Surgical blood loss in abdominal hysterectomy.

OBJECTIVE: The aim of this study was to evaluate additional error in estimating red cell loss during abdominal hysterectomy. METHODS: Eighty patients admitted consecutively for abdominal hysterectomy were recruited. The surgeries were done after heparinizing the suction tubing system to prevent clotting and reducing the vacuum pressure to reduce red cell lysis. At the end of the surgery, hematocrit was measured and compared with the patient's venous blood and the blood from the suction container. The Mann-Whitney test evaluated statistical significance. RESULTS: Eight patients were excluded for having a hemolyzed blood sample, receiving a blood transfusion, and having incomplete data. The study cohort consisted of 72 patients: 54 had a simple hysterectomy and 18 had a radical hysterectomy with pelvic and periaortic lymphadenectomy. The hematocrit (mean +/- standard deviation) in the suction container (19.8 +/- 8.8%) was lower than the hematocrit from the venous blood sample (32.4 +/- 6%) (P < 0.001). The hematocrit in the suction container decreased as the duration of the surgeries increased. Although the volume of blood in the suction container was used to estimate blood loss, the concentration of red cells in the container was consistently lower than those in the venous blood sample. The magnitude of dilution increased as the length and radical nature of the surgery increased. CONCLUSIONS: These findings suggest that other fluid, probably lymph, contributes to the dilution of red cells in the container and increases the estimated blood volume loss during surgery. Estimation of red cell surgical blood loss becomes less accurate as the length and radical nature of the surgery increase.

Cardiac disease and pregnancy.

The pregnant state imposes a supraphysiologic strain on the pregnant woman's cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the woman's hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.

Teaching the Laufe-Piper forceps technique at cesarean delivery.

OBJECTIVE: To present a method of teaching forceps technique during cesarean delivery of breech-presenting infants using Laufe-Piper forceps and to evaluate its usefulness. STUDY DESIGN: For several years, residents at the University of Texas Medical Branch, Galveston, have learned and practiced Piper forceps technique during cesarean delivery. To assess their experience with this method, we mailed questionnaires to third- and fourth-year residents and recent graduates of the Galveston program. The same surveys were mailed to a control group of residents and recent graduates of two other programs where this teaching exercise is not practiced routinely. RESULTS: Responses were received from 32 (74%) study subjects and 63 (71%) controls. Demographic characteristics and experience with vaginal breech delivery were similar between the two groups. Respondents from the Galveston program noted greater annual use of forceps for vaginal delivery of cephalic-presenting infants (P = .012). They also rated themselves as more comfortable (P = .023) and more skilled (P = .006) with Piper forceps than controls. Of 53 respondents who had had previous experience with this teaching method, 47 noted that it provided a great or moderate educational benefit, and 36 strongly or moderately believed it gave them more confidence in using Piper forceps during vaginal breech delivery. Using multiple regression analysis, sex, overall level of experience, Piper forceps experience during vaginal delivery and overall forceps use were stronger determinants of self-rated comfort and skill than was experience with Laufe-Piper forceps during cesarean. CONCLUSION: Laufe-Piper forceps can be used for cesarean delivery of breech-presenting infants. This practice promotes confidence and skill for their use at vaginal delivery.

Natural killer-cell lymphoma involving the gynecologic tract.

