Robert F. Porges

Long-term analysis of the surgical management of pelvic support defects

OBJECTIVE The aim of this study was to determine the success of various procedures to correct defects of pelvic support and to elucidate the role of sacrospinous ligament fixation in primary versus nonprimary vaginal operations. STUDY DESIGN This study was a retrospective analysis, covering 23 years, of 486 patients treated for pelvic support defects, grouped according to the location and severity of the defect, type of repair, and outcome. RESULTS For primary repairs the recurrences were more frequent the more severe the defect, but this relationship did not hold for repeat surgery. Sacrospinous ligament fixation, when performed concurrently with vaginal hysterectomy for patients with third-degree prolapse in primary cases reduced the rate of recurrence from 15.8% to 6.7%. CONCLUSION The original degree and type of pelvic support defect is important in selecting the appropriate operative procedure for the highest likelihood of cure. There may be a wider role for sacrospinous ligament fixation in primary operations for patients with severe defects.

Estrogen and progesterone receptors in the uterosacral ligament.

Objective To evaluate steroid hormone receptor status in the uterosacral ligament, a structure that contributes to pelvic support. Methods A descriptive study was conducted by sampling the uterosacral ligaments from 25 consecutive women undergoing hysterectomy by the primary author for nonmalignant conditions. Using immunohistochemical staining techniques, uterosacral ligaments were assessed for the presence and location of estrogen and progesterone receptors. Positive and negative controls were used. Confirmation of the uterosacral ligament was performed histologically. Results Using commercially available monoclonal antibodies, estrogen and progesterone receptors were detected in the nuclei of smooth muscle cells of the uterosacral ligament in all patients, regardless of variations in age, race, menopausal status, parity, body mass index, and medications affecting serum steroid hormone levels. Hormone receptors were not found in the collagen, vascular, or neuronal components. Conclusion The presence of estrogen and progesterone receptors in the uterosacral ligaments means that this structure may be a target for estrogen and progesterone. This finding might suggest a possible role for steroid hormones in pelvic support.

The risk of cystocele after sacrospinous ligament fixation

OBJECTIVE The aim of this study was to determine whether sacrospinous ligament fixation independently increases the risk of anterior vaginal wall defect. STUDY DESIGN A retrospective cohort study was conducted on patients undergoing pelvic reconstructive surgical operations by a single surgeon from 1970 through 1997. Two groups were examined and divided into subgroups to evaluate the effects of exposure to sacrospinous ligament fixation: patients with anterior wall defects undergoing standard anterior colporrhaphy with (group 1A) or without (group 1B) concomitant sacrospinous ligament fixation, and patients without anterior wall defects undergoing other pelvic reconstructive procedures (but not anterior colporrhaphy) with (group 2A) or without (group 2B) sacrospinous ligament fixation. Recurrence rates were calculated for each group according to evidence of any degree of anatomic defect. RESULTS Among 322 patients in group 1, 9 of 77 in group 1A and 23 of 245 in group 1B (11.7% vs 9.4%, P >.05) had anterior wall recurrences. Among 73 patients in group 2, 8 of 45 in group 2A and 5 of 28 in group 2B (17.8% vs 17.9%, P >.05) had subsequent anterior wall defects. CONCLUSION The occurrence of anterior vaginal wall defects was not found to be altered by the performance of sacrospinous ligament fixation. These findings may be attributable to surgical technique emphasizing maintenance of anterior vaginal wall length during sacrospinous ligament fixation.

Blood coagulation and fibrinolytic enzyme studies during cyclic and continuous application of progestational agents

Abstract In 10 volunteers two different oral progestational agents and one placebo were employed for three cycles. Blood was taken on 9 different days during each cycle and subjected to blood coagulation and fibrinolytic enzyme studies. The statistical evaluation did not reveal any changes. However, when patients were taking progestational agents in continuous high doses for treatment of endometriosis an increase in Factor VII, fibrinogen, and plasminogen was illicited. It is assumed that increase in coagulable proteins due to steroids is a dose-time response problem.

An epidemic of maternal thrombocytopenia associated with elevated antiplatelet antibody: Platelet count and antiplatelet antibody in 116 consecutive pregnancies: Relationship to neonatal platelet count☆

Twenty-eight (24%) of 116 pregnant women studied prospectively during an 8-month period in 1983 had platelet counts of less than 150,000/mm3 at least once during pregnancy. Thirteen of these were thrombocytopenic in both the prenatal and the peripartum period. Eighteen were restudied 3 to 12 months after delivery. One woman, who was pregnant again, had a platelet count of 140,000/mm3. In the others, platelet counts were in the normal range. Platelet-associated immunoglobulin G and serum antiplatelet antibody levels were elevated in 79% and 61%, respectively, of these 28 women on at least one occasion. However, 59% of 73 pregnant nonthrombocytopenic women had increased platelet-associated immunoglobulin G levels and 59% had positive serum antiplatelet antibody test results. Twenty women who had increased platelet-associated immunoglobulin G levels and positive serum antiplatelet antibody test results were normal 6 to 10 months after delivery. Of 105 infants studied, 10 were thrombocytopenic. Neonatal thrombocytopenia was not predicted by maternal platelet count, platelet-associated immunoglobulin G, or serum antiplatelet antibody. By the fall of 1984, the incidence of thrombocytopenia had dropped to two in 280 consecutive pregnancies. We conclude that (1) epidemics of thrombocytopenia can occur in pregnant women and (2) if a women is found to be thrombocytopenic for the first time during pregnancy, she should not be subjected to the measures advocated for the management of pregnancy in women with autoimmune thrombocytopenic purpura.

