Search

Isolated bilateral pleural effusion with mediastinal compression leading to hydropic change of the fetus is unusual, and carries a high risk of perinatal death. This condition can be reversed in utero by performing ultrasound-guided shunting surgery. We describe a hydropic fetus at 30 weeks' gestation with rapid recurrence of pleural effusion after thoracentesis. The pleural effusion and hydrops resolved within 1 week after ultrasound-guided thoracoamniotic shunt and the fetal lungs were restored to their normal size. The fetus was born at 35 weeks' gestation and had an uneventful postnatal course. The technique of restoring cardiopulmonary function in utero through intrathoracic decompression offers a valuable alternative to repetitive prenatal thoracentesis or preterm delivery of fetuses with hydrops caused by bilateral pleural effusion.

We reviewed 722 laparoscopically assisted vaginal hysterectomies performed between March 1991 and March 1996 at our institute, looking at the management of major complications. The indications for hysterectomy included adenomyosis, myoma uteri, intractable menorrhagia, endometriosis, and severe pelvic adhesion. During 1 to 6 years' follow-up, there were 12 (1.7%) major complications, comprising six bladder injuries, one iliac artery perforation, two bowel injuries, two cases of partial intestinal obstruction, and one pelvic abscess. Four complications were repaired successfully by laparotomy, six were repaired laparoscopically or vaginally, and two were treated conservatively. All the cases with visceral injuries were detected intraoperatively, therefore, adequate repair operations could be performed uneventfully. Early detection and treatment allow complications to be resolved more easily.

The ability to diagnose and detect the presence of debilitating and life-threatening diseases would be an invaluable asset to those involved in in vitro fertilization programs. To investigate the possibility of diagnosing severe alpha-thalassemia before implantation, DNA sequences targeting the abnormal deletion breakpoint and the normal region of the alpha-globin gene were amplified by polymerase chain reaction from blastomeres aspirated from human preimplantation embryos. Before performing this experiment, a mouse model blastomere aspiration technique was examined to confirm embryo survival and normal development capability. The mouse embryos showed undisturbed development in the five- to seven-, as well as the eight-cell stages when one, or two (eight-cell stage only) blastomeres were aspirated. The four-cell embryos had a lower survival rate but had a blastocyst formation rate comparable to the more advanced stages and the control embryos. In the human embryo experiment, no homozygous Southeast Asian alpha-thalassemia was detected in the aspirated blastomeres, although two heterozygotic alpha-thalassemia embryos were discovered. The sensitivities of targeting sequence detection in the mouse and human blastomeres were between 50% and 76% in the respective groups. This study supports the feasibility of preimplantation diagnosis of severe alpha-thalassemia when both father and mother are carriers of this inheritable disease.

Circulating levels of insulin-like growth factor-I (IGF-I) and insulin-like growth factor-binding protein-1 (IGFBP-1) in Taiwanese women during normal pregnancy were investigated. Three hundred and eighty-five pregnant women at various gestational ages and 30 nonpregnant females were recruited into the study. Serum concentrations of IGF-I and IGFBP-1 were determined by immunoradiometric assay (IRMA) and radioimmunoassay (RIA). Maternal serum levels of IGF-I increased as pregnancy progressed. Circulating IGF-I levels in women during the first trimester of pregnancy were higher than those in nonpregnant females. Serum levels of IGFBP-1 rose rapidly before 12 weeks of gestation and remained high until term. Serum IGFBP-1 levels in pregnant women during the first trimester were significantly higher than those in nonpregnant females. However, there was no difference in maternal serum IGFBP-1 levels between the second and the third trimester of pregnancy. It is concluded that serum IGF-I levels during pregnancy may be regulated by various classes of IGF-binding proteins other than IGFBP-1.

