Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion.

OBJECTIVE: Presentation of outcomes of pelvic arterial embolization for hemorrhage after spontaneous or induced abortion. STUDY DESIGN: We collected case reports of embolization after spontaneous or induced abortion from oral presentations and from members of the National Abortion Federation. RESULTS: Pelvic arterial embolization was performed for 11 women who had hemorrhage after spontaneous or induced abortion, and it was initially successful for all women. One woman ultimately required a hysterectomy after unsuccessful repeated embolization. Prophylactic embolization was done for 8 women who were at risk for hemorrhage from placenta accreta; 4 of these women had subsequent hysterectomies. CONCLUSIONS: Selective pelvic arterial embolization may be a successful treatment for hemorrhage associated with spontaneous and induced abortion. Embolization can be considered before hysterectomy is undertaken for control of hemorrhage. There may be a role for prophylactic catheterization or embolization when there is a risk of severe hemorrhage.

Brain perfusion monitoring with frequency-domain and continuous-wave near-infrared spectroscopy: a cross-correlation study in newborn piglets.

The newborn piglet brain model was used to correlate continuous-wave (CW) and frequency-domain (FD) near-infrared spectroscopy. Six ventilated and instrumented newborn piglets were subjected to a series of manipulations in blood oxygenation with the effects on brain perfusion known to be associated with brain hypoxia-ischaemia. An excellent agreement between the CW and FD was demonstrated. This agreement improved when the scattering properties (determined by the FD device) were employed to calculate the differential pathlength factor, an important step in CW data processing.

Role of frequency domain optical spectroscopy in the detection of neonatal brain hemorrhage--a newborn piglet study.

OBJECTIVE: Inability of continuous wave (CW) optical spectroscopy to measure changes in scattering, and the use of an arbitrary rather than an actual baseline, makes the CW method highly susceptible to errors that can lead to a false-positive or false-negative diagnosis. Our objective was to assess whether, and to what extent, the use of quantitative frequency domain spectroscopy would improve our ability to detect and monitor the development of brain hemorrhage. METHODS: A dual-channel frequency-domain tissue spectrometer (Model 96208, ISS, Inc., Champaign, IL) was used to monitor the development of experimental subcortical and periventricular-intraventricular hemorrhage (IVH) in 10 newborn piglets (blood injection model). The multidistance approach was employed to calculate the absorption and reduced scattering coefficients and hemoglobin changes from the ac, dc, and phase values acquired at four different source-detector distances and at 752 nm and 830 nm. RESULTS: There were significant absorption and scattering changes in the subcortical hematoma (n = 5) and the IVH groups (n = 5). The smallest detectable amount of blood in the brain was 0.04 ml. Changes associated with subcortical hematoma were several times higher than those associated with IVH, and correlated better with the estimated cross-sectional area of the hematoma than with the volume of the injected blood. As opposed to IVH, there was a significant absorption difference between the injured (subcortical hematoma) and normal side of the brain, probably because in case of IVH a significant volume of the injected blood had accumulated/spread beyond the reach of the probe. CONCLUSION: Clearly, frequency-domain spectroscopy cannot increase our ability to quantify the volume (size) or the oxygenation of the injected blood, especially in the case of IVH. However, the ability to quantify the baseline tissue absorption and scattering would significantly improve diagnostic performance, and may allow for early identification and treatment of neonatal brain hemorrhage.

Real-time optical imaging of experimental brain ischemia and hemorrhage in neonatal piglets.

Our objective was to study the development of experimental brain ischemia and hemorrhage by real-time optical imaging. Optical imaging is based on the ability of near infrared light to non-invasively penetrate through the intact scalp and skull and measure brain concentrations of oxy- and deoxyhemoglobin, dominant brain absorbers. Optical imaging was performed in 7 anesthetized, instrumented, and ventilated newborn piglets subjected to the injection of 0.3 cc of saline followed by 2 cc of blood into the left frontal subcortical brain region via a needle inserted through the skull with stereotactic guidance. The image-acquisition rate of 5.26 images per sec allowed for real-time imaging. The detection threshold of the imager at the estimated depth of 1-1.5 cm was approximately 70 microL for saline and approximately 40 microL for blood. The imager readily detected five subcortical hematomas and two large bilateral subarachnoid hemorrhages. The imager detected a global decrease in brain absorption associated with the volume-injection-related increase in intracranial pressure in the surrounding ipsilateral and contralateral brain. Any decrease in brain absorption is an equivalent to brain ischemia. This study demonstrates the capability of optical imaging in detecting brain ischemia and hemorrhage in real-time with high temporal and spatial resolution.

