Familial occurrence of cervical cancer, stages 0-IV.

All patients hospitalized in 1982 at the Department of Gynecology in Malmö because of malignancy of the cervix uteri attended an interview study concerning the presence of cervical cancer among their nearest relatives. In addition, these patients were questioned concerning earlier gonorrheal infection. The blood group was determined as also was the secretory status and Gm allotype. As a control group the families of the male consorts were used. Cervical cancer was found significantly more often in mothers of the patients (7.9%) than in the consorts' mothers (1.0%). Sisters, aged 20 or over, of the patients had cervical cancer significantly more often (7.5%) than sisters of the consorts (1.1%). Moreover, cervical cancer in mothers and/or sisters was found in 15.6% of the patients. In cases of invasive cancer or previously operated CIS, this figure was 17.5%. The patients did not differ significantly from the normal population regarding blood group or secretory status. A somewhat lower, although non-significant, frequency of Gm(1) allotype was found in patients with invasive cancer, compared with patients with CIS. Patients with a positive family history of cancer had more often had gonorrhea (24%) than patients with a negative family history (18%). The study indicates a multifactorial etiology for cervical cancer.

Isolation and characterization of human cervical-mucus glycoproteins.

Mucus glycoproteins (mucins) were extracted from human cervical pregnancy mucus by 6 M-guanidinium chloride in the presence of proteinase inhibitors. Purification was subsequently achieved by isopycnic density-gradient centrifugation in CsCl/ guanidinium chloride gradients. The purified macromolecules represented approx. 85% of the total and were devoid of nucleic acids and proteins, as judged by analytical density-gradient centrifugation, disc electrophoresis and u.v. spectroscopy. Sedimentation-velocity centrifugation revealed a single unimodal peak with S20,W 50.1S in 0.2M-NaCl and 37.0S in 6 M-guanidinium chloride. Molecular weights obtained by light-scattering were 9.7 X 10(6) and 5.9 X 10(6) in 0.2M-NaCl and 6 M-guanidinium chloride respectively. The chemical analyses were typical of those of epithelial mucins. The macromolecules contained approx. 20% (w/w) of protein, and 65% (w/w) was accounted for as carbohydrate. Serine and threonine constituted 32 mol/100 mol and proline 10 mol/100 mol of the amino acids. The major sugars found were N-acetylglucosamine (12.8%), N-acetylgalactosamine (9.7%), galactose (18.7%), sialic acid (15.0%) and fucose (7.5%).

Isolation and characterization of dermatan sulphate proteoglycan from human uterine cervix.

Proteoglycans were extracted from human uterine cervix with 4 M-guanidinium chloride in the presence of proteinase inhibitors. They were purified by density-gradient centrifugation in 4 M-guanidinium chloride/CsCl (starting density 1.32 g/ml) followed by DEAE-cellulose and Sepharose chromatography. Only one polydisperse proteoglycan was found. s020,w was 2.1S and the weight-average molecular weight was 73 000 (sedimentation-equilibrium centrifugation) to 110 500 (light-scattering). The core protein was monodisperse, with an apparent molecular weight of 47 000. The proteoglycan contained about 30% protein and probably two or three glycosaminoglycan side chains per molecule. High contents of aspartate, glutamate and leucine were found. The glycan moiety of the proteoglycan was exclusively dermatan sulphate, with a co-polymeric structure with approximately equal quantities of iduronic acid- and glucuronic acid-containing disaccharides.

The impact on labor induction of intracervically applied PGE2-gel, related to gestational age in patients with an unripe cervix.

In 54 patients with an unripe cervix in late third trimester, in which gestational age had been properly determined by repeated ultrasound scannings, labor was induced by intracervical application of 0.5 mg PGE2 in viscous gel. It was found that the outcome of the induced labor was not related to the gestational duration, but to the pre-inductive cervical score. Thus, the number of successful inductions was smaller and induction-delivery time longer, the lower the cervical score. Moreover, instrumental deliveries occurred most frequently in nulliparous women, with a low pre-inductive cervical score. Taking into consideration the difficulties of labor induction in the present type of patient, the overall proportion of instrumental deliveries (17%, including 7% cesarean sections) was low. No maternal or fetal side effects were observed. It is concluded that intracervical application a small dose of PGE2 in gel can be recommended for cervical priming and labor induction in pre- and post-term pregnancy.

Dermatan sulphate and mucin glycopeptides from the human uterine cervix.

High molecular weight glycopeptides and glycosaminoglycans were isolated from the human uterine cervix. The major part of the material (82%) was derived from cervical mucins. The remainder contained hyaluronic acid (3%), heparan sulphate (2%) and dermatan sulphate (13%). Chondroitin sulphate and keratan sulphate were not present, but chondroitin sulphate-like segments were included in the dermatan sulphate. The composition of the cervix apart from the mucus-filled crypts is similar to that of other fibrous connective tissues.

Higher fibrinolytic activity in human endometrium in direct contact with an IUD.

