Subclinical rubella reinfection during pregnancy followed by transmission of virus to the fetus

We report a documented case of rubella reinfection during pregnancy in a previously vaccinated woman with residual antibody titre to rubella of 15 IU/ml. The reinfection occurred following an exposure to rubella virus (contact with 6-year-old daughter with clinical rubella) between the 7th and 10th week of pregnancy which resulted in transmission of the virus to the fetus. Umbilical cord blood drawn by cordocentesis was found to be strongly positive for rubella IgM antibody. After termination of the pregnancy rubella virus was isolated in cell culture from fetal tissues.

Prenatal diagnosis of fetal primary cytomegalovirus infection

OBJECTIVE

To evaluate the validity of prenatal diagnosis work-up for congenital cytomegalovirus (CMV) in women with primary infection.

METHODS

Sixty-three pregnant women with primary cytomegalovirus disease (including two with twin pregnancies), referred to three tertiary perinatal centers over 4 years, underwent evaluation for congenital cytomegalovirus. Fetal diagnosis was made after 21 weeks' gestation by amniocentesis and fetal blood sampling (40 subjects), or amniocentesis only (23 subjects).

RESULTS

Twenty-two (35%) pregnancies showed evidence of vertical transmission: 13 of them underwent funipuncture, but only ten (77%) of the 13 showed positive immunoglobulin (Ig)-M results in fetal blood. No cases of positive fetal serum Ig-M with negative amniotic fluid culture or polymerase chain reaction were observed. In nine (41%) of the 22 pregnancies with evidence of vertical transmission, abnormal ultrasonographic findings were recorded. Six (27%) women with evidence of vertical transmission continued their pregnancies and in only one (with prenatal ultrasonographic abnormalities) was an infant born with neurologic sequelae. In 41 (65%) pregnancies, no evidence of vertical transmission was found, and 37 continued to term. Only one newborn from this subgroup subsequently showed mild motor disability during a median of 23 months of follow-up.

CONCLUSION

Among pregnant patients with primary CMV infection, analysis of amniotic fluid detected all of the infected fetuses. Thus, this is a reliable tool for counseling pregnant women with primary infection. This may guide the patient as to whether or not pregnancy can be continued with a high level of confidence.

Early sonographic diagnosis of Jarcho-Levin syndrome: a prospective screening program in one family

The purpose of this study was to evaluate the possibility of early diagnosis of Jarcho-Levin syndrome by ultrasound examination of the fetus. Over a period of 5 years, nine women from one Arab family, known to carry an autosomal recessive form of the disease, were prospectively and repeatedly examined using ultrasound. Out of eight pregnancies, four fetuses were diagnosed as being affected by the disease as early as 12 gestational weeks. Three elected to terminate the pregnancy before viability and one was born at term. There were no misdiagnoses. We conclude that early prenatal ultrasonographic diagnosis of Jarcho-Levin syndrome is feasible, although later sonographic confirmation is often warranted.

Essential thrombocythemia during pregnancy

Essential thrombocythemia is a myeloproliferative disorder characterized by a persistent increase in the platelet count. The disease occurs more often in late middle age, but reports confirm the possibility of earlier occurrence. When the disease affects women during pregnancy, an adverse pregnancy outcome is possible: abortion, intrauterine fetal death, abruptio placentae, intrauterine growth retardation, and premature delivery. The possibility of thrombosis formation in this disease encouraged many physicians to use various treatments aimed at lowering the platelet count. Treatments used during pregnancy include acetylsalicylic acid, dipyridamole, heparin, and plateletpheresis. This article describes pregnancy outcomes and reviews the suggested treatments.

Methotrexate as a possible cause of ovarian cysts formation: experience with women treated for ectopic pregnancies

OBJECTIVE

To evaluate ovarian morphology after either salpingostomy or local injection of methotrexate (MTX) to cause regression of tubal pregnancies and to define potential correlation to other clinical parameters.

DESIGN

Prospective longitudinal follow-up.

SETTING

Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel.

PATIENT(S)

One hundred one women who were treated for tubal pregnancy: 58 by salpingostomy and 43 by local MTX injection.

INTERVENTION(S)

Serial blood sampling for beta-hCG and serial transvaginal sonographic evaluation.

MAIN OUTCOME MEASURE(S)

Appearance of cysts in the ovaries and their location with regard to the side in which the tubal pregnancy occurred.

