Severe Asherman's syndrome complicated with placenta increta conceived by intracytoplasmic sperm injection following hysteroscopic surgery.

Although severe Asherman's syndrome is a disease that may cause infertility, pregnancy and childbirth are possible by performing hysteroscopic surgery. However, the obstetrical outcome is not always satisfactory. We report a case where severe Asherman's syndrome occurred following a cesarean section. Hysteroscopic surgery was performed due to secondary infertility, and pregnancy was achieved through a subsequent intracytoplasmic sperm injection. At 23 weeks of gestation, the patient was hospitalized due to the threat of premature labor, and a cesarean section was performed at 29 weeks of gestation after pregnancy-induced hypertension occurred. It was determined to be abnormal adherent placentation such as placenta increta through intraoperative findings, and a cesarean hysterectomy was performed. The pathological diagnosis of the uterus was placenta increta. Due to the risk of complications from placenta increta in pregnancies following hysteroscopic surgery in patients with severe Asherman's syndrome, it is important to realize the high risk involved in such cases during the pregnancy course, and careful perinatal management should be required.

Successful prenatal treatment of congenital heart block with ritodrine administered transplacentally.

Congenital heart block (CHB) is rather rare, and a poorer prognosis has been documented in fetuses with a ventricular rate <55 beats per minutes (bpm), in which therapeutic interventions during pregnancy have been warranted. We present a case of CHB associated with maternal anti-SSA/Ro antibody, diagnosed at 28 weeks' gestation. Fetal echocardiography revealed atrioventricular dissociation, with an atrial rate of 170 bpm and a ventricular rate of 54 bpm. To increase the fetal heart rate, maternal intravenous ritodrine infusion was undertaken, fetal ventricular rate was rapidly increased to 65 bpm. The pregnancy successfully continued until term, and a female infant weighing 2919 g was delivered by cesarean section with Apgar scores of 8 and 8 and 1 and 5 min. The infant is now 12 months of age and growing normally on oral terbutaline without pacing. In a case of fetal heart block, maternal administration of ritodrine may be a therapeutic intervention to improve the fetal and neonatal prognosis.

Aberrant cytokine production by peripheral blood mononuclear cells in recurrent pregnancy loss?

BACKGROUND: Successful pregnancy may depend on a Th2-type cytokine response, whilst, conversely, a poor pregnancy outcome may be associated with an increase in Th1 cytokines and a concomitant decrease in Th2 cytokines. This prospective study was designed to elucidate whether a failure of the cytokine shift pre-dated miscarriage and was therefore likely to be an aetiological factor in recurrent pregnancy loss (RPL). METHODS: Cytokine production by stimulated peripheral blood mononuclear cells from 46 pregnant women who had previously suffered idiopathic RPL during early pregnancy was compared with 25 gestationally age-matched pregnant controls and 11 non-pregnant women. RESULTS: Production of IFN-gamma was lower in pregnant than in non-pregnant women and even lower in RPL pregnant women (P = 0.0191). IL-10 was increased in pregnant women compared with non-pregnant controls, and further increased in RPL patients (P = 0.026). IL-4 was also increased in women with RPL (P = 0.0001). No differences in IFN-gamma, IL-10 or IL-4 secretion were observed in RPL patients who subsequently miscarried compared with those who successfully completed the pregnancy. RPL women with a successful reproductive outcome had similar concentrations of TNF-alpha to pregnant women, RPL women who subsequently miscarried had significantly lower levels than either pregnant women (P = 0.02) or non-pregnant controls (P = 0.0004). CONCLUSIONS: Contrary to our hypothesis, the cytokine shift, which appears to characterize normal pregnancy, was accentuated rather than diminished in RPL pregnant women.

The effect of multiple pregnancies on lumbar bone mineral density in Japanese women.

