Correlation of human chorionic gonadotropin secretion in early pregnancy failure with size of gestational sac and placental histology.

The relationships between maternal plasma human chorionic gonadotropin (hCG) levels, the gestational sac diameter, and histopathologic findings in the placenta were studied in 99 cases of bleeding during the sixth to 15th weeks of pregnancy. In cases of threatened abortion with a successful outcome of pregnancy, the maternal hCG levels and gestational sac diameter were normal, the correlation being significant during weeks seven to ten. In cases of blighted ovum and missed abortion, both the hCG concentration and gestational sac diameter were usually normal during the sixth to eighth weeks of pregnancy. After the ninth week nearly all gestational sac diameters were under the normal range, whereas normal plasma hCG levels were detected occasionally until the 14th week in these doomed pregnancies. Villous structures were histologically normal in ten of the 31 cases of blighted ovum and missed abortion. However, only two of these ten cases showed normal hCG levels and only one had a normal gestational sac diameter immediately before abortion. The results suggest a correlation between the hCG secretion of the trophoblast and gestational sac diameter in cases of bleeding during the early weeks of pregnancy, both in successful and unsuccessful outcome. Normal hCG levels in maternal plasma and nonpathologic histologic findings in the placental tissue often appear to be present in cases of blighted ovum and missed abortion until the second trimester without any mutual correlation.

Growth discordancy in twin pregnancies: a risk factor not detected by measurements of biparietal diameter.

Among 460 twin pregnancies delivered at the University Central Hospital of Turku from 1970 to 1981, there were 41 (8.9%) with a weight difference of 25% or more between twins when calculated from the weight of the larger twin. The perinatal death rate in the first group (9.7%) was significantly higher (P less than .01) than the perinatal death rate (3.7%) in the group with the weight difference of less than 25%. The intrauterine mortality rate, in particular, was significantly increased (P less than .001) in the group with 25% or more difference being 6.5-fold when compared with the more difference being 6.5-fold when compared with the group with the lower weight difference. Among 271 twin pregnancies examined by ultrasound one to two weeks before delivery, there were 31 (11.4%) pairs of twins with a 3-mm or more difference in biparietal diameter, 11 (4.1%) with a 4-mm or more difference, and seven (2.6%) with a 5-mm or more difference. The sensitivity of measurements of biparietal diameter to detect the growth discordancy was 9 to 35%, the specificity 90 to 98%, and the positive predictivity 23 to 29%. This study indicates that a divergent growth pattern in twin pregnancy carries an elevated risk of intrauterine death, especially for the smaller twin. Measurement of biparietal diameter is not a method sensitive enough to detect these high-risk twin pregnancies.

Intrauterine contraceptive device localization by clinical evaluation and real-time ultrasonography.

A total of 43 Intrauterine Contraceptive Device (IUD) wearers were examined clinically and ultrasonically in order to ascertain the intrauterine position of IUDs (copper devices of five different types). The time elapsed from the insertion was 2-26 months. The mean age of the women was 28 years; 95% of them were parous. The intrauterine location of the IUD was assessed clinically by means of threads cut to a standard length. In the ultrasound examination, the distance of the uppermost point of the stem of the device from the fundal wall was measured within an accuracy of 1 mm. The clinical assessment of the IUD location was found to agree surprisingly closely with the results of the ultrasound examination. The clinical assessment deviated significantly from the ultrasonography findings in about 10% of the cases.

Low-risk amniocentesis in the third trimester under ultrasound control.

Amniocentesis was performed under ultrasound control on 501 third-trimester gravidae out of the 509 referred. Eight patients were excluded based on the ultrasound examination, since practically no amniotic fluid could be detected. Ultrasound was used to find a pocket of amniotic fluid in which the puncture would carry no risk to the foetus. The puncture was made immediately after the examination, on the same examination table. In 17% of cases the puncture was made in the lower uterine segment behind the foetal neck. A diagnostic sample of the amniotic fluid was obtained in 87.4% of cases. In the other 12.6%, the sample either could not be obtained (7.8%) or contained blood (4.8%). In 1.8% of cases the membranes ruptured within 24 hours of the puncture. In no case could any damage be shown either to the foetus or to the placenta, nor were there any signs of intrauterine infection.

Ovarian function during and after curative intracavitary high dose-rate irradiation: steroidal output and morphology.

The endocrinological function of the ovary during and after curative intracavitary high dose-rate irradiation has been studied by determining the peripheral plasma levels of P, E1, E2, FSH, LH and PROL in 8 patients aged 37 +/- 7 yr (+/- SD). In addition, the concentrations of E1 and E2 in ovarian venous blood during the estimated ovulatory phase after irradiation were determined. The functional structure of the ovary was studied histochemically using 3 beta-hydroxysteroid dehydrogenase (HSD) and ultrastructurally and histologically with routine methods. The results during and after irradiation were compared to those before irradiation. In addition, 28 postmenopausal patients were used as controls. At the end of the irradiation course, which lasted from the premenstrual to the ovulatory phase, 3 out of 4 patients with cervical carcinoma had normal plasma P levels; the menstrual cycles of these patients was previously ovulatory. The normal P levels as well as a rise in E1 and E2 concentrations indicate ovulation. During the next menstrual cycle these values and the E2/E1 ratio in peripheral venous blood decreased and the levels of FSH and LH rose to the postmenopausal values. In patients with endometrial carcinoma, the menstrual cycle was anovulatory both before and after radiotherapy; in estrogen and gonadotrophin levels, similar changes were observed as in patients having ovulatory cycles. In ovarian venous blood, the E2 plasma levels and the E2/E1 ratios were in both groups significantly higher at the time of the second potential ovulatory phase than the corresponding postmenopausal values. As in the postmenopausal women, both E1 and E2 levels in irradiated patients were higher in ovarian effluent blood than peripherally. The ovarian/cubital E1 ratios did not differ between these groups. For E2, this ratio was, however, significantly higher in irradiated patients than in postmenopausal controls. The morphological findings--both by light and electron microscopy--as well as the enzyme-histochemical studies support the chemical results reflecting a decreased yet significant estrogen production in the ovaries after irradiation.

