Granulocyte colony-stimulating factor (G-CSF) in the mechanism of human ovulation and its clinical usefulness.

In 1980, Espey proposed a famous hypothesis that mammalian ovulation is comparable to an inflammatory reaction and many researches have proved the validity of his hypothesis in the last three decades. For example, interleukin (IL)-1beta, IL-6, tumor necrosis factor (TNF)- alpha, granulocyte-macrophage colony-stimulating factor (GM-CSF), macrophage colony-stimulating factor (M-CSF) and other inflammatory cytokines presence was proven in the preovulatory follicle. Since granulocyte is the major leukocyte and it plays a very important role during inflammation, the importance of granulocyte and its related cytokine, granulocyte colony-stimulating factor (G-CSF) in the mechanism of human ovulation is easily predictable. G-CSF is one of the hemopoietic cytokines and it has strong positive effects on granulocytes. G-CSF increases the number of granulocytes and it improves the function of granulocytes. In this review, the participation of leukocytes in the ovulation mechanism is demonstrated first. Second, the participation of G-CSF is shown in comparison with the above mentioned cytokines. Finally, since G-CSF has been used for more than 20 years as a medicine without severe side effects in the field of oncology, the clinical application of G-CSF for the treatment of an ovulation disorder, luteinized unruptured follicle (LUF), will be discussed.

Small cell carcinoma of the endometrium: report of three cases and literature review.

BACKGROUND: Small cell carcinoma of the endometrium is extremely rare. Aim. We reported three cases of this rare tumor and reviewed the literature. CASES: Case 1 was a 54-year-old woman and case 3 was a 58-year-old woman. Both patients presented with vaginal bleeding. Case 2, a 53-year-old woman, had no symptoms and had a vaginal-cervical smear suspicious for malignancy. All patients underwent surgery and their tumors originated in the endometrium. In all three cases, pathological examination revealed small cell carcinoma of endometrium, and immunohistochemical reactivity for one or more neuroendocrine markers was found in all cases. Under electron microscopy in case 2 and case 3, dense core granules in the cytoplasm of tumor cells were found only in case 3. Case 3 was stage IIIA and died of her disease 12 months after surgery. Both cases 1 and 2 were stage IB and alive with no evidence of disease for 28 months and 9 years, respectively. CONCLUSION: Although the prognosis of small cell carcinoma of endometrium is poor, early detection of this disease may contribute to an improved prognosis.

Hemodynamic response of ovarian artery after hCG injection.

We have analyzed ovarian hemodynamics immediately after human chorionic gonadotropin (hCG) administration in patients treated by clomiphene-hCG and human menopausal gonadotropin-hCG. This study involved 40 infertile women who signed consents to participate in this study. After intramuscular injection of 10000 IU hCG, the change of ovarian arterial blood flow (BF) was evaluated by color Doppler. Pulsatility index, resistance index, maximum velocity (V(max)), mean velocity, minimum velocity, cross-sectional area of ovarian artery (Area) and BF were measured before and 15-180 min after hCG administration. In the 36 subjects in which ovulation was induced successfully, V(max) and BF increased significantly even at 15 min after hCG administration and thereafter. In the 4 non-ovulatory subjects, no significant changes in any of indices at any of measured time points were observed. Comparative study of non-ovulatory and ovulatory subjects suggested that ovulation may be predicted by the ovarian hemodynamic analysis immediately after hCG administration.

Prenatal diagnosis of the hemodynamics of fetal renal disease by color Doppler ultrasound.

OBJECTIVE: Hemodynamic analysis of the fetal renal artery elucidated the function of the renal glomerulus and renal tubule in normal growth fetus and was weighed against fetal renal disease. DESIGN: The subjects were fetuses from pregnant women who gave informed consent. There were 6 cases of polycystic kidney, 4 cases of hydronephrosis and 33 cases of fetuses presenting with normal growth. A longitudinal study was performed for normal growth fetuses. Using maximum systolic velocity (V(max)), pulsatility index (PI) and resistance index (RI), the blood flow was measured initially at 20-24 weeks of pregnancy and every 4 weeks thereafter. The measurement was performed 5 times in total. Also, for fetal renal disease, the measurement was performed using the same indexes. RESULTS: In 2 cases of polycystic kidney, which led to death due to postpartum afunctional kidney, V(max) indicated the lower level of less than mean -1.5 SD. In 1 case of single hydronephrosis, the single afunctional kidney was observed postpartum due to blood flow disruption. In 7 cases of normal renal function after birth, it indicated the lower level in some gestational ages but was generally in the normal range. CONCLUSIONS: Using indexes to evaluate the glomerulus and renal tubule of fetal renal disease, mean -1.5 SD of V(max) can be considered to be the lower limit in the normal range and expected to be an important factor for the final outcome.

