Search

Forty-one women with primary or recurrent prolapse of the vagina following either vaginal or abdominal hysterectomy were treated with a vaginal operation. The retroperitoneal approach of utilization of the perirectal fascia to support the vault of the vagina is described and illustrated. This technique may also be used in selected patients to prevent this complication after vaginal hysterectomy and repair.

Acute puerperal inversion of the uterus is an uncommon but potentially fatal obstetric complication. In the 15 year period ending December 31, 1974, 11 inversions have been managed at the University of Virginia Hospital. All were recognized immediately and manually replaced and there was no significant postpartum morbidity. Successful management appears to depend largely upon prompt recognition, which can be achieved by routine postpartum examination of the vagina and cervix and manual exploration of the uterus.

Vaginal hysterectomy was performed in 56 patients with Stage I adenocarcinoma of the endometrium who were selected because of obesity or major medical problems that placed the patients at high risk for morbidity and death with an abdominal operation. Seventy percent of the patients were hypertensive and 29% were diabetic. The median weight for the 56 patients was 211 pounds. Ten patients who were age 40 or younger were included, and all showed signs of polycystic ovary syndrome. This subgroup of patients was significantly more obese, with a median weight of 331 pounds. Adjuvant radiation therapy was used in 32 of the 56 patients. There was one postoperative death from a pulmonary embolus, but there were few other major complications. The actuarial survival probability was 94% for all patients. With grade 1 tumors, the 5-year survival rate was 98%; with grade 2 tumors, it was 78%; and with grade 3 tumors, it was 84%. Although we do not recommend that vaginal hysterectomy become routine, it has cure rates comparable to those with abdominal hysterectomy and should be considered in patients who are a poor surgical risk, particularly patients with grade 1 tumors.

T H E pelvic lymph nodes have been the subject of extensive discussion in regard to both the therapy and the prognosis of carcinoma of the uterine cervix. There has been prolonged controversy concerning the relative merits of irradiation versus operation in controlling metastatic disease in the pelvic lymph nodes, and there has been a persistent belief among some advocates of surgery that irradiation is incapable of destroying metastatic cancer cells in the primary lymphatic drainage of the uterine cervix. These surgical enthusiasts have indicated that the hope of improving the 5 year survival rate in patients who already have lymph node metastases is a major argument in favor of surgery. In order properly to consider this controversy, it is essential that there be a valid appraisal of the incidence of node metastases in each stage of this disease, yet the reported incidence of metastatic disease in the pelvic lymph nodes in association with cervical cancer would seem to vary significantly (Table I). Perhaps the most frequentIy quoted figures are those of Me&,” who reported a 17.9 per cent incidence of positive

Effect on uterine dynamics of magnesium sulfate, hydralazine hydrochloride, and cryptenamine acetates was evaluated by in vitro and in vivo techniques. Magnesium sulfate depressed myometrial activity in vitro. Hydralazine hydrochloride decreased the rate and increased the amplitude of contraction of human myometrial strips. In concentrations of 6 to 8 mEq. per liter of maternal serum, magnesium reduced the uterine activity of 7 pre-eclamptic patients in active spontaneous labor. The effect of each agent on myometrial and hemodynamic variables was measured in 3 pregnant rhesus monkeys during both normotensive and induced hypertensive states. Serum magnesium concentrations of 6 to 8 mEq. per liter resulted in a reduction of arterial blood pressure, a greater decrease in extrinsic myometrial resistance, and an increase in uterine artery blood flow. Intravenous administration of hydralazine hydrochloride in quantities sufficient to produce a statistically significant decrease in arterial blood pressure did not significantly alter uterine artery blood flow or average intra-amniotic pressure. Responses to cryptenamine acetates were inconclusive.

Urinary system complications which are incompatible with life are common complications of untreated carcinoma of the cervix as recently emphasized by necropsy studies of Henriksen. 1 This study 1 and others 2, 3, 12 have pointed out the urological complications and the importance of urological follow-up studies in those patients with carcinoma of the cervix treated by irradiation therapy. With the revival of the surgical approach to the problem of cervical malignancy, urinary system complications remain one of the hazards of treatment with resultant urinary fistulas and their sequelae as reported by Meigs 4 and Thomas and associates. 5 This study is a report of late urological complications in a small group of patients with carcinoma of the cervix treated by radical operation. It is the purpose of this study to present the various types of postoperative urinary system complications as seen in our clinic.

