[Open heart surgery with extracorporeal circulation during pregnancy]

The incidence of heart disease in pregnancy has been gradually falling during the last three decades. Cardiopathy still remains a prominent cause of maternal and fetal morbidity and mortality. Most patients know about their heart disease long before conception, even though the potential risk factors of deteriorating cardiac function during pregnancy are generally not emphasized. These women when pregnant may develop heart failure due to the increased cardiorespiratory requirements. When medical therapy proves insufficient heart surgery becomes mandatory to save the patient's life. The pregnant state is not optimal for cardiac surgery as the principle interest of the mother and the fetus is different. We report on two pregnant patients who underwent unavoidable heart surgery with cardiopulmonary bypass and review the literature regarding the optimal management of open-heart operation in pregnancy aiming to decrease the feto-maternal mortality. The successful outcome of the cardiac surgery on pregnant women is determined by the severity of the preexisting disease, the surgical techniques, and the circumstances of the cardiopulmonary bypass. The best possible results can be achieved by providing preconceptional counseling for the cardiopathic patients regarding the relation between the preexisting risk factors and the adverse maternal and neonatal outcome. When heart surgery is mandatory in pregnancy the careful technical precautions and the continuous cardiotocography help to minimize fetal complications during the cardiopulmonary bypass (CPB).

The role of preoperative brachytherapy as an adjunct to surgery and postoperative radiotherapy in the treatment of stage I endometrial carcinoma

PURPOSE

Between 1978 and 1993, 817 cases of endometrial carcinoma were treated with simple hysterectomy with bilateral salpingo-oophorectomy. Five hundred and twenty-six cases had preoperative brachytherapy (Preo), and 291 cases underwent surgery without preoperative radiotherapy (Nopre). The aim of the study was to compare disease-free survival of the two groups.

METHODS AND MATERIALS

Survival comparison of the two groups was controlled for postoperative treatment type, according to stage, histological type, degree of differentiation, depth of myometrial invasion and age. The life-table method was used for survival analysis. Cumulative disease-free survival probabilities were calculated as a function of the proportion of normal remaining life elapsed from the time of diagnosis.

RESULTS

Five-year disease-free survival of patients with and without preoperative brachytherapy in stage IA, IB and IC was 93 and 93.6%, 93 and 94%, and 80 and 65%, respectively. In well differentiated tumors and poorly differentiated tumors, there was no difference in disease-free survival between patients with and without preoperative brachytherapy. Patients with moderately differentiated tumor treated with preoperative brachytherapy had significantly better disease-free survival than those without preoperative radiotherapy, however, this was confounded by uneven distribution of invasion depth.

CONCLUSION

Preoperative brachytherapy plays a limited role in the treatment of early stage endometrial carcinoma.

Placental macrophage contact potentiates the complete replicative cycle of human cytomegalovirus in syncytiotrophoblast cells: role of interleukin-8 and transforming growth factor-beta1

Although syncytiotrophoblast (ST) cells can be infected by human cytomegalovirus (HCMV), in vitro studies have indicated that ST cells do not support the complete viral reproductive cycle, or HCMV replication may occur in less than 3% of ST cells. The present study tested the possibility that placental macrophages might enhance activation of HCMV carried in ST cells and, further, that infected ST cells would be capable of transmitting virus to neighboring macrophages. For this purpose, we studied HCMV replication in ST cells grown alone or cocultured with uninfected placental macrophages. Our results demonstrated that HCMV gene expression in ST cells was markedly upregulated by coculture with macrophages, resulting in release of substantial amounts of infectious virus from HCMV-infected ST cells. After having become permissive for viral replication, ST cells delivered HCMV to the cocultured macrophages, as evidenced by detection of virus-specific antigens in these cells. The stimulatory effect of coculture on HCMV gene expression in ST cells was mediated by marked interleukin-8 (IL-8) and transforming growth factor-beta1 (TGF-beta1) release from macrophages, an effect caused by contact between the different placental cells. Our findings indicate an interactive role for the ST layer and placental macrophages in the dissemination of HCMV among placental tissue. Eventually, these interactions may contribute to the transmission of HCMV from mother to the fetus.

