Obstet Gynecol

Alternative therapies for nausea and vomiting of pregnancy.

Aikins Murphy P.
Department of Obstetrics and Gynecology, and The Center for Complementary and Alternative Medicine Research in Women's Health, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA. pam15@columbia.edu
OBJECTIVE: To review available evidence about the effectiveness of alternative therapies for nausea and vomiting of pregnancy. DATA SOURCES: MEDLINE and 13 additional US and international data bases were searched in 1996-1997 for papers that described use of alternative medicine in the treatment of pregnancy and pregnancy complications, specifically those addressing nausea, vomiting, and hyperemesis. Bibliographies of retrieved papers were reviewed to identify additional sources. METHODS OF STUDY SELECTION: All relevant English language clinical research papers were reviewed. Randomized clinical trials addressing specifically the use of nonpharmaceutical and nondietary interventions were chosen for detailed review. TABULATION, INTEGRATION, AND RESULTS: Ten randomized trials studying the effects of acupressure, ginger, and pyridoxine on nausea and vomiting of pregnancy were reviewed. Evidence of beneficial effects was found for these three interventions, although the data on acupressure are equivocal. Insufficient evidence was found for the benefits of hypnosis. Other interventions have not been studied. CONCLUSION: There is a dearth of research to support or to refute the efficacy of a number of common remedies for nausea and vomiting of pregnancy. The best-studied alternative remedy is acupressure, which may afford relief to many women; ginger and vitamin B6 also may be beneficial.

Epidemiologic differences between women with extraovarian primary peritoneal carcinoma and women with epithelial ovarian cancer.

Eltabbakh GH. Piver MS. Natarajan N. Mettlin CJ.
Department of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York 14263, USA. geltabba@aol.com
OBJECTIVE: To describe the epidemiologic features of women with extraovarian primary peritoneal carcinoma and compare them with those of women with primary epithelial ovarian cancer. METHODS: The epidemiologic features of 50 women with extraovarian primary peritoneal carcinoma were compared with those of 503 women with primary epithelial ovarian cancer. We included all women with the respective diagnoses admitted to the Roswell Park Cancer Institute between October 1982 and October 1996 who returned an epidemiologic questionnaire. Epidemiologic features of the study and control groups were extracted from a database compiled from a self-administered questionnaire that has been given to patients as part of the admission process since 1982. Individual variables between the study and control groups were compared using Student t test, chi2 analysis, and Wilcoxon nonparametric test. Two-tailed P < .05 was considered significant. RESULTS: We found few significantly different epidemiologic features between women with extraovarian primary peritoneal carcinoma and those with primary epithelial ovarian cancer. Women with extraovarian primary peritoneal carcinoma were significantly older (mean age 63.8 versus 55.0 years, P < .001), had later menarche (13.3 versus 12.8 years, P = .024), and were less likely to have used perineal talc powder (26.0% versus 48.1%, P = .003). There were no significant differences with respect to reproductive history, contraceptive use, or use of hormone replacement therapy. A larger proportion of ovarian cancer patients reported a family history of breast cancer, but the numbers were too small to reach statistical significance. CONCLUSION: The epidemiologic features of women with extraovarian primary peritoneal carcinoma compared with women with primary epithelial ovarian cancer show few differences. The observed areas of difference warrant further research to determine whether they suggest the occurrence of distinct disease entities.

Interspousal and intrafamilial transmission of hepatitis C virus: a myth or a concern?