Non-invasive optical monitoring of the newborn piglet brain using continuous-wave and frequency-domain spectroscopy.

We have used continuous-wave (CW) and frequency-domain spectroscopy to investigate the optical properties of the newborn piglet brain in vivo and non-invasively. Three anaesthetized, intubated, ventilated and instrumented newborn piglets were placed into a stereotaxic instrument for optimal experimental stability, reproducible probe-to-scalp optical contact and 3D adjustment of the optical probe. By measuring the absolute values of the brain absorption and reduced scattering coefficients at two wavelengths (758 and 830 nm), frequency-domain spectroscopy provided absolute readings (in contrast to the relative readings of CW spectroscopy) of cerebral haemoglobin concentration and saturation during experimentally induced perturbations in cerebral haemodynamics and oxygenation. Such perturbations included a modulation of the inspired oxygen concentration, transient brain asphyxia, carotid artery occlusion and terminal brain asphyxia. The baseline cerebral haemoglobin saturation and concentration, measured with frequency-domain spectroscopy, were about 60% and 42 microM respectively. The cerebral saturation values ranged from a minimum of 17% (during transient brain asphyxia) to a maximum of 80% (during recovery from transient brain asphyxia). To analyse the CW optical data, we have (a) derived a mathematical relationship between the cerebral optical properties and the differential pathlength factor and (b) introduced a method based on the spatial dependence of the detected intensity (dc slope method). The analysis of the cerebral optical signals associated with the arterial pulse and with respiration demonstrates that motion artefacts can significantly affect the intensity recorded from a single optode pair. Motion artefacts can be strongly reduced by combining data from multiple optodes to provide relative readings in the dc slope method. We also report significant biphasic changes (initial decrease and successive increase) in the reduced scattering coefficient measured in the brain after the piglet had been sacrificed.

Fetal atrial septal aneurysm. Prenatal diagnosis by ultrasonography.

OBJECTIVE: To assess prenatal diagnosis by ultrasonography in five cases of fetal atrial septal aneurysm. STUDY DESIGN: Five cases of fetal atrial septal aneurysm were diagnosed prenatally by ultrasound. Postpartum fetal cardiac echocardiography was performed in three of five infants from the first to the fourth day of life. The medical records of the five cases were reviewed and analyzed after delivery. RESULTS: Echocardiograms confirmed atrial septal aneurysm in two of the three neonates. One of the two infants was also found to have a patent foramen ovale, and the other infant had patent duct arteriosis in addition to a patent foramen ovale. Two had fetal cardiac arrythmias that resolved after birth. CONCLUSION: Atrial septal aneurysm in fetuses may be a natural transition in spontaneous closure of the associated patent foramen ovale or septal defect. The same phenomenon has been found in children and infants. Due to the uniqueness of the fetal circulation, atrial septal aneurysm may predispose to fetal arrythmias.

Septic shock, adult respiratory distress syndrome, and disseminated intravascular coagulopathy following midtrimester genetic amniocentesis.

BACKGROUND: Midtrimester genetic amniocentesis is a commonly performed procedure, with acknowledgment of some risk to mother and fetus. CASE: We present an unusual case of midtrimester genetic amniocentesis with bowel injury and resulting septic shock, adult respiratory distress syndrome, and disseminated intravascular coagulation. A total abdominal hysterectomy and bilateral salpingoophorectomy were required for resolution of sepsis. The patient also required prolonged ventilatory support postoperatively. CONCLUSION: Although relatively safe, genetic amniocentesis can result in serious morbidity, and attention to technique should be maintained.

