Hysteroscopy in the evaluation of habitual abortions

OBJECTIVES

To evaluate the incidence of structural uterine anomalies (SUAs) in women with habitual abortion (HA) as diagnosed by means of hysteroscopy and to study hysteroscopy's therapeutic potential with regard to that pathology.

METHODS

Forty-eight women with more than three consecutive pregnancy losses which occurred prior to the 20th week were included and hysteroscopy was performed on all of them.

RESULTS

Twenty-five women (52%) had a normal hysteroscopy. The remaining 23 women (48%) presented SUAs: nine patients (19%) had intrauterine adhesions, four (8%) had submucous myomas, two (4%) had polyps and eight (17%) had congenital structural uterine anomalies (five cases of septate uterus and three of bicornuate uterus). Patients with abnormal hysteroscopy underwent appropriate therapy, when applicable. In the SUA group, 18 patients (78%) achieved a successful pregnancy, and five patients (22%) had another miscarriage. In the normal hysteroscopy group, eight patients (32%) achieved a successful pregnancy without additional treatment, 15 patients (60%) had recurrent miscarriages, and two patients (8%) had persistent secondary infertility.

CONCLUSIONS

SUAs were detected in nearly half of the patients with HA. After appropriate treatment when applicable, 78% of patients with SUAs achieved a successful ongoing pregnancy. Hysteroscopy has much to offer in the diagnosis and treatment of SUAs.

Safety and effectiveness of tinzaparin sodium in the management of recurrent pregnancy loss

PURPOSE

To assess the safety and efficacy of tinzaparin sodium for the management of recurrent pregnancy loss.

METHODS

The study included 62 women with a history of recurrent pregnancy loss and at least one factor of thrombophilic disorder. Of these, 31 received 50 IU/kg of tinzaparin sodium daily (Group A), and 33 received 100 mg of aspirin daily (Group B).

RESULTS

Group A subjects (receiving tinzaparin sodium) had six new abortions, whereas Group B subjects (receiving aspirin) had 11 (significant difference). Cases of intrauterine growth restriction (none in Group A and 2 in Group B), placental abruption (one in Group A and 4 in Group B), and preeclampsia (one in Group A and 3 in Group B) were comparable between the two groups. Finally coagulation disorders (none in Group A and 6 in Group B) were significantly fewer in Group A.

CONCLUSION

A 50 IU/kg daily dose of tinzaparin sodium seems to be effective for the management of recurrent abortion and has high standards of safety.

HLA-G in murine peripheral blood after interruption of pregnancy

HLA-G antigens are highly expressed in maternal peripheral blood during early pregnancy in transgenic mice. In this study, we determined the levels of HLA-G in white blood cells during early pregnancy and after interruption of pregnancy in triple transgenic mice (H-2K(b)/HLA-G, hbeta2m, and hCD2/hCD8-TRI). The pregnancies were interrupted on day 7 using the anti-progesterone agent mifepristone (RU486). Blood samples of 20 pregnant TRI mice were taken and the HLA-G levels were determined on days 2, 4 and 6 of pregnancy and on days 9, 11 and 13 after fertilization. The monoclonal antibody W6/32, specific for monomorphic determinant HLA class I molecules, was used in combination with an immunolocalization method using a photonic microscope. The HLA-G levels increased gradually on days 2, 4 and 6 of pregnancy, and the interruption of pregnancy on day 7 was followed by a decrease of HLA-G levels. The data indicate that pregnancy is characterized by the early presence of HLA-G in maternal peripheral blood in TRI transgenic mice and suggest that HLA-G may serve as a useful indicator for pregnancy maintenance and well-being.

Doppler-ultrasound as a predictor of uterine fibroid response to GnRH therapy

OBJECTIVES

GnRH agonists (GnRHa) are able to reduce the bleeding and size of fibroids. We monitored the response of fibroids to GnRHa with power-Doppler ultrasound.

METHODS

Thirty-five women with fibroids, aged 32-48, received a 6-month course with the GnRHa triptorelin (Decapeptyl, Ipsen, France). The resistance index (RI) of the uterine artery was measured with power-Doppler ultrasound.

