Obstetric factitious disorder: is it more common than we think?

This case discusses the diagnosis of obstetric factitious disorder in a 27-year-old woman with bleeding per vagina. The case illustrates the need for a high index of suspicion in patients with unexplained physical symptoms during pregnancy, and highlights issues related to subsequent child care.

Psychological and physical determinants of premenstrual symptoms before and after hysterectomy.

The aim was to study women before and after hysterectomy (with conservation of the ovaries), in order to discover how far premenstrual symptoms are caused physically and how far psychologically. In such women both physical and psychological factors can influence premenstrual symptoms before hysterectomy; after the operation, in the absence of menstruation, only physical factors can do so. The subjects were 56 women awaiting hysterectomy for menorrhagia of benign origin. During three pre-operative months these women made daily self-ratings on a check-list in which typical premenstrual symptoms were interspersed with atypical symptoms; in this way their awareness of the premenstrual focus was minimized. Starting six months after hysterectomy, the women again kept daily check-lists for three months; over the same period their serum progesterone levels were measured to identify the premenstruum. After hysterectomy, levels of premenstrual symptoms fell significantly in the whole group, indicating that psychological factors were important determinants of such symptoms before hysterectomy.

A 2-year quantitative assessment of Chlamydia trachomatis in a sexually transmitted diseases clinic population by the MicroTrak direct smear immunofluorescence test.

The MicroTrak direct smear immunofluorescence test was used to determine the prevalence of Chlamydia trachomatis elementary bodies (EBs) in groups of patients in various clinical categories, most of whom were seen in a clinic for sexually transmitted diseases (STD). Overall, 8138 adequate specimens were tested, of which 14.3% were found to contain chlamydial EBs. Of the samples from patients seen in the STD clinic, over 70% were from women and 14.9% of these were positive, as were 15.7% of those from men. EBs were detected in 27% of samples from infants and in 7.0% of those from adults with conjunctivitis. EBs were detected most often in men with nongonococcal urethritis (40.2%), infants with conjunctivitis (30%) and contacts of chlamydiae-positive patients (24.5%) and least often in 'prostatitis' (2.9%) and patients tested to determine the success of treatment (2.7%). Over 40% of samples from both the male urethra and the cervix contained 10 or fewer EBs, highlighting the importance of recognizing small numbers and the sensitivity required of other detection procedures.

Improved sensitivity of an enzyme immunoassay IDEIA for detecting Chlamydia trachomatis.

In tests on 375 genital tract specimens a commercially available enzyme immunoassay for Chlamydia trachomatis (IDEIA; Boots-Celltech) was found to have sensitivity values of 62% for men and 74% for women, and a specificity of 97% for both groups, relative to the results obtained by a fluorescence assay (Micro Trak; Syva). The positive predictive value and the negative predictive value of the immunoassay were 91% and 87%, respectively. Collection of samples for IDEIA in transport medium in plastic phials, as opposed to glass phials recommended by the manufacturer, had no effect on these values. Tests of the sensitivity of IDEIA using laboratory strains of C trachomatis showed that the assay detected chlamydial elementary bodies only at dilutions at least 10-fold lower than those at which they could be detected by Micro Trak. Tests of the specificity of the assay with microorganisms found in the genital tract, other than chlamydiae, showed that reactions occurred with a number of these. Testing three cervical swabs from the same patient, with the material taken into a single phial of transport medium, increased the sensitivity of IDEIA from 74% to 96%, without reducing the specificity which remained at 97%. It is concluded that this approach enchances the value of the test in a sexually transmitted disease clinic population and may do so in a population with a low prevalence of chlamydiae.

Evidence that Chlamydia trachomatis causes seronegative arthritis in women.

