Charles H. Birnberg

Uterine perforation with intrauterine contraceptive devices: Review of the literature and cases reported to the National Committee on Maternal Health

The National Committee on Maternal Health reported on 28 cases of pe rforation of the uterus in a total of 16,338 first insertions of IUDs after confinement, an incidence of 1.7 perforations per 1000 insertions. 20 of the perforations followed the insertion of a bow. 16 of these occurred in patients less than 12 weeks postpartum. With the bow there is a highly significant correlation between the perforation rate and the number of weeks postpartum, especially if no menses have occurred. The perforation rate after 12 weeks postpartum for the bow is 2 per 1000 insertions. This is less than the perforation rate of 3.23 per 1000 found in a collected series of 77,903 curettages. The high perforation rate for the early postpartum insertions indicates that softness and friability of the uterus is a greater factor in the etiolog y of the perforations than the type of introducer employed. Perforation s with other devices are difficult to determine because of the lack of accompanying symptoms and the presence of a tail protruding through the cervix. Care in examining the patient, judicious timing of insertion, the use of a tenaculum, traction to straighten flexion deformities of the uterus, sounding the uterus, and gentleness during the introduction and ejection of the device into the uterus should greatly reduce the incidence of uterine perforation.

The use of ethinyl estradiol in pregnancy

Abstract 1. 1. A standard dosage schedule of ethinyl estradiol, 0.5 mg. three times a day during pregnancy, will yield excellent fetal salvage with patients who have had previous abortions. 2. 2. This standard dosage schedule of ethinyl estradiol did not materially reduce the incidence of toxemia of pregnancy. 3. 3. A progressively increasing dosage schedule of ethinyl estradiol reduced the incidence of toxemia of pregnancy. 4. 4. Labor was approached with an effacing or effaced cervix and labor appeared to be more rapid.

A simple method for the relief of postpartum perineal pain.

Abstract Sixty-two patients were studied to test the efficacy of Tronothane in relieving perineal discomfort in the immediate postpartum period. In 96.8 per cent of the cases, slight to pronounced relief was obtained. In 46.0 per cent of 50 patients in this series only slight relief was reported with the use of petrolatum.

ESTIMATION OF OVULATION PHASE BY SERIAL TESTS OF CERVICAL AND VAGINAL GLUCOSE

Estimation of the ovulation phase in 343 private patients was carried out by serial tests of cervical and vaginal glucose. It was determined that cyclic changes in cervical and vaginal glucose parallel estrogen levels with a peak occurring at or before ovulation. A plastic applicator stick provided with a cotton-tip impregnated with a glucose oxidase system (Ovutest) was used to measure these glucose levels. A special chart the Ovutest-basal body temperature Colorgraph (Ovutest-BBT Colorgraph) was devised which facilitates the recording of the daily color fluctuations and the BBT by the patients. The peak cervical glucose reactions coincided in 67% with other presumptive tests for ovulation that depend on the estrogen level. The use of the combined Ovutest-BBT Colorgraph by the infertile patient will enable her to define the ovulation phase in 77.5% of the cycles as against 60% for the Ovutest alone or 51% for the BBT graph alone. It is noted that while the test is of use to infertile patients it is of little value in the avoidance of conception since conception may occur just prior to the rise in color or where there is no vaginal color correlation to ovulation.

Effect of pregneninolone (ethinyl testosterone) upon human cervical secretion

Abstract 1. 1. Pregneninolone (pranone) was given to six patients who had a negative semen penetration test and a hydrogen ion concentration of cervical mucus ranging from 5 to 6; the hydrogen ion concentration in one of the cases, however, was 8. 2. 2. The acidity of the cervical mucus was changed to a hydrogen ion concentration of 7 or 8 and semen penetration test became positive in five cases. 3. 3. Three of these patients subsequently became pregnant. 4. 4. There was no change in one case.

Treatment of dysmenorrhea

Abstract Almost all types of hormones have been used in treating dysmenorrhea, with good results in a considerable percentage of cases. Hormone determinations have only occasionally been of value as a determining factor in treatment. Endometrial biopsy is a valuable aid in the determination of the state of uterine and ovarian activity. In our series of ten cases, eight were benefited either partially or completely by administration of corpus luteum hormone, and two were aided by anterior pituitary-like hormone. One patient helped by progesterone was definitely made much worse by anterior pituitary-like hormone.

