Improved diagnostic value of PCR in the diagnosis of female genital tuberculosis leading to infertility.

Histopathological and mycobacteriological examinations have limited utility in the diagnosis of genital tuberculosis. In this double-blind study, 61 samples, consisting of endometrial aspirates (EAs), endometrial biopsies (EBs) and fluid from the pouch of Douglas (POD), from 25 women suffering from infertility were investigated for the presence of the mpt64 gene of Mycobacterium tuberculosis by PCR and correlated with laparoscopic findings. PCR demonstrated M. tuberculosis DNA in 14 out of 25 patients (56.0 %), compared to one smear with acid-fast bacilli (1.6 %) and two culture-positive samples (3.2 %). The presence of M. tuberculosis DNA was observed in 53.3 % of EBs, 47.6 % of EAs and 16.0 % of POD fluid samples. All patients with laparoscopy suggestive of tuberculosis, 60 % of those with a probable diagnosis and 33 % of those with incidental findings were positive by PCR. However, one EA sample from an infertile patient with normal laparoscopy was also positive. Multiple sampling from different sites and amplification of the mpt64 gene segment by PCR offered increased sensitivity in determining tuberculous aetiology in female infertility.

Endometrial histology and progesterone levels in women using norethindrone acetate implants for contraception.

PIP: The effect of a single implant-D containing 40 mg of norethindrone acetate on the endometrium and serum progesterone, and its mode of contraceptive action was investigated. 20 women aged 20-40 (parity 1-5) had used implant-D for periods of 7-27 months. Endometrial biopsies and peripheral venous bloods were collected between the 16th-28th days of the menstrual cycle. Endometrial dating was done according to the criteria of Noyes et al. 19 of the 20 biopsies taken showed the endometrium in the secretory phase, and serum progesterone levels above 3 ng/ml confirming that ovulation had occurred. The biopsy of the remaining woman showed proliferative endometrium and serum progesterone of 2.15 ng/ml. The dating of the endometrium revealed disparity between stromal, glandular, and vascular components of the specimens; thus, only approximate dates could be assigned to a particular specimen. In the dating of the endometrium, 5 women showed retardation by more than 3 days and 4 women showed enhancement of 3 or more days. The results show that the norethindrone-acetate-containing silastic implant-D does not inhibit ovulation and 1 mode of its interaction in fertility control is by bringing about an imbalance in endometrial maturation during the luteal phase.^ieng

Long-term contraception by steroid-releasing implants. II. A preliminary report on long-term contraception by a single silastic implant containing norethindrone acetate (ENTA) in women.

PIP: A preliminary report on the long-term contraceptive effectiveness and acceptability of a single subdermal silastic implant containing norethindrone acetate (ENTA) is presented. The 4 types of implants used varied in length, wall thickness, and amount of ENTA; implant A contained 20-25 mg ENTA, implant B contained 30-35 mg ENTA, implant C contained 45-50 mg ENTA as was longer than all the other implants, and implant D contained 40 mg ENTA and had a greater wall thickness than all the other implants. 213 women volunteers received a single implant and were followed for a total of 909 cycles. 2 of 13 women receiving implant A, 2 of 39 women receiving implant B, 3 of 76 women receiving implant C, and none of the 85 women receiving implant D became pregnant. Implant D had the longest expected life-span (10 months). Menstrual irregularities were fewest with implants A (23%) and D (20%), and greatest with implant C (42%). there were no complaints of nausea, insomnia, tender breasts, or loss of libido. 4 patients with implant B and 6 patients with implant C had the capsules removed for medical reasons. More detailed studies of implant D are in progress.^ieng

Correlation between the serum norethindrone (NET) levels attained after insertion of a silastic implant releasing norethindrone acetate and the endogenous hormones particularly progesterone.