1. 1. A new technique utilizing an endometrial brush with vibration and centrifugation of the material obtained is described. 2. 2. This technique can be accomplished as an office procedure with safety and a minimum of discomfort to the patient. 3. 3. Enough cellular material is obtained to enable preparation of multiple cytologic spreads and usually a cell block may be prepared from the sediment. 4. 4. Correlative data with pathologic specimens are presented with complete accuracy regarding malignancy. 5. 5. The cellular criteria of the various endometrial cytologic entities are briefly discussed.

1.1. Twenty-four cases of sarcoma of the uterus, including two cases of sarcoma botryoides in children, occurring in twenty-four years at the University of Virginia Hospital are presented. 2.2. Four patients (18 per cent) received intracavity irradiation more than ten years prior to the diagnosis of sarcoma. 3.3. The diagnosis of sarcoma was established by diagnostic curettage in three patients and suggested in a fourth. 4.4. The five-year survival rate for sarcoma in adults was 8 per cent. 5.5. One child with sarcoma botryoides is alive, without recurrence, three and one-half years following x-ray therapy.

1. 1. Relaxin had no demonstrable effect on the spontaneous contractility of isolated human uterine muscle, or on the tension of cervical tissues in vitro. 2. 2. This was true for tissue samples taken from both nongravid and gravid uteri. 3. 3. It appears that the evaluation of relaxin as an adjunct to the armamentarium of the obstetrician and gynecologist must await the result of extensive clinical experience and trial.

effects of test stimuli upon isolated human myometrial samplings is dependent upon the ability of this study method to appraise correctly the direct, local response of uterine tissues to the stimulus applied. It has been shown that adequate oxygenation of the muscle strip, control of temperature, pH, ionic composition, and osmolality of the solution in which the tissue is suspended, and a knowledge of the preponderant hormonal stimulus to which the intact uterus was exposed prior to sampling are essential for a correct evaluation of the experimental data obtained.le6 In addition, since the patterns of spontaneous activity displayed by isolated strips of human uterine smooth muscle frequently are not quantitatively

Magnesium is an accepted drug in the management of toxemia of pregnancy, and is employed by many physicians as the anticonvulsant agent of choice in the therapy of this commonly encountered gestational disease. Many modes of administration and variable dosage schedules have been evolved over the past half century, ranging from small quantities given orally to relatively large amounts introduced by the parenteral route. In a recent study conducted at the University of Virginia Hospital, 5 it was suggested that prompt, rapidly attained, and effective magnesium blood levels (7 to 8 mEq. per liter) could best be effected by introducing this agent intravenously. Therefore, during the last 30 months, pre-eclamptic and eclamptic patients admitted to the Obstetric and Gynecologic Service of the University Hospital have received magnesium intravenously in high dosages. Clinical observations carried out in our labor and delivery suites have, however, given the impression that the intravenous administration of magnesium sulfate, in sufficient concentration, results in a prolongation of labor. Inasmuch as the commonly utilized sedative drugs morphine, meperidine, and phenobarbital used in the therapy of toxemia have been seemingly exonerated of a direct uterine depressant activity, 14 and since the only departure from the customary therapeutic regimen during the past 30 months from that employed previously was the elevation of the serum magnesium level, it appeared probable that, if labor were in truth prolonged in these patients, the magnesium ion was depressant to the human myometrium during labor. It was in an attempt to clarify this point that the present study was undertaken.

Electromagnetic flowmeters were used to measure cardiac output and pelvic blood flow during late gestation and parturition. Hypogastric artery blood flow consistently decreased and aortic blood pressure increased with each uterine contraction. In both anesthetized and unanesthetized monkeys, a decrease in mean cardiac output preceded the characteristic increase in output of the heart observed several seconds after onset of myometrial contractions. These observations suggest that the initial hemodynamic event associated with myometrial contraction in the gravid monkey is a decreased blood flow to the uterus occurring shortly after onset of a detectable rise in amniotic fluid pressure and preceding initiation of corresponding changes in venous outflow from the uterus. Reduction of blood flow from the uterus decreases venous return and, coupled with increased arterial pressure, engenders an initial reduction in cardiac output. This response may be masked by ancillary factors which override the basic fluid dynamics.

This study presents an analysis of the methods of treatment of transverse presentation at the University of Virginia Hospital from Jan. 1, 1935, through Dec. 31, 1956. The purpose of presenting this report is to show how a gradual but definite change in management from a policy of vaginal delivery to one of predominant use of cesarean section has favorably affected perinatal mortality in this complication of pregnancy.

