More basic forms of both human follicle-stimulating hormone and luteinizing hormone in serum at midcycle compared with the follicular or luteal phase.

The purpose of this study was to compare the heterogeneity and median charge of FSH and LH in serum at different phases of the normal human menstrual cycle. Serum specimens were obtained during the follicular phase [9.0 +/- 1.9 (+/- SD) days before the midcycle], at the midcycle LH peak, and during the luteal phase (9.75 +/- 1.6 days after the midcycle) in 16 women with normal menstrual cycles. The 48 serum specimens were subjected to electrophoresis in 0.17% agarose suspension in 0.075 M veronal buffer at pH 8.6, using a column suitable for measuring the median charge of the isoforms of FSH and LH, expressed as median electrophoretic mobility. Four sera were also analyzed by use of a larger column, giving a high resolution. The FSH and LH activities were measured with a time-resolved sandwich fluoroimmunoassay. The number of isoforms of both FSH and LH in each serum specimen analyzed by electrophoresis with high resolution was between 20-30. The median charge of the isoforms of FSH was less negative (P < 0.001) at the midcycle than in the follicular or luteal phase in all 16 women. The same was found for LH in 14 of 15 women. The median charge of FSH or LH in the follicular phase was not significantly different from that in the luteal phase of the cycle. We conclude that at least 20-30 isoforms of both FSH and LH circulate in blood during the menstrual cycle. More basic isoforms of both hormones appear in serum at midcycle than in the follicular or luteal phase. The difference is most likely due to a selective secretion from the pituitary of more basic forms of FSH and LH at midcycle.

Carotid vascular resistance in long-term estrogen users.

OBJECTIVE: To compare carotid vascular resistance in long-term estrogen users with that of age-matched nonusers. METHODS: Pairwise comparisons between 18 long-term users of 17beta-estradiol (E2) implants (mean age 67.8 years, mean duration of treatment 18.8 years, range 5.8-33.9 years) and 18 age-matched (+/- 2 years) nonusers. We used color Doppler ultrasound to assess pulsatility index (PI) and resistance index (RI) in common, external, and internal carotid arteries. RESULTS: Estrogen users compared with age-matched nonusers had significantly lower mean values for common carotid RI, -4%; -0.04 (95% confidence interval [CI] -0.07, -0.03, P =.036) and marginally significant for PI, -12%; -0.25 (95% CI -0.54, 0.04, P =.087). Differences in external and internal carotids were smaller and insignificant. Age was a determinant of internal carotid vascular resistance in estrogen users and nonusers. Increasing pairwise differences in external carotid vascular resistance with advancing age (r = 0.55; P =.02), with magnitudes of mean group differences indicate a modest but true effect of long-term estrogen therapy on vascular resistance in common carotids, less in external, and negligible in internal carotid arteries. The study had an 80% power to detect a 10% mean difference (0.08 units) in common carotid RI at the 5% level. The standard deviation was considerably lower for estimates of RI than for PI. CONCLUSION: Long-term estrogen therapy was associated with minor reduction of vascular resistance in common carotid, less in external, and negligible in internal carotid arteries. Effects on carotid vascular resistance do not seem to be a major mechanism in the long-term protective effect of estrogen therapy on cardiovascular risk.

Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 1987-1993.

OBJECTIVE: To study the influence of mode of delivery on infant mortality, neonatal morbidity, and maternal morbidity in pregnancies with nonmalformed term singleton infants presented in breech. METHODS: We studied all nonmalformed live-born singleton infants, delivered at term (at 37 weeks or later) in breech position in Sweden between 1987 and 1993 (n = 15,818). The pregnancy outcomes analyzed were neonatal and infant mortality, low Apgar score (less than 7) at 5 minutes, birth injury, and neonatal convulsions. Severe perineal or vaginal lacerations, wound rupture, infections, and thrombosis were used as measures of maternal morbidity. Logistic regression analysis was used to determine risks of infant mortality and morbidity, after adjusting for a number of potential confounders. RESULTS: Compared with infants delivered by elective cesarean, infants delivered vaginally were at significantly higher risk for infant mortality (odds ratio [OR] 2.5). Infants delivered vaginally were at increased risk for birth injury (OR 12.2), and infants delivered by emergency cesarean were at increased risk for neonatal convulsions (OR 4.1). Infants delivered vaginally or by emergency cesarean were at increased risk for a low Apgar score at 5 minutes. Maternal morbidity was highest among women who delivered by emergency cesarean (2.8%), whereas lower rates were obtained among women who delivered vaginally and those who delivered by elective cesarean (1.8 and 1.7%, respectively). CONCLUSION: Vaginal delivery of term infants presented in breech is associated with higher risks of neonatal mortality and morbidity compared with delivery by elective cesarean. We conclude that term singleton infants presented in breech would benefit from an elective cesarean delivery.

