Coagulation Status in Women with a History of Missed Abortion

The purpose of this study assess the status of coagulation function in a large series of reproductive-age women with a history of missed abortion in China. Likewise, we want to explore the association between coagulation and missed abortions, in order to evaluate whether they could be used as early predictive factors for missed abortions. A total of 11,182 women who suffered from missed abortion from Peking University Third Hospital and 5298 healthy age-matched reproductive-age women were enrolled in our study. Coagulation function tests (prothrombin time, activated partial thromboplastin time), fibrinolysis status detection (fibrinogen, D-Dimer), anticoagulation function tests (protein C, protein S and antithrombin III), and lupus anticoagulants (LAC) were examined. In addition, platelet counts were detected by automated hematology analyzer. Platelet aggregation (PAgT) was tested by light transmission aggregometry (LTA). Compared with healthy reproductive-age women, the level of D-Dimer, dRVVT-R, PC, PAgT, and platelet count was higher, and the antithrombin III (AT-III) activity was lower in women with a history of missed abortion. (P < 0.05). A total of 13.1% patients with a history of missed abortion were positive for LAC, and platelet aggregation rates were increased in 47.4% patients. Moreover, multivariate logistic regression analysis showed that D-Dimer, dRVVT-R, AT-III, PC, and PAgT had significant predictive value for missed abortion. In addition, a model based on coagulation function tests for predicting missed abortion was developed. These findings provide evidence of hypercoagulability in patients with a history of missed abortion. Lupus anticoagulant, PAgT, and D-Dimer were the strongest predictors of missed abortion.was to.

The role of mifepristone on first trimester miscarriage treatment - A double-blind randomized controlled trial - MiFirsT

OBJECTIVES

To evaluate the efficacy of combined mifepristone and misoprostol compared to misoprostol alone in outpatient medical treatment of first trimester miscarriage. Additionally, the study intends to compare the rate of complications, adverse effects, and treatment acceptability between groups.

STUDY DESIGN

Single-center double-blind randomized placebo-controlled trial including women with diagnosis of missed first trimester miscarriage up to 9 weeks of gestation.

RESULTS

Between April 2019 and November 2021, 216 women diagnosed with first trimester miscarriage up to 9 weeks of gestation were randomly assigned to mifepristone group or to misoprostol-alone group. Data from 105 women in mifepristone group and 103 women in misoprostol-alone group were analyzed, with no differences in baseline characteristics. The median time between medications (oral mifepristone/placebo and vaginal misoprostol) was nearly 43 h in both groups (p = 0.906). The median time to first follow-up was 2.6 weeks (IQR 1.0) in mifepristone group and 2.4 weeks (IQR 1.0) in misoprostol-alone group (p = 0.855). The overall success rate of medical treatment was significantly higher in the mifepristone-group comparing to misoprostol-alone group (94.3% vs. 82.5%, RR 1.14, 95% CI, 1.03-1.26; p = 0.008). Accordingly, the rate of surgical treatment was significantly lower in the mifepristone-group (5.7% vs.14.6%, RR 0.39, 95% CI, 0.16-0.97; p = 0.034). The composite complication rate was similar and lower than 4% in both groups. No case of complicated pelvic infection, hemodynamic instability or inpatient supportive treatment was reported. There were no significant differences in the rates of adverse events, median score for vaginal bleeding intensity or analgesics use. Despite the same median value, the score of abdominal pain intensity was significantly higher in the mifepristone-group (p = 0.011). In both groups, more than 65% of the women classified the treatment as "good" and 92% would recommend it to a friend on the same clinical situation.

CONCLUSION

The mifepristone plus vaginal misoprostol combined treatment for medical resolution of first trimester miscarriage resulted in significant higher success rate and lower rate of surgical uterine evacuation comparing to misoprostol-alone treatment, with no relevant differences in adverse events or treatment acceptability.

Interactions between Benzo(a)pyrene exposure and genetic polymorphisms of AhR signaling pathway on missed abortion

Benzo(a)pyrene (BaP) is an environmental pollutant widely exposed to human beings. While the relationship between BaP and missed abortion is few understood. To explore the association between missed abortion and BaP, genetic polymorphisms of AhR pathway, we recruited 112 cases women with missed abortion and 137 controls women with normal pregnancy from Shanxi, China. The BPDE-DNA adducts level in the case group was higher than that in the control group (P < 0.001). The subjects were categorized according to the tertiles of BPDE-DNA adduct concentrations: T1 ( Collapse

Key Words

• AhR signaling pathway
• BaP
• genetic polymorphisms
• missed abortion

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MESH Headings

• Pregnancy
• Humans
• Female
• DNA Adducts
• Benzo(a)pyrene/toxicity
• 7,8-Dihydro-7,8-dihydroxybenzo(a)pyrene 9,10-oxide/metabolism
• Abortion, Missed
• Signal Transduction
• Polymorphism, Genetic

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Exposure to pesticide components causes recurrent pregnancy loss by increasing placental oxidative stress and apoptosis: a case-control study

