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INVITED PRESENTATIONS EN3.01 MICROENDOSCOPY EN3.01.01 USE OF MICROLAPAROSCOPY A. J.M. Audebert, IGFI, Bordeaux, France The terminology "microlaparoscopy" was firstly used in the early 90s and is, presently, defined as the use of a scope of 2 mm, or less, of diameter. The advances of technology have allowed to develop small scopes with good quality of visualization, as demonstrated by several comparative studies. Many advantages of microlaparoscopy have been claimed: easier use under local anesthesia, lesser risks of complication, better cosmetic outcome with, indeed, better acceptability by the patients. Some of them need, however, to be further properly evaluated. Microlaparoscopy is used preferentially in three various main groups of indications: 1- Diagnostic under local anesthesia (mainly for infertility, chronic pelvic pain, acute pain, second look and emergency cases); the reduced pneumoperitoneum requires a good experience in laparoscopy. The reported failure rates vary from 1 to 12 %. A variant is the so called "Pain mapping", performed for chronic pelvic pain in patients under conscious sedation. 2- Diagnostic and operative under general anesthesia, especially in young children. If the strict definition is respected, the procedures thus performed are limited and dependant on the available instrumentation. 3- As an initial procedure for safer wall entry for patients with previous laparotomy. These patients have been shown to be at higher risk of complication during the installation phase of laparoscopy; a microlparoscopy is initially performed at the Palmers point to assess the internal umbilical area and insert under visual control the main ombilical trocar. The specific technical aspects and the assessent, based upon the latest reports, of each major indication will be presented. EN3.01.02 TRANSVAGINAL HYDROLAPAROSCOPY (THL) IN THE SUBFERTILE PATIENT S. Gordts, R. Campo, I. Brosens, Leuven Institute for Fertility and Embryology, Leuven, Belgium. Objective: To evaluate the possibilities for the exploration of the pelvis by a vaginal access and using prewarmed saline as distentionmedium. Materials and methods: The procedure is performed on an ambulatory basis with the patient in a horizontal decubitus position. After infiltration with a local anaesthetic of the posterior fornix, a specially developed Veress needle trocar system (Circon, USA) is introduced into the pouch of Douglas. A 30 angled 2.7 mm endoscope with a wide angle of 105 (Circon, USA) is used for the exploration. We now performed the procedure in 157 patients referred for primary or secundairy infertility and after informed consent. All patients had normal vaginal examination and normal ultrasound. Results: Access was obtained and 149 patients (95%). In 6 patients the technique failed due to tenting of the peritomeum, mostly during our first experiences, or due to obesity. In 2 patients the procedure was aborted due to complications : one rectumperforation, treated conservatively with antibiotics during 6 days and one hematoma formation of the broad ligament also conservatively treated with expectant management. The findings were normal in 58.5%; endometriosis was diagnosed in 16.5% and adhesions in 17.5% of the patients; 7.5% other pathology was found. On a linear painscale from 0 (no pain) to 100 (unbearable pain) 68% of the patients reported the pain to be lower than 30 and 24% between 30 and 50. Asked if they would have any objections to repeat the procedure under the same circumstances, 96% didnt object. Conclusions: In our experience THL proved to be an accurate procedure in the exploration of the subfertile patient. In contrast to standard laparoscopy it is less invasive as it can be performed under local anesthesia. Furtermore it allows the inspection of the tubo-ovarian structures in their natural position without a need for supplementary manipulation. EN3.02 SECOND GENERATION ENDOMETRIAL ABLATION EN3.02.01 ENDOMETRIAL ABLATION VIA THERMACHOICE BALLOON THERAPY CE Miller, MD, Department OB/GYN, University of Illinois, Chicago, IL, USA

Of the 600,000 hysterectomies performed in the United States each year, 120,000 are performed for abnormal uterine bleeding with no evidence of uterine fibroids. Unfortunately, the majority of hysterectomies performed are still via an open abdominal route. Moreover, hysterectomy carries with it increased morbidity and even mortality. Endometrial ablation or endometrial resection performed via the hysteroscope has enabled successful treatment of menometrorrhagia without hysterectomy. Electrosurgical instrumentation, utilizing the rollerball, and the bare fiber Nd:YAG laser can be used to ablate the endometrium, while the monopolar resectoscope can resect endometrium. Unfortunately, these techniques are limited by physician expertise. Moreover, risks include uterine perforation, fluid overload, and inadvertent bowel burn. Because of the morbidity related to the invasiveness of hysterectomy as well as secondary to the expertise required to perform endometrial ablation or resection via the hysteroscope, other techniques of endometrial ablation have come to the forefront. Originally introduced as a latex balloon, the ThermaChoice Balloon Ablation system is now a latex free silicone balloon. The balloon, fills with or D5W check with Mary normal saline and expands against and covers the endometrium. This fluid is then heated to 87 degrees centigrade to destroy the lining of the uterus. Studies in the United States as well as abroad reveal amenorrhea rates slightly less than 20% with significant reduction of blood flow and patient acceptance on par with roller ball endometrial ablation techniques. The ThermaChoice Balloon is easy to use and has been proven to be cost effective and safe. EN3.02.02 SECOND GENERATION ENDOMETRIAL ABLATION: PHOTODYNAMIC THERAPY R. L. Reid, Dept. OB/GYN, Queens University, Kingston, ON, Canada Endometrial ablation, at outpatient, day surgery procedure has broadened the indications for surgical intervention for abnormal uterine bleeding. A range of therapeutic options now exist including laser, electrosurgery, radiofrequency, microwave, and thermal ablation (both hot and cold). All of these techniques share the potential for inadvertent uterine perforation and damage to adjacent structures. Recently a technique that selectively destroys the endometrium and adjacent myometrial layers without danger to surrounding structures had been developed in the animal model. Exposure of the monkey uterus to a natural precursor (5-amino-levulinic acid {ALA}) in the heme biosynthetic pathway, resulted in endometrial accumulation of the potent photosensitizer, Protoporphyrin IX. Subsequent exposure 3-4 hr later of the endometrial cavity to activating fiberoptic light (635nm @ 300 mW) resulted in highly selective full thickness endometrial destruction. The requirement for both photosensitized tissue and exposure to activating light offers tissue selectivity and adds an additional margin of safety. Simplification of EA techniques may broaden the indications, however, failure rates with inadvertent pregnancies or the need for hysterectomy, and counselling re the need for combined hormone replacement therapy remain important issues that require monitoring. EN3.02.03 MICROWAVE ENDOMETRIAL ABLATION Togas Tulandi, McGill University, Royal Victoria Hospital, Women`s Pavilion, Montral, Qubec, Canada Hysteroscopic endometrial ablation has become an accepted alternative to hysterectomy in the treatment of dysfunctional uterine bleeding. The possible complications of hysteroscopic endometrial ablation are fluid overload, electrolytes imbalance and rarely injury to internal organs. In order to find a simpler and safer technique, non-hysteroscopic

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techniques including the used of thermal balloon and microwave energy have been employed. In microwave endometrial ablation (MEA), the energy is delivered into the endometrium by an applicator where it is radiated in a hemispherical pattern. Domestic microwave ovens use a frequency of 2-3 GHz. By increasing the frequency to 9.2 GHz, the penetrating ability of the microwaves is dramatically reduced to 6 mm. The procedure is first done by dilating the cervix. The microwave applicator is then inserted into the uterine cavity. During the procedure, the surgeon views a realtime computer display that shows the temperature at the tip of the applicator. With the tip of the applicator at the fundus, the power is switched on and heating is allowed until approximately 75oC. The applicator is moved slowly from side to side until the entire fundal area has reached the therapeutic temperature. The applicator is then gradually withdrawn continuing the side to side movement until the internal cervical os is reached. A recent randomized study demonstrates that MEA is as effective as the standard endometrial resection. The satisfaction rate (amenorrhea or minimal bleeding) after the procedure was >80%. The duration of treatment with microwaves; analgesic requirements and postoperative morbidity were significantly less than endometrial resection. It is technically very simple and the average duration of the procedure is about 3-5 minutes. MEA is a promising non-hysteroscopic technique for dysfunctional uterine bleeding.