OBJECTIVE: To elucidate the effect of multiple pregnancies on lumbar spine bone mineral density (BMD). METHODS: The BMD of the lumbar spines (L2-L4) of 1,113 healthy women was measured within 7 days of childbirth. In addition 113 women had spine BMD measurements after their next delivery. RESULTS: In the cross-sectional study, there was no apparent effect of parity on lumbar BMD. In the longitudinal study, the mean BMD after the next delivery was significantly higher than that after the initial delivery (1.019 +/- 0.115 g/cm(2) vs. 1.006 +/- 0.117 g/cm(2), P = 0.001, paired t test) with a percent change (DeltaBMD%) of 1.4 +/- 4.2%. Multiple regression analysis to identify independent predictors of DeltaBMD% showed a negative correlation with maternal age at the subsequent delivery (P = 0.033) but no correlation of DeltaBMD% with the length of lactation between the scans. CONCLUSION: Multiple pregnancies may not reduce maternal lumbar BMD, although the percentage decrease in BMD was greater in older women at the subsequent delivery. The length of lactation between the scans had no effect on these results.

Circulating CD34+ cells to predict the adequate harvest of peripheral blood progenitor cells in platinum-based chemotherapy.

OBJECTIVE: The aim of this study was to clarify the appropriate timing for peripheral blood progenitor cells (PBPC) harvesting after platinum-based mobilization chemotherapy by measurement of the circulating CD34+ cell concentrations. PATIENTS AND METHODS: PBPC were collected for autotransplantation via a total of 68 leukaphereses in 16 patients with gynecological cancer. Circulating CD34+ cell concentrations were measured by CD34-side scatter parameter analysis. RESULTS: Data could be fitted into a linear regression line described by the equation y = 0.33 + 4.14 x (x) (R2 = 0.256), where y = the number of harvested colony-forming unit granulocyte macrophage (CFU-GM (x10(5)/kg) and x = the percentage of circulating CD34+ cells and y = 1.747 + 44.53 x (x) (R2= 0.475), where y = the number of harvested CD34+ cells (x10(6)/kg) and x = the percentage of circulating CD34+ cells. Failure to mobilize sufficient CFU-GM numbers (>1 x 10(5)/kg) occurred in 29 of 31 leukaphereses when the percentage of circulating CD34+ cells was less than 0.10%. CONCLUSIONS: Harvesting procedure may be avoided when circulating CD34+ cells showed less than 0.10% after platinum-based mobilization chemotherapy.

Circulating highly fluorescent reticulocytes to predict the adequate harvesting of peripheral blood progenitor cells in platinum-based chemotherapy.

We prospectively evaluated whether peripheral blood progenitor cells (PBPC) yield from a single leukapheresis could be predicted by measurement of circulating highly fluorescent reticulocytes (HFR). PBPC were collected from 46 leukaphereses in 15 patients with gynecological cancer following platinum-based chemotherapy. Once a level of at least 5.0% HFR was achieved, sufficient PBPC were collected in a single harvest in 71% of the procedures. Whereas, failure to mobilize sufficient PBPC occurred in 24 of 28 leukaphereses when the percentage of circulating HFR was less than 5.0%. In conclusion, circulating HFR may aid in the efficiency of PBPC collections in platinum-based chemotherapy.

HLA-class I antigens in patients with unexplained recurrent abortion.

In order to clarify the genetic background of recurrent spontaneous abortion, the frequency of HLA-A, -B, and -C alleles was analyzed in eighty-nine patients with a history of unexplained primary recurrent abortion. The frequency of each HLA-A, -B, and -C antigen allele was calculated in patients with recurrent abortion and their husbands, and compared with the frequencies in the general population represented by 207 individuals in the Niigata district of Japan. The incidence of individuals homozygous for the HLA-A, -B, and -C alleles was also compared between the patient group and the control group. The frequency of HLA-B35 in the patient group (5 of 89, 5.6%) was significantly lower than in the general population (40 of 207, 19.3%) (Odds Ratio, 0.25; 95% Confidence Interval, 0.09-0.65; P < 0.005; Pc, not significant). The frequencies of other HLA-A, -B, and -C alleles were not significantly different between the patient group and the general population. No significant difference in the frequency of HLA-A, -B, and -C alleles was observed between the husband group and the general population. The incidence of individuals homozygous for HLA-A, -B, or -C alleles in the patient group was not significantly different from the general population. The significantly lower frequency of HLA-B35 in patients with unexplained recurrent abortion suggests that the Th2-associated immune reactions may be lacking in such patients, as it has been reported that an enhanced Th2 response in conjunction with a decreased T Th1 response is a common immune reaction in HLA-B35-positive individuals.