We investigated the plasma levels of pesticides components namely polychlorinated biphenyls (PCBs), dieldrin, dichlorodiphenyldichloroethylene (DDE), ethion, malathion, and chlorpyrifos in recurrent pregnancy loss (RPL) cases, and tested their associations with placental oxidative stress (OS) biomarkers [nitric oxide (NO.), thiobarbituric acid reactive substances (TBARS), reduced glutathione (GSH), and superoxide dismutase (SOD)] and with placental apoptotic/antiapoptotic indices (Bcl-2 and caspase-3), and evaluated their possible cut-off points to distinguish RPL cases. The study recruited 101 pregnant women divided into; G1 [n = 49, control, normal 1st-trimester pregnancy, normal obstetric history with at least one previous normal live birth], G2 [n = 26, cases with missed abortion (< 3 abortions) before 24 weeks of gestation], and G3 [n = 26, cases with missed abortion (≥ 3 abortions) before 24 weeks of gestation]. The plasma pesticide levels were analyzed by gas chromatography-mass spectrometry. Plasma human chorionic gonadotrophin (HCG), placental OS, Bcl-2, and caspase-3, were analyzed by their corresponding methods and kits. Plasma PCBs, DDE, dieldrin, and ethion levels were significantly higher in RPL cases than in normal pregnancies (p ≤ 0.001). These levels correlated positively with placental OS and apoptosis and negatively with plasma HCG levels. Also, these levels were reliable markers of risk to RPL. Malathion and chlorpyrifos were not detected in any of the study's participants. Pesticides may be risk factors in cases of spontaneous RPL cases. They are associated with an increasing placental OS and placental apoptosis. Specific measures should be taken to decrease maternal exposure to these pollutants' sources, especially in underdeveloped and developing countries.

[Observation on effect of five evolutive phases and six climatic factors on pregnancy and sterility]

Objective： To verify statements about the effect of five evolutive phases and six climatic factors in 《huang di nei jing》 on pregnancy and sterility. Methods： Data of missed abortion from Nanjing Maternity and Child Health Care Hospital between 2006-2020 and Yangzhou Maternity and Child Health Care Hospital between 2012-2020 were collected. According to Chinese sexagenary cycle heavenly stems and earthly branches of each year between 2006-2020 was determined. And then based on the heavenly stems and earthly branches, evolutive phases and six climatic factors of each year were established. After that data of missed abortion in each year was compared. According to relative statements in 《huang di nei jing》 , it was observed whether the number of missed abortion cases in someone year increased significantly. Results: Totally there were 28059 cases of missed abortion from the two hospital were collected between 2006-2020 and 2012-2020 respectively. It was found that in the year of Shaoyang phase fire sitian and Jueyin wind wood in the spring (that is the year of 2010 and 2016) the number of missed abortion cases was higher obviously than the other year. When the year of Taiyang cold water in the spring (that is the year of 2009 and 2015), there was a relatively increased number of missed abortion cases. Conclusions: Five evolutive phases and six climatic factors have impacts on human pregnancy and sterility. It was an adverse condition for human reproduction in the year of Shaoyang phase fire sitian and Jueyin wind wood in the spring as well as Taiyang cold water in the spring. Until to now we can still verify statements about the effect of five evolutive phases and six climatic factors on pregnancy and sterility in 《huang di nei jing》.

Medical Termination of Pregnancy (MToP) in the 1st trimester - the role of human chorionic gonadotropin and ultrasound in pregnancy diagnosis and MToP follow-up

OBJECTIVE

In the Czech Republic, it is possible, to carry out Medical Termination of Pregnancy (MToP) in the 1st trimester up until the 49th day of secondary amenorrhea. The aim of the study is to analyse the significance of serum/urine human chorionic gonadotropin (hCG) assessment and ultrasound (US) examination in pregnancy diagnosis and MToP follow-up.

METHODS

In 2017-2018, MToP was carried out in a total of 109 women by administering a combination of mifepristone (600 mg orally) and misoprostol (400 mcg orally). Serum/urine (LSUP - low sensitivity urine pregnancy test) hCG assessment and US examination were performed at pregnancy diagnosis and MToP follow-up.

RESULTS

At pregnancy diagnosis, there was a positive and medium strong correlation between serum hCG and size of the gestational sac - GS (R = 0.711; P  1,000 IU/L and LSUP test was always positive). In 5.5% of women (6/109), a subsequent surgical intervention was carried out including those with ongoing pregnancy (N = 5); missed abortion (N = 1) was treated by additional misoprostol, where surgical intervention was not necessary.

CONCLUSION

At pregnancy diagnosis, there is a positive and medium strong correlation between serum hCG and CRL. In MToP follow-up, a negative LSUP test enables reliable exclusion of ongoing pregnancy and missed abortion. In case of a positive LSUP test, US examination should be performed; however, surgical intervention should not be indicated solely on the basis of uterine cavity dilatation.

