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We present current data pertaining to angiogenesis of the ovary throughout the follicular and luteal phases of the ovarian cycle, in various ovarian pathologic conditions and in benign and neoplastic diseases. MEDLINE, Current Contents, and Index Medicus were searched for studies published between January 1966 and October 1998. All studies that incorporated human and animal models of angiogenesis of the normal ovarian physiologic state and pathologic conditions including both benign and neoplastic ovarian diseases were reviewed. Current literature supports that angiogenesis is an important component of both follicular and luteal phases of the ovarian cycle that correlates well with maturation of secretory endometrium. Angiogenesis also participates in various pathologic processes of the ovary, including follicular cyst formation, polycystic ovary, ovarian hyperstimulation syndrome, and both benign and malignant ovarian neoplasms. In the future a knowledge of specific angiogenic patterns of various pathologic processes may assist in the application of antiangiogenic medications in targeted therapy of benign and neoplastic diseases of the ovary.

Objective The objective of the study was to assess the incidence of gestational diabetes among black women according to various cut-off values of the glucose challenge test. Study design We performed a retrospective chart review of black patients who had a 50-g, 1-hour glucose challenge test between 24 and 28 weeks' gestation of 130 mg/dL or higher followed by a 100-g, 3-hour glucose tolerance test. Results were categorized in 10-mg/dL increments. Gestational diabetes was diagnosed by 2 or more abnormal values using the Carpenter-Coustan criteria. Results The study included 387 patients. The incidence of gestational diabetes diagnosed overall in all patients with a glucose challenge test of 130 mg/dL or higher was 31.2%. The incidence of gestational diabetes in individuals with a challenge test in the range of 130 to 140 mg/dL was 10.7%. The incidence of gestational diabetes with a screening test of 180 mg/dL or higher was 72.0%. Conclusion Our data support the use of 130 mg/dL as the threshold for a positive glucose challenge test and suggest the use of a glucose tolerance test to confirm the diagnosis of gestational diabetes for screening values up to 200 mg/dL.

Our purpose was to study the incidence and location of histologic evidence of intrauterine bleeding in preterm and term placentas.A total of 462 consecutive placentas delivered at32 weeks' gestation, from which cases of placenta previa, stillbirth, and multiple gestation were excluded, were compared with 108 consecutive term placentas (with similar exclusion criteria) in regard to the presence of hemosiderin in decidua of basal plate or placental membranes. Of the 462 preterm cases, 448 charts made specific reference to the presence or absence of vaginal bleeding. Bloody show alone was not considered bleeding. The blinded scoring of lesions (including acute ascending infection, uteroplacental vascular pathologic processes and related ischemic damage, chronic inflammation, and coagulation related lesions) was analyzed by contingency tables (p0.05 significant).A total of 196 of 462 (43%) preterm placentas had any decidual hemosiderin compared with one of 108 (0.8%) at term (p0.00001). Among the preterm cases, hemosiderin was significantly more common in preeclampsia (45/76, 60%) and in cases clinically diagnosed as nonhypertensive abruptio placentae (21/33, 64%) than in premature membrane rupture (72/192, 37.5%) and preterm labor (58/161, 36%, p0.003). The incidence of placental lesions in preterm cases with extraplacental membrane hemosiderin was not different than it was in cases without hemosiderin. Placental lesions related to basal-plate decidual hemosiderin in the preterm cases were villous infarct (p0.0001), uteroplacental vessels with absence of physiologic change (p0.003) and increased numbers of circulating nucleated erythrocytes (p0.0007), uteroplacental thrombosis (p0.0001), and villous fibrosis (p0.0001) and hypovascularity (p0.0001). Among the preterm cases, 23 of 48 (48%) with first-trimester bleeding, 33 of 66 (50%) with second-trimester bleeding, and 31 of 64 (48%) with multiple episodes of bleeding had decidual hemosiderin (p0.0001). A clinical history of gestational bleeding was significantly less common in cases of preterm preeclampsia with histologic evidence of bleeding (four of 73, 5.5%) than in nonhypertensive abruptio placentae (18/31, 58%), premature rupture of membranes (52/183, 28%), or preterm labor (31/161, 19%, p0.0001). Hemosiderin was not related to clinical bleeding72 hours of delivery (p0.20).Decidual bleeding is common in all clinical types of preterm birth and is most common in preterm preeclampsia and nonhypertensive abruption placentae. A clinical history of bleeding is not correlated with the presence of decidual hemosiderin. Bleeding in the basal plate is related to histologic evidence of chronic uteroplacental vascular pathologic processes, which in cases of spontaneous prematurity (premature rupture of membranes, preterm labor, nonhypertensive abruptio placentae) may be associated with decidual bleeding which occasionally may be clinically manifested as gestational bleeding.

