E. Caspi

Detrusor instability following colposuspension for urinary stress incontinence.

Summary. Sixty‐two patients with genuine stress incontinence (group A) and 30 women with combined detrusor instability and genuine stress incontinence (group B) had a colposuspension operation. The proportion with symptoms of detrusor instability was significantly reduced from 24% before operation to 9% after operation in group A and from 73% to 33% in group B. Urodynamically, detrusor instability developed after surgery in 17 of the 62 patients (27%) in group A whereas only 12 of the 30 women (40%) in group B had detrusor instability after surgery. No urodynamic explanation was found to explain the effect of colposuspension in relieving the symptoms of detrusor instability in some and causing them in others. Nevertheless, it is suggested that colposuspension is helpful for most patients with combined detrusor instability and genuine stress incontinence.

NONSURGICAL MANAGEMENT OF TUBAL PREGNANCY : NECESSITY IN VIEW OF THE CHANGING CLINICAL APPEARANCE

The incidence of ectopic pregnancy is definitely increasing. Ectopic pregnancies are diagnosed earlier these days because of the improvement in diagnostic means and the increasing awareness of the condition. It seems that there is a dramatic change in the clinical presentation of this disease; it used to be a grave and life-threatening condition, and now it is a more benign presentation. The vast majority of the diagnosed ectopic pregnancies are unruptured. This has stimulated various investigators to attempt nonsurgical methods of treatment such as systemic administration of methotrexate or RU 486 (mifepristone) or local injection of methotrexate, potassium chloride, or prostaglandins under laparoscopic or ultrasonographic guidance. Most of these conservative, nonsurgical measures proved efficient in 80% to 90% of cases. Expectant management, which was practiced in some cases, proved to be equally successful. We believe that the ideal mode of treatment in early unruptured ectopic pregnancy is still to be determined. The answer probably lies in proper selection.

Abortion at 18-22 weeks by laminaria dilation and evacuation.

Objective To evaluate the complications of late secondtrimester abortions (18–22 weeks) by laminaria dilation and evacuation, and the obstetric outcome of subsequent pregnancies. Methods Dilation of the cervix was achieved by repeated laminaria tent replacement. Evacuation was carried out in the outpatient clinic using general anesthesia. After the first menstrual period, all patients were invited for examination and thereafter were asked to report the outcome of subsequent pregnancies. Results One hundred seventy-one late second-trimester abortions were performed. Cervical dilation was satisfactory in 158 women (92%). Operative sonography was required in nine (5%) women. One had uterine atony. Follow-up from 150 (88%) women indicated no infection, but one woman required repeat curettage for retained products of conception. There was no indication of cervical injury on cervical internal os measurements remote from abortion. Of the 50 patients who conceived and elected to continue the subsequent pregnancies, two had premature deliveries unrelated to cervical incompetence, and all others reached term. Conclusion Late second-trimester termination by laminaria dilation and evacuation is safe and probably not associated with future adverse pregnancy outcome.

The value of simultaneous hysterectomy during Burch colposuspension for urinary stress incontinence.

&NA; The effect of concomitant hysterectomy during colposuspension on the cure rate of genuine stress incontinence was evaluated prospectively in 45 patients. Twenty‐two women underwent a Colposuspension only (no‐hysterectomy group) and 23 had a concomitant abdominal hysterectomy and cul‐de‐sac obliteration (hysterectomy group). Twenty‐five months postoperatively, no differences were found in the cure rate for urinary stress incontinence between the two groups (95.5 and 95.7% for the no‐hysterectomy and the hysterectomy group, respectively). In the no‐hysterectomy group, three patients (13.6%) had enterocele formation after surgery; this complication did not occur in any of the patients in the hysterectomy group.