RESULT(S)

In 6 of 42 (14.3%) patients who were treated with MTX, multiple (range, three to six) ovarian cysts occurred, as compared with 1 of 55 (1.8%) in those who underwent salpingostomy. The largest cyst was 9.4 cm in diameter. No relation of cyst occurrence to the side of the ectopic pregnancy was recorded. The women who developed cysts did not differ in either initial serum beta-hCG levels or in the rate of its subsequent regression.

CONCLUSION(S)

Multiple ovarian cysts may occur in 15% of patients who are treated with intra-amniotic MTX to cause regression of tubal ectopic pregnancy.

Late selective termination of fetal abnormalities in twin pregnancies: a multicentre report

OBJECTIVE

To evaluate the outcome of late selective fetal termination based on combined data from eight tertiary perinatal centres.

DESIGN

Israeli law requires institutional committee approval for pregnancy termination. Moreover, after 24 weeks only a district superior committee can approve the termination. A total of 36 bichorionic twin pregnancies who underwent selective fetal termination after 24 complete gestational weeks were identified in eight Israeli centres.

RESULTS

In 23 women (63.9%) the indication for selective termination was structural anomaly, and in 13 (36.1%) the indication was chromosomal abnormality. The mean gestational age at the time of diagnosis was 24.1 +/- 1.9 weeks. The termination procedure was performed at a mean gestational age of 25.5 +/- 2.0 weeks (median 25, range 24-33 weeks). There was one case of immediate procedure-related complication (i.e. amnionitis) and the unaffected infant died, which was the only perinatal death in this series. No evidence of coagulopathy was reported. Only five women (13.8%) delivered before 34 completed weeks. The mean gestational age at delivery was 36.9 +/- 2.9 weeks (28-41 weeks), and the mean procedure-to-delivery interval was 11.8 +/- 3.2 weeks (median 13, range 3-17 weeks).

CONCLUSIONS

Late (> 24 weeks) selective termination in twin pregnancies is associated with favourable perinatal outcome of the healthy twin. In countries where the law permits late pregnancy termination, the parents should be informed of that possibility.

Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis

To compare and assess ingestion of yogurt that contained live Lactobacillus acidophilus with pasteurized yogurt as prophylaxis for recurrent bacterial vaginosis (BV) and candidal vaginitis, we designed a crossover trial during which patients were examined monthly for candidal infection and BV while they were receiving either a pasteurized yogurt or a yogurt that contained live L acidophilus. Forty-six patients in 2 groups of 23 were randomly assigned to each of the study groups. At least 28 (61%) participated during the first 4 months of the study. Seven patients completed the entire study protocol. We concluded that daily ingestion of 150 mL of yogurt, enriched with live L acidophilus, was associated with an increased prevalence of colonization of the rectum and vagina by the bacteria, and this ingestion of yogurt may have reduced episodes of BV.

[Association of bacterial vaginosis in pregnancy with preterm delivery]

In a prospective study we examined the correlation between bacterial vaginosis (BV) during pregnancy and preterm labor. Direct vaginal smears were obtained during the 15th to 20th gestational weeks, and the subsequent delivery records were evaluated for the occurrence of preterm labor. BV was found in 15% of pregnant women at 15-20 gestational weeks, and in 8% at 27-32 gestational weeks. No correlation was found between BV and preterm labor.

Prenatal diagnosis of Rambam-Hasharon syndrome

Rambam-Hasharon syndrome (RHS) is a newly recognized autosomal recessive inborn error in fucose metabolism. Mental retardation, short stature, coarse facies, and recurrent infections are the main clinical findings. Several fucosilated proteoglycans are deficient in these patients. Leukocyte adhesion deficiency type 2 is associated with lack of the membrane glycoprotein sialyl-Lewisx (CD15s). In the red blood cells (RBCs), lack of the membrane glycoprotein H is manifested as a Bombay (Oh) blood type. Two consecutive pregnancies it risk for RHS were monitored during mid-trimester by cordocentesis. One fetus expressed H substance and her blood phenotype was O Rh+. The second fetus, a female, was 2 weeks smaller than expected by dates and had the Bombay blood type. The placenta of the affected fetus was small and irregular. This is the first prenatal diagnosis of this syndrome and the first case found in a female. The documentation of the syndrome in patients of both sexes and the parental consanguinity support an autosomal recessive inheritance. Two apparent recombinations between fucosyl-transferase 1 (FUT1, the H gene) and fucosyl-transferase 2 (secretor) are suggestive of non-allelic heterogeneity. We believe that the Bombay phenotype in this family is caused by a mutated gene, other than FUT1, which is causing multiple deficiencies of fucosilated proteoglycans.