Feto-maternal concentrations of diazepam and W-demethyldiazepam after intra-amniotic diazepam injection.

Ten milligrams of diazepam were injected intraamniotically in 8 mothers prior to therapeutic abortion between 12 and 19 weeks. The diazepam concentrations in the maternal plasma were comparable to those found after the same intramuscular diazepam dose to the mother. The concentration of diazepam in the amniotic fluid 12 to 18 hours after the injection was no longer significantly higher than in the maternal plasma. The concentrations of diazepam in the fetal plasma, liver and brain were comparable to the concentrations resulting from a 10 mg intramuscular diazepam dose to the mother about 2 hours before legal abortion. The feto-maternal ratio of diazepam was of same magnitude as after the intramuscular application to the mother. The results indicate that the disappearance of diazepam from the amniotic fluid in this stage of pregnancy occurs extraplacentally, through the mambranes into the uterine circulation. In the treatment of a fetus with drugs having properties similar to diazepam, intra-amniotic administration is no better than intramuscular administration to the mother.

The use of ultrasonography in the diagnosis of ectopic pregnancy.

Ultrasonography was used to examine 196 cases of suspected ectopic pregnancy. The final diagnosis was established in 185 cases by means of surgical intervention or follow-up. The actual number of ectopic pregnancies was found to be 42, of which 30 (71%) had been correctly diagnosed by ultrasound. There was a false negative rate of 29%. Of the group of 185 patients followed up, a false positive diagnosis had been made in six cases (4.2%). On the basis of these results, we conclude that, while ultrasonography offers significant help when a non-invasive diagnostic method for ectopic is desired, it is not yet, in spite of the present level of technical development, a completely reliable method in such cases.

Interventional ultrasound in diagnosis and treatment of ovarian cysts.

In 46 patients, age 17-46 years, 48 simple ovarian cysts with the median diameter of 4-14 cm were punctured using ultrasonic quidance. The aspirate of cysts was examined cytologically. The punctured cysts were observed by ultrasonic examinations performed one month and three months after the punctures. The recurred cysts (n = 16) were punctured again. If the cyst recurred again, the patient was operated. The experience up to now indicates that the results of the puncture treatment are good. Out of 46 patients of the study, 14 (30%) had to be operated, while 32 (70%) did avoid from laparotomy due to the puncture. In cytological examinations no malignant cells were established. Besides one haematoma, no complications appeared.

Progesterone support of the luteal phase in in vitro fertilization program--a hazard?

To study the effect of progesterone support of the luteal phase in a stimulated cycle a subgroup of our IVF patients was treated with progesterone vaginal suppositoria. The treatment was initiated on the aspiration day. There was no significant difference in the pregnancy or abortion rate between the control group and the gestagen therapy group. However, it seems that progesterone support may increase the pregnancy rate but also the rate of spontaneous abortion. This suggests that the effective and early started progesterone supplementation of the luteal phase may cause the implantation of abnormal nonviable embryos.

Ultrasound-guided fetal intravascular transfusion in a case of severe rhesus isoimmunization.

Intrauterine intravascular transfusion is the most effective way of correcting the fetal haemoglobin level in severe rhesus haemolytic disease. Fetal anaemia should be corrected as early as possible before the development of hydrops and ascites. When required, the transfusion can be repeated several times. We present in this publication our own experience in a severe rhesus isoimmunization case, where the fetal haemoglobin level was corrected by a successful transfusion in the intra-abdominal part of the fetal umbilical vein in the 31st week of pregnancy and the child was delivered a week later by cesarean section.

Uterine size measured by ultrasound during the menstrual cycle.

In the following study changes in the size of non-pregnant uterus were measured by B-scan ultrasonography. Uterine size in different stages of the menstrual cycle was measured ultrasonically in 16 women, whose periods were confirmed to be ovulatory, both by basal body temperature (BBT) and by the radioimmunological measurement of plasma estradiol and progesterone. It was established that the size of the uterus grows significantly towards the end of the menstrual cycle. In addition to the above mentioned, the examination was performed on a woman of child-bearing age with disturbances in her menstrual cycle. Hormone measurements indicated that her period was anovulatory. No typical uterine growth characteristic of ovulatory cycles could be observed.

Accuracy of ultrasonic fetal weight estimation and detection of small for gestational age fetuses.

One hundred and eight-six pregnant women were studied with ultrasound for clinical suspicion of poor fetal growth. Fetal weight was estimated using biparietal diameter and mean abdominal diameter with a special nomogram. The fetal femur length (FL) to abdominal circumference (AC) ratio was also calculated. The mean interval between the last ultrasound examination and delivery was 9 days (range, 0 to 14 days). Eighty-three women had their last ultrasonic examination 0 to 4 days (mean, 2 days) before delivery. In this group the arithmetic mean of weight estimation errors was -1 gm (SD, 159 gm). The signed mean percent error was +0.6% (SD, 6.6%). Neither systematic nor random errors were found between different growth percentile groups. When small for gestational age (SGA) was defined as birthweight below 2.5 percentile, the sensitivity, specificity, and positive predictive value of the weight estimations were 82%, 92%, and 84%, respectively, in 186 cases. Significant differences were found in FL to AC ratios between growth pattern groups but fetal weight estimation was found to be superior in the detection of SGA fetuses.