Detection of congenital müllerian duct anomalies using three-dimensional ultrasound

PURPOSE: The purpose of this study was to assess the value of 3-dimensional sonography in the diagnosis of congenital müllerian duct anomalies, which cause infertility, preterm labor, and first trimester abortion. METHODS: A prospective study was undertaken in which 40 patients with histories of repeated spontaneous abortions or infertility were first examined using conventional 2-dimensional sonography or hysterosalpingography. Three-dimensional transvaginal sonography was then performed. RESULTS: Twenty-eight women had müllerian duct abnormalities, and 12 women had normal uterine anatomy. Müllerian duct defects detected in this study were unicornuate uterus (3), bicornuate uterus (3), complete or partial septate uterus (12), arcuate uterus (9), and didelphic uterus (1). The diagnosis of müllerian duct anomalies in these patients was confirmed by laparoscopic and/or hysteroscopic examinations. Three-dimensional sonography demonstrated all congenital uterine abnormalities with a sensitivity and specificity of 100%. Separate uterus and bicornuate uterus could be correctly diagnosed using 3-dimensional sonography in 11 (92%) of 12 cases and 3 (100%) of 3 cases, respectively. These 2 abnormalities were commonly confused with each other using hysterosalpingography and conventional sonography. CONCLUSIONS: Three-dimensional sonography with image reconstruction is less expensive and less invasive than hysterosalpingography for the assessment of uterine anatomy and diagnosis of müllerian duct abnormalities. The ability to visualize both the uterine cavity and the myometrium on a 3-dimensional scan facilitates the diagnosis of uterine anomalies and enables the differentiation of septate from bicornuate uteri for preoperative surgical planning.     

A random single Doppler study of the umbilical artery in the evaluation of pregnancies complicated by diabetes

To evaluate a random single Doppler study of the systolic to diastolic ratio of the umbilical artery as a predictor of perinatal outcome in diabetic pregnancies, a prospective double-blind study was performed in 92 diabetic pregnant women between 28 and 40 weeks of gestation. Main outcome measures were perinatal outcome: group A, normal outcome; group B, poor outcome. The sensitivity and specificity of the Doppler studies as a predictor of poor perinatal outcome were 39% and 92%, respectively. The positive and negative predictive values were 54% and 86%, respectively. Our results suggest that the systolic to diastolic ratio of the umbilical artery offers no advantage over other well-established tests in the management of diabetic pregnancies.     

Serum levels of müllerian inhibiting substance in preterm and term male neonates

PURPOSE: Müllerian inhibiting substance, also called anti-müllerian hormone, is responsible in the embryo for the regression of the müllerian structures. During the second and third trimesters the physiological functions that müllerian inhibiting substance may have after the period of müllerian duct regression are poorly understood. We obtained information on müllerian inhibiting substance levels in the male newborn during this period of gestation. MATERIALS AND METHODS: Müllerian inhibiting substance was measured by an enzyme immunoassay in cord blood obtained at birth in 27 preterm (25 to 36 weeks of gestation) and 92 term (37 to 42 weeks) male neonates. RESULTS: Cord serum müllerian inhibiting substance concentrations were relatively high from 25 to 31 weeks (mean plus or minus standard deviation 86.4 +/- 36.1 ng./ml.) and then they decreased from 32 weeks to term (mean 24.2 +/- 14.0 ng./ml.). CONCLUSIONS: The decline early in the third trimester may be consistent with müllerian inhibiting substance having a function during the second but a diminished role in the third trimester.     

Potential anxiolytic-like activity of some amino acid derivatives

This report describes a case of uterine didelphys, lipomeningocele, meatal stenosis, and inguinal hernia presenting in a single individual. This unusual group of birth defects suggests a common mechanism of malformation in tailbud maturation which involves both the müllerian duct and the distal spinal cord.     

