Use of a bovine hemoglobin preparation in the treatment of cyclic ovarian hemorrhage in a miniature horse

Anemia that was secondary to ovarian hemorrhage in a 4-year-old miniature horse mare was treated prior to laparotomy with polymerized ultrapurified bovine hemoglobin (PUBH). Two previous whole-blood transfusions had resulted in acute transfusion reaction, and a suitable blood donor could not be found among 9 horses, necessitating use of the blood substitute. Subsequent blood typing revealed the mare to be Aa-negative, with allo-antibodies against Aa in serum. Serious adverse reactions were not observed after infusion of PUBH, and the mare recovered. Although the safety and efficacy of using PUBH in horses has not been established, PUBH may prove to be an excellent alternative to whole-blood transfusions, when indicated.

Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval

A 34-year-old white female patient with 11 years of primary infertility due to endometriosis underwent ultrasound-guided oocyte retrieval for in-vitro fertilization. A right ovarian endometrioma was aspirated during oocyte retrieval. Two weeks after follicular aspiration, the patient developed acute abdominal pain and operative laparoscopy revealed a ruptured right ovarian abscess. She responded to laparoscopic drainage and intravenous antibiotics. The patient conceived during that cycle and has a single ongoing pregnancy.

[Gonadal disorder as a result of adverse reaction to antineoplastic drugs--diagnosis, symptoms, prevention and treatment]

The past three decades have shown the increasing success of chemotherapy as the treatment of malignancies. This therapeutic success has focused attention on the associated gonadal toxicity. Cytotoxic agents may induce infertility and endocrine disfunction. Data for analysis were provided by studies on gonadal function after chemotherapy for: Hodgkin's disease, acute lymphocytic leukemia, non-Hodgkin's lymphoma, breast cancer; renal disease, bone-marrow transplantation. The likelihood of developing chemotherapy-induced damage depended on the chemotherapeutic regimen and prescribed dose, illness, sex and degree of gonadal activity at the time of treatment. Despite of the high frequency of chemotherapy-induced gonadal damage its prevention has received a little attention. LH-RHA and oral contraceptive therapy and testosterone have been tested to a limited extent of gonadal toxicity. Usually in male endocrine disfunction of testis does not need to be treated because it is moderate and does not cause any clinical symptoms. In female hormonal substitution seems to be necessary to decrease unpleasant feelings connected with menopause induced by chemotherapy. Further investigations should considered use of new cytotoxic agents without gonadal toxicity or use of new drugs which can better protect gonadal function.

Current management of ruptured corpus luteum

The objectives of the study are to assess current management of the rather frequent event of ruptured corpus luteum. Special emphasis is made on the value of ultrasonography, laparoscopy and culdocentesis in deciding appropriate treatment. A series of 70 patients with ruptured corpus luteum diagnosed and treated during a period of 6 years in one institution in Israel is reported. Eighteen patients with concurrent ruptured corpus luteum and ectopic pregnancy are included. Abdominal pain, the most prevalent presenting symptom, has no typical characteristics. The correlation between large amount of fluid as observed by ultrasound and the finding of > 250 ml of blood at laparotomy is very high. Culdocentesis was performed in only 21 patients. Surgical intervention (laparoscopy, laparotomy following laparoscopy or direct laparotomy) was carried out in 58 patients (83%). The remaining 12 cases were handled by observation only. Forty patients required laparotomy in whom 17 underwent wedge resection. We conclude that observation is sufficient treatment in hemodynamically stable patients, without severe abdominal pain and in the presence of a small amount of pelvic fluid demonstrated by ultrasound. When a large amount of fluid is observed and/or in the presence of severe abdominal pain laparoscopy should be performed on admission. Direct laparotomy is mandatory in case of circulatory collapse.

[Ovarian actinomycosis]

The authors describe a case of ovarian actinomycosis in a 50-year-old female. The initial signs of adnexitis were followed by tumor signs. The treatment included surgery and specific immunotherapy.

