Biomedical subjects
Publications and source records attributed to P S Cartwright.
First-trimester pregnancy disorders are common and range from minor to life-threatening conditions. Many of these disorders are encountered by the primary care physician and may be appropriately managed in that setting. Understanding these disorders provides a cost-effective framework for their management.
A structured interview conducted during the postpartum hospitalization of 184 patients aged 17 years or younger was used to study teenagers' perceptions of barriers to prenatal care. The interview consisted of more than 100 questions on demographic characteristics, family and social support, desire for the pregnancy, perceptions of the importance of prenatal care, practical obstacles to access to health care (such as lack of transportation, day care, etc), financial problems related to care, problems finding time to obtain health care, knowledge of available prenatal care resources, and perceptions of ease or difficulty in the use of existing clinics. Multiple regression analysis using the Kessner index as the criterion variable showed that major factors related to the adequacy of prenatal care received by these teenagers were perceptions of cost barriers, the gestational age at which the teenager discovered she was pregnant, school enrollment status (those in school received poorer care than those who had dropped out), and the degree of social support experienced by the teenager. These findings suggest that specific changes in the health care system are needed to make prenatal care more accessible for pregnant teenagers. These changes would include enhancing community awareness that Medicaid pays for prenatal care, establishing links between prenatal clinics and school health systems, and scheduling prenatal clinics at times more convenient for teenagers.
The human papillomavirus (HPV) has been associated with cervical dysplasia and carcinoma. This report summarizes the authors' experience with HPV-related problems over three years, 1987-89, while managing 1,644 women at a county hospital colposcopy clinic. Probes for HPV DNA were not used, and the diagnoses were made with cytologic and histologic criteria alone. The percentage of patients referred to the clinic with HPV found on routine Papanicolaou smears rose significantly, from 3 in 1987 to 18 in 1989. Fifteen percent of those referred because of HPV on a Papanicolaou smear were found to have cervical intraepithelial neoplasia (CIN) grade II or III after they were evaluated at the clinic. Of the 367 cases of biopsy-proven cervical HPV, only 33 (9%) were recorded on Papanicolaou smears performed immediately before the biopsy, and 140 (38%) also had concomitant, biopsy-proven CIN, grade II or III. Of the 195 instances in which the colposcopic impression was simple HPV without CIN, 46 (24%) had high-grade CIN on biopsy. We conclude that the proportion of patients with HPV-associated problems is increasing, that the Papanicolaou smear is not sensitive in detecting cervical HPV infections, that patients with HPV changes found on Papanicolaou smears should be evaluated with colposcopy and that lesions that appear colposcopically to be simple HPV should undergo biopsy to rule out the presence of high-grade CIN.
The nationwide incidence of drug abuse during pregnancy is increasing, but has not been described in our geographic area. Beginning August 1, 1989, all women admitted to the Obstetrical Service at the Metropolitan Nashville General Hospital were to have their urine tested for drugs. In the 11-month study period, 962 women were delivered of neonates, and 631 were actually screened. Those under 18 years of age seldom tested positive for either cocaine or marijuana, regardless of race or marital status. Overall, white subjects were significantly more likely to have cannabinoid metabolites detected in the urine and blacks were more likely to test positive for cocaine use, but neither drug was found in married blacks. Although gravidity was significantly higher in the group testing positive for cocaine, so was parity. Thus, abortion did not correlate with cocaine use.
Persistent trophoblast after salpingostomy occurs in up to 7% of cases of tubal pregnancy. Usually the retained trophoblast is within the fallopian tube, but recent reports have described viable implants on the serosal and omental surfaces. A survey was mailed to 100 members of the American Association of Gynecologic Laparoscopists to determine the incidence of the complication. The 25 respondents reported 14 cases of persistent trophoblast implanted on the pelvic serosal or omental surface. This complication followed 1.9% of the cases managed with laparoscopy and 0.6% managed with laparotomy. Some surgical steps can decrease the likelihood of this complication. Also, the beta-human chorionic gonadotropin level should be monitored postoperatively, even if management was with salpingectomy, and especially if the specimen was fragmented laparoscopically to facilitate its removal.
