Digoxin-like immunoreactive factor(s) in human gonadotropin stimulated follicular fluid.

Plasma digoxin-like immunoreactive factor(s) (DLIF) have been reported in various pathophysiological conditions associated with volume expansion and linked to the regulation of blood volume and pressure. We hypothesized that DLIF might be present in rapidly expanding gonadotropin-stimulated ovarian follicles. The mean total and free DLIF concentrations in the follicles (n = 9) studied were 4925 nmol/L and 1885 nmol/L, respectively. These concentrations were substantially higher than the plasma total and free DLIF levels in these women: 1216 nmol/L and 158 nmol/L, respectively (p less than 0.0001). The plasma DLIF levels in the gonadotropin-treated women were comparable to those in term pregnant women, which are known to be higher than those in non-pregnant women. The ovary thus may be a source of DLIF in the plasma of gonadotropin-treated women, and DLIF may have a role in ovarian follicular fluid homeostasis.

The effect of prophylactic antibiotics on febrile morbidity following cesarean section.

One hundred fifty patients undergoing cesarean section were evaluated prospectively for the effect of prophylactic antibiotics on postoperative morbidity. The postoperative infection rate was significantly reduced, being 30%, 16%, and 50% in the ampicillin, the cephalothin, and the control groups, respectively. The results are favorably compared with the results achieved in previously reported studies where the antibiotic treatment was started preoperatively. Our study confirms experimental studies that postoperative infection can be reduced by using prophylactic antibiotics in the immediate postoperative period. By this regimen, undesired placental transfer of the antibiotics to the fetus can be avoided.

Digoxin-like immunoreactive factor in twin and pregnancy-associated hypertensive pregnancies.

The objective of this study was to measure maternal total digoxin-like immunoreactive factor levels in singleton pregnancies with or without hypertension and in twin pregnancies. Plasma digoxin-like immunoreactive factor was measured in 113 third-trimester patients: 51 normotensives, 20 preeclamptics, 19 with latent or chronic hypertension, and 23 with twin pregnancies. The concentration of total digoxin-like immunoreactive factor in the twin gestations (1143 +/- 249 pg/mL) was significantly higher than that in either the normotensive pregnancies (890 +/- 161 pg/mL) (P less than .001) or in the hypertensive pregnancies (903 +/- 256 pg/mL) (P less than .01). However, there were no significant differences in digoxin-like immunoreactive factor levels between the normotensive and hypertensive groups. A trend of higher, although not statistically significant, levels of digoxin-like immunoreactive factor was noted in the chronic hypertensive group as compared with the preeclamptic patients (957 +/- 212 versus 852 +/- 288 pg/mL). We therefore conclude that digoxin-like immunoreactive factor does not contribute significantly to the pathogenesis or prediction of preeclampsia. The increased amount of digoxin-like immunoreactive factor in twin pregnancies may reflect a contribution from multifetal origin, or might be a physiologic adaptive mechanism allowing higher cardiac output by a possible cardiotropic effect.

Treatment of ovarian hyperstimulation syndrome by antihistamine.

Ovarian hyperstimulation was produced by human menopausal gonadotropin and chorionic gonadotropin in rabbits. A more rapid regression of the hyperstimualted ovaries was observed in an antihistamine-treated group than in a control group. The difference in regression was found to be statistically significant. The possibility of treating the ovarian hyperstimulation syndrome by antihistamine is cited.

Histamine levels in ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome was produced in rabbits by administration of human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG). Histamine levels in the animals' plasma were determined by an enzymatic-isotopic assay. The results of this study show that there is no statistically significant difference between histamine levels in ovarian hyperstimulated animals as compared with control animals. Furthermore, no differences in the number of mast cells in the ovaries could be demonstrated between the 2 groups. It is concluded that histamine probably does not play a role in the pathogenesis of this syndrome. The relevance of this suggestion to other proposed mechanisms on the etiology of ovarian hyperstimulation syndrome is discussed.

Placental concentrations of progesterone, estradiol-17 beta, and cyclic AMP at delivery.