[Virilization in women. Clinical and therapeutic aspects]

Androgenization in women can be divided, from a clinical standpoint, in two groups: a major form (with hirsutism, seborrhea, acne, hair loss, menstrual irregularities, masculinization of muscles and voice, mammary atrophy) and a minor one, with skin changes only (in particular hirsutism) with or without menstrual problems. The different clinical presentations are reviewed here: virilizing tumours of adrenal glands and ovaries, adrenogenital congenital syndromes, Cushing's syndrome and disease, iatrogenic forms, simple or idiopathic hirsutism, late onset enzymatic defects of adrenal steroidogenesis, polycystic ovary syndrome). The relevant therapeutic options are discussed. Special attention is devoted to the treatment of simple cutaneous androgenization, a problem affecting about 10% of women, by antiandrogenic drugs, mostly cyproterone acetate and spironolactone. These compounds compete with dehydrotestosterone for androgen cutaneous receptors, and have obtained good results, although not permanent. The indications, use and side-effects are also discussed.

[The current treatment of genital endometriosis]

Three therapeutic strategies are available in treating genital endometriosis (GE): medical treatment only, surgical treatment only and a combination of both, i.e. medical and surgical treatment. The author reviews the combined approach to different forms of GE, namely: cervical, ovarian, tubal, adenomyosis, retrocervical, vaginal and perineal. The common problems in decision making are: the age of the patient and her reproductive function, the localization, spread and stage of the lesion, the possible coexisting inflammatory process and its sequellae, the endometrial hyperplasia and the destructive changes of the uterus and ovaries. Hormonal drugs of choice are the anti-gonadotropin danazol and the GnRH analogues. Introduction of argon, CO2 and YAG lasers proved effective in treating certain forms of GE. Therapy results depend on the severity and spread of the process, on resection volume and completeness, on full scale hormonal therapy as well as on rehabilitation. Close follow-up, including ultrasound examination every 3 months, should be provided for immediate detection of possible side effects and complications.

Percutaneous catheter drainage of tubo-ovarian abscesses

We present the successful treatment of tubo-ovarian abscesses in three young patients by continuous percutaneous drainage, inserted under the guidance of real-time ultrasonography using only local anesthesia. Each patient had been diagnosed laparoscopically as suffering from acute pelvic inflammatory disease, but had formed abscesses despite extensive broad-spectrum antibiotic therapy. One case involved a complication of the ovum pick-up procedure; the woman had tubo-ovarian abscesses with infected hematomas. Because the abscesses were localized anteriorly in the lower abdomen and did not reach the pouch of Douglas, they could not be drained through a posterior colpotomy. Ultrasound guidance allowed us to drain all the areas of the multioculated abscesses. We suggest that percutaneous abscess drainage be the initial treatment of choice for tubo-ovarian abscesses before laparotomy is considered.

[Actinomycosis of the ovary as a cause of cachexia in a young patient]

The authors describe the case of a 40-year-old female patient treated for prolonged periods unsuccessfully with several antibiotics on account of a febrile condition of obscure aetiology and subsequently repeatedly subjected to laparotomy on account of intra-abdominal abscesses. The cause of the fever, abdominal pain and gradual cachectization was an abdominal form of actinomycosis. After establishment of the diagnosis the patient was successfully treated by long-term penicillin administration and recovered completely. The authors discuss experience reported in the literature and therapeutic possibilities in actinomycosis.

Ovarian actinomycosis presenting as acute peritonitis

A patient with acute peritonitis due to ovarian actinomycosis and the association of this disease with the intrauterine contraceptive device is discussed. Because adequate treatment requires prolonged antibiotics the diagnosis should be sure. Unfortunately if antibiotics are given pre-operatively culture is usually unsuccessful and thus careful examination of all removed material is essential. As many of these women are of child bearing age surgical intervention should aim to preserve fertility wherever possible.

