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Laparoscopic management of ectopic pregnancies is becoming more common. Having recently successfully treated one case of heterotopic pregnancy by laparoscopy in our department, the object of the present paper is to review the literature regarding laparoscopically treated cases of heterotopic pregnancy in order to assess benefits, complications and safety of this procedure. A Medline search yielded 10 additional cases with ampullary, interstitional or cornual tubal pregnancy, respectively. All surgical procedures were uncomplicated and all in utero pregnancies progressed normally. Despite a small number of cases, lack of complications in these reports is encouraging feasibility of laparoscopic management of heterotopic pregnancy.

The neurochemical differentiation of bulbospinal noradrenergic and serotonergic neurons has been followed in first trimester human fetuses. Analysis of microdissected CNS regions revealed detectable levels of noradrenaline (NA) and serotonin (5-HT) in pons, medulla oblongata and throughout the spinal cord from 5-6 weeks of gestation. In all regions there was a pronounced increase in tissue levels of the monoamines, especially from 8-9 weeks on. 5-HT levels were lower than NA levels except for pons, where the opposite was true. With increasing fetal age, the results seemed less consistent because of considerable interindividual variations. Using immunohistochemical localization of tyrosine hydroxylase (TH), a marker for noradrenergic neurons, immature cell bodies were seen in the brain stem at the earliest stage studied, that is at 4 weeks of gestation. Several TH and 5-HT-immunoreactive (IR) cell groups were found in pons and medulla oblongata at 5 weeks. Significant structural differentiation of TH- and 5-HT-IR cell bodies was seen during the first trimester. Immunoreactive fibers began to appear at 5 weeks in the cervical spinal cord. At 6 weeks both types of fibers could be found in the white matter throughout the entire spinal cord while fibers in gray matter appeared at 9 weeks. The number of TH-IR fibers was considerably larger than the number of 5-HT-IR fibers. This is the first time the biochemical development of human bulbospinal monoaminergic neurons during the first trimester has been described. Continued investigations of the ontogenetic growth and differentiation of these human bulbospinal monoaminergic neurons will gain necessary insight into the genetically determined capacity for plasticity, potentially possible to activate later in life in response to spinal cord injury. Further, intraspinal transplantation of CNS tissue relevant to the severed spinal cord would by necessity entail selection of embryonic cell populations. Using such therapeutic strategies, detailed knowledge of the inherent capacities of the donor tissues will be crucial.

In utero stem cell transplantation represents a new and still experimental therapeutic strategy for diseases related to the hematopoietic system, i.e. hemoglobinopathies, immunodeficiency diseases and metabolic disorders. To date, a total of 21 cases of transplantations using stem cells either of fetal liver or adult bone marrow origin have been reported in the literature. Success has been limited--with the exception of one case of beta-thalassemia--to four cases with immunodeficiency diseases. In this review the broad therapeutic implications as well as potentials and limitations of this technique are summarized. Furthermore, ethical considerations based on the use of fetal cells are pointed out and a prospective view concerning experimental and clinical future perspectives including the possibility for gene therapy is presented.

Fetal stem cell transplantation may rely on material from therapeutic abortions. It is essential that the stem cell transplant does not transmit any microorganisms that may affect the fetus and that genetically abnormal cells are avoided. To evaluate such contamination, human fetal stem cells collected February 1992 - December 1993 were analyzed for bacterial and fungal growth, and the placentas were karyotyped. Four samples of 70 were positive for different pathogens. Serological screening of 43 women during this period resulted in five seroconversions and revealed one carrier of anti-HCV. Karyotyping revealed two abnormal findings out of 72 samples. Thus, the concept of using material from therapeutic abortions is safe.

Serum concentrations of hCG were determined in blood samples taken 18-20 h and immediately before vacuum aspiration in 45 women in gestational weeks 7-9, admitted for legal abortion. In 35 of the women, a laminaria tent was inserted for cervical dilatation immediately after the first blood sampling. Serum hCG values decreased significantly in the women pretreated with laminaria tent, but were unchanged in the untreated women. This finding may indicate that pretreatment with a laminaria tent induces a partial placental detachment.At the Karolinska Institute at Huddinge University Hospital in Huddinge, Sweden, serum levels of human chorionic gonadotropin (hCG) in 35 patients who had been inserted with a laminaria tent 18-20 hours prior to and immediately after vacuum aspiration were compared with those of 10 women who chose not to have laminaria tents inserted prior to vacuum aspiration. Gestational age ranged from 7 to 9 weeks. All the pregnant women were primiparous. The mean serum hCG values did not differ greatly between the cases and controls (84,260 U/1 and 75,878 U/1, respectively). Yet the mean serum hCG levels of women treated with laminaria tents to induce dilation fell considerably more than those in the control group (76,468 U/1 vs. 84,939 U/1; p.01). The concentrations fell in all treated women. Since serum hCG values normally increase during this period, the decrease indicated that laminaria tents induced partial detachment of the placenta. The results also explained the significant bleeding and/or presence of placental tissue in the cervical canal. These results suggest that laminaria tents cause partial placental detachment as well as labor contractions.