Introduction to microscopic research of silver halides and related dispersed systems

> Objective: To establish whether uterine artery flow velocity waveforms in the second trimester are associated with adverse pregnancy outcome in women with a poor obstetric history. Methods: We reviewed the obstetric case notes of 50 women with a poor obstetric history in previous pregnancies in whom uterine artery flow velocity waveforms had been obtained at 18 weeks gestation. Results: In this population 40% had an adverse pregnancy outcome (preeclampsia, pregnancy-induced hypertension, preterm delivery, birthweight <10th percentile or perinatal death). Preeclampsia, perinatal death, and preterm delivery were all significantly associated with abnormal uterine artery waveforms at 18 weeks. Conclusions: Assessment of uterine artery flow velocity waveforms at 18 weeks gestation shows promise as a screening test in the high risk obstetric population. The technique requires formal evaluation in a prospective, double blinded study.     

Noncommunicating accessory uterine cavity

OBJECTIVE: To report a case of a noncommunicating accessory uterine cavity. DESIGN: Case report. SETTING: University-affiliated reproductive endocrinology practice. PATIENT(S): A 15-year-old nulligravida with increasing dysmenorrhea. INTERVENTION(S): Pelvic ultrasound, intravenous pyelogram, hysterosalpingogram, laparoscopy, laparotomy, and resection of noncommunicating accessory uterine cavity. MAIN OUTCOME MEASURE(S): Results of imaging studies, surgical examination, and resection of anomaly. RESULT(S): Complete resection of accessory cavity and resolution of dysmenorrhea. CONCLUSION(S): The patient had a müllerian anomaly in which the uterus contained two uterine cavities. One normal uterine cavity with communication to both fallopian tubes was present along with a noncommunicating, accessory uterine cavity.     

Endoscopic management of a case of complete septate uterus with unilateral pyometra

We report a case with an unusual müllerian anomaly: complete uterine septum and pyometra in the right hemicavity and pyocolpos along with a longitudinal vaginal septum. A patient with recurrent low-grade fever and lower abdominal pain was admitted. Pyometra and pyocolpos were detected in the right uterine hemicavity and in the right hemivagina. The septa were resected, the cavities were irrigated, and the patient was treated with antibiotics. The patient conceived 8 months later. Patients with abnormal vaginal findings should be approached with caution; precise knowledge of urogenital anatomy and urogenital anomalies is necessary in the management of these patients.     

Diagnosing the combination of renal dysgenesis, Gartner's duct cyst and ipsilateral müllerian duct obstruction

PURPOSE: We describe the differential points in the diagnosis of the combination of renal dysgenesis, Gartner's duct cyst and ipsilateral müllerian duct obstruction. Various imaging studies and urological procedures were performed. We report our experience in detecting these anomalies in 10 girls and review the literature. MATERIALS AND METHODS: Ten girls, 7 to 13 years old, with this combination of anomalies were identified in the last 10 years. Imaging studies as well as urological procedures were selectively performed, especially at puberty following menarche. Patients received long-term followup with ultrasound. RESULTS: Cystic dilation of Gartner's duct protruded into the bladder and presented as a ureterocele in 5 patients and posterior to the bladder in 5. Surgical removal of a partial portion of a Gartner's duct cyst was performed in 5 patients for alleviation of urinary symptoms. Unilateral müllerian duct obstruction was demonstrated in all 10 patients. Excision of the vaginal septum was performed in 6 patients for relief of genital obstruction. CONCLUSIONS: When cystic dilatation of the pelvis, especially a ureterocele-like cyst without ureteral dilatation, is found in girls with ipsilateral renal dysgenesis, the possibility of a Gartner's duct cyst should be considered. For early detection and treatment of unilateral obstruction of duplicated müllerian ducts pelvic sonography should be performed at puberty, especially just after menarche, in girls with renal dysgenesis and ipsilateral Gartner's duct cyst.     

Acremolactone A, a novel herbicidal epoxydihydropyranyl gamma-lactone from Acremonium roseum I4267

OBJECTIVE: The objective of our study was to clarify the effect of the maternal prone position on the feto-placental flow. In this position, the uterine compression of the large maternal vessels was expected to be completely eliminated. METHODS: Twenty-three normal pregnant women were cross-sectionally examined in the supine, the left lateral, the right lateral and the prone position. The systolic/diastolic ratios for the umbilical artery were calculated for each position. RESULTS: The umbilical arterial systolic/diastolic ratio in the prone position significantly decreased compared with that in the supine position. The left and right lateral position showed no significant change in the systolic/diastolic ratio. CONCLUSION: The maternal prone position can provide complete relief of uterine compression of the large maternal vessels.     

