Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies.

Previous retrospective studies have suggested that the prophylactic use of outlet forceps has a beneficial impact on the neonate because it shortens the second stage of labor and decreases the incidence of neonatal hypoxia. The purpose of this study was to compare the immediate maternal and neonatal effects of outlet forceps delivery (N = 165) with spontaneous vaginal delivery (N = 168) in term parturients. Subjects were randomized to the study or control group immediately before delivery. There were 88 nulliparas and 77 multiparas in the forceps delivery group and 90 and 78, respectively, who delivered spontaneously, a nonsignificant difference. There were no significant differences in gestational age, parity, infant birth weight, length of the first and second stages of labor, use of conduction (continuous epidural) anesthesia, decrease in hematocrit values, Apgar scores, or umbilical arterial pH values between the forceps and spontaneous delivery groups. Seventeen infants in the forceps group and 16 in the control group had cephalhematoma, facial bruising, subconjunctival hemorrhage, or scalp abrasion (not significant). No neonate had fractures, nerve palsies, or intracranial hemorrhage (determined by cranial ultrasound). In the nulliparous population, significant differences were found in the use of episiotomy (93 versus 78%) and the incidence of deep perineal lacerations (24 versus 10%) with forceps compared with spontaneous delivery, respectively (P less than .05). No significant differences between the groups were found in multiparas. We conclude that the use of outlet forceps in patients with uncomplicated labor has no immediate effect on the neonate. Furthermore, outlet forceps delivery does not significantly shorten the second stage of labor and is associated with an increased incidence of maternal perineal trauma.

Evaluation of serum haptoglobin levels in patients with adnexal masses.

Over a four-year period, serum haptoglobin was measured in 152 patients with adnexal masses in an attempt to discriminate between benign and malignant disease. When serum haptoglobin exceeded 150 mg/dl, malignancy could be identified with a sensitivity of 83% and a specificity of 84%. While the predictive value of a positive test is only 66%, the predictive value of a negative test is 93%, and this inexpensive test may be clinically useful. Stage, grade, and size of tumor did not correlate with serum haptoglobin levels.

Pregnancy following conservative surgery and adjunctive chemotherapy for stage III immature teratoma of the ovary.

A 24-year-old woman with stage III grade 3 immature teratoma of the ovary was treated with a unilateral salpingo-oophorectomy and nine courses of vincristine, actinomycin D, and cyclophosphamide combination chemotherapy. She had a negative second-look exploration; 30 months after initial surgery she became pregnant, and subsequently delivered a normal child at term. This is the first report of a successful pregnancy following conservative surgery and chemotherapy for advanced-stage immature teratoma.

Endocervical curettage in the evaluation of cervical disease in patients with adequate colposcopy.

The purpose of this study was to investigate the importance of endocervical curettage in the outpatient management of women with cervical neoplasia. From 1975-1985, 1500 patients were evaluated in our colposcopy clinic. Endocervical curettage was done routinely, even when colposcopy was adequate; 122 patients with abnormal cytology, an adequate colposcopic examination, and dysplastic epithelium in the endocervical curettings underwent conization. Of these 122 patients, 111 (91%) had cervical intraepithelial neoplasia on cone, one had microinvasion, and none had invasive cancer. In this group, there were 11 patients with abnormal cytology, normal coloposcopically directed biopsies of the ectocervix, and positive endocervical curettages. Nine of these 11 had dysplasia confirmed by conization, which would have been missed if endocervical curettage had not been performed.

Presacral neurectomy for chronic pelvic pain.

Over an eight-year period, 50 presacral neurectomies were performed at Madigan Army Medical Center for chronic pelvic pain failing response to medical management. Each hospital record was reviewed and 45 patients answered a questionnaire grading the severity of their pain from 0 to 10 for dysmenorrhea, dyspareunia, and other pelvic pain before and after surgery. The results showed success rates of 73% in relieving dysmenorrhea, 77% in relieving dyspareunia, and 63% in relieving other pelvic pains. The addition of a bilateral uterosacral ligament resection to the presacral neurectomy did not increase the success rate. There was an 18% lateral pelvic pain recurrence rate, and no recurrence of dysmenorrhea. Complications occurred in 4%.

Comparison of short and long courses of ampicillin for vaginal hysterectomy.

Administering perioperative antibiotic to reduce the morbidity associated with vaginal hysterectomy has become well accepted. Although both short and long courses of antibiotics are effective, the optimal length of treatment has not been well established by clinical studies. Our prospective study compared two groups of patients, one receiving a short course and the other a long course of ampicillin. Patients having vaginal hysterectomy were randomly assigned to the short or long course. Febrile morbidity, as well as serious morbidity and hospital stays, in the two groups was compared. Of 212 patients receiving the short course, 21 had febrile morbidity, while 14 of 215 patients receiving the long course had febrile morbidity. These rates were not significantly different. Furthermore, serious morbidity and length of hospital stay were not significantly different.

Value of a screening urinalysis in pregnancy.

In order to assess the value of a screening urinalysis in the detection of urinary tract infection, the results of routine urinalyses from 1,062 obstetric patients were compared to subsequent culture results. A positive urine culture was predicted by pyuria, bacteriuria and a positive nitrite test; the predictive values were 23%, 21% and 87%, respectively. If all the parameters were negative, 96% of the cultures were negative. These findings suggest that in the interest of cost effectiveness, the urine can be cultured only when the screening urinalysis shows pyuria, bacteriuria or a positive nitrite test.

