Changes in the rate of tubal ligation done after cesarean section.

OBJECTIVE: We studied tubal ligations done after cesarean section in a Spanish hospital during a 20-year period, in order to analyze changes in patient characteristics and indications for cesarean delivery. STUDY DESIGN: We reviewed the clinical records, for the period from 1978 to 1997, of 1996 cases of cesarean section followed by tubal ligation in 108776 births in which the fetus weighed 1000 g or more. RESULTS: During the 20-year period of study, the proportion of cesarean sections relative to vaginal deliveries increased, as did the frequency of cesarean section followed by tubal ligation relative to cesarean and vaginal deliveries. The proportion of women who underwent tubal ligation after a second cesarean section decreased from 60% during 1978-1982 to 5.6% during 1993-1997. The most frequent maternal pathology associated with gestation was previous cesarean section (60.5%), although 50% of the women had no underlying pathology. CONCLUSIONS: In our setting, the rate of cesarean section followed by tubal ligation has been increasing steadily since the early 1980s. The proportion of women who requested tubal sterilization and who had only one living child, or who had had a previous cesarean birth, also increased.

Successful pregnancy in a woman with acromegaly treated with somatostatin analog (octreotide) prior to surgical resection.

A 27-year-old woman with a GH-secreting pituitary macroadenoma was treated with continuous s.c. infusion of octreotide prior to surgical resection. Subsequently, she was found to be 6 months pregnant. Fetal echographs were normal, the newborn had no malformation, and postnatal development was normal.

Amnioinfusion in term labor with low amniotic fluid due to rupture of membranes: a new indication.

OBJECTIVE: The null hypothesis was that the use of intrapartum amnioinfusion to induce term labor because of premature rupture of membranes when labor was complicated by low amniotic fluid volume due to vaginal loss would not improve fetal heart rate patterns, decrease the incidence of operative delivery, or improve neonatal acid-base status. STUDY DESIGN: 200 term pregnancies with low amniotic fluid due to vaginal loss were randomly chosen to receive intrapartum amnioinfusion or standard obstetric care without amnioinfusion. Fetal heart rate pattern, method of delivery and neonatal acid-base status were compared with Student's t test, chi-squared analysis, Mann-Whitney U- or Fisher's exact test. RESULTS: When amnioinfusion was used, the fetuses had lower rates of variable (74 vs. 91%, P<0.01) or late (26 vs. 58%, P<0.001) decelerations. Spontaneous deliveries were more frequent (77 vs. 59%, P<0.01) and cesarean sections less frequent (3 vs. 10%, P<0.05). Mean umbilical arterial (7.24+/-0.07 vs. 7.21+/-0.08, P<0.01) and venous (7.31+/-0.06 vs. 7.28+/-0.08, P<0.01) pH were significantly higher in newborns with amnioinfusion, and babies in this group had lower rates of neonatal acidemia of arterial (22 vs. 36%, P<0.005) or venous (13 vs. 26%, P<0.005) origin. CONCLUSIONS: Amnioinfusion improved fetal heart rate pattern, lowered the incidence of operative delivery, and improved neonatal acid-base status in term labor complicated by low amniotic fluid due to vaginal loss.

Amnioinfusion in labor induction of term pregnancies with premature rupture of the membranes and low amniotic fluid.