The relationship between umbilical artery Doppler findings, fetal biophysical score and placental inflammation in cases of premature rupture of membranes

BACKGROUND: To assess the relationship between placental inflammation, umbilical artery Doppler waveforms and fetal biophysical profile score, umbilical artery Doppler studies and fetal biophysical evaluations were performed in 24 preterm pregnants with premature rupture of membranes (PPROM). SUBJECTS: After delivery, the placentas were microscopically examined and two subgroups were formed including noninflamed or inflamed placentas. RESULTS: In the first group, which includes 14 cases with no histological signs of placental inflammation, we found increased systolic/diastolic ratio only in one patient, whereas in the second group including ten cases with microscopically proven inflammation, nine were found to have increased systolic/diastolic ratios (p < 0.05). Mean systolic/diastolic ratio in the first and the second groups were 2.74 +/- 0.18 and 4.64 +/- 0.93 respectively (p < 0.001). Mean biophysical profile score was 9 +/- 1.04 in the first group and 7 +/- 1.05 in the second group (p < 0.001). CONCLUSION: Abnormal biophysical profile scores along with increased arterial systolic/diastolic ratios have been shown to be the markers of impending clinical infection.     

Premenstrual dysphoric disorder: controversies surrounding the diagnosis

OBJECTIVE: To evaluate the umbilical and uterine arterial Doppler flow velocity waveform systolic to diastolic (S/D) ratios performed at 24-30 weeks gestation for predicting fetal growth retardation (IUGR). METHODS: A prospective double blind study was conducted in 118 cases of high risk singleton pregnant women. The umbilical and uterine arterial S/D ratios were measured at 24-30 gestational weeks and the pregnancy outcomes were followed up. RESULTS: The prevalence of IUGR in our study population was 16.9%. At 24-30 weeks gestation, the S/D ratio of both umbilical artery and uterine artery in IUGR pregnant women were significantly higher than those in normal pregnant women, while the fetal biometric measurements were normal in all the 118 cases. The sensitivity, specificity and positive predictive value of umbilical arterial S/D ratio to predict IUGR were 80.0%, 83.7% and 50.0% with a Kappa index of 0.51 at 24-30 weeks gestation. With lower sensitivity, specificity, positive predictive value and Kappa index (40.0%, 84.5%, 34.8% and 0.23 respectively), the uterine arterial S/D ratio had less predictive value. CONCLUSIONS: The umbilical arterial Doppler flow velocity waveform S/D ratio may be an earlier predictor for screening of IUGR at 24-30 weeks gestation in high risk pregnant women with normal fetal biometric measurements.     

Incidental finding of Zygomyceteslike hyphae in the placenta. A case report

Persistent müllerian duct syndrome (PMDS) is a rare form of male pseudohermaphroditism. We present 5 cases with PMDS (2 cases associated with testicular malignancy) and discuss the diagnosis and management. Management strategies of PMDS have changed. Whereas in the past, removal of the müllerian remnants was targeted together with orchidopexy or -ectomy, this is no longer recommended. However, testicles that cannot be descended at an early stage are at a high risk of malignancy and should, therefore, be removed. If this is necessary on both sides, there is the additional problem of lifelong testosterone substitution which requires efficient patient monitoring and good patient compliance. In cases where this cannot be achieved, compromises, such as temporarily delayed orchidectomy, may be considered.     

Programmed cell death in the Müllerian duct induced by Müllerian inhibiting substance

The importance of a secretory product of the fetal testis, Müllerian Inhibiting Substance, in determining the fate of the Müllerian duct in the developing male fetus has been well documented. The present investigation has examined the mechanism of action of Müllerian Inhibiting Substance in the male rat fetus during the course of Müllerian duct degeneration. The action of Müllerian Inhibiting Substance mimics the general morphogenetic phenomenon of "programmed cell death," although important diferences were found compared to the majority of other studies of cell death. The initial morphological event in the degenerating Müllerian duct is an increase in lysosomes within the duct cells. Following loss of polarity and orientation, the duct cells are subsequently removed by invading macrophages from the surrounding mesenchyme. Concommitant with the differentiation of these macrophages, the adjacent mesenchyme assumes a characteristic whorled pattern around the degenerating Müllerian duct. Cytochemical localization of acid phosphatase confirmed the presence of newly formed lysosomes within the Müllerian duct cells and subsequently within the cytoplasm of the invading macrophages.     

