Recurrent spontaneous ovarian hyperstimulation syndrome associated with polycystic ovary syndrome

Ovarian hyperstimulation syndrome (OHSS) is the most serious potentially life-threatening iatrogenic complication of ovulation induction. Presented here is the first reported case of recurrent severe OHSS which developed spontaneously in a women with polycystic ovary syndrome, diagnosed early in her second pregnancy, and necessitated intensive fluid and colloid therapy.

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.

The role of sonography in the detection of vaginal foreign bodies in young girls: the bladder indentation sign

The cases of four young girls with vaginal foreign bodies, successfully diagnosed by ultrasound, are presented. The sonographic signs include varying echogenicity and acoustic shadowing, but always an indentation of the posterior bladder wall was clearly observed. Sonography should be considered as the first step in the evaluation of suspected vaginal foreign bodies in young girls.

Adnexal torsion: the contribution of color Doppler sonography to diagnosis and post-operative follow-up

Ovarian torsion is often difficult to diagnose due to non-specific clinical and clinical and ultrasonographic findings. We demonstrated the use of color Doppler for the early diagnosis of ovarian torsion and for post-operative follow-up until the normalization of the preserved ovary was confirmed by subsequent viable pregnancy. Color Doppler flow assessment can be useful as both a diagnostic tool and for evaluating the recovery of the affected ovary after conservative surgical treatment.

Malignant germ cell tumors of the ovary: a study of 20 cases

In a study of 20 patients diagnosed with malignant ovarian germ cell tumors between 1961 and 1993, clinical and pathologic findings were evaluated. Of the 20 patients, seven (35%) had dysgerminoma, two (10%) endodermal sinus tumor, three (15%) malignant teratoma, one (5%) malignant struma ovarii, one (5%) primary ovarian carcinoid, two (10%) benign teratoma with malignant transformation, and four (20%) combination germ cell tumor. Twelve patients (60%) had stage IA, five (25%) stage IC, and three (15%) stage IIIC. Twelve patients (60%) underwent conservative surgery and eight (40%) had at least bilateral salpingo-oophorectomy. At follow-up, 18 patients (90%) were alive free of disease, one (5%) had died of disease, and one (5%) had died of intercurrent disease. The actuarial 5-year survival rate was 93.3%. It is concluded that for young women who wish to preserve child-bearing capacity, regardless of the stage of the tumor, fertility-preserving surgery with complete surgical staging followed, if necessary by cisplatin-based combination chemotherapy is an appropriate and definitive treatment in the absence of involvement of the contralateral ovary and uterus. For patients in whom child-bearing capacity is not an issue, surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy with complete staging, followed if necessary by chemotherapy.

Pregnancy order. A factor influencing birth weight in twin gestations

To test the hypothesis that increased twin birth weight is expected with increased parity, we conducted a retrospective, cross-sectional evaluation of 430 twins, focusing on birth weight and growth discordance parameters in five parity groups (para 1-4 and > or = 5). The mean birth weight of twin A, B and both twins was significantly lower in primiparous patients as compared to para 2-4 but not as compared to para > or = 5 patients. The frequency of twins weighing < 1,500 g was similar in all groups, but a significantly higher frequency of twins weighing 1,500-2,500 g and lower frequency at > 2,500-g twins were found in the para 1 group as compared to the groups with higher parities. Presentation combinations were not different in the five parity groups, nor were the frequencies of growth discordance categories. However, discordants among pairs, with each infant weighing < 2,500 g, occurred almost twice as often in para > or = 5 as compared to the other parity groups. Our data indicate that primiparae seem to have significantly smaller twins as compared to multiparae. This trend was independent of the presentation combinations and growth discordance pattern and seems to result from a higher frequency of twins weighing 1,500-2,500 g in primiparae.

Ovarian volume in postmenopausal women--suggestions to an ovarian size nomogram for menopausal age

BACKGROUND

Transvaginal ultrasonography is an accurate and reliable technique for measuring ovarian size. However, there is no consensus as to the normal ovarian size in post-menopausal women. The purpose of this study was to establish normal values for ovarian volume in postmenopausal age.

METHODS

A prospective study was undertaken, in which the ovaries of 311 healthy post-menopausal women were examined by transvaginal ultrasonography. Menopausal age ranged from one to more than 15 years. Three dimensions of each ovary were measured and ovarian volume of every menopausal year was calculated.

RESULTS

Curvilinear relationships were found between ovarian volume and menopausal age. Ovarian volume (as plotted on the nomogram) shows a progessive decrease from 8.6 +/- 2.3 cm3 in the first menopausal year, to 2.2 +/- 1.4 cm3 after more than 15 years after the menopause.

CONCLUSIONS

These data represent a comprehensive characterization of normal ovarian volumes related to postmenopausal age. These baseline values provide the data which will assist the physician to obtain the sonographic diagnosis of abnormal ovarian size, thus eventually establishing early diagnosis of ovarian tumors.