OBJECTIVE: To analyze the utility of prophylactic amnioinfusion in term pregnancies with PROM and a low amniotic fluid index during labor induction. METHOD: Forty-two women with amnioinfusion and 42 in a control group with amniotic fluid index (AFI) below 10 cm when admitted to labor induction were studied. All patients had electronic fetal heart rate and intrauterine pressure continuous monitoring. Amnioinfusion of normal saline (37 degrees C) was realized in the study group, using a continuous perfusion pump at 600 ml/h for 1 h, after which the AFI was again recorded; if this was < 15, the perfusion was continued at 180 ml/h until full cervical dilatation was achieved or until uterine baseline activity reached 20 mm Hg. The control group received identical obstetric care except in respect of amnioinfusion. RESULT: Both groups were similar in age, primiparity, gestational age, initial AFI, interval from rupture of membranes until delivery and length of labor. The amnioinfusion of 600 ml in 1 h significantly increased the AFI (an increase of 7.2 +/- 3.9 vs. a decrease of 1.1 +/- 1.6, P < 0.01). In the amnioinfusion group, there was a significantly lower rate of cesarean deliveries (0 vs. 6, P < 0.05) and a better mean umbilical arterial pH at delivery (7.24 +/- 0.07 vs. 7.21 +/- 0.08, P < 0.05). No differences were observed in maternal or neonatal hospitalization days or infectious morbidity. CONCLUSION: It is concluded that prophylactic amnioinfusion improves neonatal metabolic state when used in labor induction of term pregnancies with PROM and a low amniotic fluid index.

Increase of large granular lymphocytes in human ejaculate containing antisperm antibodies.

Using flow cytometry, we studied the expression of the CD16 antigen by lymphocytes present in human semen samples from three groups of patients: 60 fertile men attending for vasectomy, 60 sterile patients without antisperm antibodies (ASA) and 18 immunological sterile patients with ASA in their ejaculate. No significant difference was found in the concentration of leukocytes or subpopulations of these cells (monocytes, lymphocytes and granulocytes) between fertile, sterile without ASA and immunological sterile groups. However, we detected a predominance of macrophages/monocytes within the population of seminal leukocytes. No statistically significant difference was found in the absolute number of T and B lymphocytes between the three groups studied. However, a significant increase in the number of CD16+ lymphocytes was observed in the ejaculate of sterile patients with ASA as compared to the other groups. This finding might establish an important parameter in the follow-up and prognosis of patients with immunological sterility.

Timing of intrapartum ampicillin and prevention of vertical transmission of group B streptococcus.

OBJECTIVE: To evaluate the relationship between the time elapsed from the administration of ampicillin prophylaxis to delivery and its efficacy in interrupting intrapartum transmission of group B streptococcus. METHODS: During the 12-month study period, all women who came to the Virgen de las Nieves Hospital (Granada, Spain) for delivery were screened for group B streptococcus vaginal carriage by a pigment-detection culture-based procedure. Colonized women were treated with ampicillin (2 g intravenously), and the interval between ampicillin administration and delivery was recorded. Newborns from colonized mothers also were screened to detect group B streptococcus colonization. RESULTS: During the study period, 4525 women were admitted to the hospital for delivery and screened for group B streptococcus vaginal colonization. Group B streptococcus was detected in 543 women (12%), of whom 454 gave birth vaginally to 454 liveborn infants. Intrapartum ampicillin was given to 201 of these 454 women (44%), and 10% of the newborns from mothers who received intrapartum ampicillin prophylaxis were colonized by group B streptococcus. The relationship between timing of ampicillin administration and rate of neonatal group B streptococcal transmission was as follows: less than 1 hour before delivery, 46%; 1-2 hours, 29%; 2-4 hours, 2.9%; and more than 4 hours, 1.2%. Among the 253 mothers who received no intrapartum prophylaxis, colonization was found in 120 of their newborns (47%). CONCLUSION: When the time between the start of ampicillin prophylaxis and delivery is at least 2 hours, vertical transmission of group B streptococcus is minimized.

Influence of obstetric and perinatal care on perinatal mortality.

OBJECTIVE: Cases of perinatal death attributed to suboptimal perinatal care between 1979 and 1992 inclusive at a large, tertiary care center are reviewed. STUDY DESIGN: The study compared two periods: 1979-1985 and 1986-1992. The perinatal morbidity-mortality committee analyzed patient records for the mothers and neonates, delivery room records, the results of fetal autopsy, and histological sections of the placenta. RESULTS: In the first period, 21.5% of the deaths were found to have received suboptimal care; this figure declined 13.5% in the second period (P < 0.05). During the second period, antenatal, intranatal and postnatal care improved, as shown by the lower suboptimal care rate for antepartum (15.8% versus 9.8%; P < 0.05), intrapartum (49.2% versus 22.1%; P < 0.001) and postpartum death (19.9% versus 8.1%; P < 0.001). During both periods, fetal death during pregnancy made up the largest proportion of deaths attributed to suboptimal care, with 44 cases (43.1%) during 1979-1985, and 36 cases (64.3%) during 1986-1992 (P < 0.01). Of these cases, fetuses with intrauterine growth retardation were the most frequent recipients of suboptimal care (20 cases (45.5%) during the first period; 18 cases (50%) during the second period). CONCLUSION: Despite better prenatal care, the highest suboptimal care rate was due to suboptimal care during pregnancy, when some high risk situations were overlooked by the obstetrician.

