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One hundred seventy thousand first-trimester abortions were performed in three free-standing clinics of Planned Parenthood of New York City from 1971-1987. Seventy percent of the procedures were done under local anesthesia; the remainder under intravenous methohexital. No preoperative medications or routine postoperative antibiotics were given. High-risk patients were referred to a hospital. The clinics operated under uniform written guidelines. Experienced physicians performed the procedures. There were no deaths in this series of patients. One hundred twenty-one patients were hospitalized (0.71 per 1000) for suspected perforation, ectopic pregnancy, hemorrhage, sepsis, or recognized incomplete abortion. There was no major extirpative surgery performed. There were an additional 1438 minor complications (8.46 per 1000). Overall, there were 9.05 complications per 1000 abortions. The complication rates for procedures done under general anesthesia and local anesthesia were similar. We conclude that outpatient abortion on selected patients to the 14th week from the last menstrual period is a safe procedure.

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Angiokeratomas of the vulva are uncommon benign lesions. They are usually unilateral, multiple in number, and occur before the age of 50 years. Angiokeratomas are papular lesions measuring less than 1 cm in diameter and are purple in color. In most patients the lesions are asymptomatic; however, intermittent bleeding, pruritus, and pain have been reported. Histologically, hyperkeratosis, papillomatosis, acanthosis, and dilated vasculature in the papillary dermis are characteristic features. Degenerative changes in the perivascular elastic tissue is observed and may contribute to the pathogenesis of vulvar angiokeratomas. In asymptomatic patients, management need only include reassurance and follow-up observation; surgical excision, electrodesiccation, or argon laser for local removal of the lesions may be useful in symptomatic women. Clinically, infections, inflammatory lesions, vascular conditions, and epithelial tumors must be differentiated.

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Massive ascites associated with pelvic endometriosis is an unusual occurrence. Two cases recently encountered by the authors are presented, and 7 additional cases from the literature are reviewed. Clinical courses and operative findings are described, and the management of the cases is presented. The etiology of ascites is explored and the possibility of conservative surgery and hormonal control with danazol is discussed.

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A clinicopathologic study of 32 consecutive patients with leiomyosarcoma of the uterus seen over a 12-year period has been evaluated and the literature has been reviewed. The mean age was 55.5 years, the youngest patient was 38, and the oldest was 86. The mean interval from menopause to diagnosis was 6.7 years. The predominant symptoms were abnormal vaginal bleeding, pain or abdominal discomfort, or enlarged pelvic mass. The preoperative dilatation and curettage established the correct diagnosis in 5 of 24 patients (20.8%). The predominant method of treatment was total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Three patients had adjuvant chemotherapy and 11 had adjuvant radiation therapy. The single most important factor in treatment was TAH and BSO. Of the total group, 25% survived 5 years or more and 43.8% died within the first 3 years following diagnosis. Age at time of diagnosis is an important prognostic indicator. When the diagnosis was made in the premenopausal and postmenopausal patients, the 5-year survival rates were 63.6 and 5.5%, respectively. Four of the 11 patients under the age of 50 (premenopausal) died from the effect of the disease, while only 1 of the 18 patients over the age of 50 (postmenopausal) lived. It is concluded that the best chance of cure lies in the early removal of the uterus when the leiomyosarcoma is still confined within a leiomyoma.

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Syringoma of the vulva is a rare disorder. The patient presented here is the seventh case in the American literature; she is the only patient with this condition in a series of 1132 women with vulvar disease. Differential diagnosis includes epidermal cyst, cherry hemangioma, angiokeratoma, comedo, soft fibroma, Fox-Fordyce disease, steatocystoma multiplex, and lymphangioma circumstriptum. Although syringoma is usually an incidental finding, the diagnosis should be considered in patients with pruritus vulvae. In such cases, examination of the skin around the eyelids and malar areas where syringoma occurs more commonly may suggest a diagnosis of vulvar syringoma that can be confirmed by histologic examination. Inspection of the vulva in cases with extragenital involvement may lead to a more frequent diagnosis of vulvar syringoma.

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In a study of 877 patients with disorders of the vulva seen at a vulva clinic, 375 (43%) presented with an erosion or ulceration or a condition in which an erosion or ulceration developed as a complicating feature. One hundred sixty-one of these patients had a sexually transmitted disease. This report identifies the conditions associated with erosions and ulcerations of the vulva by incidence and provides a simple clinical classification of them as an aid in diagnosis. Methods of study of this group of diseases and their management are discussed.

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This report presents a learning experience in the use of colposcopy in the management of 254 patients consecutively and personally studied in whom one or more Papanicolaou smears suggested a cervical intraepithelial neoplasia or early invasive carcinoma. The accuracy of cytology in predicting the degree of cervical intraepithelial neoplasia and early invasive carcinoma, within the limits of confidence of the laboratory, was 84.5 per cent. The accuracy of the colposcopic impression, within the limits of confidence, was 83.5 per cent. When only those lesions that could be satisfactorily examined were considered, the accuracy of the colposcopic interpretation within the limits of confidence was found to be 96.4 per cent. Neoplastic lesions limited to the ectocervix, and lesions that extended from the ectocervix into the lower portion of the endocervical canal and lesions limited to the canal were significantly related to the age of the patient. Of the total group of 254 patients examined, 45 patients (17.7 per cent) were subjected to a diagnostic cone biopsy.

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Postmenopausal women convert circulatory C19 steroids to estrogen. In order to study the possible role of such estrogen in endometrial cancer, the determination of the fractional conversion of circulation delta-4-androstene-3,17-dione to estrone was attempted. However, in the course of this work it became apparent that the mathematical model upon which this determination is based does not adequately represent the true physiological conditions. The reasons for the inadequacy of the model are not apparent, although they seem to bear some relationship to obesity. The direction and magnitude of the deviation of the values; determined from the true values are unknown. The values for the apparent fractional conversion of androstenedione to estrone in 9 postmenopausal women with endometrial cancer are strongly correlated with values indices of obesity. These values also correlate well with values for the apparent rate of production of estrone in our 9 patients and also in 5 postomenopausal patients with uterine bleeding reported in the literature, but no such correlation is evident for postmenopausal women without endometrial abnormality reported in the literature. The range of values for both the apparent fractional conversion and the apparent rate of production of estrone are similar to those reported by other workers using the same model. However, the data suggest that women with endometrial cancer may produce estriol by a pathway not involving circulating estrone.

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PIP: A systematic investigation of the chemical composition of the total fetus and its individual organs after intraamniotic injection of hypertonic sodium chloride, was performed in 23 fetuses, of 14 to 24 weeks gestation. Fetal death occurs prior to delivery in the great majority of hypertonic saline-induced mid-trimester abortions. This study on the chemical composition of fetal skin, gut, liver, muscle, fat, brain, and heart in 23 cases indicates a high sodium concentration in skin and in intestinal contents and a high and constant sodium concentration in cardiac muscle. Based on these observations, fetal swallowing of hypertonic saline, followed by paralysis of cardiac muscle depolarization when cardiac sodium concentration reaches a threshold level, is suggested as the mechanism of fetal death.^ieng

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