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cornerstones of obstetric care. Two options only are available delivery by caesarean section or the artificial induction of labour. The rates of caesarean deliveries continue to rise all around the world causing widespread concern. It is self evident that, where clinical circumstances call for delivery, if there is a safe and reliable alternative to caesarean section this should be preferred. It may be fanciful, at least for the present, to expect that we might devise methods of induction the results of which were labours which were shorter, easier, more efficient and altogether safer than the best spontaneous labours but we should at least strive towards such an objective. Such a goal must depend on exploiting our current state of knowledge of the physiological control of parturition and exploring new avenues as our understanding of that most complex of processes further develops. The secret of success lies in bringing about the two essential components of labour myometrial contractions and cervical connective tissue modification in a co-ordinated fashion. Without the latter, the former may be not only futile but dangerous. Methods of ripening the cervix as a prelude to myometrial contractility have paid dividends and there is still scope for further improvements. The influence of such agents as antiprogestogens, relaxin, nitric oxide, and several cytokines and chemokines (interleukin-8, monocyte chemotactic peptide-1) on the myometrium and cervix are currently the subject of keen investigation. Some or all of these may find their way into clinical practice to add to the options provided by the three main tools currently at our disposal amniotomy, oxytocin and prostaglandins. For the present however we need to improve the way in which we use these existing tools to maximum clinical benefit.

FM3.01 MATERNAL DISEASE AND PREGNANCY FM3.01.01 ANAEMIA S. Gopalan, Postgraduate Institute of Medical Education and Research, Chandigarh, India Anaemia is one of the leading causes of maternal mortality in developing countries like India and contributes to 20% of maternal deaths. If all maternal deaths are analysed, 64% have associated anaemia irrespective of the primary cause. Commonest cause of anaemia in pregnancy is still iron deficiency alone or in combination with folic acid deficiency. In spite of government of Indias iron supplementations programme, prevalence is as high as 62.3%. This could be due to a) reduced bioavailability of iron because of dietary habits b) iron deficiency anaemia antedating pregnancy c) lack of iron intake due to lack of antenatal supervision and advice. Preexisting anaemia is due to poor spacing between pregnancies, parasitic infestations such as hookworm etc. In pregnancy, treatment of anaemia includes confirmation of the type of anaemia, ascertaining the etiology and instituting appropriate therapeutic measures. Management of anaemia complicating pregnancy would depend on severity and gestation at diagnosis. In first and second trimesters of pregnancy blood transfusion may be necessary in women with severe anaemia. Majority of women will respond to oral or intramuscular iron therapy. Difficulty arises in management of women admitted in labour with severe anaemia. Cardiac output increases during labour and immediately after delivery precipitating cardiac failure. Around 30 to 40% percent are admitted in failure. Partial exchange transfusion is helpful in such instances. At term pregnancy when not in labour, packed cell transfusion under close monitoring is beneficial. Delivery should always be conducted at a hospital with adequate facilities to manage the complications since maternal mortality is highest after delivery. Prevention of anaemia would depend on creating awareness amongst women regarding importance of iron supplementation and achieving an effective programme of screening for anaemia as well as correction at the primary health care facility. FM3.02 INDUCTION OF LABOR FM3.02.01 INDUCTION OF LABOUR OVERVIEW OF METHODOLOGY Andrew Calder, Obstetrics and Gynaecology, University of Edinburgh Centre for Reproductive Biology, Edinburgh, U.K. The clinicians capability to interrupt pregnancy to the perceived advantage of the mother, her offspring or both remains one of the

FM3.02.02 MANAGEMENT OF POSTTERM PREGNANCY Mary E Hannah, Department of Obstetrics and Gynaecology, Sunnybrook and Womens College Health Sciences Centre, University of Toronto, Ontario, Canada Approximately 6% of women will reach or go beyond 42 weeks gestation, unless labour is induced electively prior to this time. The risks of stillbirth, serious neonatal morbidity, and Caesarean section are increased for postterm, compared to term, pregnancies. Routine early pregnancy ultrasound reduces the number of women who require induction of labour for postterm pregnancy. When to induce labour? Randomized controlled trials (RCTs) and metaanalyses of RCTs suggest that the risk of perinatal death will be lower if labour is induced, than if the pregnancy is managed expectantly, once the pregnancy reaches 41 to 42 weeks gestation. A policy of induction of labour at 41-42 weeks will not increase the risk of Caesarean section, regardless of parity or the state of the cervix, and may actually lower this risk. If labour is to be induced, the ripeness of the cervix should dictate the method to be used. Unless a contraindication to prostaglandins exists, cervical ripening agents (vaginal or intracervical prostaglandins, vaginal or oral misoprostol) should be considered. What is happening in Canada? The rates of induction of labour for postterm pregnancy have increased steadily over the past 15 years in most parts of Canada. The likelihood of a woman delivering at 41 0/7 41 6/7 weeks gestation has increased from 11.9% (1980) to 16.3% (1995), and a similar decline has occurred in the proportion of births delivering at 42 weeks gestation: 7.1% (1980), 2.9% (1995). Along with these changes in timing of delivery, the stillbirth rate among pregnancies delivering at 41 weeks gestation has decreased. Thus there is an association between increasing rates of induction of labour at 41 weeks gestation and decreasing stillbirth rates. There is no evidence that the increasing use of induction of labour at 41 weeks gestation has increased the rate of Caesarean section for women giving birth at 41 weeks gestation. References: 1. Hannah ME, Hannah WJ, Hellmann J. et al. Induction of labor as compared with serial antenatal monitoring in postterm pregnancy. A randomized controlled trial. N Engl J Med 1992;326:1587-92. 2. Crowley P. Interventions for preventing or improving the outcome of delivery at or beyond term. In: The Cochrane Library; Issue 4, 1999. Oxford: Update Software. 3. Sue-A-Quan AK, Hannah ME, Cohen MM et al. Effect of Induction of labour on stillbirth and Caesarean section rates for postterm pregnancy. CMAJ 1999;160:1145-9.

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FM3.02.03 INDUCTION AFTER CESAREAN SECTION Tae-Bok Song, Department of Obstetrics and Gynecology, Chonnam University Medical School, Kwangju, Korea Spontaneous labor may be preferable in a woman who has previously undergone cesarean delivery. However, there are many cases which need induction or augmentation of labor. If oxytocin is not used selectively, a significant number of VBAC-TOL (vaginal birth after cesarean trial of labor) will end up as repeat cesarean procedures. Initial concern that oxytocin usage would significantly increase the risk of uterine rupture/dehiscence has not been confirmed. Meta-analysis of selected studies indicates that the use of oxytocin during VBAC-TOL does not appear to influence the risk of a dehiscence or rupture, nor does it increase perinatal mortality rates. However, a case-control study found that excessive oxytocin infusion increased the risk for rupture or dehiscence. In 1995 the ACOG Practice Patterns Committee concluded that oxytocin use for induction or augmentation of labor was not contraindicated. Then in 1998 the ACOG advised that the use of oxytocin or PGE2 gel for VBAC requires close patient monitoring. The College also noted that this recommendation was based on ....limited or inconsistent scientific evidence, which suggests that further research in this area was needed. Although the use of prostaglandin E2 gel for cervical ripening is extensive and is likely to have been employed in many prior VBAC candidates and its use appears justified at this point, reported data are limited. There are several reports about using misoprostol for induction with risk of uterine rupture. Unfortunately, available reports involve insufficient numbers to draw a definite conclusion. The role of labor induction during VBAC-TOL is still controversial and the impact of labor induction should be studied further, controlling for multiple variables. FM3.03.02 PHARMACOLOGICAL MANAGEMENT John Tzafettas, University of Thessaloniki, Thessaloniki, Greece

