Case series of labor induction in twin gestations with an Intrauterine Balloon catheter

The efficacy and safety of labor induction using an intrauterine balloon catheter in twin pregnancies has been evaluated. During the study period (1992-1997), labor was induced at 36-42 weeks in 17 twin gestations. Labor induction was indicated for preeclampsia (n = 10), birth weight discordance (n = 3), suspected fetal distress (n = 2) and postdates (n = 2). Twin A was in vertex presentation in all cases. An intrauterine balloon catheter was inserted transcervically followed by augmentation whenever required. Vaginal delivery was achieved in 15 (88.2%) patients. The mean interval from balloon insertion to delivery was 17.05 h, with 80% deliveries occurring within 24 h of catheter insertion and 80% occurring within 12 h of catheter expulsion. Birth weight was 2,514+/-244 and 2,421+/-367 g for twin A and B, respectively. Oxytocin was required in 4 patients. Postpartum hemorrhage was noted in 1 patient. One patient with no progress of labor and 1 with suspected intrapartum fetal distress required cesarean section. All neonates had a 5-min Apgar score of 10. The data suggest that an intrauterine balloon catheter appears to be safe and effective to induce labor in twin gestations.

Preliminary experience with subcutaneous human ovarian cortex transplantation in the NOD-SCID mouse

Xenogeneic transplantation of ovarian cortex into an immunodeficient animal host may be an approach toward fertility preservation for young female patients undergoing cancer therapy. Our objective was to evaluate the development of follicles in human ovarian cortex placed s.c. in non-obese diabetic-severe combined immune deficiency (NOD-SCID) mice (n = 54). The following variables were compared: 1) male versus female mice as hosts, 2) intact versus pituitary down-regulated mice, and 3) warm versus cold tissue transport. After 2 wk, 37 of 50 (74%) of the human xenografts contained follicles. At 12 wk after transplantation, exogenous gonadotropin stimulation resulted in follicle growth in 19 of 37 (51%) of the grafts, including the development of antral follicles, which could be palpated and visualized through the mouse skin. Significantly more developing follicles were identified in male versus female mice (13 of 17 vs. 6 of 20, respectively; p = 0.013) after stimulation. No difference was found between intact and pituitary down-regulated mice as hosts. Follicular survival was significantly increased by warm versus cold tissue transport. Our results suggest that s.c. ovarian cortex xenografting into NOD-SCID mice is feasible. Primordial follicles in ovarian xenografts retain their developmental potential and form antral follicles following gonadotropin stimulation.

Efflux-mediated aminoglycoside and macrolide resistance in Burkholderia pseudomallei

Burkholderia pseudomallei, the causative agent of melioidosis, is intrinsically resistant to a wide range of antimicrobial agents including beta-lactams, aminoglycosides, macrolides, and polymyxins. We used Tn5-OT182 to mutagenize B. pseudomallei to identify the genes involved in aminoglycoside resistance. We report here on the identification of AmrAB-OprA, a multidrug efflux system in B. pseudomallei which is specific for both aminoglycoside and macrolide antibiotics. We isolated two transposon mutants, RM101 and RM102, which had 8- to 128-fold increases in their susceptibilities to the aminoglycosides streptomycin, gentamicin, neomycin, tobramycin, kanamycin, and spectinomycin. In addition, both mutants, in contrast to the parent, were susceptible to the macrolides erythromycin and clarithromycin but not to the lincosamide clindamycin. Sequencing of the DNA flanking the transposon insertions revealed a putative operon consisting of a resistance, nodulation, division-type transporter, a membrane fusion protein, an outer membrane protein, and a divergently transcribed regulatorprotein. Consistent with the presence of an efflux system, both mutants accumulated [3H] dihydro streptomycin, whereas the parent strain did not. We constructed an amr deletion strain, B. pseudomallei DD503, which was hypersusceptible to aminoglycosides and macrolides and which was used successfully in allelic exchange experiments. These results suggest that an efflux system is a major contributor to the inherent high-level aminoglycoside and macrolide resistance found in B. pseudomallei.