Six normally menstruating women were inserted each with a single silastic implant-D releasing norethindrone acetate (NETA). The levels of endogenous hormones, FSH, LH, E2 and progesterone, were estimated by radioimmunoassay (RIA) procedures in the control and treatment cycles. In addition, the levels of drug in the serum as norethindrone (NET) which is a major metabolite of NETA were also estimated by RIA procedures in the treatment cycles. In all, 12 treatment cycles were studied. In the initial treatment cycles (1st/2nd or 3rd), the serum NET levels were either 1 ng/ml or above. The LH and FSH showed either normal or suppressed mid-cycle peaks, but the progesterone levels were completely suppressed. In the sixth treatment cycles, the serum NET levels were either 0.5 ng/ml or below. The FSH and LH mid-cycle peaks were lower but distinct while the luteal progesterone levels were of normal ovulatory type. These studies lead us to the conclusion that a serum level of NET of the order of 1 ng/ml is required to bring about suppression of luteal progesterone, either as a result of direct action on the ovary or through suppression of pituitary gonadotropins. When the serum level falls to 0.5 ng/ml or below, the suppressive effect is removed and ovulatory pattern of progesterone returns.

PIP: 6 normally menstruating women were each inserted with a single silastic implant-D releasing (NETA) norethindrone acetate. The levels of endogenous hormones, FSH, LH, E2, and progesterone, were estimated by (RIA) radioimmunoassay procedures in the control and treatment cycles. In addition, the levels of drug in the serum as (NET) norethindrone which is a major metabolite of NETA were also estimated by RIA procedures in the treatment cycles. In all, 12 treatment cycles were studied. In the initial treatment cycles (1st/2nd or 3rd), the serum NET levels were either 1 ng/ml or above. The LH and FSH showed either normal or suppressed midcycle peaks, but the progesterone levels were completely suppressed. In the 6th treatment cycle, the serum NET levels were either 0.5 ng/ml or below. The FSH and LH midcycle peaks were lower but distinct while the luteal progesterone levels were of normal ovulatory type. These studies lead us to the conclusion that a serum level of NET of the order of 1 ng/ml is required to bring about suppression of luteal progesterone, either as a result of direct action on the ovary or through suppression of pituitary gonadotropins. When the serum level falls to 0.5 ng/ml or below, the suppressive effect is removed and ovulatory pattern of progesterone returns.

Effect of norethindrone acetate released from a single silastic implant on serum FSH, LH, progesterone and estradiol-17beta of women during first eight months of treatment.

PIP: 4 healthy women of proven fertility and normal menstrual cycles were implanted with a single silastic implant D, filled with norethindrone acetate (ENTA) in order to study the effect of continuously released low levels of ENTA (150 mcg/day) on serum levels of follicle stimulating hormone, luteinizing hormone, estradiol-17beta, and progesterone and to assess the site of action. Steroids were measured by radioimmunoassay before the implant and 2-4 cycles during the first 8 months of treatment. Values of steroids prior to implant indicate that all subjects were ovulatory before treatment. During the 1st few months of use, values indicate that ovulation continued unsuppressed. Later cycles demonstrated hormonal disturbances with low serum progesterone during the luteal phase in most of the treatment cycles when compared with controls. Results indicate a gradually increasing suppression on the pituitary-gonadal function.^ieng

Long-term contraception by a single silastic implant-D containing norethindrone acetate in women: a clinical evaluation.

PIP: 876 women were followed over a 3975-woman-month period after implantation of a single silastic capsule containing 40 mg of norethindrone acetate. Data were analyzed by a life-table method with 3 cut-off dates. Net cumulative pregnancy rate until 7 months was 2.3/100, whereas it rose to 3.9/100 after 8 months of implantation. Net cumulative termination rates rose from .7-10.9 at the end of 7 months and reached 13.6 after 8 months. Removal rates for planned pregnancy, personal, and medical reasons after 8 months were .6, 1.2, and 5.7, respectively. 1.4/100 requested implant removals in preparation for sterilization procedures. Expulsion occurred at a rate of .8/100 at the end of 8 months. The continuation rate was 86.4/100 after 8 months. Menstrual pattern abnormalities showed a reduction with time. This implant seems an acceptable long-term contraception alternative.^ieng

Results of radical radiotherapy in carcinoma of the uterine cervix stage I-III.

