Group A streptococcus: is there a genital carrier state in women following infection?

Group A streptococcus (GAS) is a rare but serious cause of postpartum and gynecological infections. There are no follow-up or prophylaxis guidelines for women with previous GAS genital infection. We aimed to evaluate the incidence of long-term gynecological carrier state in patients with a history of genital GAS infection. This is a prospective study of women who had a genital GAS infection and were followed for 1 year from the date of isolation. Cultures were obtained every 3-4 months. As a control group, women with no previously documented GAS infection were screened for GAS. Twenty-five women with a previous GAS infection participated in the study. Two of the 25 patients had positive vaginal GAS cultures during follow-up, giving a carrier rate of 8 %. Four hundred and thirty-six women participated in the control group; none was a carrier of GAS (p < 0.003). We found that common gynecological procedures were occasionally associated with invasive GAS infection. A significant rate of carriers was found among women with previous GAS genital infection. Common office procedures can be related to severe GAS infection. Consideration should be given to screening women with previous GAS infection prior to invasive as well as semi-invasive gynecological or obstetric procedures.

Long-term efficacy of Paula method as compared with pelvic floor muscle training for stress urinary incontinence in women: a 6-month follow-up.

PURPOSE: The purpose of this study was to examine the long-term efficacy of an exercise regimen based on circular muscle strengthening (Paula method) as opposed to pelvic floor muscle training (PFMT) on stress urinary incontinence symptoms at 6 months postintervention. SUBJECTS AND SETTING: Of 240 women who had initially participated in a randomized clinical trial, 143 women suffering from stress urinary incontinence participated in this follow-up study. METHODS: Subjects participated in a randomized controlled clinical trial comparing 2 exercise programs (12 private Paula lessons vs 6 group PFMT lessons) over a 12-week period. Of these, 143 women took part in the follow-up study: 64 from the Paula group and 79 from the PFMT group. Six-month follow-up data were gathered via telephone interviews. RESULTS: No significant deterioration in stress urinary incontinence symptoms occurred 6 months after completion of the interventions in either group. We found a statistically significant difference between the groups with regard to reported frequency of urinary leakage; 25 of subjects (39.7%) allocated to the Paula method reported a low frequency rate of incontinence episodes upon completion of the study as compared to 18 (22.8%) in the PFMT group (P = .03). Forty-nine of the 64 women in the Paula group (76.6%) and 62 of the 79 women in the PFMT group (78.5%) reported that they continued exercising 6 months after completion of the trial (P = .8). CONCLUSIONS: Both intervention methods reduced frequency of urinary incontinence over a 6-month period. Long-term adherence was similar in both groups. Pelvic floor muscle training was associated with fewer sessions and decreased cost and fewer lessons needed as compared with the Paula method. Nevertheless, results also suggest that the Paula method achieves a lower frequency of urinary leakage than PFMT.

Three-dimensional transperineal ultrasound findings associated with anal incontinence after intrapartum sphincter tears in primiparous women.

OBJECTIVE: Three-dimensional transperineal sonography (3D-TPS) performed in women following third- or fourth-degree intrapartum tears repaired with the overlapping technique demonstrates characteristic signs. The aim of this study was to investigate the correlation of these signs with clinical complaints of incontinence. METHODS: This was a prospective observational study. Sixty primiparous women underwent 3D-TPS 3-42 (mean, 10.6) months after surgical repair of third- or fourth-degree postpartum sphincter tears with the overlapping technique and were evaluated for clinical degree of incontinence using the St Mark's Incontinence Score (SMIS) questionnaire. The following signs were assessed on 3D-TPS: interruption of the internal anal sphincter or external anal sphincter, 'half moon' sign, changes in the mucosal folds and thickening of the external anal sphincter in the area of sphincter repair. As a comparison group, 27 primiparous women after normal vaginal delivery, without clinically recognized anal sphincter tears, were evaluated similarly, 3-37 (mean, 9.9) months postpartum. RESULTS: Abnormal sonographic signs were apparent in 35 (58.3%) of 60 women in the study group, and 39 (65%) of 60 had some clinical complaints of incontinence 3-42 months after delivery, most of a mild degree. Higher SMIS results were found in women of the study group than in those of the comparison group (mean (SD) 2.80 (0.481) vs. 1.15 (0.365); P = 0.018). The rates of incontinence were similar between the women in the study group with normal ultrasound findings and the women in the comparison group (9/25 vs. 10/27; relative risk (RR) = 0.97, 95% CI, 0.47-1.97). CONCLUSIONS: Sonographic signs of anal sphincter tear and repair had disappeared at follow-up examination in almost half of the patients, and therefore this examination should be deferred from the early postpartum period. A substantial proportion of women report some complaint of incontinence after sphincter repair, most of a slight degree. Such complaints are associated with abnormal 3D-TPS findings at follow up, while in women with a normal 3D-TPS scan the rate of incontinence complaints is similar to that in women after normal delivery.

