Histochemical demonstration of lysosomal hydrolase activity in endometrial mononuclear cells. I. Normal endometrium.

Interstitial cell reactivity for lysosomal hydrolases was demonstrated in 67 endometrial specimens with histochemical techniques. Cyclic changes in the number of reactive cells corresponded to the stage of the menstrual cycle. Techniques for galactosidase and glucuronidase showed increasing numbers of reactive cells through the late secretory stage. Staining for glucosaminidase and nonspecific esterase also increased in late secretory endometrium. In contrast, acid phophatase activity was biphasic, and that of leucine aminopeptidase remained relatively constant. Only minimal interstitial staining was seen in prepubertal and postmenopausal specimens.     

Histochemical demonstration of lysosomal hydrolase activity in endometrial mononuclear cells. II. Abnormal endometrium.

The mononuclear cells in the endometrial stoma change in reactivity for lysosomal hydrolases during the menstrual cycle. Lymphoid follicles may occur in the stroma in any phase of the cycle and have been found in gestational endometrium. However, these cells have no significant lysosomal activity. Alterations in the endometrium are reflected in modified patterns of activity. Endometritis, association with an intrauterine contraceptive device, pregnancy, and adenocarcinoma result in increased numbers and staining intensity of mononuclear cells. In contrast, no consistent changes were apparent in foci of glandular hyperplasia, and decreased staining was seen in atrophic areas of endometrium. These data suggest that interstitial mononuclear cells are a sensitive monitor of morphologic changes in the endometrium.     

Clinical,pathologic, and genetic findings in a case of 46,XY pure gonadal dysgenesis (Swyer's syndrome): II. Presence of H-Y antigen

Evidence that expression of histocompatibility-Y (H-Y) antigen on human cells is determined by a Y-linked gene is provided by data demonstrating that male subjects with two Y chromosomes have higher antigen levels than male subjects with one Y chromosome. The widespread evolutionary conservation of H-Y antigen and its association with the Y chromosome suggest that the antigen has a specific, crucial function. We surmise that this function is the differentiation of the embryonic gonad into whichever mature gonad, testis or ovary, typifies the heterogametic sex of each species. Of particular interest are individuals whose gonadal sex does not correspond to their somatic genotype. In the present article, we report positive results in the first case of 46,XY pure gonadal dysgenesis (Swyer's syndrome) to be typed for H-Y antigen. This case suggests that the presence of H-Y antigen may not be sufficient to complete masculinization of the embryonic mammalian gonad. Alternatively, a mutant gene may govern expression of a cell surface component which cross reacts with H-Y antigen but which lacks the ability to function in the virilization of the gonad.     

Clinical,pathologic, and genetic findings in a case of 46, XY pure gonadal dysgenesis (Swyer's syndrome): I. Dysgerminoma and gonadoblastoma

Cytogenetic, pathologic, and clinical studies were conducted on a phenotypically female patient with primary amenorrhea and infertility. Analysis of blood cultures with routine and Giemsa-banded preparations indicated that the chromosomal complement of the patient was 46,XY. Buccal and peripheral blood smears prepared for fluorescent analyses confirmed the presence of a single F-body (Y chromosome). Pathologic examination of tissues removed at total hysterectomy and bilateral salpingo-oophorectomy revealed a gonadoblastoma of the right gonad, dysgerminoma of the left gonad, and an infantile hypoplastic uterus. The data were consistent with a diagnosis of 46,XY pure gonadal dysgenesis (Swyer's syndrome).     

Cytogenetics of methadone-managed and heroin-addicted pregnant women and their newborn infants.

Chromosomal damage was assessed prenatally and at delivery from 99 addicted pregnant women (80 from a methadone maintenance program and 19 heroin addicts) and their 101 off-spring at delivery. About 10% of the 27,907 cells scored showed chromosomal abberations. Chromosome damage was random, affected all chromosomes, and was mainly of the acentric fragment type. The per cent of hypodiploidy was significantly higher than the per cent of hyperdiploidy. In the mothers, no significant differences were found with respect to dosage and duration of methadone treatment and years of heroin abuse. No significant association was found between maternal variables and infant chromosome damage. Infants with low Apgar scores (1 to 6) had cells with significantly higher levels of chromosome damage than infants with higher scores (7 to 10).     

Vascular injuries in pelvic cancer surgery.

Although pelvic cancer surgery is attended by many difficulties, vascular injuries are actually rare. New techniques of isotopic and ultrasound monitoring allow objective assessment of such patients with vascular injury. In venous problems, absolutely precise diagnosis is now possible and in both arterial and venous injury, extra-anatomic reconstructions can be done which return the vascular status of the patient to near normal.     