[Surgical management of masculine trassexualism]

The authors report on the first Hungarian case of sex-transforming operation. They present details of the social history and management of their case leading up the decision for surgery. Preoperative assessment and medication, operation technique and postoperative care are also described in detail. The case report highlights the difficult ethical and legal issues which have to be considered when such surgery is requested. Following a series of in-depth psychological, gynaecological, urological and forensic consultations that had been carried out in order to be convinced about the patients's determination for undergoing sex-transforming operation, the authors were granted legal and professional license by the Hungarian Medical Research Council to carry out the procedure. Two years after the operation, the patient commented on her full satisfaction with the care he had received.

Ovarian malignancies in childhood and adolescence

We retrospectively reviewed all cases of ovarian malignancies during a 10-year period at the Department of Obstetrics and Gynecology, University Medical School of Debrecen, Hungary. The experience with 16 cases: three epithelial tumors, one granulosa cell tumor, 11 germ cell tumors (six dysgerminoma, four teratoma, one endodermal sinus tumor), and one metastatic ovarian cancer is discussed. Malignant ovarian tumors can best be treated with conservative surgery, followed by adjuvant chemotherapy. Survival mainly depends on tumor type and stage at the time of diagnosis.

Interactions between human immunodeficiency virus type 1 and human cytomegalovirus in human term syncytiotrophoblast cells coinfected with both viruses

Human cytomegalovirus (HCMV) and human immunodeficiency virus type 1 (HIV-1) may interact in the pathogenesis of AIDS. The placental syncytiotrophoblast layer serves as the first line of defense of the fetus against viruses. We analyzed the patterns of replication of HIV-1 and HCMV in singly an dually infected human term syncytiotrophoblast cells cultured in vitro. Syncytiotrophoblast cells exhibited restricted permissiveness for HIV-1, while HCMV replication was restricted at the level of immediate-early and early gene products in the singly infected cells. We found that the syncytiotrophoblasts as an overlapping cell population could be coinfected with HIV-1 and HCMV. HIV-1 replication was markedly upregulated by previous or simultaneous infection of the cells with HCMV, whereas prior HIV-1 infection of the cells converted HCMV infection from a nonpermissive to a permissive one. No simultaneous enhancement of HCMV and HIV-1 expression was observed in the dually infected cell cultures. Major immediate-early proteins of HCMV were necessary for enhancement of HIV-1 replication, and interleukin-6 production induced by HCMV and further increased by replicating HIV-1 synergized with these proteins to produce this effect. Permissive replication cycle of HCMV was induced by the HIV-1 tat gene product. We were unable to detect HIV-1 (HCMV) or HCMV (HIV-1) pseudotypes in supernatant fluids from dually infected cell cultures. Our results suggest that interactions between HIV-1 and HCMV in coinfected syncytiotrophoblast cells may contribute to the transplacental transmission of both viruses.

Hysteroscopic vaginoscopy in the diagnosis of vaginal bleeding

Acomplete gynecological examination of young children and senile patients requires special considerations and techniques. Due to the intact hymenal ring or the very narrow, atrophic vagina, the routinely used instruments, specula, will not allow sufficient visualization. To establish exact diagnosis and apply adequate therapy, proper examination of the vagina is required. For this purpose Huffman-Huber or Cameron-Muller equipment is traditionally used (Fig. 1). A modified Foley catheter was used by Redman, further improving the obtained picture, and the application of a balloon vaginoscope has been described by Terruhn. In spite of all these developments, examinations frequently turn out to be difficult due to insufficient vaginal wall distension and bleeding. Based on our previous experience, we describe a modified vaginoscopy, using hysteroscope and continuous liquid irrigation.

[Functioning conditions of laboratories dealing with cryopreservation of human pre-embryos]

The authors discuss about the functional conditions of the Human Reproductive Laboratories dealing with the cryopreservation of the human preembryos. They determine the safety specifications and recommend documentation of the cryopreservation based on their own practice. Finally they suggest the licensing-controlling system of the Human Reproductive Laboratories concerning cryopreservation of the human preembryos.

[Ethical questions of oocyte donation]

The authors discuss about the ethical questions connected with the human egg donation. After expounding the indications of the egg donation they analyse the age limits of the donors and the recipients and the consequences of these age limits by the point of ethics. The selection of the donors, the types of them and the ethical relations of the donation rise a lot of questions. After wording the possible answers the authors state their standpoints.

Cervical cancer in young women: a poorer prognosis?

OBJECTIVE

The existence of an aggressive form of cervical carcinoma affecting young women is studied by survival analysis of a large patient population.