Current concepts in management of epithelial ovarian tumors of low malignant potential

Approximately 15 percent of epithelial ovarian tumors are tumors of LMP. Epithelial stratification, cellular atypia, mitotic activity, and abscence of ovarian stromal invasion set the histopathological criteria for diagnosis. Serous and mucinous tumors of LMP represent 80 to 95% of all cases. These tumors occur in patients at a younger age than those with invasive cancer and many times in fertile women who have not accomplished their family planning yet. Ovarian tumors of low malignant potential carry a favorable prognosis in comparison to invasive epithelial ovarian cancer. The recurrence rate after surgery for these tumors ranges from 10 percent to 30 percent, occurring as late as 10 or more years after presentation. The majority of patients (80-92 percent) with ovarian tumors of LMP present with stage I disease. Peritoneal implants display a range of histologic appearances, ranging from benign glands to those with features of invasive disease. Tumor markers such as CA-125 are not as useful in tumors of LMP as in invasive ovarian carcinoma. Elevated CA-125 are found only in patients with advanced serous tumors of LMP; thus, other markers such as transvaginal Doppler measurements of vascular resistant index has been suggested for possible differentiation between a benign and LMP ovarian tumors before surgery. Primary conservative surgery consisting of unilateral salpingo-oophorectomy is considered to be an appropriate treatment for young women with stage Ia ovarian tumors of LMP who wish to retain their fertility potential. Up to 70 percent of women who underwent conservative surgery subsequently conceive.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective randomized clinical trial comparing a new oral sustained-release ritodrine with conventional tablets

OBJECTIVES

Evaluation of maternal metabolic and cardiovascular responses to treatment with the new sustained-release oral ritodrine as compared with the conventional tablets.

METHOD

Thirty-two pregnant patients who had successful intravenous tocolysis were randomly assigned to treatment with either ritodrine tablets or sustained-release capsules. After 5 days of the randomly determined first oral treatment each patient was shifted to the alternate ritodrine formulation for a further 5-day course. Each patient underwent metabolic and non-invasive hemodynamic evaluation.

RESULTS

Echocardiographic parameters during treatment with ritodrine tablets were not significantly different from during sustained-release capsules. Mean systolic blood pressure increased significantly during peak drug activity in patients treated with ritodrine tablets and not during treatment with the sustained-release form. Fasting plasma glucose levels were higher in patients on conventional tablets therapy than in patients on sustained-release ritodrine therapy (88.9 +/- 9 mg/dl vs. 78.7 +/- 8 mg/dl, P < 0.05) while levels following a 50-g oral glucose challenge test did not differ significantly (135 +/- 32 mg/dl vs. 124.5 +/- 27 mg/dl)

CONCLUSIONS

Because of fewer metabolic and cardiovascular side-effects, the new oral therapy offers some advantages over the presently available tablets.

Single fetal demise in twin gestation resulting in the resolution of severe pre-eclampsia

A primigravida presenting with a twin pregnancy and severe pre-eclampsia which developed during early pregnancy is described. Complete resolution of symptoms and signs of pre-eclampsia were evident following the death of a growth-retarded single fetus. Pregnancy continued successfully until 35 weeks of gestation, when a single healthy infant was delivered. Few such cases of complete resolution of pre-eclampsia following the death of a single fetus are reported in the literature. The possibility that genetic susceptibility to pre-eclampsia is conferred by homozygosity for the same single recessive gene expressed by both mother and fetus is discussed.

Expectant management of interstitial pregnancy

A case of interstitial pregnancy is described. Transvaginal ultrasound examination, performed at 8 weeks' gestation, revealed an empty endometrial cavity with an eccentric gestational sac in the left uterine corner, with a clear separation between the uterine cavity (endometrium) and the gestational sac. Expectant management, consisting of repeated sonographic examinations and assessment of serum beta-human chorionic gonadotropin, resulted in a favorable outcome.

Successful resolution of persistent trophoblastic disease after partial mole with the EMA-CO regimen

A 29-year-old nullipara with partial hydatidiform mole at 8 weeks had pre-evacuation hCG levels of 275,000 mIU/ml. Free beta-hCG levels were measured as 3% (normal value below 4%). The patient developed persistent gestational trophoblastic disease, failed to respond to methotrexate and actinomycin D, but has responded to combination chemotherapy with EMA-CO. Such a response to EMA-CO was not reported previously.

Induction of follicular growth and production of a normal hormonal milieu in spite of using a constant low dose of luteinizing hormone in women with hypogonadotrophic hypogonadism