Ovarian function after radical hysterectomy with ovarian preservation for cervical cancer.

OBJECTIVE: To investigate the function of preserved ovaries following radical hysterectomy in premenopausal women with cervical carcinoma and to attempt to identify clinical factors influencing ovarian function. STUDY DESIGN: Between 1991 and 1998, 33 premenopausal patients with International Federation of Gynecology and Obstetrics stage IB and II cervical cancer underwent radical hysterectomy with ovarian preservation, including lateral ovarian transposition in 20 patients. In 12 cases of squamous cell carcinoma with deep stromal invasion or a suspicious, positive node, neoadjuvant chemotherapy was performed. Postoperative whole pelvic radiotherapy was administered to 11 patients. Ovarian function was evaluated by serum FSH level during the follow-up period, 12 months to 9 years. RESULTS: Fifteen of 33 patients became climacteric after treatment. Ten of 12 patients over 40 years old became climacteric, as did 5 of 21 under 39 (P = .0013). Using multiple regression analysis, a significant correlation between ovarian dysfunction and age (under 40) was observed (P = .0286). No ovarian recurrence or symptomatic ovarian cyst was observed in preserved ovaries during the study period. CONCLUSION: Ovarian preservation is safe in patients under 40 years old undergoing radical hysterectomy even if they received additional treatment, such as neoadjuvant chemotherapy or postoperative radiotherapy with ovarian transposition.

Effects of a beta 3 adrenergic receptor agonist on bone and bone marrow adipocytes in the tibia and lumbar spine of the ovariectomized rat.

The object of this study was to investigate the effects of a b3 adrenergic receptor agonist (ARa) and estrogen on bone remodeling and bone marrow adipocyte differentiation. Ten-week-old female Sprague-Dawley rats underwent sham operation (Sham) or were ovariectomized (OVX) and were divided into four groups: Sham, Sham+ARa, OVX, and OVX+ARa groups. They were given orally the b3-ARa, BRL 35135, or vehicle daily for 4 weeks and their tibial and lumbar spinal bone and fat histomorphometric parameters were measured. In tibial proximal metaphysis, the adipocyte number per bone marrow unit volume (N.A/MV), and the percent adipocyte volume (AV/MV) values of the OVX and OVX+ARa groups were significantly higher than the Sham and Sham+ARa groups (P = 0.004, P = 0.008 in OVX, respectively), but ARa administration had no effect on bone remodeling or adipocyte differentiation. N.A/MV and AV/MV correlated negatively with the bone volume (BV/TV, r = -0.67, P = 0.001; r = -0.62, P = 0.004, respectively), and they correlated with the bone resorption parameters, i.e., the eroded surface (ES/BS), osteoclast surface (Oc.S/BS), and osteoclast number (N.Oc/BS) in tibial proximal metaphysis. In tibial distal metaphysis, the adipocyte volume per cell (AV/N.A) values of the OVX and OVX+ARa groups were significantly higher than those of the Sham and Sham+ ARa group (P = 0.003 in OVX). In the lumbar spine, the AV/N.A values of the Sham+ARa and OVX+ARa groups were significantly lower than the Sham and OVX groups values (P < 0.0001 in ARa administration), but OVX did not affect adipocyte differentiation. Beta3-ARa administration affects the bone marrow adipocyte differentiation, which is site-specific difference, although mainly negative in the context of bone.

Use, understanding, and beliefs about complementary and alternative medicines among emergency department patients.

OBJECTIVES: To describe the extent of complementary and alternative medicine (CAM) use among emergency department (ED) patients, to evaluate patients' understanding of CAMs, and to determine gender differences in beliefs about CAMs. METHODS: This study was a convenience sampling of patients seen in an urban ED. Patient demographics were recorded. A questionnaire was administered that assessed patients' knowledge and use of CAMs. Patients were also asked about their beliefs on safety, medication interactions, and conveying information about these substances to their physicians. RESULTS: A total of 350 ED patients were included in the study; 87% had heard of at least one of the CAMs. There was no difference between genders or races concerning knowledge about CAMs. The most commonly known CAMs were ginseng (75%), ginkgo biloba (55%), eucalyptus (58%), and St. John's wort (57%). Forty-three percent of the responders had used CAMs at some time and 24% were presently using CAMs. The most commonly used CAMs were ginseng (13%), St. John's wort (6%), and ginkgo biloba (9%). All CAMs were considered to be safe by 16% of the patients. Only 67% would tell their doctors they were using CAMs. Females were more likely than males to believe that CAMs do not interact with other medications (15% vs 7%, difference 8%, 95% CI = 2% to 15%). CONCLUSIONS: Complementary and alternative medicines are familiar to most patients and used by many of them. Despite this, a large percentage of patients would not tell their physicians about their use of alternative medications. Emergency medicine providers should be aware of the commonly used CAMs, and questions about their use should be routinely included in ED exams.