To investigate the association between low amniotic fluid alpha-fetoprotein (AFP) and trisomy pregnancies, we retrospectively reviewed 26 trisomy pregnancies including 18 fetuses with Down's syndrome and eight with trisomy 18. The amniotic fluid AFP median values of Down's syndrome, trisomy 18, and the study groups were 0.73 MoM, 1.15 MoM, and 0.85 MoM, respectively. There was a significant difference between the mean values of the Down's syndrome-affected fetuses (0.78 +/- 0.29 MoM) and that of the control group (p < 0.001), whereas no such difference was found for that of trisomy 18-affected fetuses (1.16 +/- 0.38 MoM). Only three patients in the study group (3/26, 11.5%) had an amniotic fluid AFP value below 0.5 MoM, including the two cases of Down's syndrome (2/18, 11.1%) and one case of trisomy 18 (1/8, 12.5%). Most of the values for the trisomy pregnancies were within the normal range, thereby precluding the possibility of using this measurement as an alternative to fetal karyotyping as a screening test for Down's syndrome or other trisomy pregnancies.

To assess the relationship between alpha-fetoprotein (AFP) concentrations of amniotic fluid and maternal serum from 16 to 18 weeks' gestation, 890 paired samples of maternal serum and amniotic fluid were collected from women with normal singleton pregnancies. The gestational age was determined by ultrasonographic dating before amniocentesis, and the AFP measurements were performed by a single reference laboratory. There was a significant rise in the maternal serum AFP (MSAFP) concentration from 16 to 18 weeks' gestation. Amniotic fluid AFP concentrations significantly declined from 16 to 18 weeks' gestation. This study failed to demonstrate any statistical relationship between the AFP concentration of maternal serum and amniotic fluid (r = 0.031). This finding indicates that amniotic fluid AFP levels cannot be predicted by MSAFP levels between 16 and 18 weeks' gestation. Simple diffusion may not be the only mechanism for the transfer of AFP through the fetal membrane to maternal circulation.

Insulin-like growth factor-binding proteins (IGFBPs) in sera from non-pregnant and pregnant women, and from the umbilical cord at the time of delivery, were separated by gel filtration chromatography. The binding characteristics of the 150 and 40 kDa binding proteins were examined by Scatchard analysis. In serum from pregnant women, the affinity of the 150 kDa binding proteins (IGFBP-3) decreased as pregnancy progressed, with an apparent increase in the maximum binding capacity. In contrast, the affinity of the 40 kDa binding proteins showed a slight increase. In umbilical cord serum, the binding affinity of both the 150 and 40 kDa binding proteins was similar, whereas the binding capacity was two-fold higher in the 40 kDa than in the 150 kDa group. Both maternal and umbilical cord serum (artery and vein) contained unoccupied IGFBPs. Following acid treatment, there was an increase in binding of 125I-IGF-I to umbilical cord serum but a decrease in that to maternal serum. These changes in the characteristics of the binding proteins in the pregnancy sera are probably due to partial degradation of the 150 kDa binding proteins by proteases. The present data confirm that IGFBP-3 is the main binding protein for IGFs during pregnancy, although its affinity is decreased. In fetal circulation, the 40 kDa binding proteins appear to be the major IGFBP with a high affinity and high capacity.

Fecundity rates were measured for 343 patients in 467 cycles of ovulation induction with intrauterine insemination (IUI) from January 1990 to April 1992. Total pregnancy rate per cycle (PR) was 15.6% with a spontaneous abortion (SA) rate of 19.2%, an ectopic pregnancy (EP) rate of 4.1%, a multiple pregnancy (MP) rate of 19.2%, and an ongoing or live-birth (LB) rate of 12.0%. Using gonadotropins as a unique or as an additional stimulatory reagent improved the pregnancy rate of anovulatory patients by more than three-fold over use of clomiphene citrate (CC) alone (33.3% vs 10.7%). In other diagnostic entities, the PRs were higher, but the difference was not statistically significant between these two stimulation protocols (13.9% vs 8.4%; t = 1.70, p > 0.05). Pretreatment sperm motility and the post-treatment total motile sperm count were significantly correlated with the PRs. The same phenomena occurred when the number of follicles > or = 12 mm and the serum estradiol concentrations were taken into account. The highest PR was detected when the endometrial thickness fell between 8 and 13 mm. The spontaneous abortion rate was higher in CC only cycles and when the serum E2 was below 1000 pg/mL on the day human chorionic gonadotropin was administered. A multiple pregnancy could be predicted when a cycle of more than 10 follicles > or = 12 mm was detected (44.4%). The complications of controlled ovarian hyperstimulation with IUI were low and mild in our study, comprising six cases of moderate to severe ovarian hyperstimulation syndrome and three cases of acute pelvic inflammatory disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Forty-six consecutive cases of laparoscopic management of ovarian tumors are reported. In the present study, patients were not included if there was any suspicion of malignancy. Indications for laparoscopic management of ovarian tumors included ovarian cyst (n = 20), endometrioma (n = 22), dermoid cyst (n = 3) and gonadal dysgenesis (n = 1). Postoperative intra-abdominal bleeding occurred in one case in our series and laparotomy was then performed for check-up. The average hospital stay was 2.4 days. The entire tumor was removed through the infraumbilical incision or through the culdotomy. Laparoscopic management of ovarian tumors is a cost-effective and safe procedure.