The diagnosis of ectopic pregnancy remains a challenge to the clinician, despite advances in sonographic and biochemical technology. Contemporary practice requires an understanding of the normal sonographic features and hormonal profiles for normal pregnancy as well as the pathogenesis of an ectopic nidation. Frequently, the diagnosis remains uncertain until laparoscopy or dilatation and curettage have been performed.
A retrospective review of the transvaginal sonograms of 50 women with laparoscopically confirmed ectopic pregnancy was performed to determine whether certain sonographic findings can be detected to confirm the diagnosis. Forty-seven of the 50 pregnancies were tubal. A tubal ring (a 1-3-cm mass consisting of a 2-4-mm concentric, echogenic rim of tissue surrounding a hypoechoic center) was seen in 23 of 34 (68%) ectopic pregnancies in which the fallopian tube had not ruptured, and the tubal ring could be distinguished from a corpus luteum cyst in most cases. Transvaginal sonography also depicted simple (n = 22) or particulate (bloody) (n = 13) peritoneal fluid associated with ectopic pregnancy. In each case in the series, at least one abnormal uterine, adnexal, or peritoneal finding was detected at transvaginal sonography. Because of its improved resolution of uterine and adnexal structures, transvaginal sonography is recommended as a means for detailed evaluation of patients suspected of having an ectopic pregnancy.
With the advent of conservative management of ectopic gestation, several patients have had persistent trophoblastic tissue after their surgical procedure. In the past such patients required repeat laparoscopy or laparotomy and further conservative or radical surgery. However, the use of methotrexate with leukovorum rescue offers a new alternative in the management of patients with persistent trophoblastic tissue after conservative surgery. Two patients with persistent trophoblastic tissue were treated successfully with methotrexate and leukovorum rescue. The use of medical therapy in such patients avoids a second surgical procedure, is associated with few side effects and appears to be an acceptable management alternative.
A common misconception about sexual assault is that the rapist is motivated by a sexual desire stimulated by a victim seductive in her behavior or dress. A retrospective analysis of 740 reported sexual assaults revealed 21 cases involving a victim between the ages of 60 and 90 years of age. The elderly victim was more often white and the assailant more often black than when younger victims are involved. Also, the data suggest that the rape of elderly women may involve a relatively few rapists, and that their assaults are of a serial nature. This study concludes that these rapists are motivated by anger, possibly racially related, and a need to express power, rather than by sexual desire.
Microcomputers are well suited to general data management, yet applications have not been available to meet the highly specialized requirements of a colposcopy clinic. Software was developed under the hypothesis that a specifically tailored application could improve the quality of patient care and facilitate medical education.
Ectopic implantation usually begins with relatively normal growth of trophoblast and serum beta-hCG progression. However, the trophoblast eventually erodes into vessels and a variable degree of bleeding and hematoma compromises its growth. The serum beta-hCG level then usually begins to demonstrate some degree of abnormal progression. For our patients, the length of the ectopic pregnancy varied widely, depending mainly on when the individual patient chose to seek medical treatment. Infertility patients followed from the moment of conception would thus be expected to show a better correlation between early beta-hCG levels and the size of the tubal pregnancy. Preconditions for the operative laparoscopic management of a tubal pregnancy usually include that the tube be unruptured, less than 3 cm in diameter, and readily accessible via the laparoscopic approach. Ackerman et al. suggested there was a general correlation between the serum beta-hCG level and tubal rupture, and the present data demonstrate an overall positive correlation between the size of the tubal pregnancy and the serum level. However, the range of levels is so broad for any given size of mass or tubal status that this correlation is not meaningful clinically. A reliable method to determine the size and status of a tubal pregnancy before laparoscopy would be valuable. Unfortunately, we did not find the preoperative serum beta-hCG level to be useful for making this prediction.