Circulating levels of Elabela in pregnant women with missed abortion

ObjectiveThis study aimed to detect Elabela concentrations in the serum of Missed abortion (MA) and compare them with the healthy pregnancies.Materials and methodsThis retrospective case-control study was performed in the second affiliated hospital, Xi'an Jiaotong University March 2019 to September 2019. A total of 108 healthy (35 early, 36 middle and 37 late) pregnant women and 25 (early gestational stage) MA patients were involved. Demographic and clinical characteristics were recorded. The concentration of plasma Elabela was examined using ELISA.ResultsThe level of plasma Elabela was increased in early and middle stages and decreased in late stage of healthy pregnant women. Maternal serum Elabela levels were significantly lower in MA patients (4.59 ± 1.23 ng/mL) compared to healthy pregnant women (5.77 ± 1.21 ng/mL, p < 0.01).ConclusionMaternal circulating levels of Elabela were significantly lower in MA patients than in healthy pregnant women. We consider that Elabela might be a crucial biomarker of the pathophysiologic process in MA.

In missed abortion the decrease of IGF-1 down-regulates PI3K/AKT signaling pathway reducing the secretion of progesterone and β-hCG

OBJECTIVE

To explore whether the reduction of IGF-1 in missed abortion down-regulates PI3K/AKT signaling pathway, thereby causing trophoblast cell apoptosis and reducing the secretion of β-hCG and progesterone.

DESIGN

12 pairs of serum and villous tissues were selected from missed abortion patients and normal early pregnant women who had terminated pregnancy by artificial abortion. The subjects in two groups had same age and gestational week. Wes Simple Western system and qRT-PCR were used to detect the expression of IGF-1, IGF-1R, PI3K/AKT signaling pathway and apoptosis-related factors in villous tissues. Radioimmunoassay and Enzyme-linked immunosorbent assay were used to detect β-hCG, progesterone and IGF-1 in serum.

RESULTS

The serum levels of β-hCG, progesterone and IGF-1 were decreased in missed abortion group than those in normal early pregnant women. In addition, compared with normal early pregnant women, the genes and proteins levels of IGF-1 and PI3K/AKT signaling pathway and anti-apoptosis related factors were significantly decreased.

CONCLUSIONS

Our results suggested that the reduction of IGF-1 in missed abortion patients could down-regulate the expression of PI3K/AKT signaling pathway, thereby increasing the apoptosis of trophoblast cells, leading to decreased secretion of β-hCG and progesterone, which may be one of the important mechanisms of missed abortion.

[Successful pregnancy and delivery achieved with eculizumab administration initiated after a preceding missed abortion in a patient with paroxysmal nocturnal hemoglobinuria]

Pregnancy with paroxysmal nocturnal hemoglobinuria (PNH) poses a high risk of thrombosis, maternal death, miscarriage, and premature infants. Eculizumab lowers complications for pregnancy with PNH. A proposed protocol for the management of pregnancy in women with PNH by The National Research Group on Idiopathic Bone Marrow Failure Syndrome (the Japanese Guideline) recommends patients to start eculizumab at an early stage of pregnancy if they have not been treated with eculizumab or continue eculizumab during pregnancy. A 31-year-old female with PNH who was transfusion-independent but had occasional hemolysis was treated with eculizumab after a missed abortion and soon conceived. During pregnancy, the patient had neither hemolysis nor thrombosis and gave birth to a healthy child without using heparin. Heparin was initiated soon after delivery and continued for six weeks because of the known high postpartum risk of thrombosis. No postpartum complications were observed. PNH is a rare disease with fewer cases of pregnancy reported. Hence, it is essential to accumulate cases of PNH with pregnancy to establish the validity of the Japanese Guideline.

Distinguishing between interstitial and angular pregnancies: Is there a role for saline infusion sonohysterography?

OBJECTIVE

Interstitial pregnancy occurs in the intramural segment of the Fallopian tubes, while angular pregnancy is one that is located in one of the lateral angles of the uterine cavity. The differential diagnosis and treatment of these conditions are important. We have used saline infusion sonohysterography (SIS) to help in differential diagnosis.

CASE REPORT

A 36-year-old female with a case of suspected left interstitial ectopic pregnancy was admitted. Her diagnostic laparoscopy showed no tubal ectopic pregnancy, and D&C demonstrated no villi. She underwent SIS which showed a sac in the interstitial part but close to the tubal ostium. The second case involves a 21-year-old female who was 9-weeks pregnant. Ultrasonography could not differentiate between interstitial and angular pregnancy. SIS clearly demonstrated angular pregnancy with a missed abortion, and therapeutic D&C was done smoothly.

CONCLUSION

From reviewing past literature, SIS does not appear to have any proven adverse effect on the pregnancy although it is not widely accepted. This article highlights the benefits of using SIS to aid in the differential diagnosis between the two conditions, especially in unusual cases like ours.