In contrast to most mammals, human parturition is not preceded by a rise in the estradiol : progesterone ratio in peripheral plasma. Thus tissue concentrations of progesterone, estradiol-17 beta, and cyclic adenosine monophosphate (AMP) were measured in placentas obtained after spontaneous vaginal delivery (SVD, N = 11), after oxytocin-induced labor (OXIL, N = 5), and at elective cesarean section (ECS, N = 8). Both progesterone and estradiol were higher in placentas obtained from SVD compared with those from ECS (progesterone: 2.95 +/- 0.26 versus 1.96 +/- 0.29 ng/mg tissue, P < .025; estradiol: 33.6 +/- 5.2 versus 26.4 +/- 3.8 pg/mg). Placentas from OXIL had intermediate progesterone (2.50 +/- 0.47 ng/mg) but the highest estradiol concentration (41.4 +/- 3.2 pg/mg). Cyclic AMP was 29.8 +/- 1.5, 39.6 +/- 8.0, and 35.9 +/- 3.9 pmoles/100 mg tissue in SVD, OXIL, and ECS placentas, respectively. Thus no rise in the placental estradiol : progesterone ratio was found in association with spontaneous labor.

Continuous ambulatory peritoneal dialysis as the primary approach in the management of severe renal insufficiency in pregnancy.

Pregnancy is an unusual event in patients with chronic renal failure undergoing dialysis. The outcome in these cases is usually poor. We report a pregnancy complicated by severe renal insufficiency that was managed successfully by continuous ambulatory peritoneal dialysis. Dialysis was initiated at 24 weeks' gestation. At 34 weeks, premature labor associated with peritonitis resulted in the spontaneous delivery of a healthy male infant weighing 2400 g. The use of continuous ambulatory peritoneal dialysis during pregnancy offers theoretical advantages compared with hemodialysis. Our case, added to the available limited experience with this new modality, suggests that it may be an appropriate approach in women developing renal disease for the first time during pregnancy.

Evaluation of normal gestational sac growth: appearance of embryonic heartbeat and embryo body movements using the transvaginal technique.

A cross-sectional transvaginal ultrasound study was conducted in 137 normal pregnancies with gestational ages ranging from 5-12 weeks. Several biometric measurements were obtained throughout pregnancy, including the three diameters of the gestational sac, the crown-rump length, and the yolk sac. In addition, the appearance of the embryo heartbeat and embryo body movements were evaluated. Linear relationships were found between the mean gestational sac diameters and gestational age (r = 0.911; P less than .00001) and between mean gestational sac growth and crown-rump length growth (r = 0.926; P less than .0001). A gestational sac could be identified at 5 weeks' gestation; embryo heartbeat was imaged when the mean gestational sac diameter measured 2 cm, and embryo body movements could be seen when the mean gestational sac diameter reached 3 cm. In the present study, embryo heartbeat was identifiable after 6 weeks and 4 days with a sensitivity of 100%, specificity of 93.1%, positive predictive value of 96.9%, and negative predictive value of 100%. The embryo body movements, which were absent before 7 weeks' gestation, were observed after 8 weeks' gestation with a sensitivity of 100%, specificity of 92.8%, positive predictive value of 94.3%, and negative predictive value of 100%. With identification by transvaginal sonographic evaluation, the following can serve as markers of normal embryo growth: a mean gestational sac diameter greater than 2 cm in the presence of the embryo heartbeat, or a mean sac diameter measurement greater than 3 cm in the presence of embryo movement.

Sonographic growth measurements in triplet pregnancies.

Sonographic growth curves of biparietal diameter (BPD), head circumference, abdominal circumference, head circumference/abdominal circumference ratio, and femur length were generated from 24 uncomplicated, concordant triplet pregnancies. These were compared with the standard curves derived for singletons used in our medical center. Slowing of BPD, head circumference, and abdominal circumference growth was noted in triplets from the 28th week of gestation, whereas the head circumference/abdominal circumference ratio was similar to that of singletons. Femur growth was parallel to that of singletons, although on the low margin of the two standard deviations. We conclude that the growth patterns of triplets are different from those of singletons. We suggest that femur length derived for singletons may be suitable for the follow-up of triplets. However, when growth retardation is suspected, the growth curves presented herein may be used to identify the growth-retarded fetus.

Clomiphene citrate-induced simulatneous intra- and extrauterine pregnancy: case report.

A rare complication of ovulation induction with clomiphene citrate is presented. The importance of keeping in mind such a serious complication is emphasized in order to achieve early diagnosis and appropriate management. In pregnancies following clomiphene treatment, close supervision is imperative as soon as pregnancy is evident.

Sperm velocity and percentage of motility in 100 normospermic specimens analyzed by the multiple exposure photography (MEP) method.

