- Email: [email protected]
Early inflammatory response to the intrauterine device as determined by the Papanicolaou test
1162
Communications
In
brief
a normal count. A satellit{'d No. 18 chromosome occurred ill (is per cent of the cells studit·d. REFERENCES ~owell, P. C., Mellman, W . .J., Battips, D. M., and Hungerford , D. A.: Exper. Cell R es. 20: 613 , 1960. 2. Jacobs, Patricia, A., Brunton, Muriel, and Court Brown, W. M.: Ann. Hum. Genet. 27: 353. 1964.
I. Moorhead , P. S.,
Early inflammatory response to the intrauterine device as determined by the Papanicolaou test C. A. DOUGLAS RIXGROSE , M.D.
Edm onton, Alberta, Canada
TilE C E R V I X has rightly been called "thf' pelvic tonsil" as it stands, Gibraltar-like, between the contaminated vaginal tube and the st('rile endometrial cavity. The wonderfully bactericidal cervical mucus mak('s infection of thf' upper reproductive U-act uncommon despite the monthly menstrual flow, if reasonable p('rsonal hygien e standards are possible. It came as a surprise to the prof{'ssion, however, when Lippes demonstrated that polyethylene string from an intrauterine drvice (loop ) cou ld communicat(' constan tl y with the vagina without any significant increase in the incidence of endometritis and salpingitis. Mor('over, Lipp{'s has demonstrated that when usrd in wom en with a significant spontaneolls incidence of salpingitis, the occllrrence of this problem could be treated slIccessfully with tlw device in sit u.' This r<~port of 100 women attempts to ob.it'clivel y calibrate any subclinical infection or inflamm atory response to thc Lippes loop by comparing" th{~ Papanicolaou Sill ears taken on insrrtion with follow-up smears 2 to 3 months latN. Smears wen~ taken by the method suggcsted by Wied,2 with separate samples from the endo("('rvix, cervix, and the lateral vaginal wall in its upper third. In each area, lhe acuteness an d degn'{' of inflammation can be assesscd by Hot in!!; the whitc blood cell and histiocyte contl'nt, with due regard for normal cyclic variations. Other crite ria assessed are the morphology of sqllamous and columnar cells, hormonal balancc and microbiologic flora. Each smear was ]"('ad by the author.
Am .
.T.
Augu, ( 1'), 1966 Obst. & Gynec.
The 100 subjects were not consec lltive applicants for a loop because 2 per cent in this high parity group had a positive Papanico laoll smear and required l"Onization and subsequ('nt hysterectomy for confirnH'd carcinoma in sit u of tht' cervix. As well, some patients did not return for til{' suggt'sted check 2 tn 3 months after insertion. Otherwise thefe was no spjection in this series. The a.ges of the 100 subjects an' as follows: .19 wert' 20 to 29 y('ars, 3·1- wen' 30 to 3'1 years, and 7 wen' ·W years and OWl'. The parity of this group included 8 llulJigravidas, II para i, 30 para ii, 28 para iii, and 23 para iv or more. !'\o subjects haw developed a clinical infection with the technique of insertion that has been (~mpl()y{'d. ( The loop is inserted under aseptic tl'chn ique after cold stl'rilization for 18 hours. The cervix is prepared by painting with lktadinf' ,olution prior to insf'rlion of th e lo op.' Assessment of the squamous epithelial cdls rewa led changcs in 17 cast's. In 12 womf'll, the' read ing of "benign atypia" reverted to " normal ," whil .. in .'i women a " nonn al"' rc'ading /){'C;lIlI{' "/wnign atypia" in the subsequent Sliwa I'. Six subjects had glandular cells at the time of insertion, hut did not manifest them 011 tht' subSt~{ jll<'lIt slll ear. Thre(' subjects with no glandular cells on insf'rtion were oi>..;erved 10 ha\ '" them on the repeat smear. The degrep of inflalJ1mation was altered in 17 cases; 9 changed from norm al to mild {'ndoCl' lviritis and Cf'rvicitis, while in 7 there was a rt'vt'rsion to normal from the prcinsertion finding of mild cervicitis and endocervicitis. Tn o!le subject the mild endocervicitis changed to marked Table I. Frequency of microbiologic flora before and after insertion of the Lippes loop (100 su bjects ) After insertion Before (2 to 3 insertion months) I
1
Flora
Bacillus vaginal is without cytolysis Bacillus vaginalis with cytolysis Mixed flora (("::Jeri and bacilli) Cocci Cocci and trichomonads Bacilli and trichomonads Mixed flora and trichomonads Yea3t Mixed flora and yeast I ndeterminate
)
48
%
15
18
1:: 4
22
6 1 I 1
0 12
i II
0
:-l 0 1 'J
Volume 95 Numb,,. 8
Communications
