Transvaginal ultrasonographic assessment of Hyskon or lactated Ringer's solution instillation after laparoscopy: randomized, controlled study.

We sought to evaluate two common fluids placed in the pelvis after pelvic surgery for their ability to remain in the pelvis for a time thought adequate for prevention of adhesions. Thirteen patients undergoing operative laparoscopy were randomized to receive 250 ml 32% dextran 70 (Hyskon), 250 ml lactated Ringer's solution, or no fluid (control) at the end of surgery. Serial transvaginal ultrasonograms were obtained at 1 hr, 3 hr, 6 hr, 24 hr, 96 hr (4 days), and 168 hr (7 days) after surgery. Patients were asked about side effects of fluid instillation. The volume of lactated Ringer's solution declined rapidly after instillation, with no significant difference from control at 24 hr (12 ml versus 7 ml). The volume of Hyskon did not decline rapidly by 24 hr and remained higher than the volume in controls or those receiving lactated Ringer's solution (188 ml, P = 0.003). Although the volume of Hyskon remained higher than that of lactated Ringer's solution or fluid volume in control patients by days 4 and 7, this difference did not reach statistical significance (45 ml versus 7 ml and 14 ml respectively, P = 0.39, on day 4). Patients in all groups noted abdominal pain. One patient who received Hyskon developed severe vulvar edema and another developed dyspnea. We conclude that the volume of Hyskon in the peritoneal cavity after laparoscopy does not decline as rapidly as does that of lactated Ringer's solution; however, significant side effects may limit its usefulness. Transvaginal ultrasonography is useful in monitoring fluids placed in the pelvis for prevention of adhesions.

Reproductive outcome after tubal reversal in women 40 years of age or older.

OBJECTIVE: To determine the reproductive outcome of women who received a microsurgical tubal anastomosis operation at age 40 years or older. DESIGN: Multicenter retrospective cohort study. SETTING: Four university teaching hospitals. PATIENTS: Fifty-two women having undergone tubal sterilization reversal at age > or = 40 years. MAIN OUTCOME MEASURES: Pregnancy and live birth rate. RESULTS: Of the 52 women, 10 were lost to follow-up. Of those traced, 18 of 42 (42.8 percent) conceived. Of those 18, 6 patients had a live birth, 10 patients had a first trimester spontaneous abortion, 1 patient had an ectopic pregnancy, and 1 patient had an elective termination. Overall, the live birth rate was 14.3 percent, spontaneous abortion rate was 23.8 percent, and ectopic pregnancy rate was 2.4 percent. CONCLUSIONS: Microsurgical tubal anastomosis is a justifiable alternative to IVF-ET in women age 40 years or older.

Color flow pulsed Doppler ultrasound in diagnosing luteal phase defect.

OBJECTIVE: To determine whether color flow pulsed Doppler analysis of corpus luteum blood flow in normal cycles differs from cycles with a luteal phase defect. DESIGN: A prospective study of natural ovarian cycles. SETTING: The University of Vermont Reproductive Endocrinology and Infertility Service. PATIENTS: Ten women with regular menstrual cycles and at risk for luteal phase defect (LPD) four with unexplained infertility, two with recurrent abortion, and four with age > 35 years. INTERVENTIONS: All women were examined by transvaginal color flow pulsed Doppler during the early follicular, late follicular, early luteal, midluteal, and late luteal phase of the menstrual cycle. Venous blood for P concentration was drawn on each day of Doppler exam. Urine testing for LH surge and endometrial biopsy during the late luteal phase were performed on each patient. MAIN OUTCOME MEASURES: Lowest resistance index associated with the highest amplitude signal from intraovarian vessels of each ovary, dated endometrial biopsies, serum P. RESULTS: Mean resistance indexes in LPD patients (n = 3) were significantly higher compared with normal women (n = 6) throughout the follicular and luteal phases. One patient remained anovulatory and was excluded from statistical analysis. Although systolic and diastolic velocities generally were observed to be lower in LPD patients compared with normal women, these differences were not statistically significant. High correlations were observed between P and resistance index within each luteal time point, achieving its highest value during the midluteal phase. CONCLUSIONS: This initial study provides evidence that color flow pulsed Doppler analysis of blood flow impedance to the corpus luteum may aid in assessing luteal phase adequacy.

