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A 10 year review of cesarean hysterectomy
A 10 year review of cesarean hysterectomy JAMES
A.
CHARLES Nm
York,
O’LEARY, M.
h’eul
STEER,
M.D. M.D.
York
(1 N E of the trends in modern obstetric practice is the more liberal use of cesarean hysterectomy. The reasons for elective hysterectomy are sterilization and the prevention of future gynecological disease. It is occasionally used for uterine atony, occult dehiscence, uterine fibroids, and hemorrhage at the tirne of cesarean section. The operation has been advocated because of its relative ease and low morbidity rate. This study has been designed to compare the morbidity of cesarean hysterectomy with that of cesarean section and tubal ligation, and to determine the fate of the cervix in these operations. Methods
and
was slightly higher than the 2.1 for the private service (Table II). Among the 165 patients there were 100 who had had a total of 189 previous cesarean sections. Twelve ward patients with a history of previous cesarean section were seen after being in labor for an average of 5.1 hours, and 13 private patients after being in labor for an average of 3.6 hours. A control group was established by the random sampling of 165 cases of cesarean section with tubal ligation cared for over the same 10 year period. The purpose of the controls was to compare morbidity in the two groups in an effort to establish which procedure would best serve the interests of the patient. This was done with the full knowledge that the two groups were dissimilar, in that patients with uterine disease were more likely to be selected for hysterectomy.
materials
For the purpose of this report cesarean hysterectomy refers only to removal of the uterus immediately following cesarean section. Puerperal hysterectomies have been excluded. In the 10 year period, 1952 through 1961, at the Sloane Hospital for Women there were -IO.888 deliveries, 3,412 cesarean sections, and 165 cesarean hysterectomies. The incidence of cesarean hysterectomy, based on all deliveries, was 0.31 per cent on the ward service, and 0.58 per cent on the private service (Table I) _ Rased upon the number of cesarean sections, the incidences were 4.2 per cent and 5.7 per cent, respectively. There were 84 ward cases and 81 private cases. The ward patients were slightly younger (32.6 years) than the private patients (36.6 years), while the average parity of 2.4 on the ward service
From the Defwtment Gynecology, Sloane C’olunlbia-Presb3rterinn
of Obstetrics Hospital for Medical
Indications
The indications for cesarean hysterectomy are summarized in Table III. As in most series the number of indicated hysterectomies exceeds the number of elective procedures. When there were several indications in the same patient, the major indication has been given preference. Of 165 hysterectomies 31 were elective, and 134 indicated. Uterine disease accounted for over 70 per cent of the indicated procedures. These consisted of leiomyoma (45)) occult rupture (14), scarred uterus (14), impending rupture (5), and acute rupture (3). Uterine atony with hemorrhage occurred on twenty occasions. Abnormal placental implantation was noted in 17 patients, placenta previa occurred in 15 patients, and placenta accreta in 2. Cervical
and Women, Center.
227
228
O’Leary
and Steer
carcinoma was an indication for hysterectomy in 8 patients; four of the procedures were radical for invasive disease. Seven uterine incisions were extended to such a degree that the uterus was removed. Type
(sterilization), and 93 indicated (significant diseasepresent). A subtotal procedure was performed on 40 patients and, of these, 75 per cent occurred in the first 5 year period. There were 4 casesof radical hysterectomies, all in the second 5 year period (Table IV) Bilateral salpingoophorectomy was deemed necessaryin 8 cases,and unilateral in 17. Traumatic cystotomies were incurred in 4
of operation
There were 121 cases described as total hysterectomy, of which 28 were elective Table I. Incidence
-__-Cesarean
Year
-
Ward
Total deliveries
Private
.--. -------.---~
section
--
--.742
NO.
hyJterectom> Ward Private
___-
No.
/
5x2
1952
3621
2219 1402
1953
3757
2325 1432
197 175
8.6 12.2
--l:! 5
6.1 2.8
1954
3835
2516 1319
183 148
7.4 11.3
5 10
2. 7 6.1
1955
3960
2667 1293
198 135
7.5 10.5
1956
4100
2805 1295
162 115
5.8 9.0
1957
4197
2796 1401
207 150
-7.5 10.7
1958
4441
3094 1347
213 122
7.0 9.1
1959
4370
2937 1433
198 144
-6.8 10.0
7 T6
3.4 6.9
1960
4316
2960 1356
212 128
7.1 9.4
--12 8
5.6 6.2
1961
4291
2883 1408
236 112
Total
40,888
8.3 7.9 7.4 10.2
-.13 6 81 81
5.5 5.3 -1.2 ‘5.7
__-
-___ 27,202 __..__13,686 - ..__
-
207 170
.._-~ ~~~.. .
