Methotrexate treatment for retained placental tissue

Three cases of placental polyps not responding to conventional medical and surgical treatment are presented. In all three cases, hCG in serum was negative but despite this a single injection of methotrexate successfully treated the condition. It is suggested that methotrexate acts not only on dividing trophoblastic cells but also has other effects.

Amniotic septostomy for the treatment of twin oligohydramnios-polyhydramnios sequence

OBJECTIVE

To report our experience with intentional puncture of the intervening membrane ('septostomy') for the treatment of the twin oligohydramnios-polyhydramnios sequence (TOPS).

METHODS

12 patients were diagnosed with TOPS based on ultrasonographic findings. A 20- to 22-gauge spinal needle was used to puncture the membrane between the twins without any attempt at amnioreduction in 9 patients, while the procedure was combined with amnioreductions in 3 patients.

RESULTS

Gestational age was 23.1 +/- 3.3 weeks at the time of septostomy and 31.1 +/- 4.4 weeks at delivery. Rapid accumulation of fluid around the 'stuck' fetus occurred in all cases following a single procedure. Three of the 24 fetuses died in utero and 1 died on the fifth day of life, for a combined survival of 83.3%. In the survivors, the septostomy to delivery interval ranged between 0.6 and 13 weeks (mean +/- SD 8.3 +/- 4.8).

CONCLUSION

Amniotic septostomy is a promising new method for the management of TOPS and is associated with survival rates that are better than, or comparable to, more invasive modalities. A multicenter trial comparing septostomy to other modalities is warranted.

Human chorionic gonadotropin patterns in early pregnancy after assisted reproduction

BACKGROUND

Assisted reproduction implies increased risks of pathological pregnancy, necessitating close follow up of early pregnancy. The use of serum hCG levels two and three weeks after embryo transfer for prediction of pregnancy outcome after in vitro fertilization-embryo transfer (IVF/ET) or gamete intrafallopian transfer (GIFT) was evaluated.

METHODS

Three hundred and twenty-nine treatment cycles were included. Serum samples were obtained on days 14 and 21 after ET and hCG was determined by fluoroimmunoassay. Receiver operating characteristic (ROC) curves were analyzed to find cut-off levels of hCG giving maximal sensitivity and specificity, identifying a low risk group and a high risk group with regard to pathological pregnancy.

RESULTS

The group of patients carrying a viable pregnancy had significantly higher hCG levels two and three weeks after ET than the group of patients carrying a pathological pregnancy. Furthermore, the daily increase in hCG was higher. In multiple gestations, the levels of hCG were significantly higher compared to singleton pregnancies. Ninety per cent of the patients with an hCG level > or = 150 IU/L 13-15 days after ET carried a pregnancy to term (the low risk group). Conversely, 50% of the patients with hCG < 150 IU/L carried a pathological pregnancy (the high risk group).

CONCLUSION

A single determination of the hCG level two weeks after ET, combined with transvaginal ultrasound two to three weeks later, is a reliable follow-up. In cases of subnormal hCG levels (< 150 IU/L), a second hCG determination one week later followed by sonography is recommended.

Transrectal electroejaculation in combination with in-vitro fertilization: an effective treatment of anejaculatory infertility after testicular cancer

Treatment of non-seminomatous testicular cancer often leads to infertility due to anejaculation/retrograde ejaculation and poor sperm quality. In these men spermatozoa may be obtained by transrectal electroejaculation (TE), but the optimal strategy for assisted procreation in these couples is not known. Our aim was to examine whether TE and conventional in-vitro fertilization (IVF) would be successful. A total of 10 couples, with long-standing infertility due to anejaculation or retrograde ejaculation after treatment for testicular cancer 5-14 years earlier, were referred to our unit. All men underwent diagnostic TE under general anaesthesia. Spermatozoa were recovered in nine cases. The antegrade fraction was prepared and used for IVF. Sperm quality was variable and conventional IVF was considered impossible in three cases. Altogether six IVF treatment cycles in six couples resulted in five pregnancies, of which four resulted in a delivery and one resulted in a spontaneous abortion. One additional pregnancy is ongoing after transfer of cryopreserved embryos. The fertilization rate was 54% (33/61) and the cleavage rate was 97% (32/33). No complications relating to the procedure have been encountered.

Assisted ejaculation combined with in vitro fertilisation: an effective technique treating male infertility due to spinal cord injury

Infertility due to spinal cord injury (SCI) in males has been identified for decades as an area of major concern and techniques for assisted ejaculation are available. There has not been an overall consensus regarding which type of assisted procreation is the most appropriate for these couples. We describe here our experience from a programme based on assisted ejaculation combined with in vitro fertilization (IVF). Twelve couples have been treated so far and altogether 22 cycles with ovum pick-up have been completed. Fertilisation of the oocytes was obtained in 18 of these cycles. The overall oocyte fertilisation rate was 49%. Embryo transfer took place in 17 cycles, leading to seven clinical pregnancies. Four of the pregnancies are delivered or are ongoing, whereas three ended in first trimester spontaneous abortion. Thus our initial experience suggests that assisted ejaculation in combination with IVF is an effective option for these couples.