A retrospective analysis is described of 271 diagnosed cases of carcinoma of the uterine cervix who were treated with radical radiotherapy between January 1987 and July 1988 at the Institute Rotary Cancer Hospital. The mean age at presentation was 49 years and 89% of the tumours were FIGO Stage II and III. The median duration of follow-up was 60 months. The early cases were treated with two intracavitary insertions of 34 Gy each to point A with a Selectron LDR intracavitary system, followed by 36 Gy external radiotherapy to the parametrium. Late stage disease was treated with 50 Gy of external radiotherapy, followed by a single intracavitary insertion of 30 Gy to point A. To compensate for the higher dose rate of the Selectron (180 cGy/h) a dose reduction factor of 15% was applied over the intracavitary dose. There were 2.5% and 4.7% of late Grade III bladder and bowel complications, respectively, requiring surgical intervention. There was no relationship between haemoglobin level at diagnosis and the development of late complications. The actuarial 5-year survivals were 65%, 63% and 35% for Stages I, II and III disease, respectively. This study from the Indian subcontinent shows the effectiveness of radiotherapy in Stages I, II and III carcinoma of the uterine cervix, with acceptable morbidity rates.

Haemopoietic cell composition of human fetal liver, spleen and thymus.

The haemopoietic cell composition of fetal liver, spleen and thymus was studied in human aborted fetuses of 12-22 weeks gestation. Erythroid cells were present primarily in liver and to a lesser extent in spleen. Orthochromatic normoblasts were the predominant erythroid component. Lymphoid cells were seen primarily in the thymus and to a lesser extent in the spleen. There were few granulocytic and megakaryocytic cells in all these organs. A few primitive haemopoietic cells (Haemocytoblasts) were identified only in liver. These observations indicate that during mid-fetal life (12-22 weeks) the liver contributes primarily to erythropoiesis, the thymus to lymphopoiesis, the spleen to both, and that there is a lack of granulopoiesis and megakaryopoiesis at these sites.

Histologic chorioamnionitis & its association with prematurity in a hospital-based study.

This prospective study was undertaken to study the occurrence of histologic chorioamnionitis and determine its association with prematurity; and to assess whether colonization of the genital tract of pregnant women by genital mycoplasmas or Chlamydia trachomatis is a risk factor for histologic chorioamnionitis. A total of 268 women with singleton pregnancies of over 26 weeks gestation were subjected to high vaginal cultures of genital mycoplasmas and endocervical specimens for chlamydia antigen. Placental histopathology was performed on multiple sections. Histologic chorioamnionitis was documented in 22.4 per cent (60/208) placentae. Genital tract colonization with Ureaplasma urealyticum or C. trachomatis was not a risk factor for histologic chorioamnionitis. Neonates born in association with histologic chorioamnionitis had a mean birth weight 111 g lower than those born without this lesion (2626.9 +/- 702 g vs 2737.8 +/- 500 g, NS). The relative risk (95% confidence interval) of prematurity in the presence of histologic chorioamnionitis was 1.49 (0.87-2.53). Analysis of linear trend in proportions for prevalence of histologic chorioamnionitis with decreasing gestation showed a significant association (P = 0.047, 1-tail). These results taken together suggest that histologic chorioamnionitis may be a risk factor of prematurity, but of only a modest magnitude.

Ureteric calculi masquerading metastatic lymph nodes in a case of endometrial cancer.

Extensive pelvic lymph node metastasis in the absence of risk factors was noticed at surgical staging for endometrial cancer in a 55-year-old postmenopausal women. On exploration there was a dilemma as to the disappearing lymph nodes which subsequently proved to be asymptomatic ureteric calculi. The need to palpate the pelvic side walls at the time of surgery for endometrial cancer even in cases when no nodal enlargement is detected preoperatively is highlighted.

Broad ligament hematoma causing fetal death in a case of fracture pelvis.

