Biomedical subjects
Publications and source records attributed to D Dicker.
A patient is presented with primary choriocarcinoma of the fallopian tube arising from a tubal pregnancy. Treatment consisted of an initial operation including adnexectomy and resection of bilateral ovarian thecalutein cysts, followed by chemotherapy. The patient delivered a healthy infant 2 years later, and is alive and well 5 years after the event.
A case of pneumococcal peritonitis associated with an IUD is presented and four previously reported cases of pneumococcal peritonitis with IUD are reviewed. The infection may occur in previously healthy women who were fitted with an IUD, possibly by ascending infection from the genital tract via the fallopian tubes. The condition is usually accompanied by bilateral salpingitis and may be severe, with fatal outcome. We suggest that any woman over 30 using an IUD, who presents with peritonitis without obvious cause, should be given antibiotics with activity against Streptococcus pneumoniae, following removal of the IUD.
Prolapsed submucous fibroids, are not an uncommon finding in young women of fertile age. They may be either ordinary fibromyomas of any size, or else occur as necrotic or degenerated tumours. They are expelled by the uterus, and usually present in the vagina on a pedicle, following uterine contractions. In a retrospective study of 142 patients seen over a 10-year period at the Golda Meir Medical Center, 46 were managed by vaginal myomectomy, 12 by abdominal myomectomy, 68 by abdominal hysterectomy, usually following vaginal removal of the fibroids, and in 16 women vaginal hysterectomy was performed. The postoperative course and morbidity in these patients was comparable to that of abdominal and vaginal hysterectomy, performed for intramural or subserous fibromyomas.
Diabetes mellitus is a high risk complication of pregnancy and this is particularly true whenever long standing diabetes is complicated by diabetic nephropathy. Five cases are reported of diabetic pregnancy complicated by nephropathy. Four women delivered healthy babies, and one patient aborted spontaneously in the 9th week of gestation. It is suggested that first and foremost in complicated diabetic pregnancy strict normoglycemia should be adhered to prior and all through pregnancy. Our findings based on these cases also suggest that: Pregnancy does not adversely affect the renal status of a diabetic woman or vice versa. Creatinine clearance is not worsened by the course of pregnancy in the majority of these patients and proteinuria per se does not add additional risks to pregnancy or outcome. Hypertension is a separate risk factor affecting the pregnancy despite normoglycemia. Motivation of these patients to maintain normoglycemia as well as bed rest for prolonged periods, intensive use of fetal monitoring, evaluation of fetal lung maturity and improved neonatal care may contribute to improved perinatal outcome.
Two cases are reported of patients in the third trimester of pregnancy in whom routine ultrasound examination revealed progressive dilatation of the fetal intestines. Intestinal obstruction was suspected and amniocentesis as well as amniography with Urografin were done. In both cases a regression in dilatation of bowel was noted on ultrasonography. The Urografin swallowed by the fetus was deemed to have relieved the obstruction of the fetal intestine. The babies were delivered in good condition and passed large amounts of watery meconium per rectum. In spite of the risks inherent in the use of Urografin amniography, as well as of amniocentesis, there appear to be a great number of advantages to the treatment of meconium obstruction of the fetus in utero.
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In a case of spontaneous hematoma of the umbilical cord, no pathologic lesion was found in the umbilical blood vessels. However, an extremely short cord (14 cm) may have contributed to the vessel rupture. A prolonged deceleration discovered during a routine nonstress test led to emergency cesarean section, with delivery of a healthy neonate.
A case has been reported of acute torsion of a wandering spleen in a young woman. The presenting symptom was acute urinary retention, most probably due to pressure of the enlarged, ptotic spleen on the bladder. Acute abdomen with signs of peritonitis made laparotomy with resection of a necrotic spleen imperative, with complete recovery of the patient.
In a prospective study of two 5-yr periods two groups of patients undergoing pelvic operative procedures were compared. Iatrogenic femoral neuropathy occurred in 282 patients who underwent pelvic abdominal surgery in the first group of women, an overall incidence of 7.45%. The neuropathy was associated with the use of self-retaining retractors during surgery. Femoral nerve neuropathy occurred only in two patients in the second group in whom no retractors were used during operation. No other contributing factors were found. The duration of complaints ranged from 3 to 90 days. Spontaneous recovery occurred in 265 patients, while in 17 there were residual mild symptoms for up to 116 days. No serious sequelae have been observed. Prevention of this mostly mild yet annoying syndrome may be achieved if no retractors are used in gynecological operations, or, if they are necessary, due to difficult conditions at surgery or if the operation is long, they should be used with care and loosened from time to time. It is estimated that the incidence of iatrogenic femoral nerve neuropathy is higher than reported, since in very mild cases the patient fails to mention her complaints. The prognosis is usually rather good.