We describe a case in which twin-twin transfusion with fetal death of the donor at 23 weeks was complicated by suspected intracranial embolic insult of the surviving recipient twin. Dynamic transient intracranial ultrasonographic findings were noted with complete resolution by 28 weeks. Subsequent severe microcephaly of the survivor with no further growth of any of the cranial parameters beyond 25 weeks was thought to be a result of this very unusual pathophysiologic mechanism.

Our purpose was to establish a nomogram of fetal sacral length throughout gestation and to assess its value in cases of abnormal fetal growth.A prospective cross-sectional study of 506 singleton fetuses with normal growth between 15 and 41 weeks' gestation was performed. Regression analyses were performed on sacral length, gestational age, biparietal diameter, head circumference, and femur length. The sacral length in 80 singleton gestations with abnormal growth (4090th percentile and 4010th percentile for gestational age) were compared with the nomogram.Linear relationships between gestational age and sacral length, biparietal diameter, head circumference, and femur length were demonstrated. Sacral length (centimeters) as a function of gestational age (weeks) was expressed by the regression equation: Sacral length = -0.108 + 0.102 Gestational age, with a Pearson correlation coefficient of R2 = 0.959. The sacral length of all 80 fetuses with abnormal growth demonstrated the same relationship to gestational age as did the 506 normal controls.This study defines the normal limits of sacral length; demonstrates a high correlation between sacral length, gestational age, and other standard measurements of fetal growth; and indicates that sacral length can predict gestational age, irrespective of fetal nutritional status.

Previous reports of ultrasonographic and magnetic resonance imaging of placental site trophoblastic tumor have described a cystic appearance of this rare disease. We present the first case in which endovaginal ultrasonography and magnetic resonance imaging revealed a solid intramural mass. (A M J O BSTET G YNECOL 1993;170:750-2.)

Malignant transformation of leiomyomatosis peritonealis disseminata is a very rare occurrence, reported twice previously. We report the third case and present the computed tomography findings associated with the development of this unusual pathologic condition.

Congenital intracranial teratomas are rare and usually fatal. We present prenatal diagnosis of such a case associated with scalp, facial, and body skin edema, hepatomegaly, extramedullary hematopoiesis, polyhydramnios, and a hydropic placenta. These manifestations of high-output cardiac failure were thought to be the result of the large cardiac output required by massive intracranial tumor arteriovenous shunting.

Type III congenital cystic malformation of the lung with nonimmune hydrops and oligohydramnios was diagnosed at 17 weeks by ultrasonography. Massive fetal cardiac compression with probable associated left- and right-sided failure causing both the oligohydramnios and the ascites, respectively, was thought to be the underlying pathophysiologic mechanism of this unusual clinical presentation. Pathologic examination after termination of the pregnancy confirmed the prenatal diagnosis.

Although beta-sympathomimetic tocolytic therapy has been associated with transient subendocardial ischemia, magnesium sulfate has rarely been noted to cause acute chest pain and is, in fact, known to improve myocardial perfusion in patients with variant angina. We believe this report represents the first case in which intravenous magnesium sulfate administered as a tocolytic agent caused acute chest pain accompanied by transient electrocardiographic evidence of subendocardial ischemia.