Massive vulvar edema complicating tocolysis in a patient with twins. A case report.

BACKGROUND: Severe vulvar edema is an extremely rare complication of pregnancy. One other case of tocolysis-induced vulvar edema has been reported, as have five cases of postpartum vulvar edema, associated with an 80% maternal mortality rate. CASE: A multipara with a twin gestation presented with premature labor at 31 weeks. The patient had no history of trauma, lymphatic obstruction, venous obstruction or infection. On the fifth day of tocolysis with magnesium sulfate, nifedipine, terbutaline and betamethasone, edema developed in both labia. The following day the vulvar edema had increased and spread to the sacrum. The patient was normotensive and afebrile. Resolution occurred in spite of continuous tocolytic therapy, which was stopped at 35 weeks. Two days later, on hospital day 27, the patient spontaneously delivered two healthy, male infants. CONCLUSION: The two reported cases of tocolysis-induced vulvar edema were not fatal and resolved after repositioning the patient in one case and by cesarean section in the other. However, since maternal death has occurred with postpartum vulvar edema, the patient with vulvar edema merits special attention. The WBC count should be determined and the patient's circulatory status evaluated to rule out hypovolemia.

Prenatal diagnosis of fetal bladder and cloacal exstrophy by ultrasound. A report of three cases.

BACKGROUND: Bladder and cloacal exstrophy can be diagnosed with prenatal ultrasound. CASES: Three cases of bladder and cloacal exstrophy were diagnosed prenatally by ultrasound and confirmed at birth. The ultrasound findings were a soft tissue mass in the lower abdominal wall (which appeared larger and more heterogeneous in cloacal exstrophy than in bladder exstrophy), absent bladder, malformation of the external genitalia and normal kidneys along with normal amniotic fluid volume. CONCLUSION: Prenatal diagnosis of these defects will allow appropriate referrals prior to birth.

Randomized controlled trial of vaginal misoprostol and intracervical prostaglandin E2 gel for induction of labor at term.

OBJECTIVE: To compare misoprostol 25 micrograms administered at 2-hour intervals with intracervical prostaglandin (PG) E2 in women with Bishop scores of 5 or less. METHODS: Subjects were randomly assigned to receive either misoprostol 25 micrograms every 2 hours or a commercially available intracervical preparation containing 0.5 mg of PGE2 gel administered at 6-hour intervals for a maximum of two doses. RESULTS: Women who received misoprostol experienced a significantly reduced mean time (+/- standard deviation) from drug administration to onset of three contractions in 10 minutes, 6.7 +/- 5.8 versus 12.4 +/- 9.6 hours (P = .007). Mean time to rupture of membranes was also shorter in the misoprostol group, 9.7 +/- 5.5 versus 13.6 +/- 6.8 hours (P = .01), as was the mean time to delivery, 16.0 +/- 7.7 versus 22.4 +/- 10.9 hours (P = .006). Three patients in the misoprostol group experienced uterine hypertonus but not related fetal morbidity. CONCLUSION: Misoprostol is more effective than intracervical PGE2 in bringing about labor and delivery, but further work is needed to determine the ideal dosing regimen.

Evaluating the role of incidental diagnostic dilation and curettage in young women undergoing elective laparoscopic sterilization.

Two hundred twenty-two women undergoing incidental diagnostic dilation and curettage (D&C) at the time of elective laparoscopic tubal ligation were studied retrospectively to ascertain if the risks of a D&C were warranted in a group of young, healthy women with a low risk of endometrial pathology. The endometrial sampling was associated with five uterine perforations and one readmission for bleeding and did not uncover any significant pathology in women under 35. The endocervical curettings did yield pathology of some clinical significance in women of all ages. The risk of uterine perforation was significantly higher in women who were < 15 weeks postpartum. We conclude that in a population of asymptomatic women under the age of 35, a diagnostic D&C is not indicated at the time of elective laparoscopic tubal ligation.

