Evaluation of intramuscular sulprostone and vacuum aspiration for termination of early pregnancy.

The results of a comparative study of the efficacy and acceptability of sulprostone administered intramuscularly and vacuum aspiration for termination of very early pregnancy is reported. The period of amenorrhoea varied from 35 to 45 days with a positive pregnancy test. Group A (20 cases) received intramuscular sulprostone in doses of 500 micrograms and 1000 micrograms 4 hours apart without any pre-treatment. The success rate was 85%. Group B (20 cases) underwent vacuum aspiration with 100% success rate. Incidence of vomiting was comparable in both groups. Severe abdominal cramps/pain occurred in 11% following sulprostone administration. No immediate serious complication occurred. Estimation of serum HCG was done before sulprostone administration and 2 weeks later. A decline was noted 2 weeks post-treatment in successful cases, thus confirming the effectiveness of the therapy.

Three methods for gradual cervical dilatation prior to vacuum aspiration in late first trimester pregnancy.

Sixty healthy women at 8 to 12 weeks of gestation were divided into three groups of 20 women each to evaluate three methods for gradual cervical dilatation prior to vacuum aspiration - Group I: Laminaria tent: Group II: Isaptent, and Group III: 250 ug 15-methyl-PGF2 alpha intramuscular injection. The three methods showed comparable cervical dilatation (10.46 mm) over a mean period of 3 hours 40 minutes. Administration of 15-methyl-PGF2 alpha, though relatively simple, had significant gastrointestinal side effects and bleeding per vaginum (P less than 0.001) prior to vacuum aspiration and greater blood loss (P less than 0.01) during vacuum aspiration as compared with the other two groups. No sequelae, immediate or delayed, were encountered. Isaptent indigenously made and relatively inexpensive is a reliable, safe and effective method for gradual dilatation of cervix for 8 to 12 weeks of gestation prior to vacuum aspiration and is the cervical dilator of choice.

PIP: 60 healthy women at 8-12 weeks of gestation were divided into 3 groups of 20 women each to evaluate 3 methods for the gradual cervical dilatation prior to vacuum aspiration--Group 1-laminaria tents; Group 2-Isaptent; and Group 3-250 mcg 15-methyl-prostaglandin F2alpha (PGF2alpha) intramuscular injection. The 3 methods showed comparable cervical dilatation (10.46 mm) over a mean period of 3 hours and 40 minutes. Administration of 15-methyl-PGF2alpha though relatively simple, had significant gastrointestinal side effects and bleeding/vaginam (p0.001) during vacuum aspiration as compared with the 2 other groups. No sequelae, immediate or delayed, were encountered. Isaptent indigenously made and relatively inexpensive is a reliable, safe, and effective method for gradual cervical dilatation for 8-12 weeks of gestation prior to vacuum aspiration and is the cervical dilator of choice.

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

Evaluation of sulprostone for second trimester abortions and its effects on liver and kidney function.

Sulprostone was given intramuscularly in two dose schedules of 0.5 mg at 4 hourly intervals for 8 doses and 1.0 mg at 8-hour intervals for 4 doses to 56 women in the 12th-20th week of gestation coming for termination of pregnancy. Forty-nine of them aborted within the 30-hour observation period, giving a success rate of 87.5%. Within the observation period, the induction-abortion interval with the 0.5-mg schedule was 16.6 hours while the interval with the 1.0-mg schedule was 15.4 hours. Side effects caused by the drug were minimal and it was observed that patients receiving 1.0 mg Sulprostone had slightly more side effects per person than in those cases receiving 0.5 mg Sulprostone. Serum parameters assessing liver and kidney functions were carried out in 48 patients prior to, 24 hours later and two weeks after the abortion. There were significant changes in the levels of uric acid, potassium, serum proteins and SGOT, though these changes were within the normal range.

Plasma levels of 15 (S) 15-methyl-PGF 2 alpha-methyl ester following vaginal administration for induction of abortion in women.