Twelve patients with extensive epidermoid carcinoma of the vulva were selected from a group of 72 women with this malignancy for partial or total exenteration. This extended operative procedure was utilized in 10 patients as the primary treatment and in two patients after radical one-stage vulvectomy with bilateral inguinal and retroperitoneal lymphadenectomy had failed to control the malignancy. The one-stage extended procedure is described. Fifteen immediate and six late complications occurred. There was one postoperative death and four additional patients died as a result of persistent malignancy. Seven patients were without evidence of tumor seven months to 9.5 years after the primary operation.

1. 1. An attempt to assay the effects of commonly employed anesthetic and sedative agents on human uterine muscle tissues is described. 2. 2. All of the inhalation anesthetics tested were found to be markedly depressant to gravid and nongravid uterine muscle activity in vitro, with the single exception of trichloroethylene. 3. 3. Morphine, scopolamine, Demerol, atropine, and phenobarbital produced no significant effect on the activity and tonus of uterine muscle samples obtained from both nongravid and gravid uteri. 4. 4. Nembutal was found to be without marked effect on tissues from nongravid uteri, but to possess a depressant action on samples from the gravid uterus when in sufficiently high concentration. 5. 5. Magnesium sulfate depressed contractility and lowered tonus in muscle strips from both nongravid and gravid uteri.

Although the nature of the relationship of dermatomyositis and malignancy is debated, the clinical implications of their coexistence is considerable. This review details the clinical and laboratory diagnostic features of the dermatomyositis (DM). Two case reports serve to focus on the unique management problems faced by the gynecologic oncologist when DM is associated with ovarian malignancy. Cricopharyngeal achalasia, an unusual aberration of DM, complicated the course of both patients.

Thrombotic thrombocytopenic purpura (TTP), a disorder of unknown etiology, appears to be a syndrome often associated with infectious, vascular, or autoimmune diseases. When it occurs in pregnancy, TTP can mimic other gestational complications. Two patients with TTP associated with pregnancy form the basis of this report. On patient is the second person known to have survived longer than 2 years after concurrent TTP and pregnancy. This patient had underlying glomerulonephritis and was treated with corticosteroids and heparin. The other patient, in whom an underlying disease process was not identified, was treated unsuccessfully with most of the recommended therapeutic modalities. Patients with concurrent TTP and pregnancy have the same prognosis as nonpregnant patient with TTP. Both groups have a prolonged survival rate of only 10 per cent. Primary treatment should consist of corticosteroids and inhibitors of platelet aggregation. If a rapid response does not occur, splenectomy is indicated. Care must be taken to recognize the pregnancy complicated by TTP, a circumstance which appears to occur more frequently than past reports have indicated.

Primary radiotherapy as an alternative management for adenocarcinoma of the endometrium was chosen for 117 patients treated at the University of Michigan Medical Center and University of Virginia Medical Center. Cases were selected for radiation because of contraindications to surgery (52.2%) or by protocol for disease outside the endometrium (47.8%). An overall 5-year actuarial survival rate of 49.6% was attained for all stages, with 55% 5-year survival for disease limited to the uterus or cervix. Stage and grade were the most significant risk factors. The addition of external-beam irradiation did not improve local failure rates or survival. Heyman's uterine packing technique was slightly more successful than uterine "line sources" in controlling local disease ( P = 0.08). Treatment-related mortality (0.8%) and morbidity (6.8%) were minimal. Surgery, whenever possible, remains the "best standard therapy" but the radiotherapeutic alternative is of significant benefit for those deemed nonsurgical candidates.

During the 16 year period ending in November, 1978, 191 cases of ectopic pregnancy were managed at the University of Virginia Hospital. The overall incidence was 1/126 deliveries but during the last 3 years of the study the incidence was 1/60 deliveries. Only 56 patients have had a subsequent conception. Thirteen have had a recurrent ectopic implantation. Only 36 women (23.7% of those available for follow-up) have had subsequent term pregnancies. Ectopic pregnancy continues to be a major gynecologic problem and the potential for subsequent fertility is poor.

F LO w of maternal blood to the gravid uterus (placenta) is decreased during uterine contraction with the decrement in the flow roughly proportional to the magnitude of the contraction. These studies conducted, initially in dogs1 and confirmed in sheep2 and rhesus monkeys,“, 4 suggest that mechanical constriction of myometrial vascular channels incident to uterine contraction is the major underlying mechanism.

