Biomedical subjects
Publications and source records attributed to R Halperin.
Placental site trophoblastic tumor generally follows term pregnancy or nonmolar abortion. Thus far, 10 cases of placental site trophoblastic tumor have been described which were preceded by a hydatidiform mole. This is the first reported case where placental site trophoblastic tumor has been preceded by metastatic gestational trophoblastic neoplasia treated by chemotherapy.
OBJECTIVE: To evaluate the complications of late second-trimester abortions (18-22 weeks) by laminaria dilation and evacuation, and the obstetric outcome of subsequent pregnancies. METHODS: Dilation of the cervix was achieved by repeated laminaria tent replacement. Evacuation was carried out in the outpatient clinic using general anesthesia. After the first menstrual period, all patients were invited for examination and thereafter were asked to report the outcome of subsequent pregnancies. RESULTS: One hundred seventy-one late second-trimester abortions were performed. Cervical dilation was satisfactory in 158 women (92%). Operative sonography was required in nine (5%) women. One had uterine atony. Follow-up from 150 (88%) women indicated no infection, but one woman required repeat curettage for retained products of conception. There was no indication of cervical injury on cervical internal os measurements remote from abortion. Of the 50 patients who conceived and elected to continue the subsequent pregnancies, two had premature deliveries unrelated to cervical incompetence, and all others reached term. CONCLUSION: Late second-trimester termination by laminaria dilation and evacuation is safe and probably not associated with future adverse pregnancy outcome.
Correct detection of premature contractions and incompetent uterine cervix is still a challenging obstetrical problem since these factors remain a major cause of perinatal loss. Ultrasonography offers additional important data for the prediction of these pathologies which have common sonographic patterns; shortening of the cervical length, funneling of the membranes and dilatation of the endocervical canal. The first section of this review highlights sonography of normal cervical anatomy, while the second section focuses on recent advances in sonographic detection of premature contractions and incompetent cervix. It is believed that due to its accuracy and reproducibility, this noninvasive technique should become more integrated into this aspect of antenatal care.
PROBLEM: To examine the relationship between the concentration of uterine fluid human decidua-associated protein (hDP) 200, identified as a monoclonal rheumatoid factor, and different phases of the menstrual cycle. METHODS: Sequential measurements of hDP 200 concentration in uterine fluid were performed in 11 normal ovulatory women, aged 22-36 years. The samples were collected in early proliferative phase, late proliferative phase, periovulatory period, early secretory phase, and late secretory phase. RESULTS: Consistent fluctuations of hDP 200 levels in uterine fluid were found throughout the menstrual cycle. High levels were found during early proliferative phase and periovulatory period related to significantly lower levels during late proliferative and early luteal phases. CONCLUSION: There is menstrual phase dependent variation in the uterine fluid levels of hDP 200.
In the current study, the uterine fluid level of human decidua-associated protein (hDP) 200 was measured in 80 women with abnormal uterine bleeding and normal histology. In 20 women the level of hDP200 was also correlated with the endometrial thickness measured by transvaginal ultrasonography. The results demonstrated the same distribution and similar levels of uterine fluid hDP200 throughout the menstrual cycle as in regularly cycling women, with no correlation between the levels of hDP200 and the endometrial thickness. Thus, the test for uterine fluid hDP200 could serve to discriminate between benign and pathological examinations of endometrial biopsies in women of reproductive age, women with abnormal uterine bleeding and benign conditions of the endometrium. Very low levels of hDP200 are indicative of endometrial hyperplasia or carcinoma.
In this study, serum placental ferritin (PLF) levels were measured among 33 pregnant women with normal, singleton, ongoing first-trimester gestations and compared with 22 nonbleeding, missed and 14 incomplete abortions. Diagnoses were based on clinical, sonographic, endocrinologic and histopathologic criteria. At admission and before uterine evacuation of the pregnancy products, venous blood was collected from the groups for PLF determination. The mean +/- SD serum PLF levels were 18 +/- 14, 21 +/- 37, and 3.9 +/- 6.2 U/ml in normal gestations, missed and incomplete abortions, respectively. Significant differences in PLF levels were found among normal pregnancies and incomplete abortions (p < 0.05), whereas borderline significance was found in the missed abortion group (p = 0.53). No correlation was found between serum beta hCG and PLF for the various pregnancy groups. Low PLF levels in pathologic gestation may reflect abnormal trophoblastic activity. Whether these play a causal role or are the casual outcome of pathologic gestation should be the subject of further evaluation.