Ultrasound evaluation of amniotic fluid volume. II. The relationship of increased amniotic fluid volume to perinatal outcome

Qualitative amniotic fluid volume determination is a routine part of fetal biophysical profile score testing. The relationship between polyhydramnios and poor perinatal outcome has been previously documented. We have undertaken a retrospective chart review which relates qualitative amniotic fluid volume as determined at the time of last biophysical profile score assessment to perinatal outcome in 7562 referred high-risk obstetric patients. Gross and corrected perinatal mortality in association with normal qualitative amniotic fluid volume ranged from 4.65/1000 and 1.97/1000, respectively, to 32.9/1000 and 4.12/1000 in association with increased qualitative amniotic fluid volume, respectively. The incidences of major congenital anomaly and fetal macrosomia were significantly related to qualitative amniotic fluid volume.     

Hormone and enzyme levels in normal and complicated pregnancy

A retrospective study of 48 high-risk pregnancies has been made. The values of two hormonal and two enzyme assays have been compared in assessing placental function. Neither of the enzyme levels (serum heat-stable alkaline phosphatase and serum diamine oxidase) were found to be of clinical value. Serum human placental lactogen levels were consistently decreased in essential hypertension and in pregnancies terminating in stillbirth. Urinary estriol estimation proved to be more reliable, especially in monitoring the “light-for-dates baby” pregnancies and those pregnancies associated with perinatal death.     

Endometrial "sarcomas" complicating ovarian thecoma, polycystic ovarian disease and estrogen therapy

Unopposed endogenous and exogenous estrogenic stimulation has been considered by most investigators to have a role in the pathogenesis of carcinoma of the endometrium. Although a few cases of "sarcomas" of the endometrium that had developed in an estrogenic setting have been reported, a clear-cut association between estrogenic stimulation and these forms of endometrial cancer has not been established. We report six cases of endometrial sarcomas complicating ovarian thecomas, polycystic ovarian disease, or prolonged estrogen therapy. Three ovarian thecomas, which are considered to be estrogenic tumors, were associated with endometrial malignant mullerian mixed tumor, mullerian adenosarcoma, and low-grade stromal sarcoma in postmenopausal women. Polycystic ovarian disease, a condition characterized by unopposed estrinism due to the peripheral conversion of excessive androstenedione to estrone, was found in a 27-year-old infertile woman with an endometrial malignant mullerian mixed tumor. A pure osteogenic sarcoma of endometrial stromal origin developed in a 28-year-old woman with gonadal dysgenesis (Turner's syndrome) who had received estrogens for 18 years. The sixth woman, with an empty sella turcica after radiation therapy of a pituitary adenoma, had an endometrial mullerian adenosarcoma at the age of 40 years after 16 years of estrogen therapy. None of these patients had had pelvic radiation therapy. The evidence from this series of cases and from six additional cases identified in the literature suggests that the risk of endometrial sarcomas may be increased by estrogen therapy or endogenous disorders that lead to unopposed estrogenic stimulation of the uterus.     

A simplified surgical technique for the treatment of the vault in vaginal hysterectomy.

The surgical steps in the various techniques to remove the uterus by vaginal hysterectomy are quite uniform; however, the handling of the vaginal cuff differs with each and all techniques reviewed. The technique here described is a simplified method that secures hemostasis, establishes drainage of the anterior vaginal wall, and creates a vaginal canal adequate for sexual function. Emphasis is placed on the inclination of the vagina, a step that brings the vaginal axis almost perpendicular to the body axis, obviating the constant bearing-down effect on the intra-abdominal pressure on the apex of the vagina. Prevention of subsequent enterocele formation is achieved by the occlusion of the weak spot between the ulterosacral ligaments, the site of the hernial sac formation.     

Nutritional evaluation of gynecologic cancer patients during initial diagnosis of their disease

Ninety-seven gynecologic cancer patients received a thorough nutritional assessment during the initial evaluation of their disease. Patients with Stages III and IV ovarian cancer were shown to have severe protein-calorie malnutrition (p < 0.01) unrelated to any gastrointestinal obstruction or laparotomies. Patients with other types of gynecologic cancers at all stages demonstrated nearly normal nutritional assessment parameters, with the exception of recent weight loss. Nutritional assessment and active nutritional intervention therapy are suggested especially for patients with advanced ovarian cancer.     