Objective: Our goal was to evaluate angiogenesis in the ovaries and omental metastases as a prognostic indicator in patients with epithelial ovarian carcinoma. Study design: Ovarian specimens of 42 consecutive patients with primary epithelial ovarian carcinoma (stages I to IV) and omental metastases of 19 of these patients with stage IIIB or stage IIIC disease were stained immunohistochemically for factor VIII–related antigen. Microvessel counts were tested for correlation with patient age, stage of disease, type of tumor, preoperative serum CA 125 level, tumor size, tumor resectability, patient survival, and omental microvessel counts. Statistical analysis included parametric (factorial analysis of variance) and nonparametric (Mann-Whitney and Kruskal-Wallis) group comparison tests, parametric (Pearson) and nonparametric (Spearman) correlation tests, and parametric (Cox proportional hazards) and nonparametric (Kaplan-Meier) survival analysis with p Results: Microvessel counts of omental metastases in patients with stage IIIB or stage IIIC ovarian carcinoma were significantly correlated with preoperative serum CA 125 level ( p = 0.028) and patient survival ( p = 0.019). Microvessel counts of the ovaries examined were not correlated with patient age, stage of disease, type of tumor, preoperative serum CA 125 level, tumor size, tumor resectability, patient survival, or microvessel count of the corresponding omental metastases. Conclusion: Microvessel count of omental metastases is an independent prognostic indicator of survival in patients with advanced epithelial ovarian carcinoma and correlates with preoperative serum CA 125 level.

Postoperative ultrasonographic assessment as a result of unremitting fever after cesarean section depicted a large pedunculated thrombus within the inferior vena cava at the level of the right renal vein. Subsequent imaging studies revealed that this thrombus was the distal extension of right ovarian vein thrombosis into the inferior vena cava.

A large, asymptomatic retroperitoneal leiomyoma, originating at the level of the pelvic floor and occupying the entire pelvis, was noted during routine gynecologic examination. Ultrasonographic and magnetic resonance imaging findings of this unusual tumor are discussed.

Metastatic disease to the skeletal muscle is rare. Previously it was considered that secondary tumors of striated muscle represented invasion from contiguous structures. We present an unusual case in which an asymptomatic gluteus muscle metastasis from primary ovarian carcinoma was detected by computed tomography.

Placenta percreta is a severe condition associated with maternal morbidity and mortality even when surgery is performed electively. Methotrexate has been suggested as a possible treatment modality for adherent placenta to avoid catastrophic surgery. The purpose of this report is to present a case where the placenta was left in situ to avoid cystectomy at the time of cesarean section, with subsequent failure of treatment with methotrexate.

Our purpose was to evaluate the efficacy of prophylactic amnioinfusion in decreasing neonatal morbidity associated with labor complicated by particulate meconium-stained amniotic fluid and to assess potential complications of this procedure.One hundred five laboring pregnant women with particulate (moderate or thick) meconium by subjective clinical analysis were randomly assigned to receive amnioinfusion or to receive standard obstetric care without amnioinfusion. Patients with any antepartum complications, other than the presence of meconium, were excluded from the study. Statistical analyses consisted of the two-tailed and paired Student t tests, Pearson chi 2 test, and Wilcoxon nonparametric test. Significance was set at p0.05.The study included 47 patients in the study group and 58 patients in the control group. A significantly greater proportion of study patients demonstrated decreased meconium concentration between rupture of membranes and delivery (46 of 46 vs 15 of 58, p0.001). The relative dilution of meconium consistency by objective analysis was significantly different between the study group and the control group (77.1% decrease vs 9.3% increase, p0.001). The proportion of neonates with meconium below the vocal cords was reduced in the study group (two of 47 vs 36 of 58, p0.001). Umbilical artery pH was increased in the study group neonates (7.29 +/- 0.01 vs 7.25 +/- 0.009, p0.05). The rate of neonatal acidemia was reduced in the study group (4 of 45 vs 12 of 50, p0.05). The rate of meconium aspiration syndrome was reduced in the study group (1 of 47 vs 8 of 58, p0.05). Maternal and neonatal morbidity rates were similar.Prophylactic amnioinfusion should be considered a possible addition to the intrapartum management of patients with particulate meconium-stained amniotic fluid.

A bulging 5 × 5 cm tender mass appearing intermittently in the left groin in association with vigorous physical activity between 20 and 24 weeks' gestation was thought clinically and ultrasonographically to represent an inguinal hernia. Surgery after acute continuous pain and concern for incarceration revealed a nonherniated pedunculated uterine fibroid. (A M J O BSTET G YNECOL 1994;170:724-5.)

We present a case in which Doppler velocimetry of the umbilical artery in a fetus with a partial mole at 18 weeks' gestation revealed absent diastolic flow. To the best of our knowledge, this is the first report of Doppler velocimetry of the umbilical artery in this rare condition. Increased placental resistance in this abnormal placenta may explain this finding.