Percutaneous drainage of tubo-ovarian abscesses

The authors performed percutaneous drainage of 27 tubo-ovarian abscesses (TOAs) in 16 patients in whom medical therapy with triple antibiotics prior to catheter drainage had not been successful. Percutaneous drainage was successful in 15 of 16 patients (94%). One patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy 3 days after catheter placement because of persistent symptoms and lack of drainage from the catheter; at laparotomy, a large infected phlegmon was found. Two patients had recurrent disease at 3 and 4 months after catheter placement. Bilateral salpingectomy was performed in one patient and total abdominal hysterectomy and bilateral salpingo-oophorectomy in the other. One of these patients had cervical carcinoma, and the other had a long history of recurrent pelvic inflammatory disease and TOAs. The long-term avoidance of surgery was 81.2%. Access routes for catheter drainage were through the anterior abdominal wall for 10 abscesses, through the posterior transgluteal route for 11, and through the transvaginal route for six. Duration of drainage was 1-20 days (mean, 6 days). Complications consisted of transient sciatic pain in two patients and mild bacteremia in one. The results indicate that percutaneous drainage of TOAs is effective in patients in whom medical therapy is not successful.

Pelvic abscess complicating transcervical embryo transfer

A severe pelvic infection resulting in a tuboovarian abscess after transcervical embryo transfer is reported. The case is unique in that the recipient was an agonadal woman who had not undergone prior transvaginal aspiration. Although rare, pelvic infection after embryo transfer may occur in spite of normal precautions.

Ovarian abscess arising within an endometrioma

Ovarian abscess is a rare gynecologic entity; only 120 cases have been reported in the world literature. In contrast to the more commonly encountered tubo-ovarian abscess, tubal involvement is absent in the ovarian abscess. This report describes a case of an ovarian abscess arising de novo within an endometrioma. The woman presented with a 20-cm pelvic-abdominal mass with paracaval adenopathy and bilateral ureteral obstruction. Treatment with broad-spectrum antibiotics was unsuccessful. The surgical specimen revealed endometrial glands, stroma, hemosiderin-laden macrophages, and evidence of abscess formation.

US-guided transvaginal drainage of pelvic abscesses and fluid collections

Ultrasound (US)-guided transvaginal needle or catheter drainage was performed in 14 women for a variety of pelvic abscesses and fluid collections; tubo-ovarian abscesses and postoperative collections were most common. Diagnosis was achieved in all 14 patients (100%), including one patient with suspected ovarian carcinoma who underwent only diagnostic needle aspiration and no therapeutic drainage. Abscesses or fluid collections were evacuated in 13 of 13 patients (100%) with either needle (n = 7) or catheter (n = 6) drainage (with appropriate antibiotics). Twelve of the 14 patients (86%) were spared an operation; surgery was undertaken in two patients for a persistent tubo-ovarian phlegmon. No major complications were associated with drainage. Catheters were removed an average of 6.7 days after insertion. The success, safety, and advantages of US-guided transvaginal drainage in our early experience suggest its use as an alternative to standard percutaneous catheter procedures to diagnose and drain certain pelvic abscesses and fluid collections.

Incidence of ovarian dysfunction in post partum dairy cows and the effectiveness of its clinical diagnosis and treatment

Ovarian function was assessed from milk progesterone profiles in 236 cows that were presented for clinical examination after parturition and in 227 unexamined herdmates. By 30 days after calving, 81 per cent of the cows had ovulated and by 42 days 92 per cent had resumed cycling. On average milk samples were taken for 155 days, and during this period 67 luteal cysts or cystic corpora lutea and 24 follicular cysts were recorded, and 88 cows were anoestrus for more than 30 days. Luteal cysts, follicular cysts and prolonged anoestrus all occurred twice as frequently in the cows which were clinically examined as in those which were not examined. Progesterone profiles indicated that at the time of clinical examination 72.4 per cent of the cows examined were cycling normally, 11.3 per cent were anoestrus, 6.7 per cent had follicular cysts, 8.0 per cent had luteal cysts and 1.6 per cent were pregnant. Rectal palpation correctly identified ovarian function in only 63.5 per cent of examinations, with 29.8 per cent of cows that were cycling normally, 58.1 per cent that were anoestrus, 70.3 per cent with follicular cysts and 25 per cent with luteal cysts being incorrectly diagnosed. Progesterone profiles confirmed normal oestrous cyclicity in 81.9 per cent of these cows diagnosed as cycling normally by the clinician. The clinical treatments administered included prostaglandin, gonadotrophin-releasing hormone (GnRH), progesterone (PRID) and the physical expression of ovarian structures. Cows diagnosed as cycling normally were left untreated. At the time of treatment, 28.8 per cent of prostaglandin-treated cows had low progesterone concentrations indicating that no luteal tissue was present.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidental hyperstimulation during ovulation induction

