Diagnosis and laparoscopic management of a 5-week ectopic pregnancy in a rudimentary uterine horn: A case report.

Uterine anomalies result from the failure of complete fusion of the Müllerian ducts during embryogenesis. A unicornuate uterus with a rudimentary horn is the rarest anomaly and results from the failure of one of the Müllerian ducts to develop completely and an incomplete fusion with the contralateral side. Diagnosis and surgical management of a 5-week ectopic pregnancy in a non-communicating rudimentary horn in an 18-year-old nulliparous woman in whom this congenital uterine anomaly was previously unknown are described.

Anti-C1q antibodies in pregnant patients with systemic lupus erythematosus.

OBJECTIVE: To study anti-C1q antibodies in pregnant patients with systemic lupus erythematosus (SLE) and to evaluate their prognostic significance for the occurrence of disease flares or pregnancy complications. METHODS: Twenty-one pregnancies in 19 SLE patients prospectively followed were analyzed. Disease activity was evaluated on the basis of the physician's intention to treat and a modified version of the ECLAM index. Anti-C1q and anti-dsDNA antibodies were detected in the sera by an ELISA assay. Antinuclear antibodies, anti-ENA antibodies, anticardiolipin antibodies and lupus anticoagulant were also performed. RESULTS: In all the patients the disease was inactive at the beginning of the pregnancy. Four flares of disease activity were observed in 4 pregnancies (19%) and obstetric complications were encountered in 7 pregnancies (43%). Anti-C1q antibodies were positive in 4 (19%) pregnancies and anti-dsDNA antibodies in 8 (38%). The presence of anti-phospholipid antibodies at the first assessment was correlated with the occurrence of obstetric complications (p<0.05). The presence of anti-C1q and anti-dsDNA antibodies at the first assessment had no prognostic significance for the occurrence of flares or obstetric complications during the course of pregnancy. Although the small number of patients studied did not allow for statistically significant analysis, flares appeared to be more likely to occur in patients presenting with anti-dsDNA or anti-C1q antibodies during pregnancy compared to patients with no changes in these antibody titers (43% vs 8% respectively). CONCLUSIONS: The presence of anti-C1q and anti-dsDNA antibodies does not seem to be prognostic for the occurrence of flares during pregnancy. Further studies are warranted to explore this possibility.

The effects of the gabaergic drug, sodium valproate, on prolactin secretion in normal and hyperprolactinemic subjects.

To find out whether the gamma-aminobutyric acid (GABA)ergic system affects PRL secretion in humans, sodium valproate (DPA or Na-dipropyl-acetate), a drug inducing increase of endogenous GABA, was administered to 20 normal and 15 hyperprolactinemic subjects. PRL circulating levels were measured by RIA in the samples obtained after acute oral treatment with 400 mg DPA. A significant decrease (P less than 0.01) in comparison with basal levels was observed in normal women from 30-180 min after drug administration. DPA treatment also lowered blood PRL levels in hyperprolactinemic subjects (seven females) without evidence of pituitary tumor. A decrease very similar to the one found in normal subjects (P less than 0.05 vs. basal levels) was observed within 180 min from drug ingestion. Conversely, no significant changes were found after the same treatment in hyperprolactinemic patients with evidence of prolactinoma (seven females and one male). Taken together, these data seem to demonstrate that pharmacological enhancement of endogenous GABAergic tone is followed by inhibition of PRL secretion. They also suggest that GABA may exert an inhibitory control on PRL release in humans. In hyperprolactinemic subjects, this GABAergic control appears to be present only when a pituitary tumor cannot be demonstrated.

Inhibitory effect of the dopamine agonist bromocriptine on the postcastration gonadotrophin rise in women.

Basal or stimulated gonadotrophin plasma levels were measured after bilateral ovariectomy in untreated and bromocriptine (BCT)-treated normal women. BCT was orally administered from the 7th to the 14th day after ovariectomy at a dose of 3.75 mg/day. BCT significantly (P less than 0.05) inhibited LH release, both basally and after LRF stimulation. Plasma FSH levels were also reduced in treated subjects, but this decrease did not reach statistical significance relative to controls. The blunted postcastration gonadotrophin rise found with BCT administration suggests that pituitary gonadotropin secretion is, in part, under dopaminergic inhibitory control.

Pharmacological activation of gamma-aminobutyric acid-system blunts prolactin response to mechanical breast stimulation in puerperal women.