Lesson of the month 2: Use of thrombolysis for ischaemic stroke in pregnancy - a case report and review of literature

A nine-week pregnant 33-year-old female presented with sudden-onset right-sided hemiparesis, hemisensory loss, dysarthria and homonymous hemianopia. She was known to have eleven previous miscarriages and used recreational drugs. A CT-head was unremarkable. The patient was subsequently diagnosed with an acute thromboembolic infarct and chose alteplase after counselling. During thrombolysis an ultrasound identified a foetus with no concerning features.  A post-thrombolysis CT revealed a left-sided posterior cerebral infarct. CT-venography, carotid Doppler, 72-hour Holter monitor, thrombophilia and an autoimmune screen were all normal. A transthoracic echocardiogram demonstrated a mobile intra-atrial septum with a patent foramen ovale confirmed on bubble echocardiogram. Three days post-thrombolysis the patient requested a termination of pregnancy. A subsequent transvaginal ultrasound demonstrated a missed miscarriage for which the patient underwent evacuation of retained products of conception. Multidisciplinary care ensured that her sensorimotor deficit resolved grossly with only mild dysarthria and right-hand fine motor incoordination.

[Chromosome examination of missed abortion patients]

OBJECTIVE

To investigate the relationship between the missed abortion and chromosome abnormality and guide the healthy birth.

METHODS

From June 2014 to April 2015 in Tianjin central hospital of gynecology and obstetrics, we examined venous blood from 90 missed abortion couples for chromosome karyotype by lymphocyte culture method and we also examined their chromosome karyotype of abortion villus samples by high-throughput sequencing technologies.

RESULTS

Out of the 90 couples' blood chromosome examinations, 7 were abnormal, and the abnormal rate was 3.89%, including 3 cases reciprocal translocation, 2 cases robertsonian translocation and 2 cases inversion. Abortion villus samples from the same population were also checked, of which 85 cases succeeded, with the success rate of 94.4%. Among them, villi chromosome abnormalities were found in 50 cases, including 39 cases with abnormal chromosome numbers, 11 cases with abnormal chromosome structure, and the total abnormal rate was 58.8%. In addition, the villi chromosome abnormality rate of patients with recurrent missed abortion (≥2 times) and first missed abortion were 61.7% and 55.2%, respectively, and the difference was not significant (P>0.05). The villi chromosome abnormality rate of pregnant women with age≥35 years old was 71.1%, while the pregnant women with aged <35 years old was 45% (P<0.05).

CONCLUSIONS

Chromosome abnormality is an important cause of missed abortion; villi chromosome abnormality rate has nothing to do with the number of missed abortion; pregnant woman with age≥35 years old is risk factor of the villi chromosome abnormality.

Successful term delivery after laparoscopic resection of a non-communicating rudimentary horn in a patient with a unicornuate uterus: a case report

Unicornuate uterus accompanied by a non-communicating rudimentary horn is a rare uterine malformation. If a embryo is implanted into the rudimentary horn, continuation of pregnancy is difficult due to the risk of uterine rupture. We recently performed laparoscopic resection of the right rudimentary horn after two right rudimentary horn pregnancies in a woman, in whom a normal pregnancy occurred in the left unicornuate uterus, leading to successful delivery of a baby. This case is presented herein. The diagnostic procedures leading to identification of this rare malformation were prompted by inability to remove uterine contents during surgery performed after a diagnosis of missed abortion. A right rudimentary horn pregnancy, which had occurred twice, was treated with methotrexate. To prevent further pregnancy in the right rudimentary horn, resection of this rudimentary horn was planned and successfully implemented under laparoscopic guidance. This surgical procedure is usually difficult, but fertility could be preserved by employing minimally invasive surgery, involving the use of a LigaSureTM Vessel Sealing System to avoid ligation and assure virtually no bleeding. Soon after surgery, a natural pregnancy in the left unicornuate uterus was confirmed. Intrauterine fetal growth was normal, and transvaginal delivery at term was possible.

[Prediction of complications of I trimester of pregnancy in women with distressed reproductive history by detection of transcervical trophoblastic cells]

The present study investigated the possibility of using trophoblastic (fetal) cells in cervical mucus of pregnant women with complicated reproductive history to predict the course of early I trimester of pregnancy. We examined 86 women at 5-6 weeks of gestation, 56 of them with normal pregnancy, 12 with missed abortion, 18 with tubal pregnancy. As a control we used 21 non-pregnant womеn with primary infertility. Trophoblastic cells we detected by immunohistochemical method and then counted. It was revealed that in the normal course of early I trimester transcervical trophoblastic cells were detected in 4 times more likely than in missed abortion and 5 times more often than in women with tubal pregnancy. In women of the control group, who never had pregnancies, trophoblastic cells were not detected. Thus, the determination of the number of transcervical trophoblastic cells can be used in the complex diagnosis of pathological course of I trimester of pregnancy in women with complicated reproductive history.

Misoprostol administration in first-trimester pregnancies with embryonic demise reduces uterine arterial blood flow

OBJECTIVES

This study was designed to evaluate the effect of misoprostol on the blood flow in uterine arteries of pregnant women with first-trimester embryonic demise.

