A problem-oriented gynecology clinic for patients with sexually transmitted diseases

A problem-oriented clinic designed to provide continuity of care for female patients with sexually transmitted diseases (STDs) is described. The primary goal of the clinic is to ensure adequate follow-up care for individuals diagnosed as having pelvic inflammatory disease. Functions of the clinic also include follow-up care for patients with positive gonorrhea cultures and consultation for individuals with other STDs. From the time of initiation of the clinic in January, 1976, until November 15, 1979, 4,305 patients were seen. A stratified random sample of 190 of these patients revealed the reasons for attending the clinic to be: (1) follow-up for PID, 85 patients (44.7%), (2) positive gonorrhea culture, 63 (36.3%), (3) unsatisfactory gonorrhea culture, 14 (7.4%), (4) gonorrhea contact, 10 (5.3%), and (5) other, 12 (6.3%). Complete follow-up has been obtained on 3,935 (91.4%) of the patients. Of the 370 patients who did not return for follow-up visits, 336 were reported to the local health department for retrieval. There were 34 patients in whom the follow-up status could not be determined. The establishment, operation, advantages, and disadvantages of the clinic are discussed.     

Tubo-ovarian abscess: A retrospective review

The charts of 160 patients with tubo-ovarian abscesses (TOAs) were reviewed. Patients were divided into two groups according to their response to initial medical therapy. Predictive factors were identified for the two groups. Prognosis was predictable on the basis of extent of disease at diagnosis and the initial response to medical therapy. There was no apparent association between a unilateral TOA and the use of an intrauterine contraceptive device. A minimum pregnancy rate of 8% was observed in patients maintaining reproductive function. No patient with a bilateral TOA conceived. Of all patients admitted to the hospital with TOA, 53% ultimately required surgical therapy. High residual morbidity and/or resultant infertility mandates more aggressive attempts at prevention.     

Endocrine-metabolic response to acute starvation in human gestation

During a 72 hour fast in pregnant women, significant decrements in the maternal plasma glucose concentrations, accompanied by a significant increase in the plasma placental lactogen (hPL) concentration, occur. At the same time, utilization of glucogenic amino acids, principally alanine, takes place. The mean postprandial glucose concentration in pregnancy is significantly lower than that of comparable nonpregnant women (70.5 ± 1.7 versus 79.5 ± 1.3 mg. per 100 ml., p < 0.001). There appears to be a significant sparing effect on the maternal plasma glucose concentration during acute fasting which may be mediated through hPL. Concentrations of amniotic fluid and fetal plasma glucose from women undergoing fasting decrease in a manner parallel to that of the mother. Fasting provokes a mean rise in plasma hPL of 33.2 per cent over basal levels. This rise is still evident 72 hours after refeeding, after which it gradually returns to pretest concentrations. The infusion of alanine or arginine to pregnant women at the end of the fast produced increments in the peripheral maternal glucose concentration. The response was much greater with alanine than with arginine, demonstrating the increased gluconeogenic potential of this amino acid. The increment in human growth hormone (hGH) following alanine infusion was significantly greater than that observed after arginine administration. Hypoaminoacidemia was present in nonpregnant and pregnant women in response to fasting, but the decline was greater in pregnancy. Acute fasting in the first half of gestation appears to produce significant alterations in carbohydrate metabolism evidenced by profound hypoglycemia, hypoinsulinemia, and hypoaminoacidemia. This maternal deficit can be reflected in fetal substrate concentrations. The effect of these changes on fetal growth and development is speculative at this time.     

The influence of aspirin on the course of induced midtrimester abortion

Prostaglandins appear to mediate the uterine contractions of abortion and labor, and aspirin has been shown to be an inhibitor of prostaglandin synthesis. In this double-blind, placebo-controlled, prospective, and randomized study, aspirin was administered orally in doses of 600 mg. every 6 hours to patients undergoing induced midtrimester abortions with hyperosmolar urea and oxytocin augmentation. The mean injection-abortion interval was significantly prolonged by aspirin in nulliparous patients (aspirin 32.3 ± 3.3 hr. vs. placebo 21.5 ± 3.5 hr.) and no aspirin-treated nullipara aborted in less than 18 hours. There was no significant difference between treatment groups in the mean injection-abortion interval in the multiparous patients at the dose of aspirin used. The effectiveness of aspirin in the prolongation of the injection-abortion interval has potential therapeutic implications for the treatment of premature labor.     

The origin and clinical behavior of the parovarian tumor

This study of 132 benign parovarian cysts and eight parovarian neoplasms demonstrated that the majority of such lesions are of paramesonephric or mesothelial origin. Furthermore, adnexal neoplasms, not histologically associated with the tube or ovary, may arise in such parovarian structures or de novo from the pelvic mesothelium.     