Chlamydia trachomatis elementary bodies (EBs) were found in synovial membranes or synovial fluid cell deposits from five of 15 women with seronegative mono- or oligoarthritis by means of a fluorescein conjugated anti-chlamydial monoclonal antibody (Micro Trak; Syva). Genital tract specimens were taken from only five of the patients, one of whom had intra-articular EBs, but none was chlamydia positive. Six of 10 patients tested were HLA-B27 positive, and chlamydial IgG antibody, measured by microimmunofluorescence, was present at a titre of 1/greater than or equal to 64 in the sera of five of the 15 patients, three of the five having EBs in their joints. In contrast, chlamydial EBs were not detected in the joints of a control group of 10 other women, most of whom had rheumatoid arthritis. None of them was HLA-B27 positive, and only one had a chlamydial antibody titre of 1/greater than or equal to 64. Neither Mycoplasma hominis nor ureaplasmas were isolated from the synovial fluids of seven patients and five controls who were tested. Antibody to M genitalium, however, was detected in five of the 10 patients but in none of the controls. This evidence apart, there was no other suggest that mycoplasmas or ureaplasmas might be responsible for arthritis which could not be attributed to chlamydiae.

Evaluation of enzyme immunoassay (Chlamydiazyme) for detecting Chlamydia trachomatis in genital tract specimens.

An enzyme immunoassay (Chlamydiazyme) for detecting Chlamydia trachomatis was evaluated on genital specimens from 96 men and 272 women attending a clinic for sexually transmitted diseases (STD clinic). Compared with a direct immunofluorescence test for chlamydial elementary bodies, the enzyme immunoassay had a sensitivity of 58% on specimens from men, a specificity of 90%, a positive predictive value of 93%, and a negative predictive value of 88%; the assay had a sensitivity of 67% on specimens from women, a specificity of 89%, a positive predictive value of 63% and a negative predictive value of 90%. Immunofluorescence provided the most stringent test for the performance of the enzyme immunoassay as values were improved a little when a cell culture procedure was used for comparison. Further evidence for the lack of sensitivity was the detection of elementary bodies, sometimes in large numbers, in the enzyme immunoassay buffer of 13 of 19 specimens that had given a negative enzyme immunoassay result and the finding in comparative titrations of four laboratory strains that the enzyme immunoassay was at least 100-fold less able to detect chlamydiae than either immunofluorescence or the cell culture procedure. Lack of specificity may be associated with the finding that the enzyme immunoassay antibody reacted with strains of Acinetobacter calcoaceticus, Escherichia coli, Gardnerella vaginalis, Neisseria gonorrhoeae and group B streptococci. The enzyme immunoassay was not considered to be sufficiently sensitive, specific, or reproducible for routine use.

Susceptibility of different serovars of Chlamydia trachomatis to inactivation by normal human serum.

The ability of a panel of normal human serum samples to inactivate 12 strains of Chlamydia trachomatis, each of a different serovar, was investigated. A wide range of antichlamydial activity was observed, with survival rates of C trachomatis varying from less than 1% in some experiments to 100% in others. The strain specificity of the anti-chlamydial activity exhibited by individual serum samples was not, however, related to the antigenic cross reactivity between serovars demonstrable by microimmunofluorescence testing, which suggested that type specific antigens were not predominantly involved in the inactivation process.

A study of the susceptibility of three species of primate to vaginal colonization with Gardnerella vaginalis.

In an attempt to develop an animal model of Gardnerella-associated vaginitis, several strains of Gardnerella vaginalis were inoculated into the lower genital tract of female pig-tailed macaques, tamarins and chimpanzees. G. vaginalis was not recovered from either tamarins or chimpanzees, but was recovered from each of 1O pig-tailed macaques inoculated with either of two freshly isolated Gardnerella strains, colonization persisting for 11-39 days. Examination of Gram-stained vaginal smears obtained from infected pig-tailed macaques failed to demonstrate clue cells, a feature which is pathognomonic of Gardnerella-associated vaginitis in humans. Other features characteristic of non-specific vaginitis, namely an increase in vaginal pH, and an increase in the ratio of succinate to lactate (S/L ratio) in vaginal fluid were not found. However, the physiology of the macaque vagina was found to be different from that of the human, the vaginal pH and S/L ratio of uninfected macaques both being higher than that seen in humans. The physiological differences between the macaque and human vagina may be due, in part, to a difference in their anaerobic vaginal flora. While these inter-species differences in vaginal physiology and microbiology limit the relevance of the pig-tailed macaque as a model of Gardnerella-associated vaginitis, the ease with which macaques are colonized with G. vaginalis may prove useful in studying bacterial adhesion and local immunity.