We report the results of a prospective trial using a loop electrosurgical excision procedure (LEEP) on 97 patients with cervical intraepithelial neoplasia. In the LEEP group the mean cutting time and whole procedure time were 6.2 +/- 1.9 seconds and 12.7 +/- 3.5 minutes, respectively. The average blood loss was 3.6 +/- 1.9 mL. In the control group (39 cases) using laser conization, the mean cutting time and whole procedure time were 11.7 +/- 3.5 minutes and 44.9 +/- 8.9 minutes, respectively. The average blood loss in the control group was 11.2 +/- 3.1 mL. The differences between the two groups were statistically significant. During LEEP surgery, four cases had accidental vaginal excision. There were three cases of late cervical bleeding after surgery; the surface of the cervix was smooth, and no adhesion or crypt formation was noted after re-epithelialization. Eight patients became pregnant after the loop excision and no cervical incompetence was noted during antenatal care. After a one-year follow-up period in the colposcopy clinic, there was no recurrence of cervical intraepithelial neoplasia in either group. We advise that among the modalities of treatment for cervical intraepithelial neoplasia, LEEP appears to offer patients several benefits such as less bleeding, precise specimens, local anesthesia, less cost and less discomfort. It is particularly suitable for treating younger women who have not yet completed their families.

A case of adenocarcinoma of the sigmoid colon during pregnancy is reported. The patient presented with anemia and a painless mass over the left abdomen without gastrointestinal discomfort, making this case different from 25 previously reported cases of colon carcinoma above the peritoneal reflection associated with pregnancy.

A case of recurrent small-cell carcinoma of the uterine cervix, initially presenting with cardiac tamponade, is reported. After pericardiotomy, the patient was treated with an alternating combination of chemotherapy, which included cisplatin plus etoposide (CE) and cyclophosphamide, adriamycin plus vincristine (CAV). A partial response, with relief of a cough and diminishing metastatic pulmonary lesions, was noted from serial chest roentgenographs after the initial three cycles of chemotherapy. The patient did not receive any further treatment and the recurrent cough and dyspnea were noted two months later. In spite of the same chemotherapeutic regimen and chest radiotherapy, the patient died nine months after the initial diagnosis of metastasis.

From March to November 1991, 24 patients underwent laparoscopic hysterectomies at Chang Gung Memorial Hospital, Taipei. The indications for hysterectomies included seven patients with adenomyosis, 14 with myoma uteri, one with intractable menorrhagia, and two with endometriosis and severe pelvic adhesions. The surgeries were performed using the techniques of videolaparoscopy, including a combination of Kleppinger bipolar forceps for hemostasis and scissors and/or CO2 laser for lysis of adhesions. The mean blood loss was 210 mL; there was one bladder injury during these procedures. Most of the patients were discharged on the second postoperative day. The advantages of a laparoscopic hysterectomy include a short hospitalization, low blood loss and less postoperative discomfort. Laparoscopic hysterectomy is a cost-effective and safe procedure.