METHODS

Transvaginal ultrasonographic Doppler examinations (resistance index, pulsatility index, systolic/diastolic ratio) of the uterine arteries in 61 pregnant women were performed before misoprostol administration and 90 min later. Following baseline Doppler measurements, each woman received 200 microg misoprostol intravaginally and 200 microg misoprostol orally.

RESULTS AND CONCLUSION

All Doppler indices increased significantly after misoprostol administration (p < 0.0001), suggesting an increase in flow resistance.

Comparison of isosorbide mononitrate (Mono Mack) and misoprostol (Cytotec) for cervical ripening in the first trimester missed abortion

OBJECTIVE

The objective of this study was to compare NO-donor isosorbide mononitrate to misoprostol, both applied as vaginal tablets for cervical ripening prior to first trimester curettage in patients with missed abortion.

MATERIALS AND METHODS

Thirty women with missed abortion were assigned after a random list to be treated either with 200 microg gemeprost (Cytotec, Pfizer, Germany) or with 40 mg isosorbide mononitrate for cervical priming at least 3 h before curettage. Vaginal bleeding or the intracervical presence of products of conception was documented. The largest number of Hegar's dilator, which could be introduced without difficulty and the largest number of Hegar's dilator at which cervical dilation was performed and the ease of mechanical dilation was assessed.

RESULTS

There were no significant differences in cervical ripeness before procedure nor in ease of dilation. In the misoprostol group, the cervical canal was more dilated before any procedure (median of Hegar's dilator 6 vs. 5) and after dilation (median of Hegar's dilator 11 vs. 10), although this difference was not significant. Vaginal bleeding occurred in two patients in each group. Products of conception were only found in the cervix of one patient of the misoprostol group.

SYNOPSIS

Vaginal application of isosorbidemononitrate in cervical priming prior to curettage abortion is as effective as vaginal application of misoprostol.

Spectrum of normal intrauterine cavity sonographic findings after first-trimester abortion

OBJECTIVE

To characterize the sonographic appearance of the uterine cavity after uncomplicated first-trimester abortion.

METHODS

Women who underwent uterine evacuation for first-trimester abortion were referred for endovaginal sonographic examination within the week after the procedure. Special attention was directed to characterizing the intrauterine cavity. Demographic and clinical parameters were collected. A repeated postmenstrual examination was carried out in selected cases.

RESULTS

In all, 57, 10, and 7 sonographic examinations were performed after termination of pregnancy, incomplete (spontaneous) abortion, and missed abortion, respectively. Fifty-seven (77%) of the 74 examinations showed considerable amounts of intrauterine content with various echogenicities (anteroposterior thickness range, 7-61 mm). No association could be documented between the pattern of appearance and gravidity, parity, gestational age, or type of abortion procedure. All postmenstrual reevaluations of patients with excessive amounts of intrauterine material at the initial examination (n = 7) showed empty intrauterine cavities.

CONCLUSION

Within the week after first-trimester abortion, the uterine cavity is seldom empty. Thick heterogeneous material is an expected finding after examination. By being familiar with this normal range of appearances, clinicians can avoid unnecessary repeated invasive evacuation procedures. A follow-up sonographic evaluation during the follicular phase of the next menstrual cycle is recommended to confirm the absence of retained products of pregnancy.

Transcervical embryoscopy in missed abortion

PURPOSE

The present study was conducted to determine the usefulness of transcervical embryoscopy in diagnosing localized and systemic defects in embryonic morphogenesis of missed abortions.

METHODS

The study population consisted of 24 women with the final diagnosis of missed abortion. Prior to the instrumental evacuation of the uterus a rigid hysteroscope was passed transcervically into the amniotic cavity to obtain a detailed view of the embryo. Karyotyping was attempted in all cases included in this study.

RESULTS

An embryo could be visualized in 19 cases. Ten embryos showed multiple developmental defects.

CONCLUSIONS

In cases of early failure of pregnancy, embryoscopy permits visualization of the embryo in utero, unaffected by the damage usually caused by its instrumental evacuation or spontaneous passage. This technique can be a helpful tool for pathologists and geneticists in enhancing their understanding of human embryonic malformations, but more importantly, it improves clinical care and follow-up, especially in cases of repeated abortions.

Spontaneous conception in the presence of stage IIIC endometrioid ovarian cancer

OBJECTIVE

To describe a rare case of spontaneous conception in a patient with a preexisting metastatic ovarian cancer.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 39-year-old Asian woman who conceived while undergoing an evaluation for primary infertility and newly detected bilateral adnexal masses.

INTERVENTION(S)

Staging laparotomy and total abdominal hysterectomy and bilateral salpingo-oophorectomy.

MAIN OUTCOME MEASURE(S)

Anatomic pathology diagnosis.

RESULT(S)

Blighted ovum and stage IIIC endometrioid adenocarcinoma of ovary.

CONCLUSION(S)

Metastatic ovarian cancer does not prevent either spontaneous ovulation or spontaneous conception.

