Denis Cavanagh

Toxemia of pregnancy: The hypertensive effect of acute experimental placental ischemia

Abstract 1. The more important experimental observations published on the etiology and pathogenesis of eclamptogenic toxemia have been reviewed. 2. Experiments are described in which the hypertensive effect of experimental uteroplacental ischemia was investigated. 3. From these three main conclusions are drawn: a. Placental ischemia but not uterine ischemia is essential for the production of experimental hypertension in pregnant rabbits at term. b. In transient placental ischemia produced by compression of one gravid horn of the rabbit uterus, it is a neurogenic reflex which causes the evanescent rise in blood pressure. In prolonged placental ischemia, obtained by placing Z sutures, a humoral factor is responsible for the persistent increase in blood pressure. c. The kidneys are not necessary for the production of experimental hypertension in rabbits. Placental ischemia leads to experimental hypertension even in the absence of the kidneys, so it is evident that the vasopressor substances are not renal origin. Although the vasopressor agent is probably of placental origin, this cannot be stated unequivocally. 4. A classification of toxemia of pregnancy based upon the condition which may cause placental ischemia is suggested.

Primary peritoneal pregnancy: Rationalization or established entity? Omental transference as an alternative explanation

Abstract 1. 1. The types of abdominal pregnancy are defined as: 1.1. a. Primary: (1) ovarian, (2) peritoneal. 1.2. b. Secondary, occurring subsequent to primary tubal or intrauterine pregnancy and including intraligamentous and secondary ovarian pregnancies. 2. 2. The importance of abdominal pregnancy in regard to maternal and fetal mortality is emphasized; it is felt that we should strive for a better understanding of the pathogenesis in all varieties of extrauterine gestation. 3. 3. The importance of early cases in the study of the pathogenesis of primary peritoneal pregnancy is explained. 4. 4. A critical review of the literature on primary peritoneal pregnancy with accepted views on its present status is given. Studdifords criteria are enumerated. 5. 5. A case is reported which apparently fulfills these criteria. 6. 6. The possible part played by the “postmature ovum” and pelvic endometriosis in the pathogenesis of primary peritoneal pregnancy is discussed. Experimental evidence for the concept is lacking. Clinical evidence is only as strong as the cases reported and many of these are far from convincing. 7. 7. The adequacy of the present criteria for diagnosis is questioned and the difficulty in proving the concept beyond doubt is inferred. 8. 8. An alternative theory of “omental transference” is suggested which may explain many, if not all, of the well-documented cases of “primary peritoneal pregnancy” reported to date. 9. 9. It is concluded that although primary peritoneal pregnancy may occur, it is certainly not an established entity and many, if not all, of the cases reported to date may be secondary abdominal pregnancies.

Septic shock of endotoxin type: Some observations based on the management of 50 patients

Abstract Septic shock of the endotoxin type remains of major importance because of persisting high mortality rates. Theories of pathogenesis remain mutually contradictory in many respects, and more basic work is required in this area. The treatment of this condition remains controversial. Fifty cases of septic shock in gynecologic and obstetric patients are reviewed. In 44 women the condition was associated with pregnancy. Septic abortion, chorioamnionitis, and pyelonephritis were the main sources of the infection. Methods of monitoring the patient in septic shock with special attention to blood pressure, central venous pressure, blood volume changes, and urinary output are discussed. Early surgical intervention and the proper use of vasopressors and corticosteroids in pharmacologic doses yielded good results in terms of patient survival. The mortality rate was 26 per cent in the first 6 years of the study and 5.3 per cent in the last 21 months. The over-all mortality rate was 18 per cent.

Comparative effectiveness and safety of cefotetan and cefoxitin as prophylactic agents in patients undergoing abdominal or vaginal hysterectomy

In a multicenter, randomized clinical trial, 282 women who underwent abdominal or vaginal hysterectomy were given a single preoperative 2 g dose of cefotetan (171 evaluable patients) or three perioperative 2 g doses of cefoxitin (84 evaluable patients) as antibiotic prophylaxis. A successful clinical response occurred in 92 percent of those receiving cefotetan and 90 percent of those receiving cefoxitin who underwent abdominal hysterectomy, and in 94 percent of those receiving cefotetan and 93 percent of those receiving cefoxitin who underwent vaginal hysterectomy. The incidence of vaginal cuff cellulitis was 3.4 percent and 5 percent for cefotetan and cefoxitin patients, respectively, who underwent abdominal hysterectomy, and 4.8 percent and 4.5 percent, respectively, for those who underwent vaginal hysterectomy. The incidence of major wound infection was 3.4 percent and 2.5 percent for cefotetan and cefoxitin, respectively, in the abdominal hysterectomy group. Postoperative changes in oral body temperature, duration of hospitalization, and postoperative grading of surgical wounds were similar. Both drugs were well tolerated. These results suggest that a single dose of cefotetan is equally effective and as safe as multiple-dose cefoxitin for prophylaxis in patients undergoing hysterectomy.