Intracytoplasmic sperm injection after follicle stimulation with highly purified human follicle-stimulating hormone compared with human menopausal gonadotropin

PURPOSE

Our purpose was to compare oocyte nuclear maturation and embryo quality after pituitary down-regulation and ovarian stimulation with highly purified follicle-stimulating hormone (FSH) or human menopausal gonadotropin (HMG).

METHODS

Fifty-five patients 37 years of age or younger who were undergoing in vitro fertilization (IVF)-intracytoplasmic sperm injection (ICSI) were evaluated retrospectively. In all cases, male factor was the only indication for treatment, with no female-related factors identified. Following pituitary down-regulation, patients were stimulated with hMG (n = 20) or highly purified FSH (n = 35). Main outcome measures included ovarian response to stimulation, oocyte maturity, and ICSI fertilization results. Secondary outcome measures included pregnancy rates and outcome.

RESULTS

The ovarian response to stimulation was similar for the two groups, as were the percentage of metaphase II oocytes, fertilization and cleavage rates, and number and quality of transferred and cryopreserved embryos. Cycle outcome was comparable.

CONCLUSIONS

In normogonadotropic subjects, monocomponent therapy with highly purified FSH is as effective as hMG in stimulating ovarian follicular development, synchronization of oocyte maturation, and IVF-ICSI outcome. Our findings support the conclusion that the luteinizing hormone component in the stimulation protocol is unnecessary.

Striae distensae of augmented breasts after oral contraceptive therapy

A case of striae distensae (SD) of bilateral augmented breasts following oral contraceptive therapy is presented. Striae maturation and the prevention of additional skin marks was achieved with immediate cessation of oral contraceptive pill therapy and long-term daily topical application of tretinoin cream. It is suggested that patients who are candidates for breast augmentation surgery should be informed of the possible risk of developing SD if they are taking or planning to take the contraceptive pill.

The detrimental effect of increased endometrial thickness on implantation and pregnancy rates and outcome in an in vitro fertilization program

OBJECTIVE

To determine whether there is a maximal value for endometrial thickness, as measured on the day of hCG administration, above which implantation and pregnancy are unlikely to occur.

DESIGN

Retrospective analysis.

SETTING

A university-based tertiary care center for assisted reproductive technology.

PATIENT(S)

A total of 809 IVF cycles in 623 patients resulting in ET.

INTERVENTION(S)

Endometrial thickness was measured by means of transvaginal ultrasound on the day of hCG administration. Cycles were divided into two groups based on endometrial thickness. Group A consisted of 680 cycles with "normal" endometrial thickness (7-14 mm), and group B included 37 cycles with "increased endometrial thickness" (>14 mm).

MAIN OUTCOME MEASURE(S)

Implantation, clinical pregnancy and miscarriage rates.

RESULT(S)

Group B cycles had significantly lower implantation and pregnancy rates compared with group A (3% versus 15% and 8.1% versus 29.7%, respectively). Two of 3 pregnancies (66.6%) from group B miscarried, compared with 44 of 202 (21.8%) pregnancies in group A.

CONCLUSION(S)

Patients with endometrial thickness of > 14 mm on the day of hCG administration comprise approximately 5% of the patients who undergo ET in our program. Our experience suggests that implantation and pregnancy rates are significantly reduced, and miscarriage rates may be increased in this group.

Epithelial ovarian cancer, infertility and induction of ovulation: possible pathogenesis and updated concepts

Numerous case-control, cohort studies, case reports and reviews have been published during the last 5 years regarding the association between infertility and induction of ovulation and epithelial ovarian cancer. Despite this amount of published material, final conclusions regarding direct linkage between these different aspects of infertility and ovarian cancer, as well as any data relating to a putative pathogenetic mechanism, cannot be drawn. In this review we summarize the available data as well as update a previous review by Shoham published in 1994. We outline some of the information that has become available from basic research which may help to direct investigators to suitable clinical research models that may eventually serve to clarify this enigma. Finally we share ideas that focus on specific high-risk cohorts.