Delivery of the very low birthweight breech: what is the best way for the baby?

A retrospective analysis was done to determine whether vaginally vs. cesarean section-born breech infants in the very low birthweight range are at increased risk for morbidity and mortality. Eighty-three viable singleton breech infants weighing 700-1,600 g, who were delivered in our medical center during the period 1980 through 1993, were followed for up to 5 years of age. Analysis of data after correction for weight, gestational age and other confounding variables such as antepartum complications revealed that survival rates in the 700-1,000 g group were similar in both routes of delivery. In the 1,001-1,600 g group, survival rate was 60.9% after vaginal delivery, as compared to 100% after cesarean section (P < 0.01). No difference was demonstrated in long-term outcome between the vaginal and cesarean groups, although the population was too small to draw statistical conclusions. Considering the limitation of such a retrospective analysis, our data identified a trend that supports prophylactic cesarean section in cases of pre-term breech infants weighing 1,000-1,600 g.

Factors associated with withdrawal bleeding after administration of oral dydrogesterone or medroxyprogesterone acetate in women with secondary amenorrhea

The effectiveness of two treatment regiments in inducing withdrawal bleeding in secondary amenorrhea was compared and correlated with the endometrial thickness and endogenous E2 and progesterone concentrations. A prospective, randomized and double-blind study was designed at the Outpatient Clinic of Reproductive Endocrinology, Central Emek Hospital, Afula, Israel. Seventy-seven premenopausal women with oligomenorrhea or amenorrhea, 48 of whom qualified for the study, underwent a 5-day course of either medroxyprogesterone acetate (MPA) 5 mg b.i.d. or dydrogesterone (DG) 10 mg b.i.d. Endogenous pretreatment values of E2 and progesterone and endometrial thickness (by transvaginal ultrasonography) were correlated with the bleeding response. Withdrawal bleeding occurred in 93% of women taking either MPA or DG. Side effects occurred similarly among the groups. Lipid concentrations were unchanged. Endogenous E2 and progesterone were limited predictive value for withdrawal bleeding. Endometrial thickness as measured by transvaginal sonography correlated significantly with the bleeding response.

Use of cordocentesis in the management of preterm or growth-restricted fetuses with abnormal monitoring

The dilemma of when to deliver preterm or growth-restricted fetuses with abnormal monitoring is faced by all those treating such patients. Current noninvasive tests for fetal well-being have relatively high false-positive rates. Cordocentesis allows the clinician to directly analyze fetal blood and determine whether the fetus is truly in distress, is suffering from aneuploidy, or is plagued by infection. However, with improved neonatal care, otherwise normal infants of birth weight greater than 1500 gm have very low morbidity and mortality rates and any delay in delivery offered by cordocentesis is probably not justified. It is in the fetus whose estimated weight is below 1500 gm that cordocentesis should be used. If the results are normal, expectant management and the administration of corticosteroids will allow for pulmonary maturation and a more favorable outcome.

A random single Doppler study of the umbilical artery in the evaluation of pregnancies complicated by diabetes

To evaluate a random single Doppler study of the systolic to diastolic ratio of the umbilical artery as a predictor of perinatal outcome in diabetic pregnancies, a prospective double-blind study was performed in 92 diabetic pregnant women between 28 and 40 weeks of gestation. Main outcome measures were perinatal outcome: group A, normal outcome; group B, poor outcome. The sensitivity and specificity of the Doppler studies as a predictor of poor perinatal outcome were 39% and 92%, respectively. The positive and negative predictive values were 54% and 86%, respectively. Our results suggest that the systolic to diastolic ratio of the umbilical artery offers no advantage over other well-established tests in the management of diabetic pregnancies.

Recovery of ovarian function after laparoscopic detorsion

In an attempt to preserve ovarian function, we managed 58 women with adnexal torsion by laparoscopic detorsion. Follow-up ultrasound examinations were performed on 54 of the women. Follicular development was evident in 49 of 52 (94.2%) women with normal-sized ovaries. We conclude that ovarian function returns in the majority of women with adnexal torsion managed conservatively.

