Sigmoid volvulus after medical management with subsequent operative laparoscopy of unruptured ectopic pregnancy

The use of methotrexate (MTX) as a first-line treatment of ectopic pregnancies has become popular recently. This report details a previously unreported complication of MTX treatment. Presumptive ectopic pregnancy with an initial beta-hCG level of 3,500 mIU/ml was treated with a single intramuscular dose of 50 mg/m2 MTX. Three weeks later with a beta-hCG level of 870 mIU/ml, the patient was operated for suspected rupture of ectopic pregnancy. Laparotomy revealed left aborted tubal pregnancy with active bleeding from left fimbria and estimated 2,000 ml of blood in the cul-de-sac. Left salpingectomy was performed. Two days later the patient developed signs of large bowel obstruction. The second laparotomy revealed sigmoid volvulus, that was treated with detorsion of the sigmoid loop. Although generally safe and effective, MTX should be used with utmost care in treatment of ectopic pregnancies.

Parathyroid hormone levels in preterm and term labor

This prospective study was undertaken to test the hypothesis that parathyroid hormone (PTH) might be involved in preterm or term labor. Four groups of patients were formed, 15 patients in each group. The preterm labor group were patients who were admitted to our perinatal care unit with preterm labor and unruptured membranes (< 35 weeks' gestation). The preterm or term nonlabor control groups were patients matched for gestational age, maternal age, and parity, who were not in labor. The term labor group were patients matched for maternal age and parity who were in active labor. Mean (+/-SD) level of biologically intact PTH was 18.9 +/- 10.6 pgr/mL, 7.6 +/- 4.7 pgr/mL, 20.8 +/- 10.1 pgr/mL, 13.7 +/- 5.3 pgr/mL in preterm labor group, preterm nonlabor group, term labor group, and term nonlabor group, respectively (p < 0.05). No statistically significant differences were observed in the levels of calcium, phosphorus, magnesium, or albumin. We therefore suggest that PTH may have a role in preterm or term labor. The nature of its role should be investigated in further studies.

Reproductive outcome following hysteroscopic adhesiolysis in Asherman's syndrome

OBJECTIVE

To determine whether hysteroscopic adhesiolysis improves reproductive outcome in women with Asherman's syndrome and pregnancy failure.

SUBJECTS

Ninety consecutive women who had undergone hysteroscopic adhesiolysis of intrauterine adhesions during a 5-year period. Only women in whom at least two previous pregnancies had ended with either a spontaneous abortion or a premature delivery accompanied by fetal or neonatal mortality and a hysteroscopic diagnosis of intrauterine adhesions were enrolled.

RESULTS

Whereas pregnancy outcome prior to the operation was 18.3% term deliveries, 3.3% premature deliveries, 62.4% first-trimester abortions, and 16.0% late abortions, after hysteroscopic adhesiolysis pregnancy outcome was 68.6% term deliveries, 9.3% premature deliveries, 17.4% first-trimester abortions, and 4.7% late abortions. In women with two previous unsuccessful pregnancies, the operative success rate measured by delivering a healthy newborn improved from 18.3% preoperatively to 64% postoperatively. In women with three or more unsuccessful pregnancies the success rate improved from 18.3% to 75%. Successful outcome of adhesiolysis was observed in 61.9% of mild (stage I) and in 70.6% of moderate to severe cases (stages II and III) of intrauterine adhesions.

CONCLUSION

Hysteroscopic adhesiolysis in women with Asherman's syndrome and poor reproductive performance contributes significantly to a successful reproductive outcome.

Fetal oximetry monitoring: a new wonder or another mirage?

This review provides recent data and clinical opinions on a new technology in assessing fetal well-being during labor, the fetal pulse oximeter. Fetal pulse oximetry is potentially superior to electronic fetal heart rate monitoring because it allows direct assessment of both fetal oxygen status and fetal tissue perfusion. Several studies during recent years have demonstrated that fetal pulse oximetry during labor is feasible and accurate. On the other hand, these very same studies have demonstrated a few potential disadvantages and limitations of fetal oximetry. The main limitation seems to be a wide range of normal values. The correlation of fetal oximetry during labor with perinatal outcome and long-term newborn outcome has not yet been determined. In summary, fetal pulse oximetry during labor merits further randomized prospective studies, especially with regard to improvement of perinatal outcome.