METHOD

Between 1969 and 1986, 1577 cases of cervical cancer were treated according to well-defined policies at the University Department of Obstetrics and Gynaecology in Debrecen, Hungary. Patients' records were reviewed to obtain data for survival analysis. Kaplan-Meier survival curves were generated for each stage and stratified for age. The log-rank test was used to compare the survival of younger and older patients at each stage. Multivariate analysis was performed to control for stage and treatment type when 5-year survival trends across four different age groups were examined.

RESULTS

Comparison of survival of patients under 35 and over 35 years of age, and also those under 40 and over 40 years of age revealed no significant differences. Five-year survival across the < 30, 30-39, 40-49 and > or = 50 years age groups showed no significant trend. No differences in survival were revealed when the comparison was controlled for stage of disease and treatment type.

CONCLUSION

Results suggest that cervical carcinoma in young women is not more aggressive than in other age groups.

Antibody-dependent enhancement of HIV-1 infection in human term syncytiotrophoblast cells cultured in vitro

We examined if Fc receptor-mediated antibody-dependent enhancement (FcR-ADE) or complement-mediated antibody-dependent enhancement (C'-ADE) of virus infection can contribute to increasing replication of HIV-1 in human syncytiotrophoblast (ST) cells. Here we report that both FcR-ADE and C'-ADE may result in enhanced virus release from HIV-1-infected ST cells. We show that FcR-ADE of HIV-1 infection in ST cells is mediated by FcRIII and other FcR(s) belonging to undetermined Fc classes and does not require CD4 receptors, whereas C'-ADE uses both CD4 and CR2-like receptors. FcR-ADE seems to be more efficient in enhancing HIV-1 replication than C'-ADE. While FcR-ADE leads to increased internalization of HIV-1, C'-ADE does not result in enhanced endocytosis of the virus. In addition, antibodies mediating FcR-ADE are reactive with the gp120 viral envelope antigen, whereas antibodies involved in C'-ADE react with the viral transmembrane glycoprotein gp41. Data suggest that both FcR-ADE and C'-ADE may contribute to the spread of HIV-1 from mother to the fetus.

[Changes in cervical fibronectin levels during pregnancy, labor and in the postpartum period]

The authors analysed the fibronectin content of the uterine cervix during pregnancy and delivery. The aim of their investigation was furnishing data to the biochemical changes during cervical maturation. The ripening of the uterine cervix during pregnancy is a result of complicated interactions between different macromolecules, where the fibronectin plays a key role. The quantitative determination of the extracellular matrix fibronectin is impossible because its extraction from tissues recently is not solved. Taking this fact in consideration the authors choose a semiquantitative method, being reliable indicator of changes in fibronectin content of uterine cervix. They took small pieces of materials from portio vaginalis uteri of 139 women being in postmenopause and premenopause, in different stages of pregnancy and parturition concerning directly after delivery. The slides were incubated, with rabbit-anti-human fibronectin-FITC. The evaluation of fluorescence happened with an Axiophot (Zeiss) microscope. Authors stated that the fibronectin content in the cervical extracellular matrix and in the cellular membrane of fibroblasts increases during the 1st trimester pregnancy. This increase can be shown in the 3rd trimester as well and it drops significantly during delivery. They could not found any relationship between the leucocyte invasion observed during delivery and the changes of cervical fibronectin content. These observations call our attention to the importance of fibronectin in cervical ripening respectively dilatation and the need of further examinations.

[Sialidase activity in cervical connective tissue during cervix maturation and dilatation during labor]

The authors obtained small pieces of materials from portio vaginalis uteri of 122 women being in postmenopause and premenopause, in different stages of pregnancy and parturition concerning directly after delivery. Different biochemical investigations of these 30-200 mgs specimens were performed to study the physiological background of its ripening process. They examined the changes in activity of sialidase which cleaves terminal sialic acids. The authors performed these investigations with the use of Triticum vulgaris (WGA) and Limulus polyphemus (LPA) agglutinins (lectins) marked with FITC. The evaluation of the lectin linkage happened with fluorescence microscope. They evaluated the whole fluorescence of extracellular matrix but separately of different extracellular matrix elements as well. From their investigations was stated that the number of WGA and LPA binding sites of the uterine cervix increases predominantly in the 1st trimester pregnancy compared to the non-pregnant state. As compared to the 1st trimester they described a slight reduction of LPA- and WGA-binding sites in the 3rd trimester. The most impressing changes of LPA and WGA binding sites in the extracellular matrix were observed during parturition. These results coincide with the authors' previous experience whereas the sialidase activity increases significantly during parturition. These data support the assumption that the terminal sialic acids and the sialidase play a recently yet not cleared role in the ripening of the human uterine cervix during pregnancy and in dilatation at the time of parturition.