Year 1998
Kumar RM.
Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain.
OBJECTIVE: To investigate intrafamilial and interspousal transmission of hepatitis C virus. METHODS: The incidence of anti-hepatitis C virus antibodies in 224 family members of 65 index patients was studied. Sixty-five of the 94 index patients were asymptomatic, apparently healthy parturient Egyptian women, who were detected to be anti-hepatitis C virus positive at routine antenatal screening and whose spouses resided in the United Arab Emirates. The serologic status of family members of seropositive index patients was compared with that of 218 family contacts of 65 matched healthy anti-hepatitis C virus-negative parturient Egyptian women (control group). To determine interspousal transmission, hepatitis C virus genotype was determined in 35 of 36 hepatitis C virus-RNA positive index patient-spouse pairs and 22 of 25 nonrelated RNA positive pairs by polymerase chain reaction. Subsequently nucleotide sequencing of the hepatitis C virus genome was done. RESULTS: In comparison with the control group, a significantly greater number of family members of the index patients were anti-hepatitis C virus positive (five of 218 versus 60 of 224; P < .004). Husbands of index patients had the highest prevalence of anti-hepatitis C virus (74%), with longer duration of marriage being an important risk factor. Of the 35 index patient-spouse pairs analyzed, 33 (94%) had the same hepatitis C virus genotype. On nucleotide sequencing, 30 (91%) couples showed 100% homology, and two had a high (> 97%) homology. Among nonspouse pairs, six pairs (27%) had the same hepatitis C virus genotype; however, low nucleotide sequence homologies (less than 88%) were noted. CONCLUSION: These data suggest that interspousal transmission of hepatitis C virus occurs and that this may be an important route of intrafamilial spread of hepatitis C virus infection.

Transrectal ultrasonography in the assessment of rectovaginal endometriosis.

Year 1998
Fedele L. Bianchi S. Portuese A. Borruto F. Dorta M.
Department of Obstetrics and Gynecology, University of Verona, Italy.
OBJECTIVE: To evaluate the validity of transrectal ultrasonography in the assessment of rectovaginal endometriosis. METHODS: We compared the findings of transrectal ultrasonographic examination performed before surgery with the operative and pathologic findings in 140 women who underwent laparoscopy or laparotomy for suspected endometriosis. The ultrasonographer was asked to investigate whether any deep endometriotic lesions were present in the rectovaginal septum and to define the lateral extension on the basis of involvement of the uterosacral ligaments. In addition, infiltration of the rectal and vaginal walls was evaluated. RESULTS: Thirty-four women had endometriosis infiltrating the rectovaginal septum confirmed by combined operative and pathologic findings. Ultrasonography showed a sensitivity and specificity of 97% and 96%, respectively, in the diagnosis of the presence of rectovaginal endometriosis. The sonographer identified infiltration of the rectal and vaginal walls correctly in all cases in whom it was present, but also reported rectal infiltration in three cases not confirmed by the surgeon and pathologist. The sensitivity and specificity in the diagnosis of uterosacral ligament infiltration were 80% and 97%, respectively. CONCLUSION: If our preliminary results are confirmed by a larger series, transrectal ultrasonography will be considered a valid diagnostic tool in the evaluation of rectovaginal endometriosis.

Hepatitis A vaccine: ready for prime time.

Year 1998
Duff B. Duff P.
Division of Maternal-Fetal Medicine, University of Florida, College of Medicine, Gainesville 32610-0294, USA.
Two new inactivated hepatitis A vaccines are available that confer long-term protection against infection. They are indicated for pre-exposure prophylaxis in persons older than 2 years of age. For one vaccine preparation, Vaqta (Merck and Co., West Point, PA), the recommended schedule for adults is a 1.0-mL (50 U of hepatitis A viral antigen) intramuscular dose initially, followed by a booster dose 6-12 months later. Children 2-17 years of age should receive 0.5 mL (25 U of hepatitis A viral antigen) initially, followed by a booster dose 6-18 months later. The adult dosage schedule for Havrix (SmithKline Beecham, Philadelphia, PA) is a 1.0-mL (1440 enzyme-linked immunosorbent assay [ELISA] units) intramuscular dose initially, followed by a 1.0-mL booster dose 6-12 months later. Patients 2-18 years of age should receive doses of 0.5 mL (720 ELISA units). Primary candidates for vaccination are travelers to regions of endemic disease, children living in high-prevalence areas, homosexual males, users of illicit intravenous drugs, persons working directly with nonhuman primates or hepatitis A virus, patients older than 30 years of age with chronic liver disease, and persons who have received a liver transplant or are awaiting one. Seroconversion rates in healthy children and adults exceed 95%. Both vaccines are safe for use in pregnancy. The cost of the vaccine for adult patients is approximately $50 to $60.

