Showing papers in "Obstetrical & Gynecological Survey in 1995"

Reduction of maternal-infant transmission of human immunodeficiency virus 1 with zidovudine treatment

Abstract: In 1994, Edward M. Connor and colleagues published \"Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 with Zidovudine Treatment.\" Their study summarized how to reduce the transfer of human immunodeficiency virus, or HIV, from pregnant women to their fetuses with Zidovudine, otherwise known as AZT. HIV is a virus that weakens the immune system by destroying white blood cells, a part of the body ́s immune system. Fifteen to forty percent of infants born to HIVpositive mothers become infected during fetal development, labor and delivery, or breast-feeding. From April 1991 to December 1993, Connor and his colleagues researched HIV-positive pregnant women who took AZT, a drug that treats but does not cure an HIV infection. In their article, Conner and colleagues showed that AZT decreased the maternal-infant transmission of HIV and helped decrease infant mortality due to the viral infection.

Can Magnesium Sulfate Reduce the Risk of Cerebral Palsy in Very Low Birthweight Infants

Abstract: Objectives. To investigate whether in utero exposure to magnesium sulfate (MgSO4) was associated with a lower prevalence of cerebral palsy (CP) in infants born weighing Design. Singleton infants weighing Results. During the admission for delivery, 7.1% of the 42 VLBW infants with later CP and 36% of the 75 VLBW controls were exposed to MgSO4 (odds ratio (OR) .14, 95% confidence interval (CI) .05, .51). The overall association of MgSO4 with reduced risk of CP was also observed in the subgroup of infants born to women who were not preeclamptic (OR .25, CI .08, .97). Infants with CP were less often exposed antenatally to MgSO4 whether or not there was cotreatment with non-MgSO4 tocolytics (other tocolytics administered, OR for MgSO4 exposure .23, CI .06, 1.2; other tocolytics not administered, OR for MgSO4 .08, CI .02, .68), or antenatal corticosteroids (steroids given, OR for MgSO4 exposure .24, CI .06, 1.3; steroids not given, OR for MgSO4, .08, CI .02, .72). Apparent benefit of magnesium was observed in the presence or absence of a variety of characteristics of pregnancies, births, and infants. Conclusion. In this observational study, in utero exposure to MgSO4 was more frequent in controls than in children with CP, suggesting a protective effect of MgSO4 against CP in these VLBW infants.

Decline in Semen Quality Among Fertile Men in Paris During the Past 20 Years

Abstract: Background Several studies have suggested a population-wide decline in the quality of semen over the past 50 years, but clear evidence of decreasing semen quality in recent decades is lacking. Methods From 1973 through 1992 we measured the volume of seminal fluid, the sperm concentration, and the percentages of motile and morphologically normal spermatozoa in 1351 healthy fertile men. The data on the semen samples were collected at one sperm bank in Paris. The data in each calendar year were analyzed as a function of the year of donation, the age of each patient, the year of birth, and the duration of sexual abstinence before semen collection. Results There was no change in semen volume during the study period. The mean concentration of sperm decreased by 2.1 percent per year, from 89 ×106 per milliliter in 1973 to 60×106 per milliliter in 1992 (P<0.001). During the same period the percentages of motile and normal spermatozoa decreased by 0.6 percent and 0.5 percent per year, respectively (both P<0.001). ...

Increased Risk of Venous Thrombosis in Oral-Contraceptive Users Who Are Carriers of Factor V Leiden Mutation

Abstract: We investigated whether the occurrence of venous thrombosis in young women who use oral contraceptives might be explained by the factor V Leiden mutation, which leads to resistance to activated protein C and enhances susceptibility to thrombosis. We compared 155 consecutive premenopausal women, aged 15 to 49, who had developed deep venous thrombosis in the absence of other underlying diseases, with 169 population controls. The risk of thrombosis among users of oral contraceptives was increased 4-fold (relative risk 3.8 [95% CI 2.4-6.0]). The risk of thrombosis among carriers of the mutation compared with non-carriers was increased 8-fold (7.9 [3.2-19.4]). Compared with women who did not use oral contraceptives and were not carriers of the mutation, the risk of thrombosis among those with both risk factors was increased more than 30-fold (34.7 [7.8-154]). Recalculation of population incidences from these relative risks shows that the absolute risk of venous thrombosis in young women who use oral contraceptives is much larger when they carry the factor V Leiden mutation. When a young woman develops thrombosis, her factor V Leiden status should be considered in counselling about her future method of contraception.