Comparison of four antiemetic regimens for the treatment of cisplatin-induced vomiting

OBJECTIVE

To improve the treatment of cisplatin-induced acute emesis and vomiting, the adjuvant effect of two different doses of metoclopramide and metoclopramide plus droperidol was compared to a defined standard antiemetic regiment.

METHOD

One-hundred and twenty-one consecutive cisplatin-based chemotherapy treatments for ovarian carcinoma were randomly assigned to receive standard plus no adjuvant (control, n = 24), high-dose metoclopramide (HDM, n = 33), very high dose metoclopramide (VHDM, n = 50) and very high dose metoclopramide plus droperidol (VHDM+DP, n = 14) antiemetic treatment. The number of vomiting episodes up to 4 h after the treatment were recorded and compared in the four different antiemetic groups. The effect of the number of previous chemotherapy cycles, the strength of previous antiemetic treatments, age and stage of disease on the number of vomiting episodes was also assessed.

RESULT

The mean number of vomiting episodes during the first 4 h after the chemotherapy was 9, 6.4, 6.2 and 2.7 among patients receiving the standard HDM, VHDM and VHDM+DP antiemetic regimens, respectively. Analysis of variance of vomiting episodes confirmed significant differences between the groups (P < 0.001, F = 406.5, df = 120). The number of previous chemotherapy cycles and, to a lesser extent, the stage of disease, the strength of previous antiemetic regimens and the age showed significant correlation with the number of vomiting episodes (r = 0.443, -0.159, -0.14 and -0.009 respectively).

CONCLUSION

Substantial improvement in the control of cisplating-induced vomiting can be achieved by adding high-dose metoclopramide and droperidol to a basic antiemetic regimen consisting prochlorperazine, dexamethasone and thiethylperazine.

[Importance of prognostic factors in the prognosis of cancer of the endometrium]

126 stage I and II endometrial cancer patients were followed up for at least 5 years to evaluate the impact of surgical-pathological risk factors on the survival. Out of the prognostic variables evaluated the age and clinical stage failed to influence the 5-year survival rate. The effect on survival of factors such as low grade of differentiation and the depth of myometrial infiltration was however significant, (p < 0.01 and p < 0.001 respectively). The early local recurrence has also significant negative prognostic value (p < 0.05). This latter can be effectively prevented through the prehysterectomy suture of the external cervical os. On the basis of their findings authors suggest to consider the grade and the depth of myometrial invasion beside the clinical stage at the determination of the extension of the surgical procedure and at the decision on the administration of postoperative irradiation.

[Surgical cerclage in the treatment of cervical incompetence during pregnancy (determining the legitimacy of the procedure)]

The authors studied the effectiveness of the cervical cerclage operation in the therapy of cervical insufficiency during the pregnancy. Two Hundred sixteen pregnant women took part in this trial in whose pregnancy the necessity of cerclage operation was not unequivocal. It means, that the therapeutical cerclage operation was not necessary, but the necessity of prophylactic cerclage operation was doubtful as well. From the randomized 216 cases they performed cerclage operation in 108 pregnancies and in 108 cases they did not perform it. In the respect of pregnancy care they did not make any difference between the two groups. The authors from their trial draw the conclusion, that in doubtful cases where the necessity of cervical cerclage operation is not unequivocal--e.g. at serious gestational case history--it is advisable to perform the operation. The danger of premature birth can be diminished in this way.

[The role of different committees and individuals in the ethical position on the new methods of human reproduction]

Due to the research on assisted human reproduction and the application of its results we face new type ethical dilemma which had never existed before. The traditional system of ethical values does not provide a safe basis for judgement of our actions. One of the challenging questions is who has the right to authorize or prohibit performing different procedures. There might be necessary and justifiable taking into account the opinions of various bodies (professional committees, national and institutional ethical committees, religious bodies, parliamentary representatives and private organizations or persons). The authors introduce the activities of the role and importance of these bodies and investigate the position of the research and clinical professionals in obtaining permission for the application of ethically sound or less criticizable procedures. The importance of the provision of continuous and many-sided information for wide range of the society is underlined.

