Thomas B. Lebherz

Double-blind study of premature rupture of the membranes: A report of 1,896 cases

Abstract 1. A multihospital study involving 18 United States Naval Hospitals was conducted to ascertain whether a prophylactic antibiotic administered to expectant mothers with premature rupture of membranes would decrease the perinatal mortality. A double-blind protocol was followed in administering the drug and placebo to the expectant mothers. 2. Of 25,427 patients delivered, 2,934 or 11.5 per cent had premature rupture of membranes. 3. About 1 in every 5 infants delivered to mothers with premature rupture of membranes were either premature or immature. 4. Demethylchlortetracycline does not affect the perinatal mortality of infants of mothers with premature rupture of membranes. This also held true when latent period of mother and maturity of infant was held constant. 5. Perinatal mortality, by reason of infection, accounted for about 1 in every 4 perinatal deaths in the study. Demethylchlortetracycline does not affect perinatal mortality by reason of sepsis, when given to the mother ante partum and intra partum. 6. Demethylchlortetracycline does, however, lower postpartum morbidity when it is given ante partum, intra partum, and post partum, 150 mg. 2 times a day. 7. The decrease in postpartum morbidity is a function of both decreased incidence of endometritis and parametritis, and postpartum pyelonephritis. 8. Premature rupture of the membranes deserves further study from the standpoint of induction of labor in an attempt to lower fetal wastage by reason of sepsis.

Verrucous carcinoma of the female genital tract

Abstract Three recently observed cases of verrucous carcinoma involving the squamous epithelium of the female reproductive tract are the basis for this report. These are rare, locally invasive, radioresistant cancers. Both gynecologists and pathologists should be alert to the fact that precise initial diagnosis may be difficult because of the close gross and microscopic similarity to benign squamous papillomas and condyloma acuminata. The pertinent literature is reviewed and treatment discussed.

Laparoscopic tubal sterilization: Long-term postoperative follow-up

93 women who underwent laparoscopic tubal coagulation during 1972-1973 were followed up for periods of 18 months to 3 years. Ages ranged from 17 to 47 years (mean 30.7) and 71% had 2-4 children. 8 requested sterilization prior to conception and 5 had pregnancy previously terminated by abortion. Most common postoperative complaints were tenderness at the incision site and shoulder or neck pain. In the 64 cases in which sterilization alone was performed average blood loss was less than 50 cc. In 8 cases it was associated with diagnositc dilatation and curettage, in 20 with therapeutic abortion, and in 1 with laparotomy. Complications included 1 case each of bleeding mesosalpinx controlled by cautery, wound hematoma, hematoma epiploic appendix, and peritoneal burn. A detailed menstrual history 18-36 months after operation found 73 of the 93 had regular periods with amount of bleeding and length of cycle generally unchanged. Of the 20 with menstrual changes, 2 developed amenorrhea within 1 year and 8 with preoperative menstrual irregularities were unchagned. 10 developed longer periods and/or shorter intervals. 5 related these changes to discontination of oral contraceptives. Of the remaining 1 had an abnormal Pap smear, 2 were 40-45 years of age (1 of whom refused vaginal hysterectomy for stress incontinence), and 2 were 35-40 with no previous history of cesarean sections or pelvic complaints. The majority (77%) of the women were satisfied with the procedure, 16% uncertain, and 5 patients expressed regret. 4 of the 5 who regretted the operation reported gynecological complaints. 5 required subsequent surgery. In 3 of the 5 the indication preexisted the sterilization and a more thorough screening might have prevented 2 surgical procedures. In this series the incidence of postoperative gynecological disease 18-36 months after laparoscopic tubal ligation is significantly lower than that reported in the literature for conventional tubal ligation.

Management of endometriosis with nor-progesterone

Nor-progesterone (NP) management of 112 cases of endometriosis is reported. The cytologic effects of NP on the ectopic endometrium normal endometrium and fibroids are described. The results were rather satisfactory. 75-80% of the patients with ectopic endometriosis showed objective as well as subjective relief during and after therapy. However there was a high incidence of mild nausea (79.5%) fluid retention (50%) breakthrough bleeding (38.7%) and mild or severe emotional distress (9%). As long-term follow up is not yet available the duration of therapy is as long as 9 months and troublesome side effects do occur NP therapy should be restricted to symptomatic patients who are 35-years-old or younger. The mode by which NP exerts its ameliorative effect on the endometrium remains to be elucidated.

Determination of estrogen and androgen receptors in Trichomonas vaginalis and the effects of antihormones

Trichomonas vaginalis, a common genital pathogen, was found to possess both specific estrogen and specific androgen receptors. These 4.3 S macromolecules were proteinaceous in nature. Both metronidazole-resistant and metronidazole-sensitive strains possessed both types of sex hormone-binding proteins. The estrogen receptor binding was competitively inhibited by the antiestrogen tamoxifen citrate, and the androgen binding was competitively inhibited by the antiandrogen cyoctol. The presence of these specific receptors may allow the use of hormonal and antihormonal manipulation in the treatment of infections caused by these organisms.