Haematocervix is an uncommon complication after conization. This report deals with 1 case that presented with clinical signs of progressive stenosis and was diagnosed by ultrasonography. Based on analysis of the 3 previously reported cases the pathogenesis of this condition is discussed.

Serum concentrations of 17 beta-oestradiol (E2), unconjugated oestrone (E1), total oestrone (tE1), progesterone (P), follicle-stimulating hormone (FSH) and sex-hormone-binding globulin (SHBG) were measured before and after daily intravaginal administration of 250 micrograms micronized E2 and 10 mg micronized P for 14 days to 12 post-menopausal and for 1 day only (during cycle days 5-8) to 11 pre-menopausal women. In the post-menopausal women the levels of all steroids increased to maximum values on day 1, 8-10 h after administration and fell thereafter. In the pre-menopausal women the steroid concentrations rose slowly to a plateau level 10-15 h after administration. Significantly higher absorption of E2 and E1 (area under the curve increments) was noted in the post-menopausal than in the pre-menopausal women. In the post-menopausal women the steroid levels measured on days 7 and 14 corresponded to those observed in the very early or late luteal phase. Area under the curve increments were usually smaller on days 7 and 14 than on day 1 and the absorption kinetics altered to a 'pre-menopausal' pattern. FSH levels were significantly reduced as from 12 h after administration on day 1 and onwards. A slight (10%) but significant increase in SHBG levels was noted on day 14. It was concluded that the combined E2 and P treatment used in this investigation brings about a physiological response with only minimal side effects on the liver as judged from changes in SHBG concentrations.

Ten amniotic fluid samples obtained at elective caesarian section were examined for the presence of tissue-type plasminogen activator (t-PA), urokinase-type plasminogen activator (u-PA) and the two specific plasminogen activator inhibitors, PAI-1 and PAI-2. u-PA antigen was demonstrated in all samples (mean concentration equivalent to 0.35 iu/ml), but its bioactivity was very low (mean activity 0.13 iu/ml) when assessed by a bioimmuno-assay (BIA) using chromogenic substrate. None of the samples analysed by ELISA technique had measurable levels of t-PA, neither could any activity of t-PA be demonstrated by a sensitive BIA or fibrin plate technique. Significant amounts of both PAI-1 and PAI-2 antigen were present in all samples, and the mean values were 12.2 and 43.4 ng/ml, respectively. The average inhibitory capacity per ml of amniotic fluid measured by assessing the residual t-PA activity following addition of a known amount of single chain t-PA to the samples was 17.3. Thus, this study demonstrates a fibrinolytic system in amniotic fluid, which is characterised by absence of t-PA activity, low bioactivity of u-PA and excess of the two specific inhibitors, PAI-1 and PAI-2. This inhibitory capacity of amniotic fluid may play a role in preventing premature rupture of membranes.

Free amino acid concentrations were determined in maternal plasma and amniotic fluid (AF) under standardized and unstressed conditions in four groups of women comprising 6 gestational and 13 type I diabetics, 10 women with small-for-gestational-age (SGA) infants, and 18 healthy control women between 36 and 39 weeks of gestation. Plasma values for branched chain amino acids (the sum of leucine, isoleucine and valine) did not differ significantly between the four groups. The corresponding values in AF were significantly higher (P less than 0.05) in the type I diabetic group and significantly lower (P less than 0.05) in the gestational diabetic group as compared to the control group. The mean AF C-peptide concentration was elevated but not significantly so in gestational (0.69 nmol/l) or type I diabetic (0.54 nmol/l) pregnancies and significantly lower (P less than 0.05) in women with SGA infants (0.28 nmol/l) as compared to the control group (0.38 nmol/l). There was a significant correlation between C-peptide in AF and branched chain amino acids in maternal plasma (r = 0.63; P less than 0.05) as well as to maternal blood glucose (r = 0.79; P less than 0.01) in the type I diabetic group, which merely suggests a greater beta cell reactivity to insulin secretagogues in offspring of diabetic mothers. The correlation between AF C-peptide and branched chain amino acids in maternal plasma was significantly inverse in women with SGA infants (r = -0.75; P less than 0.05). Both individual, branched chain, or total amino acid concentration in AF were unrelated to AF C-peptide.