PIP: The question of whether the significant risks associated with a dilatation and curettage (D&C) are warranted in a population of young, healthy women prompted a closer examination of performing an incidental diagnostic D&C routinely to detect asymptomatic endometrial pathology. All charts of patients undergoing elective laparoscopic tubal ligation (LTL) with an incidental D&C at Maine Medical Center in the years 1989 and 1990 were reviewed. Parameters examined were age, gravidity, and parity. The medical history was reviewed, noting any history of menstrual abnormalities, bleeding, or abnormal cytologic smears. 222 charts were reviewed. The mean age of the LTL/D&C patients was 33.3 years, mean gravidity was 2.7, and mean parity was 2.0. Five patients sustained uterine perforation at the time of D&C. Four of the 5 perforations occurred in women who were 15 weeks postpartum; only 17 of the 189 parous women without perforation (9%) were 15 weeks postpartum (relative risk, 33.0). These 4 women averaged 10.5 weeks postpartum (range, 7-15). One additional patient required hospital admission postoperatively for excessive bleeding. Pathologic findings of endometrial specimens were normal in 200 cases; the diagnosis was either proliferative, secretory, menstrual, or inactive endometrium. Endocervical curettage pathology was normal in 152: the findings were read as benign, squamous metaplasia, cervicitis, or squamous metaplasia with cervicitis. In 53 cases no endocervical specimen was sent. 17 patients had findings that could have been of clinical significance. 16 patients gave a history of an abnormal cytologic smear. Of the 129 women under the age of 35, only 2 had endometrial lesions of possible significance. All other endometrial lesions occurred in women over 35 years, thus sampling the endometrium may be warranted in them. A routinely performed D&C is not warranted in women less than 35 years old who have no history of abnormal vaginal bleeding. The results also indicate that the risk of uterine perforation appears to be markedly increased up to 15 weeks postpartum.

A pilot study of cyclosporine for the prevention of postsurgical adhesion formation in rats.

OBJECTIVE: Our purpose was to evaluate the efficacy of cyclosporine in preventing primary postsurgical adhesions in the rat model. STUDY DESIGN: Thirty-two Sprague-Dawley rats underwent unilateral uterine horn injury with a combination of unipolar and bipolar cautery. Sixteen of the rats were randomized to the treatment group and received preoperative and daily cyclosporine dosing (10 mg/kg) by gavage for 14 days. At the end of the study all animals were killed, and a standard adhesion scoring system was applied by a blinded examiner. RESULTS: Adhesions were present in 75% of rats in both groups. Treatment did not affect the total adhesion score. CONCLUSION: Cyclosporine does not appear promising as a means to decrease postsurgical adhesion formation.

Use of a coagulation analyzer in managing disseminated intravascular coagulation after midtrimester pregnancy termination. A case report.

A case of disseminated intravascular coagulation occurred with midtrimester dilation and evacuation. The case was treated successfully but required substantial volumes of blood products. The use of a coagulation analyzer facilitated the diagnosis and treatment.

Septic abortion.

PIP: Abortion-related deaths, which account for 47% of total maternal mortality in the world, result primarily from sepsis and are widespread in developing countries where abortion is illegal or inaccessible. Septic abortion offers opportunities for prevention on the primary, secondary, and tertiary level of medial care. Primary prevention of septic abortion encompasses the provision of effective contraception, provision of safe and legal abortion in cases of contraceptive failure, and appropriate medical management of abortion. Secondary prevention involves the prompt diagnosis of endometriosis and effective treatment to avert more serious infection. The diagnosis of septic abortion should be considered when women of reproductive age present to health facilities with vaginal bleeding, lower abdominal pain, and fever. Tertiary prevention is aimed at avoiding the serious complications of postabortal infection, including hysterectomy and death. Women with high fever, pelvic peritonitis, and tachycardia should undergo uterine evacuation and parental antibiotic therapy. Supportive care for cardiovascular system and other organs may be essential. The medical technology needed to avert serious complications and deaths from septic abortion is available. Lacking is a political commitment on the part of many governments and health care agencies to address this avoidable contributor to maternal morbidity and mortality.^ieng

Menstrual impact of contraception.