Direct intraperitoneal insemination--clinical results and comparison between two methods of sperm preparation.

OBJECTIVE: To compare sperm preparation with a new self-migration method in sodium hyaluronate and a centrifugation/swim-up method and to study the efficiency of direct intraperitoneal (IP) insemination. STUDY DESIGN: Sodium hyaluronate and centrifugation/swim-up were used randomly for direct IP insemination in alternating cycles. Treatments were given with an interval of at least one untreated cycle. When ovulation occurred on weekends, the patients received only controlled ovarian hyperstimulation. SETTINGS: Department of Obstetrics and Gynecology University Hospital, Uppsala, Sweden. PATIENTS: Seventy-nine couples with unexplained infertility (n = 53), endometriosis (n = 17), and cervical factor (n = 9). INTERVENTIONS: Controlled ovarian hyperstimulation was accomplished by clomiphene citrate and gonadotropins. MAIN OUTCOME MEASURES: Sperm parameters and pregnancy rates. RESULTS: Sodium hyaluronate and centrifugation/swim-up resulted in similar conception rates, but sodium hyaluronate recovered more motile spermatozoa than centrifugation/swim-up (P less than 0.0001). The number of patients who became pregnant after direct IP insemination or controlled ovarian hyperstimulation only was significantly higher than that observed after untreated cycles (P = 0.00001 and P = 0.008, respectively). CONCLUSIONS: Sperm preparation with sodium hyaluronate can be used as an alternative to centrifugation/swim-up. Direct IP insemination appears to increase the cycle fecundity, but whether direct IP insemination/controlled ovarian hyperstimulation is more effective than controlled ovarian hyperstimulation alone has yet to be proven.

Transvaginal ultrasonography for identifying endometrial pathology in postmenopausal women.

The objective of this study was to evaluate the usefulness of transvaginal ultrasonography in postmenopausal women with a clinical indication for a dilatation and curettage (D&C). Of the 167 postmenopausal women included in the study, 88% were referred for a D&C because of vaginal bleeding and 12% of the women had other clinical indications such as myomas, gynecological pain or suspected gynecological tumors. Hormone replacement therapy (HRT) was used by 37% of the women. The women were examined with transvaginal ultrasonography before the D&C. The endometrial thickness and texture were used as indicators of endometrial abnormalities. The ultrasonographical findings were related to the histological diagnosis obtained from the D&C. Histologically, 31% of the women had an atrophic endometrium and the corresponding ultrasonographically mean endometrial thickness was 4.6 mm (range 0-14 mm). Endometrial cancer was histologically found in 10% of the women and the endometrial thickness of the malignant endometrium, measured by ultrasonography, was 13.9 mm (range 6-31 mm). All the malignancies were found in the group of women with vaginal bleeding, but only one was in the group of women on HRT. Histologically, endometrial hyperplasia was found in 6.5% of the women and endometrial polyps in 8.5% after the D&Cs. In these postmenopausal women it was demonstrated that if the endometrium was < 6 mm thick, no endometrial cancer was found at histopathological investigation. By using a cut-off point of 6 mm of ultrasonographically measured endometrial thickness for identification of endometrial pathology in our study, at least 50% of the D&Cs could be spared.

Ovarian function during use of a levonorgestrel-releasing IUD.

Ovarian function was studied for two complete menstrual cycles in 9 regularly menstruating women and for 8 weeks in three amenorrhoeic women who had used levonorgestrel-releasing IUDs (LNG-IUD) for more than four years. Nine patients using copper IUDs (Nova-T) were studied for two complete menstrual cycles as controls. According to progesterone levels, 15/17 cycles in women using LNG-IUDs were ovulatory, whereas only 8/17 cycles showed normal follicular growth and rupture as judged by ultrasound. In ovulatory cycles, the peak progesterone levels were lower than in the controls. The preovulatory estradiol and LH peak levels were also lower than in control subjects. SHBG levels were lower in LNG-IUD users than in copper IUD users. It is concluded that, although the dose of levonorgestrel released from the IUD is very low, it probably exerts an effect on the gonadotrophin secretion, which disturbs follicular development in many of the women studied, which in addition to the local effect on the endometrium, contributes to its high contraceptive efficacy.