A cost-effectiveness analysis of prenatal carrier screening for cystic fibrosis.

Year 1998
Vintzileos AM. Ananth CV. Smulian JC. Fisher AJ. Day-Salvatore D. Beazoglou T.
Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick 08903, USA. vintziam@umdnj.edu
OBJECTIVE: To examine the cost-effectiveness of prenatal carrier screening for cystic fibrosis. METHODS: A cost-benefit equation was developed that was based on the hypothesis that the cost of prenatal diagnosis required to diagnose and prevent one case of cystic fibrosis should be equal to or less than the lifetime cost generated from the birth of a neonate with cystic fibrosis. The formula was adjusted because a woman's positive or negative carrier status remains unchanged, thus eliminating the need for testing in subsequent pregnancies. The formula was manipulated to identify the optimal cost per screening test, as well as the net cost savings per prenatally diagnosed case of cystic fibrosis for various racial or ethnic groups. Sensitivity analyses included some key assumptions regarding the cost per screening test ($50-150), patient screening acceptance rates (25-100%), and therapeutic abortion rates (50-100%). RESULTS: Assuming therapeutic abortion rates of 50-100%, the net savings per prenatally diagnosed case of cystic fibrosis are $58,369-$382,369 among whites. Given the previously reported patient screening acceptance rates of 50-78%, the overall annual cost savings in the United States for whites are $161-251 million. However, the screening program was not found to be cost-effective for blacks, Asians, or Hispanics. CONCLUSION: Under most assumptions and sensitivity analyses, a prenatal cystic fibrosis-carrier screening program appears to be cost-effective.

Hyperemesis gravidarum associated with Helicobacter pylori seropositivity.

Year 1998
Frigo P. Lang C. Reisenberger K. Kolbl H. Hirschl AM.
Department of Gynecology and Obstetrics, University Hospital of Vienna, Austria.
OBJECTIVE: To test the hypothesis that infection with Helicobacter pylori is associated with hyperemesis gravidarum. METHODS: From January 1995 to November 1996 we enrolled 105 patients with hyperemesis gravidarum in a prospective study. The Helicobacter serum Immunoglobulin (Ig) G concentrations in these patients were compared with those in asymptomatic gravidas matched for week of gestation. RESULTS: Positive serum IgG concentrations were found in 95 of the 105 hyperemesis patients (90.5%) compared with 60 of 129 controls (46.5%). A chi2 test showed statistical significance (P < .001). The mean (+/-standard deviation) index percentages of the IgG titers were 74.2+/-23.6% in the hyperemesis group and 24.3+/-4.4% in the control group (P < .01, Student t test). CONCLUSION: Infection with H pylori may cause hyperemesis gravidarum.

Sciatic hernia as a cause of chronic pelvic pain in women.

Year 1998
Miklos JR. O'Reilly MJ. Saye WB.
Advanced Laparoscopy Training Center, Marietta Medical Center, Georgia, USA.
OBJECTIVE: To review experience with 20 women treated for sciatic hernia between 1993 and 1997. METHODS: Patients with chronic pelvic pain and sciatic hernias, identified retrospectively from chart review, were seen during a 46-month period that covered the surgical experience at our institution and included approximately 1100 cases. The median length of follow-up was 13 months (range 3-36). RESULTS: Sciatic hernia was diagnosed in 20 white women with chronic pelvic pain and was treated using laparoscopy. In 14 cases the hernias were right sided, in five they were left sided, and in one they were bilateral. All sciatic hernias contained the ipsilateral ovary alone or with its fallopian tube. All 20 patients reported symptomatic relief at follow-up. CONCLUSION: Sciatic hernia is a cause of chronic pelvic pain and should be considered in the differential diagnosis.

Prenatal ultrasound diagnosis of small-bowel torsion.

