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The first case of septicemic acute acalculous cholecystitis caused by non-O1 Vibrio cholerae is described in a healthy traveler, and biliary tract infections from V. cholerae are reviewed. Immediately after a vacation in Cancun, Mexico, a 55-year-old man developed acute cholecystitis. Blood and bile cultures grew non-O1 V. cholerae. At surgery, the gallbladder was acalculous, inflamed, distended, and nearly ruptured. Pathogenetic factors may have included diarrhea prophylaxis with bismuth subsalicylate, distension of the gallbladder from illness-induced fasting, and bacterial toxins in the gallbladder. The patient received i.v. cephapirin, followed by oral cephradine for a total of 10 days, and he made a quick and complete recovery. V. cholerae should be considered in the differential diagnosis of persons from endemic areas who present with cholecystitis or acute jaundice.

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Preterm labor becomes more difficult to inhibit as the degree of cervical dilation increases. Indeed, some physicians do not even attempt tocolysis with advanced cervical dilation. We compared single- versus double-agent tocolytic therapy when the cervix was dilated 3 cm or greater. We conducted a retrospective study of 44 patients with preterm labor of unknown etiology and with cervical dilation of greater than 3 cm. At the admitting physician's discretion, patients were treated with either magnesium sulfate or with magnesium sulfate and indomethacin in combination. Longer duration of successful tocolysis was noted in the group that received both magnesium sulfate and indomethacin (368.3 hours versus 70.9 hours). No maternal complications occurred in either group. These pilot data suggest that tocolysis with magnesium sulfate and indomethacin is a safe, effective method of tocolysis in patients with advanced cervical dilation.

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The diagnosis of tubal pregnancy, whether ruptured or unruptured, often requires a surgical procedure, such as laparoscopy or laparotomy, for confirmation. We compared women with ruptured and unruptured tubal pregnancies to determine whether the clinical presentations, morbidity and surgical complications in the two groups were significantly different. We compared the demographic characteristics, clinical presentations, laboratory findings, morbidity and complications from surgical management in the two groups. Women with ruptured tubal pregnancies had a higher incidence of abdominal pain lasting less than 24 hours, adnexal tenderness and positive culdocentesis from hemoperitoneum as compared to women with unruptured tubal gestations. Abnormal uterine bleeding was observed less frequently in women with ruptured tubal pregnancies as compared to women with unruptured ones despite similar gestational ages at presentation. All the patients with a tubal pregnancy were managed surgically. The morbidity and surgical complication rates in the two groups were not significantly different.

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With our 2 cases, there are 30 reported cases in English of snake bite poisoning in pregnancy with some details presented and 20 cases without details, for a total of 50 cases. We reviewed the maternal and fetal outcomes in the 30 cases that had such information. Poisoning by members of the Crotalidae family (rattlesnakes, cotton-mouths [water moccasins] and copperheads) during pregnancy carries with it a fetal wastage rate of 43% and a maternal mortality rate of 10%. Pit viper bites cause a bleeding diathesis from the fact that the venom of these snakes contains a procoagulant that defibrinates the blood and leads to bleeding throughout the body.

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An unruptured heterotopic ovarian pregnancy was diagnosed and managed surgically. We believe this is the first such case in a woman who was asymptomatic at presentation for an unrelated complaint.

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In cases of severe shoulder dystocia, the outcome may be improved if cephalic replacement is attempted earlier. Severe shoulder dystocia is usually unresponsive to the traditional measures. Although still controversial, this maneuver may prove to be life-saving in an undeliverable fetus.

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The purpose of this present study was to determine whether intraoperative antibiotic uterine irrigation was effective in reducing febrile morbidity (Part 1), and to determine whether ticarcillin disodium (Ticar) or cefoxitin sodium (Mefoxin) was the more effective solution (Part 2). The indications for cesarean section had an effect on febrile morbidity. In patients having nonelective cesarean section, febrile morbidity was high, occurring in 62.7% of the saline control group and 32.9% of those receiving ticarcillin disodium irrigation. In patients having elective cesarean section, febrile morbidity was lower (28% in the saline control group and 8.3% in the ticarcillin group [P less than or equal to .05]). Ticarcillin and cefoxitin were equal in reducing postoperative febrile morbidity. The use of prophylactic antibiotics, therefore, is indicated both in high-risk patients having nonelective cesarean section and in low-risk patients having elective repeat cesarean section.

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We retrospectively reviewed 76 cerclage procedures done in 62 patients from January 1980 through October 1987 at the Louisiana State University Medical Center, Shreveport. The study showed a significant increase in fetal salvage after cerclage--from 23% to 72%. Emergency cerclage resulted in a fetal salvage rate of only 12%, in contrast to elective cerclage, which yielded a fetal salvage of 81%. Furthermore, fetal salvage was lower when the cerclage was done at less than 12 weeks' estimated gestational age (65%). The McDonald cerclage was done in 69 procedures, using a single suture in 49 patients and a double suture in 20. The fetal salvage rate was the same regardless of the number of sutures placed.

