Malignant fibrous histiocytoma with myofibroblastic differentiation of the vulva in an adolescent female.

Malignant fibrous histiocytoma is a rare sarcoma. Only seven cases in the vulva have been reported. We present a case of malignant fibrous histiocytoma of the vulva in an adolescent female. The elected treatment was local wide resection.

Primary angiosarcoma of the ovary: a clinicopathologic, immunohistochemical and electronmicroscopic study.

The present report of a 25 year old woman with a primary ovarian angiosarcoma is supplemented by histochemical and ultrastructural studies and reviews the literature of this extremely rare neoplasm. Since this ovarian tumor, especially in young women, may constitute a diagnostic pitfall, problems relating to differential diagnosis are emphasized. Although the origin of this neoplasm appears to occur most likely from the rich ovarian vasculature, other less conventional histogenetic theories such as a possible origin in mixed mullerian tumor, in teratoma or in other ovarian germ cell tumors have also been proposed and are considered in this paper.

Umbilical cord blood acid-base values in uncomplicated term vaginal breech deliveries.

BACKGROUND: This prospective study was conducted to compare the umbilical cord blood acid-base values of uncomplicated, assisted, vaginal-breech-delivery term neonates with those of uncomplicated, cephalic-vaginal delivery term neonates and to determine whether a different metabolic status should be expected in neonates born by way of uncomplicated vaginal breech delivery. METHODS: Umbilical cord artery and vein blood samples were obtained from 30 term neonates with frank or complete breech presentations who were born by uncomplicated assisted vaginal breech delivery. All these neonates had an Apgar score of >7 at 5 min and an uneventful neonatal course (study group). For each neonate in the study group the two consecutive term neonates who were delivered by uncomplicated cephalic spontaneous vaginal delivery, and had uneventful neonatal courses, served as controls (control group). RESULTS: The umbilical cord artery blood pH and pO2 were significantly lower (p<0.001 and <0.01, respectively) and the pCO2 was significantly higher (p<0.001) in newborns of the study group, compared to the controls. The umbilical cord vein blood pH was significantly lower (p<0.01), and the pCO2 significantly higher (p<0.01) in the study group. CONCLUSIONS: The umbilical cord blood acid-base values of uncomplicated, vaginal-breech-delivery term neonates differ significantly from those of uncomplicated, cephalic-vaginal delivery neonates. These differences may represent a greater degree of acute cord compression that reflects the different mechanisms of labor in vaginal breech delivery.

Treatment of bilateral multiple primary ovarian leiomyomas during pregnancy by way of conservative surgery: a case report.

Primary ovarian leiomyoma is a rare, unilateral and solitary, benign tumour. We report a unique case of bilateral, multiple, primary ovarian leiomyomas diagnosed incidentally during caesarean section. As opposed to previously reported cases, conservative surgery was performed which resulted in preservation of ovarian function and anatomy.

Balloon catheter with extra-amniotic saline instillation: a method of induction in pregnancies at 41 or more gestational weeks.

One hundred five women with a documented pregnancy of 41 weeks' gestation or more, admitted for induction of labour by balloon catheter with extra-amniotic saline instillation, were retrospectively compared to 196 women admitted in spontaneous labour at the same gestational age, with regard to mode of delivery. The success rate of the induction group was 97.1%. The mode of delivery did not differ significantly between the 2 groups. The Caesarean section rates were 11.4% in the induction group versus 9.7% in the spontaneous group. The mode of delivery after induction of labour by balloon catheter with extra-amniotic saline instillation and simultaneously commenced intravenous oxytocin infusion, in pregnancies of 41 weeks or more, is similar to that of spontaneous deliveries at the same gestational age.

The optimal number of embryos to be transferred in shared oocyte donation: walking the thin line between low pregnancy rates and multiple pregnancies.

There has been growing concern about the number of multiple gestations resulting from assisted reproductive technologies. For in-vitro fertilization (IVF), there are guidelines concerning the number of embryos to be transferred. In oocyte donation, however, there is a paucity of studies addressing this issue and common practice is extrapolated from standard IVF procedures. This may not be correct since endometrial receptivity has been shown to be altered in oocyte donation. Thus the purpose of this study was to assess the optimal number of embryos to be transferred in oocyte donation. The study population included 254 patients with ovarian failure who underwent a total of 601 embryo transfers in a single shared oocyte donation programme. Pregnancy rates (PRs), multiple pregnancies, triplet pregnancy rates, and implantation rates were evaluated according to the number of embryos transferred. A significant linear increase in PRs was noted with the increasing number of embryos transferred up to five (11.1% for one embryo, 36.7% for five embryos). Multiple pregnancies increased significantly from 15.8% for two embryos transferred, to 44.4% for five embryos. The rate of triplet pregnancies also increased from 2.7% for three embryos transferred, to 8.3% for five embryos. Optimization of the number of embryos to be transferred is discussed.

