Ramon P. McGehee

Repair of vaginal vault prolapse by suspension of the iliococcygeus (prespinous) fascia

Objectives : We reviewed our experience with the use of iliococcygeus fascia for repair of vaginal vault prolapse. Study Design : A retrospective chart review identified 110 patients who had repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus fascia from March 1981 to April 1991. All patients were followed for a minimum of 3 years. Results : Thirty-seven (33.6%) patients had uterine prolapse with enterocele. Posthysterectomy enterocele was present in 73 (66.4%) patients. All had a complex pelvic floor defect including cystocele or rectocele. Mean age was 54.5 ± 14.6 years and mean parity was 4.1 ± 3.2 births. Forty-two (38%) were grand multiparous patients. Five were nulliparous. Length of the procedure was 163.2 ± 11.4 minutes. Estimated blood loss was 358.2 ± 253.6 ml. Postoperative urinary catheterization was required for 6.1 ± 4.1 days. Duration of hospital stay was 5.5 ± 2.0 days. Three patients had hemorrhage > 750 ml and two required transfusion. One bowel injury and one bladder injury occurred. Forty-one patients had postoperative complications. The patients have been followed up for a minimum of 3 years, and four have had recurrent defects. All recurrent defects involved the anterior vaginal wall. Conclusions : Suspension of the vagina to the iliococcygeus fascia for repair of vaginal vault prolapse provides excellent long-term results. Critical to the success of vaginal vault suspension are adequate dissection and repair of all fascial defects. Adequate repair of the perineal body also plays a pivotal role. The anterior vaginal wall remains susceptible to recurrence.

Life-threatening neutropenia following methotrexate treatment of ectopic pregnancy: A report of two cases*

Background Medical treatment of ectopic pregnancy with methotrexate is an increasingly common alternative to surgical management. Initial reports of methotrexate therapy described a very low incidence of complications. We report our experience with two patients who developed profound toxicity following methotrexate treatment of ectopic pregnancy. Case The first patient received a single dose of methotrexate (50 Mg/M2 intramuscularly) for a confirmed ectopic pregnancy. The second patient received three doses of methotrexate (1 mg/kg). Both patients developed life-threatening neutropenia and febrile morbidity requiring hospitalization and supportive care. Conclusion To our knowledge, this is the first description of significant morbidity secondary to bone marrow suppression following methotrexate treatment of ectopic pregnancy. Most patients with ectopic pregnancy who are treated with methotrexate can expect resolution of their symptoms and a low risk of mild complications. However, serious complications after this therapy are possible and may occur even with the single-dose regimen.

Hydatidiform Mole Pregnancy Trophoblast Extracts Differentially Suppress lnterleukin-2-lnduced Proliferation of Human T-Lymphocytes and PHA-Blasts

ABSTRACT: Immunoregulatory factors of trophoblast origin may partially abrogate maternal immune responses to the fetus during pregnancy. We have previously shown that soluble factors extracted from hydatidiform mole trophoblast suppress interleukin‐2 (IL‐2)‐dependent proliferation of a cloned murine cytotoxic T cell line (CTLL‐2). To characterize human T cell responses to this trophoblast extract, we measured the effects of molar tissue extracts (HME) on IL‐2‐stimulated proliferation of human T‐lymphocytes and mitogen (PHA) transformed T‐cell blasts (PHA‐blasts). HME significantly (P<0.05) suppressed T‐lymphocyte proliferation in response to 5 and 10 units/ml of IL‐2 at 500 and 250 μg/ml, while no effect was observed at the 100 μg/ml concentration. Suppression by HME of IL‐2‐stimulated T‐cell proliferation was partially overcome by the addition of excess IL‐2. HME also suppressed (P<0.05) IL‐2‐stimulated proliferation of PHA‐blasts at 500 and 250 μg/well at both 5 and 10 units/ml of IL‐2. As observed with resting T‐cell responses, no suppression of PHA‐blast proliferation was observed using 100 μg/ml of HME. In contrast to the response of the resting T‐cells to excess IL‐2, HME suppression of IL‐2‐stimulated blast proliferation was not affected by increasing the concentration of IL‐2. These results indicate that extracts from hydatidiform mole trophoblast contain immunosuppressive factors that block human T‐cell clonal expansion by inhibiting the utilization and/or production of IL‐2. Furthermore, the effects of HME are not reversed by excess IL‐2 when PHA‐blasts are reacted compared to resting T‐cell responses, which are partially reversed in the presence of excess IL‐2. This suggests that human trophoblast‐derived immunoregulatory factors that are present in hydatidiform mole inhibit human lymphocyte utilization of IL‐2 in a fashion similar to the murine (CTLL) model, and exhibit irreversible effects on lymphocytes containing high affinity IL‐2 receptors (PHA‐blasts) compared to lymphocytes with only low affinity IL‐2 receptors (resting T‐cell). This property of the trophoblast may partially explain how hydatidiform mole, and possibly pregnancy trophoblast in general, escapes lethal immunological challenge by the maternal immune system.