Breast cancer knowledge and preventive behaviors: An urban emergency department-based survey.

OBJECTIVE: To assess general knowledge and preventive behaviors regarding breast cancer among women who present to an urban emergency department. METHODS: During a six-month study period, a convenience sampling of women aged 21 years and older who were in treatment and waiting areas was surveyed. The anonymous written survey asked about demographic variables, knowledge, and preventive behaviors regarding breast cancer. Knowledge was assessed with questions about the recommended frequency of breast self-examination and the recommended age for first mammography. Performance was assessed by questions about breast self-exam and mammography. Subgroup analysis was done by age (above and below 40 years old), race, income (above and below the median), insurance type, history of breast lump, and family history (FH) of breast cancer. RESULTS: Four hundred women completed surveys. Two hundred twelve (53%) correctly knew the answers to the two knowledge questions. Knowledge was greater in women with private insurance. Knowledge of the frequency of breast self-exam was significantly greater among whites and Native Americans than among African Americans, Asians, or Hispanics. Stated performance of preventive behaviors was 72% (288) for breast self-exam and for mammography. Preventive behaviors were significantly more likely to be performed by higher-income and privately-insured women. Breast self-exam was more likely to be done in older women, those with a history of a breast lump, and those with a FH of breast cancer. CONCLUSIONS: Women with lower income and without private insurance were less likely to be knowledgeable and practice preventive measures for detecting breast disease.

HLA-DQB1 and HLA-DPB1 genotypes in severe preeclampsia.

OBJECTIVE: To clarify whether there are susceptible HLA-DQB1 or HLA-DPB1 alleles in women with preeclampsia. METHODS: The frequency of HLA-DQB1 and HLA-DPB1 alleles was analyzed in 47 women with previous severe preeclampsia and compared with that in 85 normal fertile women. The types of HLA-DQB1 and HLA-DPB1 alleles were assessed using a polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: The frequency of HLA-DQB1*04 allele in previously preeclamptic women was 21.3% (20 of 94 loci) and in the controls was 11.2% (19 of 170 loci). Thus, the HLA-DQB1*04 allele frequency was significantly higher in preeclamptic women compared with controls (P <.05 by chi(2) test, OR 2.15, 95% confidence interval 1.08, 4.27). The frequency of other HLA-DQB1 alleles and all HLA-DPB1 alleles was not significantly different between groups. The incidence of homozygosity of HLA-DQB1 or HLA-DPB1 alleles in preeclamptic women was not significantly different compared with that of normal fertile women. CONCLUSION: These data suggest that women who have the HLA-DQB1*04 allele might be susceptible to preeclampsia.

Blood pressure in acute vaso-occlusive crises of sickle cell disease.

OBJECTIVE: We compared blood pressure (BP) in patients with sickle cell disease (SCD)-related crises and black patients without SCD. METHODS: We retrospectively reviewed charts of emergency department (ED) patients with SCD crises in a 2-year period, recording BPs and demographic and SCD data. A cohort of consecutive black patients without SCD was compared. RESULTS: Included were 459 SCD-related visits, 187 by men and 272 by women, representing 106 patients. Women had significantly lower BP than men, diastolic BP was significantly lower in patients with hemoglobin SS disease than in those with hemoglobin SC disease, and systolic BP was significantly lower in patients with bilateral versus unilateral pain. One SCD patient had a history of hypertension. The 125 non-SCD patients, excluding 25 with a history of hypertension, had significantly higher systolic and diastolic BP than patients in SCD crisis. CONCLUSION: No patients seen in SCD crisis were hypertensive. Patients who were female, had SS disease, or had bilateral pain had lower BP. Significantly higher BP and more hypertension occurred in black patients without SCD.