Invasive hemodynamic monitoring has become an integral part of intensive care management. Whereas the pulmonary artery catheter is the mainstay for determination of the hemodynamic profile and differentiation between cardiogenic and noncardiogenic forms of pulmonary edema, immediate central venous access in itself is of importance in rapid volume replacement in cases complicated by severe hypovolemia. Central venous catheters are also the preferred route of administration of total parenteral nutrition to patients with cancer. We present our experience with real-time ultrasonographic guidance during subclavian vein catheterization in critical care obstetrics and gynecologic oncology.

Our purpose was to assess the value of the cheek-to-cheek diameter and the cheek-to-cheek diameter/biparietal diameter ratio in the ultrasonographic detection of abnormal fetal growth.The cheek-to-cheek diameter and cheek-to-cheek diameter/biparietal diameter ratio were examined in 21 small-for-gestational-age (10th percentile for estimated weight) and 87 large-for-gestational-age (90th percentile) fetuses. Statistical analysis consisted of Student's t test comparison between means and analysis of covariance for comparison of regression lines slope between these 108 fetuses and previously published nomograms of appropriate-for-gestational-age fetuses.The mean cheek-to-cheek diameters in small-for-gestational-age fetuses were significantly smaller than in appropriate-for-gestational-age fetuses (p0.0001). In large-for-gestational-age fetuses the mean cheek-to-cheek diameters were significantly larger (p0.005). Although large-for-gestational-age fetuses of diabetic mothers exhibited higher cheek-to-cheek diameter/biparietal diameter ratios than did appropriate-for-gestational-age fetuses (p0.0001), in fetuses of nondiabetic mothers this ratio was only minimally larger (p0.05).The cheek-to-cheek diameter and cheek-to-cheek diameter/biparietal diameter ratio are innovative ultrasonographic parameters for detecting abnormal fetal growth. Furthermore, the cheek-to-cheek diameter/biparietal diameter ratio permits insight into the possible underlying pathophysiologic mechanisms of fetal macrosomia.

Twin-twin transfusion syndrome is a serious complication of monozygotic twin pregnancies and is associated with high rates of perinatal morbidity and mortality. Unfortunately, therapies to disrupt the arteriovenous anastomoses are limited, and the success rates of these therapeutic modalities are poor. We present a case of severe twin-twin transfusion syndrome at 23 weeks' gestation in which selective feticide of the recipient hydropic twin by intracardiac injection of potassium chloride was followed by rapid development of hydrops in the donor twin.

We present an unusual case of partial hydatidiform mole in which extensive, multiple cystic structures encompassing the entire right abdomen and pelvis, initially thought to represent theca lutein cysts, were subsequently shown to consist of massive unilateral right hydronephrosis. Percutaneous nephrostomy decompression bypassing the ureteropelvic obstruction revealed functional renal parenchyma.

We present a rare case of recurrent sustained maternal ventricular tachycardia associated with hypomagnesemia. The frequency of this arrhythmia was markedly reduced with magnesium sulfate therapy. Both maternal and fetal outcomes were good. To the best of our knowledge this is the first description of maternal ventricular tachycardia that was associated with hypomagnesemia and did not require treatment with conventional antiarrhythmic medications. We discuss the possible underlying pathophysiologic causes of this condition.

Complete or partial absence or clefting of the fetal sternum is uncommon. A teenage primiparous patient at 34 weeks' gestation with severe preeclampsia was delivered of an infant with wide clefting of the upper two thirds of the sternum. The infant had no respiratory or cardiac symptoms. There were no other congenital abnormalities. Corrective neonatal surgery was performed at 1 month of age. Retrospective analysis of the ultrasonographic examination performed at 34 weeks revealed evidence of this fetal sternal defect.

Deviations from normal growth modify the amounts of adipose tissue and muscle mass in the adult and the fetus. As an index of the amount of adipose tissue in the fetus, the cheek-to-cheek diameter obtained on an ultrasonographic coronal view of the face at the level of the nostrils and lips was evaluated. Two hundred thirty-four singleton uncomplicated, well-dated pregnancies ranging from 20 to 41 weeks were studied. Two hundred fetuses with biometric measurements or estimated weights between the 10th and 90th percentile for gestational age were included in obtaining a nomogram. Cheek-to-cheek diameter as a function of gestational age was expressed by the regression equation: Cheek-to-cheek diameter (centimeters) = -0.908 + 0.195 Gestational age (gestational age greater than or equal to 20 weeks), with a Pearson correlation coefficient of R2 = 0.806. The cheek-to-cheek diameter/biparietal diameter ratio was almost constant, independent of gestational age, and ranged from 0.6 at 20 weeks to 0.7 at 41 weeks. Fetuses with intrauterine growth retardation tended to have lower ratios. Macrosomic fetuses of diabetic mothers had larger cheek-to-cheek diameters and elevated ratios, whereas large-for-gestational-age fetuses of nondiabetic mothers had normal ratios.

