Female sterilization and subsequent ectopic pregnancy.

An 8-year retrospective study was conducted of the metropolitan Dayton, Ohio, area from January 1970 through December 1977. During this period of time there were 86,809 births and 721 tubal pregnancies. Thirty-three of the ectopic pregnancies were in patients who had previously undergone a tubal sterilization. The 7.4% rate (29 of 393) in the past 4 years indicates the increasing importance of previous sterilization as an etiologic agent in ectopic gestation.

Heterotopic pregnancy: midtrimester management.

A case of heterotopic pregnancy is presented. A search of the English literature reveals the present case to be the first instance in which a living second-trimester abdominal fetus has been extracted while its placenta remained undisturbed, and the intrauterine pregnancy progressed normally to term.

46,XY pure gonadal dysgenesis: report of 2 unusual cases.

A review of 2 cases of 46,XY pure gonadal dysgenesis (Swyer's syndrome) is presented. In one, bilateral gonadoblastomas with dysgerminomas were found at the time of laparotomy for gonadal extirpation. The second case was of interest because of endometriosis on the mesosalpinx, an entity heretofore undescribed in pure gonadal dysgenesis.

Virologic studies of HTLV-III/LAV in pregnancy: case report of a woman with AIDS.

The number of cases of acquired immunodeficiency syndrome (AIDS) in women is increasing. As of December 30, 1985, 1075 cases in women had been reported to the Centers for Disease Control; 81% of these cases occurred in women of childbearing age (15 to 45 years). The human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) can be transmitted from mothers to their infants. Described is a woman with transfusion-acquired AIDS who was six weeks' pregnant at the time Pneumocystis carinii pneumonia was diagnosed. Despite the fact that HTLV III/LAV was isolated from her peripheral lymphocytes throughout pregnancy, transmission of the virus to her infant or husband does not appear to have occurred.

Identification and characterization of cyclo(His-Pro)-like immunoreactivity in amniotic fluid.

Amniotic fluid (AF) from 25 term pregnancies was analyzed for cyclo(His-Pro)-like immunoreactivity (CHP-LI). CHP-LI was detected in all AF samples and was indistinguishable from synthetic CHP by immunoidentity, by gel chromatography on Sephadex G-25, and by high pressure liquid chromatography. The mean concentration of CHP-LI in AF was 13,622 +/- 1288 pg/ml (+/- SE) and concentrations were not altered by maternal labor. Plasma concentrations of CHP-LI were similar in 4 pregnant and 4 control subjects [2260 +/- 432 pg/ml vs. 2162 +/- 419 pg/ml (+/- SE), respectively]. We conclude that 1) CHP-LI is readily detected in AF from term pregnancies and is indistinguishable from synthetic CHP, and 2) concentrations of CHP-LI in human AF are significantly higher than concentrations of maternal plasma CHP-LI, suggesting CHP AF originates by mechanisms other than diffusion from maternal plasma.

Radioimmunoassay of cyclo(His-Pro) in unextracted human plasma: report of a normal range and definition of factors critical for successful assay.

A radioimmunoassay for cyclo(His-Pro) (CHP) in unextracted human plasma that can detect 40 pg has been developed. Elution profile of CHP-like immunoreactivity (CHP-LI) corresponded precisely to those of [3H] cyclo(His-Pro) by both high pressure liquid chromatography and Sephadex G-25 column chromatography. In addition plasma CHP-LI exhibited close immunoidentity with authentic CHP. Charcoal treatment of plasma containing [3H] cyclo(His-Pro) resulted in loss of both CHP-LI and [3H] cyclo(His-Pro) activity. Plasma frozen at draw and assayed at 0, 6 and 24 hours displayed no change in CHP-LI while an aliquot from the same sample maintained at 4 degrees C and assayed at the same time intervals showed a 50% rise (0 hrs-856 +/- 47 pg/ml; 24 hrs-1288 +/- 85 pg/ml) (+/- SE) over 24 hours. In addition, plasma drawn from 14 volunteers and immediately frozen until assay yielded a mean CHP value of 829 +/- 64 pg/ml (+/- SE) while that of 14 volunteers that was maintained at 25 degrees C for 90 minutes was significantly higher at 1085 +/- 34 pg/ml (+/- SE) (p less than 0.03). Taken together, these data suggest that CHP can be easily measured in a direct RIA of human plasma, however, failure to maintain the sample frozen from the time of draw until assay may yield spuriously elevated values.