C’esarean
2013 --.- --. 1399 .-..__.-.__-
12.2
-. 7 6
3.4 3.5
- 9.2
~-.
Table II. Distribution Race
White
Negro
Status
Ward Private
(No.
34 3
J
lN0.J
50 78
No. Age
(mean) 32.6 36.6
Parity /mean)
2.4 2.1
No.
deliveries
.31 .58
cesarean sections (%)
4.2 5.7
Volume Number
Table
90 2
Cesarean
III.
Indication
Table No.
Elective Indicated Uterine disease Leiomyoma Occult rupture Scarred uterus Impending rupture Acute rupture Placental location Previa Accreta Hemorrhage (atony) Carcinoma Extension of incision Abdominal pregnancy
Total Subtotal Radical
31 134 81 45 14 14 5 3
Table
Cesarean
-
of twenty-
eight included the cervix-an 88 per cent recovery. In the indicated group, fifty-four of included
the
cervix-
a 58 per cent recovery. Although the latter figure is low, it is easy to appreciate how the cervix
could
be Ieft
behind
once
dilation
and
effacement has occurred. The indicated cesarean hysterectomy is usually performed with more haste, more often than not in the presence of increased blood loss, and frequently after the cervix is effaced and dilated, all of which tion.
predisposes This
relatively
to a less meticulous low
yield
Total 121 40 4
hysterectomy
20 8 7 1
specimens
1
74 10 4
V. Transfusions
15 2
specimens
1 1957-1961
47 30 -
17
twenty-five
229
of hysterectomy
( 1952-1956
Fate of the cervix In reports dealing with cesarean hysterectomy the fate of the cervix is frequently overlooked. No mention is made of whether the specimen from a “total” hysterectomy contains the cervix or not. The pathology reports from our 28 elective and 93 indicated cases of total cesarean hysterectomy were reviewed. Of the elective
ninety-three
Type
1 Total
patients, all of whom had had previous cesarean sections. These were equally divided between the elective and indicated group. This confirms the fact that patients with previous cesarean sections may incur bladder injuries when undergoing total hysterectomy.
procedures,
IV.
hysterectomy
of cervices
dissec-
Patients (No.) Total transfusions Average Single transfusions (% )
Table
VI.
Ward
58
58
10
87 1.5
139 2.4
70
ComfAication Urinary tract infection Wound infection Ileus Anemia Vault infection Thrombophlebitis Pneumonia Fever of undetermined origin Atelectasis Hematoma abdominal wound Vesicovaginal fistula Wound dehiscence Foot drop Bladder perforation Tear of mesocolon Enteritis Endometritis
45
Cesarran section and blood tranrfusion (%I 1 3 2 1 2
5 1 1 1 1 1 2 1
1
1 6 30
VII.
Fetal
deaths
16
outcome Ward
Neonatal Stillbirths Premature
90
Cesarean hysterectomy (%I 6 4 2 2 1 1 1
Total
Table
12 1.2
Per cent morbidity
is a
point against the prevention of future gynecological disorders. It has been reported that the removal of
Private
Cesarean section with tubal ligation
2 2 8
/
Private 3 2 2
__
230
O’Leary
and
Steer
the cervix can be facilitated of an oxytocic agent into to contract the cervix for tion.’ The insertion of a through the cervical canal the cervix aids greatly in
by the injection the cervical area definite identificafinger from above with elevation of its removal.
Transfusions
The use of blood transfusions is shown in Table V. Of 165 patients, 116 received at least one blood transfusion. The distribution of patients was equally divided between the ward and private service. The private service averaged 1.5 units of blood transfused per patient, and 70 per cent of these represented single unit transfusions. The ward patients received 2.4 units per patient, and 45 per cent were single unit transfusions. The discrepancy may be attributed to the higher incidence of anemia in the ward patients and the somewhat longer operating time. Morbidity
There were no maternal deaths in either series. The morbidity and complication rates in the hysterectomy series were 30 per cent and 16 per cent following cesarean section and tubal ligation. The two groups are compared in Table VI. The hysterectomy series was characterized by a higher incidence of urinary tract infections, in addition to bladder perforations (2 per cent) and vesicovaginal fistula (2 cases). There was a 5 per cent incidence of fever of undetermined etiology in the hysterectomy group, presumably caused by unrecognized pelvic cellulitis or vault infections. The major morbidity in the cesarean section tubal ligation group was a 6 per cent incidence of endometritis. Although a group of secondary and tertiary cesarean sections is not fully comparable to a group of cesarean hysterectomies, the difference in morbidity is of such a degree that a definite trend is evident. It would seem only logical that the more major procedure would have a greater morbidity and the smaller procedure a lesser morbidity. The fetal outcome is summarized in Table VII, and shows no significant deviation from the expected incidence for our Service.