Non-Hodgkin lymphomas (NHL) can involve the gynecologic tract, most often as a manifestation of systemic involvement, and most cases reported have been of B-cell lineage. We describe 2 women with natural killer (NK)-cell lymphoma involving the gynecologic tract that initially presented with vaginal bleeding. In case 1, the patient had a stage IE nasal-type NK-cell lymphoma involving the cervix. The tumor was composed of medium-sized, irregular lymphoid cells with angioinvasion and necrosis. In case 2, the patient had a stage IV blastoid NK-cell lymphoma/leukemia infiltrating all organs in a hysterectomy and bilateral salpingo-oophorectomy specimen. Subsequent biopsy specimens revealed that the bone marrow and lymph nodes were also involved. The neoplasm was composed of small to medium lymphoid cells with fine nuclear chromatin. Case 1 was assessed immunohistochemically and the neoplastic cells were positive for CD3, CD56, and TIA-1. Case 2 was analyzed using both immunohistochemical and flow cytometry methods. The neoplastic cells were positive for cytoplasmic CD3, CD4, CD7, CD43, CD45, and CD56 and were negative for surface CD3. Both cases were negative for Epstein-Barr virus (EBV) ribonucleic acid (RNA) and molecular studies showed no evidence of T-cell receptor gamma chain gene rearrangements. The immunophenotype and absence of T-cell receptor gene rearrangements support NK-cell origin. We report these cases to illustrate that NK-cell lymphomas can involve, and rarely arise in, the gynecologic tract.

The effects of pregnancy and smooth muscle contractility on cervical distensibility in the rat.

OBJECTIVE: We sought to compare distensibility of the isolated rat cervix from nonpregnant rats (n = 6), rats at midgestation (n = 5), and rats at term gestation (n = 4). STUDY DESIGN: The cervix was excised, and one cervical channel was cannulated from both ends and positioned in the organ chamber for perfusion-superfusion by a peristaltic pump at an intraluminal pressure of 30 mm Hg for 30 minutes. After the equilibration period, perfusion was stopped, the outlet was closed, and the cervix was inflated with a syringe pump. The volume was increased at a rate of 3.33 microL/s until intraluminal pressure reached approximately 120 mm Hg. The outlet was then opened, and the cervix was perfused at 30 mm Hg of intraluminal pressure for another 30 minutes. The volume-pressure relationships were obtained 3 times without any agent present and in the presence of 60-mmol/L potassium chloride or 10(-4)-mol/L 3-morpholinosydnonimine hydrochloride (also known as SIN-1). RESULTS: The volume-pressure relationship was shifted to the right during progression of pregnancy, demonstrating increased compliance of the cervix. The nonspecific depolarizing agent potassium chloride or the nitric oxide donor 3-morpholinosydnonimine did not affect volume-pressure relationships in cervices from nonpregnant rats, rats at midgestation, or rats at term gestation. CONCLUSION: The volume-pressure relationship in the isolated cannulated rat cervix reflects the resistance of the organ to increased intraluminal pressure. The compliance of the cervix is increased as pregnancy progresses, demonstrating decreased resistance to stretch. Activation or inhibition of cervical smooth muscle does not contribute to the physical properties of the cervix, which controls compliance-resistance.

Forceps-assisted vaginal delivery.

Operative vaginal delivery using forceps has been an important part of obstetric practice for nearly 400 years. Countless women and their children have benefited from timely and expertly performed procedures. Physicians must, therefore, make every effort to retain these skills, to modify and improve them in every possible way, and to pass them on. In this way, women and children of future generations will benefit from the many years of experience that have gone before them.

An animal model for hemolytic disease of the fetus and newborn. I. Alloimmunization techniques.

OBJECTIVE: Our purpose was to establish an animal model for hemolytic disease of the fetus and newborn by developing red blood cell alloimmunization techniques in the rabbit. STUDY DESIGN: Twenty-six nonpregnant New Zealand White or Red does underwent blood typing to identify them as homozygous at the HgA or HgF red blood cell antigen locus. Alloimmunization to incompatible red blood cells was attempted through a series of subcutaneous injections using complete then incomplete Freund's adjuvant. RESULTS: Successful induction of an antibody response occurred in 96% of cases. The median response in FF rabbits was 2560 (range 40 to 10,240), whereas the response in AA does was 2560 (range 320 to 20,480). These responses were not statistically different (p = 0.77). Responses were categorized as poor, moderate, or good. No difference was noted between FF and AA does in distribution of the categories of response (p = 0.53). CONCLUSION: Red blood cell alloantibodies of high titer can be induced successfully in the rabbit.