H.L. Riva

Surgical closure of the incompetent cervix during pregnancy

TE abortion or premature labor occurring after the sixteenth week of gestation as a result of cervical incompetence has emerged in recent years as a clinical entity.l> 2 Shirodkar3 in India and Lash4 in the United States recognized cervical incompetency at about the same time. Both have suggested surgical procedures for the correction of the defective cervix in the past 10 years, as has McDonald in Australia more recent.ly. That so little emphasis has been accorded second-trimester abortions is undoubtedly due to the limited number of patient,s in whom this condition occurs. By comparison with the number of patients who have first-trimester abortions or with the number of patients who have premature labors the number is indeed small. As a cause of habitual abortion in the middle trimester of pregnancy, incompetency of the cervix may be a most important factor. It is with t,hese carefully selected patients that this study has been carried out. Careful evaluat,ion of the history in a patient who has had repeated middle-trimester pregnancy losses is the best indicator that incompetency of t,he cervix may be present. Sudden loss of the amniotic fluid between the sixteenth and twenty-eighth weeks of pregnancy, not preceded by painful contractions, is t.he most striking feature in the history of such pregnancies. Cervical incompetency rarely occurs in a first gestation. In this series it did not seem to be of congenital origin, as has been reported.6, 7 These patients usually will have had trauma to the cervix in the form of a dilatation and curettage after an abortion; as the result of deep cervical lacerations from a previous delivery; or as a sequel to a surgical revision or amputation of the cervix done at the time of a previous gynecologic operation. If the patient has a history of repeated middle-trimester pregnancy losses the next most convincing means of proving that the cervix is incompetent is to examine the patient at weekly intervals during gestation. If incompetency

Vaginal delivery after cesarean section

Summary 1. Two hundred and fourteen consecutive cases of previous cesarean sections were evaluated for possible vaginal delivery. Three fourths of these patients were delivered vaginally. 2. There were 2 suspected occult ruptures which were confirmed at sec tion. 3. There were no maternal deaths in the group who were delivered vaginally. 4. The fetal mortality can readily be corrected to zero: 5. Vaginal delivery requires less blood transfusion and is devoid of the usual complications potentially a ttendant on an abdominal operative procedure.

Effect of norethynodrel on endometriosis

The authors selected norethynodrel for conservative therapy beginning in 1958 because of the hormones lack of androgenic effect inhibition of ovulation and estrogenic effect. Minimal duration of therapy was planned to be 6 months. By 1960 there were 123 patients diagnosed at Walter Reed General Hospital as having endometriosis and suitable for this treatment. Ill patients were diagnosed by culdoscopic examination and results were confirmed by the same method. 11 were diagnosed by laparotomy and 1 by colpotomy. Ages ranged from 20 to 46 years with an average of 32.8. Most frequent symptoms were dysmenorrhea dyspareunia infertility menorrhagia metrorrhagia and pelvic pain. Treatment started with 2.5 mg daily and was increased rapidly to 30 mg daily. When breakthrough bleeding occurred further increases were made in 10 mg increments up to 100 mg daily. The average dose was 49.2 mg daily. Adjacent organs and tissues particularly the ovaries were often involved. For the entire group 63 patients (79.7%) showed complete regression of endometriosis 8 showed improvement 10 were not improved. Regression rate was the same regardless of the patients age or the severity of the disease. Of side-effects irritability and nervous tension abdominal cramping vaginal discharge and leg cramps were most common. All patients gained weight. 5 required psychiatric treatment. Cervical and vaginal smears obtained before and after therapy revealed no evidence of cellular atypism. Significant uterine enlargement was noted. Estrogen effect and high progesterone effect were noted during therapy but reverted to normal when treatment ceased. Incidence of trichomonads and Candida was less than 15%. Histological examination of tissue removed by curettage after therapy showed a marked stromal decidual reaction with absence or atrophy of glandular elements. 9 patients required major surgery after 1-12 months of treatment. Of 28 patients followed up for an average of 10.9 months recurrences developed in 5 after 7.2 months of remission; in 1 of these 6 additional months of therapy produced remission. Normal ovulation returned but was delayed. 4 patients from the group of 38 who had been infertile for 3-9 years became pregnant.