To evaluate whether the gamma-aminobutyric acid (GABA)ergic system participates in the control of PRL secretion during the puerperium, different doses of sodium valproate (DPA), a drug that increases endogenous GABA activity, were administered orally to puerperal women who did not wish to breast feed their infants. Two groups of five women were each given DPA in doses of 400 and 800 mg, respectively. PRL levels were measured in plasma samples collected before and after drug administration. Another group of five puerperal women was treated with 800 mg DPA 60 min before mechanical breast stimulation using an electric breast pump for 15 min. Circulating PRL levels were measured in samples obtained before, during, and after breast stimulation. No drug-associated side effects were observed. After placebo administration, no significant variations in plasma PRL levels occurred in any subject. The lower dose of DPA (400 mg) induced a slight decrease in plasma PRL levels, but 800 mg of the drug induced a significant fall (P less than 0.05 vs. baseline values) in PRL, with a maximum percent decrease (68.2 +/- 4%) 180 min after DPA treatment. Mechanical breast stimulation performed after placebo treatment induced a significant increase (P less than 0.01) in plasma PRL levels, with peak values (37 +/- 10% above baseline values) 10 min after the onset of stimulation. When DPA was administered to the same women, a significant decrease (23 +/- 3%) in plasma PRL occurred during breast stimulation. Thereafter, PRL values continued to fall in spite of breast stimulation. PRL levels were significantly decreased after DPA treatment compared to both basal values (P less than 0.01) and the levels found in the same patients during control tests (P less than 0.05). These results demonstrate that enhancement of endogenous GABAergic tone induced by DPA significantly decreases basal PRL levels and blunts PRL release after mechanical breast stimulation. In agreement with animal data, a possible physiological role of GABA in the control of PRL release during puerperium may be suggested.

Use of sulprostone for induction of preoperative cervical dilation or uterine evacuation: a comparison among the effects of different treatment schedules.

Sulprostone was administered to 144 pregnant women to induce either preoperative cervical dilation or uterine evacuation. A comparison was performed to select the drug treatment schedule showing the greatest effects with the lowest incidence of side effects. As for preoperative cervical dilation, the local (intracervical/intramural) injection of 50 + 50 micrograms and the intramuscular treatment with 500 micrograms of sulprostone showed the most favorable effects on the cervix after 12 and 6 hours, respectively. The cervix dilated 8 mm or more in 82.6% of subjects treated locally and in 85.7% of those treated intramuscularly. No patient experienced a serious side effect, but two displayed vomiting after receiving 500 micrograms of the drug. Uterine evacuation was induced by both repeated intramuscular injections (500 micrograms every 4 hours) and continuous intravenous infusion (2.8 micrograms/minute for 6 hours) of sulprostone in more than 90% of the patients with intact pregnancy, missed abortion, or fetal death. The efficacy of the drug was not influenced by gestational age or parity. Gastrointestinal symptoms were the only recorded side effects, with negligible incidence and intensity for both routes of sulprostone administration.

Middle cerebral artery velocimetry: different clinical relevance depending on umbilical velocimetry.

OBJECTIVE: To evaluate the role of cerebral velocimetry as a predictor of perinatal outcome in high-risk pregnancies. METHODS: Middle cerebral artery pulsatility index was measured in 576 high-risk pregnancies undergoing umbilical velocimetry. The results of both tests were evaluated with respect to the birth of small for gestational age (SGA) infants and adverse perinatal outcome, defined as perinatal death, cesarean delivery for fetal distress, or low Apgar score. RESULTS: Once umbilical velocimetry was taken into account, cerebral velocimetry did not improve the prediction of fetal growth restriction or adverse perinatal outcome. Neither test was able to predict adverse perinatal outcome in normally grown fetuses. As for SGA fetuses with adverse perinatal outcome, the simultaneous assessment of both umbilical and cerebral velocimetry did not improve diagnostic accuracy (kappa index 0.37 versus 0.41 for umbilical velocimetry only). However, within the group of high-risk pregnancies with abnormal umbilical velocimetry, the risk of being SGA and having an adverse perinatal outcome was doubled (relative risk 2.1, 95% confidence interval 1.1, 4.3) if cerebral velocimetry also was abnormal. CONCLUSION: The routine use of cerebral velocimetry in high-risk pregnancies adds little information beyond that obtained from umbilical velocimetry; however, it is useful in predicting SGA infants with adverse perinatal outcome when umbilical velocimetry is abnormal.

Uterine artery velocimetry and spontaneous preterm delivery.