A colposcopic and histological study of experimental chlamydial cervicitis in marmosets.

A total of 14 marmosets were inoculated intra-vaginally with Chlamydia trachomatis and the development of genital tract disease was assessed microbiologically, by colposcopic examination of the cervical and vaginal mucosa and by cytological and histological examination of biopsy and autopsy specimens. Eight animals had infections which persisted microbiologically for 2-5 weeks, and six animals, three of which had been inoculated on multiple occasions in a previous study, apparently eliminated their infection within 1 week of inoculation. Colposcopic examination showed that four of the eight infected animals developed acute cervicitis characterized by erythema, occasional slight oedema, and the presence of cloudy or purulent cervical mucus. The other four infected animals showed minimal signs of cervical inflammation. Three of the six animals which rapidly cleared their infections developed slight cervical inflammation characterized by erythema and cloudy cervical mucus during the fortnight after inoculation. Six control animals inoculated with medium displayed minimal cervical changes. The diagnosis of acute cervicitis in the infected animals was confirmed by examination of histological sections and cervical smears, which revealed the presence of polymorphonuclear leucocytes, with lymphocytes occasionally being seen. Although inflammatory changes were occasionally noted in specimens from control animals, the changes were relatively mild and occurred at a later time than those seen in infected animals. Intracytoplasmic chlamydial inclusions in epithelial cells were not detected in any of the specimens studied. Examination of genital tract tissue obtained at autopsy from five inoculated animals generally showed inflammation of the cervix and vagina, but in only one of these animals was there evidence of endometriosis and salpingitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Vaginal colonization of pig-tailed macaques by Gardnerella vaginalis.

Ten pig-tailed macaques inoculated intravaginally with Gardnerella vaginalis organisms were colonized for 11-39 days. In contrast, 4 tamarins and 3 chimpanzees inoculated similarly failed to become colonized. Examination of Gram-stained vaginal smears obtained from infected pig-tailed macaques failed to demonstrate clue cells, a feature which is pathognomonic of non-specific vaginitis in humans. Additionally, the pH value, the levels of non-volatile fatty acids and the anaerobic flora of the macaque vagina differed from these aspects of the human vagina. While these differences indicate that gardnerella-infected macaques are unsuitable as a model of gardnerella-associated vaginitis in humans, such animals may prove useful for studying selected aspects of the biology of G. vaginalis such as the adhesion and interaction of the bacteria with the vaginal mucosa.

A study of inactivation of Chlamydia trachomatis by normal human serum.

To assess the effect of human serum on the viability of Chlamydia trachomatis, organisms were mixed with unheated and heat inactivated homologous serum, and the numbers surviving after incubation at 37 degrees C for 1 hour were compared. With a pool of sera obtained from 12 donors, the number of chlamydiae surviving incubation in unheated serum was less than 1% of that surviving incubation in heat inactivated serum. The antichlamydial activity of the unheated pooled serum samples could be noticeably reduced by treatment with Mg-EGTA (ethyleneglycolbis (beta-amino ethyl ether)-N,N'-tetra-acetic acid). This indicated a requirement for calcium ions and showed that the alternative pathway of complement activation played only a minor role, if any, in the inactivation process. When 12 serum samples were tested individually it was found that four inactivated chlamydiae to an extent comparable with that seen with the pooled serum. The other eight samples showed only moderate (or slight) antichlamydial activity, with survival rates in unheated serum of 20-60% (or more than 60%) of those in heat inactivated serum. There was no correlation between the titres of antichlamydial antibodies and antichlamydial activity, all serum samples having undetectable or low concentrations of antibody on measurement by micro-immunofluorescence. The antichlamydial activity destroyed by heating was restored, however, when heat inactivated serum was mixed with an equal volume of an unheated serum that was not inhibitory to chlamydiae. When the latter serum was heated before addition antichlamydial activity was not restored, indicating the requirement of both a heat stable and a heat labile factor. This observation and the need for calcium ions for inactivation of chlamydiae are compatable with killing mediated by antibody and complement. Thus serum samples from individuals with no clinical or serological evidence of infection with chlamydiae vary in their ability to inactivate the organism, some having antichlamydial activity which is possibly mediated by antibody and complement.