Although motor ventricular accidents complicates 6-7% of all pregnancies, the experience of pelvic fractures in near term gravid patients is limited. We present a unique case of fetal death caused by bilateral broad ligament hematomas following maternal pelvic fracture which improved our understanding of management of such cases.

Embryonal rhabdomyosarcoma of the vagina associated with pregnancy; a case report.

A case of embryonal rhabdomyosarcoma of the vagina associated with pregnancy is described. This patient delivered a healthy baby by elective classical Caesarean section; following this she was treated by radiotherapy and chemotherapy. The patient is well after 3 years of treatment.

Inversion of uterus during cesarean section.

Acute inversion of the uterus is a rare complication during cesarean section. We describe one such case in which diagnosis was made immediately and reversion was performed within few minutes. A high index of suspicion and prompt management can prevent further complications.

Biochemical hemodynamic and hematological changes during transcervical resection of the endometrium using 1.5% glycine as the irrigating solution.

OBJECTIVE: To study fluid absorption during transcervical resection of the endometrium (TCRE) and its effect on the biochemical, hemodynamic and hematological alterations so that life threatening complications of fluid overload may be prevented. METHOD: Intraoperative fluid (1.5% glycine) absorption in 46 women undergoing TCRE was studied and correlated using biochemical parameters (serum sodium, potassium, total proteins, creatinine and blood urea), hemodynamic parameters (pulse rate, blood pressure, oxygen saturation and end tidal CO2) and hematological parameters. Twenty five of these patients had received danazol (800 mg/day) for six weeks prior to TCRE. RESULT: The mean glycine deficit during TCRE was found to be 474.45 ml, with a mean total inflow of 3802.17 ml. Amongst all of the parameters, only serum sodium levels were found to be significantly inversely correlated with the glycine deficit. No case of hyponatremia occurred below a deficit of 1000 ml. Severe hyponatremia was reported in three cases (6.4%) and all three had a glycine deficit of more than 1000 ml. No case of pulmonary edema was noted. The mean glycine deficit was significantly lower (P=0.007) and the duration of procedure significantly shorter (P=0.0009) in the patients who had received danazol. None of the patients in the danazol group had fluid absorption of more than 1000 ml. CONCLUSION: Close monitoring of fluid inflow and outflow should be done during TCRE. Above a deficit of 1000 ml, serum sodium should be measured to detect significant hyponatremia. The use of danazol for endometrial preparation also reduces the mean amount of fluid absorbed.

Retrieval of lost Copper-T from the rectum.

A case of lost Copper-T lying partly in the rectal lumen and its removal through the rectal route is described. This case emphasises the importance of rectal examination in the case of lost intra-uterine contraceptive device (IUCD) and highlights the possibility of safe retrieval of an IUCD through the rectal route even when it is partly embedded in the rectal wall.

PIP: Presented is the case of a translocated Copper-T IUD, lying partly in the lumen of the rectum, which was removed through the rectal route. The 36-year-old patient presented to a hospital in New Delhi, India, with amenorrhea of 3 months' duration. A test for pregnancy was positive. A Copper-T IUD had been inserted, without difficulty, 6 years earlier, but had never been checked or replaced. The IUD threads could not be visualized. At elective abortion, the IUD was not found in the uterus or with the products of conception. Laparoscopy revealed an old healed perforation on the fundus of the uterus and adhesions of bowel loops in the pouch of Douglas. On laparotomy, thickening of the anterior rectal wall was detected, but no obvious perforation site was evident. Finally, rectal examination was performed and the vertical limb of the IUD was palpated 9 cm above the anus; the horizontal arm remained buried in the rectal wall. The device was removed intact with forceps. The literature includes only eight other cases of perforation of the rectosigmoid by an IUD and its retrieval through the rectal route. This case study underscores the need for rectal examination in cases of lost IUDs.

Ectopic hydronephrotic kidney masquerading as an ovarian cyst during pregnancy.

