Racial differences in patients with adenocarcinoma of the endometrium

OBJECTIVE

To determine the differences between white and black women with regard to the presentation and behavior of adenocarcinoma of the endometrium.

METHOD

Records of 273 (68%) white patients and 117 (32%) black patients with endometrial adenocarcinoma were reviewed in Bloemfontein, South Africa. Survival data was calculated according to the direct method where losses in follow-up were regarded as tumor deaths.

RESULTS

Most patients (82%) were treated by pre-operative radium followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with post-operative external irradiation where indicated. Pre-operatively, fewer black women had reached FIGO stage I, while a larger number had advanced to stages II-IV (P = 0.0024). In addition, the tumor differentiation was more often poor in the black group (P < 0.0001). Ten-year follow-up was achieved in 84% of the white patients and 51% of the black patients and the 10-year survival figures were 67% for white patients and 28% for blacks (P < 0.0001).

CONCLUSION

Endometrial adenocarcinoma is a more aggressive disease in black women than it is in whites.

A prospective clinical and urodynamic study of bladder function during and after pregnancy

The aim of the study was to determine whether clinical and/or urodynamic changes in bladder function occur during pregnancy. Assessment consisted of a urinary symptom questionnaire, urogynecological examination and urodynamic investigations, which were repeated 6 weeks after pregnancy. Sixty-six patients had the initial and 40 the follow-up assessments. Statistical analysis was done by 95% confidence intervals (95% CI). Nocturia, frequency, dysuria, urgency and stress incontinence occurred significantly more frequently during pregnancy. Urinary tract infection was diagnosed in 18% of patients during pregnancy and asymptomatic bacteriuria in 9%. Genuine stress incontinence was diagnosed in 12% during pregnancy and in none after pregnancy (95% CI 1% to 24%). An unstable detrusor was diagnosed in 23% of patients during pregnancy and in 15% after pregnancy (95% CI -8% to 23%). Strong desire to void, urgency, maximum cystometric capacity, maximum flow rate and average flow rate were all statistically significantly decreased during pregnancy. It is concluded that significant changes occur in bladder function during pregnancy.

The nutritional status and treatment of patients with hyperemesis gravidarum

OBJECTIVE

The objective of this study was to evaluate the nutritional status of patients with hyperemesis gravidarum and the effect of a treatment regimen administered during hospitalization.

STUDY DESIGN

This was a descriptive, controlled study of 20 patients with hyperemesis gravidarum whose nutritional status was assessed and compared with that of 20 pregnant, nonvomiting matched controls. Blood nutrient status was reassessed after 10 days of treatment with an intravenous saline solution containing a multivitamin preparation and again at day 20.

RESULTS

Mean dietary intake of most nutrients fell below 50% of the recommended dietary allowances and differed significantly (p < 0.01) from that of controls. More than 60% of the patients had suboptimal biochemical status of thiamine, riboflavin, vitamin B6, vitamin A, and retinol-binding protein. Vitamin C, calcium, albumin, hematocrit, and hemoglobin values were significantly higher in those patients where the duration of vomiting had been longer, suggesting the presence of dehydration. Treatment was associated with cessation of vomiting and improvement in blood nutrient status. Pregnancy outcome was favorable in all patients.

CONCLUSION

The hyperemetic pregnant patient is at nutritional risk; prompt initiation of corrective therapy is recommended.

Cervical intra-epithelial neoplasia and invasive cervical cancer in black and white patients

The relative incidences of cervical intra-epithelial neoplasia (CIN) and invasive cervical cancer were studied in black and white patients at the academic hospitals of the University of the Orange Free State. A statistically highly significant difference was found between black and white patients, with a higher incidence of invasive cervical cancer than stage III CIN (CIN III) in black patients and a higher incidence of CIN III than invasive cervical cancer in white patients (P = 0.000092; 95% confidence interval -0.355-(-)0.128). The time interval between the peak incidence of CIN III and that of invasive cervical cancer was found to be shorter in black than in white patients. These distressing findings emphasise the urgent need for a national cervical cytological screening programme to decrease the incidence of invasive cervical cancer. This serious yet preventable disease is still very prevalent in South Africa, especially among black women.

The incidence of surgical glove perforation during obstetric and gynaecological surgical procedures

The increasing prevalence of diseases such as AIDS and hepatitis B makes safe surgical techniques more important than ever before. Intact surgical gloves act as a barrier against these infections and a study was therefore done to determine the incidence of surgical glove perforation during obstetric and gynaecological surgical procedures. Surgical gloves were collected and tested for perforations following 353 consecutive obstetric and gynaecological operations. Forty pairs of new unused surgical gloves were tested for perforations in the same way. Whereas none of the 40 control pairs of gloves was found to be perforated, 22%-24% of used gloves were perforated. The experience of the surgeon had no influence on the incidence of glove perforation (P = 0.997; chi 2-test). Left-hand gloves were more frequently perforated than right-hand gloves, but this difference was not statistically significant (P = 0.075: chi 2-test). These findings must be a source of concern to all those practising obstetrics and gynaecology and measures are therefore suggested to decrease the risk of HIV or hepatitis B transmission during operations.