The procoagulant activity of red blood cells from patients with severe preeclampsia.

OBJECTIVE: Our purpose was to determine whether red blood cells from patients with severe preeclampsia may exhibit increased membrane exposure of procoagulant phospholipids (i.e., phosphatidylserine), which may initiate intravascular clotting and platelet activation. STUDY DESIGN: The study group comprised 28 women: 9 with severe preeclampsia in the third trimester of pregnancy, 10 normotensive with uncomplicated pregnancies, and 9 age-matched, nonpregnant, healthy women. The exposure of phosphatidylserine on the outer membrane phospholipid layer was analyzed with use of isolated, washed red blood cells that were added as a source of phospholipids to a "prothrombinase" coagulation complex. RESULTS: The resultant thrombin formed was measured by an amidolytic assay. Thrombin generation significantly increased on the addition of red blood cells from women with preeclampsia (741 +/- 132 mU/ml/min) compared with red blood cells from normotensive pregnant (422 +/- 228 mU/ml/min) and nonpregnant women (316 +/- 268 mU/ml/min, p = 0.0008). CONCLUSION: This study indicates that in patients with preeclampsia the red blood cells exhibit a significant procoagulant surface that may trigger thrombin formation, thereby playing a role in the hypercoagulable state.

Klippel-Trénaunay-Weber syndrome associated with fetal growth restriction.

Klippel-Trénaunay-Weber syndrome is a rare congenital deep-vein malformation. Pregnancy in patients with this syndrome is rare and only a few cases have been reported. Known obstetrical risks in pregnant patients with this syndrome include bleeding from angiomata in the genitalia, and coagulation disturbances. We present a 31 year old woman with this syndrome who, on two occasions, delivered small-for-gestational-age neonates. This may have been due to placental insufficiency caused by angiomatosis related to the syndrome.

Acid accumulation during end-stage bradycardia in term fetuses: how long is too long?

OBJECTIVE: To estimate the existence and degree of fetal accumulation of acid during end-stage bradycardia as reflected by the base deficit. This may set a criterion for proper intervention during labour. SETTING: Maternity unit of the Tel Aviv Medical Centre. SUBJECTS: Forty-three consecutively born term infants whose mothers were delivered by vacuum extraction were analysed: 27 because of end-stage bradycardia and 16 controls whose mothers were delivered electively because of maternal indications. MAIN OUTCOME MEASURES: Analysis of umbilical arterial cord blood for pH, PCO2 and base deficit. The base deficit was compared between the groups using the two-tailed Student's t test, and was correlated with variables of fetal heart rate monitoring using the Pearson correlation coefficient. RESULTS: The base deficit was greater in newborns who had end-stage bradycardia than in controls (11.02 vs 5.01, P < 0.0001). The duration of loss of short term variability in fetal heart rate during end-stage bradycardia correlated positively with the base deficit (r = 0.8, P < 0.0005). Conversely, the time until the loss of short term variability during end-stage bradycardia correlated negatively with the base deficit. The length and the depth of the bradycardia and their product, had a weaker correlation with the base deficit. CONCLUSIONS: End-stage bradycardia, which presumably reflects fetal hypoxia, is associated with acidaemia in the umbilical artery at birth in some fetuses. The fetuses who are predisposed to acidaemia, as reflected by an increased base deficit, are those who lost their fetal heart rate variability during end-stage bradycardia for more than 4 min or started to lose this in less than 3 min from the beginning of the end-stage bradycardia. Operative vaginal delivery should be reserved for these indications.

Mucocele formation 20 years after an appendiceal uterine transplantation for infertility mistaken for hydrops tubae profluens.

A 56 year old woman was admitted to our hospital with a 9-year history of recurrent, lower abdominal pain and mucoid vaginal discharge 20 years after an appendiceal uterine transplantation. The removal of the uterus and the attached appendix resulted in the disappearance of the symptoms. A mechanism linking the appendiceal mucoid discharge with abdominal pain in this menopausal patient is suggested.

