Deryck R. Kent

Fetal death in motor vehicle accidents

This study represents a series of cases of fetal death secondary to maternal involvement in a motor vehicle accident. During the period 1982 to 1985, nine cases were reported to the county coroners office. In approximately 50% of the cases, other injuries to the victim, excluding injuries related to the pregnancy, were minor. Evidence of fetal distress was not always apparent at the time of initial evaluation. In all cases, placental abruption was documented. The injury mechanism was generally impact with the steering wheel. At the time of the accident, none of the patients were using seat belts. These cases demonstrate that minor maternal trauma without apparent maternal distress may result in fetal demise. The data indicate the need for prolonged continuous fetal monitoring for all pregnant women involved in motor vehicle accidents.

Abnormal cervical cytology in the teen-ager: a continuing problem.

Abnormal cervical cytology is being discovered in an alarming number of sexually active teen-agers. Over an 18 month period, cytology consistent with mild dysplasia or worse was noted in 188 of 2,655 teen-agers screened. This represents a rate of 70.8 per thousand. Colposcopically directed biopsies in 65 patients revealed 15 cases of severe dysplasia-carcinoma in situ. Cryosurgery was the principle method of treatment and, combined with colposcopy, is a safe and effective means of managing these patients.

Etiologic factors in the pathogenesis of liver tumors associated with oral contraceptives.

Within the last several years, previously rare liver tumors have been seen in young women using oral contraceptive steroids. The Registry for Liver Tumors Associated with Oral Contraceptives at the University of California, Irvine, has clearly identified 27 cases. The recent literature contains 44 case reports. Common to these 71 cases has been a histopathologic diagnosis of focal nodular hyperplasia, adenoma, hamartoma, and hepatoma. Significant statistical etiologic factors include prolonged uninterrupted usage of oral contraceptive steroids. Eight deaths and liver rupture in 18 patients attest to the seriousness of this new potentially lethal adverse phenomenon.

Intraepithelial neoplasia of the uterine cervix in the teenager.

One hundred and seventeen teenagers with abnormal cervical cytology were evaluated using colposcopy and directed biopsies. Eighty‐eight cases of cervical intraepithelial neoplasia were discovered including 24 cases of severe dysplasia or carcinoma in situ. Erradication of these lesions is essential as a preventative measure. The importance of routine cytologic screening and early evaluation of abnormal Papanicolaou smears in the teenager is emphasized.

Role of oral contraceptive agents in the pathogenesis of liver tumors.

Since the introduction of oral contraceptive steroids in 1960 there has been a sharp increase in the incidence of benign liver tumors. Epidemiologic and other evidence links focal nodular hyperplasia and hepatic cell adenoma to the use of these agents. The risk increases with long-term exposure. The majority of patients were less than 35 years old. Most patients were exposed to mestranol (ME) alone or alternately with ethinylestradiol, both synthetic steroidal estrogens. Inability to demethylate ME in the smooth endoplasmic reticulum of hepatocytes may allow massive accumulation of oncogenic metabolites. This is probably a pharmacogenetic variable in a small number of women. Cholestasis, hypervascularity, induction of intracellular enzyme systems, thrombogenesis, and thickening of arterial and venous walls are other known effects of synthetic estrogens and progestogens. All may contribute to the pathogenesis of liver tumors. Many patients are asymptomatic until there is rapid expansion of the tumor. Pain occurs when Glissons capsule stretches. Intrahepatic bleeding and liver rupture are common sequelae. Ligation of the hepatic artery may be lifesaving in the face of exsanguinating liver bleeding. Reports of regression with observation alone are encouraging. Instances of progression of unresected adenomas to rupture during subsequent pregnancy dictate avoidance of sex steroids in patients with hepatic neoplasia. Sonography, computerized axial tomography, radionuclide scans, and selective celiohepatic angiography are useful methods for the diagnosis of liver tumor in the symptomatic patient. There is a primary need to develop biochemical methods for detecting patients at risk for developing liver tumors. Epidemiologic research and central reporting of case histories are needed in the search for common factors.

All vulvar lesions should be biopsied: Basal cell carcinoma—an example of the futility of diagnosis by gross appearance

Gross polymorphism of basal cell carcinoma of the vulva as well as all vulvar lesions calls for biopsy of any suspicious areas in that region. In most instances local excision is satisfactory treatment. Close follow-up is necessary as the recurrence rate is approximately 20 per cent even when the lesion is completely resected.

Liver tumors and oral contraceptives.

Data on 78 cases of benign hepatic neoplasia among women with a history of oral contraceptive (OC) use are analyzed. Data for the study were collected by the Liver Tumor Registry of the University of California Irvine Medical Center. Factors considered in the analyses include the patients age and duration of OC therapy, histopathology of the tumors, and their symptoms, findings, and prognosis. The pathogenesis and treatment of the tumors are also discussed.

Intrauterine Detection of Central Nervous System Malformations

Elevated levels of amniotic fluid α‐fetoprotein occur in at least 1% of normal pregnancies. Pelvic ultrasound and amniography should be performed in all such cases to confirm the diagnosis. Employment of this model would prevent the occasional termination of an otherwise normal pregnancy.

LIVER TUMORS AND ORAL CONTRACEPTIVES

Benign hepatocellular neoplasia has been found in 23 patients receiving oral contraceptives of various types. Because primary liver tumors are rare, this marked increase in incidence within 5 years suggests a cause-and-effect relationship. Since progestogens are enzyme inducers it is possible that they accelerate oncogenesis by increasing toxic metabolites which cannot be excreted due to the cholestatic effect of estrogens. Vascular changes and the hypercoagulation state of pill users may act synergistically to produce hemorrhagic necrosis and tumor rupture. Liver scans, celiac arteriography, and standard liver function tests are impractical and ineffective in the identification of the patient at risk. Management of the suspect patient with an intact liver should consist of biopsy at laparotomy so that the entire liver can be inspected. Observation, discontinuance of oral contraceptives, avoidance of similar steroids, and pregnancy should provide adequate prophylaxis against liver rupture. However, if a large blood-filled sinus lake or an area of coagulation necrosis is encountered, resection is imperative to prevent later rupture.