The relationship of corpus luteum volume to relaxin, estradiol, progesterone, 17-hydroxyprogesterone and human chorionic gonadotropin levels in early normal pregnancy.

Our purpose was to characterize the growth pattern of the corpus luteum of early normal human pregnancy and correlate this growth with the corpus luteum hormone products: relaxin, progesterone, estradiol and 17-hydroxyprogesterone. A prospective study of seven patients was initiated at a mean gestational age of 4 weeks and 2 days. Corpus luteum volume and hormone concentrations were determined for each study patient every 48 h for a period of 2 weeks. Transvaginal imaging of the corpus luteum was performed by a single observer. Corpus luteum volume was calculated using the formula for an ellipsoid (4/3 pi abc/8). Correlation between corpus luteum volume and hormone concentrations was tested using Pearson's r. There was a mean three-fold increase in corpus luteum volume between 4 and 6 weeks' gestational age. Concomitantly, relaxin and estradiol concentrations increased, 17-hydroxyprogesterone declined slightly, progesterone remained stable and human chorionic gonadotropin (hCG) increased exponentially. Mean positive correlations were shown between corpus luteum volume and relaxin (r = 0.72), corpus luteum volume and hCG (r = 0.68), and hCG and relaxin (r = 0.82). However, there was a lack of correlation between corpus luteum volume and estradiol, progesterone and 17-hydroxyprogesterone. We have shown that a rapid increase in the corpus luteum volume occurs in early normal human pregnancy without a parallel rise in the classic corpus luteum steroid products. We interpret these findings to suggest that growth of the corpus luteum in early human pregnancy is largely derived from the proliferation of non-steroid secreting cells. The precise role of these cells in controlling steroidogenesis in this gland has yet to be defined.

Prognostic significance of morphologic changes of the corpus luteum by transvaginal ultrasound in early pregnancy monitoring.

OBJECTIVE: To determine whether the ultrasound appearance, size, or change in size of the corpus luteum of early pregnancy correlated with serum progesterone, estradiol (E2), or 17-hydroxyprogesterone or were predictive of pregnancy outcome. METHODS: Transvaginal ultrasound assessment of the corpus luteum was performed prospectively on 55 women between 4-8 weeks' gestation. Forty-five (82%) subjects conceived in spontaneous cycles and ten (18%) conceived in cycles stimulated with clomiphene citrate. Fifty-three of 55 (96.4%) women had a second ultrasound assessment 5-8 days later (mean 6.7). Blood was drawn from each patient on the day of the ultrasound examination to measure hormone concentration. RESULTS: The appearance of the corpus luteum (macrocystic [more than 50% cystic], microcystic [less than 50% cystic], or noncystic) was not predictive of hormone concentration or pregnancy outcome. A nonviable pregnancy occurred in five of six (83%) women in whom a corpus luteum was undetectable by ultrasound and in 15 of 49 (31%) women in whom a corpus luteum was present (P = .01). There was no specific corpus luteum volume which could predict pregnancy failure. However, when a decreasing volume from first to second ultrasound examination was observed, 11 of 20 (55%) pregnancies resulted in nonviable outcomes compared to five of 27 (19%) when an increasing volume was observed (P < .01). There was no significant positive correlation between corpus luteum volume and plasma progesterone or 17-hydroxyprogesterone. A weak correlation was observed between corpus luteum volume and E2 (r = 0.38, P = .04). CONCLUSIONS: Our data reveal a lack of correlation between the size of the corpus luteum on ultrasound examination and known steroid products in pregnancies conceived during spontaneous cycles. Corpus luteum volume and steroid products were higher in those patients whose ovulation was induced with clomiphene citrate. Also, different morphologic appearances of the corpus luteum in early human pregnancy, based on the amount of cystic component, have no functional significance. However, a decreasing corpus luteum volume before 8 weeks' gestation is associated with a higher probability of early pregnancy loss.

Efficacy and safety of single-dose systemic methotrexate in the treatment of ectopic pregnancy.