Imperforate hymen and ruptured hematosalpinx: a case report with a review of the literature.

The imperforate hymen is a common genital disorder, but a ruptured hematosalpinx is a fairly rare complication. This article presents one case with an imperforate hymen as well as a bilateral hematosalpinx, with unilateral ruptured hematosalpinx, giving a picture of acute abdomen. The pathology, diagnosis, treatment, and complications of these rare cases are discussed. The most important factor for the clinician to remember is the history; a simple inspection provides the diagnostic clue.

Intrauterine cephalocentesis: a case report.

This case presents a woman with a fetus having a large hydrocephalus and other lethal malformations. The problem was how to avoid an unnecessary cesarean section at delivery because of the breech position of the baby. The solution was prenatal ultrasonographic-guided cephalocentesis after which a vaginal delivery could take place without any complications for the mother.

Birth in triplet pregnancies. Vaginal delivery--how often is it possible?

OBJECTIVE: To compare cesarean section with vaginal delivery in triplet pregnancies. DESIGN: Medical records of 16 triplet pregnancies were retrospectively reviewed. SETTING: One hospital where planned, vaginal delivery of triplet gestations is the preferred policy. SUBJECTS: Sixteen women giving birth to triplets in the University Hospital, Uppsala, Sweden. RESULTS: Nine women were delivered vaginally, seven with cesarean section. The corrected mortality was 3.3% in the group delivered vaginally and zero in the cesarean section group. Twenty-three percent of the babies in the vaginally delivered group were without any morbidity and 6% in the corresponding cesarean section group. CONCLUSIONS: In terms of fetal outcome cesarean section in triplets is not superior to a policy of vaginal delivery. Vaginal delivery may be suggested when there are no obvious obstetrical contraindications.

Pathologic torsion of the pregnant uterus.

Torsion of the human pregnant uterus is a very rare complication. This presentation describes repeated episodes of pathological CTG patterns in a woman whose uterus showed a levotorsion of 150 degrees at cesarean delivery. To our knowledge, such a pattern has never previously been ascribed to uterine torsion.

Induction of labor: a prospective, randomized study into amniotomy and oxytocin as induction methods in a total unselected population.

All women (n = 223) scheduled for induction of labor were randomized into start with oxcytocin infusion (O) or amniotomy (A). After 4 h an assessment of the progress and prognosis was made. If the progress was not acceptable O was added to A and A to O. Oxcytocin alone showed the lowest frequency of delivered patients. The "amniotomy only" group showed the shortest duration of delivery. The frequency of complications was low but somewhat higher when the initial step was oxcytocin. Oxcytocin alone is not a good method for induction. Early evaluation of the progress and prognosis of the induction is difficult. The combination of amniotomy and oxcytocin seem to be more essential than the choice of initial step. If, however, an infusion of oxcytocin is the first proceeding, amniotomy should be added on a routine basis and without delay. Bishop score is not a conclusive measure of the readiness of uterus to go into labor. Parity may partly be the explanation but other today unknown factors are probably involved in the inducibility.

Transvaginal ultrasonographic evaluation of the endometrium related to the histological findings in pre- and perimenopausal women.

OBJECTIVE: To evaluate the clinical usefulness of high-resolution transvaginal ultrasonography in pre- and perimenopausal women suspected to have endometrial pathology. PATIENTS AND METHODS: 196 women, aged between 32 and 57 years, were referred to the outpatient clinic for a dilatation and curettage (D&C). In 81% the clinical indication was irregular vaginal bleedings. Before the D&C an examination with transvaginal ultrasonography was performed, and the endometrial thickness and texture were determined. The ultrasonographic results were later compared with the histological diagnosis obtained from the D&C specimen. RESULTS: Ultrasonographically both normal and pathological endometrial changes could be detected, and 82% of the women had an endometrium characterized as normal. The endometrial phase determination correlated with the histological findings in approximately 50% of the women. Histologically 83% of the women had a normal endometrium. Endometrial hyperplasia was found in 12% and endometrial polyps in 4%. There were no malignancies found in this study. The hormone users (33% of the women) had no higher incidence of hyperplasias than non-users. CONCLUSION: Our data indicate that transvaginal ultrasonography is as effective as the D&C for depicting the endometrium in pre- and perimenopausal women with irregular bleedings.