FM3.03 ECTOPIC PREGNANCY FM3.03.01 MATERNAL MORTALITY OF ECTOPIC PREGNANCIES Hein Odendaal, Dept OB/GYN, University of Stellenbosch, Stellenbosch, South Africa Ruptured tubal ectopic pregnancy is an important cause of maternal mortality. In the USA it has a mortality rate of 38/100,000 events and is one of the major causes of maternal mortality. In Hong Kong it was found to have caused 13.7% of maternal deaths, the third most common cause after haemorrhage and pre-eclampsia. However, in the UK, according to the latest report, it caused only 4.2% of deaths, with a death rate of 0.3 per 1000 ectopic pregnancies. It is substantially more dangerous than either childbirth or legal termination of pregnancy. In certain countries the incidence of ectopic pregnancy is rising. It is also concerning that ectopic pregnancy is increasing as a cause of death in the haemorrhage group of causes. The direct cause of death is most commonly haemorrhage from a tubal rupture which occurs in about 25% of ectopic pregnancies. In developing countries the situation is much worse. In Jamaica ectopic pregnancy has been found the third most common cause of maternal death, after hypertensive diseases and obstetric haemorrhage. It is the fourth most common cause of maternal death in Zambia. An incidence of 1.1% with a mortality rate of 2% was found in the Transkei, South Africa. About 71% of cases had tubal rupture and two thirds of patients were in shock or severely anaemic in arrival. Tubal rupture cannot be predicted. A high index of suspicion should therefore be maintained, particularly in women with risk factors for ectopic pregnancy. Early diagnosis followed by prompt resuscitation and efficient transfer or immediate surgery are essential to reduce maternal deaths. As salpingitis is one of the very few preventable causes of ectopic pregnancy, early treatment is mandatory. However, it remains to be seen whether the syndromic approach to the treatment of pelvic inflammatory disease will reduce the incidence of ectopic pregnancy.

The medical management of unruptured EP, after adequate patient selectiion, in the majority of cases renders any surgical intervention unnecessary and preserves fertility potential. In both, the conservative management with MTX and the salpingostomy techniques, tubal patency and future fertility performance, seem to be similar. Repeated administration of MTX leads to regression of the EP in up to 95% of the treated cases. However, not rarely (@20%) this is accompanied by unpleasant side effects, due to systemic distribution of the drug, which can be avoided with a single dose. This is even more advantageous when the drug can be administered intra-amniotically, under ultrasound guidance. Medical management of EP, has very rarely been employed, when the gestational mass was beyond 35 mm, and/or the cardiac activity visible. In the limited number of cases that this was reported, the success rate was low and this could be attributed to the inadequate amount of MTX given ( 50mg). The above, generally accepted limitations of this treatment, have been based mostly on logical assumptions and hence, they are rather arbitrary. We found that, in the unruptured early ET (<56 days from the LMP), the local administration of 100mg MTX, under laparoscopic or sonographic guidance, seems to be effective, regardless of the pretreatment _- HCG levels, the size of the gestational sac or the presence of cardiac activity, and with no significant side effects. In view of the high initial dose(100mg), repeat MTX is not recommended. Instead, cases with persistently high _-hCG levels, should be managed by laparoscopic salpingostomy or, if the fetal heart activity is visible, by intracardiac injection of 10% KCL or other embryotoxic agent. Although in the laparoscopic linear salpingostomy, the resolution period is more predictable and shorter , local injection of MTX could be the first choice in unruptured EP, avoiding a comparatively prolonged and more complicated laparoscopic salpingostomy. Hence, the recently reported view that operative laparoscopy should remain the gold standard for treating early EP, does not seem justified, however it might be appreciated that the technique chosen , often depends on the skills of the gynaecologist. FM3.03.03 LAPAROSCOPIC MANAGEMENT OF ECTOPIC PREGNANCY. Per Lundorff, Viborg-Kjellerup Sygehus, Viborg, Germany The benefits of laparoscopic surgery were evaluated in a randomized trial and compared with atraumatic surgical treatment by laparotomy. Consecutive analysis of human chorionic gonadotropin (hCG) in serum was used for prediction and detection of persistent trophoblast. The pelvic status could be evaluated both at EP surgery and at second-look laparoscopy. Impairments or improvements of adhesions between laparotomy and laparoscopy were evaluated. Fertility outcome was assessed by questionnaires to all patients, and the impact of adhesion formation and adhesiolysis was rated with respect to the fertility outcome. Results: For the laparoscopy group the mean postoperative stay at hospital was 2.2 days and 5.4 days for the laparotomy group. The mean sick leave for the laparoscopy group was 10.9 days and 24.1 days for the laparotomy group. Thirteen patients (12%) developed complications because of persistent trophoblastic activity. There was no statistical significans between the groups. After the laparoscopic approach, the impairment of the adhesion status was considerably less than after laparotomy. HCG levels of 3000 IU/L was a valuable limit for detecting persistent trophoblast. Yet, intrauterine pregnancy rate after laparoscopic surgery did not differ from the laparotomy group. Conclusions: Pre and postoperative hCG determinations are valuable for the prediction and detection of subsequent complications. The fertility outcome of patients treated by laparoscopy or laparotomy is equal, although adhesion formation is more extensive after laparotomy.

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ON3.01 GYNECOLOGICAL PATHOLOGY: UTERUS ON3.01.01 HOW DOES THE PATHOLOGY OF ENDOMETRIAL CARCINOMA INFLUENCE CLINICAL MANAGEMENT? M. Quinn, Oncology/Dysplasia Unit, The Royal Womens Hospital, Melbourne, Victoria, Australia. The pathologist is a key member of the multidisciplinary team responsible for the care of women with gynaecological malignancies. For endometrial cancer, macroscopic and microscopic findings are the cornerstone of therapy, and ultimately are the most important influence on the outcome of our patients. When a pelvic clearance is performed in patients with endometrial cancer, then evaluation of lymph node status is critical, particularly any nodes that are enlarged. Frozen section of such nodes will not only direct any further surgery, but also will allow a rational basis for adjuvant radiation and/or cytotoxic treatment. On opening the uterus, the size and type of the tumour can usually be easily evaluated the presence of a type 1 tumour, which is usually exophytic and non-infiltrative with a good prognosis, can usually be handled conservatively, whereas those type 2 tumours which are usually endophytic and invasive, will need a more aggressive surgical approach. Tumours which extend down to the cervix or involve the tubes and ovaries will also require a thorough surgical assessment. Myometrial invasion can usually be evaluated with about 90% accuracy. Histopathological assessment should include the type of tumour, the grade, taking into account nuclear atypia, the site of the tumour, the size, the depth of invasion and total myometrial thickness, presence or absence of lymph vascular space involvement, involvement of adjacent organs and metastases, including lymph nodes, and whether peritoneal cytology is positive or negative. On this basis tumours can usually be clearly divided into high risk and low risk with an intermediate risk being slightly more difficult to define. Currently, there is no place for measurement of hormone receptors routinely since although they do provide some prognostic information, treatment strategies are not changed on their presence or absence. Despite excellent studies into ploidy status over the last 15 years, particularly from Europe, these have not found their way into the routine armamentarium of the multidisciplinary team. Likewise, recent advances in molecular biology have clearly shown a link between such tumour suppressor genes as P53 in endometrial cancers, but we are a long way from molecular biological estimations replacing the gold standard of histopathology. ON3.01.03 TAMOXIFEN AND ITS ROLE IN ENDOMETRIAL CANCER Dr. Patrick Neven, Algemene Kliniek St.-Jan, Brussels, Belgium Tamoxifen is the most important anti-breast cancer drug in clinical use and has the potential as a chemopreventive breast cancer agent. The effects of tamoxifen on the endometrium have caused concern since the late 1980s, and clear evidence of endometrial changes has emerged from our department using outpatient hysteroscopy. Based on 2 case control and 2 cohort follow-up studies, we were able to demonstrate that 50% of women receiving long term tamoxifen experienced some sort of adverse endometrial effects. Although many women retain an atrophic endometrial layer, tamoxifen intake can lead to extensive senile cystic atrophia of the human endometrium, to endometrial hyperplasia and to endometrial polyp formation. Based on three studies, one case-control study of breast cancer patients and two randomised controlled trials, one in women with early breast cancer and one in healthy women with a family history of the disease and based on a critical review of the literature, we have shown that tamoxifen doubles the risk for developing endometrial cancer in postmenopausal women, although this increased risk may be higher and is duration (i.e. time of use)-dependent. Although screening for endometrial abnormalities is feasible and may increase drug compliance it may not be cost-beneficial. However, uterine safety becomes important when only a small benefit of the treatment is to be expected as in the use of tamoxifen in healthy women for breast cancer prevention. Those who advocate screening should start with pretreatment uterine assessment using transvaginal ultrasonography or outpatient hysteroscopy. Symptom-free women with a normal pretreatment uterine