endocervicitis with a concomitant Trichomonas infestation. Histiocytcs were noted in the endocervical and cervical area of 20 subjects after insertion of the loop when they were not observed before. The microbiologic flora before and after insertion are noted in Table I. Bacillus vaginalis with or without cytolysis was noted in 63 cases before insertion and in 54 cases 2 to 3 months after insertion. A mixed flora was present in 12 subjects before insertion and in 22 subjects on follow-up. Eight subjects had trichomonads prior to insertion and 14 manifested this parasite at the subsequent smear. (The general incidence of Trichomonas infestation in this office practice is 15 per cent, with a majority being asymptomatic. ) The thread appendage from the loop, when visualized in the vagina several months after insertion, invariably had a "stalactite" of cervical mucus extending 2 to 3 cm. along the upper visible portion. This propensity appears to double the effective bactericidal length of the endocervical mucus column. At times the mucus causes the string to agglutinate to the vaginal vault surface. Normal basal cells arc a frequent finding in the smears of subjects harbaring the loop. Cytologic changes in the lower genital tract before and after insertion of a Lippes loop were recorded in 100 subjects. Xo clinical pelvic infections other than Monilia and Trichomonas infestations were encountered in subjects harboring the loop. REFERENCES 1. Lippes, J.: AM. J. 1965. 2. Wied, G. L.: Am.
OBST.
J.
& GYXEC. 93: 1024,
Clin. Path. 28: 233, 1957.
10830 Ja.rper Avenue Edmonton, Alberta, Canada
Management of missed abortion by highly concentrated intravenous oxytocin G. WAJKTRAUB, M.D.
brief 1163
In cases of missed abortion. The first to advise this treatment was Bivens. 1 Q'Driscoll and Lavelle" used it, but only in one case. Ryan 4 tried it in 3 cases. Pitocin was not given by them in high dosages. The next step was to try a drip with a high concentration. Loudon" used this method with good results. The purpose of this paper is to present the results of a series of 40 cases in which the oxytocin drip in a high roncenu-ation was used in our department. Twenty 10 30 units of oxytocin, or later Syntocinon, was thoroughly mixed with one bottle (500 m!.) of 5 per cmt dextrose. The drip-needle was inserted into a forearm vein situated in such a way as to allow the patient maximum fr<,<,dom of movement. The drops were connected at a rate of 15 to 25 drops per minute. Thereafter, the strength of the solution was gradually increased every half-hour by giving 10 units more until contractions began. The maximum quantity which we used was 140 units, only in one case, and the minimum was 20 units. The average lts<,d was 40.91 units. Most pati<'nts were in the fifth month, 21 cases (52.5 p('r cent), 12 were in the sixth month (30 per cent), and 7 were in the fourth month (17.5 per cent). The age range of our patients was from 20 to 41 years with the highest percentage in the 20 to 25 year group (Table I ) . All our patients required just one admin:stration with the exception of 2 cases where it was necessary to repeat the drip after 2 days. In 12 cases (30 per cent) we had to make a control by curettage and the rest (70 per cent) aborted completely the same day or at the latest, after 48 hours, without requiring exploration. The loss of blood was normal, ('xc<'pt in 2 cases in which it was greater and none of our patients required blood transfusion. There were no maternal deaths or ruptured uteri. The patients suffered a headache for only a short time. Blood pressure was normal as was pulse rate and urine output. Toxic manifestations were not noted in any patient. The
Table I. Age range abortion
1Il
40 cases of mi"Sed
Age (years) I 1~0-25-126-30131-35136-40 IO;;r
Department of Obstetrics and Gynecology, General Jewish Hospital "Shaare Zedek," Jerusalem , Israel
T II E I N T R VA E N 0 {; s Pitocin drip has been suggested as a method of terminating pregnancy
III
Xo. of cases Percentage
13
32.5
10 25.0
11 27.5
5
12.5
2.5
Communications
In
brief
a normal count. A satellit{'d No. 18 chromosome occurred ill (is per cent of the cells studit·d. REFERENCES ~owell, P. C., Mellman, W . .J., Battips, D. M., and Hungerford , D. A.: Exper. Cell R es. 20: 613 , 1960. 2. Jacobs, Patricia, A., Brunton, Muriel, and Court Brown, W. M.: Ann. Hum. Genet. 27: 353. 1964.