1. A simple, nontraumatic method for recording bioelectric potentials emanating from the human uterus in situ is described. 2. Potential shifts as recorded from the nongravid organ were predominantly monophasic, the frequency varying with the ovarian cycle. This frequency of potential change was highest just prior to and immediately following menstruation and lowest at a time approximating ovulation. 3. Potential shifts during pregnancy were characteristically and predominantly biphasic. The frequency of such potential changes remained relatively constant throughout gestation, approximating that seen during the ovulatory phase of the menstrual cycle. 4. Records from isolated uterine muscle strips were of such a character as to be interpreted as evidence that tracings secured from the uterus in situ represented true uterine electropotential changes. These records gave indication of the equipotentiality of various portions of the uterus as regards bioelectric activity. 5. Bioelectric activity is present in the human uterus until at least the age of 82 years.

Diurnal variations in the average intrauterine pressure and in the average frequency of contraction were demonstrated in four nonpregnant rhesus monkeys. Uterine activity is lowest between 0400 and 0700 hours and highest between 1400 and 1700 hours. There is statistically significant correlation between uterine activity and diurnal variation in core temperature.

1. 1. The capacity of human uterine muscle for spontaneous shortening was found to decrease with age, and the activity of myometrial samples from old, postmenopausal women was characterized by relatively rapid, feeble contraction waves. 2. 2. Myometrial samples excised from uteri with secretory endometria exhibited a slower rate of spontaneous motility than did those from uteri in the proliferative phase. Muscle shortening, however, was found to be unaffected by the ovarian cycle. 3. 3. Repeated pregnancies and labors, the presence of leiomyomas else-where in the uterus, sedatives, analgesics and anesthetic agents administered at the time of operation, as well as race, were found to be of no statistical significance as factors influencing the spontaneous motility of myometrial strips excised from the nongravid human uterus. 4. 4. Muscle samples removed from gravid uteri (from 2 months' gestation until term) exhibited no statistical differences in regard to motility, when compared with tissues from the nongravid viscus. 5. 5. In a limited number of tests, myometrial tissues from patients with primary uterine inertia exhibited a significantly reduced muscle shortening with increased frequency of contraction when compared with “normal” tissues from both nongravid and gravid uteri.

PRE MAT u RI T Y is a leading cause of perinatal mortality. In many instances the exact mechanism for the premature expulsion of the products of conception is not known. However, enhanced uterine activity prior to full fetal development is an obvious suspect. It is now generally accepted that myometrial activity can be suppressed temporarily by a variety of agents including ether, nitrous oxide, magnesium, etc.1-4 Search for a myometrial depressant capable of being administered to the parturient over an extended period of time without appreciable disturbance to the total physiology of mother and fetus continues. The present study was initiated in an endeavor to assess the direct? local effect of certain smooth muscle depressants on the contractility of human myometrial tissues.

Two patients with juvenile hypothyroidism and advanced sexual development, one with an ovarian mass, are presented in detail. The possibility that the ovarian mass will regress with adequate thyroid therapy is discussed. It is suggested that adequate thyroid replacement therapy be instituted to test this possibility before surgical intervention is instituted.

During the past three years Hirst, 1 Sadugor and associates, 2 and Johnson and associates 3 have called our attention strikingly to their observations that carcinoma of the cervix occurs more frequently during pregnancy than most obstetricians believe. Our purpose in presenting this paper is to further confirm their contention with the hope of stimulating greater interest in this grave complication of pregnancy. We are well aware of the difficulties encountered in differentiating intraepithelial carcinoma of the cervix from benign histopathological changes seen in the pregnant cervix as most recently described by Nesbitt and Hellman. 4 This presentation does not include intraepithelial carcinomas. Cytological screening methods during pregnancy have not been available to us and the diagnosis in each instance was made upon biopsy of suspicious or obvious lesions. We have not hesitated to biopsy any pregnant cervix, nor have we seen any ill effects from this procedure. It is our firm conviction that some sereening method must be employed if one hopes to discover the asymptomatic malignancies in the pregnant cervix. Many cervices during pregnancy appear abnormal on visualization and it is difficult to establish criteria for biopsy.

Four hundred twenty-one women were treated by an initial operative procedure for stress urinary incontinence. The patients were divided into three groups on the basis of the degree of relaxation of the anterior vaginal wall on clinical examination. Patients classified as grade O treated by vesicourethral suspension had a 98% success rate at 2 years. Similar patients treated by vaginal operation had only a 48% success rate at 2 years. In grades I and II either the vesicourethral suspension or the vaginal operations resulted in success rates in the 85% to 90% range. Chain cystourethrograms were obtained in 171 patients, but they were not predictive of success or failure for the vaginal operations. Improved results may be obtained by individualizing the choice of the operative procedure based on the anatomic findings with the vaginal procedures used for those patients with significant anterior vaginal wall relaxation.