James D. Kitchin

Ectopic pregnancy: Current clinical trends

During the 16 year period ending in November, 1978, 191 cases of ectopic pregnancy were managed at the University of Virginia Hospital. The overall incidence was 1/126 deliveries but during the last 3 years of the study the incidence was 1/60 deliveries. Only 56 patients have had a subsequent conception. Thirteen have had a recurrent ectopic implantation. Only 36 women (23.7% of those available for follow-up) have had subsequent term pregnancies. Ectopic pregnancy continues to be a major gynecologic problem and the potential for subsequent fertility is poor.

Intravasation During Hysterosalpingography Using Oil-Base Contrast Media *

The use of oil-base contrast media for hysterosalpingography provides detailed imaging and the added information of a delayed film. Intravasation with possible embolization of oily media is often cited as a morbid complication. There are reports of significant morbidity associated with the use of high-viscosity oil media such as Lipiodol. Ethiodol has a significantly lower viscosity than Lipiodol. The incidence of intravasation can be reduced by proper timing of the study and avoidance of excessive pressures during instillation. With fluoroscopy, the early manifestations of intravasation can be detected, allowing the operator to limit the volume of embolized medium. We report 13 cases of intravasation (6 with embolization) with no morbidity during hysterosalpingography performed with Ethiodol. These data suggest that embolization of low-viscosity oil contrast media in low volumes is a relatively benign process. The text of this paper contains data on the clinical histories and courses of the 13 cases cited.

Homologous insemination—Revisited

Between July 1, 1969, and December 31, 1983, 1774 patients were evaluated in the private infertility clinic at the University of Virginia Hospital. Homologous artificial insemination was performed in 158 patients for the following indications: male factor (75.3%), cervical factor (16.7%), sperm deposition problem (3.7%), patients request (2.5%), and immunologic factor (1.8%). Whole-ejaculate insemination was performed in 68 patients; split ejaculates were used in 90 women. Additional fertility factors in 140 patients included endometriosis, anatomic abnormalities, and ovulatory difficulties. Of the 158 women, 23 (14.6%) had a total of 27 pregnancies (mean number of cycles, 5.7); 135 failed to conceive during treatment with homologous artificial insemination (mean number of cycles, 8.4). Most pregnancies (70.4%) occurred in those patients in whom homologous artificial insemination was used for a male factor. Among the 135 couples who failed to conceive with homologous artificial insemination, 20 (14.8%) patients subsequently had 25 pregnancies. Male factor had been the indication for homologous artificial insemination in 72% of the couples. Pregnancy outcomes were similar in all subgroups. Homologous artificial insemination may not be indicated for male factor-related infertility.

Utility of the 24-hour delay hysterosalpingogram film

Controversy exists regarding the ideal contrast media for hysterosalpingography. A unique property of oil-base contrast media is the availability of a 24-hour delay radiograph for further assessment of tubal patency and adhesions. A review was undertaken of the delay films in 131 cases performed by use of oil-base contrast media with subsequent surgical confirmation of pelvic findings. A 97% predictive accuracy was achieved with regard to distal obstruction and a 79% accuracy with regard to pelvic adhesions. Objective criteria for the evaluation of 24-hour delay hysterogram films were developed and are illustrated.

Effects of dexamethasone therapy on serum immunoglobulin levels and peripheral cell counts in women undergoing conservative benign gynecologic surgery

Twenty women undergoing conservative gynecologic surgery were treated perioperatively with high-dose dexamethasone (DEX) for 72 hours. Serum immunoglobulin levels (IgG, IgM, IgA) and peripheral cell counts, including lymphocyte subpopulations, were measured in each patient during the immediate preoperative and postoperative periods as well as 5 to 8 weeks later. These results were compared with the levels of a control population of 16 women undergoing conservative, non-pregnancy-related gynecologic surgery for benign conditions. There was a decrease in the level of all serum immunoglobulins measured in the immediate postoperative period in both groups, with a greater statistical decrease in the control group (P less than 0.001). statistically significant transient alterations in the peripheral cell counts occurred in the DEX group, as compared with the control group (P less than 0.001). The use of DEX was not associated with any postoperative infectious morbidity.

Quantitative effects of intraperitoneal 32% dextran 70 on serum immunoglobulin levels in women undergoing gynecologic surgery.