Comment
Is cesarean hysterectomy, performed on an elective or “semielective” basis. a necessary operation? Page, in discussing Morton’s paper, noted that we would have to do 500 to 1,000 hysterectomies to prevent 1 case of cervical carcinoma.’ Benson concluded it was a much longer operation and required twice as much blood. Alford. Miller, and Simpson,” Bradbury,” Cosgrove,’ Lash and Gummings,j Watson,” and Meyer and Countiss,“’ quoting Greenhill have all concluded that cesarean hysterectomy is a relatively simple operation. The literature is filled with statements that ccsarcan hysterectomy is an easy, smooth, fast, and short operation. In our experience cesarean hysterectomies arc associated with greater blood loss, increased bladder injuries? and higher morbidity. Perhaps the pendulum has swung too far with the result that the morbidity of ccsarean hysterectomy has been underemphasized and the rare death overlooked. Eastman,“., in discussing this problem, stated that c\.cn in the hands of expert gynecologic surgeons he was not sure that the over-all benefits, including the cancer factor. would justify the more extensive procedure. A certain number of “indicated” cesarean hysterectomies can be avoided. Some cases of uterine atony and hemorrhage can be successfully managed by uterine artery ligation, and even simultaneous ovarian artery ligation.>. !’ Pletsch and Sandberg’ postulated that a relatively minor procedure cannot be justified if a more extensive procedure can be shown to offer greater advantages without unduly increasing the patient risk. If OUI statistics are valid the increased morbidity associated with cesarean hysterectomy can only be interpreted as increased patient risk. Conclusion
Total cesarean hysterectomy is not an innocuous procedure, but is preferable to the subtotal operation and should be limited to
Volume Kumbcr
90 ?
the patients who have definite abnormality. The use of this procedure for sterilization and for the prevention of future gynecological disease subjects the patient to a real
Cesarean
hysterectomy
231
immediate danger to possibly prevent a potential late danger. In addition, the complete removal of the cervix is frequently unsuccessful.
REFERENCES
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Pletsch, T., and Sandberg, E.: AM. J. OBST. & GYNEC. 85: 254, 1963. Morton, J.: AM. J. OBST. & GYNEC. 83: 1433, 1962. Montague. C.: Obst. & Gynec. 14: 28, 1959. Cosgrove. R.: AM. J. OBST. & GYNEC. 62: 584, 1951. Lash, A., and Cummings, W.: AM. J. OBST. & GYSEC. 30: 199, 1935. Watson, B.: AM. J. OBST. & GYNEC. 34: 512, 1937. Sandberg. E.: Obst. & Gynec. 11: 59, 1958. Aleksandrov, E.: Akush. Ginek. 6: 20, 1962. Tsirulnikov, M.: Akush. Ginek. 6: 24, 1962. Reis, R. A.: Clin. Obst. & Gynec. 2: 977, 1959. D’Esopo, A.: AM. J. OBST. & GYNEC. 59: 77, 1950. .4lford, C., Miller, A., and Simpson, J.: AM. J, ORST. & GYNEC. 82: 664, 1961
13.
Meyer,
H.,
and Countiss, E.: AM. J. OBST. & 1240, 1959. Brunschwig, A., and Barber, H.: AM. J. OBST. & GYNEC. 76: 199, 1958. Bradbury, W.: West. J. Surg. 63: 232, 1955. Dyer, I.: Obst. & Gynec. 9: 696, 1957. Seigal. I.: South M. J. 50: 195, 1957. Weigle, E.: West. J. Surg. 63: 123, 1955. Dyer, I., Weed, J., Nix, F., and Throne, C.: AM. J. OBST. & GYNEC. 65: 517, 1953. Davis, M.: AM. J. OBST. & GTNEC. 62: 838, 1951. McKenzie, R.: AM. J. OBST. & GYNEC. 61: 1309, 1951. Powell, L.: Obst. & Gynec. 19: 387, 1962. Eastman, N.: Obst. & Gynec. Surv. 17: 825, 1962. GYNEC.