Blood mononuclear cell gene expression signature of postpartum depression.

In sorrow thou shalt bring forth children (Genesis 3:16) seems as relevant today, with one of seven mothers afflicted by a depressive episode, constituting the most common medical complication after delivery. Why mothers are variably affected by mood symptoms postpartum remains unclear, and the pathogenesis and early molecular indicators of this divergent outcome have not been described. We applied a case-control design comparing differential global gene expression profiles in blood mononuclear cells sampled shortly after delivery at the time of inception of postpartum depression (PD). Nine antidepressant naive mothers showing high depressive scores and developing a persisting major depressive episode with postpartum onset were compared with 10 mothers showing low depressive scores and no depressive symptoms on prospective follow-up. A distinctive gene expression signature was observed after delivery among mothers with an emergent PD, with a significant overabundance of transcripts showing a high-fold differential expression between groups, and correlating with depressive symptom severity among all mothers. Early expression signatures correctly classified the majority of PD patients and controls. Those developing persisting PD exhibit a relative downregulation of transcription after delivery, with differential immune activation, and decreased transcriptional engagement in cell proliferation, and DNA replication and repair processes. Our data provide initial evidence indicating that blood cells sampled shortly after delivery may harbor valuable prognostic information for identifying the onset of persisting PD. Some of the informative transcripts and pathways may be implicated in the differential vulnerability that underlies depression pathogenesis.

The effect of hormone replacement therapy on cognitive function in post-menopausal women.

BACKGROUND: Despite interest in causes of dementia in older persons, particularly in post-menopausal women, it is unclear whether hormone replacement therapy (HRT) is a risk factor. AIM: To assess cognitive function in post-menopausal women with high educational status receiving HRT, compared to non-users. DESIGN: Cognitive functioning was assessed with in women aged 55-60 years with at least university-level education, using the Mindstreams system, a computerized cognitive battery with multiple domains. RESULTS: Of 165 women meeting the inclusion/exclusion criteria, 82 women (49.7%) declined participation. Of the remaining 83, 40 (48.2%) had never received HRT; the remainder was divided into women receiving 5-9 years HRT (n = 29)versus those with >or=10 years HRT (n = 11). There were no statistically significant differences between HRT users and non-users in global scores or sub-domains of cognitive functioning, and no difference between those women receiving HRT for 5-9 years vs. >or=10 years. DISCUSSIONS: Long-term HRT does not appear to impair cognitive functioning in highly-educated women. Recommendations regarding post-menopausal HRT should be made on an individual basis.

Amniotic fluid 3,3',5'-triiodothyronine in the detection of congenital hypothyroidism.

Amniotic fluid rT3 levels were measured during pregnancy in two women who previously gave birth to infants suffering from neonatal hypothyroidism. In the first case, hypothyroidism was strongly suspected because of repeated low levels of rT3 in the amniotic fluid (20-64 ng/dl) at 16 and 31 weeks of gestation. A normal infant was delivered. He is now 10 months old and taking no treatment; he has no clinical or laboratory signs of hypothyroidism. In the second case, amniotic rT3 levels (140-180 ng/dl) were well within the normal range for 15-19 weeks of pregnancy, but an affected hypothyroid infant was born. These data suggest that amniotic fluid rT3 levels may not be a reliable tool in diagnosing intrauterine hypothyroidism.

Eph and ephrin expression in normal placental development and preeclampsia.