The use of intraperitoneal 32% dextran 70 results in quantitative postoperative changes in human IgG and IgA levels that are statistically different from the alterations induced by the surgical procedure alone.

Effects of Intraperitoneal 6% Dextran 70 on Serum Immunoglobulin Levels, Peripheral Cell Populations, and Lymphocyte Subpopulations in Women Undergoing Gynecologic Surgery

ABSTRACT: Twelve women underwent elective major gynecologic surgery for benign, non‐pregnancy‐related conditions. No perioperative or postoperative “anti‐adhesion” adjuvants were used. Serum immunoglobulin levels (IgG, IgM, IgA) and peripheral cell counts, including lymphocyte subpopulations, were measured in each patient during the immediate preoperative and postoperative periods as well as 5 to 8 weeks later. These results were compared to a treatment population of 16 women who underwent similar surgery and received 150 ml 6% dextran 70 intraperitoneally at the conclusion of the procedure. There was a decrease in the level of all serum immunoglobulins measured in the immediate postoperative period in both groups (not statistically different). At 5 to 8 weeks postoperatively there was a greater level of IgM in the control population than in the dextrantreated group (P = 0.03). Alterations in the peripheral cell counts, including lymphocyte subpopulations, were similar in the two groups. The use of intraperitoneal 6% dextran 70 did not result in postoperative alterations in the human immune system different from those induced by the surgical procedure itself.

Effect of lengthening the fallopian tube on fertility in the rabbit

The effect of surgically lengthening the rabbit oviduct was investigated. In the study group, a lengthened fallopian tube was created by division of the left fallopian tube at the ampullary-isthmic junction and the right fallopian tube at the uterotubal junction. The proximal left tube and the entire right tube were mobilized to the midline, and a microsurgical anastomosis was performed with 10-0 nylon. This formed a tube that was lengthened by approximately 50%, with doubling of the isthmic region. In the control group, both tubes were divided at the ampullary-isthmic junction, and the proximal left and distal right segments were joined to form a tube of normal length. The left ovary and ampulla were resected in both groups. After the animal had been bred, a second laparotomy was performed to assess adhesion formation, document tubal patency, and establish a nidation index. The median nidation index of the control group (N = 11) was 0.89, whereas that of the lengthened group (N = 7) was 0. The nidation indices of the two groups were different, with P less than 0.01.

Salpingitis in a sexually inactive adolescent with congenital virilizing adrenal hyperplasia

Abstract We report a sexually inactive adolescent female with congenital virilizing adrenal hyperplasia (CVAH) and associated urogenital maldevelopment. At the age of 16 6/12 years, she developed signs and symptoms of an acute abdomen. At surgery, gross inflammation of both fallopian tubes and bilateral hydrosalpinges were observed. An anaerobic, gram-positive coccus was isolated. A subsequent sinogram demonstrated reflux of contrast agent from the urogenital sinus through the endocervical canal into the uterus. We postulate that the abnormal urogenital anatomy in our patient provided a mechanism whereby retrograde passage of vaginal bacteria resulted in salpingitis. Consideration should be given to performing a vaginoplasty early in patients with CVAH and small urogenital openings so that the morbid consequences of gynecologic infection can be prevented.

Subsequent fertility in women who undergo cardiac surgery

A retrospective review was undertaken on all pediatric and reproductive-aged females who underwent cardiac surgery and required cardiopulmonary bypass from 1958 through 1986. The purpose of this study was to define the fertility of these patients after surgery and to compare their reproductive performance with that in the general population. Analysis was complete for 208 patients. These patients make up the following cardiac surgical categories: septal defect repairs, 92; commissurotomies, 60; valve replacements, 46; tetralogy of Fallot repairs, 6; and coronary artery bypass procedures, 4. Of 208 patients, 68 (32.7%) attempted pregnancy after surgery. Infertility was defined in five women as follows: endometriosis, 3; ovulatory dysfunction, 1; unknown, 1. A total of 64 patients conceived 121 pregnancies with the following outcomes: live births, 98; spontaneous abortion, 9; ectopic pregnancy, 2; therapeutic abortion, 12. Our results suggest that infertility is not an apparent disorder after cardiac surgery and that subsequent pregnancy outcomes are similar to those in the general population. (AM J OSSTET GVNECOL 1989; 161:573-6.)