Clinical aspects of acute pelvic inflammatory disease: Cook County Hospital

We reviewed Cook County Hospital records of 134 consecutive patients hospitalized for acute pelvic inflammatory disease unrelated to intrauterine devices, delivery, or pelvic surgery. Nearly half our patients had peritonitis or a pelvic mass and most were young or nulliparous. Neisseria gonorrhoeae was recovered from the endocervices of 41 (34%) of 120 patients and was more common among younger patients. Most patients responded to antibiotic therapy; consequently, we recommend antibiotic treatment for acute PID unless surgical emergencies cannot be excluded or patients do not improve with antibiotic therapy alone.     

Choriocarcinoma associated with term gestation

Fifty-one patients with choriocarcinoma associated with term pregnancy were treated at the John I. Brewer Trophoblastic Disease Center of Northwestern University Medical School from 1962 through 1981. An overall remission rate of 61% was achieved: 65% for 43 patients who received all of their treatment at the center and 38% for eight patients who received treatment elsewhere before referral to the center. This remission rate was significantly less (P less than 0.005) than the 87% remission rate obtained in patients with choriocarcinoma after hydatidiform mole, abortion, or ectopic pregnancy combined. Three factors were determined which significantly influenced response to treatment in these patients: (1) time from delivery to treatment greater than 4 months (41% versus 80%, P less than 0.0005); (2) presenting symptomatology other than abnormal uterine bleeding (40% versus 87%; P less than 0.001); and (3) metastases to sites other than the lung and/or vagina (22% versus 72%, P less than 0.01). There appeared to be no advantage to treating all patients with choriocarcinoma after term pregnancy with initial multiple-agent chemotherapy unless other high-risk characteristics were present.     

Immune complexes in pregnancy. III. Immune complexes in immune complex-associated conditions

Seventeen patients during the third trimester of pregnancy with associated immune complex disease and/or immune complex state and their infants' cord blood were investigated for the presence of immune complexes. In comparing maternal levels of immune complex in normal third-trimester pregnancies to the study group, no statistical significant difference was noted. However, levels in cord blood were significantly lower (p less than 0.0025) than levels in paired maternal samples, but were found to correlate significantly (p less than 0.002). On the basis of the immunochemical analysis of selected pairs, the conclusion is that IgG-containing immune complexes may be responsible for this observed correlation and may represent the normal physiologic situation of pregnancy, whereas IgM-containing immune complexes may represent pathologic, and, therefore, abnormal, states. The suggestion is that the presence of such IgM-containing immune complexes may become predictive of fetoplacental compromise.     

Clinical significance of fetal heart rate patterns during labor: IV. Agonal patterns

The characteristics of fetal heart rate (FHR) patterns were reviewed in 11 cases where the infants died either intrapartum or within eight hours of birth as a consequence of distress during labor without prior recovery. The neonatal charts and the autopsy reports were also reviewed. The infants were grouped according to gestational age as premature (four), term (four), and postmature (three). Similarities and differences were studied in an attempt to delineate some common underlying factors. The premature fetuses have an extraordinary capacity to withstand clinical signs of severe distress (late deceleration and fixed and tachycardic base line) for many hours until the very moment of death and rarely pass meconium. The term fetuses can withstand less prolonged periods of severe distress, the fixed FHR base line and impressive decelerations preceding immediate death; they consistently passed meconium, three of four had aspirated meconium. All of the postterm fetuses had massive meconium aspiration, but the FHR patterns had a bizarre appearance; several hours before death some late decelerations were followed by tachycardia and fixed base lines but no decelerations. Subsequent occurrence of erratic severe decelerations immediately preceded sudden death. Possible reasons for these different pathophysiologic responses are discussed. In the study of FHR tracings, a variable of utmost importance is chronologic age of gestation. Its value cannot be overemphasized for an accurate interpretation of the fetal condition and good decisions for management.     

Factors affecting intrauterine contraceptive device performance: I. Endometrial cavity length

The relationship of endometrial cavity length to intrauterine contraceptive device (IUD) performance was evaluated in 319 patients wearing three types of devices. The rate of events, defined as pregnancy, expulsion, or medical removal, increased significantly when the length of the IUD was equal to, exceeded, or was shorter by two or more centimeters than the length of the endometrial cavity. Total uterine length was found to be a less accurate prognostic indicator of IUD performance than endometrial cavity length alone.     

The oversuppression syndrome

Evidence that suggests an etiologic relation between the use of oral contraceptive steroids and the development of the oversuppression syndrome is reviewed. Investigation and management of factors probably responsible for the syndrome are presented. It is suggested that the problem is one of hypothalamopituitary dysfunction created by estrogen-progestin combinations. Condistions such as premature menopause, adrenal tumors, and Stein-Leventhal syndrome must be ruled out before a diagnosis of oversuppression is made. Clomiphene was found to be effective in restoring normal ovulatory function.