Tympanic thermometry for recording basal body temperatures.

Evaluation of 12 menstrual cycles using oral, rectal, and TM temperature measuring devices (over 2,000 individual readings) confirmed the ovulatory thermal shift was equally detected with TM thermometry compared with the traditional methods. Although a single TM reading was satisfactory, an average of three successive readings provided a smoother graph (decreased variance). The device appears acceptable, and even preferred, for recording BBT charts, primarily because of its nearly instantaneous readings.

Relaxin, CA-125, progesterone, estradiol, Schwangerschaft protein, and human chorionic gonadotropin as predictors of outcome in threatened and nonthreatened pregnancies.

Progesterone (P), estradiol (E2), relaxin, CA-125, Schwangerschaft protein, and human chorionic gonadotropin (hCG) were measured in 221 pregnancies (less than or equal to 77 days gestation). The cohort was divided into asymptomatic subjects (group I, n = 117) and those with threatening symptoms (group II, n = 104). Outcome was ascertained as viable (normal at 14 weeks, n = 131), spontaneous abortion (n = 58), or ectopic gestation (n = 32). Statistical analysis revealed no differences in the mean maternal or gestational ages among the viable pregnancies, abortions, and ectopics in group I and group II. In group I, significant differences in the means were noted for P, hCG, relaxin, and CA-125 among those destined to abort, compared with those who were not. In group II, differences were noted in P, hCG, relaxin, and E2 when viable and nonviable pregnancies were compared. Within group II, there were significant differences between the means of E2 and CA-125 when the aborters were contrasted with ectopics. Receiver operating characteristic curve analysis revealed that P was the single most reliable predictor and was most effective in threatened pregnancies. Stepwise logistic regression of the six markers in group II provided an equation of possible clinical utility in differentiating abortion versus ectopic pregnancy in threatened gestations based on CA-125 and E2 levels.

Chromosomal abnormalities in ectopic pregnancy chorionic villi.

OBJECTIVE: To evaluate the incidence of chromosomal abnormalities in ectopic pregnancy chorionic villi. METHODS: A prospective study of patients with the diagnosis of ectopic pregnancy was conducted, with chorionic villi obtained at the time of surgical therapy cultured and analyzed for karyotype. Review of the patient's medical record and ultrasound evaluation was then completed and findings correlated with karyotype results. RESULTS: Twenty-two patients undergoing surgery for the diagnosis of ectopic pregnancy yielded chorionic villi for culture. Successful culture was performed in 21 patients, with 3 (14%) revealing abnormal karyotypes. Review of the medical record showed ultrasound results consistent with fetal development or a gestational sac in 15 of 18 patients with normal chromosomal analysis. Three of 6 patients without fetal development yielded abnormal chromosomal findings. CONCLUSION: Our results confirm that a high degree of success can be achieved in the karyotype analysis of ectopic pregnancy chorionic villi and that these conceptuses have a rate of abnormality similar to that reported for intrauterine gestations. Our data further suggest that when a gestational sac or fetal pole is identified by ultrasound, there is usually a normal karyotype.

Identification of cyclo(His-Pro)-like immunoreactivity in human follicular fluid: correlation with steroid and peptide hormones.