Clinical hyperstimulation is the most serious complication of ovulation induction, occurring in approximately 3% of cases (0.8% in the severe form). Paradoxically, it seems to be rare following in vitro fertilization, probably because all the follicles are aspirated. High-risk patients are those with polycystic ovarian disease, hyperprolactinaemia and hypothyroidism. All forms of ovulation induction have been implicated. Use of LHRH agonists have not reduced the incidence of hyperstimulation and they may even have increased it. An ongoing pregnancy seems to predispose to the occurrence of hyperstimulation, due to the secretion of hCG. Clinically, three stages of hyperstimulation have been described by the WHO (mild, moderate and severe). The pathophysiology is not completely understood, although prostaglandins, histamines and, especially, the ovarian renin-angiotensin system may be involved. Local ovarian complications and thromboembolic complications have also occurred. The treatment of severe hyperstimulation is both symptomatic (fluid replacement, aspiration of effusions, moderate sodium and water restriction, small doses of diuretics) and specific (corticosteroids, aspiration of ovarian cysts, even voluntary interruption of pregnancy in the most serious forms). If the hyperstimulation occurs in the absence of pregnancy, antihistamines or antiprostaglandins can be given. Prevention is exceedingly important. This can be helped by recognition of polycystic ovarian disease and stimulation of these cases by clomiphene citrate or pure FSH associated, for use in in vitro fertilization, with prolonged desensitization using LHRH agonists. Daily ultrasound and hormonal monitoring of ovulation induction is required. When there is excessive response to stimulation, it is prudent not to induce ovulation with hCG or, alternatively, to aspirate all the follicles and freeze the embryos obtained without giving further injections of hCG in the luteal phase. Clinical ovarian hyperstimulation is the classic form of iatrogenic disorder and is the most important complication of ovulation induction treatments, since it can be life-threatening in its most severe form. In this chapter we review current knowledge concerning the frequency, factors associated with its occurrence, clinical aspects, physiopathological mechanisms and, finally, the possibilities for treatment and prevention.

Ultrasonically guided vaginal aspiration of ascites in the treatment of severe ovarian hyperstimulation syndrome

This study included 11 cases of severe OHSS that were treated by transvaginal aspiration of the ascitic fluid guided by ultrasound. Immediate improvement of the symptoms and general condition as well as a significantly shorter hospital stay was noticed when compared with the control group. It is a safe and simple procedure that does not require anesthesia.

Transvaginal ultrasound in the diagnosis and treatment of tubo-ovarian abscess

Transvaginal ultrasound showed tubo-ovarian abscess in 10 patients admitted for acute pelvic inflammatory disease, and transvaginal ultrasound-guided aspiration of tubo-ovarian abscess was performed under antimicrobial treatment. Only light sedation was required and the procedure was well tolerated by the patients. The short-term recovery of all patients was quick and uncomplicated. This new technique is a useful alternative for the diagnosis and treatment of tubo-ovarian abscess.

Abdominal paracentesis for the ovarian hyperstimulation syndrome with severe pulmonary compromise

Abdominal paracentesis is a well-tolerated therapeutic alternative to relieve the severe pulmonary compromise caused by severe ascites and pleural effusion in the ovarian hyperstimulation syndrome. An improvement in renal function may be another benefit that deserves further investigation.