RESULTS

The uterine volume reduced from 470+/-347 to 297+/-295 cm3 (P<0.01) at the 6th month of treatment. The fibroid volume reduced after 3 months of treatment from 62+/-81 to 44+/-78 cm3 (P<0.05) and after 6 months of treatment to 30+/-70 cm3 (P<0.001 from baseline). Uterine artery RI increased from 0.73+/-0.16 to 1.05+/-0.27 at the 3rd month of treatment (P<0.001). The percent reduction of fibroid volume at the 6th month correlated with the percent increase of uterine RI at the 3rd month of treatment (r=0.45, P=0.01).

CONCLUSIONS

The administration of triptorelin reduced fibroid dimensions. The increase of the uterine artery resistance index (RI) at the 3rd month correlated with fibroid shrinkage at the 6th month of treatment and may be used to predict the response to this therapeutic maneuver.

Effects of estrogen-progestin and raloxifene therapy on nitric oxide, prostacyclin and endothelin-1 synthesis

This randomized double-blind study was conducted to investigate the effects of 17 beta-estradiol plus norethisterone acetate, and raloxifene, on nitric oxide (NO), prostacyclin (PGI2) and endothelin-1 (ET-1) serum levels in postmenopausal women. Treatment was initiated after a 28-50 day placebo period. Fourteen women were treated daily with 17 beta-estradiol 2 mg plus norethisterone acetate 1 mg (E2 + NETA), and 14 with raloxifene HCl 60 mg for a period of 6 months. Serum NO, PGI2 and ET-1 levels were estimated at baseline, after placebo, and at months 3 and 6. E2 + NETA decreased NO levels significantly, while raloxifene did not cause any appreciable change. Both regimens decreased PGI2 levels and ET-1 levels significantly. Finally, E2 + NETA and raloxifene increased the NO/ET-1 ratio by 61.4% and 81.1%, respectively. In conclusion, both regimens may exert a cardio-protective effect by decreasing ET-1 levels and increasing the NO/ET-1 ratio. In contrast, both regimens had a negative influence on PGI2 levels.

TCRgammadelta + T lymphocytes in unexplained recurrent spontaneous abortions

PROBLEM

It is generally accepted that the immune system and cellular immunity in particular are involved in the mechanisms affecting the outcome of gestation. In order to evaluate a putative role of lymphocytes in the immunological mechanisms of unexplained recurrent spontaneous abortions (URSA), we studied peripheral blood lymphocyte subpopulations in 244 women with URSA and 44 controls.

METHOD OF STUDY

Direct immunofluorescence in whole blood with the appropriate combinations of monoclonal antibodies and flow cytometry was used.

RESULTS

The study showed: a) a statistically significant increase of the mean CD4/CD8 ratio (2.12+/-0.84 vs 1.85+/-0.63, P = 0,039); b) a statistically significant decrease of the mean value of the percentage of CD5+ CD19+ lymphocytes (0.4+/-0.6 vs 1.4+/-0.78, P < 0.0001); and c) a statistically significant increase of the percentage of T lymphocytes expressing TCRgammadelta (4.68+/-3.19 vs 2.61+/-1.14, P < 0.0001). It should be noted that a statistically significant high number of women with URSA (72/195, 36.9%) showed an increased percentage of TCRgammadelta T cells (> or = 5%, where 5 equals the mean value + 2 standard deviations (SD) of the mean value of controls), whereas such a high percentage was not found in any control subject.

CONCLUSIONS

It seems that women who experienced URSA comprise a heterogeneous population, as far as immunological parameters are concerned. At least in a subgroup of them, TCRgammadelta + T cells could be considered to play a role in the immune pathogenesis of fetal loss.

Thyroid autoimmunity in patients with recurrent spontaneous miscarriages

Recurrent spontaneous miscarriage (RSM) is a multifactorial problem. Auto- and alloimmune parameters have been implicated. Antithyroid antibodies (ATA) were tested in a group of women with RSM. The presence of antipaternal antibodies (APCA) was evaluated as an index of alloimmune contribution. Thirty euthyroid women with RSM (three or more consecutive miscarriages) aged 25-37 years were compared with 15 matched controls. Thyroid peroxidase (TPO) and thyroglobulin antibodies were tested with a chemiluminescence immunoassay and APCA were tested with a cross-match reaction. Results were compared using the chi-squared test. There was a higher frequency of ATA in women with RSM compared to controls (37% versus 13%, p < 0.05). Twenty of the women (67%) with RSM were tested negative for APCA, indicating an alloimmune contribution to their infertility. In this subgroup of women, the frequency of ATA continued to be higher than controls (40% versus 13%, p < 0.05). In conclusion, women with RSM, independent of APCA status, have a higher frequency of ATA. This may represent an additional marker for impaired regulation of the maternal immune system.