Eph receptors and their ephrin ligands play a fundamental role in embryogenesis. Their functions include cell targeting and angiogenesis. In placental development, trophoblasts migrate and invade maternal tissue and spiral arteries, where they play a role in both anchoring the placenta to the uterus and increasing blood flow to the developing fetus (interstitial and endovascular invasions). We investigated the cellular distribution and expression patterns of representative Eph and ephrin RNA and protein in an effort to identify the molecules involved in trophoblast migration during normal placental development and placental pathologies. We found ephrin-A1 expressed exclusively in the invasive extravillous trophoblast (EVT) cell lineage. We therefore proceeded to investigate ephrin-A1 in placental pathologies with defects in EVT invasion. In preeclampsia, where trophoblast invasion is shallow, we observed ephrin-A1 expression similar to normal placenta. Furthermore, in initial experiments on the deeply invading trophoblasts of placenta accreta, which lacks decidua, ephrin-A1 is found to be expressed highly in extravillous trophoblasts that have invaded the myometrium. In addition, we found the prototype ephrin-A1 receptor, EphA2, localized in several placental cell types. EphB4 and ephrin-B2 molecules, which have specific expression patterns during artery and vein development, respectively, were also expressed in the placenta. The cell specific distribution of ephrin-A1 suggests that it may play a role in targeting and migration of trophoblasts, and in the vascular remodeling induced by the invading extravillous trophoblasts. Failure of ephrin-A1 expression is unlikely to be the primary cause in defective migration of trophoblasts observed in preeclampsia. Specific roles for other Eph and ephrin proteins remain to be investigated.

Antenatal presentation of carnitine palmitoyltransferase II deficiency.

Carnitine palmitoyl transferase (CPT) II deficiency is usually manifested around puberty by exercise induced myoglobinuria. Two Ashkenazi Jewish sibs with the rare antenatal form of CPTII deficiency are reported. On the 5th gestational month periventricular calcifications and markedly enlarged kidneys were found in both of them. The activity of CPTII in lymphocytes was undetectable and both sibs were homozygous for the 1237delAG mutation. Because of the serious consequences of homozygosity for this mutation, genotype determination of all Ashkenazi patients with the adolescent form of CPTII deficiency is warranted.

Rupture of ectopic pregnancy following disappearance of serum beta subunit of hCG.

The introduction of sensitive assays for the beta subunit of hCG (beta-hCG) and improved ultrasound technology for diagnosis and monitoring of ectopic pregnancy have changed the clinical approach to the management of ectopic pregnancy. Only a few reports have been published of patients with ectopic gestation and negative serum beta-hCG levels. None of these described rupture of ectopic pregnancy following the decline of beta-hCG levels to below 10 mIU/mL. We describe a case of ectopic pregnancy, managed expectantly, in which rupture and hemoperitoneum occurred after the decline of beta-hCG levels to below 10 mIU/mL.

Increased prolactin response to thyrotropin-releasing hormone in primary ovarian failure.

To investigate prolactin (PRL) and thyrotropin-stimulating hormone (TSH) secretion in ovarian failure, 14 women with primary ovarian failure were challenged with luteinizing hormone-releasing hormone (LHRH) (100 micrograms) and thyrotropin-releasing hormone (TRH) (200 micrograms) given intravenously at 30-minute intervals. Responses were compared with those of 13 healthy female controls. In the patient group, basal follicle-stimulating hormone (FSH), LH, and peak gonadotropin responses to LHRH were higher and basal estrone and estradiol levels were lower than in the controls (P less than .001). Mean basal PRL levels were similar in the 2 groups. However, the mean peak and integrated PRL responses in the patients were greater than in the controls (P less than .05). Ten patients had a markedly exaggerated PRL response to TRH. The mean basal TSH levels and the peak TSH response to TRH were similar to those of the controls. Estrogens are known to stimulate PRL secretion. These subjects had increased PRL responses with low circulating estrogens. The mechanism underlying the findings is not known, but could be related to increased aromatization of androgens to estrogens in the hypothalamus. Alternatively, other factors could be responsible for the exaggerated PRL responses to TRH noted in these patients with primary ovarian failure.

Persistent müllerian structures in infertile male.

Müllerian duct derivatives were identified in an infertile adult male patient who had long-standing azoospermia and was operated on for inguinal hernia. Persistent müllerian duct syndrome is reviewed, with special emphasis on the pathophysiologic and surgical considerations involved in the treatment of this abnormality.

Do spermatozoa secrete motility enhancing factor?