Ovarian antibodies detected by immobilized antigen immunoassay in patients with premature ovarian failure

An enzyme-linked immunosorbent assay (ELISA) was used to detect ovarian and oocyte antibodies in serum from 45 patients with premature ovarian failure (POF). Control sera were obtained from a similar group of normally cycling women without POF. A specific antibody reaction was found when POF sera were tested against human ovary (47%) or oocytes (47%). A combined total of 69% of the sera were positive for either ovary or oocytes. Fewer sera were positive for antibodies against human thyroid (18%) or human placenta (22%), and virtually no reaction with human liver (4%) was seen. LH antibodies were detected by ELISA against LH in only 3 POF sera that also contained ovarian antibodies. Therefore, gonadotropin antibodies alone do not appear to account for POF. In addition, 2 patients were treated by immunosuppression and became pregnant coincident with a decline in the serum concentration of ovarian antibodies. In summary, the results of this study are consistent with previous immunohistochemical data which indicate that ovarian and oocyte antibodies are common in patients with POF. This supports the concept that some forms of POF are associated with an autoimmune process. Furthermore, detection of ovarian and oocyte antibodies by ELISA may permit routine diagnosis of autoimmune POF and provide a basis for therapy.

Ovarian hyperstimulation: diagnosis and therapy

The administration of exogenous gonadotropins to induce ovulation is often associated with ovarian hyperstimulation syndrome. The authors discussed the pathophysiological mechanisms involved in such syndrome to suggest a treatment of choice. Moreover the authors reported their related clinical experience carried out on 9 patients suffering from such syndrome. All the patients studied improved 6-19 days after admission and start of treatment (mean 9.5 +/- 4.7 days). The patients were free from pain and general disorders at discharge and at follow up echographic examination revealed a significant reduction in the volume of the ovary.

Pregnancy in women with premature ovarian failure using tubal and intrauterine transfer of cryopreserved zygotes

Twenty-nine women, mean age 36.3 (SD 5.5) years, with premature ovarian failure received donated ova on an ovum donation programme. Three had Turner's syndrome, four a surgical menopause, one a chemotherapy-induced menopause and 21 had idiopathic premature ovarian failure. All donated oocytes were fertilized with frozen-thawed spermatozoa from the recipient's partner, and the resulting zygotes were frozen until transfer had been arranged. Overall, 19 women had intrauterine embryo transfer (ET) and a mean of 2.7 (SD 0.9) embryos were transferred on 20 occasions; 10 women underwent zygote intrafallopian transfer (ZIFT) and a mean of 3.5 (SD 0.5) zygotes were transferred on 10 occasions. Both groups were matched for age. The pregnancy rate per transfer was 20% in the ET group and 40% in the ZIFT group. After excluding the 10 women in the ET group who had fewer than three embryos transferred, the pregnancy rates were similar in the two groups, 30% in the ET group and 40% in the ZIFT group. Cryopreserved embryos may be used for ovum donation to preserve anonymity and still show a high pregnancy rate of at least 30% per transfer.

Return of fertility after twelve years of autoimmune ovarian failure

Autoimmune ovarian failure is widely regarded as irreversible, although ovarian biopsy characteristically shows follicles surrounded by lymphocytes. Two previous reports of pregnancy in this condition both followed institution of steroid replacement therapy (Finer et al., 1985; Cowchock et al., 1988). We report a case in which fertility spontaneously returned to normal twelve years after the diagnosis of autoimmune ovarian failure.

Severe ovarian hyperstimulation syndrome: a reevaluated therapeutic approach

During the 10 years 1978 to 1987, 33 patients were hospitalized because of moderate and severe ovarian hyperstimulation syndrome (OHSS) in 39 treatment cycles. Twenty-five treatment cycles ended in moderate OHSS (group A), 7 had severe OHSS without a significant amount of ascites (group B1), and 7 had severe OHSS with ascites (group B2). Groups A and B1 received intravascular volume expander, electrolytes replacement, and indomethacin up to 300 mg/day. The patients in group B2 had significant clinical and biochemical improvement after abdominal paracentesis. Urinary output and creatinine clearance improved significantly, and a decrease in hematocrit, blood osmolarity, and weight reduction were achieved. A strategy for treatment of OHSS based on consecutive ultrasonographic examination, clinical and biochemical evaluation, and abdominal paracentesis in severe OHSS with clinically significant ascites is suggested.