A rare case of severe adult respiratory distress syndrome associated with a P O 2 of 9 mm Hg after surgical resection of a cornual pregnancy at 10 weeks' gestation was treated successfully with positive end-expiratory pressure. The underlying cause, extensive pulmonary embolism, was subsequently revealed. The patient survived without residual brain damage. The possible causes of adult respiratory distress syndrome in pregnancy are discussed.

Fetal panting at a rate of 119 respiratory movements per minute, persisting for 40 minutes after external vibratory acoustic stimulation, was noted in a fetus at 33 weeks' gestation. Subsequent fetal outcome was good. The possible underlying pathophysiologic mechanism is discussed.

A heterotopic quadruplet gestation after in vitro fertilization and embryo transfer was complicated at 8 weeks by rupture of an interstitial pregnancy. Laparoscopic resection was performed and subsequently triplets were delivered at 34 weeks. To our knowledge, this is the first report of such a case.

We present an unusual case of extensive placental micrometastases of recurrent breast carcinoma. The discrepancy between the gross and histopathologic findings in this case suggests that in the absence of gross metastases, meticulous microscopic examination may reveal a higher incidence of metastases than has been reported previously.

Cytomegalovirus is present in the female lower genital tract with an incidence of 4% to 12%. Intracellular inclusion bodies, which constitute evidence of the presence of this organism, are noted on Papanicolaou smears or at direct biopsy. All previous reports regarding tissue diagnosis have involved the uterine cervix. We report an unusual case of a postmenopausal woman who was found to have recurrent symptomatic vaginal lesions; repeated biopsies of the lesion disclosed the presence of cytomegalovirus inclusion bodies.

Postpartum ultrasonographic examination of a patient with a retained placenta showed findings consistent with placenta accreta. The diagnosis was confirmed after surgery with histopathologic examination of the uterus. This case illustrates the possible clinical application of ultrasonography in the postpartum diagnosis of placenta accreta.

Unilateral primary fetal hydrothorax with spontaneous resolution is a rare occurrence. We present a case in which severe unilateral primary fetal hydrothorax was visualized at 28 weeks' gestation. Two weeks later bilateral primary fetal hydrothorax was documented. Ultrasonographic follow-up demonstrated further dynamic changes in the fetal condition, with an isolated unilateral hydrothorax 1 week later and subsequent complete resolution at 34 weeks' gestation. Delivery resulted in a normal neonate with no signs of pulmonary hypoplasia.

Severe obstructive sleep apnea, a disturbance of sleep resulting from intermittent periodic obstruction of the upper airway, was diagnosed after cardiotocography during which the external tocodynamometer disclosed a pattern initially thought to represent uterine activity. In spite of this obstructive sleep apnea with associated markedly low, hypoxic oxygen saturation levels and daytime somnolence of 10 to 12 hours from 32 weeks until delivery, subsequent fetal outcome was good.

We present a case in which electroconvulsive therapy was performed repeatedly in pregnancy because of severe depression with psychotic features and failure of chemical treatment. Each electroconvulsive treatment was immediately followed by uterine contractions and active uterine bleeding, possibly representing recurrent abruptio placentae occurring in association with the treatment. Transient acute episodes of maternal hypertension between 180/90 and 190/100 mm Hg, documented within minutes after application of each electroconvulsive treatment, might explain the abruptio placentae manifested by active uterine bleeding and uterine hyperstimulation.

Maternal varicella occurs in fewer than five per 10,000 pregnancies in the United States. A case is reported in which markedly painful, extensive vulvar and vaginal ulcers prevented cervical examination, and cesarean section was performed with the patient under general anesthesia. (Ann J OBSTET GYNECOL 1990;163:1630-1.)

A case is presented in which external vibratory acoustic stimulation performed on a term fetus produced severe prolonged bradycardia, necessitating emergency cesarean section delivery. The possible pathogenesis is discussed.