Dynamics of pulsatile prolactin release during the postpartum lactational period.

To investigate the pulsatile nature of PRL release in the physiologically hyperprolactinemic postpartum period, we sampled blood at 10-min intervals for 24 h in each of 6 healthy lactating women at both 3 weeks and 3 months postpartum. The subsequent immunoactive PRL time series were subjected to episodic peak detection (Cluster analysis) and multiple parameter deconvolution analysis. The 24-h mean serum PRL concentrations were significantly higher at 3 weeks than at 3 months postpartum; viz. 113 +/- 12 vs. 66 +/- 15 micrograms/L (P = 0.003). Assessment of episodic PRL pulsatility revealed significantly higher maximal PRL peak heights (296 +/- 63 vs. 141 +/- 44 micrograms/L), fractional peak heights (863 +/- 150 vs. 374 +/- 58%), incremental peak amplitudes (250 +/- 60 vs. 96 +/- 3 micrograms/L), and peak areas (13 +/- 3 vs. 4 +/- 1 mg/L.min) in the earlier postpartum period. In contrast, PRL peak frequencies and interpulse intervals were not different in the early and late postpartum sessions. Deconvolution analysis revealed that the mean mass of PRL secretory bursts was significantly greater at 3 weeks (182 +/- 4.1 micrograms/L) than 3 months (15 +/- 1.6 micrograms/L). There were no changes in the calculated half-life of endogenous PRL viz. 29 +/- 2.5 min (3 weeks) vs. 26 +/- 3.0 min (3 months). We conclude that physiological postpartum hyperprolactinemia is achieved by selectively altering the endogenous secretory rate in each PRL release episode, with no change in the number of bursts of PRL discharged or the PRL half-life.

Endogenous opiates participate in the regulation of pulsatile luteinizing hormone release in an unopposed estrogen milieu: studies in estrogen-replaced, gonadectomized patients with testicular feminization.

Administration of opiate receptor antagonists augmented pulsatile LH release in six estrogen-treated, orchidectomized individuals with testicular feminization. In response to an opiate antagonist, LH pulse frequency increased from 3.0 +/- 0.55 (+/- SE) to 5.0 +/- 0.45 pulses/8 h (P = 0.034). Since these patients have inborn target tissue resistance to androgens, we infer that sustained androgen action is not obligatory to the emergence of endogenous inhibitory opiate tone in man. Rather, these observations document that the suppressive effects of opiates on gonadotropin secretion can be unmasked in the presence of an unopposed estrogen milieu.

Torsion of the normal fallopian tube in pregnancy.

Two cases of torsion of the normal fallopian tubes during the third trimester of pregnancy are presented. The etiology and clinical features of this complication are discussed. Although uncommon, it should be included in the differential diagnosis of abdominal pain in pregnancy.

Intravasation during hysterosalpingography using oil-base contrast medium--a second look.

Hysterosalpingography is a study performed commonly to assess the upper reproductive tract in infertile women. A risk with hysterosalpingography is either lymphatic and/or venous intravasation with or without embolization. Of 593 consecutive hysterosalpingograms performed with a low-viscosity oil-base medium, intravasation occurred in 41 cases (6.9%). Embolization was documented in six patients. There were no recognized adverse sequelae from either intravasation or embolization. Intravasation was frequently associated with pathology of the upper genital tract, and suspected tubal occlusion was the most common abnormality detected. Proper timing of the procedure and avoidance of excessive instillation pressure will diminish the incidence of this complication. The use of both a low-viscosity oil-base medium and high-resolution fluoroscopic image intensification may increase the detection of intravasation.

Vaginal sonography findings and hCG dynamics of early intrauterine and tubal pregnancies.

Early intrauterine gestational sac recognition by ultrasound is useful for discriminating between intrauterine and tubal pregnancies. Transvaginal ultrasound offers improved resolution in the imaging of the uterus and adnexa. Seventy-four women with normal intrauterine pregnancies, 18 women with spontaneous abortions, and 34 women with tubal pregnancies were evaluated by transvaginal ultrasound and serial hCG determinations. Intrauterine pregnancies were followed within the first 50 days of gestation. In women with a normal uterus and singleton pregnancy, sacs were consistently recognized in association with an hCG level greater than 2004 mIU/mL (First International Reference Preparation). Two-to three-millimeter sacs were recognized in association with an hCG level of 2032 +/- 1253 on cycle day 36.1 +/- 2.0. When sacs were less than 5 mm in mean diameter, 33% exhibited a prominent echogenic rim, 38% exhibited a partial echogenic rim, and 29% exhibited no echogenic rim. Fetal cardiac activity was recognized in association with an hCG level of 27,284 +/- 11,479 on cycle day 45.0 +/- 2.9. The hCG doubling time was 1.46 +/- 1.0 days. Apparent loss of multiple gestational sacs was observed in five normal pregnancies. Apparent bleeding in the intrauterine cavity was observed in eight patients and associated with a 38% abortion rate. One false-positive sac was observed among 34 tubal pregnancies (3%). The extrauterine sonographic finding of a solid adnexal mass or cul-de-sac fluid was specific but not sensitive for the diagnosis of tubal pregnancy. The hCG doubling time in tubal pregnancies was 7.69 +/- 9.8 days. Transvaginal ultrasound and serial hCG determinations are useful for the early recognition of tubal pregnancy.