[The role of radical abdominal hysterectomy and lymphadenectomy (Wertheim's operation) in contemporary gynecology]

During a 20-year period between January 1964 and December 1983, 317 radical hysterectomies and pelvic lymphadenectomies were performed for stage IB, IIA and IIB carcinoma of the cervix at the Department of Obstetrics and Gynaecology, University Medical School of Debrecen. The 5-year survival rate for Stage IB patients is 88.3 per cent, in Stage IIA 82.7%, in Stage IIB 68.0% and the major prognostic factor clearly being the status of the pelvic lymph nodes. In comparison with the literary data their results seem to suggest that routine pre- and postoperative radiotherapy reduces pelvic metastases and improves survival in patients with positive pelvic lymph nodes. It was noted that closed retroperitoneal suction drainage after radical operation effectively removes fluid from the pelvis and probably prevents some of the postoperative complications. Evidence seems to suggest that properly performed radical pelvic surgery with radiation therapy is successful in treating early cervical carcinoma. There does not appear to be any contraindication to operation in this group of patient as long as the condition is deemed medically operable.

Ovarian function after the menarche and hormonal contraception

The aim of the study was to determine the date of regular ovulation after the menarche to better understand the physiology of female adolescence, especially as it pertains to the use of hormonal contraception. Early morning urine samples were collected from 51 girls in the perimenarche for 9 weeks semi-annually during 2 years. Estrone- and pregnanediol-3-glucuronide values were determined. Cycles lasting 35-40 days at the onset of menses shortened to 28 days after the 23rd-25th cycle. Menses reached a 5.0-5.5 day average length at about the same time. After the 20th cycle, ovulation could be demonstrated in more than 50% of the study patients. Using a scoring system, regular ovulation could be expected on the basis of somatic data with scores of greater than 16. Hormonal contraception may be prescribed 2 years after the menarche, based on scores of greater than 16 and ovulation proven be hormonal cytology and basal body temperature.

Importance of ultrasonography in the follow-up of patients treated for ovarian carcinoma

The importance of serial ultrasonography was studied in 28 patients with histologically verified ovarian tumors. The patients were receiving combined cytostatic treatment. By graphic illustration of tumor volume, sonography can be of help in the treatment and follow-up of patients, as well as in the choice of appropriate therapy.

Effects of hypertensive disorders on the outcome of pregnancy: early findings of maternity care monitoring (MCM) in Debrecen, Hungary

Debrecen is one of the original testing sites of MCM. This report focuses on all single births having occurred from January, 1978 to June, 1980 (N = 8818). Pregnancy outcome associated with maternal Hypertensive Disorders in Pregnancy (HDP) shall be set against pregnancy outcome among women with No Primary Antenatal Conditions (Control), the respective sample sizes being N = 540 (HDP) and N = 5, 472 women. The findings are given in four sections: (1) Occurrence of HDP; (2) Characteristics other than presence/absence of HDP; (3) Reproductive experience prior to current delivery; and (4) Maternal and infant outcome for the current delivery. A specific look is also given at smoking during current pregnancy. Special attention is called for the primordial importance of prenatal visits, preventive care and proper obstetrical management. The role of the MCM early warning system is emphasized and broader use of the system and rationale is suggested for objective international and intranational comparisons to improve pregnancy outcome for both the mother and infant.

Two modifications of the intrauterine membrane contraceptive device

The intrauterine membrane (IUM) is an intrauterine contraceptive device designed to be compliant with a range of uterine shapes and sizes and with transient dimensional changes resulting from uterine motility. This compliance was expected to contribute to low rates for removal due to bleeding and pain, but the use of the IUM resulted in heavy bleeding among its early users. Consequently, two modifications of the device were made to decrease bleeding. One group of IUMs was modified by using ethylene vinyl acetate to provide a high level of lateral compliance and another was modified by using a tissue-compatible Hydron coating in order to decrease the inflammatory response of the endometrium. One hundred of each of these modified IUMs were tested along with 100 of the standard IUMs in a double-blind study conducted at the Noi Klinika in Debrecen, Hungary. The findings of this study suggested that these two modifications did not improve the over-all performance of the IUM.

Fetal arrhythmia during pregnancy and labour

The significance of fetal arrhythmia presenting during pregnancy and labour has been examined in 68 patients. The different types of rhythm disorders diagnosed included 61 extrasystoles, 6 atrioventricular blocks and 1 auricular fibrillation. Extrasystoles were not associated with acidosis or organic cardiac disease. Atrioventricular block, though not associated with fetal hypoxia, was occasionally associated with congenital cardiac failure.