Septic shock in obstetrics and gynecology

Abstract 1.1. Thirty-five women in septic shock treated with metaraminol were studied. Their ages ranged from 17 to 65 years with the median age being 37 years. The most common cause of shock was septic abortion. 2.2. Twenty-three patients survived, but whereas 21 of 24 patients in moderate shock survived, only 3 of 11 patients in severe shock remained alive. This emphasizes the great need for early diagnosis as well as adequate treatment. 3.3. Metaraminol appears to be a useful agent in the management of septic shock. It has a relatively rapid onset and protracted action with minimal side effects. Patients who failed to respond to metaraminol were not improved when given other more potent vasopressor agents such as l-norepinephrine. 4.4. Corticosteroids were combined with vasopressor therapy in 18 patients and 16 of these responded satisfactorily. 5.5. Three patients maintained on metaraminol for over 48 hours, including one for 96 hours, recovered. Although vasopressors should be discontinued as soon as possible, these survivals suggest that perhaps the dangers of prolonged vasopressor therapy have been exaggerated. 6.6. In the patient with a septic incomplete abortion, the use of a suitable vasopressor is particularly useful to allow time for adequate evaluation of the patient, the institution of antibiotic therapy, and prompt evacuation of the uterus.

Eclampsia and the weather

Abstract 1. 1. The occurrence of 40 cases of eclampsia during the 4 year period from 1957 through 1960 was correlated with conditions obtained from climatic means. 2. 2. Twenty of 40 cases were seen during the August through October “hurricane season.” When considered as an attack rate per 1,000 deliveries, this was found to represent a threefold increase. 3. 3. A “lag” period of 60 days occurred between the onset of mean monthly temperatures above 80° F. and the increased attack rate. 4. 4. October is the peak month for eclampsia in Miami and has typically a mean temperature of 77° F., with only 1 day over 90° F. Perhaps of more immediate importance is the mean relative humidity of 87 per cent and the reduced mean barometric pressure, since both of these factors predispose to water retention.

Prematurity--the epidemiologic profile of the "high risk" mother.

Abstract 1. 1. At the Jackson Memorial Hospital, Miami, Florida, the prematurity rate is consistently about twice as high among the staff (indigent) patients as among private patients. 2. 2. An epidemiologic analysis of the indigent group further revealed the patient most likely to have a premature baby within the group. 3. 3. It is suggested that careful scrutiny of these “high risk” patients and their comparison with “low risk” patients in the same socioeconomic group would shed further light on the etiology of premature labor.

Factors affecting cone-hysterectomy morbidity: A study of 200 patients

Abstract Two-hundred consecutive total hysterectomies performed up to 222 days following cold-knife cone biopsy were studied. The febrile morbidity was 54.5 per cent compared with 44 per cent in a similar series of hysterectomy control patients. Morbidity for cone biopsy alone was 1.5 per cent of 149 patients. No deaths occurred in the 349 patients studied. The factors which significantly increased morbidity were a cone-hysterectomy interval of less than 14 days and the performance of vaginal rather than abdominal hysterectomy. Vaginal cuff and abdominal wound infections were found in 17.5 per cent of the cone-hysterectomy group compared with 9 per cent in the hysterectomy conrol group. Posthysterectomy hospital stay was the same in the cone-hysterectomy and hysterectomy control group. From this study it would appear that hysterectomy is preferably postponed for at least 14 days following cold-knife conization unless the circumstances of the individual patient dictate otherwise.

Invasive Carcinoma of the Vulva Current Views on Diagnosis and Treatment

1 An analysis of 50 patients with invasive carcinoma of the vulva seen in the Department of Obstetrics and Gynecology at the University of Miami School of Medicine, Jackson Memorial Hospital, from January 1, 1955, to August 1, 1965, is presented. 2 Predisposing conditions such as leukoplakia (6 patients), granulomatous disease (2 patients) and syphilis (2 patients) were noted in 10 patients (20%). Two patients were pregnant. 3 Use of the Collins test in patients with leukoplakia and other lesions of the vulva is suggested for the purpose of selecting optimum biopsy sites. 4 Radical vulvectomy, bilateral groin and/or pelvic lymphadenectomy was performed in 30 patients; in addition to ilio‐femoral lymphadenectomy, pelvic exenteration was performed in 3 patients. There was one death attributed to the operation (3%). 5 Significant post‐operative complications were wound breakdown in 30 (91%), rupture of the femoral artery 3 (9%), rupture of the femoral vein 1 (3%), and persistent leg oedema in 3 (9%). 6 No meaningful 5‐year survival rate statistics are available, but 1‐year survival rates were as follows: 4 of 11 patients with positive lymph nodes, and 16 of 22 patients with negative lymph nodes. For 40 patients with McKelvey 1‐3 lesions the 1‐year survival was 65%. Of 10 patients treated palliatively only, 1 survived the first year. 7 Lymphography was useful in predicting nodal metastases in 17 of 20 patients (85%). 8 No patient with negative groin nodes had positive pelvic nodes and so the wisdom of “routine” pelvic lymphade‐nectomy is in doubt.

Malignant melanoma of the vagina. Report of 2 cases

Two cases of primary malignant melanoma involving the vagina are reported. Melanoma of the vagina is a rare lesion, with only about 30 cases being reported to date. Both the patients were treated by a radical vulvo‐vaginectomy with bilateral groin and pelvic lymphadenectomy. This was combined with an anterior exenteration in one woman who had tumor involvement of the bladder. One patient required secondary skin grafting of the abdominal and groin wounds and the other required secondary closure of groin wounds with reconstruction of the vagina. Both the patients have been seen postoperatively, one woman at 9 months and the other at 15 months; both are progressing well, with no evidence of recurrence. With this lesion, as with melanoma of the vulva, results of any kind of treatment are difficult to predict but extensive resection, as for squamous carcinoma, seems justified.