Cyclic changes of granulocyte colony-stimulating factor (G-CSF) mRNA in the human follicle during the normal menstrual cycle and immunolocalization of G-CSF protein.

BACKGROUND: Ovulation has several similarities with inflammation and is closely connected to the activity of leukocytes and inflammatory cytokines. Since granulocytes are one of the major leukocytes, we focused our attention on the presence and local production of granulocyte colony-stimulating factor (G-CSF) in the human ovary. METHODS: The presence of G-CSF protein in the follicular fluid and perifollicular tissues was examined by Western blot analysis (n = 5) and immunohistochemical staining (n = 10). The relative expression levels of G-CSF mRNA in relation to GAPDH in granulosa, theca and luteal cells during the menstrual cycle were measured by quantitative RT-PCR using TaqMan technology (n = 15). RESULTS: G-CSF protein was detected in all follicular fluid and located mainly in granulosa cells of the follicle and luteal cells. The expression level of G-CSF mRNA in the late follicular phase was 137.6 +/- 18.5, which was approximately 10-fold greater than other phases during the menstrual cycle (P < 0.05). CONCLUSIONS: These results demonstrate that G-CSF is produced in the human follicle shortly before the ovulatory phase and may play an important role in the mechanism of ovulation.

Risk factors for neonatal thrombocytopenia in pregnancy complicated by idiopathic thrombocytopenic purpura.

The aim of this study was to evaluate risk factors for the occurrence of fetal/neonatal passive immune thrombocytopenia (PIT) in pregnancy complicated with ITP. We studied 52 pregnancies with ITP and the 54 neonates retrospectively. Neonatal platelet counts were compared with maternal platelet counts, platelet-associated IgG (PAIgG) values and the presence of antiplatelet antibody in maternal circulation, history of previous PIT, maternal treatments for ITP, and other maternal/neonatal factors including gestational age and birth weight. Logistic regression analysis for multivariables was performed. PIT (platelet counts < 100 x 10(3)/microl) without neonatal mortality or any morbidity was observed in eight (15.4%) of 52 pregnancies. The presence of circulating antiplatelet antibodies in maternal blood, splenectomy prior to pregnancy, and a history of previous PIT were observed more frequently with statistical significance in women giving birth to neonates who developed PIT. By logistic regression analysis, splenectomy prior to pregnancy was found to be the single significant variable (p=0.017, odds ratio 9.33) among the risk factors for PIT. Thus, splenectomy prior to pregnancy is related to increased risk for PIT in ITP-complicated pregnancy.

Transarterial embolization of the uterine arteries: patient reactions and effects on uterine vasculature.

BACKGROUND: Therapeutic embolization of the uterine arteries has been successfully used to manage profuse gynecological hemorrhage. In the present study we aimed to investigate whether embolization of uterine arteries may serve as a safe and effective alternative treatment in cases of menorrhagia in fertile and perimenopausal women. As a first step, we have evaluated the methodology, patient reactions and effects on the uterine vasculature. METHODS: The distal part of the uterine artery was embolized with polyvinyl alcohol particles via catheterization of the right femoral artery. Total abdominal hysterectomy was performed the next day. RESULTS: Bilateral embolization in two patients resulted in considerable pain that required morphine analgesic medication and epidural analgesia. One patient was embolized unilaterally and experienced only slight discomfort with no need for analgesic medication at all, indicating that unilateral embolization is a well-tolerated method. After embolization, angiography showed stagnant flow in embolized vessels without contrast filling of distal branches. Angiography of the specimen showed normal vascular architecture in non-treated vessels. In treated vessels the main arterial trunks were patent but all smaller branches were occluded. Histology showed that most of the particles lodged in small arteries and that arterioles never showed injected material. CONCLUSION: The study indicates that the procedure involves an efficient occlusion of uterine vessels and that unilateral embolization of uterine arteries is well tolerated.

Peritoneal cytology and its prognostic value in endometrial carcinoma.

