Winfred L. Wiser

Prevention of preterm birth by ambulatory assessment of uterine activity: A randomized study

Tocodynamometry, used on an ambulatory basis, has been shown to detect uterine activity. The objective of this study was to assess the effectiveness of ambulatory tocodynamometry in the early identification of preterm labor. In this investigation 67 women at risk for preterm labor were randomly divided into two groups: 34 received a uterine activity monitor while 33 patients used palpation. Approximately two thirds of the study sample developed preterm labor. Upon diagnosis of preterm labor, parturients in the control group had cervical dilatation of less than 3 cm (p less than 0.001) and effacement of greater than 50% more often than the monitored group (p less than 0.01). As a result there was a significant decrease in the number of patients who responded to tocolytic therapy in the unmonitored group. Among those with preterm labor the time gained in utero was greater in the monitored group (8.2 +/- 2.7 weeks) compared to the control group (4.2 +/- 2.9 weeks) (p less than 0.05). Subsequently 29 of 34 monitored patients attained term (36 completed gestational weeks) versus only 18 of the 33 patients in the unmonitored group (p less than 0.01). Although the sample size is relatively small, uterine activity monitoring in these very high risk patients resulted in an increased number of suitable candidates for tocolysis and allowed a significantly greater percentage of women to reach term.

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.

Pregnancy After Successful Vaginoplasty And Cervical Stenting For Partial Atresia Of The Cervix

We previously reported surgical correction of vaginal agenesis and partial cervical atresia in an 11-year-old girl with amenorrhea and a pelvic mass. This patient, the subject of this report, conceived 7 years later and delivered at term. An abdominal cerclage was placed at 12 weeks gestation to protect the cervix, and delivery was by cesarean.

External cephalic version of the breech presentation under tocolysis

External cephalic version with tocolysis at or near term has been advocated to avoid cesarean birth for breech presentation. In our institution this maneuver was successfully performed in 207 of 304 parturients without major complications, and all but six had vertex presentation at delivery. The success of version was inversely correlated with gestational age but was not correlated with ease of version, number of attempts, or placental location. When this 3-year period was compared with the previous three years (1979 to 1981), there was a significant reduction in the number of breech presentations during labor, whereas the total delivery rate remained relatively constant over the 6-year period. It appears that in a carefully selected population, external version near term can be used safely to reduce the need for abdominal birth because of breech presentation.

Danazol in the management of ureteral obstruction secondary to endometriosis

Ureteral obstruction caused by endometriosis is uncommon. It is, however, an important complication that imposes a 25% chance for permanent loss of renal function on the affected side. The standard management is surgical; however, three cases have been reported in which regression of obstruction followed medical therapy. This case report concerns a patient with long-standing partial ureteric obstruction due to endometriosis who was treated for 2 months with danazol. Clinical response of the endometriosis was excellent, but the obstruction persisted, a retroperitoneal ureteroneocystotomy was therefore performed. The ureter was found to be obstructed by dense fibrous tissue that contained endometrial glands. It seems therefore that a trial of danazol may be attempted in selected cases, but that the drug is unlikely to relieve endometriotic ureteric obstruction once dense fibrosis has occurred.

Cpmparison of oral ritodrine and magnesium gluconate for ambulatory tocolysis

Abstract Magnesium sulfate has been administered intravenously to arrest preterm labor but the oral form of this drug cannot be used for continual tocolysis. This trial involved the administration of oral magnesium gluconate to determine its effectiveness compared with that of ritodrine hydrochloride in 50 patients whose labor had been arrested by parenteral therapy. Group A (n = 25) received 1 gm of oral magnesium gluconate every 2 to 4 hours for tocolysis and group B (n = 25) received 10 mg of ritodrine every 2 to 4 hours. The number of patients who progressed to 37 weeks gestation was similar (group A, 21 versus group B, 19) and the time gained in utero was not different (group A, 6.4 weeks versus group B, 5.9 weeks). There was a trend toward more side effects with the use of ritodrine (40%) compared with magnesium gluconate (16%), but the numbers were too small to reveal a significant difference. These data suggest that magnesium gluconate used as an oral tocolytic is as effective as a R-agonist in patients whose labor is arrested initially with intravenous therapy.

Tocolysis with oral magnesium

Seventeen patients in whom uterine activity responded favorably to parenteral magnesium sulfate were given oral magnesium gluconate for continued tocolysis. The mean serum magnesium level before therapy was 1.44 +/- 0.22 mg/100 ml, whereas 2 hours after initiation of oral magnesium it was 2.16 +/- 0.32 mg/100 ml (p less than 0.05). One patient had nausea without vomiting or diarrhea. These data suggest that magnesium ingested orally can raise the serum magnesium level significantly.

Cost effectiveness of ambulatory uterine activity monitoring.

A cost analysis is presented comparing 34 patients who received uterine activity monitoring versus 33 patients who attempted to detect uterine activity by palpation. All patients were at high risk for preterm delivery and were given the same educational information and prenatal care regarding signs and symptoms of preterm labor. The results revealed an increase in newborn days (640) and cost to those patients who were in the self‐palpation group (

Comparative Study of Flurbiprofen and Morphine for Postsurgical Gynecologic Pain

13,364) compared to monitored parturients (268 days and

Prostaglandin E2 induction of abortion and fetal demise

8,633). The difference was attributed to neonatal morbidity from an increased number of preterm deliveries > 26 weeks but < 37 weeks (P = 0.04). The increase in NICU days was significant (P = 0.03). No difference in normal newborn costs for infants delivered after > 33 weeks could be detected between the two groups, but morbidity was increased among control infants delivering between 34 and 36 weeks. Uterine activity monitoring to prevent preterm birth appears to be medically effective and reduces cost.