14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
622 West New York
7:
168th Street 32, New York
A.
CHARLES Nm
York,
O’LEARY, M.
h’eul
STEER,
M.D. M.D.
York
(1 N E of the trends in modern obstetric practice is the more liberal use of cesarean hysterectomy. The reasons for elective hysterectomy are sterilization and the prevention of future gynecological disease. It is occasionally used for uterine atony, occult dehiscence, uterine fibroids, and hemorrhage at the tirne of cesarean section. The operation has been advocated because of its relative ease and low morbidity rate. This study has been designed to compare the morbidity of cesarean hysterectomy with that of cesarean section and tubal ligation, and to determine the fate of the cervix in these operations. Methods
and
was slightly higher than the 2.1 for the private service (Table II). Among the 165 patients there were 100 who had had a total of 189 previous cesarean sections. Twelve ward patients with a history of previous cesarean section were seen after being in labor for an average of 5.1 hours, and 13 private patients after being in labor for an average of 3.6 hours. A control group was established by the random sampling of 165 cases of cesarean section with tubal ligation cared for over the same 10 year period. The purpose of the controls was to compare morbidity in the two groups in an effort to establish which procedure would best serve the interests of the patient. This was done with the full knowledge that the two groups were dissimilar, in that patients with uterine disease were more likely to be selected for hysterectomy.
materials
For the purpose of this report cesarean hysterectomy refers only to removal of the uterus immediately following cesarean section. Puerperal hysterectomies have been excluded. In the 10 year period, 1952 through 1961, at the Sloane Hospital for Women there were -IO.888 deliveries, 3,412 cesarean sections, and 165 cesarean hysterectomies. The incidence of cesarean hysterectomy, based on all deliveries, was 0.31 per cent on the ward service, and 0.58 per cent on the private service (Table I) _ Rased upon the number of cesarean sections, the incidences were 4.2 per cent and 5.7 per cent, respectively. There were 84 ward cases and 81 private cases. The ward patients were slightly younger (32.6 years) than the private patients (36.6 years), while the average parity of 2.4 on the ward service
From the Defwtment Gynecology, Sloane C’olunlbia-Presb3rterinn
of Obstetrics Hospital for Medical
Indications
The indications for cesarean hysterectomy are summarized in Table III. As in most series the number of indicated hysterectomies exceeds the number of elective procedures. When there were several indications in the same patient, the major indication has been given preference. Of 165 hysterectomies 31 were elective, and 134 indicated. Uterine disease accounted for over 70 per cent of the indicated procedures. These consisted of leiomyoma (45)) occult rupture (14), scarred uterus (14), impending rupture (5), and acute rupture (3). Uterine atony with hemorrhage occurred on twenty occasions. Abnormal placental implantation was noted in 17 patients, placenta previa occurred in 15 patients, and placenta accreta in 2. Cervical
and Women, Center.
227
228
O’Leary
and Steer
carcinoma was an indication for hysterectomy in 8 patients; four of the procedures were radical for invasive disease. Seven uterine incisions were extended to such a degree that the uterus was removed. Type
(sterilization), and 93 indicated (significant diseasepresent). A subtotal procedure was performed on 40 patients and, of these, 75 per cent occurred in the first 5 year period. There were 4 casesof radical hysterectomies, all in the second 5 year period (Table IV) Bilateral salpingoophorectomy was deemed necessaryin 8 cases,and unilateral in 17. Traumatic cystotomies were incurred in 4
of operation
There were 121 cases described as total hysterectomy, of which 28 were elective Table I. Incidence
-__-Cesarean
Year
-
Ward
Total deliveries
Private
.--. -------.---~
section
--
--.742
NO.
hyJterectom> Ward Private
___-
No.
/
5x2
1952
3621
2219 1402
1953
3757
2325 1432
197 175
8.6 12.2
--l:! 5
6.1 2.8
1954
3835
2516 1319
183 148
7.4 11.3
5 10
2. 7 6.1
1955
3960
2667 1293
198 135
7.5 10.5
1956
4100
2805 1295
162 115
5.8 9.0
1957
4197
2796 1401
207 150
-7.5 10.7
1958
4441
3094 1347
213 122
7.0 9.1
1959
4370
2937 1433
198 144
-6.8 10.0
7 T6
3.4 6.9
1960
4316
2960 1356
212 128
7.1 9.4
--12 8
5.6 6.2
1961
4291
2883 1408
236 112
Total
40,888
8.3 7.9 7.4 10.2
-.13 6 81 81
5.5 5.3 -1.2 ‘5.7
__-
-___ 27,202 __..__13,686 - ..__
-
207 170
.._-~ ~~~.. .
