Placenta accreta: Elective versus emergent delivery as a major predictor of blood loss.

OBJECTIVE: To compare blood loss and the use for blood transfusion between elective (planned) and emergent cesarean hysterectomy performed for placenta accreta by a single, multidisciplinary team and to present the team's pre-operative evaluation and the surgical technique. STUDY DESIGN: Prospective cohort study at a single tertiary care center. Maternal and neonatal outcomes were compared between elective and emergent delivery of pregnancies complicated by placenta accreta. The primary outcomes were the need for blood transfusion and the number of units transfused. RESULTS: A total of 28 cases of confirmed placenta accreta underwent peripartum hysterectomy, including 22 as elective and 6 as emergent. Eleven out of 22 (50%) subjects in the elective group received blood transfusion, while all subjects in the emergency group required transfusion (p = 0.03). More importantly, the number of units of packed red blood cells transfused was only 1.90 (±2.20) units in the elective cases compared to 7.83 (±4.90) units in cases performed emergently (p = 0.03). CONCLUSION: Elective cesarean hysterectomy for this indication using a clearly outlined surgical approach is associated with significantly lower blood loss and hence less need for transfusion, compared to its emergent counterpart.

Laparoscopic splenectomy for isolated parenchymal splenic metastasis of ovarian cancer.

Metastatic carcinoma of the spleen occurs in a setting of widespread malignant disease. Solitary parenchymal splenic metastasis of ovarian carcinoma is rare. We report a case of a 59-year-old woman who presented with an elevated serum CA125 level due to a solitary splenic metastasis after a long disease-free period. She was treated with laparoscopic splenectomy followed by chemotherapy. The literature contains 16 cases of solitary parenchymal splenic metastasis of ovarian carcinoma. Our case is the third case that was treated with laparoscopic splenectomy. We review the literature, and we focus on the laparoscopic approach in managing these cases.

Prevalence of genital human papillomavirus among Lebanese women.

PURPOSE: The purpose of this study was to determine the prevalence of human papillomavirus (HPV), and more specifically of HPV 16, in a group of Lebanese women. MATERIALS AND METHODS: Type-specific prevalence of cervical HPV and the presence of cytological abnormalities were determined in a cohort of Lebanese women. The population included 1,026 women, 18-76 years, seeking routine gynecological care at a tertiary care center. Demographic and behavioral data were collected. HPV DNA was detected in cervical scrapes by polymerase chain reaction using consensus primers. Cervical cytological abnormalities were identified by Papanicoleau (Pap) smears. RESULTS: The mean age of our population was 40 +/- 11.3 years. General HPV DNA was detected in 50 patients (4.9%). The high-risk HPV type 16 DNA was detected in 31 patients (3%). Patients with HPV 16 were more likely to have an abnormal pap smear than those with negative tests (6.6% vs 1.6%, p < 0.05), and more likely, but not significantly, to be smokers (21.4% vs 18.4%, p = 0.5). The age-specific prevalence of HPV increased with age and peaked at 60-69 years. CONCLUSIONS: The prevalence of HPV in this small group of Lebanese women is similar to its prevalence in the Mediterranean countries. The presence of HPV, its known association with the development of cervical neoplasia, and the lack of a universal screening program for cervical cancer in our country should be used to enforce implementation of proper screening programs.

Primary umbilical endometriosis.

A case of primary solitary umbilical endometriosis is presented. The presentation, differential diagnosis and work-up is discussed and the literature is reviewed.

Estimation of body fat from skinfold thickness.

The fat content of the human body has physiological and medical importance. It may influence morbidity and mortality, it may affect the ability to withstand exposure to cold and starvation, and it may alter the effectiveness of drugs and anaesthetics. It may also be the cause of reduced insulin sensitivity in some population groups. Thus, the measurement of the total body fat provides useful information. A computer program, written in quick basic language, was developed, to compute the equivalent fat content, as a percentage of body-weight, for a range of values for the sum of the four skinfolds, of Egyptian males and females of different ages. This is based on a table developed by Durnin and Womersley. The computer program was run using skinfolds of Egyptian males and females of different ages. Satisfactory results were obtained. This program can be used to calculate the total body fat with relative ease and reasonable accuracy. This should make it of common use in many fields of medicine, physiology, nutrition and anthropology, particularly in population studies comprising a large number of subjects.

Case report: endometrial cancer implanting in the laparotomy scar.

