Hydrosalpinx with adnexal torsion in an adolescent virgin patient--A diagnostic dilemma: case report and review of the literature.

Hydrosalpinx is one of the predisposing factors of adnexal torsion. However, because the incidence of hydrosalpinx in adolescent virgin patients is very rare, it may cause diagnostic dilemma, leading sometimes to suboptimal treatment. We present the case of an 18-yr-old female, not sexually active, presenting with acute lower right abdominal pain. The working diagnosis was of a simple ovarian cyst, so aspiration was performed. Abdominal symptoms reoccurred and sonography revealed a large hemorrhagic cystic mass adjacent to an edematous right ovary. The patient was referred to immediate laparoscopy due to suspected right adnexal torsion. On laparoscopy, the right adnexa was twisted three times causing an edematous ovary with a hematosalpinx. Detorsion was performed. Five weeks later, transabdominal ultrasound reviled normal bilateral ovaries and the hematosalpinx disappeared. In conclusion, hydrosalpinx, although very rare in adolescence, must be considered in the differential diagnosis. Aspiration in such cases is not the treatment of choice and moreover, it may cause complications.

Hemorrhagic corpus luteum is associated with ovarian edema.

BACKGROUND: Most cases of ovarian edema are thought to result from intermittent ovarian/adnexal torsion. This study describes how, in some cases, this etiology was ruled out even though the edema was unexplained. STUDY OBJECTIVE: To evaluate the association between ovarian edema and hemorrhagic corpus luteum. SETTING: Department of gynecology in an urban medical center. PARTICIPANTS: Five patients admitted to the department of gynecology with a sonographic diagnosis of ovarian edema of unexplained etiology. RESULTS: Laparoscopy performed on three of five patients in whom a diagnosis of unexplained ovarian edema revealed hemorrhagic corpus luteum and ovarian edema. The remaining two patients displayed typical sonographic imaging of hemorrhagic corpus luteum and ovarian edema and they were managed expectantly. The affected ovaries were between 4.8 and 10 times larger than the unaffected ovaries. During follow-up, the affected ovaries returned to their normal size and appearance. CONCLUSIONS: Hemorrhagic corpus luteum can cause ovarian edema without interrupting the blood flow supply. The outcome of expectant management without any surgical intervention is the gradual disappearance of the ovarian edema in these patients and the return of ovaries to a normal sonographic appearance.

Tamoxifen modulates apoptotic pathways in primary endometrial cell cultures.

Clinical data indicate that tamoxifen (TAM) therapy may cause an increased risk of endometrial pathology in postmenopausal but not in premenopausal women. Molecular mechanisms of the uterotrophic activity of TAM have not been clearly established nor its relevance to apoptosis in endometrial cells. The present study was implemented to evaluate the apoptotic effect of TAM on primary endometrial cell cultures in the presence or absence of steroid hormones (SHs). A total of 14 primary endometrial cell cultures were established and maintained both with and without SHs. Cell cultures were treated for 24 h with either 20 microM TAM or 10 nM estradiol. Apoptotic cells presented in a pre-G1 peak and the expression of bcl-2 were studied using flow cytometry. All endometrial cell cultures maintained in a SH-containing environment, except one, responded to TAM by a significant increase (P = 0.03) in the pre-G1 cell fraction, indicating a proapoptotic effect. A significant (P = 0.03) reduction in the pre-G1 peak equivalent to an antiapoptotic response was observed in 6 of 13 cell cultures maintained in a SH-deficient environment. In 4 of 10 cell cultures evaluated in both media, the pre-G1 population was medium dependent. In 8 of 10 cultures evaluated for Bcl2 levels, no trend was found in either media, but a dependency on SH content was observed. Comparison between effects of TAM and estradiol demonstrated identical trends, regardless of the menstrual phase or SH content in cell environments. These results suggest that TAM acts as an estrogen agonist on endometrial tissue in both environments. We conclude that TAM modulates apoptotic pathways in primary endometrial cell cultures. The SH content in the cell environment influences the apoptotic effect of TAM and determines the propensity for a cell to undergo apoptosis or, on the contrary, to resist apoptotic death in response to TAM treatment. This is in concordance with the observed clinical risk of endometrial pathologies in postmenopausal versus premenopausal women.

Small marker chromosome mosaicism confirmed in two cases ascertained prenatally.

Two cases of chromosomal mosaicism were prenatally diagnosed and confirmed in tissues cultured from subsequently aborted fetuses. In both cases a small marker chromosome was observed which proved de novo in origin, since parental chromosomes were normal. The implications and interpretation of such findings in counselling families undergoing amniocenteses is discussed. Mosaicism for small marker chromosomes may be more frequent than hitherto suggested.