BACKGROUND: There has been a controversy about the prognostic significance of positive peritoneal cytology in endometrial carcinoma. MATERIALS AND METHODS: Peritoneal cytology was obtained at the time of surgery, including systematic retroperitoneal lymph node dissection, in 114 patients. RESULTS: The incidence of positive peritoneal cytology was 35.1%. The 5-year survival rates of the stage IIIA and IIIC (FIGO, 1988) cases were 82.8% and 58.3%, respectively. In pathological stage I (the disease was histologically confined to the uterine corpus), there was no significant difference in 5-year survival rates between patients with and without positive peritoneal cytology. Though the patients in stage IIIA who had only positive peritoneal cytology were given no postoperative therapy unless they had extrauterine disease, no patients developed recurrence. In stages IIIC and IV, the prognosis was significantly poorer for patients with positive peritoneal cytology than for those with negative cytology. CONCLUSION: Positive peritoneal cytology is not an adverse prognostic factor endometrial carcinoma if disease is limited to the uterus.

A clinical and pathologic study on para-aortic lymph node metastasis in endometrial carcinoma.

BACKGROUND: Recent studies have shown that poor survival for patients with early endometrial cancer was related to the extrapelvic spread of the cancer. The purpose of this study was to evaluate the correlation between para-aortic lymph node (PAN) metastasis and histopathologic findings and to assess the clinical utility of identifying PAN metastasis of endometrial carcinoma. METHODS: The correlation of para-aortic lymph node metastasis to the clinical stages of endometrial carcinoma (FIGO, 1982), histopathologic findings, and prognosis were investigated in 200 patients with endometrial carcinoma, who were treated by radical operations, including systematic retroperitoneal lymphadenectomies, between July 1982 and February 1996. RESULTS: Of these, para-aortic lymph node (PAN) metastasis was seen in 18 (9.0%) and pelvic lymph node (PLN) metastasis in 40 (20.0%). The incidence of PAN metastasis according to clinical stages Ia, Ib, II, and III were 2.5%, 8.5%, 15.7%, and 33.3%, respectively. The incidence of metastasis was significantly higher in stage II than in stage Ia (P < 0.05), and in stage III than in stage Ia (P < 0.01). PAN metastasis occurred significantly more frequently in the first of each of the following groups: invasion of > 1/2 of the myometrium (15.7%) vs. invasion of < 1/2 of the myometrium (3.6%) (P < 0.01), the group with cervical invasion (23.5%) vs. the group without (4.0%) (P < 0.0001), the group with lymph-vascular space involvement (17.2%) vs. the group without (1.0%) (P < 0.0005), and PLN-metastasis-positive group (40.0%) vs. the negative group (1.3%) (P < 0.0001). Multivariate analysis showed a significant correlation between PAN and PLN metastases (P < 0.0005). Positive PAN metastasis is not related to multiple PLN metastasis (bilateral PLN metastasis and the number of PLN metastatic groups). However, a correlation was seen between PAN metastasis and common iliac node metastasis. The prognosis was significantly poorer (P < 0.05) for patients with both PLN and PAN metastases than for those with PLN metastasis alone. CONCLUSIONS: The results of the present study suggest that PAN metastasis may occur as a consequence of PLN metastasis or the two may occur simultaneously as PLN metastasis and also that careful examination of PAN metastasis is necessary to determine the prognosis.

Importance of the transitional zone between the cervical stroma and the parametrium in the treatment of cervical carcinoma.

OBJECTIVES: Parametrial invasion is an important risk factor in cervical carcinoma. Because the vessels of the parametrium start in the zone between the cervical compact stromal layer and the parametrium, which we have defined as the parametrial initial zone (PIZ) or transitional zone, the invasion of a carcinoma into this part of the cervix is also important. Our objectives in this study were find a characteristic index of the transitional zone and to clarify the relationship between a transitional-zone invasion and the prognosis in a case. METHODS: Thirty-three cases of carcinoma in situ were available to use for the morphological examination of the cervix. The cervix was divided into 8-12 sections. In each section, the outer diameters of the short axis of the arteries were measured with a light microscope and a micrometer. Using the arterial diameter as the characteristic index of the transitional zone, we performed epidemiological studies on 312 patients with clinical Stage Ib-III squamous-cell carcinoma of uterine cervix. RESULTS: The arteries with an axis exceeding 300 microns were concentrated in the transitional zone at a rate of 94.6%. Therefore, arteries of this size are used as the characteristic index of the transitional zone. Patients with invasion to transitional zone only had lymph node metastasis at the rate of 28.1%, compared with 0% for patients who had no permeation to the zone (p < 0.001). The 5-year survival rate of patients with invasion to the transitional zone only was 87.3%, which is significantly lower than those without invasion (99.2%) (p < 0.01). CONCLUSIONS: Measuring the short axis (300 microns < or = ) of the artery is the best method by which to pinpoint the transitional zone. The invasion of a carcinoma into the transitional zone in the cervix should be treated as a parametrial involvement.

