The placenta: Immunologic or hemodynamic protector of the fetus?

Complete separation of the maternal and fetal circulation during normal pregnancy has been regarded as an extremely important protective factor from the immunologic standpoint. This hypothesis was tested in outbred rabbits in which a direct maternal-fetal parabiosis was established during the last week of pregnancy by implanting an intact maternal omental pedicle subcutaneously into the fetus. A functional cross-circulation, which developed after 48 hours as evidenced by maternal⁵¹Cr-labeled erythrocytes, led to pathologic changes culminating in fetal death within 70 to 80 hours postoperatively. Hyperacute graft rejection, previously postulated as the etiology of these fetal changes, was ruled out since the same characteristic syndrome occurred in similarly treated inbred fetuses syngeneic with their mothers. This study indicates that the absence of direct vascular intercommunication between mother and fetus at the level of the placenta is clearly necessary for physiologic as well as immunologic reasons.     

Response of pituitary LH and FSH to synthetic LH-releasing hormone in normal subjects and patients with Sheehan's syndrome

Serum levels of LH and FSH were determined by radioimmunoassay in seven patients with Sheehan's syndrome, eight women with normal menstrual cycles, and five normal men following intravenous injection of synthetic luteinizing hormone-releasing hormone (LH-RH) in a dose of 100 μg. The mean maximum increases of LH (M. ± S.E. mI.U./ml.) were in the following order: 279.4 ± 87.6 at the preovulatory phase, 69.2 ± 12.6 in normal males, 48.2 ± 3.5 at the midluteal phase, and 29.9 ± 4.9 at the early follicular phase. The response of serum levels of FSH was found to parallel the change in the levels of LH, but these changes were less pronounced. No response of LH and FSH to LH-RH was observed in five patients with Sheehan's syndrome while the remaining two patients showed an increase of LH around normal lower limits. These findings seem to indicate that LH-RH test is useful for the evaluation of pituitary reserve function of gonadotropin secretion.     

Intrauterine contraception in nulliparas with the Dalkon shield

The small Dalkon Shield was used for intrauterine contraception in a series of 1,697 nulliparous women over a 2 year study period. Of these women 80 per cent were nulligravid. The device is well tolerated and has low expulsion and medical removal rates. The pregnancy rate of 1.2 per cent remained constant after 12 months of use. The nulliparous model Dalkon Shield is an effective and extremely acceptable means of intrauterine contraception in the nulliparous female.     

An analysis of the impact of pathology review in gynecologic cancer

Purpose: To analyze the impact of pathology review in gynecologic malignancies.

Methods and Materials: For all new gynecologic patients seen between December 2, 1993 and January 4, 1996, we conducted a retrospective chart review to determine if a pathology review by the institute’s consultant pathologist changed the diagnosis, and if so whether the change altered patient management. A total of 514 patients were seen, of whom 120 had cervical cancer, 226 had endometrial cancer, 122 had a primary ovarian or peritoneal malignancy, 9 had a vaginal malignancy, 28 had vulvar cancer, and 9 had a miscellaneous gynecologic malignancy.

Results: On pathology review the diagnosis changed for 200 of 599 specimens (33%). This altered management for 63 of 514 patients (12%). For patients with cervical cancer, the grade of tumor was the main change in pathologic diagnosis, with occasional change in the presence of lymph vascular invasion. These did not translate into patient management alterations. Eight patients (1.5%) had management alterations. The changes in depth of invasion and vascular invasion altered management for 3 patients. Changes in pap smears resulted in two management alterations, and changes in histologic diagnoses altered management for 3 cases. For endometrial primaries the changes in pathologic diagnosis included grade, depth of invasion, and the presence of cervical involvement. This did alter management in 40 cases (8%). For the ovarian malignancies, the main changes were grade, extent of disease, or histologic classification, some of which (10 patients, 2%) resulted in altered management. One patient with a vaginal lesion had the diagnosis changed, which did alter management. Of the patients diagnosed with vulvar cancer, the pathologic diagnosis changed for 11 patients. This included changes in grade and depth of invasion. This altered management of 2 patients. The remaining miscellaneous gynecologic malignancies had only two diagnosis changes that altered management.

Conclusions: Pathologic review of gynecologic malignancies is justified as it can alter patient management. In addition, the process facilitates cooperation of the multidisciplinary team and provides a valuable educational forum to enhance patient care.     

Robotic-Assisted Laparoscopic Cervicovaginal Myomectomy

Study Objective

To illustrate a robotic-assisted laparoscopic resection for cervicovaginal myomectomy.

Treatment of advanced uterine sarcoma with adriamycin

Between 1971 and 1979, 39 patients with clearly measurable metastatic or advanced recurrent sarcoma of uterine origin were treated with Adriamycin, either alone or in combination with other chemotherapeutic drugs. The median survival was 7.2 months. No patient lived beyond 32 months from the start of chemotherapy. The response rate was 10.3% (10.3% partial responses and no complete responses). The median duration of a partial response was 4 months. There was no difference between the median survival of the responders and nonresponders.     

Pelvic infections following gynecologic procedures in Bangladesh

Data were collected to establish the rate of pelvic infection following various gynecologic procedures, including postpartum intrauterine device (IUD) insertions, IUD insertion following menstrual regulation procecures, IUD insertion in women who were not recently pregnant, and induced and spontaneous abortions. The pelvic infection rate was only 1% in 97 women who underwent postpartum IUD insertions. The infection rate was related to the timing of IUD insertion and the type of IUD used. Finally, the pelvic infection rate was unacceptably high (10.3%) in women undergoing induced abortions vs. women having spontaneous abortions (1.1%).     

A contemporary approach to suspected ectopic pregnancy with use of quantitative and qualitative assays for the beta-subunit of human chorionic gonadotropin and sonography

Although assays for the beta-subunit of human chorionic gonadotropin (beta-hCG) and ultrasonography have become popular diagnostic aids in the approach to patients with a suspected ectopic pregnancy, their true utility has not been clearly defined; in fact, the beta-hCG assay is so sensitive that proper clinical interpretation is sometimes difficult. A recent study describing a "discriminatory zone" (beta-hCG level of 6000 to 6500 mIU/ml), which correlates beta-hCG levels with appearance of a gestational sac on ultrasound scans, has been reported to be of diagnostic benefit. A prospective study of 103 women with suspected ectopic pregnancy was undertaken utilizing an algorithm which included beta-hCG assays (quantitative as well as qualitative) and ultrasonography. Seventy-three patients were found not to be pregnant, and seven had a normal pregnancy, 14 patients ultimately had a spontaneous abortion, and seven ectopic pregnancies were identified. The following conclusions were drawn: (1) a qualitative beta-hCG assay with a sensitivity of 25 mIU/ml is an effective test in screening for ectopic pregnancies; (2) the concept of a "discriminatory zone" is valid but not of frequent clinical utility, since most patients suspected of having an ectopic gestation have beta-hCG levels below this zone; (3) serial monitoring of beta-hCG values is an important diagnostic aid; (4) culdocentesis is still an important contemporary diagnostic test for the patient suspected of ectopic pregnancy.