Measurement of intrauterine human decidua-associated protein 200 and diagnosis of ectopic pregnancy

The aim of the current study was to examine whether the measurement of intrauterine human decidua-associated protein (hDP) 200 might be of clinical value in the diagnosis of ectopic pregnancy versus early missed abortion. Uterine fluid levels of hDP 200 were measured in two groups of patients: 20 women with ectopic pregnancy, diagnosed by laparoscopy, and 20 women diagnosed (after curettage) as having a missed abortion. No significant difference in hDP 200 levels was observed comparing patients with ectopic pregnancy (mean 114.0+/-58.2 mU/ml) and patients with early missed abortion (mean 222.0+/-116.0 mU/ml), although a trend towards lower levels of uterine fluid hDP 200 was noted in the group of patients presenting with tubal pregnancy. Thus, according to our data, intrauterine hDP 200 is not sufficiently discriminative to be of clinical value in the diagnosis of ectopic pregnancy.

Ectopic production and localization of beta-human chorionic gonadotropin in lymphoepithelioma-like carcinoma of the cervix: a case report

A 32-year-old woman underwent a suction curettage for missed abortion. The initial serum human chorionic gonadotropin (beta-hCG) level was 40 IU/ml. The histologic examination of the uterine curettage specimen showed scant strips of a poorly differentiated malignant neoplasm and no chorionic villi. The tumor showed strong immunoreactivity for cytokeratin (AE1/AE3) and beta-hCG but no reactivity for human placental lactogen. The combination of histologic appearance, beta-hCG immunoreactivity, and elevation of serum beta-hCG raised a strong suspicion for epithelioid trophoblastic tumor (ETT). Postcurettage serial serum beta-hCG levels remained in the range of 20 to 45 micrograms/ml. Computerized tomographic scan showed a 1.0-cm circumscribed mass in the upper endocervix. A radical hysterectomy and pelvic lymphadenectomy were performed. Gross examination of the hysterectomy specimen likewise showed a well-circumscribed mass in the upper endocervix. Histologic examination revealed an undifferentiated carcinoma accompanied by intense lymphoplasmacytic infiltrate. A final diagnosis of lymphoepithelioma-like carcinoma (LELC) was rendered. LELC with elevated serum beta-hCG level and immunoreactivity to beta-hCG should be distinguished from ETT in a small endocervical curettage sample.

[Pregnancy after liver transplantation in Groningen: benign course for mothers and children]

OBJECTIVE

Analysing the course and outcome of pregnancies in liver transplant recipients.

DESIGN

Retrospective and descriptive.

METHOD

Since 1979 liver transplantations have been performed in the University Hospital Groningen, the Netherlands. Seven female patients conceived 12 times after transplantation. These pregnancies were managed by a team of liver transplantation specialists and obstetricians. Hypertensive disorders, foetal growth, liver function tests and infective disorders were monitored specially. The course and outcome of the pregnancies were determined.

RESULTS

The incidence of complications was much lower than in published patient series. The differences in premature deliveries (9 versus 40%) and caesarean births (18 versus 57%) are largely explained by the difference of incidence of hypertensive disorders (18 versus 35%). One woman developed a liver function disorder during pregnancy (9 versus 38%). In the long term the function of the donor liver appeared not to be disturbed; this finding is in accordance with data from other reports. Ten of the 12 pregnancies resulted in the birth of a healthy child. All children were born in good condition and all of them were alive at the completion of the study (minimal follow-up: 10 months).

CONCLUSION

After liver transplantation there is no need to advise against pregnancy.

Increased blood vessel density in decidua parietalis is associated with spontaneous human first trimester abortion

Spontaneous pregnancy loss affects 15-18% of couples, and a number of potential causes are being discussed. The purpose of the present study was to assess if angiogenic disorders in the decidua of early human pregnancy could be related to spontaneous abortions. First trimester human decidua from elective terminations of normally progressing pregnancies and from missed abortions were investigated immunohistochemically. We quantified vessel density in decidua from normal pregnancies and from abortions by von Willebrand factor (vWF), platelet endothelial cell adhesion molecule (PECAM-1) and CD34 staining. Decidual blood vessel expression of alphavbeta3 integrin was also investigated. Significant increase (P < 0.02) in vessel density was observed in decidua parietalis of abortions, compared to decidua basalis. This increase was detected on slides stained for vWF and CD34, but not for PECAM-1. We observed a 15% increase analysing with vWF and a 77% increase with CD34 staining. alphavbeta3 integrin expression was not significantly different, neither in decidua parietalis from abortion, nor parietalis from normal pregnancies. Our data suggest that the increased vascularization in decidua parietalis from abortions could reflect complex disorders, such as specific cytokine expressions and hypoxia phenomena during the development of the decidua.