OBJECTIVES: To determine whether medium conditioned with human spermatozoa was capable of enhancing sperm motility and penetration ability. DESIGN: Paired aliquots of washed spermatozoa were allowed to incubate for nine different incubation periods, ranging from 15 to 240 minutes in 37 degrees C in humidified atmosphere with 5% CO2. After this, they were centrifuged at 600 x g for 6 minutes. The conditioned medium was removed from one tube of each pair and replaced with fresh medium. In the other tube of the same pair the sperm pellet was resuspended in the same medium. In a second set of experiments, conditioned medium was removed from tubes containing samples of spermatozoa after different predefined incubation periods. This was used to replace medium that had been removed from sperm cells that had been incubated for 120 minutes. Motility and penetration of zona-free hamster eggs were assessed. RESULTS: Removal of the incubation medium at times between 15 to 240 minutes resulted in sperm that showed a gradual decrease in motility and penetration ability followed by a gradual increase in motility and penetration ability, i.e., an inverted bell-shaped effect. The addition of conditioned medium obtained after different periods of incubation to spermatozoa where medium was removed after 120 minutes of incubation resulted in an increase in sperm motility and penetration ability. The longer the medium was conditioned with spermatozoa the more prominent the effect on sperm motility and penetration ability, with maximal effect observed with medium conditioned for 120 minutes. CONCLUSIONS: Medium conditioned with human spermatozoa enhances sperm motility and penetration ability.

The effect of ethinyl estradiol on endometrial thickness and uterine volume during ovulation induction by clomiphene citrate.

OBJECTIVE: To assess the deleterious effect of clomiphene citrate (CC) on the development of the endometrium and its improvement by the addition of ethinyl estradiol (E2). PARTICIPATING PATIENTS: Infertility-treated patients, monitored for induction of ovulation or timing of insemination (control group). DESIGN: We studied four groups of women during an ovulatory cycle with various treatment schedules. Group 1: untreated patients; group 2: patients treated by CC; group 3: patients treated by CC + ethinyl E2; group 4: patients treated by human menopausal gonadotropin. Follow-up of the patients was done by vaginal ultrasonography and measurements of blood E2. RESULTS: In the group treated by CC, both endometrial thickness and uterine volume growth during the follicular phase were lower as compared with untreated controls and menotropin-treated patients. The addition of ethinyl E2 to these patients reversed this deleterious effect of CC without interfering with ovulation. CONCLUSION: Ethinyl E2 may reverse the deleterious effect of CC on endometrial development during the follicular phase.

Pharmacokinetics of raloxifene and its clinical application.

Hormone replacement therapy (HRT) administered to postmenopausal women relieves climacteric symptoms, prevents loss of bone mass, and counteracts the development of coronary artery disease. However, whereas all the benefits associated with HRT are achieved only following long-term therapy, the long-term compliance to the regimen is poor. The most common reasons for discontinuance are uterine bleeding, breast pains, and a fear of breast cancer. Long-term HRT may be associated with an increased risk of breast cancer. Consequently, there is a need for an "ideal estrogen", designed to pinpoint desired target tissues for estrogen, such as the bone and liver, while acting as an antiestrogen in uterus and breast tissues. Raloxifene belongs to a new class of compounds, selective estrogen receptor modulators (SERMs). It binds to and interacts with estrogen receptors, acting as an estrogen agonist in bone and liver, but as an estrogen antagonist in breast and uterus. Therefore, raloxifene represents a potentially important alternative to HRT in postmenopausal women for the prevention and treatment of osteoporosis and cardiovascular disease. Clinical studies regarding the drug's long term benefits are still required.

Maternal blood pressure response to the intravenous administration of pethidine-promethazine during labor.

A double blind study on the effect of an intravenous injection of a combination of 75 mg pethidine and 25 mg promethazine was conducted on 200 women during normal deliveries. Four groups of 50 women each received injections of pethidine and promethazine, promethazine alone, pethidine alone and normal saline. In the pethidine-promethazine group there was a significant elevation in blood pressure in the first 10 min following the injection as compared with the other groups. The mean (+/- S.D.) systolic blood pressure after the injection was 143.2 +/- 14.3 mmHg as compared with 118.9 +/- 8.4 mmHg before the injection, and the mean diastolic blood pressure as 96.9 +/- 8.4 mmHg after the injection as compared with 77.7 +/- 9.3 mmHg before the injection. 25 mg promethazine alone caused slight elevation in blood pressure which was further increased by combination with pethidine. The clinical significance of these observations is discussed.