From 18 apparently healthy women wearing a copper-IUD, endometrial biopsy specimens were obtained under hysteroscopic control, both from the site of the IUD and from a distant area. The fibrinolytic activity proved significantly higher in the former specimens than in the latter. The results provide a theoretical basis for the development of an IUD which releases a synthetic inhibitor of fibrinolysis.

PIP: Endometrial biopsy specimens were taken under hysteroscopic control from an endometrial area in contact with an IUD and from a distant area in 18 apparently healthy women who requested removal of Gravigard or Copper T IUDs worn for 6-12 months. Control biopsy specimens were obtained 3 months after IUD removal on corresponding cyclic days from 9 of the women. Histochemical comparisons showed significantly greater fibrinolytic activity in 16 of the 18 women in the specimens obtained at the site of the device than in more distant sites. The fibrinolytic activity was largely confined to the superficial layer of the endometrium in contact with the device. Fibrinolytic activity in distant specimens was mainly localized around small vessels. The fibrinolytic activity of the endometrial specimens taken 3 months after removal of the devices was about the same as in that of the earlier distant samples. Increased fibrinolytic activity does not induce endometrial bleeding but might prevent effective hemostasis when the endometrium is traumatized. The results provide a theoretical basis for development and testing of an IUD which releases a synthetic inhibitor of fibrinolysis.

Local application of prostaglandin E2 in gel. A new technique to ripen the cervix during pregnancy.

The methods used to date to ripen the unfavorable cervix during pregnancy have considerable disadvantages, chiefly from the practical point of view. Intracervical application of a small dose (0.5 mg) of prostaglandin E2 (PGE2) in viscous gel is a safe, easily performed and effective method to ripen the cervix in both early and late pregnancy. A new starch-based gel seems to have solved the pharmaceutical problems associated with gel preparations used hitherto. The histological and biochemical changes induced by local application of PGE2 are similar to those occurring spontaneously during late pregnancy.

Intracervical instillation of PGE2-gel in patients with missed abortion or intrauterine fetal death.

A single intracervical instillation of prostaglandin E2 (1.0 mg or 0.5 mg in viscous gel) was given to dilate the cervix before dilatation and evacuation in patients with missed abortion or intrauterine fetal death in late pregnancy. The 1.0-mg dose of PGE2 gave more prominent cervical dilatation in early pregnancy. In late pregnancy 1.0 mg PGE2 induced labor in the majority of patients and with shorter induction delivery time than in patients given 0.5 mg PGE2. There was no uterine hypertonus and no patients complained of gastrointestinal symptoms. We conclude that intracervical instillation of 1.0 mg of PGE2 in viscous gel is a safe and effective method both for dilating the cervix before dilatation and evacuation and as a method of inducing labor in patients with intrauterine fetal death.

Intracervical application of PGE2-gel combined with early intravenous infusion of oxytocin for induction of term labor in women with unripe cervix.

Fifty-four women with an unripe cervix at term were given 0.5 mg intracervical prostaglandin E2 (PGE2) gel. In 37 of them (70%) the cervix ripened within 5 h and seven of them were in labor at that time. Of the remaining 30 patients, 15 were randomly given an i.v. oxytocin infusion and 13 were delivered within 12 h. In 17 women (30%) the cervix was still unfavorable 5 h after PGE2-gel application but seven of them had a favorable cervix when reassessed 24 h after PGE2-gel instillation. All these patients went into labor with an i.v. infusion of oxytocin. The remaining 10 patients required another dose of PGE2-gel and subsequent i.v. oxytocin. Only in two of these patients did induction fail so that delivery by Caesarean sections was required. All infants were born in good condition.

Human cervical connective tissue and its reaction to prostaglandin E2.

A survey of connective tissue in general and human cervical connective in particular is presented. It is concluded that about 90% of the human cervix consists of fibrous connective tissue which, according to the composition of the collagen and the proteoglycans, is very similar to that in skin and sclera. The high activity of collagenase probably gives the cervical connective tissue from pregnant women its potential to ripen following prostaglandin treatment. Electron microscopical examination has revealed an increased amount of amorphous substance after such treatment. This may be caused partly by degraded collagen fibers and partly by newly synthesized proteoglycans.

Biochemical changes in human cervical connective tissue after local application of prostaglandin E2.

Intracervical application of prostaglandin E2 in the late first trimester induces (1) softening of the cervix tissue; (2) increase in sulfated glycosaminoglycans (18 +/- 12%, mean +/- SEM); (3) no change in hyaluronic acid and water; (4) decrease in pepsin-extractable collagen, and (5) apparent decrease in collagenase. A high activity of collagenase in combination with a replacement of collagen with sulfated glycosaminoglycans may be of importance for the ripening process.

Effects of intracervical PGE2-gel on myometrial activity and cervical state in first trimester pregnancy.