Specimens from 100 fertile or potentially fertile men with sperm counts above 20 million/ml were analyzed objectively by the new multiple exposure photography method (MEP). The following results (means and standard deviations) were obtained: sperm concentration, 66 million/ml +/- 47; percentage of motile spermatozoa, 45% +/- 18; speed of motile spermatozoa, 30.3 micrometer/second +/- 5.5; abnormal forms, 29% +/- 10.2; average motility index (product of sperm speed and fraction of motile spermatozoa), 14 +/- 7.5. Low correlations were found between sperm concentration, percentage of motility, and spermatozoal velocity. Moderate correlations were found between percentage of motility and spermatozoal velocity. Negative moderate correlations were found between abnormal forms and spermatozoal velocity as well as between abnormal forms and percentage of motility. The differences between some of our results and those obtained by others are discussed.

Factors affecting sperm motility. I. In vitro change in motility with time after ejaculation.

Semen specimens from 33 donors were analyzed intermittently between 1 and 24 hours after ejaculation. Motility was determined objectively by analyzing still-camera photomicrographs taken with the aid of the new multiple exposure photography (MEP) technique, from which the following information was obtained: the percentage of motile spermatozoa, the average velocity and frequency distribution of spermatozoal velocities, and index of motility as well as sperm concentration. From curves drawn for each of the 33 analyzed specimens, these conclusions were drawn: 1. The percentage of motile spermatozoa decreases progressively, beginning 1 hour after ejaculation, at a rate of about 5% to 10%/hour. 2. In the majority of cases, sperm velocity increases for the first 4 hours and then decreases gradually. 3. There is no unique pattern of sperm motility and velocity with time for all specimens, especially during the first 4 hours. However, three typical curves of motility change were found during the first 4 hours: increase in motility, moderate decline in motility, and rapid loss of motility. 4. The frequency distribution of velocities of motile spermatozoa revealed typical normal curves at all times, but these curves became flatter as time elapsed. An explanation for these divergent patterns and the possible role of these findings in some physiologic and clinical problems are discussed.

Factors affecting sperm motility. II. Human sperm velocity and percentage of motility as influenced by semen dilution.

Spermatozoal velocity and percentage of motility were analyzed objectively with the multiple exposure photography method before and after specimens from fertile and infertile men were diluted in their own seminal plasma or normal saline. No significant change in percentage of motility was found in samples diluted up to 1:6 in both kinds of diluents. However, a significant relative increase (up to 25% of the original velocity) was found when a specimen was diluted with its own seminal plasma, and an even greater increase (up to 37% of the original velocity) was found when it was diluted with saline. Compared with undiluted specimens, there was no delayed effect on spermatozoal motility when semen was diluted with saline after up to 4 hours' incubation time. Contrary to the findings in animal and human semen described by others, there was no deleterious effect on sperm motility with this kind and rate of dilution and duration of time. The assumption that the increase in sperm velocity caused by dilution is not excitatory but is due only to a decrease of seminal fluid viscosity and a reduced number of spermatozoa which interfere with sperm free movement is discussed. We recommend evaluation of spermatozoal motility in diluted specimens in addition to evaluation of the original specimen in any routine semen analysis in order to determine true spermatozoal motility potential under optimal conditions.

Vaginal bleeding in premenarchal girls: a review.

Vaginal bleeding in childhood is not a common complaint. Serious medical or sociological problems can underly this irregular symptom in young girls. Therefore it requires careful medical investigation followed by appropriate sociologic and psychologic support. The variable etiologies of vulvovaginitis are the most common causes of vaginal bleeding during the prepubertal period. External blood loss can be related to trauma or urologic factors. It can be the presenting sign of relatively rare benign and malignant neoplasms of the genital tract. Precocious menstruation in itself or as a part of precocious puberty must be suspected in these cases. Vaginal bleeding in prepubertal girls is uncommon but warrants careful evaluation because of the special status of the young patient.

Nonstress Test in standing and lying women.

The effect of the maternal postural position on the Nonstress Test (NST) was evaluated in 14 normal pregnancies at 38-40 weeks of gestation. Each women was studied for two periods of 30 min, each in the standing and left lateral recumbent positions. Comparing both positions no significant difference was found in the number of fetal movements and heart rate accelerations. The total surface area of accelerations (TSAA) was significantly larger in the standing position.

Bilateral adnexal agenesis with an ectopic ovary--case report and review of the literature.

Bilateral adnexal agenesis (both ovaries and tubes) is not a common finding. Ectopic ovaries are also very rare. A report of the combination of the two, as far as we know, has never been published. Such a case is presented here with its endocrinological evaluation. The literature concerning these entities is reviewed.