Ovarian hyperstimulation following the sole administration of agonistic analogues of gonadotrophin releasing hormone

Ovarian hyperstimulation following the sole administration of gonadotrophin-releasing hormone agonists (GnRHa) is exceedingly rare. We hereby report on two infertile patients undergoing in-vitro fertilization-embryo transfer who developed ovarian hyperstimulation under such circumstances. In both patients, GnRHa were administered using the 'long protocol' regimen. The first patient developed ovarian hyperstimulation on two occasions, with mid-luteal depot administration of triptorelin and with early follicular triptorelin, administered as daily subcutaneous injections. In both cycles, within 2 weeks of triptorelin therapy, massive ovarian multifollicular enlargement occurred, concomitant with high serum oestradiol concentrations, which resolved spontaneously following expectant management. The second patient developed ovarian hyperstimulation following daily injections of leuprolide acetate starting at the mid-luteal phase. The final stage of ovulation was triggered by human chorionic gonadotrophin (HCG) and 11 oocytes were retrieved. In-vitro fertilization resulted in embryo formation, but failed to result in pregnancy. The same phenomenon recurred in a subsequent cycle despite preventive pretreatment with an oral contraceptive. A negative GnRH test, performed just before HCG administration, suggested than an ongoing 'flare-up effect' was unlikely to cause ovarian stimulation. Ovarian hyperstimulation can occur following the sole administration of GnRHa irrespective of the preparation used and the administration protocol. Although spontaneous resolution is the rule, once this condition has developed, HCG administration and oocyte retrieval are feasible. This rare entity probably represents an exaggerated form of ovarian cyst formation following GnRHa administration, the underlying pathophysiology of which remains unresolved.

Ovarian stimulation and in vitro fertilization in women with mature cystic teratomas

OBJECTIVE

To report the results of ovulation induction and in vitro fertilization-embryo transfer (IVF-ET) in patients with ovarian cystic teratomas.

METHODS

Six women with ultrasonographically diagnosed ovarian cystic teratomas (mean diameter 2.4 cm) who presented with infertility underwent IVF-ET (n = 4) or ovulation induction (n = 2). Serial ultrasound examinations were used to determine the size of the cystic teratomas during therapy and throughout pregnancy.

RESULTS

Ovarian stimulation was successful, as evidenced by the serum estradiol concentration on the day of hCG administration (mean in IVF-ET patients, 3558+/-1319 pg/mL) and the number of oocytes retrieved (10+/-4.24). Three patients having IVF-ET and both patients having ovulation induction conceived, and six healthy infants were born. Cyst sizes remained unchanged throughout treatment and pregnancy. There were no cyst-related complications during ovulation induction or IVF-ET, or during the entire course of pregnancy, labor, and delivery.

CONCLUSION

The presence of ovarian cystic teratoma should not be considered a contraindication for therapy in women undergoing ovulation induction and IVF-ET.

The outcome of abdominally delivered triplets and twins: a matched case-control study

OBJECTIVE

To compare the outcome of matched triplets and twins delivered by cesarean section by order of delivery.

STUDY DESIGN

39 sets of triplets delivered abdominally were matched to 39 sets of twins also delivered by cesarean section in the same gestational age. The newborns outcome according to their birth order was analyzed.

RESULTS

The mortality rate of triplets was twice than that of matched twins. While first born triplets had mortality rates similar to the first and second twins, there was a threefold increase in mortality rates of the second and third triplets as compared to the first triplet or twin.

CONCLUSIONS

Triplets have a poorer outcome than twins even when they are delivered abdominally at the same gestational age. These differences are particularly noted in the second and third newborns.

Acute changes in endometrial thickness after aspiration of functional ovarian cysts

OBJECTIVE

To evaluate the influence of aspiration of functional ovarian cysts on endometrial thickness.

DESIGN

Prospective study.

SETTING

An IVF Unit of an academic medical center.

PATIENT(S)

Twenty-two patients from our IVF program, in whom administration of a gonadotropin-releasing hormone agonist preparation in the "long protocol" failed to induce pituitary desensitization, as evidenced by a serum E2 concentration of >55 pg/mL and the presence of an ovarian cyst of >20 mm in diameter.

INTERVENTION(S)

Transvaginal ultrasonographic-guided cyst aspiration was performed, and 2 days later, serum E2 concentration and endometrial thickness were reassessed.

MAIN OUTCOME MEASURE(S)

The values of serum E2 concentration and endometrial thickness before and after cyst aspiration were compared.