Endometrial morphology in stimulated in vitro fertilization cycles and after steroid replacement therapy in cases of primary ovarian failure

Endometrial morphology and ultrastructure are studied in 17 spontaneous, 23 stimulated, and 18 artificial cycles in cases of primary ovarian failure. Normal light-microscopic aspect was found, but impaired development of nucleolar channel system and stronger intercellular junction have been observed by electron-microscopic studies in stimulated cycles with relative excess of luteal estrogen. Normal glandular maturation can be obtained in patients with premature menopause, given adequate steroid replacement, but an abnormally dense fibrocytic aspect of the stroma is characteristic of the first treatment cycles.

Management of common gynecologic problems encountered during abdominal exploration

Although general surgeons receive little training in the management of gynecologic conditions, they should be able to make intraoperative decisions about unexpected gynecologic abnormalities encountered during abdominal exploration. This report examines the six most common gynecologic problems found during abdominal exploration (salpingitis, tubo-ovarian abscess, ectopic gestation, endometriosis, uterine mass, and ovarian mass) and reviews their proper management with particular emphasis on conserving reproductive function.

Emergency treatment of adnexal masses in a nonpregnant woman

Both benign and malignant adnexal masses can present as an emergency. Differential diagnosis, as well as practical clinical maneuvers to differentiate the two, and initial treatment are discussed in this article.

Tubo-ovarian abscess: pathogenesis and management

That a female patient with abdominal pain is often considered to have pelvic inflammatory disease until proven otherwise is ubiquitous in the medical literature. This view is dangerous and should be challenged because it has resulted in episodes of ruptured appendix, death from ruptured ectopic pregnancies, and serious morbidity from delayed diagnoses of such entities as diverticulitis and endometriosis. Proper diagnostic steps should be taken for all patients with abdominal pain of unclear etiology.This article reviews the pathogenesis of tubo-ovarian abscesses so as to separate and clearly identify fact from fiction. Diagnostic steps and management guidelines are discussed.

Current trends in the diagnosis and treatment of tuboovarian abscess

Tuboovarian abscess is a well-recognized complication of acute salpingitis and has been reported in as many as one third of hospital admissions for acute salpingitis. The incidence of tuboovarian abscess is expected to increase as a result of the current epidemic of sexually transmitted diseases and their sequelae. Patients with tuboovarian abscess most commonly present with lower abdominal pain and an adnexal mass(es). Fever and leukocytosis may be absent. Ultrasound, computed tomographic scans, laparoscopy, or laparotomy may be necessary to confirm the diagnosis. Tuboovarian abscess may be unilateral or bilateral regardless of intrauterine contraceptive device usage. Tuboovarian abscess is polymicrobial with a preponderance of anaerobic organisms. An initial conservative antimicrobial approach to the management of the unruptured tuboovarian abscess is appropriate if the antimicrobial agents used can penetrate abscesses, remain active within the abscess environment, and are active against the major pathogens in tuboovarian abscess, including the resistant gram-negative anaerobes such as Bacteroides fragilis and Bacteroides bivius. However, if the patient does not begin to show a response within a reasonable amount of time, about 48 to 72 hours, surgical intervention should be undertaken. Suspicion of rupture should remain an indication for immediate operation. Once operation is undertaken, a conservative approach with unilateral adnexectomy for one-side tuboovarian abscess is appropriate if future fertility or hormone production is desired.

[Ovarian hyperstimulation: treatment of voluminous cysts by percelioscopic puncture]

Enlarged fluid-filled cysts are a complication encountered with ovarian overstimulation. In order to hasten their resolution, and to avoid the possibility of adnexal torsion, we drained cysts greater than 4 cm in diameter by laparoscopic puncture.

[Hyperprolactinemic ovarian insufficiency]

About 20% of all menstrual cycle disorders are due to a hyperprolactinemia. Although changes in the bony area of the sella indicating intrasellar space-requiring processes have been found in only 30% of these women presenting hyperprolactinemic ovarian insufficiency, an adenoma of the pituitary gland is probably also responsible for the hyperprolactinemia observed in the rest of the cases. Treatment is however not strictly necessary, as long as there are no other endocrine dysfunctions, and a pregnancy is not desired. Side-effects of a therapy of dopamine agonists can be diminished by a gradually increasing dosage.

Management of endocrine disorders in pregnancy. Part II. Pituitary, ovarian and adrenal disease

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