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A retrospective study of 440 cases of reported sexual assault was undertaken in order to identify factors that correlated with which victims sustained physical injury. Overall, 40% sustained nongenital and 16% genital injury, but most injuries were not severe. Which victim was injured strongly correlated with her age and race, the race of her assailant, and whether he had a weapon. White victims sustained both genital and nongenital injury almost twice as often as black victims. Whether she knew her assailant was less important, unless the victim was a child. Survivors attacked by a single assailant were injured as often as survivors of a "gang rape." Conclusions drawn from these data must take into account that these victims choose to report the event to the authorities, and self-reporting bias might explain some of the findings. Approximately half the victims seen sustained no injury. Apparently, physical injury is not a inevitable consequence of being raped.
A review of the experience of 440 women reporting they had been raped was made from their initial contact with the police, through their medical-forensic examination at the county hospital emergency room, by any judicial proceedings, and by their longer term psychological counseling. The data were then compared with those from other municipalities. The assailant's use of a weapon seemed the strongest variable correlated with the victim's decision to press for prosecution. Being raped by a stranger or being physically injured did not correlate with this decision. Women most likely to have been victims of a previous rape were over 40 years old, were black, were assaulted by someone well known to them, or had some sort of mental health problem, and these variables were independent of each other. This implies these victims somehow suffer from an increased vulnerability to repeated rape. The data suggest that use of a county hospital emergency room for the medical management of rape victims discourages their reporting the event to the authorities and their seeking medical treatment.
Delaying delivery of a premature abdominal pregnancy may allow for fetal pulmonary maturation. Prolonged extreme oligohydramnios, however, resulting in significant pulmonary hypoplasia would frustrate any effort to wait for pulmonary maturation. Little mention of this complication is found in the literature. Therefore, two cases of abdominal pregnancy are presented, one with fetal pulmonary hypoplasia and one without. Assessing the volume of amniotic fluid is suggested when a decision is being made to deliver this type of pregnancy.
An enzyme-linked immunoassay urine pregnancy test was used on a group of patients suspected of having an ectopic pregnancy. Patients were seen in the county hospital emergency department and had the urine test correlated with a serum beta-hCG level determined by radioimmunoassay. There were 884 patients with urine ICON-serum beta-hCG correlations. The ICON was positive in each of the 247 patients whose serum value was over 50 mIU/mL, and was negative in each of the 619 patients whose serum level was below 5 mIU/mL. Eighteen patients had a serum level between 10 and 50 mIU/mL and the ICON was positive in 13. The five patients with a low serum beta-hCG level and a negative ICON had dilute urine when tested. Using a modified testing procedure, each of these produced a positive ICON. Of the 27 patients with an ectopic pregnancy the urine ICON was positive in 26. The urine ICON is an improved assay for hCG in patients suspected of having an ectopic pregnancy, and is ideally suited for ED use.
Laparoscopic management of selected cases of tubal pregnancy may be an alternative to the conventional approach, laparotomy. Twenty-seven patients were managed with this technique; each had a readily accessible unruptured ampullary pregnancy less than 4 cm in diameter. All but one went home by the second hospital day. One suffered an immediate postoperative hemorrhage that required laparotomy to control. Six of eight patients tested from three to ten months after the operation had tubal patency. Five of eight patients attempting conception have become pregnant, with one repeat ipsilateral tubal pregnancy. In five patients, serum beta-human chorionic gonadotropin remained elevated for more than 30 days after laparoscopy with no untoward effect. Although insufficient data exist to compare reproductive outcome after this technique with that after laparotomy, in properly selected cases operative laparoscopy seems to be safe and effective conservative therapy, decreasing the need for laparotomy and the duration of hospitalization.
A review of 440 cases of reported rape was undertaken to see if sustaining injury to the genital area was an inevitable consequence of being raped. Injuries to areas other than the genital were taken as objective evidence that the victim did not consent to the encounter, while sperm found in her vagina that could not be accounted for by voluntary coitus was taken as objective evidence that penile penetration of the vagina had occurred. Of the 75 victims with objective evidence of both noncompliance and vaginal penetration, 28% sustained genital injury. The absence of genital injury does not imply consent by the victim or the absence of vaginal penetration by the assailant.