Superficial hemosiderosis in a second trimester fetus: pathological and clinical manifestations.

Prenatal brain hemorrhages are associated with considerable morbidity and mortality in neonates. They appear predominantly as bleeding into periventricular germinal matrix with subsequent hemorrhages into lateral ventricles and subarachnoid space. Other patterns of brain hemorrhage are not widely documented in second trimester fetuses. We report a case of hemorrhage presenting as extensive hemosiderin deposits in leptomeninges and adjacent brain parenchyma, as observed in superficial hemosiderosis. The lesion was associated with substantial tissue damage. Clinically, it was diagnosed during the second half of second trimester by successive ultrasound examinations. If differs from germinal matrix hemorrhage and other forms of hemorrhage in origin, pathogenesis, morphology, and probably in clinical manifestations.

Endometrial pathology in postmenopausal tamoxifen treatment: comparison between gynaecologically symptomatic and asymptomatic breast cancer patients.

AIMS: To evaluate whether endometrial pathology is more likely to be diagnosed in gynaecologically symptomatic rather than in gynaecologically asymptomatic postmenopausal breast cancer patients with tamoxifen treatment; and to evaluate the possible influence of various clinical factors on the incidence of endometrial pathology. METHODS: Endometrial histological findings, transvaginal ultrasonographic endometrial thickness, demographic characteristics, health habits, and risk factors for endometrial cancer were compared between 14 gynaecologically symptomatic (group I) and 224 gynaecologically asymptomatic (group II) postmenopausal breast cancer patients with tamoxifen treatment. RESULTS: Overall, 28.6% of the study population had endometrial pathology. The incidence of overall positive endometrial histological findings was significantly higher in group I than in group II (92.9% v 24.6%, p < 0.0001). Atrophic endometrium was more common in group II than in group I (75.3% v 7.1%, p < 0.0001). Most other endometrial pathology was significantly more common in group I than in group II (endometrial hyperplasia, 35.7% v 5.6%, p < 0.0001; endometrial polyps, 35.7% v 13.4%, p < 0.0111; endometrial carcinoma, 21.5% v 0.9%, p < 0.0001). Endometrial pathology appeared considerably later in the gynaecologically asymptomatic patients than in gynaecologically symptomatic patients (p = 0.0002). Vaginal bleeding or spotting occurred exclusively in group I. The incidence of endometrial pathology in the entire study population was consistent with that reported elsewhere, and higher than that reported for healthy postmenopausal women. CONCLUSIONS: Endometrial pathology is more likely to be diagnosed in gynaecologically symptomatic postmenopausal breast cancer patients with tamoxifen treatment, and after a shorter duration of time, than in gynaecologically asymptomatic patients.

Pulmonary complications following endotracheal intubation for anesthesia in breech extraction.

A 28-year-old, healthy pregnant patient developed bilateral pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum and pneumoperitoneum following endotracheal intubation and manual ventilation during general anesthesia for breech extraction. It is likely that positive-pressure ventilation was the cause for this very rare combination of complications. Early recognition and treatment may prevent such a catastrophe.

Fibromuscular dysplasia of the carotid arteries complicating pregnancy.

Fibromuscular dysplasia is an arteriopathy of unknown etiology that affects the intermediate-size branches of the aorta. Partial occlusion of these arteries may result in neurologic symptoms when carotid arteries are affected, and impaired liver or kidney function when their blood supply is compromised. Pregnancy and delivery in women who are diagnosed as having fibromuscular dysplasia may be associated with disease-related complications such as ischemic attacks. We report the course of a pregnancy and delivery in a patient with carotid artery fibromuscular dysplasia and suggest steps for general obstetric management and contraception in patients suffering from fibromuscular dysplasia.

Autologous blood transfusions and pregnancy.

The application of autologous and frozen red blood cell (RBC) programs is described for 3 pregnant women with antibodies to high-incidence blood group antigens (anti-Lutheranb, anti-Cellano, anti-Vel). The cases illustrate how readily available supplies or rare blood types can be maintained throughout pregnancy using autologous and frozen RBC techniques, including selective predeposit, "family-sharing," and intensive phlebotomy with fluid replacement. The RBC phenotypes described in this paper are exceedingly rare since they occur in only 0.1-0.001% of random donors. However, the principles of autologous blood transfusions are universal and they can be applied to the general problems of blood group incompatibility in pregnancy.

Tuboovarian autoamputation and infertility.

Asymptomatic or undiagnosed tuboovarian autoamputation in teenagers may have its impact on fertility later in life. Two cases are presented with infertility following unilateral adnexal autoamputation. The importance of awareness for possible subtorsion or torsion of adnexa in childhood and adolescence and its impact on fertility are discussed.

Ovarian implantation into the uterus (Estes operation): clinical and experimental evaluation.