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cavity can be screened annually with transvaginal sonography from 2 to 3 years after the start of tamoxifen. Hysteroscopy or saline infusion sonography will be required if there is endometrial thickening because the only value of transvaginal ultrasonography is a normal finding being a thin rectilinear endometrium. In summary, postmenopausal women on tamoxifen have an increased risk for developing endometrial cancer. ON3.02 VULVAR DISORDERS ON3.02.01 MANAGEMENT OF VULVAR INTRAEPITHELIAL NEOPLASIA L. Micheletti, M. Preti, F. Bogliatto, M. Massobrio Department of Gynecology and Obstetrics, University of Torino, Torino, Italy. Objectives: The aim of the study is to present the outcome of vulvar intraepithelial neoplasia (VIN) treated or followed without treatment at the Vulvar Clinic of the Department of Gynecology and Obstetrics of the University of Torino. Study Methods: From June 1981 to December 1999 114 VIN were histologically diagnosed: 27 VIN I, 15 VIN II and 72 VIN III. For the purpose of the study the retrospective recruitment of the cases was stopped in December 1998 and the patients were followed until December 1999. Results: The follow up (median 3.6 years, range 1- 14.9) is available in 64 patients surgically treated: 12 VIN I, 9 VIN II and 43 VIN III. The median age of the patients was respectively 51.1, 31.5 and 53.7 years. In 6% (2 VIN I, 1 VIN II and 1 VIN III) of the 64 patients a spontaneous regression was observed and the median age of these patients was 44 years. Recovery at the first treatment was obtain in 49/60 patients (82%): 8 VIN I, 6 VIN II and 35 VIN III. Recurrence was observed in 6% of the patients (1 VIN I and 3 VIN III), median age 66 years, and progression in 11% (1 VIN I, 2 VIN II and 4 VIN III), median age 58 years: all patients except one were cured after further treatment. Among the progressed group, five patients developed an invasive carcinoma and in three of them, median age 70 years (mean 66), a lichen planus was originally associated. Conclusions: According to our experience, despite VIN grade, excisional versus destructive approach should be preferred since an invasive neoplasia could arise both in patients with low and high-grade VIN. Therefore observation could be done for low grade VIN arising in women under 45 years or pregnant or reliable for strict follow up ON3.02.03 THE MANAGEMENT OF VULVODYNIA Ph.Weijenborg, Dept Psychosom Gyn & Sexology Leiden University Medical Center, Leiden, The Netherlands. Vulvodynia is defined as chronic vulvar discomfort, especially characterized by the patients complaint of burning, stinging, irritation and/or rawness (1). It is important to recognize the different subsets of vulvodynia, since treatment options differ (2). There has been much controversy about the etiology, diagnosis and management of one of these subsets: the vulvar vestibulitis syndrome (3 ). The syndrome (VVS) is characterized by the complaint of dyspareunia, tenderness of the vestibule to cotton-swab palpation and vestibular erythema (4). Still the ideal approach is not determined. Some basic ideas on the management of VVS will be considered, referring to a model for this pain problem. Somatic as well as psychological aspects are discussed. 1.Burning Vulvar Syndrome: Report of the ISSVD. J Reprod Med 1984;29:457. 2.Wesselmann U, Burnett AL, Heinberg LJ. The Urogenital and Rectal Pain Syndromes. Pain 1997;73:269-94. 3.Bergeron S, Binik YM, Khalif S, Pagidas K. Vulvar Vestibulitis Syndrome: A Critical Review. Clin J Pain 1997;13:27-42. 4.Friedrich EG. The vulvar Vestibulitis Syndrome. J Reprod Med 1987;32:110-4.

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RM3.01 ENDOSCOPIC MANAGEMENT OF ENDOMETRIOSIS RM3.01.02 EXCISION OF PELVIC ENDOMETRIOSIS David B. Redwine, Endometriosis Institute Of Oregon, Bend, OR, United States No medicine eradicates endometriosis, and medicine treats only the symptoms, not the disease. For these reasons, surgery is the treatment of choice. Because endometriosis can invade beneath the visible pelvic surface to varying degrees, thermal ablation with laser vaporization or electrocoagulation may leave disease incompletely treated. Excision of endometriosis gives the surgeon a better chance of completely removing all disease, including deeply invasive disease. Mature excisional techniques have been described and evaluated for endometriosis of any location and any depth of invasion. Excision can be performed with sharp scissors, monopolar or bipolar electrosurgery, or laser. Monopolar electrosurgical excision is the most versatile technique, since the scissors can be used to palpate, grasp and rearrange tissue, cut sharply, cut with electrosurgery, coagulate bleeders, blunt dissect, and retract. This eliminates most instrument changes and speeds surgery along. Excision results histologic confirmation of endometriosis which enhances the scientific process, since the visual identification of endometriosis is not always correct. The technique of monopolar electroexcision of endometriosis is simple in concept. Abnormal peritoneum is grasped and elevated away from underlying vital structures. 90 watts of pure cutting current passed down 3 mm scissors is used to incise normal peritoneum around the lesion of interest. Retroperitoneal blunt dissection is used to separate fibrosis associated with endometriosis from vital structures. Remaining tendrils of connective tissue held on stretch can then be quickly cut with electrosurgery. Parenchymal disease, such as of the uterosacral ligaments, can be quickly resected using 50 watts of coagulation current, which has a higher voltage and therefore a more powerful cut. Recurrent disease after complete excision is uncommon, calling into question Sampsons theory of origin of endometriosis. Symptom relief is excellent and fertility is not compromised by excision. RM3.01.03 THE ENDOMETRIOTIC DISEASE THEORY P.R. Koninckx, University Hospital Gasthuisberg, Department Obstetrics-Gynaecology, Division Endoscopic Surgery, Catholic University of Leuven, Leuven, Belgium The Sampson and metaplasia theories consider endometriosis as normal glands and stroma outside the uterus. The key phenomenon is the implantation/metaplasia, whereas the subsequent growth and development is considered inevitable, albeit modulated by peritoneal and immune factors. The disease therefore is considered progressive and recurrent. EDT considers retrograde menstruation of viable endometrial cells and occasional implantation of these cells a normal physiologic phenomenon. These nonimplanted or implanted cells are normally removed by the defence mechanisms of the body, such as macrophages. Attachment and implantation is favoured when the mesothelial layer is damaged by trauma, infection, or even by low-grade inflammation (e.g. irritation caused by CO2 pneumoperitoneum) or by abundant retrograde menstruation. It seems logical to postulate that by mere statistical mechanisms, attachment and implantation must occur more frequently when more viable cells are present in peritoneal fluid. Although these cells can temporarily grow and develop depending upon the environment, their ultimate fate when left alone will be a spontaneous regression. This can be complete disappearance/removal or this can result in some fibrotic or scar tissue as the remnant of local inflammation, containing eventually some endometrial cells, shielded from the bloodstream and from immunocompetent cells, comparable to the bacteria in an abscess. ED is caused by a cellular modification, e.g. a genetic mutation, as observed in many benign tumours. This cellular accident will happen more frequently in genetically predisposed persons, and will be favoured by other factors such as total body irradiation, or chemical pollutants such as dioxins. It seems logical that the probability of such a cellular accident increases when more cells are present. The type of cellular modification, together with local factors such as the peritoneal fluid microenvironment or the intra-ovarian milieu, will determine whether they will develop into typical lesions, deep endometriosis or cystic ovarian endometriosis, and whether the morphologic characteristics will