A single suppository containing 3.0 mg 15 (S)15-methyl-PGF2 alpha-methyl ester was administered vaginally in women to terminate mid-trimester pregnancy. Plasma levels of the drug (both methyl ester and free acid forms) were measured at different time intervals using deuterated carriers and gas chromatography-mass-spectrometry. 15(S)15-methyl PGF2 alpha (sum of methyl ester + free acid) was found to have a mean value of 1166 pg/ml plasma at 3 hrs after administration of the suppository. The mean levels were subsequently found to be maintained in the range of 1000 pg/ml. Preliminary studies showed that unlike the successfully aborted women, in those who did not abort within 30 hrs with this suppository, the plasma levels of the drug were not maintained for a sufficiently long time. The episodes of side effects, body surface area and the induction-abortion interval in relation to the plasma levels are discussed.

Correlation of computed tomography with second-look laparotomy in ovarian carcinoma.

BACKGROUND: Cancer of the ovary is the second commonest gynaecological malignancy after cancer of the cervix. Surgery followed by cisplatin-based chemotherapy is the standard treatment approach. In patients with persistent disease, second-look laparotomy offers an opportunity to debulk the tumour. This is usually followed by an alternative method of chemotherapy. We compared the findings at surgery (second-look laparotomy) with the preoperative computed axial tomography scan assessments. METHODS: Thirty-seven patients with epithelial ovarian carcinoma were assessed with computed axial tomography scans of the abdomen and pelvis prior to undergoing a second-look laparotomy. RESULTS: Tumour was correctly identified on computed axial tomography scan in 11 patients who had macroscopic evidence of cancer at laparotomy. In 6 patients, both computed axial tomography scan and surgery showed no disease recurrence. In the remaining 20 patients, there was a mismatch between the computed axial tomography scan and the surgical findings. In 16 of the 20 (80%) patients, computed axial tomography scans were negative but tumour was present. When the tumour was less than 1.5 cm in diameter it was missed in 8, and when equal to or greater than 1.5 cm, it was missed in 5 patients. These small tumour deposits were located in the retroperitoneal area, under the dome of the diaphragm, omentum or peritoneum, liver surface, and in the pouch of Douglas. In one case each, infiltration of the urinary bladder, sigmoid colon and rectum was also not detected. In 4 patients, computed axial tomography scans showed tumour when none was present. CONCLUSION: Computed axial tomography scan cannot detect small nodules often present in ovarian cancer, and thus even if a computed axial tomography scan is normal it should not exclude a second-look laparotomy.

Correlation of radiological and pathological assessment of tumour volume with lymph node involvement in cancer cervix.

The present study was carried out in 18 patients with carcinoma cervix stage IB through early IIB-Preoperative computerised tomography (C.T.) was done within seven days before surgery. Volume of tumour was determined from the C. T. films. Radical hysterectomy Type-III was performed in all 18 patients and specimens of cervix, parametrium and lymph nodes subjected to histopathological examination. Each specimen of cervix was cut into 4 to 12 equal sections depending on the size of the tumour mass. Cervical tumour volume was measured. Correlation of radiological with pathological tumour volume and of tumour volume with lymph node involvement was done. C. T. Scan was able to detect tumour mass accurately only four patients (Sensitivity 40%, Specificity 28.5%). In the Indian setting the conventional surgical approach appears to be the more appropriate.

Immunohistological localisation of vascular endothelial growth factor in human endometrium.

Several polypeptide growth factors regulate epithelial and stromal development in endometrium under the influence of estrogen and progesterone, and thereby regulate growth and differentiation of endometrium during menstrual cycle. However, little is known about the angiogenic growth factors that may affect endometrial vasculature throughout each menstrual cycle. Vascular endothelial growth factor (VEGF) is suggestively an important angiogenic growth factor in the female reproductive tract. The aim of the present study was to immunolocalize and assess semi-quantitatively VEGF immunostaining in cells of proliferative phase (n = 3), secretory phase (n = 6) and hyperplastic (n = 6) human endometrial samples. VEGF concentrations were significantly higher in glandular (P < 0.001) and stromal (P < 0.01) compartments of proliferative stage endometrium compared with those in secretory stage and hyperplastic endometrial samples, with no difference in the scores for glandular and stromal compartments between secretory stage and hyperplastic endometrial samples. Generally, glandular expression of VEGF was higher as compared to stromal compartment. Thus, it appears that endometrial VEGF expression and concentration are enhanced by estrogen, and may be correlated with neovascularization and increased vascular permeability during late proliferative period. Additionally, there was no enhancement in VEGF expression in hyperplastic glands, suggesting that regulation of glandular growth and that of angiogenesis in human endometrium operate through different mechanisms.

