10 patients symptomatic for fecal incontinence. We used a vaginal probe (5-9-MHz) with the footprint placed in the fourchette pointing towards the anus in a transverse and then in a median (sagittal) plane. If seen, the combined internal and external anal sphincter thickness at the 12 o'clock location was measured. We visualized normal star-shaped mucosal folds on the transverse section and described the sonographic anatomy in both planes. RESULTS: The mean sphincter thickness measured at 12 o'clock in Group I was 2.3 (range, 1.0-4.7) mm, in Group II it was 2.9 (range, 2.4-3.4) mm, and in Group III it was 2.3 (range, 1.0-3.7) mm. The differences between these three groups were not significant. Patients from Group IV showed thinning or discontinuous sphincter anatomy at the 12 o'clock position. All symptomatic patients from Group V showed abnormal sphincter anatomy, and the normal star-like appearance of the anal mucosa on the transverse section was deformed, radiating from the point of the sphincter damage. Four of the 10 patients in this group underwent surgical repair. In these patients the sonographic findings were confirmed. CONCLUSIONS: The images obtained using this imaging modality show the sphincter muscle anatomy as well as the possible pathology. Due to its simplicity the technique can be applied in any place where a vaginal transducer is available.

The risk of cystocele after sacrospinous ligament fixation.

OBJECTIVE: The aim of this study was to determine whether sacrospinous ligament fixation independently increases the risk of anterior vaginal wall defect. STUDY DESIGN: A retrospective cohort study was conducted on patients undergoing pelvic reconstructive surgical operations by a single surgeon from 1970 through 1997. Two groups were examined and divided into subgroups to evaluate the effects of exposure to sacrospinous ligament fixation: patients with anterior wall defects undergoing standard anterior colporrhaphy with (group 1A) or without (group 1B) concomitant sacrospinous ligament fixation, and patients without anterior wall defects undergoing other pelvic reconstructive procedures (but not anterior colporrhaphy) with (group 2A) or without (group 2B) sacrospinous ligament fixation. Recurrence rates were calculated for each group according to evidence of any degree of anatomic defect. RESULTS: Among 322 patients in group 1, 9 of 77 in group 1A and 23 of 245 in group 1B (11.7% vs 9.4%, P >.05) had anterior wall recurrences. Among 73 patients in group 2, 8 of 45 in group 2A and 5 of 28 in group 2B (17.8% vs 17.9%, P >.05) had subsequent anterior wall defects. CONCLUSION: The occurrence of anterior vaginal wall defects was not found to be altered by the performance of sacrospinous ligament fixation. These findings may be attributable to surgical technique emphasizing maintenance of anterior vaginal wall length during sacrospinous ligament fixation.

The use of transvaginal ultrasound and saline infusion sonohysterography for the evaluation of asymptomatic postmenopausal breast cancer patients on tamoxifen.

Tamoxifen has been shown to decrease the recurrence rate of breast cancer. Evidence that tamoxifen use may be associated with an increased risk of endometrial cancer has caused investigators to recommend routine invasive sampling. We have assessed a minimally invasive alternative for endometrial surveillance of tamoxifen-treated patients utilizing transvaginal ultrasound and saline infusion sonohysterography. Asymptomatic women (n = 44) with breast cancer on postoperative tamoxifen treatment were referred to our gynecological ultrasound unit. Initially, the endometrial echo was measured with unenhanced transvaginal ultrasound. If a distinct echo measured < or = 5 mm, no further procedure was performed. For thickened or inadequately visualized echoes, sonohysterography was performed. If a thin echo was noted on sonohysterography, no further procedure was performed. If focal changes were detected, hysteroscopy/dilatation and curettage (D&C) was performed. For generalized symmetrically thickened echoes, a blind biopsy was done. If sonohysterography was unsuccessful, hysteroscopy/D&C was performed. Eleven (25%) patients had thin unenhanced echoes of < or = 5 mm. Twenty-five (57%) patients had thickened endometrial echoes. Three (7%) had naturally occurring endometrial fluid outlining a polyp. An endometrial echo could not be visualized in five (11%) patients. Sonohysterography was successfully performed in 21 out of 30 (70%) patients with either thickened or non-visualized unenhanced echoes. Of these, two patients had thin endometria with coexisting myomas; seven had thin endometria with typical tamoxifen-induced subendometrial changes: and seven had focal polypoid thickening confirmed by hysteroscopy/D&C. Histology revealed carcinoma associated with two, proliferation in one and four polyps. Five patients had thickened unenhanced echoes with symmetrically thickened single-layer measurements on sonohysterography. Histology revealed that three were proliferative, one was inactive and one was hyperplastic. In the nine patients with unsuccessful sonohysterography, hysteroscopy/D&C revealed inactive endometria in six, and three polyps. Our paradigm of evaluating the endometrial response to tamoxifen is concluded to overcome the shortcomings of either unenhanced transvaginal ultrasound or blind biopsy alone while it kept the number of invasive sampling procedures to 55% (24 out of 44).

Estrogen and progesterone receptors in the uterosacral ligament.

OBJECTIVE: To evaluate steroid hormone receptor status in the uterosacral ligament, a structure that contributes to pelvic support. METHODS: A descriptive study was conducted by sampling the uterosacral ligaments from 25 consecutive women undergoing hysterectomy by the primary author for nonmalignant conditions. Using immunohistochemical staining techniques, uterosacral ligaments were assessed for the presence and location of estrogen and progesterone receptors. Positive and negative controls were used. Confirmation of the uterosacral ligament was performed histologically. RESULTS: Using commercially available monoclonal antibodies, estrogen and progesterone receptors were detected in the nuclei of smooth muscle cells of the uterosacral ligament in all patients, regardless of variations in age, race, menopausal status, parity, body mass index, and medications affecting serum steroid hormone levels. Hormone receptors were not found in the collagen, vascular, or neuronal components. CONCLUSION: The presence of estrogen and progesterone receptors in the uterosacral ligaments means that this structure may be a target for estrogen and progesterone. This finding might suggest a possible role for steroid hormones in pelvic support.