Oocyte morphology correlates with embryo quality and pregnancy rate after intracytoplasmic sperm injection

OBJECTIVE

To evaluate the relation of oocyte morphology with embryo quality and pregnancy rates (PRs) after intracytoplasmic sperm injection (ICSI).

DESIGN

Retrospective study of patients undergoing ICSI.

SETTING

University Hospital IVF Center.

PATIENT(S)

Sixty-eight patients who underwent ICSI and had transfer of good-quality embryos (grade 3), 60 patients with transfer of both good- and poor-quality embryos (grade 3 and grade 2), and 18 patients with transfer of poor-quality embryos (grade 2).

INTERVENTION(S)

Comparison of the outcome of ICSI in the three groups of patients and the relation of oocyte morphology to embryo quality.

MAIN OUTCOME MEASURE(S)

Oocyte morphology and embryo quality (grade). Fertilization, cleavage, and pregnancy rates. Serum E2 on the day of hCG administration.

RESULT(S)

Oocytes with poor morphology (dark cytoplasm; many vacuoles or fragments in cytoplasm) led to poor-quality embryos and consequently to lower PRs (5.5% versus 29.4%). Serum E2 on the day of hCG administration was significantly higher in the group with good-quality embryos compared with that with poor-quality embryos (2,047 +/- 135.7 versus 1,651 +/- 164.8 pg/mL, respectively).

CONCLUSION(S)

Serum E2 on the day of hCG administration is a marker of embryo quality. Oocyte morphology correlates well with embryo quality and PRs after ICSI.

Use of Marlex mesh in the repair of recurrent incisional hernia

Recurrent incisional hernia remains a major problem for the general surgeon. The rate of recurrence of hernia repaired by primary closure using nylon sutures or with knitted monofilament polypropylene (Marlex) mesh was studied. A total of 102 repairs were performed over a 19-year period. Marlex mesh was used in 49 cases and primary closure in 53. All except two patients were followed from 1 to 15 (mean 7.6) years or to death. The incidence of recurrence was 8 per cent when Marlex was used and 25 per cent after primary closure. In both groups the majority of the recurrences were in the first 16 months after repair. The use of Marlex mesh should be considered in the management of recurrent incisional hernia.

Surgical management of primary retroperitoneal liposarcomas

During a 21-year period (1970-1991), 7 patients with primary retroperitoneal liposarcomas were treated surgically in our department. All the tumours were excised completely, and in 2 patients an additional nephrectomy was performed. Postoperatively 4 patients had adjuvant radiotherapy. Two other patients received adjuvant chemotherapy. Both of them had to be reoperated, because of a local recurrence 12 and 9 months after their first operation. There was one death on the first postoperative day, and 4 patients died 1 1/2-2 years after the initial operation. Two patients are still alive 34 and 22 months after their first operation with recurrent disease. Adjuvant therapy proved to be ineffective on the survival of our patients. The prognosis of retroperitoneal liposarcomas continues to be poor and the primary treatment has to be aggressive with complete resection of the tumor.

Fetal tachycardia and meconium staining: a sign of fetal infection

A retrospective study was carried out on 72 liveborn babies in whom perinatal infection was suspected. Twenty-nine of the 72 neonates were effectively infected. Analysis of intrapartum FHR recordings showed that tachycardia (base line FHR above 160 beats/min) during labor, occurred more often among infected babies (P less than 0.001). When fetal tachycardia is associated with meconium stained amniotic fluid (MSAF), the relative risk of fetal infection is 51 times as great as in babies without MSAF. Fetal tachycardia is not related to maternal fever nor to prematurity. It is not a sign of limited placental or amniotic fluid infection, but implies infection of the fetus itself. Since most infected babies displayed infectious diarrhea immediately at birth, it is suggested that MSAF may eventually be due to antenatal intestinal infection and intrauterine emission of infected stools. Although great caution is advocated for the management of labor in the presence of fetal tachycardia, MSAF should not be always regarded as a sign of acute fetal distress when antenatal infection of the fetus is suspected.