Comparison of age distribution of umbilical cord erythrocytes in preeclampsia versus uncomplicated pregnancy

OBJECTIVE

To evaluate the age distribution of umbilical cord (fetal) erythrocytes in preeclamptic women.

METHODS

Prospective evaluation of density distribution of erythrocytes was performed using the density distribution of cells method. Ten consecutive patients having preeclampsia in the third trimester and ten matched controls were studied. Maternal blood samples were taken during the latent phase of labor. Umbilical cord samples were taken immediately after the umbilical cord was cut. An additional control group that consisted of nonpregnant women (n = 30) was determined from our previously published studies.

RESULTS

The erythrocyte population of umbilical cord blood of preeclamptic women has a younger age distribution than the erythrocyte population of umbilical cord blood of women with a normal pregnancy.

CONCLUSION

The shift in age distribution of erythrocytes in umbilical cord blood of preeclamptic women could be attributed to a shorter life span of erythrocytes compared with that of uncomplicated pregnancy.

Human chorionic gonadotropin: pharmacokinetics of subcutaneous administration

The objective of the present study was to evaluate the pharmacokinetics of human chorionic gonadotropin (hCG) following different regimens of subcutaneous and intramuscular single-dose administration. Two hypogonadotropic hypogonadal volunteers received hCG injections without prior ovarian stimulation. The regimens included a single dose of 10,000 IU hCG either subcutaneously or intramuscularly, or 5000 IU hCG intramuscularly. Serum beta-hCG concentrations were measured periodically up to 13 days after hCG administration. Each of the three regimens exhibit a similar pharmacokinetic profile and the highest serum beta-hCG concentrations were achieved with a dose of 10,000 IU administered subcutaneously. Seven days after hCG administration beta-hCG was detectable only after subcutaneous or intramuscular administration of 10,000 IU, but not after a single intramuscular injection of 5000 IU. From the preliminary results of the study it is suggested that a single intramuscular dose of 5000 IU hCG might be sufficient to trigger ovulation, but for luteal-phase support a higher dose may be needed. Subcutaneous administration of hCG for the induction of ovulation or luteal-phase support in gonadotropin-induced cycles is feasible and might offer a better tolerance and cost-effectiveness of infertility treatments, leading to their further simplification.

Induction of labor at 38 to 39 weeks of gestation reduces the incidence of shoulder dystocia in gestational diabetic patients class A2

The purpose of this study was to test the hypothesis that the incidence of shoulder dystocia could be reduced in insulin-requiring diabetic women by elective induction of labor at 38 to 39 weeks of gestation. A prospective study protocol in which labor was induced at 38 to 39 weeks of gestation in insulin-requiring diabetic women was executed between January 1, 1990, and July 31, 1994 (n = 96). The outcome was compared to the results of a previous protocol (years 1983 to 1989) in which the pregnancies were allowed to progress to spontaneous labor, unless fetal health became compromised (n = 164). The incidence of shoulder dystocia in patients in whom labor was electively induced at 38 to 39 weeks of gestation was 1.4% as compared to 10.2% in patients who delivered beyond 40 weeks' gestation (p < 0.05). No increase in cesarean section rate was demonstrated. We conclude that elective induction of labor is suggested for insulin-requiring diabetic women in order to reduce the incidence of shoulder dystocia.