RESULT(S)

Two days after ovarian cyst aspiration, the serum E2 concentration dropped from a mean (+/-SD) of 203 +/- 93 to 37 +/- 34 pg/mL. The mean (+/-SD) endometrial thickness was 9.6 +/- 2.0 mm before cyst aspiration and decreased to 5.9 +/- 2.4 mm after the procedure.

CONCLUSION(S)

Within 48 hours after ovarian cyst aspiration, a significant reduction in endometrial thickness occurs concomitant with a sharp decline in serum E2 levels. The phenomenon of acute reduction in endometrial thickness in response to acute estrogen withdrawal has not been described previously. The exact mechanism and endometrial component involved in the "shrinking" process should be further investigated.

Association of the Lewis blood-group phenotype with infertility in women

OBJECTIVE

To evaluate the distribution of Lewis blood group phenotype and secretor status among women treated for infertility.

SETTING

In vitro fertilization unit of a university hospital.

PATIENTS

Forty-seven consecutive infertile women with mechanical (n = 31) or unexplained (n = 16) infertility scheduled for IVF-ET. The control group was formed of 47 fertile women from our database and additional new women matched for age.

MAIN OUTCOME MEASURES

Determination of ABO and Lewis blood group phenotypes.

RESULTS

Of the 47 subfertile women, 12 had blood type A (25.5%), 10 type B (21.3%), 4 type AB (8.5%), and 21 type O (44.7%); 38 had Le (a-b+) (80.9%), 4 had Le (a+b-) (8.5%), and 5 had Le (a-b-) (10.6%). Of the 47 controls, 17 had type A (36.2%), 12 type B (25.5%), 4 type AB (8.5%), 14 type O (29.8%); 26 had Le (a-b+) (55.3%), 11 had Le (a+b-) (23.4%), and 10 had Le (a-b-) (21.3%). The difference in the proportions of the A, B, AB, and O phenotypes was not statistically significant. The proportion of combined recessive and nonsecretor phenotypes Le (a+/-b-) was significantly lower in subfertile women (9/47) as compared with fertile controls (21/47) (P = 0.014). The difference in the proportions of the Lewis blood group phenotypes between the unexplained and the mechanical infertility groups was not statistically significant.

CONCLUSIONS

Subfertile women have an increased frequency of the Le (a-b+) blood group phenotype. Our hypothesis is that the presence of exposed fucosylated determinants such as Le(b) on the surface of endometrial cells may interfere with implantation.

Prospective evaluation of endometrial thickness as a predictor of pituitary down-regulation after gonadotropin-releasing hormone analogue administration in an in vitro fertilization program

OBJECTIVE

To determine whether pituitary down-regulation after gonadotropin-releasing hormone analogue (GnRH-a) administration can be accurately predicted by transvaginal ultrasonographic measurement of endometrial thickness.

DESIGN

Prospective study.

SETTING

An IVF unit of an academic medical center.

PATIENT(S)

One hundred eighty-one patients undergoing 265 IVF-ET treatment cycles using GnRH-a in the long protocol.

MAIN OUTCOME MEASURE(S)

Serum concentrations of E2 were determined, and endometrial thickness was measured by transvaginal sonography. The accuracy of endometrial thickness for predicting pituitary down-regulation was calculated.

RESULT(S)

Pituitary down-regulation, defined as a serum E2 concentration of < or = 55 pg/mL, was achieved in 77% (204 of 265) of the cycles. An endometrial thickness of < or = 6 mm was found in 92.2% (188 of 204) of cycles in which down-regulation was achieved. An estradiol level of < or = 55 pg/mL was present in 95.9% (188 of 196) of cycles with endometrial thickness of < or = 6 mm.

CONCLUSION(S)

A state of relative hypoestrogenism after GnRH-a administration, indicative of pituitary down-regulation, can be predicted with a high degree of accuracy by ultrasonographic measurement of endometrial thickness. Thus, routine testing for serum E2 concentration may be safely omitted. This may allow further simplification of IVF protocols and increase both cost-effectiveness and patients' convenience.