Neonatal recognition of familial dysautonomia

respiratory distress syndrome. It is unclear why SOD appeared to be effective in modifying pulmonary disease in human infants at relatively low doses, yet failed to modify sequelae in the present animal models, despite substantially higher doses of the enzyme. The lungs of both the preterm infant (<28 to 30 weeks gestation) and the mature newborn rat are both structurally immature and in a prealveolar, or saccular, stage of development. H Efficacy of SOD supplementation could relate to relative differences in the dose of oxygen exposure or the adequacy of available endogenous antioxidants. Alternately, SOD may reduce acute pathologic processes such as pulmonary edema and small airway damage, yet fail to prevent the oxygen toxic effect that disturbs normal lung parenchyma and vascular growth. Further investigation is necessary to establish the role of oxygen radicals and antioxidant therapy in neonatal lung disease. Until more data can be obtained from appropriate animal models, we caution against the use of SOD supplementation in human infants.

The response of the New York Obstetrical Society to the report by the New York Academy of Medicine on maternal mortality, 1933–1934

My topic for this address concerns an event in the life of the New York Obstetrical Society. During the past year, I went to the rare books section of the library of the New York Academy of Medicine, the repository of the archives of this Society. At the beginning I had no clear idea of what my subject for this address was going to be. Apart from the illustrious careers and important contributions of the many fellows, which are well known to most of you, the accomplishments of this society in its separate life are more obscure. Although monthly meetings have been held with faithful regularity here at the Yale Club since 1927, there seemed to be no record of any special linkage between the society and the important obstetric events of the time, with one notable exception. From Claude Heatons History of the First One Hundred Years of the Society through 1963, my attention was directed toward and came to rest on a thick dossier which held information about the dramatic events of the season of 1933 to 1934, exactly 50 years ago, and they took place here, perhaps in this room. The president of our society for the 1933-1934 season was Dr. Edward Bullard. The membership consisted of 69 active fellows, 35 life fellows, and 10 nonresident fellows. The first three programs of that year, which included case presentations and a study of the time of ovulation by Dr. Kurzrok, gave no indication of the explosion that was to rock the foundation of the society with the announcement that appeared on the opening page of The New York Times on Monday, November 20, 1933 (Fig. 1). As you can see, the top headlines concerned local and national events of no enormous consequence, but farther down on the page (Fig. 2) was an article of consuming interest about the brew-

Changing indications for vaginal hysterectomy

The recent history of vaginal hysterectomy in America is summarized to bring current trends into focus. A series of 252 vaginal hysterectomies is analyzed. The discussion deals with factors contributing to morbidity, the relative advantages of various techniques, and the recognition and management of complications.

Factors affecting the introduction of new vaccines to poor nations: a comparative study of the Haemophilus influenzae type B and hepatitis B vaccines.

Background A major effort to introduce new vaccines into poor nations of the world was initiated in recent years with the help of the GAVI alliance. The first vaccines introduced have been the Haemophilus influenzae type B (Hib) and the hepatitis B (Hep B) vaccines. The introduction of these vaccines during the first phase of GAVIs operations demonstrated considerable variability. We set out to study the factors affecting the introduction of these vaccines. The African Region (AFRO), where new vaccines were introduced to a substantial number of countries during the first phase of GAVIs funding, was selected for this study. Methodology/Principal Findings GAVI-eligible AFRO countries with a population of 0.5 million or more were included in the study. Countries were analyzed and compared for new vaccine introduction, healthcare indicators, financial indicators related to healthcare and country-level Governance Indicators, using One Way ANOVA, correlation analysis and Qualitative Comparative Analysis (QCA). Introduction of new vaccines into AFRO nations was associated primarily with high country-level Governance Indicator scores. The use of individual Governance Indicator scores, as well as a combined Governance Indicator score we developed, demonstrated similar results. Conclusions/Significance Our study results indicate that good country-level governance is an imperative pre-requisite for the successful early introduction of new vaccines into poor African nations. Enhanced support measures may be required to effectively introduce new vaccines to countries with low governance scores. The combined governance score we developed may thus constitute a useful tool for helping philanthropic organizations make decisions regarding the type of support needed by different countries to achieve success.

Vaginal delivery and serum markers of ischemia/reperfusion injury

Objective: Vaginal deliveries have been associated with pelvic organ prolapse and incontinence. The objective was to show whether markers of ischemia/reperfusion injury are dependent upon the mode of delivery and length of labor. Method: Complete venipuncture sets were obtained on 62 subjects. All samples collected were analyzed for serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH). Lipid peroxidation was analyzed, using thiobarbituric acid reactive substances (TBARS), on a subset of 37 patients. Results: There was a significant increase in CPK from admission to 1 h postpartum and postpartum day 1 in vaginal delivery versus cesarean delivery. Longer second stages were associated with significant increases in CPK. There were no significant changes in either LDH or TBARS from admission to any other time point regardless of mode of delivery. Conclusion: Vaginal delivery and longer second stages were associated with a much greater increase in one of these injury markers.