Unilateral uterine artery embolization and systemic methotrexate therapy in cervical pregnancy.

The authors report a case of cervical pregnancy successfully treated with combined methods of uterine artery embolization and systemic methotrexate therapy. Unilateral selective embolization may play a role in preserving reproductive functions.

Breech delivery in a Middle East hospital.

This paper provides an analysis of the results of 206 deliveries in which the patient's preference influenced the mode of delivery.

Prediction of size of infants at birth by measurement of symphysis fundus height.

Symphysis fundus heights (SF) were measured approximately 15 times during pregnancy in a consecutive series of 2941 women with regular menstrual cycles and known last menstrual period. A reference SF chart from 17 to 40 weeks of pregnancy was derived from measurements in 1350 of these women who were healthy, and heights and pre-pregnancy weights within the 10th and 90th centiles and were delivered vaginally of healthy infants with a birthweight/length ratio within +/- 2 SD. The reference chart was used to predict fetal growth deviations in the unselected series of pregnancies. The effectiveness of SF measures to detect fetuses with an infant birthweight/length ratio below -2 SD or a birthweight below the 10th centile was low; the sensitivity was only 16.7 and 26.6% and the predictive value of positive screening result was 1.8 and 18.0%, respectively. Corresponding values for fetuses with an infant birthweight/length ratio above + 2 SD or a birthweight above the 90th centile were 31.8 and 37.5% and 3.3 and 24.5%, respectively. Symphysis fundus (SF) measurement has thus been found to be of limited value as a screening method to detect abnormal size at birth.

Spiral artery lesions in relation to metabolic control in diabetes mellitus.

Decidual and intramyometrial spiral arteries from 18 insulin-dependent diabetic and 18 non-diabetic women were compared histologically. All women were normotensive and none had signs of pre-eclampsia. None of the infants in either group had intra-uterine growth retardation. Metabolic control in the diabetic women was assessed by pregnancy glucose level from the last trimester of pregnancy and by C-peptide in amniotic fluid and cord blood as a measure of the fetal beta-cell function. The intramyometrial and decidual parts of the spiral artery were normal in the non-diabetic group. None of the diabetic patients showed pathological changes in the intramyometrial part of the spiral artery. Two of the 18 diabetic patients had pathological changes (intramural fibrosis) in the decidual portion of the spiral artery. These two women had signs of diabetic angiopathy (White's class D and F) and in one of them, the background diabetic retinopathy progressed markedly during pregnancy. The pregnancy glucose level was above normal (greater than 6.2 mM/l) in 3 of 18 diabetics. The C-peptide values in amniotic fluid and cord blood were above normal in 11 of 17 and in 5 of 17, respectively. Both patients with spiral artery lesions had pregnancy glucose levels in the upper range, 5.86 and 5.98 mM/l, respectively and the highest value of C-peptide in the amniotic fluid and cord blood, suggesting exaggerated fetal beta-cell function.

[Ultrasonic diagnosis of scar defects following cesarean section]. / Ultraschalldiagnostik von Narbendefekten nach Kaiserschnitt.

The clinical signs and the diagnosis of deficient healing of the scar following caesarean section are reviewed. Maternal mortality following repeated caesarean section is four times higher than by normal vaginal delivery. Uterine rupture is accompanied by a 25-fold increase in perinatal mortality. At the department of obstetrics at Danderyd's Hospital 2542 case histories were reviewed. Caesarean section rate was 11,3%. At reoperation 2,8% of the scars exhibited deficient healing.--Because of this experience the ultrasound method was used to examine the echo-structures between the urinary bladder and the amniotic cavity. A Real time US-apparatur Axiscan 5 B-S was used. Corresponding to the scar-region smooth or pathologically deformed structures were observed. The clinical diagnosis of the scar healing was made at the time of delivery. 68 patients were examined. In 31% of the cases a vaginal delivery was planned and carried through without complications. In an additional 9% vaginal delivery was planned but it was necessary to perform an acute caesarean section. Only in two of these cases the indication for operation was imminent scar-rupture. In the following 41 patients (60%) a planned caesarean section was performed. In no case there was clinical suspicion of defective scar healing.--In the whole material (n = 68) 1,5% fenestrations were found. Ten of the 15 (22%) deficiently healed uterine scars were diagnosed with aid of ultrasound before onset of labor. The ultrasonic risk group comprised 18% of the material. The sensitivity of the ultrasonic method was 67% and the specificity 96%.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of an early diagnosis on the results of surgical treatment of ectopic pregnancy.