The pregnancy rates for the gamete intra-fallopian transfer (GIFT) and tubal embryo transfer (TET) methods have been shown to be high. The oviductal environment appears to be suitable for fertilization and subsequent cleavage. Many authors have reported that when co-cultured with human ampullary cells, the embryos can develop in vitro as well as in vivo. Thus, significantly more embryos reach the early blastocyst stage, and more successful implantation may be obtained. However, the characteristics of the ampullary cells may change after a series of sub-cultures. In this study, we compared the first and the seventh sub-culture ampullary cell co-cultured systems with a control group. There were significantly more embryos cleaved to blastocysts in these two co-cultured systems than in the control group, but no significant difference between these two co-cultured systems. Detoxification of the medium by co-cultured cells may play an important role in improving embryo quality.

We present a case of non-mosaic trisomy 20 in amniotic fluid associated with major congenital anomalies. A detailed prenatal ultrasonic examination was performed, and revealed dilatation of the cisterna magna and the fourth ventricle with hypoplasia of the vermis of the cerebellum. Fetal echocardiography showed overriding aorta and ventricular septal defects with pulmonary atresia. However, the karyotype of the lymphocyte in the cord blood was normal female 46, XX. The occurrence of the Dandy-Walker malformation in non-mosaic trisomy 20 has not been reported before, and the clinical significance of this major defect for prenatal diagnosis is discussed.

Ectopic pregnancies continue to be a major complication of in vitro fertilization and embryo transfer (IVF-ET). A case of bilateral simultaneous tubal pregnancy after IVF-ET is described. The patient underwent ovum pick-up (OPU) through a laparotomy with concomitant pelvic surgery. Embryo transfer (ET) was performed two days after OPU; this resulted in bilateral tubal pregnancies, diagnosed and treated one month apart. There are several possible causal mechanisms for the increased rate of ectopic pregnancies following IVF-ET. It is important to recognize that care in the transfer technique, with respect to the catheter position and limiting the volume of transfer medium to 20 microL, and an awareness of previous occlusion of the tubal ostia, or of a salpingectomy before IVF-ET, can help to minimize this complication rate. Two important points are the possibility of a simultaneous bilateral tubal pregnancy after IVF-ET, and the necessity of carefully examining both adnexa at the time of surgery for an ectopic pregnancy. Early and accurate diagnosis of a simultaneous bilateral ectopic pregnancy can prevent the necessity of a second operation and reduce maternal morbidity and mortality.

From 1982 to 1984, 189 patients with stage Ib carcinoma of the uterine cervix underwent radical abdominal hysterectomies as primary treatment at Chang Gung Memorial Hospital. Of these patients, six were lost to follow-up. Nineteen of the 183 patients with regular follow-up recurred at intervals of from 9 to 55 months. An assessment of prognostic factors was made by reviewing the chart and pathological findings and correlating them with the patient's present status. Using univariate analysis, bulky tumor size was found to bear the greatest risk of tumor recurrence. Six of the 15 patients (40%) with a diameter of more than 4 cm recurred. The other risk factors included parametrial involvement, histologic type of adenosquamous or adenocarcinoma, lymph node metastasis, poor differentiation, deep cervical stromal invasion, and lymphatic or vascular space invasion. In conclusion, analysis of prognostic factors identified a group of patients at high risk of recurrence and decreased survival, for whom prospective trials of adjunctive treatment should be considered.

Infertility and amenorrhea are reported in most cases of Wilson's disease. In this report, we describe a case of Wilson's disease with pancytopenia and liver cirrhosis for over 4 years, without any specific treatment. After 2 years of D-penicillamine therapy, the patient became pregnant and delivered a liver mature female baby with a body weight of 2,800 g. Both before the pregnancy and after delivery, brainstem auditory evoked potential studies showed similar bilaterally abnormal prolongation in the III-V and I-V intervals. In visual evoked potentials, the P 100 latency was delayed bilaterally. Although serial evoked potential studies failed to show any improvement, a successful pregnancy was proven to be possible in a patient with Wilson's disease who had received regular D-penicillamine treatment.

Peripartum cardiomyopathy is defined as the development of heart failure during the later part of pregnancy or during the first three to six postpartum months, without an obvious underlying cause or prior evidence of cardiac disease. We present one case of peripartum cardiac failure which occurred in a 25-year-old primigravida with twin gestation. The patient underwent an emergency Cesarean section followed by successful medical treatment. An endomyocardial biopsy was performed 12 days after delivery and the pathological changes were consistent with the diagnosis of peripartum cardiomyopathy.