Treatment with nafarelin for endometriosis in young women. Efficacy, safety and lipid metabolism. Niigata Nafarelin Study Group.

OBJECTIVE: To assess the efficacy, safety and effect on lipid metabolism of treatment with nafarelin acetate for clinical endometriosis symptoms in young women. STUDY DESIGN: A multicenter, open-label, nonrandomized clinical trial was conducted on subjects who were 19-29 years of age with clinical symptoms and signs of endometriosis demonstrated by laparoscopy, ultrasonography, magnetic resonance imaging, computed tomography or pelvic examination. For 24 weeks, 34 women received intranasal nafarel, 200 mg twice daily. The main outcome measures were changes in signs and symptoms, lumbar bone mineral density by dual energy X-ray absorptiometry and serum parameters of lipid metabolism. RESULTS: Symptoms and signs of endometriosis decreased significantly during treatment and at the first posttreatment menses. CA-125 level decreased significantly, from 84.0 +/- 20.2 U/mL at baseline to 13.4 +/- 1.9 at the 24th week (P = .0014). The mean high density lipoprotein cholesterol, total cholesterol, apoprotein A-I and A-II, lipoprotein (a) and remnant lipoprotein cholesterol levels significantly increased, and cholesterol ester transfer protein activity slightly increased, by the 24th week but fell to baseline values by the first posttreatment menses. Despite a low mean serum estradiol level (20 pg/mL) at the end of treatment, the reported incidence of hot flushes was low (24%), and only one woman withdrew because of hypoestrogenic symptoms. CONCLUSION: Twenty-four-week nafarelin treatment for clinical endometriosis symptoms in women < or = 29 years was safe and effective.

Screening of BRCA1 mutation using immunohistochemical staining with C-terminal and N-terminal antibodies in familial ovarian cancers.

We examined the subcellular localization of BRCA1 proteins using immunohistochemical staining with C-terminal (GLK-2 antibody) and N-terminal (Ab-2 antibody) monoclonal antibodies in 44 familial ovarian cancers. Among these, 24 cases were associated with 13 independent germ-line mutations of BRCA1, and loss of heterozygosity (LOH) at one or more BRCA1 microsatellite markers was found in all 21 informative tumors tested. With GLK-2 antibody, cytoplasmic staining was observed in 15 of 16 tumors (93.8%) with mutation in exon 11, and BRCA1 staining was absent in 8 of 8 tumors (100%) with mutation in exons other than exon 11. When immunohistochemical staining was performed with Ab-2 antibody, both nuclear and cytoplasmic staining were observed in 14 of 16 tumors (87.5%) with mutation in exon 11. Interestingly, nuclear staining was observed in 3 of 3 tumors (100%) with mutation downstream of exon 11, even though no staining was detected in 5 of 5 tumors (100%) with mutation upstream of exon 11. On the other hand, in familial ovarian cancers without BRCA1 mutations, nuclear staining or both nuclear and cytoplasmic staining was observed in 18 of 20 specimens (90%) and 20 of 20 specimens (100%) with GLK-2 antibody and with Ab-2 antibody, respectively. These results suggest that an immunohistochemical assay in combination with employing the C-terminal and the N-terminal antibodies appears to have potential as a reliable and useful technique for the screening of BRCA1 mutations, at least to predict the status of mutation, upstream or downstream of exon 11.

Effects of pregnancy and lactation on trabecular bone and marrow adipocytes in rats.