The postoperative fertility of 292 cases of ectopic pregnancy treated 1972-1979 was studied. Of these 156 were operated upon during 1972-1976, when only determinations of HCG in urine were available and 136 during 1977-1979, when RIA-determinations of HCG in serum made an earlier pregnancy diagnosis possible. In spite of the fact that the time of observation was shorter in the second group the pregnancy rate was 41% compared to 31% in the first one (P less than 0.05). The rate of childbirth among the pregnancies in the second group was 72% compared to only 55% in the first one (P less than 0.05).

Behavior of moderate cervical dysplasia during long-term follow-up.

Eight hundred ninety-four women with cytologically diagnosed moderate cervical dysplasia were followed by cytology without major treatment. The results were regression in 54% (follow-up 78 months), progression in 30%, and persistence in 16%. Biopsies were performed in 54%. Results in patients without biopsies were regression in 50%, progression in 35%, and persistence in 15%, implying a statistically significant difference between biopsied and nonbiopsied lesions. Fewer lesions progressed in patients age 51 or older than in younger patients, the progression time also being significantly longer. The cytology periodically returned to normal for more than 12 months in 3.8% of patients with persisting moderate dysplasia. Life table analysis indicated the risk of progression of moderate dysplasia to be 5 to 9/100 women/year. A comparison with the incidence of carcinoma in situ, 4/100,000 women/year, illustrates the yearly progression risk for a cervix with moderate dysplasia as 2000 times greater than for a woman without cervical dysplasia.

Amniotic fluid volumes and concentrations of C-peptide in diabetic pregnancies.

Amniotic fluid (AF) volumes were determined by sodium p-aminohippurate (PAH) dilution in a consecutive series of 24 diabetic women at 34-35 weeks gestation. AF and maternal venous blood samples were analysed for C-peptide immunoreactivity (CPR). When the patients were subgrouped according to the presence (n = 17) or absence (n = 8) of neonatal morbidity, AF volumes (1340 +/- 236 ml vs 807 4/- 130 ml; mean +/- SEM), AF concentrations of CPR (1.38 +/- 0.54 nmol/l vs 0.61 +/- 0.14 nmol/l) and maternal blood glucose levels (5.3 +/- 0.2 nmol/l vs 4.8 +/- 0.3 nmol/l) during the last trimester of pregnancy were not different. The total content of CPR was significantly (P less than 0.05) greater in pregnancies with neonatal complications (1.25 +/- 0.31 nmol/ compared with that in pregnancies without neonatal complications (0.54 +/- 0.18 nmol). AF volumes were significantly (P less than 0.02) larger in pregnancies where feeding problems occurred (1546 +/- 307 ml, n = 9) compared with that in pregnancies without such problems (957 +/- 188 ml, n = 16). These findings indicate an impact of fetal hyperinsulinism on the functional maturation of the fetus. When the patients were subgrouped according to the presence or absence of detectable maternal plasma CPR, i.e. greater than 0.05 nmol/l, and to insulin dependent and gestational diabetes no differences of AF volumes, AF concentrations of CPR or total AF contents of CPR were found.

Vaginal involvement in familial benign chronic pemphigus (Morbus Hailey-Hailey).

Vaginal pain over a period of 3 years has been shown to be based on a vesiculo-bullous acantholytic disorder suggesting familial chronic benign pemphigus (Morbus Hailey-Hailey). Local applications of 5 ml 1% hydrocortisone-enterochinol cream resulted in an almost total regression of all the symptoms, including dyspareunia.

Amniotic fluid volumes in pregnant diabetics during the last trimester. A comparative study using ultrasound and PAH dilution.

Amniotic fluid was measured by ultrasound and PAH dilution technique in 15 insulin-dependent diabetics during the last trimester of pregnancy. Total uterine volume and fetal volume were estimated by ultrasound. The amniotic fluid volume was obtained by subtracting fetal volume and approximated values for placental volume obtained from the literature from the total uterine volume. The mean amniotic fluid volume determined by ultrasound was 1261 ml (range 278-3563). The mean amniotic fluid volume determined by PAH dilution was 1264 ml (range 344-3852). The values for amniotic fluid determined by these two methods were closely correlated (r = 0.96).

Surgical treatment of post abortum endometriosis of the bladder and postoperative bladder function.