Ovairan implantation into the uterus was performed in 27 women, none of whom conceived during the 4- to 6-year follow-up period. Bypassing the fallopian tube may, in itself, explain the disappointing results of this procedure in our series as well as in those reported in the literature. Experimental ovarian implantation into the uterus of rats supplied information regarding additional factors underlying the low success rate of this operation. It is concluded that this surgical intervention has been made superfluous in view of the poor results and the modern methods for extracorporal fertilization at present being developed.

PIP: Clinical and experimental data which may help to explain the high rate of failure of ovarian implantation into the uterus is presented. During the 1973-1975 period, 27 patients underwent implantation of the pedicled ovary into the uterine cavity in the Department of Obstetrics and Gynecology of the Hadassah University Hospital in Israel. 19 of the women had primary infertility and 8 had secondary infertility. Among the 8 women with secondary infertility, 2 had living children. 6 of these 8 women had previously undergone bilateral salpingectomy for tubal pregnancy. Implantation of the ovary into the uterus was performed according to a modification of the Estes technique. Experimental ovarian implantation into the uterus of 10 rats provided information concerning additional factors underlying low success rate of this operation. The 27 patients were followed for 4-6 years, and some of the group conceived. There were only 2 cases of postoperative complications -- urinary tract infections. The poor results may be explained by the fact that the fallopian tubes are bypassed in this technique. Both the poor results and the modern methods for extracorporal fertility now being developed suggest that this surgical intervention technique is superfluous.

Ovum capture and fertility following microsurgical fimbriectomy in the rabbit.

Microsurgical fimbriectomy with removal of the fimbria ovarica was performed on one side in 19 rabbits. The other tube was left intact as a control. In 10 animals the new ostium was left free, some distance from the ovary. In the remainder, the ostium was fixed to the ovarian capsule. Three animals with a fixed ostium developed mild hydrosalpinx even though the neostomy was patent. Of the remaining 16 rabbits, 15 conceived and became pregnant in both uterine horns. There was no significant difference between nidation index on the two sides. It is concluded that intact fimbriae with a fimbria ovarica are not essential for normal ovum capture. It is therefore suggested that methods for clinical salpingostomy may require re-evaluation.

Potentially deleterious effect of cornstarch glove powder in tubal reconstructive surgery.

Even with the most painstaking techniques, cornstarch granules used as surgical glove powder are deposited in the abdominal cavity during laparotomy. In tubal reconstructive surgery, aimed at the elimination of fibrous adhesions, this deposition may have undesirable consequences. After a successful operation, starch particles introduced in the abdominal cavity may result in the formation of new adhesions. It is therefore desirable to develop an alternative, completely nonreactive, glove powder.

PIP: This study attempted to determine whether cornstarch granules when used as surgical glove powder are deposted in the peritoneal cavity during surgery. To this end 10 women undergoing tubal reconstructive surgery by microsurgical techniques and 10 women undergoing total abdominal hysterectomy were studied. Their abdominal cavities were washed 2 times; once at the start of the operation and once at its close using 50 ml of normal saline to irrigate before 20 ml fluid samples were extracted from the pouch of Douglas for cytological examination. All 40 fluid samples were heavily contaminated with starch particles; some of the fluid samples from the end of surgery also showed phagocytosis beginning. Therefore, even with microsurgical techniques designed to minimize adhesion formation postoperatively, the cornstarch in which surgical gloves are packed may result in pelvic adhesion formation. A new nonreactive glove powder must be developed.

Retrograde seeding of endometrium: a sequela of tubal flushing.

The problem of retrograde seeding of endometrial tissue fragments to the peritoneum was investigated by injecting fluids through the cervical canal into the uterus before and after curettage. Fluid samples were collected from the peritoneal cavity through a laparoscope. Endometrial glands were detected in almost all of the fluids samples, and seeding was greater after curettage than before. It is concluded that any procedure in which fluids are pushed through the uterus may cause peritoneal seeding of endometrium.

Therapeutic maturation of endometrium in in vitro fertilization and embryo transfer.