Spermatozoa, obtained from 20 healthy individuals, were incubated with crude uterine fluid or with a purified IgG fraction obtained from uterine fluid before adding them to cultures with allogeneic lymphocytes. Untreated spermatozoa induced a proliferative 1.5- to 6-fold increase, while the spermatozoa treated with crude uterine fluid or with purified IgG fraction caused 84-100% suppression of lymphocyte blastogenesis. These results suggest the existence of an endogenous uterine fluid factor, apparently IgG, which causes inhibition of lymphocyte proliferation induced by spermatozoa in the uterine lumen.
We have previously described the identification of the human decidua-associated protein hDP200 as a rheumatoid factor [1]. Assuming that rheumatoid factor binds to Fc of immunoglobulins, the existence of high-molecular-weight complexes was studied in decidual extract, pooled uterine fluid from proliferative and early secretory phase, menstrual fluid and amniotic fluid. High-molecular-weight complexes containing hDP200 and other immunoglobulins were found only in menstrual and amniotic fluids and not in decidual extract or uterine fluid. It is possible that complexing of the immunoglobulins by hDP200 serves as one of the mechanisms that ensure suppression of the immune response to fetal antigens.
A case report of myxoid leiomyosarcoma of the uterus is presented as a rare variant of uterine sarcoma. This case, contrary to most of the 11 cases previously described in the literature, is characterized by highly atypical pleomorphic cells and numerous mitoses. Furthermore, myxoid material is also found in the cytoplasm of pleomorphic tumor cells, a feature, that to our knowledge, has not been previously described. All these tumors, no matter what the microscopic appearance is, exhibit a highly malignant behavior. The best therapy for this tumor is unknown, since there are too few cases from which to draw conclusions.
There is no consensus concerning optimal adnexal surgery during abdominal hysterectomy, when continued hormonal function is desired, associated with reduced sequelae in the future. The aim of the study was to compare residual ovarian function following abdominal hysterectomy with preservation of one or both ovaries, in a prospective randomized study. Forty patients were allocated randomly and sequentially into two groups: those undergoing abdominal hysterectomy with unilateral oophorectomy, and those undergoing abdominal hysterectomy only. Ovarian function was evaluated by measuring FSH, TLH and E2 before, and 1 week, 1 month, 3 months and 6 months after the operation. Thirty-five percent of the patients undergoing abdominal hysterectomy with unilateral oophorectomy demonstrated impaired ovarian function 6 months after the operation. None of the patients with both preserved ovaries showed impaired ovarian function 6 months later. Therefore, when continued ovarian function following abdominal hysterectomy is desired, preservation of both ovaries seems to be more beneficial.
The past few decades have witnessed such a rapid rise in the incidence of ectopic pregnancy that it verges on the point of an 'epidemic disease'. Its early detection, with the aid of serum beta-hCG, high resolution ultrasound and the more liberal use of laparoscopy, has dramatically altered the clinical presentation of this disease and permits the use of more conservative methods of management directed towards preserving fertility and reducing morbidity. In this review of 1197 patients, compiled from the English literature, various conservative or tubectomy operative laparoscopic procedures have been employed, with 93% and 98% respectively, being able to avoid further surgery. Among the group treated by the conservative approach, a 6% post-operative complication rate was reported, of which 4% were persistent ectopic, 48% intra-uterine, and 18% repeated ectopic pregnancies. Among the radically treated patients, 2 intra- and 1 post-operative complications necessitated laparotomies. The fertility work-up and performance outcome are less obvious among this group. The benefits, safety and efficacy of each of the laparoscopic options, with appropriate recommendations for their use, are discussed. However, despite the aforementioned dramatic progress, women with previous ectopic pregnancies still have reduced fertility potential. Preventive measures aimed at reducing its overall occurrence therefore seem to be the major factor towards preserving a patient's future fertility potential.
The concentration of human decidua-associated protein (hDP) 200 was measured in 238 menstrual fluid samples obtained from normal fertile women and in 26 menstrual fluid samples obtained from infertile women who failed to conceive and menstruated following in-vitro fertilization (IVF)/embryo transfer treatment. A significant association was observed between the concentration of hDP200 and the age of the women. A maximal concentration of hDP200 was observed in women aged 28-30 years, with significantly lower concentrations in those aged 18-20 and 39-41 years. The presence of an intra-uterine device had no effect on menstrual fluid hDP200 concentrations. A significantly lower mean concentration of hDP200 (82 U/ml) was measured in menstrual fluid samples obtained from failed IVF/embryo transfer patients as compared with that in menstrual fluid samples from normal fertile women (191 U/ml). These findings support the concept that adequate endometrial function, as evaluated by menstrual fluid concentration of hDP200, is important for the success of the fertility process.