Gonadotrophin-releasing hormone agonist compared with human chorionic gonadotrophin for ovulation induction after clomiphene citrate treatment

The objective of this study was to compare hormonal response, luteal phase adequacy and pregnancy and abortion rates in patients randomized to receive human chorionic gonadotrophin (HCG) or gonadotrophin-releasing hormone agonist (GnRHa) during ovulation cycles stimulated by clomiphene citrate. Anovulatory patients received either one s.c. dose of tryptorelin (0.1 mg; n = 104) or one i.m. dose of HCG (10,000 IU; n = 106) after clomiphene citrate stimulation had induced enlarged ovarian follicles (> 17 mm in diameter). A short-lived, transitory increase in serum luteinizing hormone (98 +/- 9 IU/l) and follicle-stimulating hormone (30 +/- 5 IU/l) concentrations was measured at 12 h following the injection of GnRHa, and these concentrations returned to baseline levels by 36 h post-injection. Midluteal progesterone concentrations were similar in both groups (> 10 ng/ml), and the mean luteal phase duration was also not significantly different (13 days). There were no significant differences in the mean number of pregnancies (12.0 versus 12.6% per cycle) and the abortion rate (18.2 versus 12.5%) between the GnRHa- and HCG-treated groups respectively. There were no complications related to treatment in either group. The results show that a relatively low dose of GnRHa can be used in place of HCG to induce ovulation in clomiphene citrate-treated patients.

Induction of pre-ovulatory gonadotrophin surge with gonadotrophin-releasing hormone agonist compared to pre-ovulatory injection of human chorionic gonadotrophins for ovulation induction in intrauterine insemination treatment cycles

The clinical outcome of intrauterine insemination (IUI) treatment cycles employing a gonadotrophin-releasing hormone agonist [GnRHa, triptorelin (Decapeptyl)] or human chorionic gonadotrophin (HCG) for ovulation induction was compared. A group of 48 patients presenting with amenorrhoea, oligomenorrhoea or unexplained infertility were all treated with human menopausal gonadotrophins (HMG) from day 5 of the cycle, on an individualized schedule. They were then randomly divided into two groups to receive either a single s.c. injection of 0.1 mg triptorelin or a single i.m. injection of 10,000 IU HCG after follicular maturation. IUI was performed approximately 24 and 48 h following the injection. A transitory increase in serum luteinizing hormone and follicle stimulating hormone concentrations was achieved following injection of GnRHa. A total of 24 patients received 72 treatment cycles with GnRHa, producing 11 conceptions (15.3%) and two abortions (18.2%), resulting in a term pregnancy rate of 13.6%. There were four cases of grade 3-4 ovarian hyperstimulation syndrome (OHSS), two of which were conception cycles. In all, 24 patients underwent 68 cycles treated with HCG, producing 18 conceptions (26.5%) and six abortions (33.3%), resulting in a term pregnancy rate of 19.0%. There were eight cycles of grade 3-4 OHSS, two of which were conception cycles. These results show that an s.c. injection of a relatively low dose of GnRHa can be as effective as HCG in producing pregnancy in IUI treatment cycles.

Decreased incidence of severe ovarian hyperstimulation syndrome in high risk in-vitro fertilization patients receiving intravenous albumin: a prospective study

The administration of human serum albumin has been reported to prevent severe ovarian hyperstimulation syndrome (OHSS) while undergoing ovarian stimulation protocols for in-vitro fertilization (IVF). This prospective, randomized study investigated the effectiveness of a single dose of human serum albumin (20 g) administered i.v. immediately after oocyte retrieval. Women enrolled in the IVF programme were treated with long gonadotrophin-releasing hormone agonist, triptorelin, and an individually-adjusted human menopausal gonadotrophin protocol. The criteria for inclusion in the study were young age, non-obesity, oestradiol concentration > 9200 pmol/l on the day of human chorionic gonadotrophin administration and > 20 follicles > 14 mm diameter as observed by transvaginal sonography. The treatment group (n = 22) received albumin while the control group (n = 18) did not. Patients were followed-up using ultrasound every 3 days. There was a significantly higher number of severe OHSS cases in the control group (n = 4) than in the treatment group (n = 0) (P = 0.035). Where the data base was restricted to patients with an oestradiol concentration > 15,000 pmol/l, the difference between control and treatment groups was highly significant (P = 0.008). These findings support the use of i.v. albumin in preventing severe OHSS during IVF treatment.

