Deborah J. Dotters

Necrotizing fasciitis of the vulva

OBJECTIVE We attempted to characterize the natural history of necrotizing fasciitis of the vulva. STUDY DESIGN The records of 29 nonpregnant women with necrotizing fasciitis of the vulva were evaluated. RESULTS These women experienced a rapidly progressing polymicrobial infection. Initially, the infections in many women were thought to be labial cellulitis, appearing mild and innocuous. Delays in recognition and aggressive surgical management were associated with increased morbidity and mortality. Of 15 women with a delay greater than 48 hours between presentation and treatment, 11 died. Twenty of 29 (69%) were diabetic, accounting for 11 of the 14 deaths. CONCLUSION Early diagnosis and aggressive surgical debridement in spite of mild symptoms will improve outcome in this serious disease process.

Focus on primary care: from nevus to neoplasm: myths of melanoma in pregnancy.

Malignant melanoma is one of the few malignancies that regularly affect women during their childbearing years. Additionally, the incidence of melanoma has been increasing over the last several decades. Early diagnosis of stage I disease may lead to curative therapy; thus it is important for physicians and midwives to do a full examination of the skin. However, the myth that nevi may naturally grow or change during pregnancy has been shown not to be true and should not delay a diagnostic evaluation of a suspicious nevus. Older studies had theorized a worse outcome for pregnant women with melanoma. However, multiple controlled series and investigations have found that stage for stage this cancer is not affected adversely by pregnancy. Prognosis, recurrence, and incidence of melanoma seemed to be unaffected. Estrogen-containing oral contraceptives, as well as hormone replacement therapy, have no adverse affect on the disease. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to list the various types of melanomas, to outline potential risk factors for melanomas, to summarize the misconceptions about melanomas and pregnancy, and to describe the management of melanomas.

Nylon brush improves collection of cervical cytologic specimens

A prospective, randomized study was performed to compare the efficacy of a combined endocervical and ectocervical nylon brush with the cotton-tipped swab and wooden spatula for obtaining cervical cytologic specimens. Strict objective criteria were used to determine the adequacy of Papanicolaou smears on the basis of the number of cells present. The two methods were equally effective in collecting ectocervical smears. However, 96% of endocervical smears obtained with the nylon brush contained greater than 50 cells, compared with 58% of swab and spatula smears. Only 1.4% of brush samples contained no endocervical cells, versus 19% of swab and spatula smears. The presence of endocervical cells confirms adequate sampling of the transitional zone. Use of the cytologic Papanicolaou brush may result in fewer false negative and inadequate Papanicolaou smears.

Massive ovarian cyst: a comprehensive surgical approach.

The massive ovarian cyst (greater than 25 pounds) presents a challenging opportunity for surgical intervention and potential cure of a debilitating problem. Although infrequently seen, such a patient requires awareness of the unique problems removal of these large masses may cause. Successful management requires a comprehensive approach before, during, and after the operative procedure. There are three keys to optimal management: 1) a multisystem, team approach, 2) intact cyst removal, and 3) a special incision and reconstructive technique.

Computed tomography: Does it really improve the treatment of cervical carcinoma?

OBJECTIVE The purpose of this study was to determine if computed tomography in cervical cancer staging resulted in treatment modifications leading to improved survival. STUDY DESIGN Medical records of 246 consecutive women treated over a 3-year period for primary cervical cancer were reviewed. Frequency of recurrence was the outcome measure of interest and subjected to chi 2 analysis. RESULTS Only eight patients had improved survival from treatment modifications based on computed tomography findings. Eight patients underwent additional surgical procedures because of computed tomography findings that proved to be erroneous. CONCLUSIONS Considering the high cost and limited benefit, computed tomography for cervical cancer staging is not recommended.

Low dose dopamine in the treatment of persistent oliguria in pre-eclampsia

Oliguria in pre‐eclamptic women is most often a result of decreased intravascular volume. In a small number of patients, renal vascular spasm may be the cause of decreased urine output. Prolonged oliguria/anuria secondary to vasospasm may lead to permanent renal damage. When volume repletion is unsuccessful in restoring urine output, some authors have suggested the use of peripheral vasodilators such as hydralazine. Dopamine in low doses 2 μg/kg per min was used successfully to restore urine output within an hour in a pre‐eclamptic patient who had been essentially anuric for 8 h. Volume administration and hydralazine were unsuccessful. In the rare instance of a patient who is unresponsive to conventional methods, low dose dopamine may provide an adjunctive therapy to restore urine output after delivery. Central monitoring is essential in following such patients.