A 58-year-old woman underwent abdominal hysterectomy and bilateral salpingo-oophorectomy for stage Ib, grade 2 endometrial adenocarcinoma followed by external pelvic irradiation. Five years later she presented with a 7 cm solitary infraumbilical incisional tumor recurrence that was resected. Histology of the tumor implant was similar to that of the primary cancer. The patient was then started on progestin therapy with no evidence of recurrence for four years. To our knowledge this is the fourth reported case of endometrial cancer implanting in an abdominal scar.

Giant cervical polyp. A case report.

BACKGROUND: Very large cervical polyps are rarely reported. CASE: A giant cervical polyp, 17 x 10 x 5 cm, protruded through the vaginal introitus in a 27-year-old, sexually inactive woman. CONCLUSION: Although carcinomatous change occurs in 1.7% of cervical polyps, malignant degeneration did not occur in the six reported cases. Thus, biopsy of these tumors before excision may not be necessary.

Prolonged intake of chlorambucil for ovarian cancer.

The use of alkylating agents has been reported to be a cause of secondary leukemia particularly in patients surviving for 2 years or more after treatment of ovarian carcinoma. The risk of developing leukemia is possibly related to the duration of treatment and the total dose of alkylating agents administered. We report a patient with epithelial ovarian carcinoma who received chlorambucil for 130 consecutive months with no clinical or laboratory evidence of leukemia.

Prenatal sonographic findings in trisomy 13, 18, 21 and 22. A review of 46 cases.

A study of 46 patients with trisomic fetuses was performed to determine if there are one or more second-trimester ultrasonic findings predictive of aneuploidy. Videotapes of ultrasonography performed prior to amniocentesis on the 46 fetuses with autosomal trisomy and from a control group of 50 chromosomally normal fetuses were reviewed without knowledge of the karyotype. Fetuses with autosomal trisomies had short long bones, especially femurs, as well as high biparietal diameter/femur length ratios. In addition, a nuchal thickness of > 5 mm, abnormal heart anatomy, slight pyelectasis, increased bowel echogenicity and/or abnormal flexion of the hands were all predictive of autosomal trisomies.

Leiomyosarcoma of the vulva: report of a case.

A 52-year-old female presented with a progressively enlarging vulvar mass. Pathological evaluation revealed a high-grade vulvar leiomyosarcoma. Immunohistochemical and ultrastructural studies were performed to support the diagnosis. In an effort to better understand the biology of this tumor additional immunohistochemical studies for the protein product of p53 tumor suppressor gene and estrogen receptor expression by tumor cells, as well as the type of immune cells infiltrating the tumor were performed. Tumor cells showed an overexpression of p53 protein and were estrogen receptor-positive. Macrophages and T and B lymphocytes infiltrated the tumor in moderate numbers with occasional lymphoid aggregate formation. This study is the first attempt to better understand the biology of these tumors.

Outcome of pregnancies complicated by sickle cell and sickle-C hemoglobinopathies.

Retrospective analysis was made of office and hospital records of patients with sickle cell hemoglobinopathies. Blood products were transfused only when indicated for symptomatic anemia, severe anemia with a hematocrit less than 18%, sickle crisis, cardiovascular instability, and preoperatively. The Fisher exact test and the Student t test were used for statistical analysis; P < 0.05 was considered significant. All mean values are reported +/- 1 standard deviation. From 1981 to 1991, 40 patients with sickle cell hemoglobinopathies had a total of 61 singleton pregnancies: 36 were complicated by SS disease (SSD), 22 by sickle cell disease (SCD), two by sickle-thalassemia, and one had CC disease (CCD). Only patients with SSD and SCD are reported here. The mean maternal age was 24.3 +/- 5.3 and 19.5 +/- 0.6 years in patients with SSD and SCD, respectively. There was a high occurrence of preterm labor (45% and 20%), preeclampsia (20% and 8.7%), pain crisis (50% and 34.2%), pulmonary complications (25% and 16.7%), and cesarean sections (52.6% and 37.1%) in SSD and SCD, respectively. An average of two units of blood was required by 43.1% of the patients. Two patients with SSD had unpreventable deaths. The mean gestational age at delivery was 35.5 +/- 4.3 and 37.0 +/- 3.7 weeks (P < 0.05), and the mean birthweight was 2443 +/- 926 and 2997 +/- 807 g (P < 0.05), respectively. There were two intrauterine fetal deaths and one neonatal death in the SSD group and one neonatal death in the SCD group. The perinatal mortality was 10.5% and 2.9%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war.