Comparison of 12- and 72-hour expectant management of premature rupture of membranes in term pregnancies

OBJECTIVE

To compare 12-hour and 72-hour expectant management of premature rupture of membranes (PROM) in singleton term pregnancies.

METHODS

In a prospective, nonrandomized study, 566 low-risk women with singleton term pregnancies presenting with PROM were assigned to either 12-hour or 72-hour expectant management. Patients who had not entered labor at the end of the assigned period were induced with oxytocin. The pregnancy outcome of both methods was compared with regard to infectious complications and method of delivery.

RESULTS

There was no statistical difference in the rate of chorioamnionitis between the 12-hour and 72-hour expectant management groups (11.7 versus 12.7%; relative risk [RR] 0.9, 95% confidence interval [CI] 0.6-1.5; P = .83). Cesareans were performed to a similar degree in both groups (4.7 versus 6.7%; RR 0.7, 95% CI 0.3-1.4; P = .39). Fifty-five percent of the 12-hour group underwent oxytocin induction, compared with 17.5% of those in the 72-hour group (RR 5.8, 95% CI 3.9-8.5; P < .001). Women undergoing induction after 72-hour expectant management had an increased risk of cesarean delivery compared with those after a 12-hour wait (RR 5.9, 95% CI 2.3-15.1; P < .001). Overall, women in the 12-hour group had shorter admission-to-discharge times than the 72-hour group (5 versus 6 days, 95% CI of the difference 0.6-1.3; P < .01).

CONCLUSION

Regimens of 12-hour and 72-hour expectant management of PROM are comparable regarding infectious complications and pregnancy outcome. However, the longer wait prolongs the interval to delivery and increases hospitalization costs.

[Laparoscopic surgery]

Laparoscopy is a common and important technique in gynecology, oncology and general surgery. At first laparoscopy was used only as a diagnostic tool, but today it is also used for operations. We describe our experience with laparoscopies in 1155 patients, 923 of which were operative and 232 for diagnosis. Complications included: herniation (2 cases), subcutaneous hematoma (16), wound infection (6) and serous discharge (2). The laparoscopic technique is highly successful and efficient for both diagnosis and surgery. The complication rate is lower, hospitalization and recovery times shorter, and the cosmetic results are excellent.

Limited role for intratubal methotrexate treatment of ectopic pregnancy

OBJECTIVE

To test the effectiveness of laparoscopic intratubal methotrexate (MTX) injection or salpingostomy in the treatment of ectopic pregnancy (EP).

DESIGN

Prospective predefined protocol.

SETTING

Department of Obstetrics and Gynecology of a university-affiliated hospital.

PATIENTS AND INTERVENTIONS

Between January 1988 and December 1993, we treated 342 women with EP, of which 99 were treated by either laparoscopic salpingostomy (n = 55) or intratubal MTX injection (n = 44).

MAIN OUTCOME MEASURES

The success and failure rates were calculated for each treatment protocol. Also analyzed were subsequent tubal patency and fertility rates.

RESULTS

Salpingostomy was successful in 51 of 55 patients (92.7%), whereas intratubal MTX injection was successful in only 27 of 44 women (61.4%). Methotrexate injection particularly was unsuccessful if the initial hCG was > 2,000 mIU/mL (conversion factor to SI unit, 1.00) or the size of the tubal mass was > 2.0 cm as measured during laparoscopy. There was no difference in the subsequent tubal patency rates of fertility rates between women undergoing MTX injection or salpingostomy.

CONCLUSIONS

These results suggest that salpingostomy is effective in the treatment of EP. Methotrexate injection failed in more patients despite preferential selection criteria, suggesting that its use should be limited to the subgroup of women with initial hCG < 2,000 mIU/mL and size at laparoscopy < 2.0 cm.

Spontaneous resolution of ectopic tubal pregnancy: natural history

OBJECTIVE

To determine the characteristics and long-term outcome of women succeeding or failing expectant management of ectopic pregnancy (EP).

DESIGN

Prospective, defined protocol.

SETTING

University-affiliated gynecology department.

PATIENTS

We used a protocol that selected women with laparoscopic confirmed ectopic tubal pregnancy and declining plasma hCG values. Over a 5-year period, 60 women representing 20.1% of EPs fulfilled the inclusion criteria. Women were followed with serial hCG testing and transvaginal ultrasound.