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Cesarean sections were performed on 30 rabbits at term pregnancy. Two incisions were made in each of the two uterine horns, and each incision was closed according to a predetermined method (continuous, everted; continuous, inverted; interrupted, everted; or interrupted, inverted). Tissue from the uterine scar region was sampled at three different time periods (5-8 days, 12-15 days, or 28-30 days) post-surgery to evaluate the degree of uterine healing by a variety of histologic criteria. The initial healing response in the scarred region occurred around 28-30 days post-surgery. The different uterine closure techniques did not appreciably influence the healing response in this study. We evaluated tensile strength in 36 uterine muscle specimens containing the scar obtained from nine animals in the 28-32-days post-surgery group. Of these 36 specimens, 86.1% tore through the muscle instead of through the scar when tension was applied to the muscle.

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A case of puerperal hemorrhage was associated with disseminated intravascular coagulation following hysterectomy. Following unsuccessful surgical intervention, pelvic tamponade was accomplished via use of the Logothetopulos pack.

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The perinatal prognosis associated with the sinusoidal heart rate pattern (SHR) remains controversial. Twenty-nine cases of SHR from 670 fetal heart rate tracings were correlated with narcotic analgesic use and perinatal outcome. Twenty-five of the SHR patterns followed either alphaprodine or demerol use; four were spontaneous. All neonates had Apgar scores of greater than 7 at five minutes. The prognosis of drug-related SHR is benign.

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Terbutaline was administered to 50 women, all diagnosed as being in labor prior to 36 weeks' gestation. In 47, uterine activity was initially arrested with intravenous therapy. The infusion rate required to arrest uterine activity ranged from 10 to 80 microgram/min and 21 of the 50 patients (42%) required more than one intravenous infusion. The average prolongation of gestation was 3.7 weeks in those successfully treated. Twenty-four delivered within 48 hours after the terbutaline was discontinued. Treatment failures occurred in 11 (22%). Not a single infant died of the respiratory distress syndrome. Side effects were mild and well tolerated.

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A triple-blind prospective study of women undergoing vaginal hysterectomy was conducted to compare cefazolin, cephaloridine and no antibiotic, Both cefazolin and cephaloridine were given preoperatively, whereas only cephaloridine was given postoperatively. One gram of cefazolin given intramuscularly on call to the operation room was found to be a safe and effective antibiotic for prophylaxis against febrile morbidity. The proper utilization of prophylactic antibiotics seems to be in the immediate preoperative period. The use of antibiotics after the first day of surgery is unnecessary.

PIP: A triple-blind prospective study of 153 women undergoing vaginal hysterectomy between March 1974-February 1975 at Brooke Army Medical Center, was conducted to compare prophylactic antibiotic treatment with nontreatment. The antibiotics studied included cefazolin and cephaloridine. Treated patients received either 1 gm cefazolin on call to the operating room, 3 gm cephaloridine divided into 1 gm doses on call to the operating room, and 1 gm 12 hours later; or were untreated. Febrile morbidity occurred in 7.7% of patients on cefazolin, 12% on cephaloridine, and in 49% of the controls. The predominant organisms recovered were beta hemolytic Streptococcus, group D, intraoperatively and Escherichia coli, postoperatively. The effective use of preoperative prophylaxis is demonstrated.

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The purpose of this investigation was to determine whether the oxytocin challenge test (OCT) could serve as the primary method for managing pregnancies characterized by possible placental insufficiency. One hundred and five patients underwent 225 oxytocin challenge tests; no perinatal deaths occurred. Eight tests were positive, 21 suspicious, and 196 negative. Because of data obtained in a preliminary study, all 8 fetuses with positive tests were delivered by cesarean section. Four of the 8 had repetitive suspicious tests prior to a positive test, suggesting that utero-placental function may deteriorate gradually. Urinary excretion of estriol did not decrease significantly in any patient, suggesting that the OCT is a more sensitive indicator of placental function than excretion of estriol. Except for patients with preeclampsia who were induced for maternal indications, all pregnancies with a negative OCT were allowed to terminate spontaneously. Five of the 97 fetuses with negative tests developed late-onset deceleration patterns during labor. This indicates that a negative OCT will not necessarily predict fetal tolerance to labor, contrary to assertions made by some other investigators. It is concluded that the OCT can serve as the primary method for assessing the fetal status in pregnancies characterized by placental insufficiency.

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A prospective bacteriologic study on 67 women undergoing either vaginal or abdominal hysterectomy was done to elucidate causes of debrile morbidity. Forty-one percent of the vaginal and 35% of the abdominal hysterectomy patients met the criteria for febrile morbidity postoperatively. Preoperative and 24-hour postoperative urine samples were obtained by transvaginal bladder tap, and the freshly cut edge of the vaginal cuff was routinely swabbed following removal of the uterus. In addition, the subcutaneous layer was cultured during closure of the abdominal wound. Escherichia coli, Enterococcus, and alpha- and beta-Streptococcus were the predominant organisms recovered. The importance of routine vaginal cuff cultures at the time of surgery for the treatment of postoperative morbidity is discussed.

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