Persistent bleeding is a common reason for the discontinuation of contraception. Standard terminology for describing bleeding patterns by reference period is presented. Observed bleeding patterns with oral contraceptives, depot medroxyprogesterone acetate, the levonorgestrel subdermal implant, and intrauterine devices are described. Bleeding days are least with oral contraceptives that are highest in progestin and estrogen potency and dose, but the ratio of the two steroids is also important. Published studies suggest that oral contraceptives containing new nonandrogenic progestins have bleeding patterns as acceptable as older low estrogen formulations. Approaches to the evaluation and treatment of intermenstrual bleeding with contraceptive methods are reviewed. Patient education on expected bleeding patterns is essential to compliance and continuation.

PIP: Many women discontinue hormonal contraceptives because of persistent bleeding. Discontinuation can result in unwanted pregnancy. Hormonal contraceptives may have 2 effects on the menstrual cycle: continued cyclic bleeding or partial or complete suppression of the normal cycle. Oral contraceptives (OCs) suppress the normal ovarian cycle with an artificial cycle caused by withdrawal of the hormones on day 21. Progestin-only OCs, subdermal implants, injectable steroids, and the levonorgestrel-releasing IUD cause partial or complete suppression of the normal cycle. OCs with the highest progestin and estrogen potency and dose are associated with the least number of bleeding days. The ratio of the 2 steroids may affect bleeding. For example, an increase in either steroid appears to decrease breakthrough bleeding (BTB). In some women, BTB or spotting is associated with OC use. Clinical trials of OCs do not use standard terminology and definitions, making it difficult to analyze bleeding patterns. OCs with the new nonandrogenic progestins and low-estrogen doses tend to effect acceptable bleeding patterns similar to those of the older low-dose estrogen OCs. Among Norplant users experiencing persistent bleeding, levonorgestrel (0.03 mg 2 times/day for 20 days), ethinyl estradiol (0.05 mg/day for 20 days), and ibuprofen (800 mg 3 times/day for 5 days) reduce bleeding days and episodes of treatment. Some possible regimens to treat persistent bleeding in OC users include 7 day courses of estrogen (0.02 mg ethinyl estradiol or 2.5 mg conjugated equine estrogens). When BTB occurs in an OC user who has previously had normal menstrual cycles, providers should consider causes other than OCs, such as trauma-vaginal laceration, cervical lesion, endometrial lesion, fallopian tube cancer, and pregnancy. They should deliver good patient education on bleeding patterns to achieve good compliance and continuation.

Treatment of twin-twin transfusion syndrome.

OBJECTIVE: To determine whether therapeutic amniocentesis may improve outcomes in patients with twin-twin transfusion syndrome. METHODS: Thirteen patients with possible twin-twin transfusion syndrome were evaluated for treatment. Therapeutic amniocenteses were performed on nine, and four patients were managed conservatively depending on the clinical severity of the twin-twin transfusion syndrome. RESULTS: Therapeutic amniocenteses resolved the syndrome in three of nine cases, with an overall neonatal survival rate of 83.3% (15 of 18) and neonatal morbidity of 53.3% (eight of 15) among the survivors. The survival rate in patients with expectant management was 75% (six of eight), with a neonatal morbidity of 33.3% (two of six). An association between amniotic fluid status and fetal outcomes was observed. Patients with normalization of polyhydramniosoligohydramnios had the best outcomes. CONCLUSION: Early, aggressive amniocentesis may be an effective therapy for twin-twin transfusion syndrome. Therapeutic amniocentesis may have the capability to alter inter-fetal blood flow, possibly as a result of changes in intravascular pressure, which are related to changes in intra-amniotic pressure.

The effects on hemostasis of oral contraceptives containing desogestrel.

Epidemiologic research has shown that current low-dose estrogen oral contraceptives are associated with a low risk of vascular events (e.g., myocardial infarction, stroke, and venous thrombosis or thromboembolism). Yet questions still persist about the effects of low-dose oral contraceptives on the cardiovascular system. Changes in the coagulation system have been linked primarily to the estrogen component; however, it has been proposed that the progestin may have an influence on the fibrinolytic system. Desogestrel, a new gonane progestin, has been commercially available in Europe since 1981. It has been widely shown to produce minimal changes of the coagulation and fibrinolytic systems, and it has not been associated with an increased risk of thromboembolic disorders.