A case is described in whom pelvic kidney presented as tumor praevia in early labor. Ultrasound examination revealed that the mass was a ptotic, functioning pelvic kidney, indicating that abdominal delivery should be resorted to in order to avoid its damage.
The use-effectiveness and continuation rates of 4 methods of contraception were studied during a 2 year follow-up period in a group of 405 teenage girls. Results were compared in 2 groups of adolescents, 1 of highly motivated, high socioeconomic status girls (A) and 1 of poorly motivated, low socioeconomic status adolescent clinic patients (B). The method of contraception was selected by the girls, who were instructed in their proper use. Results showed good rates of continuation among girls of the 1st group as compared to those of the 2nd group. Pregnancy rates after 24 months of use, as calculated by Pearl's formula, was 3.6 and 5.4 respectively with the use of a condom, and 5.8 and 10.8 when the diaphragm was used. When using vaginal foam alone, the rates were 4.2 and 12.3 and with the rhythm method, 8.5 and 13.1. The foam-alone method was unpopular in both groups. No serious side effects or complications were recorded. The study demostrated a reasonable acceptability and use-effectiveness for barrier contraceptives. It is suggested that these harmless and complication-free methods, especially the condom and diaphragm, may be reasonable alternatives for the more modern methods in teens of all socioeconomic strata; an effort must be made to educate and instruct the poorly motivated and encourage them to present themselves for regular follow-up.
Five cases of cervical pregnancy were treated with hysterectomy. In addition to previous pelvic pathology, iatrogenic interventions can be possible predisposing factors in this type of pregnancy. The association of cervical pregnancy and induced abortion, with traumatic curettage damaging the endometrium, rendering it unsuitable for nidation, is well documented. The two cases of severe intrauterine adhesions in our series suggest that partial or complete obliteration of the uterine cavity by such adhesions might be an important cause of cervical pregnancy. The presence of an IUD and the administration of hormonal therapy for the treatment of Asherman's syndrome might have contributed to our cases of cervical pregnancy.
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A rare case of metastatic melanoma of the ovary and extension to the omentum is reported. The tumor was discovered 25 years following enucleation of one eye for malignant melanoma of the choroid.
Bilateral renal agenesis (BRA) or Potter syndrome is a relatively rare congenital defect in which agenesis of the kidneys is associated with oligohydramnios, pulmonary hypoplasia, characteristic facial features and other abnormalities. The etiology is unknown. While the possibility of autosomal recessive inheritance has been suggested in familial cases, the syndrome most probably develops as a pattern of multiple anomalies derived from one single, mechanical factor. The initiating event of this syndrome is oligohydramnios. This condition in the neonate is incompatible with life. Unfortunately, these infants are often delivered by caesarean section, as it is usually associated with premature delivery, and breech presentation is a frequent finding. Consequently the prenatal diagnosis of BRA is important in order to avoid unnecessary operations. The antepartum diagnosis is possible in most cases by means of ultrasound scanning, and should be made in the second trimester, when therapeutic abortion is still possible. We have reviewed the obstetric course of 10 women who delivered such babies in recent years in our department. In 4 out of 6 cases of premature labor and breech presentation the diagnosis was made predelivery, and caesarean section was avoided.
Ectopic pregnancy may be a dramatic occurrence, such as in the acutely ruptured extrauterine entity, or diagnosis may be delayed in the chronic ectopic gestation. Eight cases of infected ectopic pregnancy simulating tubo-ovarian abscess are reported; the diagnosis may be difficult and misleading. Symptoms and signs include abdominal pain and vaginal bleeding following a period of amenorrhea, usually accompanied by fever. All patients in our series presented with a picture of tubo-ovarian or pelvic abscess; however, the diagnosis of infected ectopic pregnancy was made preoperatively in all due to a positive beta-hCG test. Surgery in our cases included unilateral salpingo-oophorectomy in 7, and salpingectomy in one. Attention was drawn to the fact that, in the case of unilateral tubo-ovarian abscess, infected ectopic pregnancy should be suspected whenever preoperative beta-hCG is positive.
A case of torsion of the pregnant fallopian tube is presented. Although uncommon, this entity should be considered in the differential diagnosis of abdominal pain in a young female patient. Early surgical intervention is recommended in order to salvage the affected tube by microsurgical techniques.