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be chocolate cysts, endometrial glands and stroma, or adenomyosis externa. Typical lesions are considered either as the remnant of a normal physiologic condition, or as a benign tumour with such a low invasiveness and growth potential that the lesions remain inactive over longer periods. The EDT has the following clinical implications. According to the implantation theory endometriosis is a recurrent disease and women in whom the diagnosis of (minimal) endometriosis is made are considered at risk for developing severe endometriosis later in life. According to the EDT, minimal endometriosis, especially subtle or nonpigmented lesions, are no longer considered a pathologic condition and these women should not be considered as having an increased risk to develop severe endometriosis. Since the EDT considers endometriotic disease as a benign tumour, complete surgical excision would eradicate the disease with no risk of recurrence. The actual data showing low recurrence rates after excision of severe and cystic ovarian endometriosis are consistent with this view. According to the EDT the increase with age and heriditary aspects can be interpreted as the probability for a cellular incident to happen. The importance of the EDT as opposed to the Sampson and metaplasia theories, is that implantation is viewed as relatively unimportant, whereas the driving motor become the cellular changes. This obviously is crucial for research and treatment which should reorient from preventing implantation to understanding, preventing or treating cellular damage or the consequences. According to the EDT endometriosis is entering the era of tumour biology. RM3.02 NEW METHODS OF CONTRACEPTION RM3.02.01 NESTORONE ROD: A SECOND GENERATION SUBDERMAL IMPLANT R. Massai1, Moo-Young A2, 1Instituto Chileno de Medicina Reproductiva (ICMER), Santiago, Chile. 2The Population Council, New York, USA. The Nestorone (NES) implant is a second generation implant for female contraception. It is easy to insert and remove and very efficacious and safe. Its adverse effects are minimal. This implant contains NES, a potent 19 Nor-progesterone derivative, which does not affect lipoproteins and does not bind to SHBG. The steroid is not biologically active when administered by the oral route due to its rapid biotransformation by first-pass hepatic metabolism. Thus NES is ideally suited for breastfeeding and non-breastfeeding women. In previous dose-finding studies in non-breastfeeding women, only one pregnancy was reported, and it occurred in the 24th month of use of a single implant (100 mg/d). Experience with this implant in 3576 womanmonths of use demonstrated high contraceptive efficacy for nearly two years (Pearl Index: 0.34). The mode of action is primarily ovulation inhibition and secondarily, increased viscosity of the cervical mucus. The contraceptive effectiveness of the implant was also assessed in breastfeeding women during lactation and after weaning, for up to two years. In 2195 woman-months of use, there were no pregnancies and no adverse effects on breastfeeding or infant growth and health. In order to provide a greater margin of safety beyond two years, this implant was reformulated to deliver a higher dose of NES (125 mg/d) for a longer time. This reformulated version is currently being tested in a multicenter Phase II clinical study designed to measure its contraceptive efficacy beyond two years. RM3.02.02 IMPLANON A SINGLE ROD SUBDERMAL IMPLANT J. Newton, Birmingham University/Birmingham Women`s Hospital, Birmingham, United Kingdom. Implanon is a single rod subdermal implant containing 68mg Etonogestrel. It lasts for at least 3 years and should only be be administered by those familiar with the insertion technique. In our centre, we have been working with this implant for the last 10 years and have published the results of the Pase 2 clinical studies of the pharmacodynamics of leeched implant system, the endometrial response in Implanon users, ultrasound and endocrine parameters, and the bleeding patterns associated with Implanon use. In addition, we participated in the multi-centre clinical tudy of Implanon use and the comparative study of Implanon versus the 6 rod Norplant system. This

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new subdermal device has proved to be highly effective with no pregnancies being reported after more than 70,000 cycles of use. The single rod implant is 4cm in length and 2mm in diameter. The Etonogestrel is contained within a flexible EVA membrane. The initial relcase rate of hormone is 67mg per day. Each Implanon rod comes individually packed within the needle of a sterile disposable specially designed inserter. Within one day after insertion, serum blood levels are greater than 90pg/ml of Etonogestrel, which is the critical serum level required to inhibit ovulation. These levels are maintained for at least 3 years in a controlled release. Within one week of removing the single rod, serum blood levels are below the sensitivity of the assay and more than 90% of women ovulate within 30 days of removal. There appears to be no effect of patient weight on the serum level, even those weighing more than 70Kg also have levels of Etonogestrel which inhibit ovulation. Its primary effect is of ovulation inhibition, but it has secondary effects on cervical mucus and the endometrium. In clinical studies, both FSH and LH, ultrasound follicle monitoring and serum progesterone levels confirm these statements. In 2,362 women, over 73,429 cycles, no pregnancies were seen. Using a 90 day WHO reference period analysis, the main difference with Implanon is the increased incidence of amenorrhoea, which may be perceived as an advantage rather than frequent and prolonged bleeding episodes. Compared to studies of Implanon versus a multi-implant device, there was an increased incidence of amenorrhoea with Implanon compared to the other device. Despite the menstrual change, discontinuation rates are low if effective pre-insertion counselling has taken place, with more than 80% of women remaining on Implanon at the staart of the third year. Adverse experiences in the multi-centre study compared with a multi-implant device show no major differences and a low overall incidence of adverse experience. Weight change is unremarkable. Effects on acne and dysmenorrhoea will be presented. One of the key features of Implanon in addition to its high efficacy and current absence of pregnancy, is the difference in insertion and removal time compared with a multi-rod system. With Implanon the mean time to eject the subdermal implant is 1.1 minute compared with a mean time of 4.3 minutes for the multi-implant system. Removal times show a similar, highly significant difference, 2.6 minutes being the mean removal for Implanon, with 10.2 minutes being the mean removal time for multi-rod implants. Counselling is essential and must include contraindications to progestogens and local anaesthetics, a medical and family history, advantages and limitations of hormone implants, correct timing for injection and removal techniques, effect on menstruation and the incidence of other adverse effects is also important to stress the rapid return to reproductive function after removal of the implant, the maximum period of use, i.e. 3 years, at the present time, and its overall safety. UR3.01 STRESS URINARY INCONTINENCE UR3.01.01 DIAGNOSTIC PROCEDURES IN STRESS URINARY INCONTINENCE THE ROLE OF URODYNAMICS AND ULTRASOUND IN UROGYNECOLOGY Heinz Koelbl, Martin Luther University, Halle-Wittenberg, Halle/Saale, Germany Introduction: Since 50 years urodynamics and ultrasound have contributed a lot to our clinical knowledge in urogynecology including lower urinary tract and pelvic floor dysfunction. With the time the importance of various diagnostic techniques has changed, especially in regard to their clinical relevance. The euphoric phase of urodynamics was replaced by the increasing number of reports about the necessity of ultrasound. Generally, we have to differentiate between diagnostic procedures found in clinical routine and procedures important for urogynecologic reasearch. In genuine stress incontinence (GSI) urodynamics is helpful to exclude other forms or to identify mixed forms of urinary incontinence by application of filling cystometry. The value of uroflowmetry to assess detrusor function in the emptying phase of the bladder should not be underestimated in regard to the increasing number of older women with impaired detrusor function especially when undergoing stress incontinence surgery with the potential risk of postoperative impaired voiding funciton. The urethral pressure profile at rest helps to identify the, hypotonic urethra, a term defined as a maximum urethral pressrue

WEDNESDAY, SEPTEMBER 6
of less than 20 cm H2O, and urethral length. Patients with hyptonoc urethras have an increased risk to develop recurrent GSI, which at least should be included in preperative information of the patient. There urethral pressure profile during stress is irrelevant in clinical practice to assess GSI, due to its lack of sufficient sensitivity and specificity. Sonographic imaging of the lower urinary tract has replaced conventional radiology in many institutions. In regard to urethrocystography quantitative and qualitative assessment has beeen shown to help the investigator to identify urethrovesical morphology and its surrounding structures in patients with GSI and / or pelvic floor relaxation. The techniques can be combined with urodynamics comparable to conventional videourodynamics. Three-dimensional ultrasound and endosonographic techniques are still a matter of scientific discussion, but have enlarged the knowledge about the functional anatomy of the urethra and the periurethral structures. Comparative studies of MRI and ultrasound are able to identify site-specific lesion in patients with GSI and pelvic floor disorders. Meanwhile, identificitaion of middle and posterior compartemental defects of the pelvic floor is not restricted to radiological and clinical examination techniques. Urodynamics and sonographic techniques are not conclusive methods to identify patients with GSI. They complement each other in conjunction with patient history, symptoms, quality of life, and last but not least clinical findings. Both techniques earn their merits in the broad field of urogynecology including the pelvic floor.