PIP: Epidemiologic research has correlated current low-dose estrogen oral contraceptives with a low risk of myocardial infarction, stroke, and venous thrombosis or thromboembolism. Nevertheless, misgivings still linger about the effects of low-dose oral contraceptives on the cardiovascular system. Changes in the coagulation system have been linked primarily to the estrogen component; however, the progestin may have an influence on the fibrinolytic system. Oral contraceptives (OCs) containing desogestrel, a new progestin, became commercially available in Europe in 1981. Since that time, more than 30 million women have used the monophasic preparation containing 150 mcg of desogestrel and 30 mcg of ethinyl estradiol. During this widespread clinical use, desogestrel-containing OCs have not been associated with an increase in the risk of thromboembolic disorders. A total of 13 studies from different countries involving different ethnic groups were reviewed concerning the effects of OCs containing novel progestins on coagulation and fibrinolytic variables. The observed changes indicate that a new balance has occurred, increases in both procoagulation and profibrinolysis factors and their inhibitors. With the exception of two studies, all studies were comparative versus a variety of low-dose oral contraceptives. None of the studies observed a notable difference between the desogestrel OC and the comparison OC, and no incidental difference between OCs was confirmed in a subsequent study. This lack of a specific progestin effect confirms an earlier theory that any thrombogenic effect of oral contraceptives is caused by the estrogen component. Desogestrel differs from progestins currently in use in its lower relative androgenicity, which eliminates or reduces adverse effects on lipid and carbohydrate metabolism. The use of the desogestrel-containing OC is associated with minimal changes in the coagulation and fibrinolytic systems. A careful medical and family history rather than the selection of a particular OC combination is an effective means of preventing thromboembolic disorders.

Cigarettes, coffee, and preterm premature rupture of the membranes.

Premature (prior to 37 completed weeks of gestation) rupture of the membranes (preterm PROM) is one of the most common underlying causes of preterm delivery. However, there have been few epidemiologic studies of this obstetric complication. The authors studied the relation of maternal cigarette smoking and coffee consumption to both preterm PROM and spontaneous preterm labor not complicated by premature rupture of the membranes (preterm NONPROM) in a large cross-sectional data base. The 307 preterm PROM and 488 preterm NONPROM cases who delivered during 1977-1980 at the Boston Hospital for Women were compared with 2,252 randomly selected women who delivered at term at that institution. Multiple logistic regression techniques were used to derive maximum likelihood estimates of adjusted odds ratios (OR) and 95% confidence intervals (CI). After confounders had been adjusted for, the relative risk of preterm PROM for women who reported ever having smoked during pregnancy, as compared with nonsmokers, was 1.6 (95% CI 1.1-2.4). However, no gradient between the number of cigarettes smoked per day and the risk of preterm PROM was observed. Similar results were observed for preterm NONPROM. Women who consumed three or more cups of coffee daily during the first trimester had a 2.2-fold greater risk of preterm PROM than did women who drank two or fewer cups (95% CI 1.5-3.3). Among coffee drinkers, there was some evidence of a linear trend in the risk of preterm PROM as coffee consumption increased. Consumption of three or more cups of coffee per day was less strongly associated with the occurrence of preterm NONPROM (adjusted OR = 1.4, 95% CI 1.0-1.9).

Intraovarian abscess treated with laparoscopic aspiration and povidone-iodine lavage. A case report.

Intraovarian abscess is an unusual form of pelvic inflammatory disease usually managed with laparotomy. A patient with prolonged morbidity from an intraovarian abscess following pelvic inflammatory disease associated with an intrauterine contraceptive device was managed with laparoscopically guided needle aspiration of the abscess and povidone-iodine lavage. Laparoscopy should play a greater role in the management of pelvic inflammatory disease.