Efficacy of a universal screening program for the prevention of neonatal group B streptococcal disease.

Universal antepartum vaginal cultures for group B streptococcus (GBS) were initiated in a Spanish hospital in 1994 using Granada medium. Infants born to carriers were monitored closely, and blood, urine and mucocutaneous areas were cultured for GBS. Group B streptococcus was detected in 543 of 4,525 women (12%). Of these, 454 gave birth vaginally, of whom 201 (44%) received intrapartum ampicillin. Prophylaxis was not administered to 253 women (56%). In this group, infants of 120 women were colonized and 1 case of neonatal GBS disease occurred. Using this protocol, most GBS carriers with risk factors received intrapartum prophylaxis. This protocol also led to early identification of colonized newborns.

Undetectable expression of genomic progesterone receptor in human spermatozoa.

The expression of genomic progesterone receptor in human ejaculated spermatozoa was investigated. Spermatozoa from 10 fertile donors who exhibited normal semen parameters were analysed. Indirect immunofluorescence and an enzyme immunoassay using monoclonal antibodies against genomic progesterone receptor were used. Different types of spermatozoa were studied: fresh, post-swim-up (migrated), capacitated and post-artificial induction of the acrosome reaction by calcium ionophore A23187. Progestin receptor-rich T47D human breast cancer cells were used as a positive control, and progestin receptor-poor MDA-MB-231 human breast carcinoma cells were used as a negative control. Genomic progesterone receptor was not detected in fresh, migrated, capacitated and post-acrosome reaction induction human spermatozoa and MDA-MB-231 cells by either indirect immunofluorescence or enzyme immunoassay. However, in T47D cells a mean concentration of 1043.2 +/- 125.2 fmol genomic progesterone receptor/mg protein was observed by enzyme immunoassay, and indirect immunofluorescence results were positive using both flow cytometry and fluorescence microscopy. These findings suggest that the effect of progesterone on human spermatozoa is not mediated by genomic progesterone receptor.

Reactive sacroiliitis as late sequela after severe pelvic inflammatory disease verified by laparoscopy or laparotomy.

OBJECTIVE: To investigate the frequency of lumbosacral pains and sacroiliitis as late sequela of severe pelvic inflammatory disease (PID) confirmed by laparoscopy or laparotomy. DESIGN: The sacroiliac joints were examined radiographically and scintigraphically to search for signs of reactive sacroiliitis. SETTING: Department of Obstetrics and Gynecology, Hospital General Virgen de las Nieves, Granada, Spain. PATIENTS: Thirty-five out of 70 women admitted with severe clinical symptoms of PID during a five-year period. PID was confirmed by laparoscopy or laparotomy. MEASUREMENTS: The sacroiliac joints were examined radiographically, and bone scintigraphic studies of the pelvic girdle were performed with 99technetium labelled pyrophosphate. RESULTS: Twenty out of 35 patients reported lumbosacral pain. The bone scintigraphic findings were positive for sacroiliitis in 18 out of 33 patients (54.6%), and the radiographic findings were positive in 11 women (33.3%). CONCLUSIONS: Patients with previous severe clinical PID complaining of lumbosacral pains may be offered a bone scintigraphy, a sensitive procedure using low-dose radiation, to search for early signs of reactive sacroiliitis.

Serum CA-125 in the diagnosis of acute pelvic inflammatory disease.