MAIN OUTCOME MEASURE

Success or failure of expectant management.

RESULTS

Expectant management was successful in 28 (47.7%) of the patients. Thirty-two (53.3%) failed expectant management, and a treatment procedure was required. There was no difference in the resultant ipsilateral tubal patency or 1-year fertility rates of those women succeeding or failing expectant management. Analysis showed that in the face of declining values and with a starting hCG > 2,000 mIU/mL (conversion to SI unit, 1.00), 93.3% failed expectant management, whereas < 2,000 mIU/mL, 60.0% succeeded.

CONCLUSION

We conclude that expectant management should be offered as a treatment option only in those women fulfilling the criteria for a good prognosis.

Superovulation and intrauterine insemination in the treatment of male factor infertility

Recent studies report that superovulation combined with intrauterine insemination (IUI) is more successful than superovulation alone, IUI alone or superovulation with intracervical insemination in couples with male subfertility. Our study evaluated two superovulation protocols in the management of male factor infertility using IUI: (A) clomiphene citrate and human chorionic gonadotropin (HCG) and (B) human menopausal gonadotropin and HCG. Fifteen couples with severe oligoasthenozoospermia (OAS) were treated with protocol A in 54 cycles, and no pregnancies were achieved. Eight of the 15 couples with severe OAS subsequently received protocol B for 24 cycles and elicited no pregnancies. Thirty-seven couples with moderate OAS received protocol A for 169 cycles, and 2 pregnancies ensued (5.4% per couple and 1.12% per cycle). Twelve of the 35 nonpregnant couples with moderate OAS then received protocol B for 31 cycles, and 4 pregnancies were recorded (33.3% per couple and 12.9% per cycle).

[Neonatal alloimmune thrombocytopenia]

Neonatal alloimmune thrombocytopenia (NAIT) was first described in the 1950s. The disease results from maternal antiplatelet antibodies against surface antigens on fetal platelets due to feto-maternal platelet incompatibility. Although NAIT is transient, during its active phase thrombocytopenia can cause intracranial hemorrhage with grave neurological sequelae or death. We characterized the alloimmune antibodies in 29 mothers and found anti-HPA-1a (in 11 cases), anti-HPA1b (1), anti-HPA-5a (1) and anti-HPA-5b (5). In 11 women no specific antibodies were identified despite characteristic disease in the newborns. 3 neonates in the anti-HPA-1a, and 1 in the anti-HPA-1b groups were born with intracranial hemorrhage and are severely disabled. We described a case of successful prenatal treatment by a combination of steroids, high-dose immunoglobulins and intraumbilical platelet transfusion in a mother known to have anti-HPA-1, whose previous child was severely affected. It is important to examine antibodies in any woman whose neonate has thrombocytopenia of unknown etiology.

Sonographic presentation of Hirschsprung's disease. A case of an entirely aganglionic colon and ileum

Prenatal sonographic presentation of Hirschsprung's disease has been considered non-specific and uncommon. This report presents a second-trimester fetus with an aganglionic colon and ileum diagnosed by the sonographic presentation of dilated fetal bowel loops, increased abdominal circumference, and mild polyhydramnios. The prenatal sonographic diagnosis of Hirschsprung's disease helped to expedite early neonatal treatment.

Postpartum thrombotic thrombocytopenic purpura: report of a case and review of the literature

Thrombotic thrombocytopenic purpura (TTP) is a severe multisystem disease of unknown etiology that reaches its peak incidence when the patient is between ages 20 and 40 years; it is more common in women than in men. Since 1966 there have been six reported cases of TTP occurring in the puerperium. A patient who developed TTP 24 hours after cesarean delivery is described, and the literature regarding TTP occurring in the puerperium is reviewed. Although this patient responded to plasma infusion, the recent literature suggests that plasmapheresis is the treatment of choice for TTP.

Routine thyroid function tests in infertile women: are they necessary?

To investigate the yield of routine thyroid function testing in infertile women, the records of 444 infertile women were categorized to standard infertility groups. Thyroid function was evaluated by measuring plasma free thyroxine and thyroid-stimulating hormone. All free thyroxine values were in the normal range (0.8 to 1.8 ng/ml), and only three thyroid-stimulating hormone values were higher than the normal range (0.15 to 4.5 mIU/L). The three women had ovulatory dysfunction. Thyroid function testing is more prudent in screening the subset of infertile women with ovulatory dysfunction and not as a routine measure in the infertile population.