OBJECTIVE: To provide an up-to-date review of studies that have examined the relative role of endometrial development in in vitro fertilization (IVF) and embryo transfer (ET) treatment in relation to the treatment outcome. DATA IDENTIFICATION: The most important published studies and personal communications related to this topic have been identified through a computerized bibliographical search (MEDLINE). STUDY SELECTION: Studies that have evaluated the endometrial maturation in IVF and ET treatment with respect to different treatment protocols of ovarian stimulation. Clinical trials exploring the efficacy of various combinations of hormonal supplementation that aim to improve the endometrial environment and treatment outcome. Publications and personal communications reporting a variety of treatment protocols and drugs utilized for the creation of artificial endometrial cycles in IVF treatment employing donated eggs. RESULTS: Ovarian stimulation frequently adversely affects the process of endometrial maturation. Various kinds of hormonal supplementation, used in clomiphene citrate- and/or human menopausal gonadotropin (hMG)-stimulated cycles have not improved treatment outcome. Human chorionic gonadotropin or natural progesterone (P) supplementation administered after controlled ovarian stimulation with gonadotropin-releasing hormone and hMG effectively corrected the luteal phase defect and resulted in an improved conception rate. The endometrium of agonadal women is highly conducive to hormonal manipulation. All estrogen preparations used effectively promoted endometrial growth and proliferation. Natural P is superior to synthetic progestins for induction of receptive secretory endometrium. CONCLUSION: The development of adequately receptive endometrium is a major factor determining the outcome of IVF and ET treatment.

Foreign body granulomas in peritubal and periovarian adhesions: a possible cause for unsuccessful reconstructive surgery in infertility.

A major problem in tubal reconstructive surgery is the recurrence of peritubal and periovarian adhesions which negate the surgical endeavors. In many cases the etiology of these adhesions is obscure. Histologic re-evaluation with polarized light of 49 resected adhesions revealed residual cornstarch glove powder and suture material in seven specimens. It is concluded that cornstarch powder may be an active agent, and may not be as innocuous as its widespread use indicates.

The inability of preovulatory ovarian scan to predict multifetal pregnancy occurrence in a follow-up of induction of ovulation with menotropins.

OBJECTIVE: To establish the predictive role of preovulatory ovarian ultrasonography in the occurrence of multiple pregnancy after hMG and hCG treatment for anovulatory infertility. DESIGN: Prospective. SETTING: Outpatient Infertility Clinic. PATIENTS: Ninety-five anovulatory women who conceived after gonadotropin therapy. INTERVENTION: Induction of ovulation by hMG and hCG monitored by plasma E2 measurements and ovarian ultrasonography. MAIN OUTCOME MEASURES: All follicles visualized on the day of hCG administration were recorded and divided into the following four groups: group I, 10 to 12 mm; group II, 13 to 15 mm; group III, 16 to 18 mm; and group IV, 19 mm and larger. The sonographic findings were statistically evaluated to 80 singletons and 45 multiple pregnancies. RESULTS: No statistical correlation was found to exist between the number of follicles from the different groups and the number of fetuses. CONCLUSIONS: The number and sizes of follicles visualized on the day of hCG administration have no predictive value regarding the occurrence of a multiple pregnancy.

Relationship between embryo morphology and implantation rate after in vitro fertilization treatment in conception cycles.

OBJECTIVE: To investigate the relationship between the embryo number and morphology in conception cycles and the incidence of multiple pregnancies. DESIGN: The study is based on information received from a computerized data base. SETTING: In Vitro Fertilization Unit, Sapir Medical Center, Kfar Saba, Israel. PATIENTS: A total of 117 consecutive pregnancies resulted from replacement of fresh embryos in our IVF-ET program. MAIN OUTCOME MEASURES: The impact of embryo quality, as assessed by morphological parameters, on the multiple pregnancy rate (PR). RESULTS: Implantation rates positively correlated with the number and the quality of transferred embryos. However, no multiple pregnancies occurred when only two embryos were replaced. There were no multiple pregnancies when only embryos of low quality (grades 1 and 2) were transferred. Furthermore, there was no correlation between the number of replaced embryos of poor quality and the rate of implantation. The multiple PR increased from 10% when a mixture of high and low quality embryos were transferred to 30.76% when only embryos of highest quality were transferred. CONCLUSION: The implantation rate of transferred embryos is directly correlated with the morphological scoring. The results of the study suggest that the number of embryos transferred should be balanced against their morphological quality to reduce the rate of multiple pregnancies.

Uniocular congenital blindness as a complication of midtrimester amniocentesis.

A 6-month-old baby girl with congenital unilateral blindness had an eyelid coloboma and clear evidence of an old vascularized corneal perforation, indicating that the cause of the blindness was an ocular trauma sustained during a midtrimester amniocentesis.

Elevated plasma immunoreactive beta-endorphin in anorexia nervosa.

Basal morning plasma levels of immunoreactive-beta-endorphin (ir-beta-EP), and 17-beta estradiol (E2) were assessed in 25 adolescents with anorexia nervosa (AN) in comparison to 24 healthy controls. All subjects were drug free for at least 6 weeks. The mean plasma level of ir-beta-EP was significantly higher (84%) in the AN patients when compared with the control subjects. The elevated plasma ir-beta-EP may be relevant to the suppression of appetite, tolerance of fasting, and to the hypothalamic hypogonadism in AN.