During the years 1953-1967, 17 women with endometriosis of the urinary bladder were treated with extirpation of the endometrial tissue, including partial or total resection of the trigone. In all cases the endometriosis had followed vaginal hysterotomy for legal abortion. Urethrocystoscopy was performed and the residual urine and bladder capacity were measured in all the patients one month and one year after the bladder operation. At follow-up in 1978 only 4 of the 17 women were available for urodynamic studies. Combined urethrocystometry, recording of the urethral pressure profile and measurement of the maximal urethral pressure in supine and standing positions were performed in these four patients, using the technique of Ulmsten et al. In all cases in the series, including those with trigone extirpation, all the tested parameters were normal. The writers therefore conclude that even total trigone resection can be done without disturbance to the bladder function.

Periurethral aerobic microflora of pregnant and non-pregnant women.

Seventy-two pregnant and 88 non-pregnant women were examined to see whether the periurethral region had been colonised with group B streptococci (Streptococcus agalactiae), enterococci, and Gram-negative rods belonging to the Enterobacteriaeceae. A semi-quantitative method was used for periurethral sampling, and paired urethral swabs were also collected to compare the isolation rates of group B streptococci from the two sites and with the two sampling methods. A higher isolation rate was found with periurethral sampling. Most specimens showed no or scanty growth of Gram-negative rods. Pregnancy was often associated with heavy growth of enterococci. Sampling performed during menstruation and while oral contraceptives were being used produced high isolation rates of group B streptococci. These results seem to suggest that the periurethral area might protect against genital colonisation with group B streptococci as it does against urinary tract infection and that hormonal factors influence the carriage of these organisms.

Follow-up studies in dysplasia and cancer in situ of the cervix uteri.

In order to study when recurrences appear following conization for dysplasia or cancer in situ of the cervix uteri, a series of 477 patients has been investigated. They all underwent conization at Sabbatsberg 1965-1970. Among the 181 cases of dysplasia two developed recurrences one respectively three years after treatment. In the series of 296 patients with cancer in situ thirteen recurrences appeared. Eight of them were detected within the first three years. The other five were spread out during the next four years. About 50% of all patients had been followed-up for five years or more (Table I). The conclusion is reached that a yearly follow-up is necessary for at least ten years. As it is impossible to take care of such an accumulating number of examinations at the Swedish departments of obstetrics and gynecology without extra personnel, the following proposal is made. During the first three years after treatment the examinations are performed at the department where the conization has been performed. After that period the follow-up is limited to vaginal smears taken once every year in connection with the general gynecologic health control.

Intrauterine death due to infection with group B Streptococci.

During the 6-year period 1970-1975 5 cases of late intrauterine death caused by group B streptococcal infection were seen in two obstetrical departments in the Stockholm area. During the same period 17 638 infants were born in the two departments, and in 117 cases intrauterine death occurred. Hematogenous spread of the infection from the mother was the most likely cause in the 5 cases. This figure should be compared with a carrier rate of 15-20% in pregnant women in the Stockholm area.

The site of placental attachment as a factor in the aetiology of breech presentation.

The frequency of cornu-fundal implantation of the placenta in association with breech presentation was investigated in the following study. In a series of 124 women with breech presentation, and 125 women with cephalic presentation at or near term, the implantation site of the placenta was demonstrated by ultrasonography. It was found that with breech presentation the placenta was implanted in the cornual region in 72.6% of the cases, as compared with 4.8% in cephalic presentation. The placental implantation site may therefore have a determining effect upon the presentation of the foetus.

Ultrasonic pelvimetry. A method for preliminary estimation of the pelvic outlet.

Vaginal sound, with transmitter crystals of 2 MHz, is used when measuring the interspinous diameter. The echo from pelvic wall, the effect on the measured spinal diameter by altering the position of the ultrasonic transmitter, and the influence of air or faeces between the ultrasound transmitter and the pelvic wall, have been analysed in a series of model trials on a dummy submerged in water. Thereafter clinical trials were performed on 102 women, pregnant in their 9th month. The results obtained when measuring the interspinous diameter on the ultrasonic tomogram were compared with the results obtained when measuring the same distance on a frontal x-ray picture taken using the orthographic technique according to Borell-Frenström. The method is suitable for selecting those cases with suspect constriction of the pelvic outlet for an x-ray examination by the Borell-Fernström technique.

The persistence of group B streptococci in families.

Four years ago the relative occurrence of group B streptococci was studied in a group of 118 term pregnant women of which 17 were B-streptococcal carriers. Of these, 15 were investigated in connection with the delivery. 11 of these women were reexamined 45-50 months after delivery together with their families. A high frequency of positive cultures without symptoms (50%) was found in this small group of women and their husbands compared with male and female control groups. Persistence seems to be common, a fact to be remembered in subsequent pregnancies.