I. Moorhead , P. S.,
Early inflammatory response to the intrauterine device as determined by the Papanicolaou test C. A. DOUGLAS RIXGROSE , M.D.
Edm onton, Alberta, Canada
TilE C E R V I X has rightly been called "thf' pelvic tonsil" as it stands, Gibraltar-like, between the contaminated vaginal tube and the st('rile endometrial cavity. The wonderfully bactericidal cervical mucus mak('s infection of thf' upper reproductive U-act uncommon despite the monthly menstrual flow, if reasonable p('rsonal hygien e standards are possible. It came as a surprise to the prof{'ssion, however, when Lippes demonstrated that polyethylene string from an intrauterine drvice (loop ) cou ld communicat(' constan tl y with the vagina without any significant increase in the incidence of endometritis and salpingitis. Mor('over, Lipp{'s has demonstrated that when usrd in wom en with a significant spontaneolls incidence of salpingitis, the occllrrence of this problem could be treated slIccessfully with tlw device in sit u.' This r<~port of 100 women attempts to ob.it'clivel y calibrate any subclinical infection or inflamm atory response to thc Lippes loop by comparing" th{~ Papanicolaou Sill ears taken on insrrtion with follow-up smears 2 to 3 months latN. Smears wen~ taken by the method suggcsted by Wied,2 with separate samples from the endo("('rvix, cervix, and the lateral vaginal wall in its upper third. In each area, lhe acuteness an d degn'{' of inflammation can be assesscd by Hot in!!; the whitc blood cell and histiocyte contl'nt, with due regard for normal cyclic variations. Other crite ria assessed are the morphology of sqllamous and columnar cells, hormonal balancc and microbiologic flora. Each smear was ]"('ad by the author.
Am .
.T.
Augu, ( 1'), 1966 Obst. & Gynec.
The 100 subjects were not consec lltive applicants for a loop because 2 per cent in this high parity group had a positive Papanico laoll smear and required l"Onization and subsequ('nt hysterectomy for confirnH'd carcinoma in sit u of tht' cervix. As well, some patients did not return for til{' suggt'sted check 2 tn 3 months after insertion. Otherwise thefe was no spjection in this series. The a.ges of the 100 subjects an' as follows: .19 wert' 20 to 29 y('ars, 3·1- wen' 30 to 3'1 years, and 7 wen' ·W years and OWl'. The parity of this group included 8 llulJigravidas, II para i, 30 para ii, 28 para iii, and 23 para iv or more. !'\o subjects haw developed a clinical infection with the technique of insertion that has been (~mpl()y{'d. ( The loop is inserted under aseptic tl'chn ique after cold stl'rilization for 18 hours. The cervix is prepared by painting with lktadinf' ,olution prior to insf'rlion of th e lo op.' Assessment of the squamous epithelial cdls rewa led changcs in 17 cast's. In 12 womf'll, the' read ing of "benign atypia" reverted to " normal ," whil .. in .'i women a " nonn al"' rc'ading /){'C;lIlI{' "/wnign atypia" in the subsequent Sliwa I'. Six subjects had glandular cells at the time of insertion, hut did not manifest them 011 tht' subSt~{ jll<'lIt slll ear. Thre(' subjects with no glandular cells on insf'rtion were oi>..;erved 10 ha\ '" them on the repeat smear. The degrep of inflalJ1mation was altered in 17 cases; 9 changed from norm al to mild {'ndoCl' lviritis and Cf'rvicitis, while in 7 there was a rt'vt'rsion to normal from the prcinsertion finding of mild cervicitis and endocervicitis. Tn o!le subject the mild endocervicitis changed to marked Table I. Frequency of microbiologic flora before and after insertion of the Lippes loop (100 su bjects ) After insertion Before (2 to 3 insertion months) I
1
Flora
Bacillus vaginal is without cytolysis Bacillus vaginalis with cytolysis Mixed flora (("::Jeri and bacilli) Cocci Cocci and trichomonads Bacilli and trichomonads Mixed flora and trichomonads Yea3t Mixed flora and yeast I ndeterminate
)
48
%
15
18
1:: 4
22
6 1 I 1
0 12
i II
0
:-l 0 1 'J
Volume 95 Numb,,. 8
Communications