The effects of tamoxifen treatment on the endometrium.

OBJECTIVE: To investigate the association between tamoxifen and endometrial cancer. BACKGROUND: Tamoxifen is a nonsteroidal antiestrogenic drug that has been used successfully for 15 years in the treatment of all stages of breast carcinoma. In light of the positive results, several studies are now being conducted to test prolonged tamoxifen treatment as a prophylaxis against breast cancer in high-risk women. Although tamoxifen was thought to have only a few side effects, reports indicate that it is associated with an increased incidence of proliferative and neoplastic changes in the endometrium. As the current trend is to administer tamoxifen for prolonged periods and for more indications, the detrimental effects on the endometrium have vast implications. METHODS: Review of the current literature. RESULTS: Tamoxifen treatment is associated with an increased incidence of proliferative and neoplastic changes in the endometrium, with a 1.3 to 7.5 relative risk of developing endometrial carcinoma. CONCLUSIONS: The results of tamoxifen treatment in breast carcinoma override the risk of developing endometrial carcinoma. Any vaginal bleeding in women treated with tamoxifen should be investigated carefully and promptly. In the future it may be necessary to advise these women to undergo routine uterine cavity examination.

Prospective study of incidence and predisposing factors for clavicular fracture in the newborn.

OBJECTIVE: To determine the incidence of clavicular fracture, associated fetal and maternal risk factors and its connection with quality care control. SUBJECTS AND METHODS: A total of 3030 newborns delivered vaginally were evaluated for clavicular fractures by three separate physicians. The study group included all newborns with fractured clavicle. A control group consisted of 52 newborns delivered vaginally with no history of fractures. Maternal records were evaluated for possible predisposing factors. RESULTS: Forty-six (l.5%) newborns were found to have clavicular fractures. When compared to the control group, they were found to have a higher birthweight (3710+/-352gm vs 3235+/-405gm) an older maternal age (30.5+/-5 bs 27.7+/-6), a longer second stage of labor (34 min vs 23 min), higher rate of instrumental deliveries (13/46 vs 6/52) and shoulder dystocia (6/46 vs 1/52). Nearly 80% of newborns with clavicular fractures weighed less than 4000 gm. Multivariate analysis demonstrated two independent variables; birthweight over 3500 gm and maternal age >29. CONCLUSION: Clavicular fractures are associated with higher birthweight, older maternal age, longer second stage of labor, instrumental deliveries and shoulder dystocia. However, in most cases this injury cannot be predicted prior to delivery and thus cannot be an indicator of quality control.

Congenital cytomegalovirus infection.

OBJECTIVE: Congenital cytomegalovirus is the most common viral infection affecting approximately 1% of newborns. The virus can be transmitted to the fetus during both primary and recurrent infection. Although most of the infants are asymptomatic at birth, up to 15% develop late complications. The annual cost of treating cytomegalovirus infection complications in the USA is two billion US dollars. Many issues regarding cytomegalovirus infection such as routine screening, antenatal diagnosis and vaccination during pregnancy are unsettled and disputed. The aim of this article is to review the current literature on the subject and to draw some conclusions. DESIGN: Review of the current literature. CONCLUSIONS: At present, it appears that there is no indication for routine prenatal screening, while other issues, such as the most accurate method for antenatal diagnosis and the indications for pregnancy termination are, as yet, unsettled.

The effect of an in-vitro fertilization pregnancy on a woman with genital tuberculosis.

The coexistence of an in-vitro fertilization (IVF) pregnancy and genital tuberculosis may pose life-threatening consequences. This case report describes catastrophic dissemination of latent genital tuberculosis, followed by IVF and pregnancy. The role of both IVF manipulation and the pregnancy itself in the exacerbation of latent tuberculosis is discussed. In addition, some measures for the detection, follow-up and treatment of latent genital tuberculosis in patients who undergo IVF are proposed.

Soluble tumor necrosis factor receptors in maternal plasma and second-trimester amniotic fluid.