This study was designed to examine ovarian performance, i.e. follicular growth, normal steroidogenesis and luteal phase function, following the administration of multiple increasing doses of human follicle stimulating hormone (FSH) with a constant low dose of luteinizing hormone (LH) in women with isolated hypogonadotrophic hypogonadism. Human menopausal gonadotrophin (HMG) was used in the first treatment cycle, starting with 150 IU of LH and 150 IU of FSH per day, for 7 days. The dose was increased daily with 75 IU of LH and 75 IU of FSH for another 7 days if no response was detected by serial ultrasound measurements and serum oestradiol determinations. In the second treatment cycle, a constant dose of 75 IU of LH (using HMG) was administered per day and up to 150 IU of FSH (using urofollitrophin) was supplemented. If no response was detected after 7 days of treatment, the dose of FSH was increased. For the final stage of ovulation induction, human chorionic gonadotrophin (HCG) was administered in the presence of at least one follicle > 17 mm in diameter but with no more than three follicles > 16 mm in diameter. To verify the adequacy of the luteal phase, a pharmacokinetic/pharmacodynamic study of beta-HCG, oestradiol and progesterone was performed following the second treatment cycle only. Ovarian stimulation using a constant dose of 75 IU of LH and increasing doses of FSH up to 225 IU, resulted in normal follicular growth and hormonal milieu. Both women showed normal luteal phase oestradiol and progesterone production and both women conceived following the second treatment cycle.

The role of cordocentesis in assessment of mosaicism found in amniotic fluid cell culture

Chromosomal mosaicism presents one of the most difficult problems in prenatal cytogenetic diagnosis, requiring the differentiation of true mosaicism from pseudomosaicism. To overcome associated problems and to prevent termination of normal pregnancies, we investigated 23 pregnancies in which true mosaicism has been found in amniotic fluid cell culture. A fetal blood sample was obtained by cordocentesis for rapid karyotyping, and meticulous sonographic examinations were carried out for detecting fetal abnormalities. The 23 cases in which mosaicisms were found in amniocytes involved five cases with sex chromosomal abnormalities, twelve with autosomal trisomy, four with autosomal structural defects, one with a supernumerary marker and one with tetraploidy. The karyotype from fetal leukocytes confirmed the diagnosis of mosaicism in only three out of 23 cases. These three included: two autosomal trisomies (47,XY + 13/47,XY + 21 and 46,XY/47,XY + 21) and one sex chromosome mosaicism (45,X/46,XY). These were all selected for elective termination of pregnancies by the parents' request. Post abortion karyotype re-confirmed previous karyotype. The other twenty lymphocyte karyotypes were normal, and of these, 19 patients gave birth at term, and one delivered prematurely due to premature rupture of membranes. All 20 born infants were found normal by both neonatal examination and re-karyotypes. We conclude that finding of mosaicism in amniotic fluid culture requires further investigation. Furthermore, in the presence of amniotic fluid cell true mosaicism and normal karyotype in fetal blood, continuation of the pregnancy is safe and to be recommended.

Endothelin-1,2 levels in umbilical vein serum of intra-uterine growth retarded fetuses as detected by cordocentesis

INTRODUCTION

The objective of this study was to determine whether the circulatory levels of endothelins, potent vasoconstrictor polypeptides produced mainly by endothelial cells, are increased in growth-retarded fetuses.

STUDY DESIGN

Fetal venous serum samples, withdrawn by ultrasound-guided cordocentesis from 11 growth-retarded fetuses and 10 normally-growing fetuses who underwent the procedure because of other unrelated indications, were examined for immunoreactive endothelin-1,2 by radioimmunoassay.

RESULTS

Higher mean endothelin-1,2 levels were found in the sera of growth-retarded fetuses than in controls (16.8 +/- 4.2 versus 10.9 +/- 4.3 fmol/ml, p = 0.008). Within the growth-retarded group, there were no differences in endothelin-1,2 levels in the presence of either abnormal umbilical Doppler, asymmetry of growth-retardation, maternal signs of preeclampsia, or fetal acidosis.

CONCLUSION

High levels of endothelin-1,2 in the fetoplacental circulation may be pathophysiologically important in fetal growth retardation. However, the clinical significance of these elevated levels is yet to be determined.

Declining beta-human chorionic gonadotropin level may provide false security that tubal pregnancy will not rupture

Two patients with declining serum concentrations of beta-human chorionic gonadotropin (beta-hCG) and a ruptured tubal pregnancy with hemoperitoneum are described. Declining beta-hCG does not rule out the possibility that the ectopic pregnancy will rupture.

A comparison of the nonstress test, oxytocin challenge test, Doppler velocimetry and biophysical profile in predicting umbilical vein pH in growth-retarded fetuses

OBJECTIVE

To examine and compare the value of the nonstress test (NST), oxytocin challenge test (OCT), Doppler velocimetry (S/D ratio), and biophysical profile (BPP) in predicting fetal acidosis.

METHOD

NST, OCT, S/D ratio and BPP were performed in 23 pregnancies with growth-retarded fetuses. The value of each parameter in predicting fetal acidosis (umbilical vein pH obtained by cordocentesis) was examined.

RESULT

The NST, OCT and BPP were found to have the same positive predictive value of 57.1% in predicting fetal acidosis. The S/D ratio was found to have a very low positive predictive value (14.3%). The only combination of two parameters that showed improved positive predictive value, was that of OCT and NST (66.7%).

CONCLUSION

(1) The best indirect method in assessing fetal well-being is the combination of NST and OCT. (2) Since the positive predictive value of the indirect methods is still low, direct assessment of the fetal metabolic status is recommended in premature growth-retarded fetuses with an abnormal test.