OBJECTIVE: To evaluate if idiopathic spontaneous preterm delivery is associated with abnormal uteroplacental circulation, as assessed by Doppler velocimetry. METHODS: The study was carried out on 417 women who had Doppler velocimetry performed between 25-36 weeks' gestation and were subsequently delivered vaginally. The systolic-diastolic ratio (S/D) was computed for the uterine and umbilical arteries, and the outcomes of pregnancies with spontaneous preterm and term deliveries were compared. RESULTS: Uterine artery S/D was significantly higher (P < .0001) in the 31 patients delivered preterm, whereas no significant difference was observed in the umbilical S/D. Abnormal values of uterine S/D were detected in 58.1% of the preterm group, independent of the gestational age at examination. No significant increase in S/D was observed in patients hospitalized for preterm labor who delivered subsequently at term. Spontaneous preterm delivery was associated with increased uterine S/D among both pregnancies with small for gestational age fetuses and those with appropriately grown fetuses. CONCLUSION: Preterm delivery is associated with modifications of uterine artery Doppler velocimetry, suggesting that impaired trophoblastic invasion of the placental bed may play a role in determining preterm delivery.

Hormone excretion during early pregnancy following spontaneous and clomiphene citrate-induced ovulation.

Endocrine changes during early pregnancy have been studied in 12 patients between days 35 and 91 from the last menstrual period. Ovulation had occurred spontaneously in five patients and was induced with clomiphene citrate (CC) in the remaining seven women. All the patients collected daily samples of early morning urine throughout the period of study; on each sample, human chorionic gonadotropin (hCG), pregnanediol-3-alpha-glucuronide (PGDG) and estrone-3-glucuronide (E1G) were measured by chemiluminescence immunoassay. No significant difference was observed between the two groups of patients with respect to the concentrations of hCG and PGDG. The excretion of E1G, however, was significantly higher in patients treated with CC. These data suggest that the induction of ovulation with CC may affect estrogen production in early pregnancy.

Pharmacologic induction of multiple follicular development improves the success rate of artificial insemination with husband's semen in couples with male-related or unexplained infertility.

The use of artificial insemination with husband's semen (AIH) as treatment for couples with male-related or unexplained infertility is often disappointing. The aim of the present study was to evaluate whether the induction of multiple ovulation can increase the pregnancy rates in couples treated with AIH. Multiple follicular development was induced by means of clomiphene citrate (CC) plus purified follicle-stimulating hormone (FSH) in 17 couples undergoing AIH for male-related or unexplained infertility. In spite of the long duration of infertility (greater than 6 years), 10 couples (58.8%) achieved pregnancy within 6 months of treatment. This figure was significantly higher than that obtained in 120 couples who underwent AIH either during spontaneous cycles or after induction of follicular development with CC alone. These results suggest that the availability of multiple mature oocytes increases the conception rate during each cycle, as reported for in vitro fertilization (IVF) programs. It is therefore suggested that a trial of induction of multiple follicular development be performed in couples with male-related or unexplained infertility before their inclusion in protocols for invasive procedures, such as IVF or gamete intrafallopian transfer.

Adjusting the dose to the individual response of the patient during the induction of ovulation with pulsatile gonadotropin-releasing hormone.

To identify the effective dose of intravenous pulsatile gonadotropin-releasing hormone necessary to induce ovulation in patients with chronic anovulation of diverse etiology, 40 women were subdivided into four groups: idiopathic hypogonadotropic hypogonadism (IHH), functional hypothalamic amenorrhea, normoandrogenic oligomenorrhea, and polycystic ovarian syndrome (PCOS). During 90 treatment cycles, the dose was the only parameter that was progressively adjusted. The overall ovulation rate per cycle was 100% in IHH, functional hypothalamic amenorrhea, and normoandrogenic oligomenorrhea, using only 5 micrograms/90 minutes in functional hypothalamic amenorrhea and normoandrogenic oligomenorrhea and up to 7.5 micrograms/90 minutes in IHH. In PCOS, the ovulation rate was 67.6%, using up to 20 micrograms/90 minutes. The lesser degree of effectiveness observed in PCOS can probably be explained by the different basal endocrine profile presented by these subjects.

Modifications in uterine and intraovarian artery impedance in cycles of treatment with exogenous gonadotropins: effects of luteal phase support.