Lymphoma of the ovary: Report of twenty new cases and update of previous series

Ovarian lymphoma is a rare entity. This review of 55 cases, including 35 that were previously reported, updates and reclassifies the cases from the Ovarian Tumor Registry and the Gynecologic Pathology Laboratory. The problems of differential diagnoses are stressed.     

Glucocorticoids and the rhesus fetal lung.

The effects of glucocorticoids on primate fetal lung function have not been clearly delineated. In this prospective study of preterm rhesus fetuses exposed in utero to betamethasone for 72 hours, the most significant alteration was a striking increase in maximum lung volumes. Functionally less significant increases in residual lung volumes were also noted. The lungs of the treated fetuses did not exhibit lower extract surface tensions or increased phospholipid concentrations. These findings suggest that the major effect of betamethasone is on lung connective tissue elements, with minimal effects on alveolar surfactant. Additional evidence of the multisystemic effects of glucocorticoids was obtained in that significant differences in fetal, adrenal, hepatic, and placental weights also were observed.     

Latent ectopic pulmonary choriocarcinoma associated with renal cell carcinoma

A case of latent ectopic pulmonary choriocarcinoma associated with renal cell carcinoma is reported. The pulmonary choriocarcinoma appeared in a 48-year-old woman, 26 years after her last pregnancy and 8 years after a total hysterosalpingo-oophorectomy. The various possible mechanisms of latent ectopic choriocarcinoma are discussed.     

The inhibition of premature labor with indomethacin

We administered indomethacin orally for the treatment of premature labor in a prospective, randomized, double-blind fashion, and all infants were followed up. Indomethacin was significantly more effective than placebo in inhibition of premature labor during a 24-hour course of therapy, with treatment failure during therapy occurring in only one of 15 indomethacin-treated patients compared to nine of 15 placebo-treated patients (p < 0.01). Mean plasma concentrations of indomethacin were approximately 0.8 μg/ml at both 4 and 12 hours after administration. Mean plasma levels of 15-oxo-13, 14-dihydroprostaglandin F_2α (PGFM) were similar in the two groups before treatment, decreased markedly in the indomethacin group by 4 hours, and were not detected at 12 hours in all but the one indomethacin-treated patient who was delivered within 24 hours. Patients in the placebo group who were delivered prematurely had higher pretreatment PGFM levels (mean ± SE, 83 ± 18 pg/ml, n = 9) than the patients who responded to placebo (25 ± 6 pg/ml, n = 6) (p < 0.05). There was no difference between the indomethacin and placebo groups with respect to gestational age at delivery, birth weight, and neonatal morbidity and deaths. In particular, we found no evidence of premature closure of the ductus arteriosus, pulmonary hypertension, or increase in bleeding problems among the infants exposed to indomethacin in utero. Although no difference in neonatal outcome was observed in this small number of patients, it would seem prudent still to consider indomethacin as an experimental therapy.     

Application of cephalosporins to obstetrics and gynecology: Transfer of cefazolin and cephalothin to uterine tissue

Antibiotics should be administered so as to maintain effective therapeutic levels in target organs. In routine clinical treatment, however, doses of antibiotics are determined on the basis of their achievable concentrations in blood. To determine the optimum doses of antibiotics against obstetric and gynecologic infections, the authors gave a single intravenous dose of 2 gm of cefazolin or cephalothin to 51 patients before hysterectomy and measured the levels of the antibiotics in uterine tissues and compared them with corresponding serum levels. The maximum tissue levels of cefazolin were generally about 6 to 7 times higher than those of cephalothin: In the perimetrium, levels were 154 μg/gm for cefazolin and 24.1 μg/gm for cephalothin; in the myometrium, 109.5 μg/gm for cefazolin, and 15.5 μg/gm for cephalothin; and in the endometrium, 98.9 μg/gm for cefazolin and 10.4 μg/gm for cephalothin. In the tissues, however, cephalothin reached peak levels more rapidly than cefazolin. Comparisons of the tissue levels and MIC of cefazolin and cephalothin revealed that cefazolin was maintained at over 12.5 μg/gm for at least 150 minutes in the perimetrium, myometrium, and endometrium, whereas cephalothin was maintained at these levels for 40 to 50 minutes only in the perimetrium and myometrium. The ratio of tissue levels to serum levels was 40–70 to 100 for cefazolin and about 30 or less to 100 for cephalothin.     