OBJECTIVES: To determine the efficiency of different tumor markers (CA-125, carcinoembryonic antigen, CA-15.3, CA-19.9) and insulin-like growth factor I (IGF-I) measurements as a screening procedure for acute pelvic inflammatory disease (PID). METHODS: Peripheral blood samples were obtained at the time of laparoscopy from three groups of women: (1) 50 women who underwent laparoscopic tubal ligation and had no evidence of PID (control group); (2) 20 women admitted because of suspected PID, but at laparoscopy or laparotomy had no signs of PID; (3) 20 patients who underwent acute PID diagnosed by laparoscopy. Serum levels of: CA-125, carcinoembryonic antigen, CA-15.3 and CA-19.9, and plasma IGF-I, were measured by radioimmunoassay. RESULTS: No differences were observed in the levels of CA-15.3, CA-19.9, carcinoembryonic antigen and IGF-I between the three groups studied. Serum levels of CA-125 were significantly higher in patients who had PID. Analysis of receiver operating characteristic curves showed that only CA-125 was useful in diagnosis of acute PID. The cut-off level was 43.7 U/ml for CA-125. CONCLUSIONS: Measurement of serum CA-125 concentrations is recommended as a useful test for acute PID in patients undergoing laparoscopy for pelvic pain.

Lack of expression of HLA antigens on immature germ cells from ejaculates with antisperm antibodies.

PROBLEM: The lack of expression of HLA antigen on immature germ cells from ejaculates with antisperm antibodies has been reported. METHOD: The expression of human leukocyte antigens on immature germ cells from ejaculates with antisperm antibodies (ASA) was investigated by indirect immunofluorescence using a panel of monoclonal antibodies (MAb) and automated flow cytometry. Patients were divided into two groups: fertile (prevasectomic; N = 10), and ejaculates with ASA (10 samples with IgG and IgA ASA, and five semen samples with only IgG ASA). ASA were detected on sperm using the direct immunobead test. After centrifuging semen samples on a Ficoll-Hypaque gradient, round cells obtained at the gradient interface were gated by a flow cytometer. The "immature germ cell window" was defined in terms of cellular volume and granularity. RESULTS: The percentage of gated round cells from semen samples that reacted with anti-CD45 was always less than 5%, and with anti-CD44 less than 3%. This lack of reactivity of gated round cells with MAb specific for leukocytes and epithelial cells suggests that they were immature germ cells. Immature germ cells were unreactive with W6/32 and anti-beta-2-microglobulin MAb, which suggests that these cells do not express HLA class I molecules. Similarly, no reactivity of the immature germ cells with the MAb that recognize HLA class II molecules was found. No significant differences were observed in the expression of HLA molecules on immature germ cells between the different semen samples studied: fertile, and ejaculates with ASA. CONCLUSION: The presence of ASA in ejaculate is not associated with abnormal HLA antigen expression on immature germ cells.

Follicular fluid alpha-fetoprotein, carcinoembryonic antigen, and CA-125 levels in relation to in vitro fertilization and gonadotropin and steroid hormone concentrations.

OBJECTIVE: To investigate the possible role of alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and CA-125 in the ovarian follicle. DESIGN: alpha-Fetoprotein, CEA, and CA-125 were measured in human follicular fluid (FF) and correlated to IVF outcome and gonadotropin and gonadal steroid hormones. SETTING: The In Vitro Fertilization Program at Virgen de las Nieves Hospital, Granada, Spain. PATIENTS: Thirty-six FF from 12 infertile women with irreparable tubal damage who underwent treatment for ovarian stimulation with clomiphene citrate, hMG, and hCG. INTERVENTIONS: Laparoscopic follicular aspiration followed 48 hours later by ET. MAIN OUTCOME MEASURE: Serum and FF AFP, CEA, and CA-125 levels. RESULTS: alpha-Fetoprotein, CEA, and CA-125 were detected in all samples of serum and FF. There were no significant differences between the serum and FF levels. Follicular fluid AFP, CEA, and CA-125 of fertilized oocytes were similar to those in the unfertilized oocytes group. There were no significant correlations between the FF AFP, CEA, and CA 125 levels and gonadotropin and gonadal steroid hormone levels. CONCLUSIONS: alpha-Fetoprotein, CEA, and CA-125 are present in FF after ovarian stimulation, but the mean intrafollicular levels do not differ significantly regardless of the outcome of oocyte IVF.