C’esarean
2013 --.- --. 1399 .-..__.-.__-
12.2
-. 7 6
3.4 3.5
- 9.2
~-.
Table II. Distribution Race
White
Negro
Status
Ward Private
(No.
34 3
J
lN0.J
50 78
No. Age
(mean) 32.6 36.6
Parity /mean)
2.4 2.1
No.
deliveries
.31 .58
cesarean sections (%)
4.2 5.7
Volume Number
Table
90 2
Cesarean
III.
Indication
Table No.
Elective Indicated Uterine disease Leiomyoma Occult rupture Scarred uterus Impending rupture Acute rupture Placental location Previa Accreta Hemorrhage (atony) Carcinoma Extension of incision Abdominal pregnancy
Total Subtotal Radical
31 134 81 45 14 14 5 3
Table
Cesarean
-
of twenty-
eight included the cervix-an 88 per cent recovery. In the indicated group, fifty-four of included
the
cervix-
a 58 per cent recovery. Although the latter figure is low, it is easy to appreciate how the cervix
could
be Ieft
behind
once
dilation
and
effacement has occurred. The indicated cesarean hysterectomy is usually performed with more haste, more often than not in the presence of increased blood loss, and frequently after the cervix is effaced and dilated, all of which tion.
predisposes This
relatively
to a less meticulous low
yield
Total 121 40 4
hysterectomy
20 8 7 1
specimens
1
74 10 4
V. Transfusions
15 2
specimens
1 1957-1961
47 30 -
17
twenty-five
229
of hysterectomy
( 1952-1956
Fate of the cervix In reports dealing with cesarean hysterectomy the fate of the cervix is frequently overlooked. No mention is made of whether the specimen from a “total” hysterectomy contains the cervix or not. The pathology reports from our 28 elective and 93 indicated cases of total cesarean hysterectomy were reviewed. Of the elective
ninety-three
Type
1 Total
patients, all of whom had had previous cesarean sections. These were equally divided between the elective and indicated group. This confirms the fact that patients with previous cesarean sections may incur bladder injuries when undergoing total hysterectomy.
procedures,
IV.
hysterectomy
of cervices
dissec-
Patients (No.) Total transfusions Average Single transfusions (% )
Table
VI.
Ward
58
58
10
87 1.5
139 2.4
70
ComfAication Urinary tract infection Wound infection Ileus Anemia Vault infection Thrombophlebitis Pneumonia Fever of undetermined origin Atelectasis Hematoma abdominal wound Vesicovaginal fistula Wound dehiscence Foot drop Bladder perforation Tear of mesocolon Enteritis Endometritis
45
Cesarran section and blood tranrfusion (%I 1 3 2 1 2
5 1 1 1 1 1 2 1
1
1 6 30
VII.
Fetal
deaths
16
outcome Ward
Neonatal Stillbirths Premature
90
Cesarean hysterectomy (%I 6 4 2 2 1 1 1
Total
Table
12 1.2
Per cent morbidity
is a
point against the prevention of future gynecological disorders. It has been reported that the removal of
Private
Cesarean section with tubal ligation
2 2 8
/
Private 3 2 2
__
230
O’Leary
and
Steer
the cervix can be facilitated of an oxytocic agent into to contract the cervix for tion.’ The insertion of a through the cervical canal the cervix aids greatly in
by the injection the cervical area definite identificafinger from above with elevation of its removal.
Transfusions
The use of blood transfusions is shown in Table V. Of 165 patients, 116 received at least one blood transfusion. The distribution of patients was equally divided between the ward and private service. The private service averaged 1.5 units of blood transfused per patient, and 70 per cent of these represented single unit transfusions. The ward patients received 2.4 units per patient, and 45 per cent were single unit transfusions. The discrepancy may be attributed to the higher incidence of anemia in the ward patients and the somewhat longer operating time. Morbidity
There were no maternal deaths in either series. The morbidity and complication rates in the hysterectomy series were 30 per cent and 16 per cent following cesarean section and tubal ligation. The two groups are compared in Table VI. The hysterectomy series was characterized by a higher incidence of urinary tract infections, in addition to bladder perforations (2 per cent) and vesicovaginal fistula (2 cases). There was a 5 per cent incidence of fever of undetermined etiology in the hysterectomy group, presumably caused by unrecognized pelvic cellulitis or vault infections. The major morbidity in the cesarean section tubal ligation group was a 6 per cent incidence of endometritis. Although a group of secondary and tertiary cesarean sections is not fully comparable to a group of cesarean hysterectomies, the difference in morbidity is of such a degree that a definite trend is evident. It would seem only logical that the more major procedure would have a greater morbidity and the smaller procedure a lesser morbidity. The fetal outcome is summarized in Table VII, and shows no significant deviation from the expected incidence for our Service.