Nucleolar organiser regions and morphologic subtypes of squamous cell carcinoma of cervix.

Nucleolar organiser regions (NOR) are chromosomal segments coding for ribosomal RNA. The number of nucleolar organiser regions correlates with cellular proliferation and has a diagnostic and prognostic value in neoplastic diseases. The aim of this study was to study the morphologic subtypes of squamous cell carcinoma of the uterine cervix in biopsy and hysterectomy specimens and to determine the AgNOR counts in these morphologic subtypes. One hundred and seventy-nine cases of squamous cell carcinoma of the uterine cervix were classified into three morphological subtypes namely large cell non keratinising squamous cell carcinoma (113), keratinising squamous cell carcinoma (64) and small cell carcinoma (2). A correlation of histologic typing on biopsy and hysterectomy specimens was done in 142 cases with a complete correlation in 90.5%. Fifty-eight of these tumours were stained with silver nitrate to demonstrate Nucleolar organiser regions (AgNORS). The mean AgNOR count was higher (3.66) in keratinising squamous cell carcinoma, which is known to have a worse prognosis as compared to 3.04 in large cell non keratinising carcinoma and (3.45) in the two cases of small cell carcinoma of the uterine cervix.

Immediate sequelae and rationale of menstrual regulation.

PIP: Menstrual regulation as a contraceptive method, as well as a form of early pregnancy termination, was studied in 200 patients presenting at the All India Institute of Medical Sciences Hospital for pregnancy termination. Findings supported the contention that menstrual regulation is a simple, safe, and effective procedure. Recommendations were made to incorporate the procedure into family planning services. Women were deemed eligible for the menstrual regulation study if no more than 45 days had elapsed since their last menstrual cycle and if their medical history did not contraindicate the use of the procedure. The women were given a pregnancy test prior to aspiration. The menstrual regulation procedure was performed with an electric vaccum aspirator and the patients received no anesthetic. Following the procedure the aspirate was histologically examined for pregnancy determination. Four weeks later the patients were given a pelvic examination and a urine pregnancy test. Histological examination of the aspirate confirmed pregnancy in 80.5% of the patients. When the findings were compared to the preoperative pregnancy test results, 2.5% of the pregnancy tests were false positives and 4% were false negatives. No severe complications occurred at the time of the procedure an only 2% of the patients required additional curettage. In the 4 week follow-up examination, 10% of the patients reported minor symptoms, 3% reported minor infections, and all pregnancy tests were negative. Following the procedure, 20% of the patients accepted IUDs, 15% accepted horomonal contraceptives, and the remaining 65% opted for conventional methods. Tables show 1) age distribution of patients; 2) distribution of patients by gestation and amount of aspirate; 3) accuracy of pregnancy test compared to histological findings; 4) frequency of histological findings; 5) reported follow-up symptoms for those patients who accepted IUDs and those who did not accept IUDs immediately after menstrual regulation.^ieng

Intravenous immunoglobulin as primary therapy or adjuvant therapy to intrauterine fetal blood transfusion: a new approach in the management of severe Rh-immunization.

Maternal high dose intravenous immunoglobulin (IVIG) has shown promise in the management of severe Rh-immunization. Intravenous immunoglobulin, blocks Fe mediated antibody transport across the placenta and blocks destruction of fetal red cells and reduces maternal antibody levels. We have tried this new therapy in 6 patients with severe Rh-immunization, with high maternal antibody titres and previous hydrops and intrauterine deaths. Intravenous immunoglobulin was given from 13-18 weeks of gestation 3-4 weekly, till intrauterine transfusion (IUT) or delivery. Intensive fetal monitoring was done. No fetal hydrops or deaths occurred in any of the 6 cases. Only 2 cases needed intrauterine transfusion. IVIG delayed the onset of fetal anemia by 8-17 weeks thus deferring the need for IUT. All pregnancies continued till 32-36 weeks and all 6 babies did well in the neonatal period.