Scanning electron microscopy of the interaction between Haemophilus influenzae and organ cultures of rat trachea.

Organ cultures of rat trachea inoculated with either a type b or a non-capsulated strain of Haemophilus influenzae showed loss of ciliary activity and disruption of the mucosal surface. Examination of tissue pieces by scanning electronmicroscopy showed that mucosal damage was due to the sloughing of epithelial cells. Bacteria associated with the epithelial surface were seen infrequently and this, together with the observation that sloughed cells were usually free of adherent bacteria, indicated that bacterial attachment was not a necessary prerequisite for the production of tissue damage.

Sexual problems in obstetrics and gynaecology.

PIP: Some efforts have been made to investigate sexual functioning in obstetric patients, and these are considered in 3 areas: pregnancy, the postpartum period, and the sequelae of episiotomy. Most research in the area of pregnancy suggests that sexual activity and libido decline steadily during pregnancy, but some studies such as that of Masters and Johnson (1966) report that sexual functioning varies during pregnancy. In this study, 101 North American women were interviewed in each trimester of pregnancy and again 3 months after delivery. In primiparous women there was, compared with preconception levels, a marked reduction of sexual activity and libido during the 1st and 3rd trimesters of pregnancy, but an increase during the 2nd trimester. Multiparous women showed a similar pattern. The finding of an improvement in sexual performance during the 2nd trimester has not been supported by subsequent research. Studies in which sexual functioning was assessed during pregnancy and retrospectively during the puerperium have reported a steady decline in libido and coital frequency throughout the 3 trimesters. Childbirth appears to be associated with diminished frequency and enjoyment of sexual intercourse for at least a year after delivery, but there is a gradual improvement in sexual functioning during this period. The level of sexual functioning before conception appears to determine sexual behavior in the year after delivery. Available findings cannot provide a basis for determining whether episiotomy is a specific cause of dyspareunia, but Beischer's (1967) findings suggest that there is little relation between the anatomical results of episiotomy and subsequent development of pain on intercourse. Sexual problems encountered in gynecology may be of 2 main types: those accompanying gynecological disorders and those arising from gynecological treatments. Research has focused mainly on sexual problems in 2 gynecological conditions--the menopause and infertility. In contrast to previous findings, recent studies have suggested that there is little sexual disturbance at the time of menopause. It seems likely that the loss of libido and orgasmic dysfunction are not specifically associated with the menopause, but vaginal dryness is not an uncommon feature of ovarian failure and may give rise to dyspareunia. Infertility is reported to be associated with a substantial prevalence of sexual dysfunction, some of which may be a direct cause of the failure to conceive. Certain sexual problems have no etiological relation to infertility but are nevertheless distressing to the patients involved. Sexual dysfunction has been studied in relation to surgical procedures and oral contraceptive use.^ieng

A study of the relationship between ABO blood groups, secretor status and infection with Neisseria gonorrhoeae.

The distribution of ABO blood groups and secretor status among 216 male caucasian patients with gonorrhoea was not significantly different from that in 2043 male caucasians who formed a comparison population.

Effect of various analgesics and lubricants on isolation of Chlamydia trachomatis and Neisseria gonorrhoeae.

Five preparations used as analgesics or lubricants in surgical, obstetrical, gynecological, and investigative procedures were tested for their effect on the isolation of Chlamydia trachomatis. Three lignocaine preparations and a lubricating jelly containing 2% phenol were inhibitory to chlamydiae. In contrast, K-Y lubricating jelly was relatively nontoxic to chlamydiae. Since K-Y jelly also had only slight toxic activity against gonococci, it is recommended for the lubrication of instruments which need to be used for the efficient isolation of these microorganisms.