Successful pregnancy outcome in uterus didelphys with leiomyoma uteri

Müllerian anomalies are in different degrees complicated by poor fetal outcome. Our young patient had in addition to uterus didelphys a leiomyoma of the nonpregnant part of the double uterus. Though her pregnancy was complicated, it was conserved to 37 weeks, when the baby was delivered by cesarean section. The right uterine body with a leiomyoma weighing 1500 grams was removed at the same time.     

Determinants of the pulmonary artery pressure rise in left ventricular dysfunction

Pulmonary artery hypertension in patients with left ventricular dysfunction is related to poor outcome but the role of cardiac functional abnormalities in the genesis of pulmonary hypertension remains unknown. The aim of this prospective study was to identify the determinants of pulmonary hypertension in 102 consecutive patients with primary left ventricular dysfunction (ejection fraction < 50%). Systolic pulmonary artery pressure was measured by continuous wave Doppler. Left ventricular systolic and diastolic function, severity of functional mitral regurgitation, cardiac output, and left atrial volume were assessed using Doppler echocardiography. In patients with left ventricular dysfunction, systolic pulmonary artery pressure was increased (51 +/- 14 mmHg, range 23 to 87 mmHg). Mitral deceleration time (r = -0.61; p = 0.0001) and mitral effective regurgitant orifice (r = 0.50; p = 0.0001) were the strongest parameters related to systolic pulmonary artery pressure. Multivariate analysis identified these two variables as the strongest predictors of systolic pulmonary artery pressure in association with the mitral E/A ratio (p = 0.006) and age (p = 0.005). In conclusion, pulmonary hypertension is common and variable in patients with left ventricular dysfunction. It is closely related to diastolic dysfunction and severity of functional mitral regurgitation but not independently to the degree of left ventricular systolic dysfunction. These findings underline the importance of assessing diastolic function and quantifying mitral regurgitation in patients with left ventricular dysfunction.     

Smoking and pregnancy: search for a correlation between cotininemia and Doppler findings

OBJECTIVE: To search for a possible correlation between an effective marker of smoking and uterine and placental resistance during pregnancy. STUDY DESIGN: A prospective study was conducted at the Intercommunal Hospital Center of Montreuil, France: 81 healthy pregnant women underwent uterine and placental Doppler and cotidin blood assay, the best current test for smoking. RESULTS: This study shows a significative increase of utero-placental vascular resistances according with increased cotidine levels. CONCLUSIONS: The previously observed association between smoking and perinatal events most likely involves vascular resistance of uterus and placenta.     

Sexually dimorphic development of the mammalian reproductive tract requires Wnt-7a

An important feature of mammalian development is the generation of sexually dimorphic reproductive tracts from the Müllerian and Wolffian ducts. In females, Müllerian ducts develop into the oviduct, uterus, cervix and upper vagina, whereas Wolffian ducts regress. In males, testosterone promotes differentiation of Wolffian ducts into the epididymis, vas deferens and seminal vesicle. The Sertoli cells of the testes produce Müllerian-inhibiting substance, which stimulates Müllerian duct regression in males. The receptor for Müllerian-inhibiting substance is expressed by mesenchymal cells underlying the Müllerian duct that are thought to mediate regression of the duct. Mutations that inactivate either Müllerian-inhibiting substance or its receptor allow development of the female reproductive tract in males. These pseudohermaphrodites are frequently infertile because sperm passage is blocked by the presence of the female reproductive system. Here we show that male mice lacking the signalling molecule Wnt-7a fail to undergo regression of the Müllerian duct as a result of the absence of the receptor for Müllerian-inhibiting substance. Wnt7a-deficient females are infertile because of abnormal development of the oviduct and uterus, both of which are Müllerian duct derivatives. Therefore, we propose that signalling by Wnt-7a allows sexually dimorphic development of the Müllerian ducts.     