Air embolism following intra-uterine hypertonic saline instillation: treatment in a high-pressure chamber; a case report.

Air embolism was encountered in a patient following induced abortion by means of intra-amniotic hypertonic saline instillation. The only symptom present was isolated cortical blindness. The patient was treated in a high-pressure chamber and a nearly complete recovery was achieved.

PIP: Air embolism, diagnosed by clinical therapeutic trial in the Navy hyperbaric chamber, occurred in a woman having labor induced by hypertonic saline for intrauterine fetal death at 25 weeks' gestation. 20 hours after saline administration, and 2 hours after 2 mU/minute diluted oxytocin was started, she had a sudden cardiovascular collapse with cyanosis and dyspnea. She was resuscitated by ventilation by mask and iv fluids. When she regained consciousness she was cortically blind. During treatment by the Navy's protocol, 30 minutes of compression at 6 ATA alternating cycles of 100% oxygen and air after rapid decompression to 2.8 ATA for 5 hours 19 minutes, there was a dramatic improvement in vision. After treatment, she showed left hemianopsia with macular damage. A year later only slight loss of left visual field remained. Air embolism can only be differentiated from amniotic fluid embolism by demonstration of amniotic fluid or fetal components in the maternal central circulation, or a therapeutic trial in a hyperbaric chamber. It is safer to try the pressure chamber immediately.

Sinusoidal pattern together with signs of moderate fetal hypoxia associated with a true knot of cord.

The fetal heart rate pattern of a dying fetus due to tightening of a true knot of cord is presented. Sinusoidal pattern was electronically recorded along wih bradycardia--tachycardia. The importance of the sinusoidal pattern is discussed. It seems to imply fetal compromise if observed together with other signs of moderate fetal distress.

Serotonin and the ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome was induced in rabbit by administration of human menopausal gonadotropin (HMG) and human chorionic gonadotropin (HCG). In an attempt to establish whether serotonin plays a part in the induction of this syndrome, the hyperstimulated rabbits were divided into two groups and were administered known anti-serotonin drugs, cyproheptadine and methysergide, respectively. The group treated with cyproheptadine, a non-specific serotonin antagonist, exhibited significant acceleration in the regression of the syndrome. Methysergide, a specific serotonin antagonist, administered to the second group, neither prevented the occurrence of the syndrome nor accelerated its regression. The results of this work indicate that serotonin does not seem to be directly involved in the production of the ovarian hyperstimulation syndrome in rabbits.

The "grand multipara"--is it a problem? A review of 5785 cases.

The Grand Multipara (GM) has almost disappeared in the Western countries due to the advancement of family planning. Having a heterogeneous population, the problem of Grand Multiparity still exists in our country. This study is based on 5785 cases of GM which were treated in our Obstetrical Department during a period of 16 years (1960-1975). We have compared this group to the general obstetrical population in terms of pregnancy and delivery complications. Face and breech presentations as well as transverse lie were twice, brow presentations were three times as frequent in the GM group. Postpartum hemorrhage (P.P.H.) was four times and premature separation of the placenta twice as frequent. Rupture of the uterus was about 20 times more frequent. Forceps delivery and Cesarean section rate were twice, while the vacuum extraction 5-fold more frequent. Though there was no material mortality and perinatal mortality was not higher than in the general population. Even though the percentage of GM in our population has been decreased in the last 10 years, our results suggest that Grand Multiparity is still a high risk obstetrical problem.

PIP: The grand multipara (GM) has almost disappeared in the Western countries due to the advancement of family planning. Having a heterogenous population, the problem of grand multipara still exists in Israel. This study is based on 5785 cases of grand multipara, which were treated in the obstetrical department of the Rambam Medical Center, Technion during a period of 16 years (1960-75). The authors compared this group to the general obstetrical population in terms of pregnancy and delivery complications. Face and breech presentations as well as transverse lie were twice, brow presentations were 3 times as frequent in the GM group. Postpartum hemorrhage was 4 times and premature separation of the placenta twice as frequent. Rupture of the uterus was about 20 times more frequent. Forceps delivery and Cesarean section rate were twice, while the vacuum extraction 5-fold more frequent. There was no maternal mortality, and perinatal mortality was not higher than in the general population. Even though the percentage of GM in this population has decreased in the last 10 years, the results suggest that grand multiparity is still a high risk obstetrical problem.