Immunity to reinfection of the genital tract of marmosets with Chlamydia trachomatis.

Eleven marmosets inoculated intra-vaginally with either of 2 serotypes (D/E and H) of Chlamydia trachomatis developed a self-limited infection which persisted usually for 10-42 days. Animals re-inoculated on one or more occasions were, however, infected generally for a shorter duration, usually 3-7 days. Curtailed infections were observed after re-inoculation with either the same or a different serotype, indicating that immunity was not serotype specific but cross-protective. IgM and/or IgG chlamydial antibody, measured by micro-immunofluorescence, developed in most of the marmosets on primary infection and was not serotype specific. The antibody titres were boosted on re-infection and there was a correlation between pre-existing high antibody titres and infections of short duration. Chlamydial infection of the genital tract was accompanied by acute inflammation which persisted in about half of the immune animals for up to several weeks despite rapid clearance of the organisms. These features of the experimental infection should help to provide a greater understanding of the immunobiology and pathogenesis of chlamydial genital-tract infections of humans.

A comparison of the association of Neisseria gonorrhoeae with human and guinea-pig genital mucosa maintained in organ culture.

Organ cultures of human and guinea-pig genital mucosa were inoculated with Neisseria gonorrhoeae, and the association of the bacteria with the epithelial surface of each tissue was studied by light microscopy and by scanning electron microscopy. Gonococci attached to the mucosa of human fallopian tube, adhering specifically to the surface of non-ciliated epithelial cells. In contrast, gonococci rarely attached to the mucosal surface of guinea-pig uterine horn, vagina or bladder, although organisms were occasionally seen associated with the submucosal tissue in areas where the epithelium had sloughed, and in extracellular mucus secretions. There is no evidence from this study that gonococci adhere to guinea-pig tissue in a manner analogous to that seen with human genital tissue.

Experimental infection of the marmoset genital tract with Chlamydia trachomatis.

A strain of Chlamydia trachomatis isolated in McCoy cells from the urethra of a patient suffering from non-gonococcal urethritis was inoculated into the vagina of 8 female marmosets. Chlamydiae were isolated repeatedly for 10-42 days from the lower genital tract of 7 of the marmosets. Six of the infected animals developed an acute inflammatory reaction in the genital tract and chlamydial inclusions in epithelial cells were seen in smears from 2 of them. In addition, each of 6 infected marmosets examined developed humoral antibodies to C. trachomatis. In contrast, 3 control animals inoculated intravaginally with chlamydia-free McCoy cells showed no evidence of chlamydial infection. Since the marmoset is small and easily bred in captivity, it should provide a useful model for studying the mechanisms of chlamydial pathogenicity.

Effect of T-cell deficiency on the chronicity of arthritis induced in mice by Mycoplasma pulmonis.

Mycoplasma pulmonis inoculated parenterally into athymic nude mice congenitally deficient in T cells caused a chronic arthritis of significantly greater magnitude than in immunologically normal mice. During the chronic phase of arthritis, M. pulmonis organisms were isolated from the joints and spleens of athymic nude mice more frequently and in larger numbers than from immunologically normal mice. The results support the concept that impaired T-cell function predisposes the mice to a severe degree of chronic arthritis as a result of their failure to eliminate the causative organisms.

Failure of iron to promote attachment of gonococci to human spermatozoa under physiological conditions.

The effect of iron on the attachment of gonococci to human spermatozoa was investigated using the three iron salts, ferric chloride, ferric nitrate, and ammonium ferric citrate (AFC). Ferric chloride and ferric nitrate were found to be unsuitable for such studies because they were insoluble at physiological pH values, produced a marked decrease in the pH of unbuffered medium (Ringer's solution), and agglutinated spermatozoa. AFC, in contrast, was soluble at physiological pH, did not affect the pH value of Ringer's solution, and did not agglunate spermatozoa. When gonococci and spermatozoa were mixed together in media with and without AFC, the proportion of spermatozoa with adherent gonococci was approximately the same in each case. Thus, in contrast to previous report, we have found that the addition of iron does not increase the attachment of gonococci to human spermatozoa.