Prenatal diagnosis of congenital dysgranulopoietic neutropenia

Congenital dysgranulopoietic neutropenia is a severe life-threatening disease characterized by specific dysmorphic granulocytes. Prenatal diagnosis of congenital neutropenia was reported first in 1983. In 1989 we reported a family with congenital dysgranulopoietic neutropenia in two siblings (one male and one female); in 1992 the mother became pregnant and prenatal diagnosis was performed by cordocentesis. The results we obtained from the fetus at risk enabled us to suggest that it was not affected, and we advised the parents that the pregnancy could continue: a healthy female was born. The neutrophil count at 2 and 4 months was normal.

[Pulmonary sequestration detected by ultrasound]

Pulmonary sequestration is part of the spectrum of bronchopulmonary foregut anomaly. It is a rare type of congenital malformation in which a mass of pulmonary tissue is separate from the normal lung and receives its arterial supply directly from the systemic circulation. Angiographic demonstration of a systemic artery leading to the sequestrated lung has usually been used to diagnose this condition. In the past 10 years cases of this rare anomaly have been detected and diagnosed by ultrasonography in the pre- and postnatal period. We describe a very rare case of intraabdominal, extralobar pulmonary sequestration detected in the antenatal period. Ultrasonography showed a hyperechoic subdiaphragmatic mass above the left kidney, near the aorta. In the mass were 2 echo-free vascular structures. 2 arterial branches originating from the abdominal aorta which traversed the subdiaphragmatic mass. The near-diaphragmatic location of many pulmonary sequestrations provides an excellent acoustic window for sonographic detection. MRI can help in the diagnosis when ultrasonographic findings are equivocal. Ultrasound and MRI will soon replace aortic angiography in the diagnosis of this condition in the pre- and postnatal period, pulmonary sequestration should be included in the differential diagnosis of upper abdominal masses identified by ultrasonography.

Ultrasound controlled operative hysteroscopy

BACKGROUND

Uterine perforation is one of the risks of operative hysteroscopy. Although usually performed alone, laparoscopy has been recommended to aid the surgeon in preventing uterine perforation at the time of operative hysteroscopy.

STUDY DESIGN

Since women suffering from infertility or habitual abortion with known or suspected intrauterine pathologic factors are at low risk for secondary pelvic abnormalities, we have been using ultrasound for control during operative hysteroscopy in these women. One hundred twenty-eight women underwent ultrasound-guided operative hysteroscopy.

RESULTS

There were no complications, such as uterine perforation, during or after any of the procedures.

CONCLUSIONS

Women with known intrauterine pathologic factors should be offered operative hysteroscopy controlled by ultrasound, avoiding the use of unnecessary laparoscopy.

Intraamniotic infection with Candida albicans successfully treated with transcervical amnioinfusion of amphotericin

We present a case in which a pregnant woman was seen at 27 weeks' gestation with premature rupture of membranes and intraamniotic infection with Candida albicans, which was treated with transcervical amnioinfusion of amphotericin B. After 7 days of treatment spontaneous vaginal labor developed. A female newborn of 1030 gm was delivered. The infant was normal and did well.

Laparoscopic management of adnexal cystic masses in postmenopausal women

OBJECTIVE

To evaluate laparoscopic treatment of postmenopausal women with an adnexal cystic mass predicted to be benign.

METHODS

Selection criteria were transvaginal sonographic appearance other than a complex cyst and a normal serum CA 125 level. During the period May 1988 to June 1993, 55 women fulfilled the criteria and underwent operative laparoscopy. During the same period, 75 postmenopausal women underwent exploratory laparotomy for an adnexal cystic mass that was complex in appearance or associated with elevated serum CA 125.

RESULTS

Laparoscopic bilateral oophorectomy was performed in all 55 women. All had benign masses (positive predictive value 100%). Malignant tumors were found in 23 of the 75 women undergoing laparotomy (negative predictive value 30.7%). There was no significant difference in size of the tumors between women undergoing laparoscopy or laparotomy.

CONCLUSION

Because of its safety and efficacy, laparoscopic management is the preferred procedure in postmenopausal women with a non-complex adnexal mass and a normal CA 125 level.