The incidence of multiple pregnancies is increasing, mainly as a consequence of the widespread use of various infertility protocols. Since such gestations present a high risk of feto-maternal morbidity and mortality, selective first trimester fetocide remains one of the few reasonable options. We reviewed the literature dealing with the outcome of 804 multiple pregnancies following the use of transcervical, transvaginal or transabdominal approaches. Questions relating to dealing with technical failure, method of fetocide and procedural improvements are examined. In a comparison of the variables: miscarriage, preterm delivery, perinatal and neonatal loss rates, the transvaginal approach fares better, but statistical significance (P < 0.001) is achieved only for preterm delivery. We speculated that this might be attributable to the very early gestational age at which the procedure is usually performed. However, the transabdominal approach offers better results when post-manipulation maternal morbidity is considered, i.e. infection and vaginal bleeding. Since each option offers different advantages and disadvantages, additional experience and larger population samples are required to further clarify this important issue.
Uterine fluid samples from 109 patients undergoing in-vitro fertilization and embryo transfer were obtained so as to examine the relationship between the uterine fluid concentration of human decidua-associated protein (hDP) 200 and the implantation rate. The sampling was performed on the day of embryo transfer with a Wallace catheter, used for the testing of cervical patency before embryo replacement. The implantation rate, as well as the pregnancy rate, demonstrated a significantly positive correlation with the concentration of hDP 200 in the uterine fluid, measured just before embryo transfer. These results indicate that hDP 200, identified as a rheumatoid factor secreted by the endometrium, may be involved in the implantation process.
Transabdominal Doppler velocity waveform measurements of the uterine arteries during the third stage of labor were performed upon 25 patients with uncomplicated vaginal deliveries and 5 with prolonged third stage in order to further assess third-stage mechanisms. Based on Doppler flow measurements, three phases of the third stage of labor were observed: (1) a latent phase with a systolic/diastolic ratio (S/D) and a pulsatility index (PI) of 2.14 +/- 0.49 and 0.89 +/- 0.17, respectively; (2) a contraction and detachment phase with an S/D and PI of 2.53 +/- 0.53 and 1.28 +/- 0.37, respectively, and (3) an expulsion phase with an S/D and PI of 2.20 +/- 0.34 and 0.91 +/- 0.20, respectively (p < 0.05). During the third stage of labor, it was shown that uterine contractions squeezed the uterine vessels as they traversed the myometrium, leading to an increase in the extrinsic resistance, which was reflected by high resistance flow. Following placental separation and changes in the placental-site wall, there was slight uterine relaxation resulting in decreased uterine vessel resistance. This observation encourages the authors to continue investigating the contribution of ultrasound and Doppler flow for studies of the postpartum period.
Simultaneous transabdominal injection of potassium chloride (KCl) assisted by transvaginal ultrasonographic guidance was evaluated in 5 patients who conceived due to various assisted reproductive techniques and ovarian stimulation. All 5 underwent first-trimester fetal reduction for multiplicity of high-order pregnancies. Four sets of triplets were reduced to twin, and 1 twin pregnancy was reduced to a singleton. Less than 2 ml of 2 mEq/ml KCl per fetus was needed for each case. No fetal or maternal complications nor technical failure attributable to the procedure were recorded. All pregnancies were delivered > or = 35 weeks of gestation. Transabdominal fetal reduction using simultaneous transvaginal ultrasonographic guidance for selective feticide combines the benefits of both the transabdominal and transvaginal approaches, mainly in selected cases in which some experts prefer the abdominal route, but find it technically difficult to practice. Further experience is needed to confirm our encouraging preliminary results before drawing any definitive conclusions.
Prospective uterine fluid sampling in 140 patients was performed using a Wallace catheter. The levels of human decidua-associated protein (hDP)-200 in the uterine fluid and in the serum, and the total protein concentration in the uterine fluid were determined. Uterine fluid volumes were scored during the hysteroscopy and no correlation was found with the phase of the menstrual cycle. The total protein concentration in the uterine fluid did not vary significantly during the menstrual cycle. The hDP-200 levels in uterine fluid were significantly higher than those in the serum, although considerable individual variation in the level of uterine fluid hDP-200 was found.
Hysterosocpic intrauterine findings and levels of human decidua-associated protein 200 (hDP 200) in the uterine fluid were recorded in 116 women investigated for infertility or recurrent abortions. The levels of hDP 200 were significantly higher in the presence of submucous myomas or endometrial polyps, and lower in the presence of intrauterine adhesions in comparison to those in normal uterine cavities. hDP 200, an immunoglobin secreted by the endometrium, may be involved in implantation and placentation and its level in the uterine cavity is influenced by the presence of intrauterine pathology.