Use of thrombolytics for the treatment of thromboembolic disease during pregnancy

Abstract: The incidence of thromboembolic disease is increased during pregnancy. Prevention and treatment of thromboembolic disease can have a significant impact on the morbidity and mortality of pregnant women. Anticoagulation with heparin is the treatment of choice; however, in some instances this is inadequate or contraindicated. In the nonpregnant patient, alternative therapies have included surgical intervention or fibrinolytic agents. Traditionally, thrombolytic therapy has been considered a relative contraindication during pregnancy due to the maternal and fetal risk of hemorrhagic complications. Hence, no controlled trials of agents such as streptokinase, urokinase, or tissue plasminogen activator for the treatment of thromboembolic events during pregnancy, have been performed, or are currently feasible. Since 1961, 36 reports have been published describing the use of thrombolytic agents during pregnancy. In a review of the world's literature, 172 pregnant women affected with thromboembolic conditions were treated with thrombolytic medications. A maternal mortality rate of 1.2 percent was observed. Approximately 10 pregnancy losses were noted (5.8 percent). Hemorrhagic complications were reported in 8.1 percent of patients. We summarize the published literature on the use of thrombolytic agents during pregnancy and discuss the treatment success and reported complications.

Progesterone Synthesis and Myelin Formation by Schwann Cells

Abstract: Progesterone is shown here to be produced from pregnenolone by Schwann cells in peripheral nerves. After cryolesion of the sciatic nerve in male mice, axons regenerate and become myelinated. Blocking either the local synthesis or the receptor-mediated action of progesterone impaired remyelination. Administration of progesterone or its precursor, pregnenolone, to the lesion site increased the extent of myelin sheath formation. Myelination of axons was also increased when progesterone was added to cultures of rat dorsal root ganglia. These observations indicate a role for locally produced progesterone in myelination, demonstrate that progesterone is not simply a sex steroid, and suggest a new therapeutic approach to promote myelin repair.

Age-Related Changes of the Population of Human Ovarian Follicles: Increase in the Disappearance Rate of Non-Growing and Early-Growing Follicles in Aging Women

Abstract: The effect of aging on the number of non-growing follicles (NGF) and early-growing follicles (EGF) was studied in humans through use of a database obtained by pooling two subsets of ovarian pairs (2 x 43 pairs) collected in two distinct populations. A previously suggested model of exponential regression of NGF counts in relation to the subject's age was tested but did not adequately fit the observed data points. This lack of fit is attributable mainly to the existence of a significant relation between a woman's age and the corresponding NGF count decay rate. Consequently, various regression models were tested. Two different periods of decay rate were observed for each population of small follicles. The first corresponds to younger ages with a decay rate that is slow for both types of follicles, although faster for NGF than for EGF. The second period corresponds to older ages with an accelerated decay rate that appears similar for NGF and EGF. The changing points were found at 38.0 +/- 2.4 and 39.0 +/- 1.9 yr (mean +/- SD) for NGF and EGF, respectively. Extrapolation of the fitted model suggested the presence of approximately 402,000 healthy NGF per ovary at birth and a total exhaustion of the follicular stock at around 74 yr of age. These results support the view that depletion of the NGF pool is caused mainly by atresia in younger women but mainly by entrance of NGF into the growing pool in older women. The mechanisms triggering accelerated entrance into the growth phase of NGF are discussed in relation to the previously reported increase in FSH plasma levels that starts in the late thirties, approximately, and precedes the menopausal period by several years.

Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part I.

Abstract: The professional literature on the benefits and risks of episiotomy was last reviewed critically in 1983, encompassing material published through 1980. This paper reviews the evidence accumulated since then. (Part II follows in this issue.) It is concluded that episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days.

Early complications of abdominal and vaginal hysterectomy.