OBJECTIVE: The purpose of this study was to evaluate human follicular fluid (FF) for the presence of cyclo(His-Pro)-like immunoreactivity (CHP-LI). After verifying its presence, we quantitated the levels and investigated correlations with other follicular parameters, including hormone levels. METHODS: Follicular fluid was collected from female volunteers undergoing controlled ovarian hyperstimulation. Fluid was collected by follicular puncture, either transvaginally (in vitro fertilization) or laparoscopically (gamete intrafallopian transfer) at the time of oocyte retrieval (N = 137). Follicular size was determined ultrasonographically. Assays for steroid and peptide hormones were determined with commercially available radioimmunoassay kits. CHP-LI was measured using a previously reported assay; parallel dilution curves and column chromatography aided in immunoidentity. RESULTS: The mean FF CHP-LI concentration (13.10 +/- 1.83 nmol/L, N = 137) was greater than the corresponding serum values (9.42 +/- 2.45 nmol/L; N = 21) (P < .05). Large follicles (20 mm or greater; 14.45 +/- 1.74 nmol/L) contained significantly more CHP-LI than either medium follicles (16-19 mm; 11.51 +/- 1.88 nmol/L) or small follicles (15 mm or smaller; 10.83 +/- 2.12 nmol/L) (P < .05). Positive correlations were found between FF CHP-LI values and corresponding FF progesterone and prolactin concentrations (r = 0.67 and 0.62, respectively; P < .05). CONCLUSION: Mean CHP-LI levels in the FF are greater than those in the corresponding serum. We suggest that the neuropeptide may be originating from either peptidase cleavage of precursor peptides or from granulosa cell production.

Cesarean scar endometriosis: a review.

Endometriosis in the abdominal scar following cesarean section is a rare event, but may be more frequent than estimated from the literature. Five cases collected over 5 years are presented suggesting an incidence over 1 percent. Diagnosis and management are discussed and the literature regarding this entity is reviewed. Newer methods of treatment are available, but surgical excision remains the method of choice.

Outpatient laparoscopic management of ectopic pregnancy with a local methotrexate injection.

Nine patients with unruptured tubal ectopic gestations were treated as outpatients utilizing a laparoscopically directed injection of methotrexate into the tubal mass. The initial quantitative serum human chorionic gonadotropin values ranged from 34 to 17,100 mIU/mL. Eight of nine subjects had complete resolution of the pregnancy over the ensuing 10-33 days; the remaining patient, with plateauing human chorionic gonadotropin levels, required a laparotomy.

MR imaging of endometriosis arising in cesarean section scar.

Endometriosis of the abdominal wall is rare and usually arises in a surgical incision. Magnetic resonance (MR) has been used to evaluate endometriosis of the ovaries. A case of endometriosis in a cesarean section scar is presented and evaluated with CT and MR.

Indications for examination of spontaneous abortion specimens: a reassessment.

The clinical evaluation of recurrent pregnancy loss is assessed in light of recent technical advances in trophoblast culture, ultrasonography, and chromosome analysis. With an algorithm based on karyotype results, cost-benefit calculations confirm that an average savings of $1099.47 per patient could be achieved if a policy of karyotype analysis of recurrent abortion specimens was emphasized. It is estimated that a specific chromosomal cause could be identified in 45% to 70% of such cases. A more concerted effort should be made to culture trophoblast tissue from recurrent pregnancy losses; such a policy would result in both emotional and financial rewards.

Paternal pericentric inversion of chromosome 4 as a cause of recurrent pregnancy loss.

A paternal pericentric inversion of chromosome 4 was ascertained through karyotype analysis of an abortus specimen proven to be 46,XX,rec(4),dup q, inv (4)(p13q28). The relationship of paternal pericentric inversion to pregnancy loss is discussed, and a recommendation for karyotype analysis of recurrent abortion specimens is made.

Trophoblast production of hCG and ahCG from normal and abnormal pregnancies.

This study was designed to correlate early pregnancy outcome with serum and trophoblastic culture media levels of hCG, alpha hCG, and the alpha hCG/hCG ratio. Maternal serum was obtained from 104 women with normal gestations (n = 25), ectopic pregnancies (n = 43) and spontaneous abortions (n = 36); trophoblastic tissue was obtained from 10 subjects in each group. The alpha hCG/hCG ratio was abnormally elevated in the serum of 46% of women with abortions and 26% of those with ectopic pregnancies. Tissue culture experiments confirmed the relative increase in alpha hCG levels. Deteriorating trophoblast tissue from compromised or poorly oxygenated placental implantations results in abnormally elevated alpha hCG/hCG ratios; this occurs secondary to a greater relative decrease in hCG than alpha hCG production. The clinical utility of this knowledge is under investigation.

Potential limiting factors in resident training for laparoscopic management of ectopic pregnancies.