Comparison of first-trimester transvaginal amniocentesis with chorionic villus sampling and mid-trimester amniocentesis

Between August 1989 and December 1991, 356 patients underwent first-trimester transvaginal amniocentesis (10-12 weeks). The same number of patients referred in the same period for mid-trimester amniocentesis (14-21 weeks) was matched also for maternal age and indication. A third group consisted of the first 356 cases in which chorionic villus sampling (CVS) was attempted. The overall success rate was 99.7 and 100 per cent for early and mid-trimester amniocentesis, respectively, and 97.2 per cent for CVS. The mean harvesting time was 12.8, 11, and 7.9 days, respectively. The percentage of patients rescheduled was 3.4 per cent in first-trimester amniocentesis, 1.7 per cent in mid-trimester amniocentesis, and 6.2 per cent in the CVS group. The early (less than 2 weeks) pregnancy loss was 1.7 and 0.6 per cent in early and mid-trimester amniocentesis, respectively, and 1.7 per cent in CVS. The total pregnancy loss was 3.2, 0.9, and 2.9 per cent, respectively. The rate of preterm birth was 6.0, 5.2 and 6.9 per cent, respectively. The results indicate that CVS has the shortest procedure-result interval, but the highest rescheduling rate. First-trimester amniocentesis has a higher procedure and laboratory success rate but, until otherwise proved, mid-trimester amniocentesis is the most efficient and safest procedure.

Induction of pre-ovulatory luteinizing hormone surge by gonadotrophin-releasing hormone agonist for women at risk for developing the ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a major risk in patients undergoing ovulation induction protocols. Withholding injection of human chorionic gonadotrophin (HCG) may prevent the development of OHSS, but can also result in failure to ovulate and conceive. We have used a gonadotrophin-releasing hormone agonist (GnRHa) as an alternative to HCG in women not undergoing in-vitro fertilization in an attempt to prevent OHSS. The study included 12 cycles in 12 women scheduled for ovulation induction with human menopausal gonadotrophin (HMG) who were at risk of developing OHSS (oestradiol > 3500 pg/ml, number of follicles > 20). GnRHa was injected to induce the pre-ovulatory, luteinizing hormone surge which triggers follicular maturation. Progesterone was administered for luteal support. Six pregnancies were achieved, and none of the 12 women developed OHSS. Since the pregnancy rate in this study was acceptable, we can recommend the use of GnRHa instead of HCG in any case at risk of developing OHSS.

A successful pregnancy after bone marrow transplantation for severe aplastic anaemia with pre-transplant conditioning of total lymph-node irradiation and cyclophosphamide

Pregnancy after bone marrow transplantation (BMT) for severe aplastic anaemia (SAA) is now an encouraging reality. We present a successful pregnancy, 4 years after BMT for SAA, in a woman being immunosuppressed before transplantation with cyclophosphamide and total lymph-node irradiation (TLI). No fetal complication was diagnosed.

[Colonic carcinoma during pregnancy]

A case of adenocarcinoma of the splenic flexure during pregnancy is reported. A 27-year-old woman was admitted at 34 weeks of pregnancy with abdominal pain and vomiting. 36 hours after normal delivery an emergency exploratory laparotomy was performed for intestinal obstruction. A huge tumor of the splenic flexure with retroperitoneal extension was found. She died 1 year later of metastatic disease. Delay in diagnosis and complications of colonic cancer are more prevalent in pregnancy. While colonic carcinoma during pregnancy is extremely rare, it should be included in the differential diagnosis of colonic symptoms. The 24th case of this type is reported.

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.

Exogenous estrogen therapy concurrent with clomiphene citrate--lack of effect on serum sex hormone levels and endometrial thickness

The antiestrogenic action of clomiphene citrate (CC) is claimed to have an adverse effect on the development of the secretory endometrium. This effect can be assessed: (1) sonographically by measuring endometrial thickness, and (2) by serum hormone levels. The aim of this study was to evaluate whether administering ethinyl estradiol (EE) during CC treatment has any effect on endometrial thickness and/or hormone levels. Seventeen patients were treated with CC for one cycle and with CC plus EE in an adjacent cycle either before or after. The patients were followed by daily assessment of endometrial thickness, follicular growth and serum estradiol levels as well as midluteal prolactin and progesterone levels. We did not find any significant difference in either endometrial thickness, estradiol level, midluteal prolactin or progesterone levels between the two treatment protocols. We conclude that exogenous EE, in the dosage used in this study, does not overcome CC-induced alterations in endometrial thickness.

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.