Transvaginal sonographic evaluation of endometrial growth and texture in spontaneous ovulatory cycles--a descriptive study.

Repeated transvaginal ultrasonographic examinations were performed during spontaneous ovulatory cycles to follow the texture and growth pattern of the endometrium in 23 healthy volunteers. The serum concentrations of oestradiol, progesterone and luteinizing hormone (LH) were measured regularly. The day of the LH peak was designated as day 0. On ultrasound only one thin echogenic line was seen from menstruation to day -7. From days -6 to -1 a change from one to three thin lines was observed together with an increasing hypoechogenic texture between the lines. These changes corresponded to the increasing serum concentration of oestradiol and increasing thickness of the endometrium. At ovulation there was maximum hypoechogenic texture between the lines which had become thicker. At ovulation the endometrium had a mean thickness (both layers) of 12 mm. From days +1 to +6 an increasing blurring of the three lines became apparent and the previously hypoechogenic layers gradually displayed a more echogenic texture. From day +7 to menstruation the lines were indistinguishable due to the appearance of a general hyperechogenic texture of the endometrium. In the luteal phase the growth of the endometrium plateaued. The results indicate that ultrasound assessment of endometrial growth and texture may be an important tool to evaluate normal ovulatory endometrial development. It can also be useful in monitoring stimulated cycles in different treatment modalities of assisted reproduction.

Very prolonged membrane rupture and delayed delivery of the second twin.

OBJECTIVES: To present the complications of twin pregnancies with delayed delivery of the second twin, 32 days after expulsion of the first twin. CASE: A 29-year-old woman with a twin pregnancy at gestational age 13 weeks and 5 days presenting with a rupture of the membranes of the first twin. At 21 completed weeks the umbilical cord prolapsed and at 23 weeks the first twin was stillborn with the placenta in the uterus. After maternal septicemia the second twin was delivered by caesarian section, at 28 complete weeks, liveborn. The mother and child were discharged from hospital 10 weeks later, corresponding to 38 completed weeks of pregnancy. CONCLUSIONS: A very early premature rupture of membrane (PROM) occurs more often in twin pregnancies. The delivery of one twin most often results in expulsion of the second twin. With PROM there is a great risk of chorioamnionitis, as in our case, which resulted in an acute cesarean section. In this case, conservative management achieved a viable fetus in spite of very early and serious complications.

Transvaginal ultrasound for identifying endometrial abnormality.

Transvaginal ultrasound was used preoperatively to evaluate the endometrium in 96 patients referred for dilatation and curettage. The sonographic display was correlated to the histopathologic diagnosis. In 45 patients with postmenopausal bleeding, 4 patients had adenocarcinoma of the endometrium. All were identified by ultrasound. None of the 22 patients with a normal sonographic appearance had an abnormal histopathologic diagnosis. An endometrial thickness (single layer) cut-off point of greater than or equal to 4 mm precluded any missed malignancies but halves the number of dilatations and curettages in this postmenopausal group. The sensitivity of ultrasound in diagnosing endometrial pathology was 100% and the specificity was 61%. The positive and negative predictive values were 39% and 100% respectively. In 51 premenopausal women there was good agreement between histology and ultrasound. In this group a cut-off point of greater than or equal to 8 mm was used. The sensitivity in diagnosing endometrial pathology was 67% and the specificity 75%. The positive and negative predictive values were 14% and 97%. With further experience, transvaginal ultrasound might be used in clinical routine for diagnosing endometrial pathology.

Ultrasonographical and hormonal description of the normal ovulatory menstrual cycle.

