Cytoreductive surgery for ovarian cancer with the Cavitron Ultrasonic Surgical Aspirator and the development of disseminated intravascular coagulation.

OBJECTIVE: To explore the association between the use of the Cavitron Ultrasonic Surgical Aspirator for cytoreduction of ovarian cancer and the intraoperative development of disseminated intravascular coagulation (DIC). METHODS: A retrospective chart review was performed of all patients undergoing surgery for ovarian cancer from September 1991 to February 1993. Data were extracted to correlate clinical and hematologic evidence of DIC with and without intraoperative use of the Cavitron Ultrasonic Surgical Aspirator. Statistical analyses were done by chi 2 and analysis of variance. RESULTS: Fifty-one patients underwent surgery for ovarian cancer; 33 had stage IIIB, IIIC, IV, or recurrent disease and could be evaluated for this study. Nineteen patients were treated with the surgical aspirator, five of whom developed an intraoperative coagulopathy, as compared to none of 14 patients treated with conventional cytoreduction (P < .04, chi 2). The duration of use of the surgical aspirator correlated with the risk of coagulopathy (P < .001, analysis of variance). CONCLUSION: These data suggest a potential risk of developing DIC after extended use of the Cavitron Ultrasonic Surgical Aspirator for cytoreduction of ovarian cancer.

Nosocomial infections in an obstetric and gynecologic hospital.

A prospective study was undertaken at Wesson Women's Unit of Baystate Medical Center to characterize and evaluate nosocomial infections. Using Center for Disease Control criteria, 59 of 1,297 patients undergoing obstetric or gynecologic procedures over a two-month period manifested nosocomial infections. The infected patients were proportionately divided between the obstetric and gynecologic services. However, within each group, certain procedures were associated with a greater incidence of postoperative hospital-acquired infection. Patients who underwent primary cesarean sections and vaginal hysterectomies were most at risk of developing nosocomial infections (22% and 19%, respectively). Nosocomial infection is still a major problem to the obstetrician-gynecologist. However, careful study can delineate patients at high risk, allowing appropriate intervention, including the use of prophylactic antibiotics. This may lead to a significant reduction in the incidence of nosocomial infections.

Experience with midtrimester abortion.

The midtrimester abortion program at a large community hospital was evaluated. During the 3-year study, 1839 patients aborted in the midtrimester by intraamniotic injection of hypertonic saline, prostaglandin F2alpha or a combination of saline and prostaglandin F2alpha. The method, using a combination of saline and prostaglandin F2alpha together with intracervical laminaria, showed significant reduction in the number of failures (4.3 to 1.0%), reduction in the injection-abortion interval from 33.9 to 14.6 hours, shortening of the hospital stay from 2 1/2 to 1 1/3 days, minimum incidence of live abortions (0.9%), infrequent need for oxytocin to effect delivery (7.7%); and low rates of hemorrhage (1.5%) and fever (2.8%). The main disadvantage was an increased rate of incomplete abortions (32.3%), which could be reduced to 27% by patient selection.

PIP: A retrospective study was performed of all patients undergoing midtrimester abortion at the Baystate Medical Center from 1975-1977 (1839 patients). A comparison was made of the 3 methods employed: intraamniotic hypertonic saline, intraamniotic prostaglandin F2 alpha, and a combination of intraamniotic hypertonic saline and prostaglandin F2 alpha. It was found that use of the combination method resulted in significantly fewer failures and a significantly lower injection-abortion interval (from 33.9-14.6 hours) which resulted in a shorter hospital stay. In addition, the combination method resulted in fewer reinjections (as did use of hypertonic saline alone) than use of prostaglandin alone and less frequent use of oxytocin for delivery. The rate of live abortion was .2% for saline, 9% for prostaglandin alone, and .9% for the combination method. The side effects of hemorrhage and fever occurred in 2.8% and .2% of the patients who underwent the combination procedure, respectively.

The nonstress test.

Antepartum fetal evaluation by heart rate monitoring was carried out on a clinical service during a 1-year period utilizing the nonstress test as the primary screening device. Nonreactive nonstress tests were supplemented by the oxytocin contraction stress test. In this study, the use of the nonstress test appropriately led to the identification of all fetuses who were in jeopardy and, in the majority of instances, identified fetuses in good condition who did not require the administration of oxytocin to determine fetal well-being. In our experience, the nonstress test is a reliable, inexpensive, convenient, time-saving screening procedure which can be made available to a greater number of patients than the contraction stress test alone.

Changing indications for cesarean section. A 38-year experience at a community hospital.

A review of a 38-year experience with cesarean section at a community hospital shows considerable change in both the rate and indication of cesarean sections. A marked increase in the cesarean section rate was noted after 1972. This increase was due primarily to an increase in the primary cesarean section rate for cephalopelvic disproportion and labor abnormalities, fetal distress, and the breech presentation. As a result of this study, we anticipate a primary cesarean section rate of approximately 10%: 3-5% for cephalopelvic disproportion and labor abnormalities, 1-1 1/2% for fetal distress, 3% for breech presentation, and 1-2% for all other indications.

Influence of thyrotropin-releasing hormone on the postmenopausal female.

Daily blood samples were obtained from 5 postmenopausal patients for 21 days and analyzed for plasma follicle stimulating hormone (FSH), luteinizing hormone (LH), estrone, estradiol, progesterone, and serum T4. On days 8 through 14, oral thyrotropin-releasing hormone (TRH) was administered, 50 mg, 4 times a day. All patients showed asignificant T4 response. There was, however, no significant change in the plasma FSH, LH, estrone, estradiol, or progesterone. We conclude that oral administration ofTRH has no influence on the elevated circulating concentration of FSH and LH seen in the postmenopausal female.

The ovulatory cycle. A histologic, thermal, steroid, and gonadotropin correlation.

PIP: Relationships of the day of thermal nadir, day of estradiol peak, and day of LH peak to the endometrium and corpus luteum dating system were studied. Blood samples and rectal basal body temperatures were obtained daily during an ovulatory cycle from 8 healthy women who requested tubal ligation or tubal reconstruction. The tubal surgery was performed at planned intervals (1-12 days) after the luteinizing hormone (LH) peak. Endometrium and corpus luteum biopsies were taken at the same time. Daily blood samples were analyzed for plasma estrone, estradiol, progesterone, follicle stimulating hormone and LH by radioimmunoassay. The correlation of corpus luteum and endometrial dates was .97. Correlations were made between endometrial dates and time of thermal nadir (.97). Correlations were also made between corpus luteum date and time of thermal nadir (.96), time of the estradiol peak (.9) and time of the LH peak (.93). There was histologic evidence of ovulation during the 24-hour time period designated as Day 0.^ieng