Complex genetic counseling and exclusion of Duchenne muscular dystrophy in a twin pregnancy after in vitro fertilization (IVF)

A twin pregnancy following in vitro fertilization-embryo transfer coincidentally at risk for the X-linked recessive Duchenne muscular dystrophy is described. First-trimester prenatal diagnosis by transabdominal chorionic villus samplings on the dichorionic placentae and molecular linkage analysis could exclude the disorder in both fetuses. Genetic counseling and prenatal diagnosis were particularly complex due to the twin pregnancy, the need for linkage analysis, and confined placental mosaicism 45,X/46XX in one of the fetuses. All parties should be aware that additional invasive diagnostic procedures in the second trimester might be required. It is proposed that, in similar situations, only one, arguably two, fertilized egg be transferred at a time to facilitate prenatal diagnosis and decision making for these rare couples. This problem, however, may be increasingly overcome by preimplantation diagnosis.

[Diagnosis of intrauterine growth retardation--comparison of clinical findings, total oestrogen determination from 24-hour urine and ultrasound biometry (distance measurement, biparietal head diameter and thoraco-abdominal transverse diameter) considering the antepartal and subpartal CTG's]

This article presents the results of clinical examination, total oestrogen determination from 24-h urine and ultrasound biometry -- measurement of the biparietal head diameter and the thoraco-abdominal transverse diameter (under routine conditions) -- for diagnosing intrauterine growth retardation (IUGR). In addition, the antepartal and subpartal CTG's are evaluated in cases of foetal retardation of growth "Single determinations" are confronted with so-called "serial examinations (= observation of the course)". Repeated clinical examinations and multiple determinations of the total oestrogen elimination with the 24-h urine did not result in any clear improvement of the detection rates of deficient development of the foetus (discovery rate with clinical examination = 54%, total oestrogen determination = 60%); there was, in fact, a relatively high rate of false-positive diagnosis (false-positive diagnoses on clinical examination = 31%). On the other hand, simple ultrasound biometry (distance measurements) led to the discovery of about 78% of all foetal growth retardations (perc. less than 10), the false-positive diagnoses rate being only 9%. Pathological antepartal CTG's (less than 8 points according to the Meyer-Menck score) were seen in about 27% of the cases with growth retardation -- with, however, an approximately equal rate of pathological CTG's in newborn of "normal weight". The discovery rate of deficient development of the foetus has been increased by combining ultrasound biometry with the total oestrogen determination from the 24-h urine, to 88% (perc. less than 10). The same applies to the combination of ultrasound biometry with the clinical examination (rate of detection: 87%). Up to 77% of all cases with IUGR have been discovered both by combining the clinical examination with the total oestrogen determination or antepartal CTG, as well as by combining total oestrogen determination with antepartal CTG.

[Ultrasound diagnosis of omphalocele during the first trimester of pregnancy (author's transl)]

Ventral defects in the fetus occur in 1/3200 to 1/10,000 deliveries. Prognosis for the newborn is mostly fatal since these anomalies are frequently combined with other congenital anomalies. A through ultrasound study of the fetus in its longitudinal and transverse diameter permits the antenatal diagnosis of this severe fetal anomaly. The earliest diagnosis of the fetal omphalocele in the first trimester of pregnancy is described in detail in this paper.

Monitoring of HMG-stimulated follicular development by real-time ultrasound

Monitoring of human follicular development by real-time ultrasound during HMG-HCG treatment is presented. With the aid of ultrasound monitoring, the ovulation rate is raised to 94.3% (formerly 80% without ultrasound). Serious side effects such as ascites and/or hydrothorax did not occur in this study (1.2% without ultrasound controls). The pregnancy rate was 21/47 (44%) of all hormonally treated patients. By means of real-time sector scan examination, the growing follicle could be detected in 103/106 (97.3%) of HMG-HCG treated cycles. Thus real-time ultrasound examinations provide results comparable to those achieved mostly by time-consuming compound scan in demonstration of the growing follicle.