endocervicitis with a concomitant Trichomonas infestation. Histiocytcs were noted in the endocervical and cervical area of 20 subjects after insertion of the loop when they were not observed before. The microbiologic flora before and after insertion are noted in Table I. Bacillus vaginalis with or without cytolysis was noted in 63 cases before insertion and in 54 cases 2 to 3 months after insertion. A mixed flora was present in 12 subjects before insertion and in 22 subjects on follow-up. Eight subjects had trichomonads prior to insertion and 14 manifested this parasite at the subsequent smear. (The general incidence of Trichomonas infestation in this office practice is 15 per cent, with a majority being asymptomatic. ) The thread appendage from the loop, when visualized in the vagina several months after insertion, invariably had a "stalactite" of cervical mucus extending 2 to 3 cm. along the upper visible portion. This propensity appears to double the effective bactericidal length of the endocervical mucus column. At times the mucus causes the string to agglutinate to the vaginal vault surface. Normal basal cells arc a frequent finding in the smears of subjects harbaring the loop. Cytologic changes in the lower genital tract before and after insertion of a Lippes loop were recorded in 100 subjects. Xo clinical pelvic infections other than Monilia and Trichomonas infestations were encountered in subjects harboring the loop. REFERENCES 1. Lippes, J.: AM. J. 1965. 2. Wied, G. L.: Am.
OBST.
J.
& GYXEC. 93: 1024,
Clin. Path. 28: 233, 1957.
10830 Ja.rper Avenue Edmonton, Alberta, Canada
Management of missed abortion by highly concentrated intravenous oxytocin G. WAJKTRAUB, M.D.
brief 1163
In cases of missed abortion. The first to advise this treatment was Bivens. 1 Q'Driscoll and Lavelle" used it, but only in one case. Ryan 4 tried it in 3 cases. Pitocin was not given by them in high dosages. The next step was to try a drip with a high concentration. Loudon" used this method with good results. The purpose of this paper is to present the results of a series of 40 cases in which the oxytocin drip in a high roncenu-ation was used in our department. Twenty 10 30 units of oxytocin, or later Syntocinon, was thoroughly mixed with one bottle (500 m!.) of 5 per cmt dextrose. The drip-needle was inserted into a forearm vein situated in such a way as to allow the patient maximum fr<,<,dom of movement. The drops were connected at a rate of 15 to 25 drops per minute. Thereafter, the strength of the solution was gradually increased every half-hour by giving 10 units more until contractions began. The maximum quantity which we used was 140 units, only in one case, and the minimum was 20 units. The average lts<,d was 40.91 units. Most pati<'nts were in the fifth month, 21 cases (52.5 p('r cent), 12 were in the sixth month (30 per cent), and 7 were in the fourth month (17.5 per cent). The age range of our patients was from 20 to 41 years with the highest percentage in the 20 to 25 year group (Table I ) . All our patients required just one admin:stration with the exception of 2 cases where it was necessary to repeat the drip after 2 days. In 12 cases (30 per cent) we had to make a control by curettage and the rest (70 per cent) aborted completely the same day or at the latest, after 48 hours, without requiring exploration. The loss of blood was normal, ('xc<'pt in 2 cases in which it was greater and none of our patients required blood transfusion. There were no maternal deaths or ruptured uteri. The patients suffered a headache for only a short time. Blood pressure was normal as was pulse rate and urine output. Toxic manifestations were not noted in any patient. The
Table I. Age range abortion
1Il
40 cases of mi"Sed
Age (years) I 1~0-25-126-30131-35136-40 IO;;r
Department of Obstetrics and Gynecology, General Jewish Hospital "Shaare Zedek," Jerusalem , Israel
T II E I N T R VA E N 0 {; s Pitocin drip has been suggested as a method of terminating pregnancy
III
Xo. of cases Percentage
13
32.5
10 25.0
11 27.5
5
12.5
2.5