Diagnosis of pelvic inflammatory disease with 99mtechnetium-hexamethylpropylenamine-oxime-labeled autologous leukocytes and pelvic radionuclide scintigraphy.

In a prospective study, we assessed the performance of pelvic radionuclide scintigraphy after the injection of 99mtechnetium-hexamethylpropylenamine-oxime-labeled autologous leukocytes as a noninvasive tool for the differential diagnosis of pelvic inflammatory disease (PID). The results of radionuclide scintigraphy in 20 women with PID confirmed laparoscopically were compared with the findings in 20 others hospitalized for suspected PID but with PID ruled out later by laparoscopy. The proportion of radionuclide scintigraphic findings demonstrating increased uptake in the genital region, compatible with an inflammatory process, was significantly larger (P < .001) in patients with PID (95%) than in those without PID (15%). The sensitivity of the technique was 95% and specificity was 85%; in all, 90% of the patients were correctly classified. We conclude that radionuclide scintigraphy preceded by the injection of 99mtechnetium-hexamethylpropylenamine-oxime-labeled autologous leukocytes can detect PID in a high proportion of patients.

Sex differences in serum hormone levels in umbilical vein blood.

OBJECTIVE: To determine the serum levels of FSH, LH, PRL, estradiol, progesterone and testosterone in umbilical vein blood in a group of normal neonates. METHOD: Umbilical vein blood was obtained for serum analyses from 52 newborns (25 females and 27 males) in the Maternity of the Hospital Regional Virgen de las Nieves, Granada (Spain) and means were compared with Student's t-test. RESULT: Mean values of prolactin, estradiol and progesterone were similar in both sexes. The levels of gonadotropins in umbilical vein blood found were significantly higher in newborn males than in females (P < 0.001 for LH, P < 0.007 for FSH). Testosterone levels were higher in male neonates than in females (P < 0.004). CONCLUSION: Our data reflect the dynamic state of male fetal endocrinological status in comparison to female fetuses, and strongly suggest that the mechanisms of hormonal regulation differ in the two sexes.

Perinatal morbidity and mortality in twin pregnancies.

We reviewed 488 twin pregnancies that resulted in the birth of neonates weighing 1000 g or more. Complications were present in 56.7% of all pregnancies; most common were threat of premature labor (17.4%) and preeclampsia (14.5%). Perinatal mortality was 31.8 per thousand. Eighty percent of neonatal deaths in twin pregnancies involved newborns weighing less than 2000 g. Twin pregnancies are high risk pregnancies and benefit from early diagnosis, prevention and treatment of the threat of premature birth.

Mononuclear cell subpopulations in human follicular fluid from stimulated cycles.

The study of lymphocyte subsets from human follicular fluid (FF) provides an opportunity to evaluate immunological features of the ovary. We investigated the mononuclear cell subsets in FF and peripheral blood obtained at the time of laparoscopy from ten in vitro fertilization (IVF) patients. Midcycle nonpregnant peripheral blood was used as the control. A marked increase in the proportion of monocytes (CD14+) was observed in FF. Although FF was enriched with CD8+ lymphocytes, a decrease in the proportion of CD4+ lymphocytes was observed. "Memory" T cells in FF, identified by the CD4+ CD45R- phenotype, predominated over "naive" T cells (CD4+ CD45R+) at a ratio of 2:1, which differs from the ratio yielded by control blood samples (1:1). The percentage of activated T cells (CD3+ HLA-DR+ cell) increased significantly in FF. When lymphocyte subsets were studied in the peripheral blood of IVF patients, changes similar to but less significant than those in FF were found. These data support the concept that lymphocytes play an important role in ovarian physiology.