Appropriate interpretation of monitored fetal growth throughout pregnancy in individual patients and populations is dependent upon the availability of adequate standards. Previously published standards either were based on small samples, data decades old or were characteristic of foreign subpopulations. We have reviewed the data on a series of 46,575 singleton live births at Chang Gung Memorial Hospital from 1979 to 1989. The ratio of males to females was 1.08. The fetal growth pattern in the third trimester of pregnancy approximates a sigmoid curve. Fetal growth was most rapid from the 32nd to the 37th week of gestation with an average increase of 240 g per week. The birth weight declined beyond 42 weeks' gestation. There were significantly greater weight gains amongst male fetuses as compared to female fetuses from the 34th to the 42nd week of gestation. The mean birth weight recorded at 40 weeks' gestation in male and female newborns was 3,381 g and 3,262 g, respectively. Comparing the birth weight of term pregnancies using our data, with those of a previous, two-decade old report (1945-1967) by Chen, we found that birth weight were slightly higher in this study. The derived fetal growth curves are useful for clinical, public health, and investigational purposes.

We describe one case of endocardial cushion defect during the second trimester when a consultative fetal echocardiography was undertaken for fetal intrauterine growth retardation with oligohydramnios. Positive cytomegalovirus IgM in cord blood and cytomegalovirus DNA particles in the amniotic fluid were found incidentally. The relationship between possible intrauterine cytomegalovirus infection and the endocardial cushion defect in this case is not clear.

Since the immunological interaction between a mother and her intrauterine embryo is thought to be very important and since the human leukocyte antigens (HLA) are considered to be the most important correlative immunoresponsive antigens presently known, the present study was designed to investigate the HLA phenotype frequencies and antigen sharing percentages in couples suffering from recurrent abortion, as compared with normal fertile couples. The results showed that there were no HLA associations among these groups. The sharing study analyzed the similarities between single antigen groups (A, B, C, and DR) and multiple antigen complexes (AB and ABDR). The incidences for sharing more than one single antigen were 63.9%, 44.4%, 61.1% and 30.6% in the study group and 57.1%, 22.9%, 71.4% and 40.0% in the control group. Sharing of more than two antigens in the multiple antigen combinations were 36.2%, 47.2% for the study group and 22.9%, 42.9% for the control group. The statistical analyses reveals no significant differences. We conclude that although immunological reaction during the periimplantation period may be important and may play a role in later pregnancy stages, no single HLA antigen presentation or sharing of a certain number of antigens is related to the prognosis of pregnancy outcome.

In this study the levels of lead, arsenic, cadmium and mercury were measured by the method of graphite-furnace atomic absorption spectrophotometry in paired maternal and fetal cord blood (n = 168) collected from three cities in Taiwan, (Kaohsiung, Taipei and Keelung). The mean values of those heavy metals were within normal limits. There was no difference in levels by maternal parity or fetal sex. The mean value for the level of lead in maternal blood was 64.8 micrograms/L, and 40.9 micrograms/L for the umbilical-cord blood; comparing the three locations by ANOVA analysis, there was no difference in maternal or fetal blood levels. Mean maternal As concentrations (6.8 +/- 0.58 micrograms/L) and umbilical cord blood levels (7.9 +/- 0.67 micrograms/L) were within reference levels. The mean Cd concentrations in maternal blood were (1.30 micrograms/L) significantly higher than that of the umbilical-cord blood concentrations (0.78 micrograms/L). The maternal Cd concentrations (1.62 micrograms/L) of Kaohsiung were significantly higher than that (1.24 micrograms/L) of Taipei. The fetal Cd concentrations of Kaohsiung (1.04 micrograms/L) were also significantly higher than those (0.7 micrograms/L, 0.6 micrograms/L) of Taipei and Keelung. The mean umbilical-cord blood Hg concentration (28.8 micrograms/L) was higher than that (19.4 micrograms/L) of maternal blood. The maternal Hg concentrations of Taipei were significantly higher than those of Keelung. The fetal Hg concentrations (28.8 micrograms/L) of Taipei were also marginally higher than that of Keelung and Kaohsiung.