Gordon Watkins Douglas

Placental bacteremia: a significant finding in septic abortion accompanied by vascular collapse.

Abstract A preliminary report is made of seven cases of septic abortion, associated with hypotension not related to blood loss. In severe cases a placental lesion characterized by bacteremia of the fetal vessels was found. Pathological findings, including those at autopsy in four cases, are presented. Management of these cases is discussed.

Consumptive coagulopathy associated with intra-amniotic infusion of hypertonic salt.

Abstract A coagulation defect was observed in 3 patients with hemorrhage after abortion induced by the intra-amniotic infusion of hypertonic NaCl. This observation resulted in a study of the coagulation system in 25 patients during the abortion program. A decrease in platelet number, fibrinogen concentration, and factor V activity as well as an increase in fibrinolysis breakdown products was observed in nearly all patients. It developed in different degrees, most pronounced at the time of abortion. Fibrin monomers were observed 24 hours after the salt infusion. Plasninogen, alpha-2 macroglobulin and antithrombin III values remained unchanged. Neither a reduction in urinary output nor an increase in plasma hemoglobin was observed. This suggests that glomerular fibrin deposition does not occur. The syndrome is therefore, best characterized as a consumptive coagulopathy. The decreased coagulation factors return to normal without treatment after the expulsion of the fetus. The development of a consumptive coagulopathy associated with termination of pregnancy by the intra-amniotic infusion of hypertonic salt may explain the hemorrhagic syndrome reported in the literature and provide evidence for an unwanted pathophysiologic development.

Immunological competence of placenta.

The presence of immunologically competent cells in placenta has been investigated by use of the experimental model of runt disease in inbred strains of mice. The injection of placental cells from C57/B1 mice into newborn Balb/C mice resulted in death in the 2nd to 4th week. Evidence is presented that death was caused by immunologically competent fetal cells.

Colposcopy and the management of cervical intraepithelial neoplasia.

Abstract The accuracy of the colposcopically directed punch biopsy and its value in the management of cervical intraepithelial neoplasia (C.I.N.) was evaluated among 272 consecutive patients with abnormal Pap smears who were followed in a cervical dysplasia clinic (Bellevue Hospital, New York University Medical Center). The authors conclude that many unnecessary surgical operations were eliminated with this technique. One hundred and eighty-five patients (68%) underwent a colposcopically directed punch biopsy, usually followed by endocervical curettage. Only 22 patients (8%) had subsequent surgical conizations and 11 patients (4%) underwent hysterectomies. All cases diagnosed as mild or moderate dysplasia were treated by cryocauterization. For the cases with severe dysplasia or C.I.N. the treatment was individualized. Surgical conization or hysterectomy was performed in those cases with additional indications such as uterine prolapse, desire for sterilization, or advanced age. To minimize the risk of a later invasive carcinoma, a continuous follow-up with colposcopy and cytology is necessary.

The fibrinolytic enzyme system in pregnancy

Abstract The fibrinolytic enzyme system was evaluated from blood from antecubital veins, the inferior vena cava, and the ovarian veins in nonpregnant and pregnant women at term. The systemic fibrinolytic activity was decreased in pregnancy. No difference was found in plasminogen, plasmin, urokinase, and streptokinase inhibitor. In general, the activity was higher in ovarian veins than in the antecubital sample, both in pregnant and nonpregnant patients, which might be attributed to direct drainage from the activator-rich myometrium and Fallopian tubes.

IMMUNOLOGIC COMPETENCE OF MOUSE PLACENTAL CELLS IN IRRADIATED HOSTS.

Abstract Evidence for the presence of immunologically competent cells in placenta was obtained in studies involving the injection of placental cells from C57B1/6J mice into irradiated CBA mice. The possibility that these cells were contributed by contaminating maternal tissue or circulating fetal blood was excluded by appropriate control experiments.

Malignant change in trophoblastic tumors

Abstract In a study of 206 hydatidiform moles, histologic grading as described by Hertig and Sheldon confirmed the view of these authors that there is an over-all correlation of histologic appearance to clinical outcome. In 6 cases, among 20 in which multiple specimens of tissue were available over an extended period, a significant change in histologic grade was noted, and designated progressive anaplasia. The appearance of this change shows a close correlation with the development of the invasive process in some patients with chorioadenoma destruens. In view of the propensity for malignant change in trophoblastic tumors, hysterectomy should be considered in primary treatment of hydatidiform moles in patients over the age of 35, and recommended after the age of 40. A plea is made for the wider use of a repeat curettage as a means of detecting incipient or actual malignant change following hydatidiform mole. The demonstration of morphologic as well as clinical evidence of rapid malignant change in trophoblastic tumors confirms the oft-stated view that in these diseases the unexpected and atypical are commonplace.

Clinical management of septic abortion complicated by hypotension

A mortality of 22% is reported for 50 cases of septic abortion complicated by hypotension. Patients were treated by a variety of medical managements, and 44 underwent surgery. 38% were subjected to hysterectomy based on the following indications: 1) unresponsive septic, hypotension, large uterus; 2) intrauterine douche with necrosis; and 3) anuria. Experience with this series indicated the following procedural principles: 1) hourly recording of blood pressure and urinary output; 2) gram-stained smears from cervix; 3) infusion of intravenous fluids and antibiotics geared to combat gram-negative organisms and Clostridium welchii (vasopressor may be required for patients in deep shock); and 4) surgical treatment to remove the source of infection and toxicity. Rationale for clinical management is discussed.

The fibrinolytic enzyme system in the newborn

Abstract 1. 1. In confirmation of previous reports the plasminogen level in cord blood is shown to be low and decreases further in the first days of life. 2. 2. Plasmin, urokinase, and streptokinase inhibitor levels are in the normal adult ranges. 3. 3. Activator is present in cord blood and is considered to be responsible for spontaneous lysis in vitro when fibrinogen is used as a substrate. 4. 4. Whartons jelly and umbilical vessels are free of tissue activator. 5. 5. If the activator inhibitor EACA is infused to pregnant women during labor, it passes the placental barrier, is found in the cord blood, and inhibits activator in the fetal blood. Plasminogen remains at the same low level, indicating that the decrease in plasminogen is not caused by consumption, but is due to a lack of synthesis by the immature liver. 6. 6. The fibrinolytic system in the newborn is considered as a physiologic protective mechanism against untoward clot formation.

Lack of coagulation defect after terminating second-trimester pregnancy by the catheter technique

Abstract Second-trimester abortion was performed by the extraovular insertion of a Foley catheter in 7 patients. There was no change in any of the parameters of the coagulation system present, in contrast to those which were previously observed in patients after the intrauterine instillation of hypertonic salt. Fibrin monomers became positive and fibrin (ogen) derivatives increased when hypertonic saline was instilled after a failed catheter technique. Based on the negative results with the catheter technique, a second-trimester pregnancy was terminated uneventfully in a patient with idiopathic thrombocytopenia. These data are suggestive that salt is an essential factor for the development of the consumptive coagulopathy during second-trimester abortion. This is supported by experimental animal data which indicate that disseminated intravascular coagulation develops in the rat if an endotoxin infection is followed by an infusion of saline, whereas the infusion of glucose is inert.