Fetal acrania: five new cases and review of the literature

Acrania is a lethal malformation in which there is an absence of the flat skull bones covering the brain. Five new cases are described, and a review of the English-language medical literature is presented. The sonographic differential diagnosis of acrania includes anencephaly, large cephalocele, osteogenesis imperfecta, and hypophosphatasia. The diagnosis of acrania can be established sonographically even in the first trimester if a large mass of disorganized brain tissue covered only by a thin membrane is detected.

Sonographic measurements of the umbilical cord in pregnancies complicated by gestational diabetes

The aim of the present study was to investigate the umbilical cord measurements in pregnant patients with gestational diabetes. We found that the umbilical cord was significantly larger in fetuses of mothers with gestational diabetes than in the normal population and that the main increase in the width is attributed to an increase in Wharton jelly content. It is suggested that this finding may be an additional parameter that can differentiate between the appropriate-for-gestational-age fetus from a normal pregnancy and that from a pregnancy in a mother with gestational diabetes, and between the macrosomic fetus of a diabetic pregnancy from the genetically large fetus.

Congenital heart defects: natural course and in utero development

BACKGROUND

Most congenital heart defects (CHDs) are diagnosed on targeted prenatal transvaginal (TVS) or transabdominal (TAS) ultrasonography during the early second trimester or at midgestation. Nevertheless, delayed diagnosis in some cardiac malformations still remains despite detailed echocardiographic examination. The present study was conducted to evaluate the evolution of fetal cardiac anomalies and assess their development in utero.

METHODS AND RESULTS

We retrospectively reviewed 22,050 pregnant women who were divided into two groups: 6924 who had initial TVSs at 13 to 16 weeks' gestation, followed by TASs at 20 to 22 weeks, and 15,126 who had initial TASs at 20 to 22 weeks. Both groups were subsequently examined in their third trimester. All newborns were examined by certified pediatricians. CHD was diagnosed in 168 babies: 66 in group A and 102 in group B. In group A, 42 malformations (64%) were detected at the first TVS examination, and 11 (17%) were found during the subsequent TAS. Three additional anomalies (4%) were found during the third trimester, and 10 malformations (15%) were detected postnatally. In group B, 80 malformations (78%) were detected in the initial examination at midtrimester, and an additional 7 (7%) were found in the third trimester, whereas 15 (15%) were diagnosed postnatally. The 10 anomalies (group A, n=3; group B, n=7) that were detected only during the third trimester comprised aortic stenosis (n=2), cardiac rhabdomyoma (n=2), subaortic stenosis (n=1), tetralogy of Fallot (n= 1), aortic coarctation (n=1), sealed foramen ovale (n=1), ventricular septal defects (n=1), and hypertrophic cardiomyopathy (n=1).

CONCLUSIONS

Although most fetal cardiac anomalies are detectable early in gestation, some may evolve in utero at different stages of pregnancy.

Ovarian cysts and cyclic hormone replacement therapy: is there an association?

OBJECTIVES

To evaluate whether there may be an association between postmenopausal ovarian cysts and hormone replacement therapy.

METHODS

The study comprised 564 consecutive, asymptomatic, postmenopausal women who were referred for routine, transvaginal ultrasound examinations between January 1 and December 31, 1995. Various demographic and ultrasonographic parameters were recorded on a prospectively-created, computerized data base.

RESULTS

There was no difference in the prevalence of ovarian cysts with or without hormone replacement therapy (10.5% vs. 12.5%, respectively). However, in the subgroup of early postmenopausal women (40-55 years), the use of hormone replacement therapy was associated with a significantly reduced prevalence of ovarian cysts (10.4% vs. 28.6%; p < 0.05).

CONCLUSIONS

Hormone replacement therapy is associated with a reduced prevalence of ovarian cysts in early postmenopause.

The age of consumerism in healthcare

Health plans and employers are increasingly relying on patient satisfaction surveys to evaluate care. If administered and interpreted properly, these surveys can help providers, employers, and patients mine a wealth of information.