Abstract: In 1982, the Collaborative Review of Sterilization (CREST) study was published, reviewing the complications accompanying and following both abdominal and vaginal hysterectomy. This review was undertaken to see how these rates have changed in the ensuing years. All large series of abdominal and vagin

School-Age Outcomes in Children With Birth Weights Under 750 g

Abstract: BACKGROUND Since the mid-1980s, increasing numbers of children with birth weights under 750 g have survived to school age. METHODS We matched a regional cohort of 68 surviving children born from 1982 through 1986 with birth weights under 750 g (mean, 670 g; gestational age, 25.7 weeks) with 65 children weighting 750 to 1499 g at birth and 61 children born at term. Growth, neurosensory status, and functioning at school age in the three groups were compared. Associations of biologic and social risk factors with major developmental outcomes were examined by means of logistic-regression analyses. RESULTS Children with birth weights under 750 g were inferior to both comparison groups in cognitive ability, psychomotor skills, and academic achievement. They had poorer social skills and adaptive behavior and more behavioral and attention problems. The mean (+/- SD) Mental Processing Composite score for the cohort was 87 +/- 15, as compared with 93 +/- 14 for children with birth weights of 750 to 1499 g and 100 +/- 13 for children born at term (P < 0.001). The rates of mental retardation (IQ < 70) in the three groups were 21, 8, and 2 percent, respectively; the rates of cerebral palsy were 9, 6, and 0 percent; and the rates of severe visual disability were 25, 5, and 2 percent. Major cerebral ultrasonographic abnormalities were associated with mental retardation (odds ratio, 5.4; 95 percent confidence interval, 1.8 to 15.8) and cerebral palsy (odds ratio, 15.2; 95 percent confidence interval, 3.0 to 77.4). Oxygen dependence at 36 weeks was associated with mental retardation (odds ratio, 4.5; 95 percent confidence interval, 1.2 to 10.7) and severe visual disability (odds ratio, 4.3; 95 percent confidence interval, 1.3 to 14.2). Social disadvantage, though associated with several neuropsychological outcomes, was not associated with major developmental impairment. CONCLUSIONS Children with birth weights under 750 g who survive represent a subgroup of very-low-birth-weight children who are at high risk for neurobehavioral dysfunction and poor school performance.

A Comparison of Cabergoline and Bromocriptine in the Treatment of Hyperprolactinemic Amenorrhea

Abstract: Background Cabergoline is a long-acting dopamine-agonist drug that suppresses prolactin secretion and restores gonadal function in women with hyperprolactinemic amenorrhea. We designed a study to compare its safety and efficacy with those of bromocriptine, which has been the standard therapy. Methods A total of 459 women with hyperprolactinemic amenorrhea were treated with either cabergoline (0.5 to 1.0 mg twice weekly) or bromocriptine (2.5 to 5.0 mg twice daily), administered in a double-blind fashion for 8 weeks and subsequently in an open fashion for 16 weeks, during which adjustments in the dose were made according to the response. Of the 459 women, 279 had microprolactinomas, 3 had macroprolactinomas, 1 had a craniopharyngioma, 167 had idiopathic hyperprolactinemia, and the remainder had an empty sella. Clinical and biochemical status was assessed at 2-week intervals for 8 weeks and monthly thereafter for a total of 6 months, with an additional assessment at 14 weeks. Results Stable normoprolactinem...

Birth Complications Combined With Early Maternal Rejection at Age 1 Year Predispose to Violent Crime at Age 18 Years

Abstract: Background: This study tests the biosocial interaction hypothesis that birth complications when combined with early maternal rejection of the infant predispose to adult violent crime. Methods: This hypothesis was tested using a cohort of 4269 consecutive live male births on whom measures of birth complications (age 0), early maternal rejection (age 1 year), and violent crime (age 18 years) were collected. Results: A significant interaction (P Conclusions: To our knowledge, this is the first study to show that birth complications in combination with early child rejection predispose to violent crime. The findings illustrate the critical importance of integrating biological with social measures to fully understand how violence develops and also suggest that prenatal, perinatal, and early postnatal health care interventions could significantly reduce violence.

Estrogen Replacement Therapy and Fractures in Older Women

Abstract: Objective: To determine the relation between estrogen replacement therapy and fractures. Design: Prospective cohort study. Setting: Four clinical centers in Baltimore County, Maryland; Minneapolis,...

