Biomedical subjects
Publications and source records attributed to M L Tancer.
A fetal extracranial mass seen on ultrasound was found by Doppler velocimetry to have low resistance to blood flow through its channels. The antenatal diagnosis of giant cavernous hemangioma was confirmed after birth.
The literature concerning coexisting massive genital and intussuscepting rectal prolapse is reviewed, two cases in point are presented, and the rationale for concurrent surgical management is offered. The technique of combined colporecto-sacropexy is described in detail.
We report a case of a vesicouterine fistula with menouria (vesical menstruation) secondary to an intrauterine contraceptive device. Of the 23 cases of menouria reported previously 21 occurred after cesarean section, 1 was secondary to a traumatic forceps delivery and 1 was owing to infection. In our case the fistula did not close after removal of the perforated intrauterine contraceptive device and 2 months of catheter drainage. Closure was achieved by excision of the fistula and hysterectomy.
Ninety-two cases of vesicouterine fistula reported in the world literature since 1908 are reviewed. The lesion was rarely seen before 1947. It usually followed a vaginal operative delivery and the usual complaint was total urinary incontinence. Diagnosis was most often made indirectly by seeing urine or dye pass through an intact external cervical os. Management usually involved a vaginal, surgical approach to repair. Since 1947, vesicouterine fistula, while not common, is no longer rare. It occurs most often after low segment cesarean section. While urinary incontinence may occur, the major symptom is cyclic hematuria (menouria). The diagnosis is best made by hysterogram performed with a short-tipped cannula. Management consists of an abdominal, surgical approach, the technique of which varies with the patient's need for future reproductive capacity.
Uterine perforation occurred during abortion in a patient with placenta percreta. The predisposing factor in the invasive placenta in this case was a uterine scar from a cesarean section.
This report evaluates the role of laparoscopy in patients admitted with the diagnosis of "Rule Out Ectopic". There were 186 patients admitted to the Brookdale Hospital Medical Center in the 6-year period 1974-1979 inclusive with a diagnosis of "Rule Out Ectopic" or "Possible Unruptured Ectopic". These patients were all laparoscoped. There were 157 satisfactory and 27 unsatisfactory laparoscopies. There were 71 ectopic pregnancies: 42 ruptured, 25 unruptured. Thirty-six cysts were diagnosed. The value of early laparoscopy is clearly established. Particular emphasis is placed on the diagnosis of the unruptured ectopic so that appropriate conservative management of the tube can be instituted in order to preserve potential reproductive capacity.
The surgical technique of partial ablation was used to treat 34 patients with a symptomatic suburethral diverticulum. Results were excellent: Symptoms disappeared and the complications of urinary fistula and stress incontinence did not occur. There were no recurrences.
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Ten cases of abdominal pregnancy managed at the Brookdale Hospital Medical Center over a 17-year period are presented. An incidence of 1 abdominal pregnancy in 7095 deliveries occurred in this series; another institution reported 1 in 7931. A perinatal mortality rate of 80% and no maternal mortality in the study are contrasted to rates of 75 to 95% and 2 to 18%, respectively, from the world literature. Recurrent abdominal pain in the gravid patient with a prior history of infertility, tubal pregnancy, and/or surgery may signal abdominal pregnancy. Similarly, the management of fetal death should include consideration of the presence of abdominal pregnancy. The role of ultrasonography in diagnosis and the importance of immediate surgical intervention with minimal disturbance of the placenta are stressed.
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The increasing importance of an ectopic pregnancy as a cause of maternal death presents a challenge that will be met when primary care physicians combine a high index of suspicion with the ability to recognize the patient most at risk. The major symptoms, abdominal pain, secondary amenorrhea and abnormal vaginal bleeding are well known, as are the major signs, abdominal tenderness, adnexal mass and tenderness on motion of the cervix. Less well known are factors in the clinical history which indicate the patient to be at high risk. These include primary or secondary infertility, previous abortion or ectopic pregnancy and previous tubal operation, either reconstructive or sterilizing. In addition, the use of an intrauterine contraceptive device or its recent removal because of abdominal pain or bleeding, or both, is highly significant. Of major importance is a history of recent uterine evacuation. Should the diagnosis of ectopic pregnancy be under consideration, procrastination by observation is no longer acceptable. An active effort must be made to confirm or deny the diagnosis, Culdocentesis should be performed in the emergency department or clinic. If positive, prompt laparotomy is indicated. Should the result of culdocentesis be unsatisfactory or negative, laparotomy should be undertaken with further delay.
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The reproductive performance of 106 patients exposed in utero to diethylstilbestrol by maternal ingestion is described. Fetal wastage is high, apparently because of spontaneous abortion during the first and second trimesters. Recommendations are made for preconception counseling of exposed progeny to increase fetal salvage.
The histologic diagnoses of premalignant and malignant lesions of the cervix obtained by examining the colposcopically directed biopsy material from 643 patients were compared with those of the surgical material subsequently obtained. The procedures during which samples were acquired included hysterectomy (370), cervical conization (263), cervical amputation (2), and removal of a retained cervical stump (8). The diagnostic accuracy of colposcopically directed biopsy was 93.0% in those patients with satisfactory colposcopy, ie, the final diagnosis did not differ by more than 1 grade from that of the directed biopsy diagnosis. Two patients with widespread stage III cervical intraepithelial neoplasia on directed biopsy had microinvasive carcinoma in the therapeutic cone specimen. All invasive carcinomas (stage IB, occult) were diagnosed by directed biopsy and confirmed by subsequent examination of the surgical specimen.
Acute febrile neutrophilic dermatosis, otherwise known as Sweet syndrome, usually occurs in women after prior respiratory infections. The first case of Sweet syndrome with involvement of the female genital tract is reported here. The woman recovered completely, and no evidence of other underlying disease has appeared.
Clear cell adenocarcinoma of the vagina occurred in a diethylstilbestrol (DES)-exposed patient in the fourth year of continuous observation for adenosis. Diagnosis was suspected by digital and colposcopic examination and confirmed by target biopsy. Cytology was negative. The development of malignancy in a patient who has been known to have adenosis has been previously described but is very rare. The necessity for careful regular follow-up using cytology, digital palpation, and colposcopy at 6-month intervals is emphasized.
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