Hysterogram in the diagnosis of uterine bleeding

BNORMAL uterine bleeding is a A problem frequently confronting the physician. Since accurate diagnosis is complicated and often burdensome for both the patient and the physician, there is a tendency to rely upon hormone therapy which often yieIds gratifying results. However, the indiscriminate use of injection therapy with a multiplicity of hormones is not without danger. 1 In spite of this injection therapy for uterine bleeding is becoming increasmglg popular with the physician. It is obvious that proper treatment can follow only when an accurate diagnosis is first estabhshed. To establish an etioIogic diagnosis in a case of uterine bleeding, a certain minimum of oflice procedure is required. A complete physical examination is the first essential Careful visual and manual examination of the peIvic organs is extremeIy important. Simple blood studies and a basal metabolic rate and other oflice laboratory procedures may be indicated. After the routine physical and gynecologic examination a number of patients wiI1 fail to show any adequate cause for the bleeding. Pelvic examination may be norma or unsatisfactory because of obesity, tenderness or v-oluntary or invoIuntary spasm. Some of these patients are investigated further with a diagnostic curettage. This procedure requires hospitaIization and anesthesia, is disturbing emotionalIy and may. be burdensome linanciaIly. It is possrbIe that a curettage, even when properly done, may not reveal the cause of the bleeding. (Fig. I .) It is not justifiabIe then, without further investigation, to attribute uterine bleeding to endocrine disturbance even when a pelvic examination fails to reveal any pathologic disorder. Because of these difliculties it was decided to investigate the possible advantages and feasibility of routine hysterography in patients with uterine bleeding. Contraindications. Hysterography is considered by many”” to be contraindicated in bIeeding because oil may be introduced through open sinuses or malignant cells may be diffused through the tubes into the peritoneal cavity. There have been reports ‘.‘) of oil emboli in the vessels of the broad ligaments and death from generalized embolization. These comprications occurred as a result of using an oily radiopaque medium in the procedure. In this study a non-oily radiopaque material is used calIed Rayopake. It is the diethanolamine saIt of 2,+dioxo-3-iodo6-methy tetrahydropyridine acetic acid, with 354 per cent concentration of polyvinyl alcohol. No iI effects were observed in our series and none have been reported. As wiI1 be noted below, smaller amounts of radiopaque material (I .5 to 3.0 cc.) are used. This diminishes the likelihood of dissemination of emboli.’ The objection may be raised that profuse uterine bleeding wouId make the intrauterine injection of radiopaque material impossible or untrustworthy. Experience in reading hysterograms wiI1 eIiminate this error. One of our most concIusive diagnoses (Case III) was made under just such circumstances. Contraindications to hysterography do exist. Most important of these is the presence of acute inflammation. Chronic inflammation is no deterrant since the amount of radiopaque material injected is sufficient only to outline the uterine cavity and there is IittIe opportunity for the spread of disease through the fimbriated ends of the tubes. Bleeding in possible early pregnancy is another contraindication but there have been reports of pregnancies going to term in spite of

The treatment of amenorrhea of endocrine origin

Abstract Careful investigation and accurate diagnosis are a prerequisite for successful therapy in amenorrhea of endocrine origin. Twenty cases of amenorrhea were treated with various therapeutic agents. Of thirteen patients treated with estrogenic hormone, bleeding and enlargement of the uterus with improvement in secondary sexual characteristics was produced in every case. One patient became pregnant while under treatment after eight months of amenorrhea. Four patients continued to menstruate after treatment was discontinued, and one of these subsequently became pregnant after three years of sterility. Gonadotropic hormone was used in five cases and bleeding accomplished in three. One of these three later became pregnant. X -ray, in stimulating doses to the ovaries, has been unsuccessful in three cases. However, as this was used only in those cases where vigorous therapy by other methods had failed, this poor result is not so significant as if the cases had been unselected. Dilatation of the cervix to produce menstruation through pituitary stimulation was successful in the two cases in which it was attempted. One of these patients later became pregnant after twelve years of sterility.