John E. Gunning

Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial *

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience *

Seven women with unruptured tubal pregnancies diagnosed on laparoscopy were treated with methotrexate and citrovorum rescue. Criteria for inclusion in the study were that the level of human chorionic gonadotropin (hCG) be plateaued or rising, that the ectopic pregnancy not exceed 3 X 3 cm, that the tubal serosa be intact, and that there be no active bleeding. The women were followed with serial measurements of hCG, complete blood counts, and liver function tests. All women responded to a single course of therapy. The median time to resolution (from the first day of treatment to when the hCG was undetectable) was 31 days (range, 5 to 50 days). Follow-up hysterosalpingograms were available for five women. Four women demonstrated tubal patency, and one showed a unilateral occlusion on the side of the ectopic. One woman was found to have an intrauterine pregnancy prior to the scheduled time of hysterosalpingogram.

Urodynamic effects of a vaginal pessary in women with stress urinary incontinence

The manner in which a vaginal pessary restores urinary continence is poorly understood. This report provides an explanation. Following placement of the vaginal pessary, detailed urodynamic studies in a group of 12 women with stress urinary incontinence demonstrated consistent and significant (p less than 0.005) increase in urethral functional length and urethral closure pressure under varying stressful conditions, when compared with prepessary studies. Postpessary stress testing also became normal (p less than 0.005). Prepessary and postpessary simultaneous voiding urethrocystometry and instrumented uroflowmetry demonstrated absence of obstruction to free flow of urine. Clinically, 10 of 12 patients became continent. Characteristic postpessary urodynamic alterations and Q-tip test changes provided an objective explanation that the vaginal pessary restored continence by stabilizing the urethra and urethrovesical junction to allow proper pressure transmission and by actively increasing urethral resistance to escape of urine under resting and stressful conditions.

Conservative management of options for patients with dysplasia involving endocervical margins of cervical cone biopsy specimens

OBJECTIVE Our purpose was to study the feasibility of conservatively managing selected cases of dysplasia involving endocervical cone margins. STUDY DESIGN A retrospective review of patients conservatively managed after being found to have squamous cell dysplasia involving the endocervical margins of their cervical cone biopsy specimens. In phase I patients who had cold-knife conization with positive endocervical margins underwent repeat Papanicolaou smears and colposcopy, with biopsies and endocervical curettage as indicated. Those found free of disease were followed up with frequent Papanicolaou smears. In phase II patients with dysplasia to the endocervical resection edges on loop electrical excision procedure biopsy specimens were followed up with frequent cytologic studies. RESULTS In phase I, 31 patients with positive endocervical margins on cold-knife conization and no evidence of dysplasia on reevaluation were followed up for 1 to 18 years. Dysplasia was detected in one patient during cytologic surveillance. In phase II, 11 patients were followed up for 12 to 31 months; only one patient has dysplasia. CONCLUSION Selected patients with squamous cell dysplasia at endocervical cone biopsy margins may avoid additional surgery.

The Effect of Medroxyprogesterone Acetate on Endometriosis in the Human Female

The effect of Depo-Provera (medroxyprogesterone acetate) alone or w ith various estrogens was studied in 14 patients with endometriosis. A ll the paitents except 1 were followed for 13-62 months. Depo-Provera was administered in doses of 100 mg every 2 weeks for a total dosage of 1000-2000 mg. The drug had an effect lasting 4-7 months after the last injection. The effect on endometriotic tissue was striking and was similar in many respects to those conditions occurring during pregnancy. Except for spotting and breakthrough bleeding side effects were less frequent than those reported for oral progestins and estrogen-progestogen combinations. It is concluded that Depo-Provera is a potent long-lasting progestational agent which is highly useful as an adjunct to surgery in cases of advanced endometrial lesions.

Obtaining drug exposure histories during pregnancy

One hundred fifty-three pregnant patients were included in this study to verify the amount of drugs ingested during their pregnancies. The results demonstrate that, unknown to the physician, pregnant patients take a variety of pharmacologic agents. The patients medical record is considered grossly inadequate in documenting an accurate assessment of a patients exposure to drugs taken during pregnancy. Drug histories were obtained utilizing the hospital pharmacist drug history interview and home diary. Validity testing of the pharmacists drug history and of the medical record history was not performed. The patients compliance for utilizing the home diary for drugs or chemicals taken during their pregnancy was 83% (127 patients). It was shown that the usual methods of drug history documentation will identify only 30% of the actual drug exposure to the fetus.

Training and function of a women's health-care specialist, a physician's assistant, or nurse practitioner in obstetrics and gynecology.

Serious manpower shortages exist in the United States. Proposed corrective measures indicate the need for nonphysicians to provide medical care for well or worried well patients. We have tested this proposed solution in the field of obstetrics and gynecology using allied health personnel to provide health maintenance services to well women, and feel that the experiment has been a success. Using principles of pattern recognition allied health workers recognize normal and abnormal findings. Patients with abnormalities are referred to the supervising physician for diagnosis and therapy. Allied health workers can also perform technical health-maintenance tasks such as inserting intrauterine devices and obtaining Pap smears. This article describes the historical evolution of our allied health personnel workers, called womens health-care specialists (WHCS), the selection and training of students, functions and levels of performance of the specialists, and the future role of such individuals in obstetrics and gynecology. We feel that with appropriate preparation of the physician, co-workers, and patients, the integration of the WHCS into the health-care system is both desirable and appropriate and will offer significant advantages to the patient and the practicing obstetrician-gynecologist in either the clinic or private practice setting.

Fiber Optic Cinephotography In Clinical Practice And Reproductive Physiology Research

I want to thank the Society for inviting me to present this material to you. I hope that it will give you some idea of what we can do now, what some of the technical problems are, and perhaps, stimulate your interest and solicit your help.