Symptomatic arteriovenous malformation of Bartholin's gland. A case report.

BACKGROUND: Arteriovenous malformations are composed of large, tortuous arteries and misshapen, veinlike structures. They are extremely uncommon in the genital tract. CASE: An arteriovenous malformation in a Bartholin gland presented as intermittent vaginal bleeding in a 43-year-old woman. CONCLUSION: Persistent unexplained bleeding from Bartholin's gland requires surgical excision.

Predictive value of history and physical examination in patients with suspected ectopic pregnancy.

STUDY OBJECTIVE: To identify historical and physical examination findings that are predictive of ectopic pregnancy (EP) in pregnant patients with abdominal pain or bleeding. METHODS: This study was conducted in an urban academic emergency department as a prospective observational study of consecutive patients from August 1, 1991, to August 31, 1992, who had abdominal pain or vaginal bleeding and a positive beta-human chorionic gonadotropin level. Patients were excluded if they had a diagnostic ultrasound during a previous visit, or if the uterine size was larger than 12 weeks by pelvic examination. Data were analyzed using chi2 with a P value less than. 05 identified as significant. Odds ratios were determined for significant variables. A classification and regression tree analysis was then performed using the predictive variables to derive a decision tree. RESULTS: Four hundred forty-one patients were enrolled, 57 of whom (13%) had an EP. Factors by history that increased the risk of EP included pain that was described as moderate to severe, lateral, or sharp. Pain located in the midline decreased the risk of EP. A history of previous intrauterine device use, infertility, prior pelvic surgery, or tubal ligation were each found to be predictive. On physical examination, the presence of peritoneal signs, cervical motion tenderness, or lateral or bilateral abdominal or pelvic tenderness increased the risk of EP. A uterine size larger than 8 weeks by pelvic examination decreased the risk of EP. Combinations of predictive variables identified subsets of patients with either an increased or decreased frequency of EP, but in no case was a combination identified that would confirm or exclude this diagnosis with a high degree of certainty. CONCLUSION: History and physical examination findings predictive of EP were identified. However, no constellation of findings could confirm or exclude this diagnosis with a high degree of reliability.

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.