In 7 primigravidae admitted for first trimester abortion by dilatation and evacuation, 0.5 mg PGE2 in viscous gel (5 patients) or placebo gel (2 patients) was applied intracervically 6 hours prior to the operation. Throughout the treatment period intrauterine pressure was recorded. Application of placebo gel induced no cervical ripening or myometrial activation. In all patients receiving active gel, a marked improvement of the cervical state was induced by the treatment. In three cases, this priming occurred in parallel to minimal changes in myometrial activity, without regular uterine contractions. In two patients, marked uterine activation was registered due to partly extraamniotic application. It is suggested, that the PGE2-gel has a direct effect on the cervical tissues. Further, the risk of partially applying the gel in the extraamniotic space, thus stimulating the myometrium, depends on the gel volume relative to the dimensions of the cervical canal and the application technique.

PIP: In 7 primigravidae admitted for 1st trimester abortion by dilatation and evacuation, 0.5 mg prostaglandin E2 (PGE2) in a viscous gel (5 patients) or placebo gel (2 patients) was applied intracervically 6 hours prior to the operation. Throughout the treatment period, intrauterine pressure was recorded. Application of placebo gel induced no cervical ripening or myometrial activation. In all patients receiving active gel, a marked improvement of the cervical state was induced by the treatment. In 3 cases, this priming occurred parallel to minimal changes in myometrial activity without regular uterine contractions. In 2 patients, marked uterine activation was registered due to partial extraamniotic application. It is suggested that the PGE2 gel has a direct effect on cervical tissue. Furthermore, the risk of partially applying the gel in the extraamniotic space, thus stimulating the myometrium, depends on gel volume relative to the dimensions of the cervical canal and the application technique.

Evidence for a local effect of intracervical prostaglandin E2-gel.

Eight primigravid women with a mean gestational age of 9.4 weeks (9 to 10 weeks) who were admitted for first-trimester abortion by dilatation and evacuation were preoperatively treated for 6 hours with either intravenous infusion of oxytocin or a strictly intracervical application of prostaglandin E2 (PGE2) in viscous gel. Myometrial activity was monitored by intrauterine pressure recording throughout the treatment. Contractile activity was more pronounced in the oxytocin-treated group, whereas cervical priming occurred after the PGE2 treatment only. Intracervical PGE2-gel is suggested to have direct effects on the cervical tissues, independent of uterine contractile activity. Furthermore, myometrial stimulation induced by escape of gel into the extra-amniotic space can be avoided by adjusting the volume of gel and technique of application to the dimensions of the cervix.

Intracervical application of prostaglandin gel for induction of term labor.

A new gel for local application of prostaglandins has been elaborated. The new gel, based on a lyophilized prostaglandin E2 (PGE2) starch powder, seems to have solved most of the pharmaceutical and clinical problems associated with local administration of prostaglandins. In a randomized double-blind study, 50 nulliparous patients with an unfavorable cervical state at term were given 2 ml gel containing 0.5 mg PGE2 (PGE2 gel) or gel without PGE2 (placebo gel). The gel was deposited into the cervical canal. Among patients given PGE2 gel, 11 of 25 had induced labor, delivering without further stimulation within 24 hours. In patients given placebo gel, 2 of 25 were delivered with 24 hours. This difference is statistically significant (P less than .01). Patients undelivered after treatment with PGE2 gel achieved a considerable and statistically significant improvement of cervical score, whereas in patients in whom labor was not induced successfully by placebo gel treatment no significant changes in cervical score were registered. In a subsequent open study another 70 term patients of varied parity were given 0.5 mg PGE2 gel. Thirty-eight patients (54%) had successfully induced labor. Among the remaining undelivered patients, considerable ripening of the cervix occurred. Thus, the cervical score changed from a mean of 3.2 prior to treatment to a mean of 6.5 by 24 hours after treatment. Gastrointestinal discomforts were not observed. Signs of uterine hyperstimulation were registered in 1 patient.

Single application of prostaglandin E2 in a viscous gel for induction of labor at term in patients with favorable cervix.

A single dose of 0.5 mg prostaglandin E2 in viscous gel was administered intracervically to induce labor in 150 patients with a favorable cervix. All but 5 patients (97 per cent) were delivered within 12 hours. No adverse maternal or fetal effects were registered. The method, which enables induction without primary amniotomy, was easy to perform and well accepted by the patients.

A new prostaglandin E2-gel for pretreatment of the cervix in nulliparous patients having a late first trimester termination of pregnancy.

A new PGE2-gel, based on a cross-linked starch powder, has been developed. This gel seems to have solved several of the pharmaceutical and practical problems connected with local administration of prostaglandins. In a three-center study 120 nulliparous patients were given 0.5 mg PGE2 in 2.2 ml gel intracervically prior to dilatation of the cervix and evacuation of the uterus in late first trimester. Considerable cervical dilatation was obtained within 15 h. The frequency of side effects, including pain and gastro-intestinal discomfort was low. The technique can be recommended for outpatients.