Changes in the structure and metabolism of trabecular bone and marrow adipocytes in rats during pregnancy and the early stage of postpartum were evaluated by investigating bone mineral density (BMD) and bone and fat histomorphometry. Forty-nine female virgin Sprague-Dawley rats aged 200 days were mated and divided into seven groups: (1) beginning controls; (2) antepartum-on-day-7; (3) antepartum-on-day-21; (4) nonlactating on the fourth postpartum day; (5) nonlactating on the sixth postpartum day; (6) nonlactating on the eighth postpartum day; (7) lactating on the eight postpartum day. The significant decreases occurred in the trabecular bone at the end of pregnancy and lactation, and the bone formation increases and the bone structure is almost recovered in nonlactating rats within 6 days of postpartum. The percent adipocyte volume, adipocyte number, and unit adipocyte volume significantly decreased during postpartum whether lactating or nonlactating, and they significantly showed negative correlation with the osteoid volume values. The serum triglyceride value and body weight of the seven groups correlated significantly with the unit adipocyte volume value (r = 0.49, P = 0.004; r = 0.58, P = 0.0005, respectively). We concluded that bone resorption and formation are regulated separately during late pregnancy and lactation and that the recovery of BMD from lactation appears to rely on an acceleration of bone formation. Furthermore, the metabolism of the marrow adipocyte may be correlated with bone formation rates, serum triglyceride value, and body weight during pregnancy and early stage of puerperium.

Paclitaxel in combination with cisplatin is less effective for peripheral blood progenitor cell mobilization.

The purpose of this study was to determine the efficacy of paclitaxel in combination with cisplatin and granulocyte-colony stimulating factor (G-CSF) for mobilization of peripheral blood progenitor cells (PBPC). Twenty-seven patients with gynecological cancer received paclitaxel and cisplatin (TP, n = 9) or other platinum-based chemotherapy (n = 18) (etoposide and cisplatin [n = 5]; cyclophosphamide, adriamycin, and cisplatin [n = 8]; or pepleomycin, etoposide, and cysplatin [n = 5]). Each combination was followed by G-CSF. The mean number of colony-forming unit granulocyte macrophage (CFU-GM)/kg and CD34+ cells/kg collected per cycle was 1.2 x 105 and 0.8 x 106 after the TP regimen, compared with 2.6 x 105 (P < 0.05) and 2.0 x 106 for patients who received other platinum-based chemotherapy. The CFU-GM target yield (>/=1.0 x 105/kg) was achieved in 56% and 83% patients in the TP and comparison group, respectively. With the TP regimen, a younger age (

Palmar fasciitis and polyarthritis associated with squamous cell carcinoma of the cervix.

Palmar fasciitis and polyarthritis (PFPA) is an uncommon syndrome characterized by progressive and extensive rheumatic disease. We present the first example of PFPA in association with squamous cell carcinoma of the uterine cervix and peritoneal carcinoma. A 54-year-old woman developed pain in both shoulders and flexion deformities of all fingers in both hands due to an increasing swelling of both palms. She underwent surgery and histologic examination of the removed uterus revealed squamous cell carcinoma, nonkeratinizing type with a small portion of undifferentiated carcinoma. Chemotherapy resulted in an excellent response, during which the arthritic symptoms improved gradually. PFPA can occur in a wide range of cancers and warrants extensive investigation for a malignant tumor.

Possible susceptibility of the HLA-DPB1*0402 and HLA-DPB1*04 alleles to unexplained recurrent abortion: analysis by means of polymerase chain reaction-restricted fragment length polymorphism method.

PROBLEM: To clarify whether HLA-DP antigens are associated with patient population of unexplained recurrent abortion. METHOD OF STUDY: The frequency of HLA-DPB1 alleles in patients with unexplained recurrent abortion, and the compatibility of HLA-DPB1 alleles between patient couples, were studied using a polymerase chain reaction (PCR)-restricted fragment length polymorphism (RFLP) method. Thirty patients who had a history of unexplained primary recurrent abortion, and their husbands, were typed for HLA-DPB1 genotype. Two hundred and ninety-nine base pair fragments from the second exon of HLA-DPB1 genes were selectively amplified using the PCR-primers. After amplification, the DNAs were digested with restriction endonucleases, and subjected to electrophoresis in a 12% polyacrilamide gel to determine HLA-DPB1 genotype. RESULTS: The frequency of HLA-DPB1*0402 and DPB1*04 alleles in the patient group (n = 30) was significantly increased, as compared to that in the normal fertile women (n = 30). The frequency of HLA-DPB1*04 allele in the patient group was significantly increased, as compared to that in the general population (n = 112). No significant compatibility of HLA-DPB1 alleles could be observed between patient couples and normal fertile couples. CONCLUSION: These findings suggest a possible new class II association with patient population of unexplained recurrent abortion.