OBJECTIVES: We assessed maternal plasma and second-trimester amniotic fluid for levels of the p55 and p75 soluble tumor necrosis factor receptors. STUDY DESIGN: Blood was drawn from 61 healthy pregnant women (group A) before second-trimester genetic amniocentesis, and an aliquot of amniotic fluid was also obtained for this study. An additional blood sample was obtained from 13 of these patients at 36 to 40 weeks' gestation. Twenty-three healthy, nonpregnant women of reproductive age donated blood as a control group (group B). All plasma and amniotic fluid specimens were collectively assayed for the p55 and p75 soluble tumor necrosis factor receptors by specific enzyme-linked immunoassays. Additionally, tumor necrosis factor-alpha concentrations were measured in second-trimester plasma and amniotic fluid of 22 patients in group A and in all 23 of the nonpregnant women. RESULTS: The p55 and p75 soluble tumor necrosis factor receptors were detectable in all plasma samples from both groups of patients. The concentrations of both soluble receptors were significantly higher in second-trimester plasma compared with nonpregnant measurements (p < 0.01), and the plasma concentrations of both soluble receptors increased significantly from the second to third trimester (p < 0.01). The p55 and p75 soluble tumor necrosis factor receptors were also detectable in all amniotic fluid samples. Tumor necrosis factor-alpha was detected in the plasma of 15 of 22 patients in the second trimester but in none of the amniotic fluid samples and in none of the plasma samples from the nonpregnant cohort. CONCLUSIONS: Both the p55 and p75 soluble tumor necrosis factor receptors are physiologic constituents of second-trimester maternal plasma and amniotic fluid. Concentrations are elevated in pregnancy and further increase from the second to third trimester.

Extended induction of ovulation by human menopausal gonadotropins and a gonadotropin-releasing hormone analog in high responders for in vitro fertilization and oocyte donation.

OBJECTIVE: To examine the efficacy of extending ovulation induction for the in vivo maturation of oocytes. STUDY DESIGN: Fifty-nine high responders underwent 72 in vitro fertilization (IVF) cycles with a conventional protocol of human menopausal gonadotropin and a gonadotropin-releasing hormone analog. These patients donated oocytes to 81 recipients. The same 59 patients underwent 90 subsequent cycles in which the duration of induction was extended by two to three days. The oocytes were also donated to 138 patients. RESULTS: With the extended protocol, significantly more oocytes were retrieved (29.1 vs. 20.6), and a greater proportion of them were mature. Fertilization rates were significantly higher for both donors (67.7% vs. 36.2%) and recipients (67.5% vs. 47.1%). Conception rates were also significantly higher for both donors (24.4% vs. 11.1%) and recipients (38.4% vs. 24.7%). CONCLUSION: Extending the duration of ovulation induction in high responders is associated with in vivo maturation of oocytes and improved success rates in IVF and ovum-donation programs.

High progesterone levels adversely affect embryo quality and pregnancy rates in in vitro fertilization and oocyte donation programs.

OBJECTIVE: To assess the effect of P levels on oocyte and embryo quality and pregnancy rates (PRs) in IVF and oocyte donation. DESIGN: Retrospective analysis of PRs in ovum donors and their recipients with regard to P levels on day of hCG administration. SETTING: In Vitro Fertilization Units, oocyte donation programs. PATIENTS: In vitro fertilization patients who agreed to donate oocytes were treated by hMG alone (53 cycles) or in combination with a GnRH analog (122 cycles). INTERVENTIONS: Uterine preparation in oocyte recipients consisted of 6 mg/d E2 valerate. Progesterone (100 mg/d) was added when oocytes became available. Hormonal treatment was continued until 12 weeks of gestation. RESULTS: Using a series of Fisher's Exact Tests, a critical threshold for P was identified at 1.9 ng/mL (conversion factor to SI units, 3.185). With elevated P levels (> 1.9 ng/mL), lower PRs were noted for the donors (7.1% versus 17%), as well for the recipients (8.3% versus 26.7%). CONCLUSIONS: Exposure to elevated P levels resulted in lower PRs for the donors and significantly lower PRs in the recipients. Because the endometria in the recipients were prepared uniformly, we conclude that this is the result of detrimental effects of P on oocyte or embryo quality.

Ovarian hyperstimulation syndrome manifests as acute unilateral hydrothorax.

Ovarian hyperstimulation syndrome may be a serious complication of ovulation induction usually manifested by ovarian enlargement and ascites. In its severe form, haemoconcentration, oliguria and hydrothorax may ensue. As evident from this case report, the usual sequence of events does not necessarily occur in all cases. Unilateral hydrothorax may be the only extra-ovarian manifestation of ovarian hyperstimulation syndrome.