Comment
Is cesarean hysterectomy, performed on an elective or “semielective” basis. a necessary operation? Page, in discussing Morton’s paper, noted that we would have to do 500 to 1,000 hysterectomies to prevent 1 case of cervical carcinoma.’ Benson concluded it was a much longer operation and required twice as much blood. Alford. Miller, and Simpson,” Bradbury,” Cosgrove,’ Lash and Gummings,j Watson,” and Meyer and Countiss,“’ quoting Greenhill have all concluded that cesarean hysterectomy is a relatively simple operation. The literature is filled with statements that ccsarcan hysterectomy is an easy, smooth, fast, and short operation. In our experience cesarean hysterectomies arc associated with greater blood loss, increased bladder injuries? and higher morbidity. Perhaps the pendulum has swung too far with the result that the morbidity of ccsarean hysterectomy has been underemphasized and the rare death overlooked. Eastman,“., in discussing this problem, stated that c\.cn in the hands of expert gynecologic surgeons he was not sure that the over-all benefits, including the cancer factor. would justify the more extensive procedure. A certain number of “indicated” cesarean hysterectomies can be avoided. Some cases of uterine atony and hemorrhage can be successfully managed by uterine artery ligation, and even simultaneous ovarian artery ligation.>. !’ Pletsch and Sandberg’ postulated that a relatively minor procedure cannot be justified if a more extensive procedure can be shown to offer greater advantages without unduly increasing the patient risk. If OUI statistics are valid the increased morbidity associated with cesarean hysterectomy can only be interpreted as increased patient risk. Conclusion
Total cesarean hysterectomy is not an innocuous procedure, but is preferable to the subtotal operation and should be limited to
Volume Kumbcr
90 ?
the patients who have definite abnormality. The use of this procedure for sterilization and for the prevention of future gynecological disease subjects the patient to a real
Cesarean
hysterectomy
231
immediate danger to possibly prevent a potential late danger. In addition, the complete removal of the cervix is frequently unsuccessful.
REFERENCES
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Pletsch, T., and Sandberg, E.: AM. J. OBST. & GYNEC. 85: 254, 1963. Morton, J.: AM. J. OBST. & GYNEC. 83: 1433, 1962. Montague. C.: Obst. & Gynec. 14: 28, 1959. Cosgrove. R.: AM. J. OBST. & GYNEC. 62: 584, 1951. Lash, A., and Cummings, W.: AM. J. OBST. & GYSEC. 30: 199, 1935. Watson, B.: AM. J. OBST. & GYNEC. 34: 512, 1937. Sandberg. E.: Obst. & Gynec. 11: 59, 1958. Aleksandrov, E.: Akush. Ginek. 6: 20, 1962. Tsirulnikov, M.: Akush. Ginek. 6: 24, 1962. Reis, R. A.: Clin. Obst. & Gynec. 2: 977, 1959. D’Esopo, A.: AM. J. OBST. & GYNEC. 59: 77, 1950. .4lford, C., Miller, A., and Simpson, J.: AM. J, ORST. & GYNEC. 82: 664, 1961
13.
Meyer,
H.,
and Countiss, E.: AM. J. OBST. & 1240, 1959. Brunschwig, A., and Barber, H.: AM. J. OBST. & GYNEC. 76: 199, 1958. Bradbury, W.: West. J. Surg. 63: 232, 1955. Dyer, I.: Obst. & Gynec. 9: 696, 1957. Seigal. I.: South M. J. 50: 195, 1957. Weigle, E.: West. J. Surg. 63: 123, 1955. Dyer, I., Weed, J., Nix, F., and Throne, C.: AM. J. OBST. & GYNEC. 65: 517, 1953. Davis, M.: AM. J. OBST. & GTNEC. 62: 838, 1951. McKenzie, R.: AM. J. OBST. & GYNEC. 61: 1309, 1951. Powell, L.: Obst. & Gynec. 19: 387, 1962. Eastman, N.: Obst. & Gynec. Surv. 17: 825, 1962. GYNEC.
14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
622 West New York
7:
168th Street 32, New York