An ectopic iliopelvic kidney with hydronephrosis causing fetal malpresentation is a rare occurrence. We describe this case for its unusual presentation which was mistaken for an ovarian cyst. The difficulty in diagnosis and the need for a high index of suspicion is highlighted.

Maternal and perinatal outcome in thyrotoxicosis complicating pregnancy.

In this report we describe 32 pregnancies complicated by hyperthyroidism cared for over a 7-year period at AIIMS, New Delhi. In 6 cases hyperthyroidism was diagnosed during pregnancy; others were diagnosed before conception and were on antithyroid therapy during pregnancy. For control of thyrotoxicosis thiourea derivatives, carbimazole (CMZ) and propylthiouracil (PTU), were both used. The dosage of antithyroid drugs could be decreased or stopped in the third trimester in only 28% cases, while 50% cases did not require any change in the dosage during gestation and 21% required an increase in dosage with advancing gestation to control thyrotoxicosis. Maternal and fetal complications included preterm labour (25%), PIH (22%), thyroid crisis (9%) and intrauterine growth retardation (13%). Thyroid status of neonates was found abnormal in 9% cases, including 1 case (3%) of neonatal thyrotoxicosis with goitre and 2 (6%) cases of neonatal hypothyroidism. One maternal death occurred due to thyroid storm. No case of stillbirth or perinatal death occurred in the present study. In our experience of 32 cases maternal and fetal complications are reported with increased frequency, requiring close surveillance of thyroid status to maintain euthyroidism and intensive fetal monitoring during pregnancy to achieve good maternal and perinatal outcome.

Laparoscopic gonadectomy in male pseudohermaphrodites.

OBJECTIVE: To study patients of male pseudohermaphroditism and establish the laparoscopic approach for gonadectomy in these cases. STUDY DESIGN: Seven phenotypic females with XY karyotype were evaluated through a diagnostic protocol which included clinical, cytogenetic, hormonal, endoscopic and histologic evaluation. The gonads were then removed by laparoscopic surgery. RESULTS: The seven patients included three patients of pure gonadal dysgenesis, two patients of testicular feminization and one patient each of mixed gonadal dysgenesis and dysgenetic male pseudohermaphroditism. Two of the seven patients (28.57%) had gonadal neoplasias on histopathology-one dysgerminoma and one occult seminoma. In all of these patients, removal of the gonads was accomplished laparoscopically. No complications occurred during any of the surgeries. CONCLUSION: Due to the reduced morbidity, shorter hospital stay and safety, laparoscopic gonadectomy can be considered the treatment of choice for the removal of gonads in male pseudohermaphrodites in the hands of experienced laparoscopic surgeons.

Aplastic anaemia during pregnancy: variable clinical course and outcome.

Aplastic anaemia occurring during pregnancy is a rare event and is associated with high maternal and fetal morbidity and mortality. Prognosis is poorer when aplastic anaemia develops during pregnancy and many such patients have an unsuccessful pregnancy outcome. We report two cases of aplastic anaemia associated with pregnancy. Both the patients had very different antenatal course and outcome. Their etiopathogenesis and management is discussed.

Hydatiform mole with coexisting live fetus in dichorionic twin gestation.

A case of dichorionic twin pregnancy was diagnosed in a 29-year-old, on routine ultrasound at 12 weeks. Subsequent ultrasounds for persistent vaginal bleeding at 16 weeks revealed molar placenta with viable fetus in both gestational sacs. The patient declined any invasive prenatal testing to confirm the karyotype of the fetus. The pregnancy was managed expectantly until 21 weeks, when she had a spontaneous abortion of twin fetuses and separate placentae with attached molar tissue. A final karyotype on cord blood samples confirmed 46XY and 46XX for both fetuses. Histopathology of molar tissue reported complete mole, with diploid chromosomal pattern on subsequent DNA flow cytometry. The clinical, ultrasound and chromosomal examination suggest that there has been a quadruplet pregnancy where two embryos developed into normal fetuses and other two degenerated to complete moles.