Current management of ruptured corpus luteum

The objectives of the study are to assess current management of the rather frequent event of ruptured corpus luteum. Special emphasis is made on the value of ultrasonography, laparoscopy and culdocentesis in deciding appropriate treatment. A series of 70 patients with ruptured corpus luteum diagnosed and treated during a period of 6 years in one institution in Israel is reported. Eighteen patients with concurrent ruptured corpus luteum and ectopic pregnancy are included. Abdominal pain, the most prevalent presenting symptom, has no typical characteristics. The correlation between large amount of fluid as observed by ultrasound and the finding of > 250 ml of blood at laparotomy is very high. Culdocentesis was performed in only 21 patients. Surgical intervention (laparoscopy, laparotomy following laparoscopy or direct laparotomy) was carried out in 58 patients (83%). The remaining 12 cases were handled by observation only. Forty patients required laparotomy in whom 17 underwent wedge resection. We conclude that observation is sufficient treatment in hemodynamically stable patients, without severe abdominal pain and in the presence of a small amount of pelvic fluid demonstrated by ultrasound. When a large amount of fluid is observed and/or in the presence of severe abdominal pain laparoscopy should be performed on admission. Direct laparotomy is mandatory in case of circulatory collapse.

Conservative management of interstitial pregnancy using operative laparoscopy

Interstitial pregnancy has been treated so far mainly by either resection of the cornu or hysterectomy. In this article, two patients with cornual pregnancy were operated upon laparoscopically with an uneventful postoperative recovery. This laparoscopic treatment is simple, does not require extensive operative laparoscopic expertise, and is relatively short and less expensive than laparotomy.We suggest that laparoscopic conservative repair be used to replace cornual resection by laparotomy or hysterectomy in cases of early diagnosed interstitial pregnancy.

Changes in amniotic fluid lecithin-sphingomyelin ratio following maternal dexamethasone administration.

The effect of dexamethasone on amniotic fluid lecithin-sphingomyelin (L/S) ratio was measured in 15 fetuses of 34 weeks or less of gestation. Six of the patients presented with premature rupture of the membranes. A rise in the L/S ratio is mature levels (two or more) was observed 24 hours to 11 days after the start of treatment in 12 patients. In 2 patients (one second twin and one anencephalic fetus), no rise in L/S ratio occurred. Of 12 cases whch ended in premature delivery (29 to 35 weeks) only one infant, a second twin delivered at the thirtieth week with a posttreatment L/S ration o1.4 weighing 1,240 grams, developed severe respiratory distress syndrome and died. Tt is suggested that dexamethasome accelerates fetal lung maturation by increasing surfactant synthesis or release, and this may be achieved as early as the twenty-eighth week of pregnancy.

Triplet, quadruplet and quintuplet pregnancies: Management and outcome

The management and outcome of 46 pregnancies, 37 triplets, 7 quadruplets and 2 quintuplets, were analysed. Management of pregnancies, initiated upon diagnosis of multiple pregnancy, included bed rest, β‐mimetic agents, dexamethasone late in the second trimester and selective cerclage. The mean gestational age at labor was 235 days in triplet pregnancies, 241 for quadruplets and 220 days for quintuplets. Fifty‐four percent of the deliveries were by cesarean section and the remainder per vaginam. The mean weight of the neonates was 1809 g for the triplets, 1837 g for quadruplets and 1284 g for the quintuplets. The mean overall Apgar score was 8.13, total perinatal mortality 14.8% and 9.4% in cases more than 28 weeks. There was no statistically significant difference in the outcome for triplets born vaginally or by cesarean section. In recent years there has been a pronounced reduction in neonatal mortality, dropping from 17.3% during 1970–78 to 5.9% from 1979 to 1983 (p<0.05), probably due to the improved neonatal treatment.

Extremely large number of twists of the umbilical cord causing torsion and intrauterine fetal death

Extremely large number of twists of the umbilical cord causing torsion of the entire length of the umbilical cord was found in two cases of intrauterine fetal death. It was twistd in one case 35 times and in the other 20 times. No additional pathology, such as stricture or abnormality of the Whartons jelly, was found. The two mothers complained of decreased fetal movements and both newborns were found later to be growth retarded. A long cord of 120 cm was present in one case and normal length of 70 cm in the other. Close antenatal care in cases with growth retarded fetuses or decreased fetal movements may help in avoiding fetal demise in such rare cases.

Brucella septicemia in pregnancy

A case of Brucella melitensis septicemia in a second-trimester pregnancy causing intrauterine fetal death and Gram-negative septic shock with diffuse intravascular coagulation is reported. The literature is reviewed. This is the first reported case of human brucellosis in association with Gram-negative sepsis and DIC during pregnancy. The importance of blood cultures and agglutinins for Brucella in febrile pregnant patients is re-emphasized.