Eclampsia in the United Kingdom

Abstract: Objectives: To measure the incidence of eclampsia, establish how often it is preceded by signs of pre-eclampsia, document the morbidity associated with eclampsia, and determine the maternal case fatality rates. Design: A prospective, descriptive study of every case of eclampsia in the United Kingdom in 1992. Information was collected from reviews of hospital case notes and questionnaires to general practitioners. Setting: All 279 hospitals in the United Kingdom with a consultant obstetric unit. Results: Obstetricians and midwives notified 582 possible cases, and 383 were confirmed as eclampsia. The national incidence of eclampsia was 4.9/10000 maternities (95% confidence interval 4.5 to 5.4). Most convulsions occurred despite antenatal care (70%) and within one week of the woman9s last visit to a doctor or midwife (85%). Three quarters of first seizures occurred in hospital, of which 38% developed before both proteinuria and hypertension had been documented. Forty four per cent of cases occurred postpartum, more than a third (38%) antepartum, and the remainder (18%) intrapartum. Nearly one in 50 women (1.8%) died, and 35% of all women had at least one major complication. The rate of stillbirths and neonatal deaths was 22.2/1000 and 34.1/1000, respectively. Preterm eclampsia occurred more commonly antepartum and was associated with more maternal complications and fetuses that were small for gestational age, as well as with higher rates of stillbirth and neonatal mortality. Antepartum eclampsia, which was more likely to occur preterm, was associated with a higher rate of maternal complications and a higher neonatal mortality. Both factors (gestational prematurity and antepartum occurrence) contributed independently to the severity of the outcome. Conclusion: Eclampsia occurs in nearly one in 2000 maternities in the United Kingdom and is associated with high maternal morbidity and fatality in cases. It may present unheralded by warning signs. Preterm and antenatal eclampsia seem to be particularly severe.

Why Do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action

Abstract: To examine the reasons patients and their relatives take legal action, we surveyed 227 patients and relatives who were taking legal action through five firms of plaintiff medical negligence solicitors. Over 70% of respondents were seriously affected by incidents that gave rise to litigation with long-term effects on work, social life, and family relationships. Intense emotions were aroused and continued to be felt for a long time. The decision to take legal action was determined not only by the original injury, but also by insensitive handling and poor communication after the original incident. Where explanations were given, less than 15% were considered satisfactory. Four main themes emerged from the analysis of reasons for litigation: concern with standards of care--both patients and relatives wanted to prevent similar incidents in the future; the need for an explanation--to know how the injury happened and why; compensation--for actual losses, pain and suffering or to provide care in the future for an injured person; and accountability--a belief that the staff or organisation should have to account for their actions. Patients taking legal action wanted greater honesty, an appreciation of the severity of the trauma they had suffered, and assurances that lessons had been learnt from their experiences. A no-fault compensation system, however well intended, would not address all patients' concerns. If litigation is viewed solely as a legal and financial problem, many fundamental issues will not be addressed or resolved.

Preliminary Experience With Endoscopic Laser Surgery for Severe Twin-Twin Transfusion Syndrome

Abstract: Background In monozygotic twin pregnancies, there are placental vascular communications between the two fetuses. In 15 percent of such pregnancies there is an imbalance in net blood flow between the twins, resulting in the twin–twin transfusion syndrome. The recipient twin may have severe hydramnios during the second trimester of pregnancy, and there is a high risk of perinatal death and cerebral palsy in survivors. This condition can now be treated by endoscopic coagulation of the vascular anastomoses responsible for fetofetal transfusion with a neodymium:yttrium–aluminum–garnet (Nd:YAG) laser. Methods We performed intrauterine surgery in 45 pregnant women carrying twins at 15 to 28 weeks of gestation (median, 21); in each case there was severe hydramnios in one fetus due to the twin–twin transfusion syndrome. With the use of local anesthesia and continuous ultrasound visualization, a rigid fetoscope 2 mm in diameter, housed in a 2.7-mm cannula, was introduced transabdominally into the amniotic cavity of...

T-Helper 1-Type Immunity to Trophoblast in Women With Recurrent Spontaneous Abortion

Abstract: Objective. —To test the hypothesis that peripheral blood mononuclear cells in women with unexplained recurrent abortion (URA) produce T-helper 1 (TH1)—type cytokines in response to trophoblast antigens. Design. —Cohort study. Setting. —Medical center. Participants. —A total of 244 women with URA, 13 reproductively normal parous control women, and 10 men. Main Outcome Measures. —Supernatants from trophoblast-activated peripheral blood mononuclear cells from all participants were tested for toxic effects on mouse embryos and by enzyme-linked immunosorbent assay (ELISA) for interferon gamma (IFN-γ). Supernatants from 20 URA patients with embryotoxic activity and IFN-γ, 13 reproductively normal parous women, and 10 men were further tested by ELISA for other TH1-type cytokines (interleukin-2 [IL-2], tumor necrosis factor—β [TNF-β]), TH2-type cytokines (IL-4, IL-10), and TNF-α. Results. —Embryotoxic activity was detected in supernatants from 160 of 244 URA patients and in none of the controls. Interferon gamma was detected in supernatants from 125 of 244 URA patients and was significantly associated with embryotoxicity (121 of 160 supernatants with embryotoxicity vs four of 84 supernatants without embryotoxicity [P Conclusion. —Whereas TH1-type immunity to trophoblast is associated with URA and may play a role in reproductive failure, TH2-type immunity may be a natural response to trophoblast contributing to successful pregnancy. (JAMA. 1995;273:1933-1936)