Reversible Inhibition of Tomato Fruit Gene Expression at High Temperature (Effects on Tomato Fruit Ripening)

The reversible inhibition of three ripening-related processes by high-temperature treatment (38[deg]C) was examined in tomato (Lycopersicon esculentum L. cv Daniella) fruit. Ethylene production, color development, and softening were inhibited during heating and recovered afterward, whether recovery took place at 20[deg]C or fruit were first held at chilling temperature (2[deg]C) after heating and then placed at 20[deg]C. Ethylene production and color development proceeded normally in heated fruit after 14 d of chilling, whereas the unheated fruit had delayed ethylene production and uneven color development. Levels of mRNA for 1-aminocyclopropane-1-carboxylic acid oxidase, phytoene synthase, and polygalacturonase decreased dramatically during the heat treatment but recovered afterward, whereas the mRNA for HSP17 increased during the high-temperature treatment and then decreased when fruit were removed from heat. As monitored by western blots, the HSP17 protein disappeared from fruit tissue after 3 d at 20[deg]C but remained when fruit were held at 2[deg]C. The persistence of heat-shock proteins at low temperature may be relevant to the protection against chilling injury provided by the heat treatment. Protein levels of 1-aminocyclopropane-1-carboxylic acid oxidase and polygalacturonase also did not closely follow the changes in their respective mRNAs. This implied both differences in relative stability and turnover rates of mRNA compared to protein and nontranslation of the message that accumulated in low temperature. The results suggest that high temperature inhibits ripening by inhibiting the accumulation of ripening-related mRNAs. Ripening processes that depend on continuous protein synthesis including ethylene production, lycopene accumulation, and cell-wall dissolution are thereby diminished.

The correlation between heat-shock protein accumulation and persistence and chilling tolerance in tomato fruit

Heating tomato fruit (Lycoperiscon esculentum) for 48 h at 38 degrees C prevented chilling injury from developing after 21 d at 2 degrees C, whereas unheated fruit developed high levels of injury. Although the overall protein pattern as seen by Coomassie blue staining was similar from heated and unheated fruit, some high- and many low-molecular-mass proteins were observed in the heated fruit that were absent or present in reduced amounts in unheated fruit. When fruit wer injected with [35S]methionine at harvest and then heated, they accumulated high levels of specific radiolabeled proteins that could still be detected after 21 d at 2 degrees C. If the fruit were held at 20 degrees C after heating, the label in the proteins declined rapidly and these fruit were also sensitive to chilling injury. Hsp70 antibody reacted more strongly with proteins from heated and chilled fruit than with proteins from chilled fruit. Hsp18.1 antibody reacted strongly with proteins from heated fruit but not with those from unheated fruit. A 23-kD protein, highly labeled in heated fruit but not in unheated fruit, had its amino terminus sequenced. To our knowledge, this is the first report showing a relationship between the persistence of heat-shock proteins and chilling tolerance in a plant tissue.

The perinatal emphasis of Segawa's syndrome

Segawa's syndrome is a hereditary progressive dystonia with diurnal fluctuation, which in contrast to other chronic dystonia in childhood responds dramatically to levodopa therapy. Very little is known on how it affects pregnancy or how it is affected by the pregnancy. We present a case of pregnancy of a patient, suffering from Segawa's syndrome. The patient received levodopa throughout entire two consecutive pregnancies and gave birth to two healthy male infants. The only perinatal pathology was non-progressive labor. The safety of levodopa use in pregnancy is also discussed.

Beneficial effect of hysteroscopic metroplasty on the reproductive outcome in a 'T-shaped' uterus

Eight women (aged 27-43) with reproductive dysfunction who were diagnosed by hysterosalpingogram and hysteroscopy as having a 'T-shaped' uterus were operated on using fiberoptic hysteroscopic guidance; the uterine side walls were incised until a normal uterine cavity was achieved. The women's gynecologic and obstetric records were compared before and after the operation. In all the 8 women the operation was without complications and resulted in a satisfactory uterine cavity. Before the operative procedure, the women had had 10 spontaneous abortions and 1 ectopic pregnancy. The postoperative performance available for 7 of the 8 women showed 4 term pregnancies in 3 women, 1 ectopic pregnancy, and no abortions. Our study suggests that hysteroscopic metroplasty in women with a T-shaped uterus improves the reproductive outcome, mainly in women with repeated abortions. We conclude that women with a T-shaped uterus who want to improve their reproductive function should be encouraged to undergo hysteroscopic metroplasty.