A randomized double-blind placebo-controlled study to assess the effect of oral contraceptive pills on the outcome of medical abortion with mifepristone and misoprostol

This was a randomized double-blind placebo-controlled trial to determine the effect of oral contraceptive (OC) pills taken immediately after medical abortion on the duration of bleeding and complete abortion rate. Two hundred women in the first 49 days of pregnancy were given 200 mg mifepristone orally followed by 400 microg misoprostol vaginally 48 h later. One day later, they were randomized to receive either OC pills (30 microg of ethinyl oestradiol and 0.15 mg of levonorgestrel per tablet) or placebo for 21 days. The complete abortion rates were 98% in the OC group and 99% in the placebo group. The median duration of bleeding was similar: 17 (range: 5-57) days in the OC group and 16 (range: 6-55) days in the placebo group. In the OC group there was a small but significant fall in the haemoglobin concentration by 14 days (5.3 g/dl) after administration of mifepristone. The incidence of side-effects was similar in the two groups. We conclude that the use of OC pills does not decrease the duration of bleeding after medical abortion nor does it affect the abortion rate.

Transcervical embryoscopic diagnosis of conjoined twins in a ten-week missed abortion

Embryoscopic diagnosis of conjoined twins presenting with a missed abortion has never been reported. The morphological and pathological examinations, and the exact time of death in the conceptus of a missed abortion are seldom clearly delineated. The newly developed field of embryoscopy has created a new frontier in early embryonic/fetal visualization and is able to confirm the sonographic diagnosis. In this report, we used a transcervical endoscope to verify conjoined twins (thoraco-omphalopagus) in a 10-week missed abortion. Based on the size and the external features of the dead embryo, which exhibited developmental arrest at nine weeks and three days of menstrual age, we estimated that the embryo had died four days before examination. The whole procedure proceeded smoothly without any immediate complications.

Significance of yolk sac measurements with vaginal sonography in the first trimester in the prediction of pregnancy outcome

BACKGROUND

The purpose of this prospective clinical study was to determine and evaluate the prognostic value of secondary yolk sac diameter of the embryo on pregnancy outcome.

METHODS

One hundred and thirty pregnant women in the first trimester were included in the study. Crown-rump length (CRL) and yolk sac diameters were measured in every patient and the outcome of the pregnancies were compared with the measurements. Intact normal pregnancy (group A), threatened abortion (group B) and missed abortion (group C) were diagnosed in 67, 43 and 20 pregnancies, respectively.

RESULTS

We detected a significant linear correlation between secondary yolk sac diameter and gestational age in group A (r = 0.5085; p < 0.0001) and a moderate correlation in group B (r = 0.4048; p = 0.007) and C patients (r = 0.3478; p = 0.1333). When the groups were evaluated irrespective of gestational age, a significant difference in secondary yolk sac diameters among the groups was noted (p = 0.037). When confidence intervals for secondary yolk sac diameters of intact normal pregnancies (group A) were calculated by linear regression, two patients in group B were below the 5% confidence interval. However, in group C patients, the yolk sac diameter of six patients were detected below the 5% confidence interval, while two of the measurements were above 95% confidence interval. Therefore, eight measurements (40%) of group C patients were outside the 5-95% confidence interval.

CONCLUSION

In the first trimester, when discrepancy is detected between secondary yolk sac diameter and gestational age, additional sonographic investigation should be performed one or two weeks later, in order to estimate the pregnancy outcome.

Zoonotic and viral infection in fetal loss after 12 weeks

One hundred and thirty-six women from an urban, rural and farming community were recruited to a study of infectious causes of midtrimester miscarriage (n = 85), stillbirth (n = 32), or termination for developmental (n = 17) or chromosomal (n = 2) abnormalities. No woman had evidence of acute infection with toxoplasma, listeria, leptospira or Chlamydia psittaci (ovine enzootic abortion). One woman had midtrimester miscarriage associated with primary cytomegolovirus infection and five women had evidence of parvovirus B19 infection, although fetal infection was not proven. Zoonoses were not identified as a cause of fetal loss or malformation in this at-risk population, but parvovirus B19 was a significant cause of midtrimester fetal loss.

Urorectal septal defects in a female and her offspring

We report on a patient with an ectopic urethra opening into a septate vagina which was distended with urine. The anus and rectum were normal but separated from the urogenital sinus by a thin septum. After surgical repair the patient did well with the exception of recurrent urinary tract infections. At 16 years, she delivered a healthy boy by Cesarean section but miscarried a subsequent pregnancy 3 years later. The 12-13 week female fetus lacked a urethra and had an atretic vagina and cloacal anomalies consistent with a urorectal septum developmental defect. This report provides evidence that cloacal anomalies resulting from the improper development of the urorectal septum may have a genetic cause. Furthermore, we support the proposition previously set forth by Allen and Husmann [J Urol 145:1034-1039, 1991] that such anomalies be referred to as urorectal septal defects rather than cloacal anomaly variants. This terminology accurately represents the developmental defect and clearly distinguishes them from cloacal exstrophies, which are due to the abnormal development of the cloacal membrane and the subumbilical ventral abdominal wall.

An unusual clinical course after mole evacuation: a case report

A 27-year-old woman evacuated a hydatidiform mole at 11 weeks of gestation. Her serum human chorionic gonadotropin (hCG) levels declined progressively but reached a plateau of 2-3 mIU/ml thereafter. The patient was treated with two courses of methotrexate, which did not affect her hCG levels. She refused further chemotherapy and, for more than one year, she was managed expectantly until a significant rise in her hCG titer. Fortunately, an unexpected pregnancy and subsequent missed abortion led to a spontaneous regression of her hCG levels.