Predictive Testing for Huntington Disease: Nonparticipants Compared With Participants in the Dutch Program

Abstract: Attitudes toward predictive testing programs, in individuals who choose not to undertake the test (i.e., nonparticipants), may be influenced by fears of an unfavorable result. The reasons not to participate in predictive testing programs for Huntington disease (HD) were studied in members of the Dutch Huntington Association who were at 50% risk. They had completed the same baseline psychological questionnaires as had the participants in the Dutch DNA-testing program. The group of 34 nonparticipants was similar to the tested participants in the Dutch predictive testing program, with respect to average age (31.1 years), male:female ratio (1:2), the frequency of a stable relationship (70%), and level of education (67% had high school education or higher). Testing did not seem to be a realistic option for nonparticipants for improving their quality of life. In comparison with participants, nonparticipants had a significantly more pessimistic outlook on themselves and their futures. When asked to consider the possibility of an unfavorable result, nonparticipants expected more difficulties in their families; more problems for their children, their partners, and themselves; a lowered quality of life; and, more often, a depressive reaction. In their opinion, a favorable result would reduce the problems for their children but not for themselves, a result that was found more often in the nonparticipant than in the participant group. Nonparticipants learned about their being at risk for HD during adolescence (mean age 15.6 years), whereas participants did so in adulthood (mean age 22.7 years). The nonparticipants' attitude toward the test might be explained by the influence of HD in the adolescent's separation-individuation process and personality development. This finding could be relevant for future research and for the discussion about testing minors for delayed-onset disorders.

Long-Term Effects of Calcium Supplementation on Bone Loss and Fractures in Postmenopausal Women: A Randomized Controlled Trial

Abstract: purpose To determine the long-term effects of calcium supplements or placebo on bone density in healthy women at least 3 years postmenopause. patients and methods Eighty-six women from our previously reported 2-year study agreed to continue on their double-blind treatment allocation (1 g elemental calcium or placebo) for a further 2 years, with 78 women (40 on placebo) reaching the 4-year end point. Median (interquartile range) dietary calcium intakes for the whole group were 700 mg (range 540 to 910) per day at baseline, 670 mg (range 480 to 890) per day at 2 years, and 640 mg (range 460 to 880) per day at 4 years. The bone mineral density (BMD) of the total body, lumbar spine, and proximal femur was measured every 6 months by dual-energy, x-ray absorptiometry. results There was a sustained reduction in the rate of loss of total body BMD in the calcium group throughout the 4-year study period ( P = 0.002), and bone toss was significantly less in the calcium-treated subjects in years 2 through 4 also (difference between groups 0.25% ± 0.11% per year, P = 0.02). In the lumbar spine, bone loss was reduced in the calcium group in year 1 ( P = 0.004), but not subsequently. There was, however, a significant treatment effect at this site over the whole 4-year period ( P = 0.03). In the proximal femur, the benefit from calcium treatment also tended to be greater in the first year and was significant over the 4-year study period in the femoral neck ( P = 0.03) and the trochanter ( P = 0.01). Nine symptomatic fractures occurred in 7 subjects in the placebo group and 2 fractures in 2 subjects receiving calcium ( P = 0.037). conclusions Calcium supplementation produces a sustained reduction in the rate of loss of total body BMD in healthy postmenopausal women.

Megestrol acetate for the prevention of hot flashes

Abstract: Background Vasomotor hot flashes are a common symptom in women during menopause and in men who have undergone androgen-deprivation therapy for prostate cancer. Although treatment with estrogens in women and androgens in men can attenuate these symptoms, these hormones may be contraindicated in women with breast cancer and in men with prostate cancer. Pilot trials have suggested that the progestational agent megestrol acetate can ameliorate hot flashes in both groups of patients. Methods The patients included 97 women with a history of breast cancer and 66 men with prostate cancer who had undergone androgen-deprivation therapy. All patients had experienced bothersome hot flashes (median number per day at base line, 6.1 for the women and 8.4 for the men). After a one-week pretreatment observation period, the patients received megestrol acetate (20 mg twice daily) for four weeks, followed by placebo for four weeks, or vice versa in a double-blind manner as determined by pretreatment randomization. The patien...