OBJECTIVE: To describe the changes in uterine volume, endometrial thickness and follicular size during the normal menstrual cycle by use of transvaginal ultrasonography and to correlate these changes with the endocrine events in the same cycle. METHODS: A group of 23 healthy women with normal body mass index and with a history of regular menstruations were monitored with repeated hormonal and vaginal ultrasonographical investigations during the menstrual cycle. RESULTS: Sixteen of the women fulfilled the hormonal criteria for ovulation. The mean length of the cycles was 28 days (range 25-30 days) with a mean length of the follicular and the luteal phases of 14.4 days (range 12-17 days) and 13.5 days (range 12-16 days), respectively. The estradiol level in serum the day before the peak of the luteinizing hormone varied between 490 and 1710 pmol/l (mean 1087 pmol/l). Ultrasonographically, the most clinically relevant changes were the increase in diameter of the dominant follicle and the growth of the endometrium. At ovulation the dominant follicle had a mean diameter of 21.4 mm (range 17.4-27.0), whereas the endometrium had a mean thickness of 12.8 mm (range 10.0-15.9). When analysed over the entire follicular phase, the serum estradiol concentration correlated both with the diameter of the dominant follicle (r = 0.93, p = 0.0001) and with the thickness of the endometrium (r = 0.79, p = 0.0001). However, no such correlations were found when only the last part of the follicular phase was analysed. In the luteal phase there was no correlation between the size of the corpus luteum and the serum concentration of progesterone. CONCLUSIONS: Vaginal ultrasonography is a practical and reliable method to monitor structural changes in the ovaries and the uterus during the menstrual cycle. The results are of clinical importance for a better understanding of the physiological changes and helpful when monitoring induction of ovulation in assisted reproduction.

Hormone and ultrasound parameters in ovarian stimulation cycles for direct intraperitoneal insemination.

To determine hormonal and ultrasound parameters associated with pregnancies, 115 women with unexplained infertility (n = 82), endometriosis (n = 22) or cervical factor (n = 11) were treated with direct intraperitoneal insemination (DIPI) after ovarian stimulation with clomiphene citrate and human menopausal gonadotrophins (HMG). Twenty women conceived and were compared with the remaining 95 non-pregnant women during one treatment cycle. Women with basal FSH levels less than or equal to 1.25 micrograms/l responded with higher oestradiol levels (P less than 0.0001), with the development of more follicles (P less than 0.05) and higher progesterone levels (P less than 0.05) than women with basal FSH levels greater than 1.25 micrograms/l, but the conception rates were similar. Women with miscarriages or biochemical pregnancies had a higher basal FSH value than both the women with term pregnancies and the non-pregnant women. Women with at least 3 preovulatory follicles greater than or equal to 15 mm had a higher pregnancy rate than those with fewer follicles, but a further increase was not observed above that number. The endometrium was thicker on the day of ovulation induction in cycles leading to a term pregnancy than in cycles without conception or with a biochemical pregnancy. No term pregnancy was observed when the endometrium was thinner than 8 mm. Women with a short luteal phase (less than 12 days) had a higher ratio of oestradiol/progesterone in the midluteal phase than women with a luteal phase of greater than or equal to 12 days and pregnant women.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonic evaluation of the uterus and uterine cavity after normal, vaginal delivery.

OBJECTIVE: To describe uterine and uterine cavity changes throughout the puerperium, as revealed by ultrasound. METHODS: This was a prospective, longitudinal study in which 42 women with uncomplicated vaginal term deliveries were examined serially by ultrasound on postpartum days 1, 3, 7, 14, 28 and 56. The first four examinations were performed transabdominally and the last two transvaginally. The involution process of the uterus was assessed by measuring the anteroposterior diameter of the uterus and uterine cavity. Morphological findings were recorded. The influence on the involution process of parity, breast-feeding, maternal smoking and infant's birth weight were also evaluated. RESULTS: The maximum anteroposterior diameter of the uterus diminished substantially and progressively from 92.0 mm on day 1 postpartum to 38.9 mm on day 56. The maximum anteroposterior diameter of the uterine cavity diminished from 15.8 mm on day 1 to 4.0 mm on day 56. However, the anteroposterior diameter of the uterine cavity, 5 cm from the fundus, typically increased on days 7 and 14 postpartum. The position of the uterus and the shape and the appearance of the cavity change in a unique way during the normal puerperium. The uterus was most often retroverted and empty in the early puerperium. Fluid and debris in the whole cavity were seen in the middle part of the puerperium. In late puerperium the cavity was empty and appeared as a thin white line. Endometrial gas was occasionally visualized. No correlation was found between the involution of the uterus and parity, breast-feeding and the infant's birth weight. CONCLUSION: Transabdominal sonography is suitable for examination of the uterus during the first 14 days postpartum but from day 28 the transvaginal route is preferable. The uterine body and position, as well as the cavity, are easy to examine by ultrasound. Accumulation of fluid and debris in the uterine cavity is a common and insignificant finding of the involuting uterus. It is located in the cervical area in the early puerperium and in the whole uterine cavity in the middle part of the puerperium. Findings from uncomplicated vaginal deliveries are needed as a reference when the diagnostic efficacy of ultrasound for pathological conditions is to be tested.