Year 1998
Miyakoshi K. Tanaka M. Miyazaki T. Yoshimura Y.
Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan. kei@mc.med.keio.ac.jp
BACKGROUND: We report a case of congenital small-bowel torsion detected by prenatal ultrasonographic examination. CASE: A 27-year-old primigravida was found to have a fetus with a small-bowel obstruction by ultrasound examination during the third trimester. At 35 weeks of gestation, she complained of absence of fetal activity. A nonstress test showed a nonreactive pattern with reduced baseline variability. Sonographic examination revealed heterogeneous echogenicity within the dilated bowel, and loss of peristalsis. Also noted was a small amount of fetal ascites. After birth, torsion of the dilated small bowel associated with ileal atresia was found at exploratory laparotomy. CONCLUSION: Serial sonographic examinations with special attention to changes in the dilated bowel are useful in the management of prenatally diagnosed small-bowel obstruction.

Acute fatty liver of pregnancy in triplet gestation.

Year 1998
Davidson KM. Simpson LL. Knox TA. D'Alton ME.
Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, Massachusetts, USA. kdavidson@bics.bwh.harvard.edu
BACKGROUND: Acute fatty liver is reported to be more common in twin than in singleton pregnancies. We report three cases of biopsy-proven acute fatty liver in triplet gestations. CASES: In all three cases of acute fatty liver complicating triplet pregnancies, the presenting features were vague abdominal complaints with elevated hepatic aminotransferase levels. A liver biopsy was performed in each case, and cesareans were performed immediately after the diagnosis was confirmed histologically. Clinical resolution occurred in all cases, and all infants did well in the neonatal period. CONCLUSION: Patients with triplet gestations should be monitored closely for the early signs of acute fatty liver. Triplet gestations may contribute to the onset of acute fatty liver by further stressing the fatty acid oxidation capabilities of the susceptible woman.

Delayed diagnosis of bowel infarction secondary to maternal midgut volvulus at term.

Year 1998
Ventura-Braswell AM. Satin AJ. Higby K.
Department of Obstetrics and Gynecology, Wilford Hall Medical Center/Brooke Army Medical Center/Darnall Army Community Hospital, San Antonio, Texas, USA.
BACKGROUND: Intestinal volvulus is responsible for 25% of acute bowel obstructions in pregnant women but only 3-5% in nonpregnant patients. Pregnancy may hinder early diagnosis. CASE: A woman in early labor subsequently developed hypotension and a nonreassuring fetal heart rate tracing. Emergency cesarean was performed and a live infant was born. At surgery, the patient was noted to have ascites, necrotic bowel, and a congenital gut malrotation with a complete midgut volvulus. Several congenital peritoneal bands were lysed, the volvulus was reduced, and 184 cm of small bowel were resected. CONCLUSION: This patient represents a case of midgut volvulus with bowel infarction and necrosis secondary to congenital malrotation of the gut.

Gallstones presenting as a cul-de-sac mass.

Year 1998
Robbins ML.
Department of Obstetrics and Gynecology, Medical Associates, Waukesha, Wisconsin 53188, USA.
BACKGROUND: Pelvic masses requiring surgical evaluation have many different causes. CASE: In an unusual case, a pelvic mass was found to comprise approximately 40 gallstones. Laparoscopy was performed, and the gallstones were removed easily. CONCLUSION: Nongynecologic causes should be considered in the differential diagnosis of pelvic masses.

Remarkable response of primary squamous cell carcinoma of the ovary to paclitaxel and cisplatin.

Year 1998
Eltabbakh GH. Hempling RE. Recio FO. O'Neill CP.
Department of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York 14263, USA. geltabba@aol.com
BACKGROUND: The survival rate of patients with advanced stage primary squamous cell carcinoma of the ovary is dismal and the best treatment is unknown. We describe the response of this tumor to systemic chemotherapy employing paclitaxel and cisplatin. CASE: A 31-year-old white woman diagnosed with International Federation of Gynecology and Obstetrics stage IV primary squamous cell carcinoma of the ovary associated with ovarian endometriosis underwent cytoreductive surgery followed by paclitaxel and cisplatin every 4 weeks for 12 courses. The patient tolerated chemotherapy well, demonstrated a dramatic response with disappearance of hepatic metastases, and remains without evidence of disease 2 years after diagnosis. CONCLUSION: Paclitaxel and cisplatin may be effective in treating primary squamous cell carcinoma of the ovary.