Outcome of non-immune hydrops fetalis and a fetus with hydrothorax and/or ascites: with some trials of intrauterine treatment.

The subject of this study was 38 cases of non-immune hydrops fetalis and 11 cases of fetal hydrothorax and/ or ascites (FH/A), a syndrome characterized by the accumulation of pleural effusion and/or ascitic fluid, without generalized skin edema, due to various etiologies, admitted to the obstetrics ward of Hokkaido University Hospital during the period between 1987 and 1994. Fetal treatment consisted of (1) intravascular transfusion or intra-abdominal transfusion for anemia, (2) frequent centesis or shunt insertion for pleural effusion and ascites, (3) reduction of cystic hygroma by puncturing and OK432 injection, and (4) intravascular or maternal injection with an anti-arrhythmic drugs to treat tachycardia. The outcome of NIHF and FH/A was assessed to be able to make a prognosis in NIHF and to compare the efficacy of fetal therapy in cases with (15 cases: 9 NIHF, 6 FH/A) and without (34 cases: 29 NIHF, 5 HF/A) intrauterine treatment. The average survival rates were 23.1% in NIHF and 54.5% in FH/A. None of fetuses with a chromosomal abnormality or cystic hygroma survived. The average GW at the time of detection of NIHF by ultrasonography was week 24.9 +/- 1.1 (mean +/- S.E., n = 38). The average GW at the time of detection of FH/A by ultrasonography was week 26.6 +/- 1.8 (n = 11). NIHF was detected significantly earlier in the IUFD and early neonatal death group (GW 22.4 +/- 1.4) than in the survivor group (GW 27.6 +/- 1.2) (p < 0.05). FH/A was also detected earlier in the IUFD/early neonatal death group than in the survivor group (GW 21.8 +/- 2.4 vs. 31.1 +/- 1.1, n = 11, p < 0.05). The survival rate in the intrauterine treatment group was higher than in the nontreatment group (treatment group: 10/15; non-treatment group: 5/34, p < 0.001). After the trial of intrauterine treatment in the 15 cases mentioned above, some efficacy was observed in 7 cases (reduction of cysts, effusion or edema, disappearance of arrhythmia).

Lectin affinity electrophoresis in a yolk sac tumour in the vagina with yolk sac tumour-type glycoform of alpha fetoprotein.

AIMS: To investigate a potential diagnostic use of alpha fetoprotein (alpha FP) isoform analysis by lectin affinity electrophoresis to distinguish between endodermal sinus tumours arising in the vagina in infants from those at other sites. METHODS: alpha FP in the serum of a patient with a vaginal endodermal sinus tumour was analysed for its isoforms by lectin affinity electrophoresis. The isoforms were compared with that of cord serum, sera of hepatoid adenocarcinoma of the uterus, and endodermal sinus tumour of the ovary. RESULTS: The isoforms of alpha FP obtained by lectin affinity electrophoresis in the serum of the patient with vaginal endodermal sinus tumour differed from the isoforms of alpha FP in the cord serum of normal neonates, and sera of patients with hepatoid adenocarcinoma of the uterus or endodermal sinus tumour of the ovary. CONCLUSIONS: Endodermal sinus tumour arising in the vagina could be distinguished from that in the ovary by the lectin affinity electrophoresis, and a potential diagnostic use of alpha FP isoform analysis by the lectin affinity electrophoresis for the detection of the endodermal sinus tumour in infants was demonstrated.

Erythropoietin, granulocyte-colony stimulating factor, interleukin-1 beta and interleukin-6 during the normal menstrual cycle.