Vaginal delivery for the selected frank breech infant at term.

A retrospective analysis of 254 term breech deliveries was done, with term breech presentations managed by a protocol in which cesarean section was done for nonfrank breech presentation, or estimated fetal weight in excess of 4000 g. Patients with frank breech presentation were assigned to one of three groups based on x-ray pelvimetry and estimated fetal weight. Of 70 group 1 patients (adequate pelvis with estimated fetal weight less than 3600 g), 79% had a vaginal delivery. Of 21 group 2 patients (borderline pelvis or estimated fetal weight of 3600 to 4000 g), 67% delivered vaginally. In group 3 (contracted pelvis or estimated fetal weight greater than 4000 g), all patients were delivered by cesarean section. The overall cesarean section rate for frank breech infants was 36%. Apgar scores were not significantly different for infants delivered vaginally or abdominally. The crude perinatal mortality rate was 11.8; the corrected perinatal mortality rate was 0. These findings further substantiate the safety of these criteria in management of term breech presentations.

Splenosis mimicking endometriosis.

Splenosis, the autotransplantation of splenic tissue following traumatic rupture of the spleen, can mimic endometriosis when discovered at laparotomy. The splenic implants are usually widespread throughout the peritoneal cavity. The differential diagnosis includes metastatic cancer, hemangiomas, and accessory spleens as well as endometriosis. The authors present a case of splenosis mistaken at laparotomy for endometriosis, and review the literature on splenosis encountered at gynecologic surgery. As splenosis is usually asymptomatic and may partially compensate for the asplenic state, it is recommended that asymptomatic splenosis not be resected when encountered at surgery.

A critical review of the frequency of lymph node metastasis and death from microinvasive carcinoma of the cervix.

The lack of a uniform, specific definition of microinvasive carcinoma of the cervix has made it difficult to extract from the literature a sufficient number of cases similarly defined from which to estimate the risk of nodal metastasis or death from tumor. Factors potentially biasing the frequency of nodal metastasis and death from tumor are examined, and series lacking such factors are used to provide estimates of the risk of metastasis or death from tumor for various specific definitions, but the number of cases fitting each definition are too few at present to give reliable estimates.

Microinvasive carcinoma of the cervix.

The clinical and pathologic features of 51 cases of microinvasive carcinoma of the cervix treated by radical hysterectomy and pelvic lymphadenectomy are presented. Microinvasion was defined as stromal penetration by carcinoma not exceeding a depth of 5 mm from the surface at the point of origin. Patients with confluent patterns and lymphatic invasion were not excluded. Lymphatic invasion was demonstrated in 24% of the patients, but none of the resected lymph nodes from the entire series contained metastatic tumor. Residual invasive disease was present in 9 of 47 patients who underwent conization including 1 in which the residual tumor invaded to 8 mm, although the depth of invasion in the cone biopsy was only 2.5 mm. Factors related to the presence of residual invasive disease included the pattern and extent of invasion and involvement of the cone margin. There were no surgery-related deaths or fistulae in this series; the actuarial survival rate at 5 years was 100%. Simple hysterectomy seems justified if the cone margin is free of tumor since none of these patients has residual disease. In contrast, radical hysterectomy may be indicated if the cone margins are involved in view of high frequency of residual tumor (39%) and the possibility of invasion in the cervix exceeding 5 mm.

Immature (malignant) teratoma of the ovary: a clinical and pathologic study of 58 cases.

Fifty-eight immature ovarian teratomas were studied. Neoplams with other germ cell elements (endodermal sinus tumor, choriocarcinoma, and dysgerminoma) were excluded so that the clinical and pathologic features of "pure" immature teratomas could be defined and correlated with the prognosis. The primary tumors and their metastatic growths were graded from 0 to 3. Forty were stage I; nine, stage II; and nine, stage III. The size and stage of teratomas were related to survival, but it was the grade of the primary tumor that best determined the likelihood of extraovarian spread, and it was the grade of the metastases that related best to the subsequent course. Actuarial survival was 63% at 5 years and also at 10 years. Regardless of the grade of the primary tumor, only one of six with grade 0 metastases progressed, and that neoplasms may not have been adequately sampled. Two of five neoplasms having grade 1 metastases did not progress, and two of six patients with grade 2 metastatic growths were living after relatively long intervals. All seven patients with grade 3 metastases died with tumor, none surviving more than 2.1 years. Survival of patients with grade 1, 2, and 3 neoplasms was 81, 60, and 30% respectively. The importance of adequate sampling of primary tumor and metastases for estimating prognosis and determining therapy is stressed.

Intravenous alcohol -- a single blind study in the prevention of premature delivery: a preliminary report.

A single blind study for the evaluation of intravenous ethanol in the prevention of premature delivery is reported. Randomly selected patients admitted to Tripler General Hospital with uncomplicated pregnancies between 24 and 36 weeks' gestation having regular, sustained contractions were evaluated. Therapy consisted of intravenous 5% ethanol in 5% dextrose/water according to a weight-time-dose schedule. Control patients were given conventional treatment. Statistical evaluation of data has shown no significant difference between success and failure between the study and control groups to date.