Uterus didelphys. Ultrasound diagnosis in the case of an adnexal mass as a presenting symptom in early pregnancy.

Uterine anomalies are one of the various processes in the pelvic organs which present themselves as adnexal masses in pregnancy. In pregnancy associated with congenital uterine anomalies, complications are likely to occur. Ultrasonography is of great importance in early recognition of the anomalies, which can prevent unnecessary surgical intervention. A case of ultrasonic detection of uterus didelphys with unicavitary pregnancy is described.

Sonographic evaluation of the uterus in postmenopausal women receiving tamoxifen: characterization of mid-uterine abnormalities.

BACKGROUND: Tamoxifen is known to exert agonist estrogenic effects on the uterus. Its use in postmenopausal women has also been associated with various endometrial and uterine abnormalities that can be detected by endovaginal sonography. OBJECTIVE: To study postmenopausal patients receiving tamoxifen who were referred for evaluation following the detection of abnormal uterine findings by endovaginal sonography. METHODS: Fifty-two women treated with tamoxifen for breast cancer who were found to have an abnormal uterine sonogram constituted the study population. Uterine sonograms were reviewed and clinical and sonographic data were correlated with the results of the histologic examinations. RESULTS: Forty-five women demonstrated a thickened mid-uterine structure. Of these, in thirty-nine patients (87%) either no tissue of scant fragments of normal endometrium were obtained on curettage, and six women (13%) had endometrial hyperplasia. Seven women had fluid loculation lined by thin endometrium. Their subsequent histologic examination was normal. The sonograms of the women who demonstrated an appearance of a thickened endometrium but no neoplasia, characteristically demonstrated hyperechogenic cystic area with no midline echo. CONCLUSIONS: Among 52 postmenopausal patients receiving tamoxifen presented with an abnormal uterine sonogram, 39 (75%) women were found to have a thick mid-uterine structure resembling a thickened endometrium without histologic evidence of neoplasia. This phenomenon can be characterized by typical sonographic features, and may be differentiated from other uterine abnormalities.

The significance of baseline tachycardia in the postterm fetus.

Two cases of uncomplicated fetal baseline tachycardia in postterm pregnancies that resulted in fetal death are reported. The tachycardia was the only sign of fetal distress in both cases. Although the condition is not usually considered and ominous sign of fetal outcome, the authors recommend immediate cesarian section in postterm cases of severe fetal baseline tachycardia occurring before or during labor.

Pelvic abscess associated with a Lippes loop. An unusual case.

An unusual case occurred of Lippes-Loop-associated pelvic abscess, characterized by a relatively mild clinical course and an unusual localization in the pelvis. This case emphasizes the importance of considering the association between intrauterine devices and pelvic abscess.

PIP: An unusual case of pelvic abscess characterized by a relatively mild clinical course and unusual localization occurred in a previously healthy, married, 26-year old woman with 2 children and 1 previous abortion. The woman was admitted to the hospital for lower abdominal pain of 1 week's duration. A Lippes Loop C inserted 5 years earlier, 4 months after a term delivery, had caused no complications. The last menstrual period was 2 weeks before admission. 1 week before admission lower abdominal cramps and dysuria had started, and nitrofurantoin 400 mg daily was prescribed for suspected urinary tract infection. The patient was hospitalized when the pain worsened. The patient appeared well on admission. Abdominal examination disclosed a very tender suprapubic mass the size of a 14-week pregnancy. Vaginal examination revealed an anterior, normal-sized uterus adherent to the mass. An examination under general anesthesia revealed a 12 cm mass adherent to a normal sized uterus. Multiple adhesions prevented visualization of the pelvic organs during laparoscopy. The IUD was removed and sent for bacteriologic examination. Laparotomy revealed a mass with a diameter of 10 cm located between the bladder and the uterus and adherent to them and to the anterior abdominal wall. The tubes were hyperemic and edematous, and pus was noted in both fimbriae. Both ovaries appeared normal. The mass was excised and a frozen section examination established the diagnosis of an abscess, which was later confirmed by histopathologic examination. A course of intravenous gentamycin, ampicillin, and clindamycin was started. Polymicrobial infection with Streptococcus viridans, Staphylococcus, coagulase negative, and diptheroids was subsequently established. The postoperative course was uneventful, and physical examination a month later was normal. No explanation of the unusual location of the abscess in the visicouterine space or of the absence of most of the symptoms of an abscess was found.