Congenital atresia of the uterine cervix with pelvic endometriosis.

Congenital atresia of the uterine cervix is a rare Müllerian anomaly. About half of the reported cases are associated with pelvic endometriosis. We describe a 20-year-old woman with congenital cervical atresia and pelvic endometriosis whose manifesting symptoms were primary amenorrhea and pelvic pain. Surgical treatment consisted of excision of bilateral ovarian endometrial cysts and hysterectomy. A review of the literature suggests that successful surgical management with regard to preservation of reproductive potential may be possible in some cases, but treatment must be individualized and hysterectomy is sometimes indicated.

Homologous insemination.

Between July 1, 1969, and October 31, 1977, 619 patients were evaluated for infertility. Homologous insemination (AIH) was employed in 53 patients, many of whom had other contributory causes of infertility. There have been 14 single pregnancies in 11 women, including 4 spontaneous abortions, 1 ectopic pregnancy, 8 term deliveries, and 1 pregnancy in progress. Twenty women are currently under treatment. Another 16 women had unsuccessful AIH prior to beginning donor insemination. Seven subsequently conceived with donor semen. Specific indications for AIH and the recommended technique are discussed in detail as well as the occurrence and management of concomitant infertility factors in this study group. It is concluded that AIH does have a role in the management of certain infertile couples.

Intravasation during hysterosalpingography using oil-base contrast media.

The use of oil-base contrast media for hysterosalpingography provides detailed imaging and the added information of a delayed film. Intravasation with possible embolization of oily media is often cited as a morbid complication. There are reports of significant morbidity associated with the use of high-viscosity oil media such as Lipiodol. Ethiodol has a significantly lower viscosity than Lipiodol. The incidence of intravasation can be reduced by proper timing of the study and avoidance of excessive pressures during instillation. With fluoroscopy, the early manifestations of intravasation can be detected, allowing the operator to limit the volume of embolized medium. We report 13 cases of intravasation (6 with embolization) with no morbidity during hysterosalpingography performed with Ethiodol. These data suggest that embolization of low-viscosity oil contrast media in low volumes is a relatively benign process. The text of this paper contains data on the clinical histories and courses of the 13 cases cited.

Effects of dexamethasone therapy on serum immunoglobulin levels and peripheral cell counts in women undergoing conservative benign gynecologic surgery.

Twenty women undergoing conservative gynecologic surgery were treated perioperatively with high-dose dexamethasone (DEX) for 72 hours. Serum immunoglobulin levels (IgG, IgM, IgA) and peripheral cell counts, including lymphocyte subpopulations, were measured in each patient during the immediate preoperative and postoperative periods as well as 5 to 8 weeks later. These results were compared with the levels of a control population of 16 women undergoing conservative, non-pregnancy-related gynecologic surgery for benign conditions. There was a decrease in the level of all serum immunoglobulins measured in the immediate postoperative period in both groups, with a greater statistical decrease in the control group (P less than 0.001). statistically significant transient alterations in the peripheral cell counts occurred in the DEX group, as compared with the control group (P less than 0.001). The use of DEX was not associated with any postoperative infectious morbidity.

Utility of the 24-hour delay hysterosalpingogram film.

Controversy exists regarding the ideal contrast media for hysterosalpingography. A unique property of oil-base contrast media is the availability of a 24-hour delay radiograph for further assessment of tubal patency and adhesions. A review was undertaken of the delay films in 131 cases performed by use of oil-base contrast media with subsequent surgical confirmation of pelvic findings. A 97% predictive accuracy was achieved with regard to distal obstruction and a 79% accuracy with regard to pelvic adhesions. Objective criteria for the evaluation of 24-hour delay hysterogram films were developed and are illustrated.

Quantitative effects of intraperitoneal 32% dextran 70 on serum immunoglobulin levels in women undergoing gynecologic surgery.

The use of intraperitoneal 32% dextran 70 results in quantitative postoperative changes in human IgG and IgA levels that are statistically different from the alterations induced by the surgical procedure alone.

Hypergonadotropic ovarian failure in young women.

The purpose of this study is to evaluate 13 patients with primary ovarian failure (POF). All patients were less than 35 years of age. Serum FSH, performed by RIA, was in the post-menopausal range in all patients. Karyotype with Q-banding was performed on peripheral leukocytes and/or ovarian tissue. All patients had 46XX karyotype. Eleven patients had laparoscopy or laparotomy and ovarian biopsy. Two of the 11 patients had ovarian follicles. One patient had Graves' disease. Based on our data, we offer these conclusions. A thorough evaluation of patients with premature ovarian failure is essential. Testing for autoimmune endocrinopathies should be considered in POF patients who exhibit any signs of endocrine dysfunction. A peripheral karyotype with banding should be performed on all patients. The resistant ovary syndrome may occur with greater frequency than has previously been reported and a review of the literature on the resistant ovary syndrome is presented.

Disseminated intravascular coagulation in pregnancy. The role of heparin therapy.

Treatment of the underlying cause and supportive care constitute the basic principles of management of disseminated intravascular coagulation. The role of anticoagulation with heparin is controversial in the absence of any controlled studies. This case report describes two patients with acute obstetric disseminated intravascular coagulation in whom the use of heparin resulted in marked clinical improvement. Treatment with heparin may be of help in situations where there is a delay in elimination of the underlying cause.