Density distribution of erythrocytes in class A2 (insulin requiring) gestational diabetes

We evaluated the age distribution of erythrocytes in pregnancy complicated by gestational diabetes class A2 by the density distribution of cells (DDC) method. The values for normal pregnancy and nonpregnant women were obtained from recently published studies. The cumulative density distribution of cells (DDC) of women with gestational diabetes resembled that of normal pregnancy.

The evaluation of accelerated fetal growth

The timely recognition of fetal macrosomia may reduce the complications associated with vaginal delivery of a macrosomic fetus. Today, the most frequently used tool for identification of fetal macrosomia is ultrasound. Although many different calculations have been applied, the most commonly used is the estimation of fetal weight. Generally, the detection rate of fetal macrosomia is 33-82%, with a specificity of 70-100%, a positive predictive value of 40-83%, and negative predictive value of 66-92%. Adding amniotic fluid volume, cheek-to-cheek diameter or fetal subcutaneous tissue: femur length ratio may improve the accuracy of the diagnosis. Other promising diagnostic tools include the echo-planar imaging and the neural network. Despite the progress that has been achieved since the use of Nagele's rule, our ability to fetal macrosomia remains limited.

Adnexal torsion in adolescents: prompt diagnosis and treatment may save the adnexa

Adnexal torsion, although infrequent, may have a devastating effect on the future reproductive performance of adolescents and young women. However, clear variables predicting a favorable operative outcome have not yet been identified. In this retrospective study the authors analyzed the charts of 72 adolescent girls hospitalized for acute lower abdominal pain. In 13 cases (18%) torsion of the adnexa was found and six of them ended with reproductive compromise expressed by either adnexectomy or salpingectomy. We have found that in the cases of adnexal torsion, the time factor, from admission until final diagnosis and treatment, was the only significant variable affecting the operative results. A shorter time until the operation, resulted in less harm to the reproductive organs involved. Therefore, we conclude that whenever an adnexal torsion is suspected, a quick diagnostic laparoscopy followed by an operative procedure when needed, may contribute to better reproductive performance in the future.

Comparison of sperm parameters, in vitro fertilization results, and subsequent pregnancy rates using sequential ejaculates, collected two hours apart, from oligoasthenozoospermic men

OBJECTIVE

To evaluate the effect of second consecutive ejaculate collected 2 hours after the first one from infertile men on sperm quality and fertilization and pregnancy rates (PRs) in IVF.

DESIGN

A prospective case-control study.

SETTING

In vitro fertilization unit of a university hospital.

PATIENTS

Thirty-nine consecutive infertile patients with oligoasthenozoospermia scheduled for IVF-ET.

MAIN OUTCOME MEASURES

Two consecutive ejaculates were obtained 2 hours apart and were assessed for volume, sperm count, motility, morphology, and quality of swim-up fraction. The subsequent fertilization, cleavage, and PRs (as defined by the appearance of intrauterine gestational sac) were compared between the two ejaculates.

RESULTS

In 28.2% of the individuals the semen analysis of the first ejaculate precluded proceeding with IVF. A statistically significant improvement was shown in sperm cell motility (31.9% +/- 20.7% versus 15.6% +/- 15.3%) and in motile count after swim-up (4.9 +/- 4.5 versus 2.6 +/- 3.1 x 10(6) sperm). No improvement could be demonstrated in sperm density or morphology. The volume of the second ejaculate was decreased significantly as compared with the first one. The fertilization rate, the cleavage rate, and PR were all increased when oocytes were exposed to sperm from the second ejaculate compared with oocytes exposed to sperm from the first ejaculate. The overall PR in our series was 25.6%.