OBJECTIVE: To evaluate the safety and efficacy of single-dose systemic methotrexate (MTX) in the treatment of ectopic pregnancy (EP). DESIGN: A database was started and continued prospectively for 35 patients meeting criteria for MTX therapy from June 1991 to October 1993. Follow-up was performed retrospectively on all patients with EPs (n = 82) by evaluating hospital and clinic records and by contacting affiliated physicians and individual patients. SETTING: The University of Vermont Reproductive Endocrinology Service. INTERVENTIONS: Methotrexate 50 mg/m2 was administered IM; blood samples were collected on days 0, 4, and 7 of MTX therapy and weekly thereafter until hCG titers became < 4 mIU/mL. RESULTS: Thirty-five of 82 (42.7%) patients diagnosed with EP were treated with MTX. The mean hCG concentration on day of treatment was 1388.1 +/- 463.5 (+/- SE) mIU/mL, and mean time to complete resolution of hCG was 23.1 +/- 2.9 days. Thirty of 35 (85.7%) were successfully treated with a single dose of MTX. Five of 35 (14.3%) failed therapy and required laparoscopic surgery. Twelve of 35 (34.3%) experienced mild side effects that resolved spontaneously. Ten of 13 (76.9%) demonstrated tubal patency at follow-up hysterosalpingogram. Of the 15 patients seeking pregnancy, 3 of 15 (20.0%) conceived, resulting in 3 term deliveries and 2 spontaneous abortions. CONCLUSIONS: Our results support the use of single-dose systemic MTX for the treatment of unruptured EP in carefully selected patients.

Reproductive performance following a second ectopic gestation.

OBJECTIVES: Our purpose was to determine the obstetric outcome following a second ectopic gestation in women actively trying to conceive, with a review of the literature. METHODS: Charts of 37 patients coded for having at least two ectopic pregnancies between 1986 and 1989 were reviewed. Duration of follow-up ranged from 7 months to 7 years with a mean follow-up time of 25 months. RESULTS: We report a 45.4% intrauterine pregnancy rate, 27.3% live birth rate, and 36.4% recurrent ectopic pregnancy rate. Review of the literature shows an intrauterine pregnancy rate of 26-50%, live birth rate of 25-31.2%, and recurrent ectopic pregnancy rate of 7.7-40%. CONCLUSIONS: Four of five studies report the risk of a third ectopic gestation is less than an intrauterine gestation. This may prove helpful in counseling patients with a history of recurrent ectopic gestation in choosing IVF or attempting conception naturally.

Efficacy and safety of nifedipine versus magnesium sulfate in the management of preterm labor: a randomized study.

OBJECTIVE: Our purpose was to establish the efficacy and safety of nifedipine versus magnesium sulfate in arresting preterm labor and the efficacy of nifedipine versus terbutaline in preventing recurrent labor. STUDY DESIGN: Singleton pregnancies at < 34 weeks in preterm labor were randomized to either oral nifedipine or intravenous magnesium sulfate. In case of tocolysis failure ritodrine was added. After labor was arrested, the patients in the nifedipine group were maintained on oral nifedipine, and those in the magnesium sulfate group were treated with oral terbutaline until completing 34 weeks. RESULTS: Of 100 patients 80 were considered eligible, of whom 39 were randomized to the nifedipine group. Both groups were comparable in terms of a number of entry variables, including cervical examination, contraction frequency, and gestational age. Both drugs were equally effective in arresting labor and delaying delivery > 48 hours, 92% versus 93%. Both study groups had a similar incidence of side effects, although four (10%) of magnesium sulfate-treated patients required drug discontinuation because of severe symptoms. Nifedipine was as effective as terbutaline in preventing recurrent labor, 26% versus 24%, and in achieving a gestation > 34 weeks, 62% versus 68%. CONCLUSIONS: Oral nifedipine is as effective as magnesium sulfate and terbutaline in arresting and preventing idiopathic preterm labor.

Acute epiglottitis during pregnancy.

A 26-year-old woman in her third trimester of pregnancy had stridor. Epiglottitis was diagnosed by fiberoptic laryngoscopy. Staphylococcus aureus was the predominant organism isolated from the laryngeal aspirate. Early intubation proved effective in managing this potentially life-threatening disease. Although pharyngitis is the most common cause of sore throat in the adult, acute epiglottitis must be considered in the differential diagnosis when there is unrelenting throat pain and minimal objective signs of pharyngitis. An early diagnosis with aggressive airway management can be life saving to both mother and fetus.