Long-term analysis of the surgical management of pelvic support defects.

OBJECTIVE: The aim of this study was to determine the success of various procedures to correct defects of pelvic support and to elucidate the role of sacrospinous ligament fixation in primary versus nonprimary vaginal operations. STUDY DESIGN: This study was a retrospective analysis, covering 23 years, of 486 patients treated for pelvic support defects, grouped according to the location and severity of the defect, type of repair, and outcome. RESULTS: For primary repairs the recurrences were more frequent the more severe the defect, but this relationship did not hold for repeat surgery. Sacrospinous ligament fixation, when performed concurrently with vaginal hysterectomy for patients with third-degree prolapse in primary cases reduced the rate of recurrence from 15.8% to 6.7%. CONCLUSION: The original degree and type of pelvic support defect is important in selecting the appropriate operative procedure for the highest likelihood of cure. There may be a wider role for sacrospinous ligament fixation in primary operations for patients with severe defects.

Incarcerated uterine prolapse associated with a cul-de-sac abscess.

BACKGROUND: Incarceration is a rare complication of uterine prolapse and is usually associated with bladder calculi. We report a case of uterine incarceration associated with an abscess in the cul-de-sac. CASE: A 64-year-old woman presented with complaints of vaginal prolapse. Pelvic examination on admission revealed an edematous, prolapsed uterus and eversion of the vagina. The bladder was catheterized, and subsequent attempts to reduce the prolapse were unsuccessful. Conservative treatments were initiated including Trendelenburg positioning, estrogen cream, and moist soaks. Failure to reduce the prolapse under general anesthesia necessitated a vaginal hysterectomy and anteroposterior repair. When the cul-de-sac was entered, there was purulent material draining from an abscess behind the uterus. Postoperatively, the patient received antibiotics for 3 days and was sent home on day 4. CONCLUSIONS: Irreducible uterine prolapse is a rare condition and may be attributed to a narrowed introitus, bladder calculi, or pelvic abscesses. Historically, conservative management has attempted to alleviate the edema and restore the prolapse, to allow definitive surgery at a later date. We believe that the pelvic abscess in our case exemplifies a danger of delaying surgery. We recommended that when the patient is in stable condition, a hysterectomy and plastic repair be performed promptly.

An epidemic of maternal thrombocytopenia associated with elevated antiplatelet antibody. Platelet count and antiplatelet antibody in 116 consecutive pregnancies: relationship to neonatal platelet count.

Twenty-eight (24%) of 116 pregnant women studied prospectively during an 8-month period in 1983 had platelet counts of less than 150,000/mm3 at least once during pregnancy. Thirteen of these were thrombocytopenic in both the prenatal and the peripartum period. Eighteen were restudied 3 to 12 months after delivery. One woman, who was pregnant again, had a platelet count of 140,000/mm3. In the others, platelet counts were in the normal range. Platelet-associated immunoglobulin G and serum antiplatelet antibody levels were elevated in 79% and 61%, respectively, of these 28 women on at least one occasion. However, 59% of 73 pregnant nonthrombocytopenic women had increased platelet-associated immunoglobulin G levels and 59% had positive serum antiplatelet antibody test results. Twenty women who had increased platelet-associated immunoglobulin G levels and positive serum antiplatelet antibody test results were normal 6 to 10 months after delivery. Of 105 infants studied, 10 were thrombocytopenic. Neonatal thrombocytopenia was not predicted by maternal platelet count, platelet-associated immunoglobulin G, or serum antiplatelet antibody. By the fall of 1984, the incidence of thrombocytopenia had dropped to two in 280 consecutive pregnancies. We conclude that (1) epidemics of thrombocytopenia can occur in pregnant women and (2) if a women is found to be thrombocytopenic for the first time during pregnancy, she should not be subjected to the measures advocated for the management of pregnancy in women with autoimmune thrombocytopenic purpura.

Changing indications for vaginal hysterectomy.

The recent history of vaginal hysterectomy in America is summarized to bring current trends into focus. A series of 252 vaginal hysterectomies is analyzed. The discussion deals with factors contributing to morbidity, the relative advantages of various techniques, and the recognition and management of complications.

Pregnancy in familial dysautonomia.

This report describes the first two known instances of viable pregnancies in two patients with familial dysautonomia (Riley-Day syndrome). The offspring were apparently normal. Several conditions, specifically related to autonomic and sensory dysfunction in pregnancy, are discussed.

Indications for hysterectomy and for oophorectomy in various adult age groups - in audit.

PIP: Hysterectomy is indicated for specific diseases of the uterus and for sterilization. Now that modern methods of contraception are available and abortion laws have been liberalized it should be possible in many instances to avoid sterilization procedures. Oophorectomy is indicated in the presence of ovarian disease, for castration in selected patients with carcinoma of the breast, and as prophylaxis against the potential development of carcinoma of the ovary. Incidental oophorectomy at the time of pelvic surgery generally should be reserved for women in their 40s in whom the anticipated functional lifetime of the ovary is less than 5-10 years and who may receive supplemental exogenous hormones. The operative risk of hysterectomy is greater than for tubal ligations, but comparisons usually fail to consider the risk of the disease for which the hysterectomy is performed. Generally, women in their 20s who wish only sterilization should be able to retain their uteri. A careful history should be taken and a physical examination given in order to eliminate the possibility of pelvic abnorm alities such as fibroids, adenomyosis, endometriosis, and dysplasia that may necessitate a future hysterectomy.^ieng