OBJECTIVE: To evaluate the value of selective laparotomy in pregnant women with penetrating abdominal injuries. METHODS: A retrospective survey was carried out at our center over 16 years of civil war, extending from 1975 to 1991. Fourteen pregnant women had uterine injuries secondary to high-velocity abdominal penetrating trauma. The corresponding management was evaluated carefully with respect to maternal and fetal outcomes. RESULTS: Two maternal deaths occurred, neither resulting solely from intra-abdominal injuries. Visceral injuries were present when the entrance of the missile was in either the upper abdomen or the back. When the entry site was anterior and below the uterine fundus, visceral injuries were absent in all six women upon surgical exploration. Perinatal deaths occurred in half of the cases and were due to maternal shock or uteroplacental or direct fetal injury. Immediate cesarean delivery was performed because of either limited surgical field exposure, fetal injury, or distress. Three patients explored were managed by delaying delivery. All later delivered vaginally with successful fetal outcomes in all three. CONCLUSION: Selective laparotomy may be considered in pregnant women with anterior penetrating abdominal trauma, as the likelihood of intra-abdominal injuries may be predicted based on the location of the penetrating wound.

Peritoneal papillary serous carcinoma in a woman with a history of utero DES exposure.

Antenatal exposure to diethylstilbestrol (DES) has been implicated in the development of clear-cell adenocarcinoma of the vagina and cervix. In addition, there are a handful of case reports of gram cell tumors and other benign ovarian tumors in the offspring of women treated with DES during pregnancy. This the first report of a papillary serous carcinoma of the peritoneum following in utero exposure to DES. As the population of women with a history of in utero exposure to DES is reaching into the fourth decade, these patients need to be closely monitored for the development of gynecologic malignancies, especially epithelial and germ cell ovarian tumors. We also encourage the reporting of these tumors of the DES registry to document the exact incidence of these malignancies.

Gynecologic tumors in tamoxifen-treated women with breast cancer.

OBJECTIVES: To present six additional cases of gynecologic tumors in tamoxifen-treated breast cancer patients, review the literature, and recommend measures for surveillance. METHODS: The hospital and office records of patients treated with tamoxifen at the University of Kansas Medical Center and Research Medical Center were analyzed. A comprehensive review of tamoxifen in the English and European literature was performed using MEDLINE and the bibliographies of various articles. RESULTS: From 1985-1992 at our institutions, six tamoxifen-treated breast cancer patients developed gynecologic tumors: three endometrial adenocarcinomas, a mixed müllerian sarcoma, a fallopian tube carcinoma with adenofibroma of the endometrium, and recurrent hyperplastic endometrial polyps. The literature contained 61 cases of adenocarcinoma of the endometrium and possibly four cases of uterine sarcomas in tamoxifen-treated breast cancer patients. The number of gynecologic malignancies reported is now 70. In 35 of the patients, the mean age (+/- standard deviation) was 63.9 +/- 12.0 years, and 61 of 66 patients (92.4%) were postmenopausal. Of the endometrial adenocarcinomas, 25 of 27 (92.6%) were stage I, and 11 of 27 (40.7%) were grade 1. The dose of tamoxifen was 20 mg/day in 15 (23.4%), 30 mg/day in 11 (17.2%), and 40 mg or higher in 38 (59.4%); 57% were treated with tamoxifen for less than 2 years. CONCLUSIONS: Tamoxifen is a safe and reliable treatment of breast cancer, but data suggest an association with endometrial cancer. We propose close monitoring of patients taking tamoxifen and prompt evaluation of any uterine bleeding or pelvic complaint.

Electrical breast stimulation. Oxytocin, prolactin and uterine response.

Electrical breast stimulation using a modified electromyograph was performed on 10 pregnant women between 38 and 42 weeks of gestation. An adequate uterine contraction pattern (at least three contractions lasting > or = 30 seconds in a 10-minute interval either recorded by external tochodynamometry, palpated and/or felt by the patient) was obtained in 8 of the 10. Two patients, however, had uterine hyperstimulation (contractions lasting > 90 seconds). In contrast to previous reports, serum oxytocin levels increased significantly in 7 of the 10 patients. Moreover, this increase preceded or was concomitant with the uterine contractions. Serum prolactin varied unpredictably following electrical breast stimulation. The stimulation was well tolerated, without any discomfort, by all the patients. Electrical breast stimulation can thus be used for the stimulation of uterine contractions.