James R. Scott

Anticardiolipin antibodies: clinical consequences of “low titers”

Objective To clarify the implications of low levels of immunolobulin (Ig)-G or IgM anticardiolipin antibodies. Methods Women who underwent clinically indicated testing for antiphospholipid antibodies were divided into four groups based on results: 1) high-positive (lupus antiocoagulant or more than 19 IgG binding units of anticardiolpin antibodies: N = 131,) 2) low-positive IG (fewer than 20 IgG binding units: N = 93), 3) IGM only (more than nine IGM binding unis; N = 97), and 4) negative (N = 153). the development of antipholipid antibody-related (N = 153). The development of antiphospholipid antibody-related disorders was assessed for the time interval from initial antiobyd testing to patient interview. The median study interval for each group was at leat 4 years. Forty-five percent of women had repeat testing at the time of interviewe. Results Women in the high-positive group were more likely to develop at least one new medical complication than those in the low-positive IgG (odds ratio [OR] 4.49, 95% confidenc interval [CI]2.01–10.03), IgM only (OR 6.0, 95% CI 2.65–13.59), and negative (OR 9.11, 95% CI 3.92–21.2) groups. In contract, the low-positive IgG, IgM only, and negative groups had similar risks for the development of new disorders. Twelve of 129 (9.3%) women in the low-positive IgG, IgM only, or negative groups had lupus anticoagulatn or more than 19 IgM binding units on retesting. Half of these women developed at least one new disorder. Conclusion Women with IgM or low levels of IgG anticardilipin antibodies compriswe distinct populations from those with lupus anticoagulatn or moderate to high levels of anticardiolipin antibodies. These women are not at risk for antiphospholipid antiobyd-related disroders beyond the risk conferred by theri medical histories. However, repeat testing is warranted with new or recurrent clinical symptoms.

Fetal platelet counts in the obstetric management of immunologic thrombocytopenic purpura

The optimal method of infant delivery for gravida women with immunologic thrombocytopenic purpura (ITP) is controversial because of the unpredictability of the fetus developing thrombocytopenia and the uncertainty of the relation between vaginal birth and intracranial hemorrhage in thrombocytopenic infants. We have employed the technique of platelet counts on fetal scalp blood obtained prior to or early in the course of labor in 12 patients with ITP. A count of 50,000/cu mm, selected on the basis of literature review and retrospective analysis of our own experience, was used to define fetal thrombocytopenia. Three thrombocytopenic fetuses were delivered by cesarean section. Trial labor was permitted in the other nine cases in which fetal scalp platelet count exceeded 50,000/cu mm. The outcome was good in all instances. If cesarean section is to be employed in ITP patients to obviate the potential danger of fetal hemorrhage with vaginal delivery, the use of platelet counts of fetal scalp blood seems to provide the most rational basis for management at present.

Antiplatelet antibodies and platelet counts in pregnancies complicated by autoimmune thrombocytopenic purpura

In 48 pregnant women with autoimmune thrombocytopenic purpura, no consistent correlation was found between the infant platelet count and either the maternal platelet count, a previous maternal splenectomy, or maternal treatment with corticosteroids. Although the concentration of antiplatelet antibody in maternal serum frequently reflected the severity of neonatal thrombocytopenia, a number of exceptions to this observation limited the clinical usefulness of the test for individual patients. Antiplatelet antibody levels in the amniotic fluid were always low. A twin gestation in this series of patients in which one infant was thrombocytopenic and the other was not also showed that no antepartum maternal clinical characteristic or laboratory test can accurately predict the fetal platelet count. Only fetal platelet counts from scalp samples obtained prior to or early in labor from 25 patients with autoimmune thrombocytopenic purpura proved to be reliable in assessing the degree of fetal thrombocytopenia and selecting the appropriate route of delivery.

Immunologic aspects of pre-eclampsia

It has been suggested by a number of investigators that immune reactions of the mother against antigens of her conceptus contribute to the development of pre-eclampsia. Evidence for and against this hypothesis is reviewed and the possible clinical implications are discussed.

Surgical management of urethrovaginal and vesicovaginal fistulas

This report reviews a 50 year period during which 157 vesico- and 24 urethrovaginal fistulas were managed. Although the etiologic factors have changed, there has not been a dramatic decrease in the incidence of this complication. In the last 17 years we have noted an increased number of both types of fistula, primarily related to the increased frequency of gynecologic operative procedures. Only 11 (6%) of the fistulas reported in this series resulted from surgical procedures performed in our department. In this series 96% were repaired vaginally but the abdominal approach was used for certain complicated fistulas. Our initial cure rate was 89% and the final success rate in 157 vesicovaginal fistulas was 94.3%. The urethrovaginal fistulas represent a special problem because of the location, scarring, and lack of sufficient fascia for a second-layer closure. In such instances we have successfully used the bulbocavernous fat pad. The success rate for 24 patients with this type of fistula was 87.5%.

Cervical-vaginal flora of immunosuppressed renal transplant patients

The purpose of this investigation was to determine the endocervical microflora present in 25 renal allograft recipients hwo were receiving therapeutic dosages of azathioprine or cyclophosphamide and prednisone. The aerobic flora was similar to that found in other populations. However, these immunosuppressed patients had more different anaerobic species per culture than were found in most other populations. This was reflected in the more frequent isolation of many species of anaerobic bacteria, especially the anaerobic gram-negative rods. The clinician should be aware of these differences since they may be significant in regard to gynecologic or obstetric postoperative infectious morbidity in women using immunosuppressive medications.

Congenital Atresia of the Uterine Cervix

ALTHOUGH DEFECTS in Müllerian duct fusion produce a variety of congenital anomalies, the lack of communication between the uterus and vagina is extremely rare. Only 10 patients with congenital atresia of the cervix in association with a functioning uterus and normal vagina have been reported in the literature.Our patient with this anomaly had the typical clinical picture consisting of primary amenorrhea and cyclic lower abdominal pain, but she differed from previous cases in that she had a bicornuate uterus and retrograde menstruation with pelvic endometriosis.

Vaginal bleeding in the midtrimester of pregnancy.

Abstract One hundred and two cases of vaginal bleeding during the midtrimester of pregnancy occurring over a 10 year period were reviewed. This condition is more common than generally recognized, and the perinatal mortality rate is extremely high. The etiology of the bleeding was found to fall into five general categories: hydatidiform mole, placenta previa, premature placental separation, extrinsic causes, and undetermined causes. The prognosis for the fetus becomes progressively more grave with increased amount of bleeding, the number of bleeding episodes, and if accompanied by uterine cramps. The perinatal mortality rate was 42 per cent when the bleeding was due to placenta previa, 83 per cent when secondary to premature placental separation, and 33 per cent when due to an unknown cause. Cases of second-trimester bleeding severe enough to require transfusion were associated with a perinatal mortality rate of 84 per cent. In view of these findings, heroic measures are not indicated, and a suggested therapeutic regimen is discussed.