Proinsulin, insulin, C-peptide, insulin-binding antibody, and glucose concentrations were measured in amniotic fluid samples from 43 insulin-treated diabetic patients and 17 nondiabetic control patients between the thirty-sixth and thirty-ninth weeks of gestation. Insulin-binding antibodies in amniotic fluid were present in only three diabetic patients, although antibodies in maternal serum were found in 22 of the diabetic subjects. In the diabetic group, maternal serum insulin-binding antibodies were statistically unrelated to levels of C-peptide in amniotic fluid. The mean amniotic fluid concentrations of proinsulin (0.07 nmole/L), insulin (0.08 nmole/L), C-peptide (1.17 nmoles/L), and glucose (2.09 mmoles/L) were markedly elevated (p

The fatty acid composition in cervical mucus was determined in 37 pregnant and 17 nonpregnant women using gas liquid chromatography. In both groups palmitic acid (16:0) and oleic acid (18:1) were the predominant acids comprising more than half of the total amount. Compared to nonpregnant controls, pregnant women had markedly elevated levels of oleic acid (18:1), while mean levels of myristic acid (14:0) and stearic acid (18:0) were significantly lower. These pregnancy-induced changes in fatty acid pattern could not be ascribed to the increased viscosity of cervical mucus. Only minor differences in fatty acid pattern were found between women in first trimester and at term. In contrast to nonpregnant controls, a significant negative correlation between levels of myristic acid (14:0) and docosahexaenoic acid (22:6) was found in pregnant women, indicating a redistribution of these two fatty acids during pregnancy. The present study demonstrates that pregnancy alters the fatty acid composition of cervical mucus lecithin, and that the characteristic changes are present before the 10th gestational week.

This report concerns one case of tubal pregnancy in which the initial PAD indicated a hydatidiform mole. However, re-examination revealed histologically marked hydropic degeneration. This implication emphasizes the complexity of histopathologi-cal examination of placental tissue.

In a prospective study of 83 women, two different physiotherapy methods for strengthening the pelvic floor muscles after childbirth were evaluated. The training program was carried out by the patients at home for 12 weeks, starting 8 weeks after spontaneous uneventful delivery. Forty-two women did pelvic floor exercises in accordance with the method presented by Kegel (1). Forty-one women used standard vaginal cones with weights increasing in 10 g stages from 20 to 100 g, to be retained in the vagina both when standing erect and moving. Pelvic floor muscle strength, defined as the weight in grams of the heaviest cone that could be retained in the vagina, was recorded before and after the 12-week training period. Training with vaginal cones produced significantly better pelvic floor muscle strength than did exercise without cones.

Amniotic fluid concentration and content (amniotic fluid volume X concentration) of C-peptide and catecholamines (epinephrine, norepinephrine) and their interrelationship was studied in nine women with gestational diabetes, in 14 women with type I diabetes, and in 20 healthy control women between the thirty-sixth and thirty-ninth week of gestation. Mean amniotic fluid volume was significantly larger (p less than 0.05) in the type I diabetic group than in the control group. Mean concentration and content of amniotic fluid C-peptide were elevated in women with gestational diabetes, significantly so in women with type I diabetes (p less than 0.05) as compared with nondiabetic control women. Mean amniotic fluid catecholamine concentrations were lower, although not statistically so, in both insulin-dependent and gestational diabetic women than in control women. Mean amniotic fluid catecholamine content was higher, although not statistically so, in women with gestational diabetes than in control women. In the type I diabetic group, epinephrine content was significantly lower (p less than 0.05) and norepinephrine content significantly higher (p less than 0.05) than in the control group. A significant positive correlation between the content of norepinephrine and C-peptide was found in control women (r = 0.57; p less than 0.05) and in women with gestational diabetes (r = 0.75; p less than 0.05). The close interrelationship could indicate a parallel maturation of these two hormonal systems.

The interrelationship between amniotic fluid (AF) concentration and content (AF X conc) of C-peptide and cortisol was studied in four groups of women comprising 10 gestational and 16 type-I diabetics, 11 women with intrauterine growth retarded fetuses (IUGR), and 17 healthy control women. Mean AF volume was significantly greater (P less than 0.05) in the type-I diabetic group than in the control group. Both concentration and content of AF C-peptide was significantly higher in the type-I diabetic group than in the control group (P less than 0.05 and P less than 0.01, respectively). The corresponding values were significantly lower in mothers with IUGR fetuses compared to controls (P less than 0.05). AF cortisol content was significantly higher (P less than 0.05) in the gestational diabetic group compared to the control group; there were no other significant differences between the groups regarding the cortisol concentration or content. Both cortisol and C-peptide contents were significantly interrelated in both control women (r = 0.68, P less than 0.01) and women with gestational (r = 0.68, P less than 0.05) and type-I diabetes (r = 0.63, P less than 0.01). The C-peptide/cortisol ratio was lowest in the IUGR group and highest in the type-I diabetic group. The same ratio was intermediate and almost equal in the control and gestational diabetic group. Both C-peptide and cortisol concentrations were unrelated to AF volume as well as infant birthweight. C-peptide content was significantly correlated to birthweight percentile in type-I diabetic women (r = 0.61, P less than 0.05). No such correlation was found in the three other groups.

During the last 7-year period, the second twin was delivered by cesarean section in three of 161 twin pregnancies in our Department. The main reasons for this procedure were fetal distress caused by malpresentation or cord prolapse in 2 cases and in the third case placental separation. Cesarean section for delivery of the second twin is justified only in selected cases.