UR3.01.03 NEW DEVELOPMENTS IN THE TREATMENT OF STRESS URINARY INCONTINENCE THE TVT PROCEDURE. C. G. Nilsson, Dept. of Obstetrics & Gynecology, Helsinki University Central Hospital, Helsinki, Finland Surgical Treatment of female stress urinary incontinence has focused on the hypermobility and anatomical changes of the bladder neck and the proximal urethra. The majority of our traditional incontinence operations are thought to cure urinary leakage by restoring pressure transmission conditions at the bladder neck (1). A new integral theory has been presented, according to which the main closure mechanism of the urethra is situated at the mid-urethra (2). Anatomical structures such as the pubo-urethral ligaments, the anterioir part of the pubococcygeal muscle and fibrous tissue elements within the anterioir vaginal wall, are all situated at the mid-urethra. The operation is performed in local anesthesia. Through three 1-1.5cm long incisions a Prolene tape is brought under the mid-urethra and paraurethrally on both sides of the urethra, in close contact with pubic bone, by a specially designed device. The tape is intended to support the mid-urethra and strengthen the pubourethral ligaments. Clinical experience with this new method are encouraging. Cure rates of 85-95% have been reported (3). Intra-and postoperative complications are minor and few. The method is suitable for primary as well as recurrent cases of stress incontinence. The operation can be performed as a day surgical procedure and there seems to be one decline in cure rate by time. 1) Enhming, Acta Chir Scand Suppl. 1961 2) Petros & Ulmsten, Scand J Urol Nephrol 1993 3) Ulmsten et al. Int Urogynecol J 1998 SS3.01 COLLECTION AND CLASSIFICATION OF PERINATAL DATA SS3.01.01 CURRENT PROBLEMS IN GLOBAL PERINATAL DATA MANAGEMENT Jelka Zupan, World Health Organization, CH-1211 Geneve 27, Switzerland Current data are critical in the goal of international health efforts to improve the global health of mothers and infants. Perinatal mortality is an important health indicator often used as evidence of the effect of prenatal and obstetric care. For international use and comparison the indicator has little meaning unless standard definitions are used, the reporting is consistent and sufficient attention is given to data quality. International surveillance is conducted through vital national registration systems, population based surveys, hospital discharge data systems, disease reporting and other sources.

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Around 150 countries have a system of civil registration and statistics, and half of them are considered to be complete. They are an important source of population based data for critical outcomes, however, they provide inadequate measures for service programs and no data on morbidity. Hospital discharge data systems routinely provide estimates of causes of major morbidity and mortality in the population, however, these estimates are not representative of the population. Early postnatal stay also limits the completeness of data particularly where most babies are born and die at home. Population based surveys give important data on health and use of services despite their limitations such as small sample size for rare events and recall bias. The role of computer and communication technology should bring huge changes to surveillance of perinatal events and enable expanding surveillance efforts in less developed settings. SS3.02 MICROINVASIVE LESIONS OF BREAST CANCER SPANISH LANGUAGE SESION SS3.02.02 CONSERVATIVE TREATMENT OF MICROINVASIVE BREAST CARCINOMA. AJ. Herruzo. Facultad de Medicina. Basque Country University. Bilbao. Spain

SS3.01.03 INNOVATIVE TOOLS FOR PROCESSING PERINATAL DATA. JM Belizn and G Lindmark, FIGO Committee of Perinatal Health,. Latin American Center for Perinatology (PAHO/WHO), Montevideo, Uruguay and Uppsala University, Uppsala, Sweden A crucial element to improve health care is the knowledge and analysis of information. When countries and hospitals lack an evaluation of the characteristics of the population assisted, the care provided and the outcomes of such care are blinded and consequently have no orientation to guide their practice and their resources. All of those providing health care should be aware of the relevance of the data they are collecting and translating into records. Each data collected and then analyzed should be fully justified about its usefulness. Quality is more important than quantity. FIGO Committee on Perinatal Health estimated than with only 15 indicators it is feasible to have a good diagnosis of the characteristics of the population, the care provided and the results obtained. The Latin American Center for Perinatology (PAHO/WHO) is developing a tool to analyze perinatal data that will provide to the user a friendly output with vital statistics, trends of indicators and risks. This system will be linked to the Epi-Info statistical package and consequently worldwide available. The Minimal Perinatal Data Set proposed by FIGO as well as any data set could use this analytic system to obtain useful outputs to orient care.

Microinvasive breast carcinoma (MIC) is a controversial lesion, and the natural history of patients with intraductal carcinoma (DCIS) and microinvasion is poorly defined. Microinvasive breast carcinoma (MIC) has a good prognosis. Microinvasion is defined as a single focus of invasive carcinoma < or = 2 mm or up to 3 foci of invasion, each < or =1 mm in greatest dimension. The extent of DCIS did not correlate with the number of foci of microinvasion. It has a different biology than T1 invasive carcinoma with > or =90% DCIS, which may progress and cause death. Large tumors with multiple foci of microinvasion may have metastatic potential. and the clinical management of these patients, with particular reference to management of the axilla, has been controversial. Breast-conserving surgery and definitive irradiation should be considered the alternative to mastectomy and the correct treatment for appropriately selected and staged patients with microinvasive ductal carcinoma of the breast. The size (extensive intraductal component -EIC- ) and margin status of DCIS each are found to be independent predictors of residual disease. The cases of microinvasive carcinoma not associated with axillary lymph node metastases and appeared to be associated with an excellent prognosis. Further study is indicated to determine the appropriate management and long term prognosis of patients with this lesion.

SS3.02.04 CELLULAR MARKERS Jordi XERCAVINS, Sabina SALICR, M Dolors SABADELL, Unidad de Patologa Mamaria,. Hospitals Vall dHebron,. Barcelona., Ctedra de Obstetricia y Ginecologa,. Universidad Autnoma de Barcelona. El carcinoma ductal in situ es la proliferacin de clulas epiteliales malignas dentro del sistema galactofrico de la mama sin evidencia de invasin del estroma subyacente a travs de la membrana basal en la observacin al microscopio ptico. Existen diversas clasificaciones de microinvasin aunque la ms aceptada es la que se refiere a focos de cancer invasivo con un dimetro mximo de 1mm. La predisposicin hereditaria al cancer de mama y la progresin de la enfermedad desde lesiones benignas hasta la malignidad tienen su base en alteraciones genticas diversas como en los genes que regulan el crecimiento celular (oncogenes), la supresin tumoral o la apoptosis pero teniendo en cuenta que es un proceso multisecuencial. Se han utilizado multiples gradaciones de los marcadores celulares con el objetivo de establecer el pronstico para cada lesin siendo los de ms inters: - tipo y grado histolgico - marcadores del fenotipo de la neoplasia: ndice de proliferacin, morfologa nuclear, angiognesis. - receptores hormonales, receptores nucleares de retinoides, BCAR1 - marcadores indicativos de integridad de respuesta: receptores de progesterona - oncogenes de supresin tumoral - marcadores de inestabilidad gentica - ciclina El uso de biomarcadores para cuantificar la variabilidad interindividual en la respuesta a la exposicin a carcingenos tiene implicaciones significativas para el consejo sobre el riesgo carcinognico y para plantear estrategias de quimioprevencin. Del mismo modo podemos establecer ndices pronsticos basndose en estos marcadores y a otros factores importantes como el ndice pronstico de Van Nuys.

SS3.01.04 SIMPLIFIED ICD CODING MANUAL FOR PERINATAL HEALTH P. Lumbiganon, Dept. OB/GYN, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand Objectives: To develop a simplified ICD 10 coding manual to be used by Perinatal health personnel. Methods: The first step involved communications with all national societies affiliated with FIGO, to review existing systems used for the collection of perinatal data and obtain comment on the existing ICD 10 classification. The provincisional simplified version of the ICD 10 classification related to Pregnancy, Childbirth and the Puerperium was developed using a manual developed by the Swedish Association of Ob & Gyn as a model. The WHO committee on ICD 10 classification was also contacted for comment and suggestion. This draft manual was circulated to relevant FIGO Advisory Expert Panel members and some selected delegates in different regions of the world with a request to test it in the actual clinical settings for a one-month period or a minimum of 100 deliveries. Results: Eleven countries requested to take part in the field test completed the trial. Their response in general terms were positive. All comments arising from the field testing were carefully reviewed by FIGO Committee on Perinatal Health and a final draft of the simplified version is to be planned in conjuction with WHO-ICD office. Conclusions: A simplified ICD-10 coding manual for perinatal health will be developed in the form of pocket size list which is handy for clinical use.