Suppression of lymphocyte proliferation in vitro by macromolecules in the vesicle fluid and tissue extracts of hydatidiform mole

This study examines the effects of vesicle fluid and tissue extracts from hydatidiform mole trophoblast on lymphocyte proliferation in vitro. Samples were obtained by direct aspiration of vesicles (hydatidiform mole vesicle fluid (HMF] or homogenization of molar tissues (hydatidiform mole extract (HME] following therapeutic uterine evacuation of hydatidiform mole. Dialyzed and lyophylized HMF pooled from two patients exhibited a 30% suppression (P less than 0.05) of mitogen-induced lymphocyte proliferation at a concentration of 12.5 micrograms protein/ml. Similarly, lymphocyte transformation was significantly suppressed (P less than 0.05) by HME at concentrations of 500 and 250 micrograms/ml. Molecular weight chromatography of HME resolved 4 protein fractions. Fraction 3 (35--50 kDa) and fraction 4 (less than 35 kDa) significantly suppressed mitogen-induced lymphocyte transformation while fractions 1 and 2 demonstrated no immunosuppression. Heat treatment (56 degrees C, 30 min) abolished the immunosuppressive activity of HME as well as fractions 3 and 4. These results suggest that hydatidiform mole trophoblast contains heat-labile macromolecules which suppress mitogen-mediated lymphocyte transformation. Such trophoblast-derived factors may interfere with maternal rejection of the allograft.

Retroperitoneal fibrosis associated with carcinoma of the cervix: Review of the literature☆

Microinvasive cervical cancer presented in a woman with retroperitoneal fibrosis in remission following steroid therapy. The cervical lesion was treated surgically with good outcome. Review of the literature documenting this association reveals three other cases, one following and two preceding the diagnosis of retroperitoneal fibrosis. The case reports are reviewed and potential difficulties in the management of these patients are discussed.

Evaluation of the B-protein assay in cancer management

Previous data have suggested that the B-protein assay might prove to be useful in the assessment of patients with cancer after various therapeutic modalities. The assays effectiveness was evaluated by prospective study of 133 patients with cervical, uterine, or ovarian cancer. After therapy, B-protein levels remained elevated in 17 nonresponding patients who eventually died of the disease. In contrast, 88 patients experienced a significant reduction in B-protein levels measured 90 days after treatment. Among this group, 25 patients demonstrated elevated B-protein levels during the 2-year follow-up period and all were confirmed to have persistent or recurrent disease. These data indicate that monitoring serum B-protein levels can be beneficial in the posttherapeutic management of gynecologic malignancies.

Gestational Age Correlates With Immunosuppressive Properties of Hydatidiform Mole Pregnancies

PROBLEM: Soluble trophoblast extracts (HME) from some human hydatidiform mole pregnancies suppress IL‐2‐dependent T‐cell proliferation, while others express no immunosuppressive bioactivity. This study was designed to determine if suppression by HME was correlated with gestational age, uterine size, or hCG secretion.