Quadruplet in vitro fertilization pregnancy complicated by fetal reduction and leiomyoma

A woman had a quadruplet IVF pregnancy with a leiomyomatous uterus. Pregnancy resulted in the birth of one baby after missed abortion of one fetus and selective reduction of two others. The woman had a left deep calf vein thrombosis in the first half of pregnancy.

Intrauterine pregnancy following endometrial ablation

BACKGROUND

Only five pregnancies have been reported after endometrial ablation by resectoscopic endometrial resection, for a rate of 0.7% on the basis of three series.

CASE

Endometrial ablation was performed using a roller-ball electrode on a 37-year-old woman who had menorrhagia and dysmenorrhea. She subsequently conceived but experienced a missed abortion.

CONCLUSION

Pregnancy is a rare occurrence following endometrial ablation. The effect of endometrial ablation on pregnancy outcome is unknown.

Confined placental mosaicism and intrauterine development

Confined placental chromosomal mosaicism can be detected in 1-2% of pregnancies studied by chorionic villus sampling at 9-12 weeks of gestation. It is more commonly found in the cytotrophoblast than in placental connective tissue. Aneuploid conceptions are more likely to have confined chromosomal mosaicism than euploid ones. Although intrauterine survival of chromosomally abnormal embryos and fetuses appears to be significantly enhanced by placental mosaicism, the effect of placental mosaicism on chromosomally normal fetuses is variable and, at the present time, still unpredictable.

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.

Fertility after nonsurgical treatment of ectopic pregnancy

There is no question that the treatment of choice for ectopic pregnancy is surgery. However, since some ectopic pregnancies terminate in tubal abortion or complete resorption, it is questionable whether surgery is necessary in every case. Some patients can be managed by monitoring rising or falling levels of beta-human chorionic gonadotropin (beta-HCG) until tubal abortion or resorption occurs. This approach, which may be the best means of preserving tubal function and fertility, was used in 14 patients who fulfilled extremely selective criteria. In some of the patients, surgery later proved to be necessary, but in 11 nonsurgical management was followed by a fall in beta-HCG levels, and there were no further untoward effects. Three of these patients subsequently developed intrauterine pregnancies, and one patient had a repeat ectopic.

Chorionic villus sampling. Clinical experience in 50 diagnostic cases

The results of 50 diagnostic chorionic villus samplings (CVS) are presented. In all but 2, the fetus was at risk of a chromosomal abnormality. Sampling was successful in 48 cases. One patient aborted 4 days after the procedure. Two patients had missed abortions diagnosed on ultrasound 44 and 56 days after CVS. Seven patients elected to have their pregnancies terminated. All samplings were undertaken with a specially designed cannula using realtime ultrasound guidance between 9 and 11 weeks of amenorrhoea. Endocervical swabs and blood for maternal serum alpha fetoprotein estimations before and after the procedure were routinely taken. All patients were notified of the results in 8 days or less except in 3 where long-term cultures were necessary. Six patients have delivered and 34 pregnancies are continuing satisfactorily.

[16-Phenoxy-prostaglandin-E2 for inducing abortion in intact and complicated pregnancy]

The prostaglandins used so far in early pregnancy exercise distressingly strong side effects (Table 5). These side effects are closely correlated with the effectiveness of the prostaglandins. 16-phenoxy-prostaglandin-E2 (SHB 286) was employed in 476 women for inducing abortion in intact and disturbed pregnancy and for priming before performing a planned abruptio. During the priming of 64 women before inducing abortion, this was induced in 59% of the women already by a single intramuscular application of 500 micrograms SHB 286-depending on parity, whereas in the remaining cases it was possible to avoid dilatation of the cervix or to substantially facilitate dilatation technique. For inducing abortion during the second trimenon, SHB 286 was applied extra-amnially in 15 cases, intra-amnially in 24, intravenously in 56 and intramuscularly in 99 cases. The dosage was lowest on extra-amnial administration (50 micrograms on the average), and highest on intramuscular application with a mean of 1760 micrograms. The time until induced abortion set in was between 16 hours (intra-amnial application) and 12 hours (intravenous application). The rate of abortions was more than 90% on intra-amnial, intravenous and intramuscular application, and 80% on extra-amnial application. In case of missed abortion and hydatid mole, SHB 286 was applied systemically only. In missed abortion the mean dosage up to expulsion was 1700 micrograms on intravenous administration, whereas it was 1126 micrograms only if given intramuscularly. The dosage for inducing abortion was 8 hours by the IV route and 10 hours by the IM route.(ABSTRACT TRUNCATED AT 250 WORDS)

Familial trophoblastic disease: case report

Presented is a report of familial trophoblastic disease (repeated hydatidiform mole) which is of interest because of the double familial components. The patients were sisters who were married to two brothers.