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FM3.04 FETAL ORIGINS OF ADULT DISEASE FM3.04.01 OVERVIEW F. Andr Van Assche, University Hospital Gasthuisberg, Leuven, Belgium There is evidence that an abnormal intra-uterine environment has long lasting consequences in adult life. However, when we published in 1979 for the first time in the international litterature that an abnormal intra-uterine environment could induce consequences in later life, we felt major septicism at that time. At this moment, epidemiologic data show that intra-uterine growth restriction is related with insulin resistance in adult life expressed as vascular diseases and type II diabetes. Asymetric fetal macrosomia may be responsible for reduced insulin secretion in adult life. Animal experiments may explain some of the working mechanisms. Severe diabetes or malnutrition during pregnancy in the rat induces fetal growth restriction; at adulthood these offspring show insulin resistance and vascular dysfunction. We suggest that an underdevelopment during fetal life of insulin receptors may be operational. There is also evidence that oxidative stress is involved. Mild diabetes in the rat induces fetal macrosomia, in adult life there is a reduced insulin secretion. It is clear that the maternally derived changes in fetal plasma composition (glucose, amino-acids, fatty-acids) certainly influence the development and function of the fetal endocrine pancreas, but they affect other organs and functions as well (kidney, hypothalamus, endothelium, etc). The consequences are mostly seen at older age, since the vitality of the organism is reduced and can not more compensate for these alterations. FM3.04.02 PLACENTAL GLUCOCORTICOID METABOLISM: AN ENDOCRINE LINK WITH THE BARKER HYPOTHESIS M. D. Kilby, Birmingham Womens Hospital, Birmingham, United Kingdom Babies who are born small at birth and continue to be small during infancy are known to be at increased risk of developing cardiovascular disease in adult life. It is thought that these adult diseases are programmed by an inadequate supply of nutrients or oxygen in-utero. As well as birthwieght, placental weight has also been correlated with adult cardiovascular disease, independently of birthweight. Babies with a placenta that is disproportionately large (in relation to their birthweights), are at increased risk of cardiovascular disease also. In animals, fetal hypercortisolaemia is associated with impaired fetal growth. The placenta is the site of production of a unique enzyme which metabolises cortisol to relatively inactive, cortisone, called 11b hydroxysteroid dehydrogenase 2. We have demonstrated that placental weight is directly proportional to the activity of this enzyme in the placenta and that in severely growth restricted babies, the 11b HSD2 expression is significantly reduced, especially if associated with placental vascular disease. Also, in uncomplicated pregnancies in which amniocentesis has been performed and fetal size estimated using ultrasound, there appears to be an inverse relationship between amniotic fluid cortisol concentration and fetal size (independent of gestational age). This provides further evidence of an association between placental/fetal weight ratio and fetal cortisol metabolism in-utero. Such evidence, indicates that the placenta is more than a transport system for nutrients and oxygen. It has the ability to at as an endocrine organ and data presented in this presentation further expands on this hypothesis. FM3.04.03 PERINATAL OUTCOME AND THE PLACENTA T T Lao, Department of Obstetrics & Gynaecology, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China. There is now evidence of an association between an increased placental weight to birthweight ratio (placental ratio) with cardiovascular complications and diabetes mellitus in adulthood. Yet there is scanty information on the relationship between the placental size or pathology

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with the perinatal outcome, despite that fact that the placenta has been referred to as the diary of the pregnancy. Placental infarction and chronic villitis has been associated with fetal growth restriction in preterm and term infants. In the preterm infant, the presence of chorionic and umbilical vasculitis, which are thought to represent pre-existing infection, are associated with increased risk of intraventricular haemorrhage independent of confounders. While the placental weight is correlated with infant birthweight, a disproportionately heavier placenta, as reflected by an increased placental ratio, can be found with the smallfor-gestational age (SGA) newborns, as well as maternal anaemia and gestational diabetes mellitus. An overweight placenta is associated with evidence of acute or subacute antenatal hypoxia, including low Apgar scores, respiratory distress, neurological abnormalities, and neonatal death, especially in infants born before 35 weeks. Some of the neurological abnormalities persisted into childhood. Most recently, it has been shown that in SGA infants without major anomalies, a high placental ratio was due to increased placental weight and decreased birthweight in the absence of any difference in maternal characteristics or antenatal complications. Furthermore, the infants with a high placental ratio had increased incidence of meconium stained liquor, hypocalcaemia, hypomagnesaemia, phototherapy for neonatal jaundice, and sepsis. While histological examination of the placenta may not be feasible as a routine in many centres, the placental weight is usually available soon after childbirth. Further studies are warranted to determine whether this information may help to identify not only subjects who are at risk of diseases in adulthood, but also newborns who may have increased morbidity in infancy and childhood. FM3.04.04 FETAL CARDIOVASCULAR PROGRAMMING K. Marsal, H. Gardiner, J. Brodszki, Department of Obstetrics and Gynecology, University Hospital, Lund, Sweden The reactive fetus responds to severe uteroplacental insufficiency by reducing flow to non-essential organs, and increasing flow to the cerebral circulation, heart and adrenal glands. Obstructed areas within the placenta result in increased impedance and may even cause reversal of flow back into the fetal arterial circulation at end-diastole thus increasing the ventricular afterload and compromising fetal cardiovascular function. We have studied the hypothesis that abnormal arterial flow patterns in SGA fetuses program early vascular development which, by a process of amplification, may result in adult onset hypertension. Fetal cardiovascular function was examined using ultrasound. Pulse waveform and pulse wave velocity in the thoracic descending aorta was investigated using a phase-locked echo-tracking system. Spectral pulsed Doppler ultrasound was used for examination of aortic, middle cerebral arterial and intracardiac blood flow velocities and the velocity waveform was evaluated. The dimensions of the descending aorta in growth restricted fetuses were equivalent to younger, normally grown fetuses of similar mean fetal weight. SGA fetuses had lower ventricular diastolic filling than normal fetuses and did not show gestational increase in fractional shortening. The maximal velocity through the aortic valve was less in growth restricted fetuses, but there were no significant differences in the pulmonary artery maximal velocity. The pulse wave characteristics of the descending aorta differed in SGA fetuses (lower late decremental velocity and reduced relative pulse amplitude). The differences in the vascular biophysical properties observed in growth restricted fetuses support the hypothesis that vascular remodelling occurs and attempts to maintain stable arterial wall stress. However, whilst fetal adaptive mechanisms may aid survival they may result in cerebral, and vascular abnormalities.

ON3.03.01 OVERVIEW OF CERVICAL SCREENING WORLDWIDE Saloney Nazeer, Clinique de Strilit et d`Endocrinologie Gyncologique, Geneva, Switzerland Cervical cancer is perhaps the most preventable major form of cancer to date, yet 450 000 women develop invasive disease which causes more than 200 000 deaths each year, globally. Developing countries account for 80% of the cervical cancer disease burden but only 5% of the global resources for cancer control. In these

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countries incidence often equates to mortality because of unawareness, poverty, lack of or in adequate screening programmes with limited technical and fiscal resources. In the face of the above Pap-smear, which continues to be the initial screening test for cervical cancer, will not be available in most settings for several decades. It has been estimated that 40-50% women in developed countries have had a Pap-smear in the last five years compared to 5% in the developing countries. Consequently the disease burden is increasing in these countries with 80-85% cases seen at late, incurable stages (III & IV) making incidence equivalent to mortality. Studies conducted worldwide, to evaluate alternative feasible techniques for cervical cancer screening in comparison to Pap-smear were reviewed at the Consensus Conference on Cervical Cancer Screening & Management, Tunis 1999. Data from initial studies shows Visual Inspection with Acetic Acid' and 'HPV detection' to be the most promising methods with high sensitivity. The issues regarding practical implementation of these research findings in actual screening programmes is being addressed through Regional technical workshops under the umbrella project of the International Network on Control of Gynaecological Cancers (INCGC). It is now established that 95% of cervical cancer cases are associated with oncogenic types of Human Papilloma Virus. Clinical trials on preventive and therapeutic vaccines are underway. The vital question however, prevails as to what will come first - an effective screening tool or a preventive vaccine? It then leads to the question, whether the availability of vaccine will obviate the need for screening? identified 88% of the cases of HSIL and cancer. Cytology was positive in 8% of women and identified only marginally more cases of HSIL and cancer at 78%. While the sensitivity of DVI and HPV testing were almost equivalent to cytology, the specificity was lower. Data from phase 2 is in process of being analysed and will be presented at the conference. Conclusion: Both DVI and HPV testing have equivalent or better sensitivity to expert cytology, although both tests lack specificity which would result in large numbers of women being overtreated were women to be treated in a 'screen and treat' protocol. HPV testing has considerable potential as a screening test, as it also identifies women at greatest risk of developing HSIL in the future allowing resources to be targeted to this group of women. Methods of improving specificity of DVI and HPV testing will be discussed as well as the expected outcome of different screening protocols based on the performance of the screening tests.