Cost-effective use of antibiotic prophylaxis for cesarean section

Clinical experience has indicated that the prophylactic use of antibiotics reduces infectious morbidity in patients undergoing cesarean section. Several factors must be considered (for instance, in vivo and in vitro efficacy, patient allergies, side effect profiles, status of host defenses, the total cost of therapy, and the risk of selecting resistant organisms that cause superinfections) before prescribing prophylactic antibiotic drugs for this indication. Moreover, medical-legal consequences associated with potential postpartum infections must be considered in assessing the costs and impact of a prophylactic regimen. Results of comparative antibiotic trials in indigent patients undergoing cesarean section demonstrated differing rates of successful antibiotic prophylaxis: piperacillin, 98%; cefoxitin, 91%; cephalothin and ceftazidime, 82%; cefotaxime, 80%; and ampicillin, 77%. Although the acquisition costs of antibiotics vary greatly, these costs are dwarfed by the substantial cost savings that can be realized by use of broad-spectrum antibiotics, which, in our hands, have resulted in reduced laboratory and pharmacy expenses and decreased hospital stays for both mother and neonate. Controlled studies designed to investigate microbiologic as well as clinical efficacy of antibiotics are indicated. Further refinements in individualizing antibiotic regimens according to patient population should be sought.

Culdoscopy, an appraisal of results: A review of 450 cases

Abstract 1. The results of 444 consecutive cases of culdoscopic examinations are presented. 2. Patient preparation, preoperative and operative techniques are described, and anesthesias specified. 3. The culdoscope has proved to be a very worthwhile part of the gynecologistss diagnostic armamentarium. 4. It is of greatest benefit to patients who complain of chronic pelvic pain, and has helped considerably in the investigation of patients suspected of having endometriosis, pelvic inflammatory disease, ectopic pregnancy, and infertility problems. 5. Culdoscopy is considered a safe procedure and there was only a 6 per cent rate of minor complications which occurred in this series. 6. Culdoscopy reduces diagnostic errors, prevents unnecessary exploratory laparotomies, and shortens periods of hospitalization. 7. Twenty-eight failures (6 per cent) were due mainly to obliteration of the cul-de-sac, to failure of the instrument itself, and to unfavorable reactions to the preoperative intravenous medications.

Risks of prophylactic anti-D immunoglobulin after second-trimester amniocentesis.

Amniocentesis performed for intrauterine diagnosis of genetic disease is a relatively safe and accurate procedure. However, this procedure carries some risk of sensitization of Rh-negative patients.‘, * This potential hazard could be decreased by the administration of anti-D immunoglobulin to Rh-negative women. There is no consensus concerning the administration of anti-D immunoglobulin after second-trimester amniocentesis. Miles and Kaback3 reported possible adverse effects of anti-D immunoglobulin including a higher rate of fetal loss when anti-D immunoglobulin was administered prior to 20 weeks’ gestation to Rhnegative unsensitized women. To cast further light on the subject, a retrospective study was undertaken with the aims of: (1) determining the risk of maternal sensitization after anti-D immunoglobulin administration and (2) determining the risk and safety of anti-D immunoglobulin to the fetus when administered prior to 20 weeks’ gestation. A retrospective chart review was performed for 300 Rh-negative patients who had undergone 321 secondtrimester genetic amniocenteses in the prenatal diagnosis program of the University of California (Los Angeles) Medical Center between 1977 and 1981. All of these Rh-negative patients had Rh-positive partners. A control group of 321 Rh-positive patients was stud-

Candida albicans Vaginitis: The Problem Is Diagnosis, the Enigma Is Treatment

At the UCLA Vulvovaginitis Clinic, 63 patients were diagnosed as having symptomatic Candida albicans vaginal infections. In a random select manner 3-day treatment with 200-mg clotrimazole suppositories was compared with 7-day treatment using 100-mg clotrimazole suppositories. 7- and 35-day follow-up of all patients entered revealed no statistical difference between the two groups, suggesting that short-term treatment is most efficacious and can be expected to work better since patient compliance is primarily a function of duration of treatment. In 50 cases of C. albicans patients treated with miconazole or clotrimazole in a random manner, the recurrence rate was 8 or 16. All patients in the study received perianal cultures for C. albicans before treatment and 7 and 35 days after treatment. 5 of the 8 patients with recurrence had perianal positive cultures at the 7- and 35-day check suggesting this as a source of recurrence. It is suggested that patients with persistently high perianal cultures after treatment be given an oral fungicide or fungistat to lower chronic recurrent C. albicans.

Neural tube defects: maternal serum screening and prenatal diagnosis.

Neural tube defects represent some of the most common and serious of the congenital malformations. Although elevation of alpha-fetoprotein in amniotic fluid is not diagnostic, it does indicate an abnormality of the fetus in a very high proportion of cases. A normal level, however, does not exclude the possibility of a closed neural tube defect. It is therefore recommended that all amniocenteses performed between 15 and 20 weeks of gestation include measurement of alpha-fetoprotein. Maternal serum alpha-fetoprotein assay is a screening test and pilot studies will be necessary to determine its value as a routine prenatal blood test.