STUDY OBJECTIVE: To evaluate resident exposure and training in operative laparoscopic management of ectopic pregnancy (EP). DESIGN: A review and comparison of the profile and management of consecutive series of patients with EP in two different clinical settings. SETTING: A university-affiliated obstetrics and gynecology residency program caring for indigent women, and a private, office-based infertility practice. PATIENTS: Fifty-three consecutive patients with EP treated surgically in an infertility practice (group 1) were compared with 68 such women managed in a residency program (group 2). RESULTS: Evaluation at the time of hospital admission confirmed significantly lower systolic and diastolic blood pressures (mean +/- SD 106.2 +/- 12.2 mm Hg vs 114.8 +/- 9.1 and 61.1 +/- 14.4 mm Hg vs 71.7 +/- 11.8 mm Hg, p <0.05) and hemoglobin (10.9 +/- 2.7 g/dl vs 12.2 +/- 2.2 g/dl, p <0.05), and higher pulse rates (96.1 +/- 12.1 bpm vs 84.0 +/- 7.7 bpm, p <0.01) for groups 2 and 1, respectively. The mean gestational age at diagnosis was greater in group 2 (52.1 +/- 14.8 days) than in group 1 (46.7 +/- 11.1 days, p <0.05). That the overall clinical picture in group 2 was more serious was confirmed by a larger mean gestational mass (4.4 +/- 3.1 cm vs 2.8 +/- 2.6 cm, p <0.01), more frequent rupture (69% vs 21%, p <0.01), and a larger hemoperitoneum (547 +/- 488 ml vs 215 +/- 202 ml, p <0. 05). Similarly, 49% of group 2 patients required postoperative or intraoperative blood transfusion, compared with 13% of group 1 (p <0. 01). Forty-four of 53 women in group 1 were managed laparoscopically (83%), whereas only 16 (24%) in group 2 were so treated (p <0.05). CONCLUSION: Patients in group 2 were more hemodynamically compromised, had more advanced gestations, and had more ruptured EPs, leading to decreased opportunities for laparoscopic management. Active resident participation in operative management of nonindigent women with EP may be necessary to ensure appropriate training.

Coccidioidal placentitis with normal umbilical artery velocimetry.

BACKGROUND: Disseminated coccidiomycosis during pregnancy can lead to both maternal and neonatal mortality. Placentitis is an uncommon sequelae and its effect on placental function remains speculative. The present report describes our management of such a case and describes serial umbilical artery velocimetry of an affected placenta. CASE: A pregnant woman with coccidioidal placentitis confirmed histologically was treated with systemic and intrathecal amphotericin B starting at 28 weeks gestation. Serial umbilical artery velocimetry revealed that all systolic/diastolic ratios remained normal, and a normal infant was delivered at term. CONCLUSION: Coccidioidal placentitis was successfully treated with amphotericin B; serial umbilical artery velocimetry monitoring exhibited no abnormalities and, along with other reassuring fetal parameters, allowed continuation of the pregnancy to term.

CA 125 levels in abruptio placentae.

The diagnosis of abruptio placentae is frequently difficult despite ultrasonography; additional diagnostic parameters would be useful. Maternal serum CA 125, which is believed to derive from the decidua, is elevated in the first trimester and immediately after delivery when placental separation occurs, possibly because of decidual disruption. Serum CA 125 was measured in 27 patients beyond 20 weeks' gestation who were first seen with vaginal bleeding and in 17 control patients of similar gestational age and labor status. Mean (+/- SD) CA 125 levels were higher (p less than 0.01) among patients with abruptio placentae (105.9 +/- 115 U/ml) than among those with alternate sources of bleeding (13.7 +/- 10 U/ml) or control patients (18.2 +/- 11.7 U/ml). Mean (+/- SD) serum CA 125 levels in seven control patients within 6 hours post partum (194 +/- 80.5 U/ml) were higher than those among patients first seen with abruptio placentae (p less than 0.01). Sensitivity and specificity of CA 125 for abruptio placentae were 70% and 94%, respectively. Our data support a decidual source for CA 125 and may indicate utility of CA 125 as a marker for abruptio placentae.