Hernioscopic retrieval of bowel for evaluation of viability during repair of a Richter''s-type incarcerated femoral hernia

A case of endometrial ossification in a 62 year old woman is reported. The patient presented with increased vaginal discharge. On transvaginal ultrasonography, a hyperechoic area within the uterine cavity, suggestive of an intrauterine foreign body, was noted. Histological examination of the endometrial curettage showed mature bone with neutrophilic infiltration. There was no evidence of malignancy. Endometrial ossification in postmenopausal women is very rare; most women presenting with this condition are between 20 and 40 years of age. Therefore, clinicians should consider the possibility of endometrial ossification as a differential diagnosis of intrauterine foreign body on ultrasound, even in older patients. In addition, pathologists should be aware of this rare entity to avoid a misdiagnosis of malignant mixed müllerian tumor in the endometrial curettage specimen, which may result in unnecessary hysterectomy.     

A study for predicting toxemia of pregnancy by the diastolic notch in pulsed Doppler flow velocity waveforms of the uterine arteries--quantitative analysis of the diastolic notch as uterine arterial index (UTAI)

To investigate the ability of measurement of the diastolic notch in Doppler flow velocimetry to predict development of toxemia of pregnancy, analysis of uteroplacental and fetal blood flow waveforms was performed. The waveforms were analyzed by calculating the resistance index (RI) and the pulsatility index (PI) and were investigated whether diastolic notches existed or not. In the prospective study, the uterine arterial index (UTAI; an index introduced to evaluate the degree of diastolic notch quantitatively) was also calculated. RETROSPECTIVE STUDY: The waveforms in the uterine arteries, the umbilical artery and the fetal vessel (inferior vena cava, descending aorta and middle cerebral artery) were measured in 153 pregnant women. PROSPECTIVE STUDY: Uterine artery velocimetry was performed at 16-23 weeks' gestation in 387 pregnant women. RESULT 1: Subjects with a diastolic notch had significantly higher rates of development of toxemia of pregnancy. Indexes of the fetal blood flow waveforms had no significant correlations with the development of toxemia of pregnancy. RESULT 2: UTAI showed an equivalently high negative predictive value (98.1%) and higher positive predictive value (17.6%) than RI (98.2%, 10.2% respectively) and PI (98.7%, 12.7% respectively). CONCLUSION: UTAI measurement was more useful for predicting toxemia of pregnancy than RI or PI.     

Randomised trial of management of hypertensive pregnancies by Korotkoff phase IV or phase V

BACKGROUND: There is debate about whether diastolic blood pressure should be recorded as the fourth (muffling, K4) or fifth (disappearance, K5) Korotkoff sound in pregnancy. We compared maternal and fetal outcomes and the likelihood that episodes of severe hypertension would be recorded when hypertensive pregnancies were managed according to either K4 or K5. METHODS: 220 pregnant women with diastolic hypertension (K4 > or =90 mm Hg) after the 20th week of gestation were enrolled in a prospective randomised study at two obstetric units in Australia; they were randomly assigned management with K4 (n=103) or K5 (n=117) for the remainder of the pregnancy. Clinical management was according to a uniform department protocol. Analysis was by intention to treat. All the women completed the trial. FINDINGS: An episode of severe hypertension (systolic > or =170 mm Hg, diastolic > or =110 mm Hg, or both) was more likely to be recorded with use of K4 than with use of K5 (39 [38%] vs 30 [26%] women, p=0.051), mainly because of a greater likelihood that severe diastolic hypertension would be recorded (34 [33%] vs 20 [17%], p=0.006). The frequency of severe systolic hypertension and simultaneous severe systolic and diastolic hypertension did not differ between groups. Pregnancy was prolonged by an average of 2 weeks in both groups, and there were no significant differences between the groups in laboratory data, requirements for antihypertensive treatment, birthweight, fetal growth retardation, or perinatal mortality. There was no eclampsia or significant maternal morbidity in either group. INTERPRETATION: A change from use of K4 to K5 would mean that one fewer case of severe diastolic hypertension would be recorded for every six hypertensive pregnancies, but all other episodes of severe hypertension would be recorded with similar frequency. Since the K4/K5 difference is smaller in hypertensive than in normotensive pregnant women and since K5 is closer to the actual intra-arterial pressure and more reliably detected, universal adoption of K5 to record diastolic blood pressure in hypertensive pregnancy should be considered.