Hemolytic anemia in pregnancy: Report of two cases

Abstract Two cases of hemolytic anemia associated with pregnancy are added to the literature. The first patient was treated conservatively and the second by splenectomy. In the first and second trimesters, a transthoracic splenectomy is suggested. A conservative approach should be followed, if possible, if the disease is encountered in the third trimester. Hemolytic crises were not encountered in either case when whole blood was administered to the patients. Obstetrical complications were not increased by the presence of hemolytic anemia. The method of delivery should be governed by obstetrical indications only. The infant apparently is not affected by the disease in a well-managed case. However, the congenital tendency of the disease is well known. A careful follow-up of both mother and infant is, therefore, imperative. Since hemolytic anemia associated with pregnancy is quite rare and its mode of therapy not well established, all such cases should be reported by the profession.

Culdoscopy for infertility: An analysis of 203 cases

Abstract A review of 203 patients having culdoscopies for infertility at Walter Reed Army Hospital between December, 1948, and July, 1958, has been presented. The indications, preoperative impressions, findings, and minimal complications have been discussed. The value of culdoscopy in infertility investigations has been emphasized.

Polyostotic fibrous dysplasia and pregnancy: A case report

Abstract A second case of polyostotic fibrous dysplasia in pregnancy has been reported. Two of the classic abnormalities were present, namely, unilateral cystic changes within the skeleton, and associated unilateral pigmentation in the skin. Delivery was accomplished vaginally without damage to the architecture of the pelvis.

Pain associated with endometriosis.

Endometriosis occurs in about 5% of patients and is found in up to 20% of major operative procedures. The origins of endometriosis are explained through menstruation coclomic metaplasia and embolic phenomena. The symptoms of endometriosis mimic the pain of related and unrelated tumor masses as well as inflammatory processes ectopic pregnancy and infiltrating malignant processes. Active endometriosis is probalby associated with the onset of the menarche; it can be symptomatic in menopausal women. It usually affects women between the ages of 25 and 45. Symptoms may vary from minimal to severe. Patients with endometriosis have been known to improve or become asymptomatic during pregnancy. Norethynodrel has been employed with encouraging results in the treatment of endometriosis. In some instances additional culdoscopy and laparotomy have been used. Relief of pain correction of menstrual irregularity improvement of fertility and prevention of further ovarian destruction are idications for therapy in the young. Mild analgesics and elimination of constipation elimination of premenst rual tension syndrome hormonal therapy with natural or synthetic estrog ens androgens or progestins and/or surgery are choices in the treatmen t of endometriosis.

Carcinoma in situ and the role of cytology in its detection

Abstract 1. Eighty-four cases of carcinoma in situ, with reference to determining the role of cytoanalysis, have been reviewed. Of the 72 smears taken on these patients, there were 3 false negatives, making the rate of false negatives 2.4 per cent. 2. There were 34 cases, or 40.5 per cent of the cases reviewed, in which a positive smear was the initiating step in establishing a diagnosis that would otherwise have been totally unsuspected. 3. The normal-appearing cervix offers the greatest challenge to early detection of unsuspected cervical carcinoma, and this is one of the values of the cytological smear.

Experience with hydrazinophthalazine in hypertensive states of pregnancy.

Abstract 1. 1. Results of clinical trial of 1-hydrazinophthalazine in 34 pregnant toxemic and hypertensive patients have been presented. 2. 2. Vasodepressor response was achieved in all but one of the 29 patients who were given the drug intravenously. 3. 3. Oral and subcutaneous administration did not result in uniform or satisfactory blood pressure response. This may have been related to dosage. 4. 4. Theoretical basis for the advantages of this drug appears to be the increased renal blood flow with reduction in blood pressure and no decrease in cardiac output. No decrease in urinary output or increase in albuminuria was noted. 5. 5. No claim concerning the reversal of the basic toxemic disease process is presented for this drug. 6. 6. 1-hydrazinophthalazine is recommended for further trial in the control of the hypertensive aspects of pre-eclampsia and hypertension in the pregnant patient.

Knee Rest Apparatus for the Culdoscopy Patient

A knee rest apparatus used by various endoscopists in culdoscopy ins ures the patients maximum comfort prevents injury from undue pressure over the knees and lateral peroneal surfaces and permits proper positioning of the patients knees. The patient does not require mechanical braces or straps over the thighs or calves to maintain the thighs in flexion. Adequate space is needed between the patients abdominal wall and the table to permit adequate pneumoperitoneum for visualization and to permit palpation of the abdominal wall. The knee rest allows the performance of culdoscopy in the presence of operator and anesthetist only. It has been employed over 1000 times and has shown satisfactory results.