OBJECTIVE: Menstruation and ovulation are the main events during the menstrual cycle. Menstruation may influence the complete blood count because of its blood loss. Since ovulation is an inflammatory-like phenomenon, white blood cell count may change during ovulation. For these reasons, we have investigated the complete blood count and peripheral serum concentrations of associated cytokines during the normal menstrual cycle. MATERIALS AND METHODS: Normal healthy female volunteers (N = 9; age, 21-33 years) with menstrual cycles of 25-33 days recorded basal body temperature every day and venous blood samples were collected three times per week. Complete blood count was performed and erythropoietin, granulocyte-colony, stimulating factor, interleukin-1 beta, interleukin-1 beta, interleukin-6 and hormones (FSH, LH, estradiol and progesterone) were measured. RESULTS: The red blood cell, total white blood cell, granulocyte and platelet counts showed no statistically significant changes during the menstrual cycle when using analysis of variance with the Scheffe F-test. No changes in erythropoietin, interleukin-1 beta and interleukin-6 were seen throughout the menstrual cycle. In contrast, serum granulocyte-colony stimulating factor concentrations increased significantly to 28.0 +/- 3.1 pg/ml (mean +/- S.E.M.) during the ovulatory phase, compared to 10.7 +/- 0.6 pg/ml in other phases. CONCLUSION: These results indicate that menstrual blood loss does not affect the complete blood count and suggest that granulocyte-colony stimulating factor plays and important role in the mechanism of ovulation.

Serum and tissue measurements of CA72-4 in patients with endometrial carcinoma.

AIMS: To evaluate the clinical usefulness of CA72-4 as a serum tumour marker for endometrial carcinoma and to investigate its immunohistochemical localisation in endometrial carcinoma cells. METHODS: Serum concentrations of CA72-4 were determined in 72 patients with endometrial carcinoma. Immunohistochemical localisation of CA72-4 was investigated using the streptavidin-biotin method, using monoclonal antibodies B72.3 and CC49. RESULTS: Serum CA72-4 was increased above the cut off value in 31.9% of the patients with endometrial carcinoma. Serum CA72-4 positivity was correlated with depth of myometrial invasion, adnexal metastasis, lymphovascular space involvement, and pelvic and para-aortic lymph node metastasis. Multivariate analysis showed a significant correlation between serum CA72-4 positivity and adnexal metastasis. The serum concentrations of CA125 and CA19-9, which could be tumour markers for endometrial carcinoma, were measured at the same time. In seven of 72 patients increased concentrations of serum CA72-4 were found while those for CA125 and CA19-9 were within the normal ranges; in four of the seven patients the disease had spread beyond the uterus. Immunohistochemical positivity for CA72-4 antigen was 76.9% and occurred in the tumour cell membrane and cytoplasm. There was no significant difference in immunohistochemical positivity between patients with increased CA72-4 and those with normal CA72-4 values. CONCLUSIONS: The measurement of serum concentrations of CA 72-4 could be useful for predicting and monitoring the progress of disease-for example, extracorporeal spread.

A case of intrauterine medical treatment for cystic hygroma.

We report the first case of an intrauterine treatment for cystic hygroma. Guided by ultrasonography, we first removed intracystic fluid from two cysts and then injected OK-432 into each fetal cyst at 21 and 28 weeks of gestation. No re-enlargement of the cysts was subsequently observed. At 38 weeks of gestation, a male infant was delivered transvaginally. Only a slight skin fold was observed in the nuchal area of the neonate, indicating the effectiveness of OK-432 for the intrauterine treatment of cystic hygroma.

Diagnosis of premature rupture of the membranes in preterm patients, using an improved AFP kit: comparison with ROM-check and/or nitrazine test.

OBJECTIVE: We developed a new kit for detecting AFP in leaked amniotic fluid. Later, we developed an improved AFP kit utilizing the same anti alpha-fetoprotein (AFP) monoclonal antibody. In this study, we evaluate the clinical usefulness of this improved kit in the diagnosis of preterm premature rupture of membranes (PROM). METHODS: We compared this improved AFP test with the ROM-check and/or the nitrazine tests in 46 preterm patients. RESULTS: The ROM-check and nitrazine tests showed a diagnostic accuracy of 89.1 and 87.0%, respectively, compared with 95.7% with the improved AFP test. The sensitivity of the improved AFP test on cervical samples was significantly higher than that of the nitrazine test on vaginal samples (P < 0.05). The reaction time with the improved AFP kit test is 90 s. CONCLUSION: This study has confirmed a great clinical utility of the improved AFP test kit as a method of PROM diagnosis.

Non-grafting method of vaginal construction for patients of vaginal agenesis without functioning uterus (Mayer-Rokitansky-Küster syndrome).