[Foetomaternal transfusions after amniocentesis in early pregnancy - evaluation of 1,000 cases (author's transl)]

The foetal haemoglobin (HbF) content was determined before and 2 hours after amniocentesis in 1,000 cases of amniocentesis conditioned by genetic indication (between the 15th and 20th pregnancy week). HbF-identification was effected according to the method of Kleinhauer and Betke. In primarily (before amniocentesis) negative HbF findings, HbF positive findings after amniocentesis were obtained in 7.2% of the patients. However, if the HbF-determinations were positive already before amniocentesis, a quantitative increase of HbF-cells in the maternal blood smear after amniocentesis was observed in 15.9% of the patients. Patients with punctures in the case of placenta of the anterior wall showed and increase in HbF values after amniocentesis in 12.2% of the cases, compared against 8.9% only in patients with posterior wall placenta, but these differences were statistically not significant. Amniocentesis under ultrasonic visual control caused a drop in the number of repeated amniocentesis trials to 20/500, aspiration of bloodstained amniotic fluid to 3.6% and HbF-cell positive blood smears after amniocentesis to 7%. (Free-hand-needle-technique: amniocentesis failures 42/500, amniotic fluid samples contaminated with blood in 9.6% of the cases and increases in HbF-values after amniocentesis in 12.6% of the cases). A total of 82 Rh-negative patients were given conventional anti-D-prophylaxis independent of the localisation of placenta. No sensitization was observed in any of the cases. No boosting was caused by early amniocentesis in cases where a positive anti-body finding had been established (3 cases to date).

[Genetic amniocentesis: technique and results in 1,000 first trimester amniocenteses (author's transl)]

The results of 1,000 transabdominal amniocenteses between 15 and 20 weeks gestation are reported. The method is described. The bio-chemical and cytogenetic results are reported. - Amniocentesis in the first trimester is not a routine investigation since fetal and maternal risks are associated with this procedure. The risk of abortion following amniocentesis was lowered from 6/1000 to 2/500 by improvement of the technique under ultra-sound control. The worst maternal complication observed was a septic abortion one day after amniocentesis. 96% of all cyto-genetic examinations showed normal karotypes. The largest group at risk were mothers over 35 years of age. In this group chromosome anomalies were found in 17 cases. All neural tube defects were found by determination of the alpha-fetoprotein in the amniotic fluid. 26 terminations of pregnancy for fetal indications were carried out. Two patients refused therapeutic abortions despite trisomy 21 for ethical reasons. One patient continues her pregnancy with a 47 XYZ pregnancy.

Toxemia of pregnancy: assessment of fetal distress by urinary estriol and circulating human placental lactogen and alpha-fetoprotein levels

The efficacy of three biochemical methods for the detection of fetal distress was assessed in a prospective study of 224 singleton pregnancies complicated by toxemia. Fetal distress was diagnosed in 65 cases (29 per cent). Abnormally low urinary estriol (E3) excretion pointed out 63 per cent, low serum levels of human placental lactogen (HPL) 27 per cent, and elevated maternal serum alpha fetoprotein (AFP) 10 per cent of distressed fetuses. The efficacy of each test increased with the severity of maternal disease. The frequencies of false pathologic levels were: E3 19 per cent, HPL 0 per cent, and AFP 1 per cent of the cases with a normal fetal outcome. Although E3 was by far the most effective marker, abnormal levels of HPL and AFP provided supportive evidence for fetal distress by pointing out those cases in which E3 reading was not a false positive.

Prediction of fetal outcome by urinary estriol, maternal serum placental lactogen, and alpha-fetoprotein in diabetes and hepatosis of pregnancy

Urinary estriol, serum placental lactogen (hPL), and alphafetoprotein (AFP) levels were investigated in singleton pregnancies of 75 diabetic women and 84 women with obstetric hepatosis. Fetal distress was demonstrated in 19 diabetic patients (25%) and in 18 cases of obstetric hepatosis (21%). Low urinary estriol correctly predicted fetal distress in 26% of the cases of diabetes and in 29% of the cases of hepatosis. False pathologic readings were found in 9% of pregnancies in either group. Diabetes was associated with higher than normal hPL levels with overlap of levels between cases with fetal distress and normal outcome. hPL levels were higher than normal and correctly predicted fetal distress in 2 of 18 cases of hepatosis (11%) with no false pathologic values. In diabetes, AFP predicted fetal distress in 2 of 4 cases in which a subsequent perinatal death occurred, and 1 additional case of fetal distress. False pathologic values were found in 4% of cases. Maternal AFP levels were normal in 2 cases of closed neural tube anomalies. In cases of hepatosis, AFP gave no information. In combination, estriol and AFP determinations gave correct information in 35% of diabetic pregnancies with pernatal morbidity or death. In hepatosis, estriol and hPL pointed out 33% of the cases of fetal distress.

Prediction of fetal outcome in threatened abortion by maternal serum placental lactogen and alpha fetoprotein

Abnormally low human placental lactogen (HPL) or high alpha fetoprotein (AFP) levels in maternal serum are unfavorable prognostic signs in women with threatened abortion but normal levels cannot be used to discriminate between viable and nonviable pregnancies. Out of 112 women with threatened abortion, 69 aborted; of these, 36 had a low HPL level and they all aborted. Five women had an increased AFP concentration. Four of these aborted and the remaining case was a twin pregnancy in which one fetus died and the other survived. HPL and AFP levels provide complementary information as to the fetal outcome in threatened abortion. This was indicated by a normal HPL level in all of the five cases with raised maternal AFP, and by a normal AFP level in 35 of the 36 women with low maternal HPL.