Estrogen Resistance Caused by a Mutation in the Estrogen-Receptor Gene in a Man

Abstract: Background and Methods Mutations in the estrogen-receptor gene have been thought to be lethal. A 28-year-old man whose estrogen resistance was caused by a disruptive mutation in the estrogen-receptor gene underwent studies of pituitary-gonadal function and bone density and received transdermal estrogen for six months. Estrogen-receptor DNA, extracted from lymphocytes, was evaluated by analysis of single-strand-conformation polymorphisms and by direct sequencing. Results The patient was tall (204 cm [80.3 in.]) and had incomplete epiphyseal closure, with a history of continued linear growth into adulthood despite otherwise normal pubertal development. He was normally masculinized and had bilateral axillary acanthosis nigricans. Serum estradiol and estrone concentrations were elevated, and serum testosterone concentrations were normal. Serum follicle-stimulating hormone and luteinizing hormone concentrations were increased. Glucose tolerance was impaired, and hyperinsulinemia was present. The bone mineral d...

The Economic Impact of Multiple-Gestation Pregnancies and the Contribution of Assisted-Reproduction Techniques to Their Incidence

Abstract: Background Although the medical complications associated with multiple-gestation pregnancies have been well documented, little is known about the effects of such pregnancies on the use of health care resources and the associated costs. This is an important issue because of the increasing use of assisted-reproduction techniques, which commonly result in multiple-gestation pregnancies. Methods We determined hospital charges and the use of assisted-reproduction techniques (such as induction of ovulation, in vitro fertilization, and gamete intrafallopian transfer) for 13,206 pregnant women (11,986 with singleton pregnancies, 1135 with twin pregnancies, and 85 with more than two fetuses) who were admitted for delivery to Brigham and Women's Hospital, Boston, in 1986 through 1991 and their 14,033 neonates (11,671 singletons, 2144 twins, and 218 resulting from higher-order multiple gestations). Results After we controlled for variables known to affect hospital charges, the predicted total charges to the family i...

Vulvar pain syndrome: a review.

Abstract: Vulvar pain syndrome (vulvar vestibulitis, vulvodynia, burning vulvar syndrome) was first described at the end of the last century. Although more than 100 years have passed, the cause(s) of the disorder remains elusive. This review of the literature endeavors to collate the known facts relating to vulvar pain syndrome and to expose those hypothetical etiologies which fall short of establishing any scientific foundation. The diagnosis of vulvar pain syndrome is established on the basis of historical data which detail a rather abrupt onset of vestibular itching, burning, dryness which may be intermittent or continuous. Commonly, patients present with a history of chronic treatment for recurrent fungal infections. Sexual relations become uncomfortable or intolerable. Unanimously, the patients describe a panorama of topical creams and ointments which fail to alleviate the symptoms. Physical examination typically verifies hyperesthesia of the vestibular skin when touched lightly with a cotton-tipped applicator. Similarly, the vestibular skin shows varying degrees of redness. The treatment programs for vulvar pain syndrome are as diverse as the multitude of etiological hypotheses. This review includes data pointing out those therapeutic measures that appear valueless and that may add to the patient's chronic discomfort.

Pregnancy Is Associated With a Lower Risk of Onset and a Better Prognosis in Multiple Sclerosis

Abstract: The effects of pregnancy were studied in a multiple sclerosis incidence cohort. In order to eliminate interaction bias between the disease and pregnancy, analysis of the risk of relapse during pregnancy and the puerperium was limited to the onset bout, using fecundity figures for Sweden. The risk of onset bout was significantly reduced during pregnancy while the risk of onset bout in the post-partum period did not differ significantly from the risk during non-pregnancy periods. We also found a decreased risk of multiple sclerosis onset in parous compared with nulliparous women. The association between nulliparity and multiple sclerosis tended to increase with age. Furthermore, the effect of pregnancy on the long-term prognosis in established multiple sclerosis was analysed by comparing the risk of change from a relapsing-remitting to a chronic progressive course and the risk of reaching level 6 of the Disability Status Scale in women with pregnancy after multiple sclerosis onset with that in non-pregnant control patients, matched for neurological deficit, disease duration and age. There was a significantly decreased risk of a progressive course in women who were pregnant after multiple sclerosis onset.