We have treated 18 patients with vaginal agenesis without functioning uterus (MRK syndrome) during the period between January 1984 and December 1995 by Frank's dilatation method followed by the surgical method without grafting. Clinical records were retrospectively examined in regard to the size and functions of the constructed vagina and problems of the treatment procedure. The treatment by non-invasive dilatation was first carried out starting at the age of 21 years 2 months +/- 2 years 9 months (Mean +/- SD) for the duration of 10.9 +/- 9.8 months. It was successful (constructed vaginal length by pressure: 60 mm or more) in 6 patients (35.3%). The non-grafting surgical method was then performed. The operation time was 2:11 +/- 0:37 hours and no complications were observed. The vaginal lengths 1 month after operation and at the latest follow-up were enough to have coitus and no severe complications including shrinkage were observed. Our method to construct a new vagina is simple and useful, since it left no operation scar in contrast to McIndoe's method and other methods with grafting.

[An analysis of pelvic and para-aortic lymph node metastasis in ovarian carcinoma by systematic retroperitoneal lymph node dissection].

We performed a systematic retroperitoneal lymph node dissection (RPLND) on 137 patients with primary ovarian carcinoma, of whom 97 had undergone RPLND during the primary surgery before chemotherapy and 40 had undergone RPLND during the secondary cytoreductive surgery after preoperative chemotherapy. The tentative staging of the ovarian carcinoma used in this study was determined according to the FIGO criteria without considering the pathologic findings of retroperitoneal lymph nodes. Nodal metastasis was seen in 21.9% (30/137) of them. Thirteen had positive pelvic lymph nodes (PLN) but no positive para-aortic nodes (PAN). Eleven had both positive PLN and positive PAN. Six had positive PAN but no positive PLN. The PAN was the most frequent site of metastasis (17/137). Next were the common iliac, obturator, and lateral group of deep inguinal nodes. Solitary metastasis in the patients who had undergone RPLND during the primary surgery was seen in a PAN and a common iliac node. Among 24 patients with PLN metastasis, there was a significant (p < 0.05) difference in the number of positive PLN between the patients with PAN metastasis (5.27 +/- 3.00) and the patients without PAN metastasis (2.62 +/- 1.66). These results indicate that the PAN and common iliac nodes are the most important site of nodal metastasis in ovarian carcinoma. The metastasis to PLN such as obturator node and internal iliac node seems to occur independently of the PAN metastasis, and the PAN metastasis occurs not only through the direct route but also as a consequence of extension of PLN metastases. Systematic retroperitoneal lymph node exploration therefore seems to be necessary to clarify the lymph node status.

Alpha-fetoprotein production by a hepatoid adenocarcinoma of the uterus.

A case of a 62 year old Japanese woman with an endometrial adenocarcinoma producing alpha-fetoprotein (AFP) is described. Microscopically, the tumour was composed of a major medullary portion and a minor tubular adenocarcinoma which had invaded the myometrium, the myometrial lymphatics and blood vessels. Neoplastic cells in the medullary portion were polygonal with glycogen-rich cytoplasm. Vascular permeation by neoplastic cells was prominent. Extensive hepatoma-like features were observed. The tumour cells lacked features suggestive of a diagnosis of embryonal carcinoma or endodermal sinus tumour. The production of AFP by the tumour cells was demonstrated immunohistochemically using the PAP technique. Only two cases of AFP producing endometrial adenocarcinomas have been reported previously.

Correlation between cytokine levels of amniotic fluid and histological chorioamnionitis in preterm delivery.

The aim of this study was to investigate the correlation between the cytokine levels in the amniotic fluid (AF) and the histological stage of chorioamnionitis (CAM) in premature labor. AF of 6 cases (7 samples of AF were obtained as one was a twin pregnancy) in whom CAM was diagnosed histologically, and 12 cases without CAM were included in this study. Amniotic fluid was obtained within 24 hours prior to delivery. Cytokine levels (IL-2, -4, -6, TNF-alpha, IFN-gamma) in AF were measured by an ELISA method. Levels of IL-2 and -6 in the CAM-positive group (mean +/-S.E., 52.9 +/- 83.9 pg/ml, and 20,537.9 +/- 8853.7 pg/ml, respectively) were higher than those in the CAM-negative group (i.e. undetectable, and 65.6 +/- 27.5, respectively) with a statistical significance of p < 0.05, p < 0.001, respectively. There was a positive linear relationship between IL-6 levels of AF and the placental histological inflammatory stages of Blanc in the CAM-positive group. From these results it would appear that the IL-6 level in AF is the most sensitive test in the detection of extraamniotic infection or intraamniotic infection in preterm labor with intact membranes and also indicates the severity infection.