Surgical glove powder and intraperitoneal adhesion formation. An appeal for the use of powder-free surgical gloves

Intraperitoneal adhesion formation is a major cause of infertility and/or intestinal obstruction. Among the many well-known aetiological factors responsible for peritoneal inflammatory reaction is surgical glove powder; for example, cornstarch powder. A study was undertaken on 30 rats to determine whether cornstarch powder caused intraperitoneal adhesions. The rats were randomised into two groups under laboratory conditions. Laparotomies were performed on all the rats and trauma inflicted to the right uterine horn. The study group received cornstarch powder suspended in normal physiological salt solution intraperitoneally, and the control group received only normal physiological salt solution. Peritoneal adhesions were evaluated after 2 weeks and statistically analysed with a t-test and 95% confidence intervals. The study group showed a statistically significantly higher incidence of intraperitoneal adhesions (P = 0.0003). It is concluded that cornstarch, as used on surgical gloves, caused peritoneal adhesions and should therefore be removed before surgery. Powder-free gloves are more suitable for preventing adhesion formation.

Morular metaplasia of the endometrium misdiagnosed as adeno-acanthoma in a patient with tubal pregnancy. A case report

A 41-year-old woman underwent a fractional dilatation and curettage for menorrhagia and a diagnosis of adeno-acanthoma was made from the curettings. However, the subsequent hysterectomy and bilateral salpingo-oophorectomy specimen revealed the presence of a clinically undiagnosed tubal pregnancy and extensive immature squamous metaplasia (morules) of the endometrium. No malignancy was present. A review of the original curettings lead to the recognition of the benign lesion already present at that stage. Difficulties in the differential diagnosis are discussed. The presence of endometrial polyps is considered as a possible factor responsible for the morular metaplasia rather than the tubal pregnancy, which seems to be a previously undescribed and interesting coincidence.

Clinical effects of epidural block during labour. A prospective study

The aim of this study was to evaluate the clinical effects of epidural block for pain relief during labour in an obstetric unit which manages mainly high-risk pregnancies. In the majority of the 62 patients studied only 5 ml of a 0,5% solution of bupivacaine was sufficient for effective pain relief. In 75% of patients total pain relief was obtained. Complications of the procedure were hypotension in 32% of patients and bladder atony needing catheterization in 19%. The mean fall in blood pressure was greater in patients with pre-existing hypertension. The incidence of instrumental delivery was 40%, inadequate bearing-down effort being the indication in 54% of these cases. An abnormal fetal heart rate pattern on cardiotocography developed in 13 of 58 fetuses who were monitored internally, while in 3 cases an abnormal pattern because even more abnormal (in one-third of these cases this followed hypotension in the mother). The only statistically significant change in fetal heart rate patterns on cardiotocography was a decrease in the beat-to-beat variability. Epidural block is a very effective form of pain relief during labour but has potentially serious effects, especially in high-risk pregnancies. Precautions to minimize the risk of complications include the administration of intravenous fluid before the procedure and careful monitoring of the patient and her unborn baby. A cardiotocographic monitor is essential for the latter purpose.

[Fetal transverse position caused by giant leiomyoma in the lower segment of the uterus. A case report]

A 20-year-old primigravida presented at 39 weeks' gestation with the fetus lying in the transverse position. Ultrasound examination indicated an anterior placenta praevia grade II-III. During a vertical lower uterine segment caesarean section, a giant intramural leiomyoma of approximately 25 X 25 cm was found. The uterine incision was extended into the upper segment and a healthy male fetus of 2 568 g delivered. The placenta was situated anteriorly but did not extend into the lower uterine segment. A myomectomy had to be performed to enable closure of the uterine incision. The association of a transverse lie with anterior implantation of the placenta may result in a false ultrasound diagnosis because the lower anterior portion of the uterine wall and the attached portion of the placenta simulate a placenta praevia. In our case, an unsuspected leiomyoma in the lower segment contributed to this. Furthermore, this case illustrates the advantage of using a lower uterine segment vertical incision when performing a caesarean section for transverse lie. The incision can then readily be extended into the upper uterine segment when necessary.

Thiamine deficiency-induced gestational polyneuropathy and encephalopathy. A case report

A 22-year-old multigravida presented with polyneuropathy and encephalopathy at 18 weeks' pregnancy. After excluding other applicable conditions, the diagnosis of a hyperemesis-induced thiamine deficiency was made. With the necessary vitamin supplementation the patient gradually recovered over a period of 4 months and was delivered of a normal infant at term. Gestational polyneuropathy and encephalopathy due to thiamine deficiency has very rarely been reported. The literature is reviewed with discussion of the differential diagnosis, the treatment and the prognosis.

Youssef's syndrome: a case report

Youssef's syndrome, or menouria following a vesicouterine fistula, has been reported rarely. This case differs from the previously reported cases in that the menouria was caused by a double vesicocervical fistula and that, in contrast to the generally preferred transabdominal approach, a transvaginal approach was used for successful surgical repair of the fistulas.

An unusual case of uterine rupture. A case report

An unusual case of uterine rupture in a primigravida, in which the left leg of the infant ruptured through the posterior fundal part of the uterus, is presented. No definitive predisposing cause could be found. Some of the clinical signs and symptoms resembled those of abruptio placentae. Recording of internal uterine pressure revealed increased basal tone and frequent small contractions, as are often seen with abruptio placentae. This could possibly have been due to prostaglandin release from the injured decidua.