OBJECTIVE: To determine the effects of induction of multiple ovulation and of luteal P supplementation on the impedance to blood flow in the uterine and intraovarian arteries during the luteal phase. DESIGN: A prospective study using transvaginal color flow Doppler imaging. SETTING: A university-based infertility center. PATIENTS: Fifty-six women with unexplained or male factor-related infertility undergoing IUI. INTERVENTIONS: The patients were studied either during spontaneous cycles (n = 16) or in cycles of induction of multiple follicular development with purified FSH (n = 40). In 18 treated cycles, the luteal phase was supplemented with natural P. MAIN OUTCOME MEASURES: The pulsatility index was recorded from uterine and intraovarian arteries on the day of E2 peak and 5 and 10 days thereafter. On the same days, E2 and P plasma levels were measured by RIA. RESULTS: The intraovarian pulsatility index was significantly lower in FSH-treated than in spontaneous cycles on the day of E2 peak. Also, the uterine pulsatility index was significantly lower in treated cycles than in spontaneous cycles on the day of E2 peak and 5 days thereafter. In the late luteal phase, P supplementation was correlated with a significant decrease in uterine pulsatility index as compared with both spontaneous cycles and FSH-treated cycles without luteal support. CONCLUSIONS: Multiple follicular development is associated with a significant reduction in the impedance to perifollicular blood flow. Progesterone, as well as E2, seems able to decrease the impedance to blood flow in uterine arteries in women.

Norethisterone enanthate as an injectable contraceptive in puerperal and non-puerperal women.

Norethisterone enanthate (NET-EN) was intramuscularly administered to 5 puerperal women and 20 non-puerperal women for a total of 366 months. Contraceptive effectiveness and side effects of the drug were evaluated. Basal levels of LH, FSH, prolactin (PRL), estradiol 17 beta (E2) and progesterone (P) were measured in blood samples collected from 5 non-puerperal women, while LH, FSH, PRL and norethisterone (NET) plasma levels were evaluated in puerperal women. NET was also assayed in plasma from breast-fed newborns. No woman became pregnant. Side effects consisted of only menstrual abnormalities. Ovulation (P plasma levels higher than 2000 pg/ml) was achieved in 3 patients during the first month of NET-EN treatment but luteal function appeared to be insufficient. In puerperal women, NET plasma levels showed a course similar to the one observed outside puerperium. Lactation was not inhibited, and NET transfer to newborn through milk was negligible, since NET was undetectable in newborn plasma when maximal levels were measured in the mother. It was concluded that NET-EN is an effective contraceptive drug, deprived of major side effects, and particularly useful in women affected by metabolic diseases or during puerperium.

PIP: 5 puerperal and 20 nonpuerperal were treated with intramuscular injections of norethisterone enanthate (NET-EN) for a total of 366 months. Basal hormonal levels were measured in blood samples, and NET was also assayed in plasma from breastfed newborns. There were no pregnancies and only minor menstrual disorders. Lactation was not inhibited in breastfeeding women, and NET transfer to newborn was negligible, even when maximal levels were measured in the mothers. Ovulation was achieved in 3 patients, but with insufficient luteal function. NET-EN seems therefore to be an effective contraceptive, deprived of major side effects, and particularly advisable during puerperium.

Urinary excretion of N-acetyl-beta-D-glucosaminidase and alanine aminopeptidase during pregnancy.

The assay of enzyme activity in urine seems a reliable and safe method to monitor different kidney diseases. However, its use in pregnant patients might be limited by the modifications of kidney function during pregnancy. The aim of the present study was to evaluate the trend of excretion of the lysosomal enzyme N-acetyl-beta-D-glucosaminidase (NAG) and the brush border enzyme alanine aminopeptidase (AAP) during uncomplicated pregnancies. NAG excretion showed a significant increase (P less than 0.001) throughout pregnancy, while no significant modification of AAP levels was demonstrated. These data support the hypothesis that the two enzymes are excreted into the urine through different mechanisms and might constitute markers for different pathological events. As the increase of NAG excretion may be related to the kidney functional adaptation to pregnancy, different cut-off limits must be established in this period.

[Use of a new synthetic prostaglandin (sulprostone) in various obstetrical conditions]. / L'uso di una nuova prostaglandina di sintesi (sulprostone) in diverse condizioni ostetriche.

PIP: A new prostaglandin E2 (PGE2) derivative, the 16 phenoxy-omega-tetranor PGE2 methylsulphonylamide of Sulprostone, was administered to 56 patients to induce preoperative cervix dilatation (1st trimester) and termination of pregnancy for missed abortion (1st and 2nd trimester), or fetal death (3rd trimester). Different dose schedules have been administered intramuscularly. Hourly side effects were recorded. Among 46 patients, Sulprostone induced cervical dilatation (8 mm or more) in 36 subjects. In the others, the cervix dilated at least 6 mm. With regard to the termination of pregnancy, uterine contractions and discharge occurred within a short time. The incidence of side effects was minimal. Our study seems to indicate the usefulness, efficacy, and acceptability of Sulprostone in the management of different obstetric conditions. (author's modified)^ieng