The effect of prophylactic antibiotics on pelvic infection following vaginal hysterectomy

The effect of prophylactic penicillin and streptomycin on postoperative pelvic infection and hospital stay following vaginal hysterectomy was studied. 92 patients received 600,000 U procaine pencillin plus .5 gm streptomycin 12 hours prior to operation and every 8 hours following operation for 3 days. 8 patients allergic to penicillian received 1 gm cephaloridine rather than penicillian and streptomycin. 100 patients undergoing vaginal hysterectomy received no prophylactic antibiotics. Morbidity caused by pelvic infection was significantly reduced (p less than .01) from 19 to 1% and urinary tract infection decreased from 6 to 2% when prophylactic antibiotics were employed. Total postoperative morbidity was decreased from 37 to 8% (p less than .01) and postoperative hospital stay was reduced from 6.3 to 5 days (p less than .002) when prophylactic antibiotics were administered.     

Purification of lamellar bodies from human amniotic fluid

Lamellar bodies were purified from human amniotic fluid obtained from pregnancies at 17, 31, and 40 weeks' gestation by means of Sephacryl S-300 column chromatography. Fractions were labeled with diphenylhexatriene and two peaks of phospholipid were identified at each gestational age. The size of peak I increased relative to that of peak II with advancing gestational age. Further study of the two peaks from 40-week pregnancies showed that peak I contained lamellar bodies that could be identified by electron microscopy. The ratio of the concentration of protein to phospholipid for peak I varied from 0.2 to 1.1. There were four proteins which could be identified by sodium dodecyl sulfate polyacrylamide gel electrophoresis (130K, 80K, 50K, and 20K), and there was 90-degree scattering of 400 nm light. Peak II also contained phospholipid. However, bilayer structures could not be visualized by electron microscopy, and there was no 90-degree scattering of 400 nm light. Peak II had a much higher ratio of protein to phospholipid (approximately 100) and two broad bands of protein on sodium dodecyl sulfate electrophoresis (80K, 50K). The anisotropy of diphenylhexatriene in both peaks decreased with advancing gestational age. The anisotropy in peak I was always lower than that in peak II, indicating that the microenvironment in peak I was more fluid. Peak I may represent mature surfactant and peak II, precursors of surfactant.     

Definitions of high risk in pregnancy and evaluation of their predictive validity

The predictive validity of Hobel's criterion (score of 10 or more) for high prenatal and intrapartum risk and two alternative definitions was evaluated in two sociodemographically similar samples from two different institutions. At one institution, intrapartum risk was associated with neonatal morbidity independently of prenatal risk; at the second institution, both were related to neonatal morbidity, depending on the definition of high risk. Definition of high risk as a score of 15 or more improved the prognostic ability of Hobel's method at the first institution, but not at the second. Grouping prenatal and intrapartum risk as low (0 to 9), medium (10 to 19), and high (20 or more) provided a clearer understanding of the association between prenatal/intrapartum risk and neonatal morbidity, although differences between the two institutions presisted. Modifications and validation of risk assessment methods are necessary when used in populations other than the one for which they were originally developed.     

Posterior cervical rupture following prostaglandin-induced mid-trimester abortion

Two cases of transverse posterior cervical rupture in association with mid-trimester abortion induced by prostaglandin F_2α (PGF_2α) are reported. The mechanism of rupture is described. It is suggested that the effects of PGF_2α upon cervical dilatation must be further explored.     

Serum concentrations of beta-melanocyte-stimulating hormone in human pregnancy

β-Melanocyte-stimulating hormone (β-MSH) has been measured in pregnant women with the use of a sensitive tube radioimmunoassay technique which does not require prior extraction. This peptide rises progressivley throughout pregnancy with its highest concentration at term. Measurable quantities exceeding maternal levels were observed in both cord blood and amniotic fluid and elevated levels of β-MSH were found in lactating women. The role and possible chorionic origin of β-MSH remain to be determined, as well as the possible clinical use.     

A prospective randomized study of doxycycline as a prophylactic antibiotic in patients undergoing radical hysterectomy

A prospective randomized study was undertaken to evaluate doxycycline as a prophylactic antibiotic in patients undergoing radical abdominal hysterectomy and pelvic lymphadenectomy. Although 69 patients were initially randomized, 64 patients (34 study, 30 control) are the basis of this report: 5 patients were omitted because large pelvic lymph nodes positive for tumor were found at laparotomy and radical hysterectomy was abandoned. The two study groups were similar in both preoperative and operative risk factors. There was a statistically significant reduction in the 7- and 14- day febrile index in the doxycycline group. The rate of cuff and/or pelvic cellulitis was 2.3 times higher in the control group. Thus, single-dose doxycycline as a prophylactic antibiotic reduced both febrile morbidity and the rate of serious infections in the radical hysterectomy patient.