CONCLUSIONS

We suggest that in the group of infertile men with oligoasthenozoospermia, whose partners are scheduled for IVF-ET, if on the day of retrieved oocytes insemination, the ejaculate is of unacceptable quality, a second ejaculate collected 2 hours after collection of the initial ejaculate may produce a sample that exhibits improvements in both semen parameters and reproductive potential.

Induced midtrimester abortion and future fertility--where are we today?

OBJECTIVE

To review recent data and clinical opinions on the impact of induced midtrimester abortion on future fertility.

DATA

MEDLINE search from 1971 to June 1994. Studies on complications and sequelae of induced midtrimester abortion and impact upon future fertility were included.

RESULTS

The possible complications that might be involved include uterine rupture, intrauterine adhesions, pelvic inflammatory disease, subsequent spontaneous abortions, cervical incompetence, subsequent premature labor, and ectopic pregnancy. Very little has been published on the effect of induced midtrimester abortion on future fertility, thus making a clear-cut conclusion difficult.

CONCLUSIONS

As with first trimester abortion, midtrimester abortion seems to have no great effect on future fertility; and the rate of complications could be significantly reduced using appropriate measures, as discussed in the paper.

Continuous wave Doppler velocimetry of the main-stem uterine arteries: the transvaginal approach

The purpose of the study was (1) to establish the efficacy of the transvaginal approach for continuous wave Doppler velocimetry of the main-stem uterine arteries in normal pregnancy and (2) to provide reference values for the flow velocity waveform indices of the main-stem uterine arteries in normal pregnancy. In a cross-sectional study from 16 to 40 weeks of pregnancy, 201 healthy normal women were examined by transvaginal continuous wave Doppler, and flow velocity waveforms were obtained from the main branch of the uterine artery on both sides. Nomograms were compiled for the systolic: diastolic ratio, pulsatility index and resistance index. Values for all variables declined during the course of pregnancy until 22 weeks' gestation, and then remained stable to term. Intra- and interobserver variations were 5% and 8%, respectively, and the examination time was < 5 min. Flow velocity waveform indices declined during pregnancy, indicating a decrease of resistance in the uteroplacental circulation. Our results are comparable to those obtained transvaginally by pulsed wave Doppler, previously reported in the literature. The transvaginal approach for continuous wave Doppler velocimetry of the main-stem uterine arteries is a simple, quick, accurate, safe, cheap and highly reproducible method, and is therefore suitable for evaluating the uteroplacental circulation.

Hemoglobin levels during twin vs. singleton pregnancies. Parity makes the difference

A retrospective, case-control study of 200 consecutive twin and singleton gestations matched for parity was conducted to challenge the hypothesis that lower hemoglobin values appear more often during twin gestations. The database consisted of hemoglobin levels recorded during each trimester. Comparisons were made between the mean hemoglobin levels and incidence of values > 11, 9-11 and < 9 g/dL. Significantly lower mean (+/- SD) hemoglobin values were observed during the first (11.94 +/- 1.1 vs. 12.17 +/- 1.0, P = .026) and second (11.1 +/- 1.0 vs. 11.48 +/- 0.9, P = .00001) trimesters in twin vs. singleton pregnancies, respectively. The differences resulted from lower values in multiparas with twins as compared with their singleton-pregnancy controls (11.8 +/- 1.2 vs. 12.2 +/- 0.9, P = .015, for the first trimester and 11.0 +/- 1.0 vs. 11.5 +/- 0.9, P = .0001, for the second trimester). During the second trimester, the lower incidence of values > 11 g/dL (P = .005, odds ratio = .475, 95% confidence interval = .31-.73) and higher incidence of values between 9 and 11 g/dL (P = .0008, odds ratio = 2.06, 95% confidence interval = 1.34-3.19) may account for the significant differences in mean values. There were no differences between third-trimester values, between nulliparas in both groups or between nulliparas and multiparas in each group. We conclude that the lower hemoglobin levels in twin gestations were associated with multiparity and were statistically significant during the first and second trimesters. This subgroup of twin pregnancies may benefit from further research and possibly from closer hematologic care and monitored iron supplementation.