Effects of Tamoxifen on Uterus and Ovaries of Postmenopausal Women in a Randomised Breast Cancer Prevention Trial

Abstract: Randomised, double-blind controlled trials have been started to determine whether tamoxifen can prevent or delay development of breast cancer in healthy women with a family history of the disease. We recruited a randomised cohort of 111 postmenopausal women (aged 46-71 years) from the Pilot Breast Cancer Prevention Trial at the Royal Marsden Hospital to study the effect of tamoxifen on the uterus and ovaries. The main outcome measures were obtained by transvaginal ultrasonography with colour doppler imaging and microscopic examination of endometrial biopsies removed at the time of the scan. There was no significant difference between tamoxifen (20 mg/day) and placebo groups in the age of the women, or the time of the scan (and sampling) after randomisation. Women taking tamoxifen had a significantly larger uterus and a lower impedance to blood flow in the uterine arteries. 39% of women taking tamoxifen had histological evidence of an abnormal endometrium compared with 10% in the control group. 10 patients in the tamoxifen group (16%) had atypical hyperplasia and another 5 (8%) had a polyp. Women with a histological abnormality had a significantly thicker endometrium and a decreased impedance to blood flow in the uterine arteries. There was no correlation between the presence of uterine abnormalities and the age of the women, or the concentrations of tamoxifen or desmethyl tamoxifen in the peripheral blood. These findings confirm that tamoxifen can cause potentially malignant changes in the endometrium of postmenopausal women. Transvaginal ultrasonography can be used to identify those women who should have endometrial samples removed for microscopic analysis.

Prenatal Diagnosis of Congenital Toxoplasmosis With a Polymerase-Chain-Reaction Test on Amniotic Fluid

Abstract: Background Congenital infection with Toxoplasma gondii can produce serious sequelae. However, there is little consensus about screening during pregnancy, and the tests used to establish a prenatal diagnosis of toxoplasmosis are complex and slow. We evaluated a simpler approach that is based on a polymerase-chain-reaction (PCR) test. Methods Prenatal diagnostic tests, including ultrasonography, amniocentesis, and fetal-blood sampling, were performed in 2632 women with T. gondii infection acquired during pregnancy. In 339 consecutive women, a competitive PCR test for T. gondii was performed on amniotic fluid, and its results were compared with those of conventional diagnostic tests. The PCR test targets the B1 gene of T. gondii, uses an internal control, and can be completed in a day. Positive tests were confirmed by serologic testing of newborns or by autopsy in terminated pregnancies. Results Overall, the risk of fetal infection was 7.4 percent, but it increased sharply with gestational age. Congenital in...

Low Implantation Rate After In Vitro Fertilization in Patients With Hydrosalpinges Diagnosed by Ultrasonography

Abstract: The purpose of this study was to assess whether patients with tubal infertility and a hydrosalpinx have a reduced implantation rate after in-vitro fertilization. The study included 741 patients who had 1190 consecutive oocyte aspirations. The presence or absence of hydrosalpinges was assessed by transvaginal ultrasonography on day 2 of all cycles. In 62 patients treated in 104 cycles a hydrosalpinx was diagnosed, whereas 493 patients treated in 813 cycles had no hydrosalpinx and eight patients treated in 16 cycles had uncertain hydrosalpinx. The results show that the presence of a hydrosalpinx is associated with a reduced pregnancy rate per aspiration (19.2 versus 32.6%; P < 0.01), reduced implantation rate (2.9 versus 10.3%, P < 0.0005), reduced delivery rate per aspiration (5.8 versus 20.9%, P < 0.0005), reduced delivery rate per embryo transfer (6.6 versus 22.8%, P < 0.0005) and increased early pregnancy loss (70 versus 36%, P < 0.005). Among 178 patients with unexplained infertility or other infertility factors treated with 257 aspirations the results were similar to those in patients with tubal infertility without a hydrosalpinx. In conclusion, the presence of a hydrosalpinx does not impair the number of embryos transferred but seems to impair the implantation process. We hypothesize that this may be due to leakage of fluid into the uterine cavity which may disturb the receptivity of the endometrium and/or the developing embryos.