Infection by parvovirus B 19 during pregnancy: a review

Fetal infection by Parvovirus B 19 is a common cause of fetal anemia and nonimmune hydrops fetalis and may result in fetal death. Recent improvements in diagnosing parvovirus infections by sensitive molecular biology techniques now allow for a new insight into its pathogenic rule, immunology, and the varied clinical manifestations. The estimated overall risk of fetal loss after maternal exposure is about 6.5 percent, which is much less than previously thought. Inasmuch as complete spontaneous reversal of fetal hydrops has been commonly described, controversy exists regarding the management of the fetus with clinical signs of infection by Parvovirus B 19. According to the experience that has accumulated, it seems that only cases with severe fetal anemia or signs of fetal compromise should be managed by intrauterine transfusion. This procedure, however, is not without risk. Although an association between fetal viral infection and structural abnormalities has been described, it has not been proved yet. However, infection by Parvovirus B 19 has been recently proposed as a causative factor for congenital red blood cell aplasia.

Malignant paraganglioma of the prostate: case report, depiction by meta-iodobenzylguanidine scintigraphy and review of the literature

OBJECTIVE

To describe the 123-I-MIBG scintigraphic, CT, MRI, operative and pathological findings in a case of malignant prostatic paraganglioma and to review the literature on this very rare tumor.

EXPERIMENTAL DESIGN

Clinical imaging and pathological correlation of data in a referred patient.

SETTING

Regional referral center and tertiary referral academic medical center.

PATIENT

17 year old man presenting with painless hematuria and a large prostatic mass. Interventions and measures. Renal ultrasound, transrectal ultrasound, ultrasound guided prostatic biopsy, pelvic CT and MRI, planar and SPECT 123-I-MIBG scintigraphy, and surgical exploration.

RESULTS

The patient had a significant hydronephrosis of the left kidney and marked enlargement (120 ml) of the prostate gland by ultrasound. Ultrasound guided biopsies of the prostate and a left pelvic lymph node revealed a neuroendocrine tumor staining positive for chromogranin. CT and MRI revealed a large tumor of the prostate invading the seminal vesicles, bladder and rectum with extensive pelvic lymph node spread. The primary tumor and one of the nodes were shown to be 123-I-MIBG avid confirming the neuroendocrine nature of the tumor. The lesion was unresponsive to chemotherapy and unresectable at surgical exploration.

CONCLUSIONS

To date there have only been 5 reports of prostatic paragangliomas. To our knowledge this is the first to have been studied by MIBG scintigraphy and like most paragangliomas it was MIBG-avid.

Sonographic evaluation of the uterus in postmenopausal women receiving tamoxifen: characterization of mid-uterine abnormalities

BACKGROUND

Tamoxifen is known to exert agonist estrogenic effects on the uterus. Its use in postmenopausal women has also been associated with various endometrial and uterine abnormalities that can be detected by endovaginal sonography.

OBJECTIVE

To study postmenopausal patients receiving tamoxifen who were referred for evaluation following the detection of abnormal uterine findings by endovaginal sonography.

METHODS

Fifty-two women treated with tamoxifen for breast cancer who were found to have an abnormal uterine sonogram constituted the study population. Uterine sonograms were reviewed and clinical and sonographic data were correlated with the results of the histologic examinations.

RESULTS

Forty-five women demonstrated a thickened mid-uterine structure. Of these, in thirty-nine patients (87%) either no tissue of scant fragments of normal endometrium were obtained on curettage, and six women (13%) had endometrial hyperplasia. Seven women had fluid loculation lined by thin endometrium. Their subsequent histologic examination was normal. The sonograms of the women who demonstrated an appearance of a thickened endometrium but no neoplasia, characteristically demonstrated hyperechogenic cystic area with no midline echo.

CONCLUSIONS

Among 52 postmenopausal patients receiving tamoxifen presented with an abnormal uterine sonogram, 39 (75%) women were found to have a thick mid-uterine structure resembling a thickened endometrium without histologic evidence of neoplasia. This phenomenon can be characterized by typical sonographic features, and may be differentiated from other uterine abnormalities.

Sonographic measurement of amniotic fluid volume in the first trimester of pregnancy

The sonographic estimate of amniotic fluid volume from 7 to 13 weeks of gestation in 95 pregnancies was calculated. Amniotic fluid volume increased from 1.5 ml at 7 weeks to 25 ml at 10 weeks and 100 ml at 13 weeks. The nomograms constructed may be used in the objective evaluation of the fetal condition in the first trimester.