ON3.03.04 HEALTH ECONOMIC CONSIDERATIONS IN CERVICAL SCREENING K. L. Noller, University of Massachusetts Memorial Healthcare, Department of Obstetrics & Gynecology, Worcester, MA, USA During the past several years chages in the preparation and laboratory interpretation of cervical cytologic specimens have been developed. Based on publications to date, these techniques generaly produce modest increases in the accuracy of cervical cytologic sampling. Unfortunately, all of the proposed techiniques result in increased cost. In many cases, it is unclear whether the expense of such systems is justified. However, because pap smear screening varies greatly in different parts of the world, no one statement concerning the cost efficiency of these new techniques is appropriate. For example, at one end of the spectrum there are countries where many women, most of whom are at low risk for cervical cancer, have annual cervical cytologic screening. For these women (who do not need yearly screening in the first place) the increased cost of the new technologies is probably not warranted. At the other end of the spectrum are those women, a screening method that i most likely to detect disease would almost certainly be cost effective. Health care resources are not unlimited anywhere in the world. The judicious use of new technology requires a careful assessment of the needs of the population and the financial support available. RM3.03 POLYCYSTIC OVARIAN DISEASE RM3.03.01 WHAT IS PCO? Z.M. van der Spuy, Dept. OB/GYN, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa The polycystic ovary syndrome is arguably the most common endocrinopathy of women. Ultrasound assessment of ovarian morphology is the gold standard for the diagnosis of polycystic ovaries (PCO). The typical ultrasound features include increased stroma and multiple discreet follicles (at least 8 of <10mm in diameter) often arranged peripherally. The polycystic ovary syndrome (PCOS) is diagnosed when PCO occurs in the presence of clinical symptoms such as menstrual dysfunction, hirsutism or infertility. It is an heterogenous condition with variable clinical and endocrine features. Presentation is influenced by a variety of extra-ovarian factors. Hyperinsulinaemia in a feature in many women with PCOS and appears to be the trigger for clinical expression of this condition. It is a major determinant of excessive androgen secretion and is implicated in other aspects of PCOS including anovulation and dyslipidaemia. Obesity is a common feature and has an independent effect on the endocrine profile. Polycystic ovaries are an inherited phenotype and have been found in about 20% of healthy volunteers. In contrast they are present in over 90% of women with hirsutism and in about 75% of patients with anovulatory infertility. Hypertension, diabetes mellitus and dyslipidaemia occur more frequently in women with PCOS when compared with control subjects. It has become evident that PCOS is more than an ovarian disturbance and the metabolic disorders may have long-term consequences both in terms of reproductive function and of general health

ON3.03.02 THE ROLE OF HUMAN PAPILLOMAVIRUS TESTING IN CERVICAL SCREENING J. Cuzick, Imperial Cancer Research Cancer Fund, Department of Mathematics, Statistics & Epidemiology, London, United Kingdom The human papilloma virus is now established as the primary cause in over 95% of all cervix cancers world-wide. It is readily detectable in material collected in a smear, and is an obvious candidate for screening. Thee are three potential roles for the test i. Improving management in women with borderline or midly dyskaryotic smears ii. Post-treatment surveillanc to detect incomplete excision of CIN iii. As a primary screening test HPV has better sensitivity for CIN 2/3 than cytology, and thus argues for its use in the first two situations. There are number of possible ways in which HPV testing could be employed as a primary screening test either alone, in conjunction with cytology or only where cytology is equivocal. In addition, self-sampling is a possbility. The high sensitivity of HPV makes it a good candidate for primary screening, but issues of specificity are likely to determine its ultimate role. Results from currently available trials on HPV screening will be presented as well as the status of ongoing studies. ON3.03.03 PROSPECTS FOR CERVICAL SCREENING IN DEVELOPING COUNTRIES L.Denny (1), L.Kuhn (2), T.C.Wright Jr. (2), (1) Groote Schuur Hospital, University of Cape Town, Cape Town, Western Cape, South Africa, (2) Columbia University, New York City, NY, United States. Objectives:To evaluate alternative methods to cytology for the prevention of cervical cancer in developing countries. Methods: A volunteer sample of 2944 previously unscreened women recruited from a squatter camp outside Cape Town, were screened using 1] Pap smear 2] HPV DNA detection using HC 1 and HC 11,with probes for oncogenic types HPV 3] Direct Visual Inspection of the cervix (DVI) after 5% acetic acid and 4] Cervicography. Women who were positive on any of the screening tests were referred for on-site colposcopy and histological sampling. In Phase 2 of the study an additional 3000 women were screened and tested for HIV, chlamydia and gonococcus infection of the cervix. Results:Of the initial 2944 women screened, there were 95 (3.5%) cases of LSIL, 74 (2.4%) of HSIL and 12 (0.4%) of cases of cancer. DVI and HPV DNA testing using HC 1 at the standard cut-off for a positive test identified 18 and 16% of women as positive and detected 67% and 73% of the cases of HSIL and cancer. Using HC 2, HPV DNA testing

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RM3.03.02 GENETICS OF POLYCYSTIC OVARY SYNDROME Stephen Franks, Imperial College School of Medicine, St Mary's Hospital, London W2 1PG Polycystic ovary syndrome (PCOS) is one of the most common cause of anovulatory infertility. It is now recognised that, in addition to the reproductive implications, PCOS is associated with a characteristic metabolic disturbance of which hyperinsulinaemia and insulin resistance are the central features. This is in turn related to an increase in the risk of type 2 diabetes in later life. Despite the clinical significance of PCOS, its aetiology remains uncertain but the high prevalence of cases within the families of affected cases suggests that there is a major genetic cause. Most of the clinical genetic studies published to date, including our own, have concluded that the most likely mode of inheritance is autosomal dominant but recent studies at our centre suggest that PCOS may represent a complex trait involving the interaction of a small number of genes with environmental - principally nutritional - factors (Franks et al, Hum Reprod 1997;12:2641-8). We have evidence that polymorphism of the insulin gene (INS) variable number tandem repeat (VNTR) is a major susceptibility locus for PCOS. The INS-VNTR is in the 5' regulatory region of the gene; it has been shown to be involved in insulin secretion and has been implicated in the aetiology of type 2 diabetes. Abnormalities in the regulation of key genes in the androgen biosynthetic pathway have also been uncovered. In particular, alleles of CYP11a (coding for P450 cholesterol side chain cleavage) are associated with PCOS and there is also evidence for linkage at this locus. Recently, genes implicated in ovarian follicular development have been suggested to have a role in the aetiology of PCOS, as demonstrated by the recent identification of the follistatin gene as a potential disease locus (Urbanek et al, Proc Natl Acad Sci 1999; 96: 8573-8578). It seems unlikely that PCOS can be explained on the basis of a single gene disorder although, in a given family, one gene may have a predominant effect. An oligogenic model seems the most appropriate basis on which to understand the genetic origins of PCOS. RM3.04 FEMALE STERILIZATION RM3.04.01 CREST STUDY: HOW EFFECTIVE IS TUBAL STERILIZATION? H. B. Peterson, World Health Organization, Geneva, Switzerland A 1997 report from the U.S. Collaborative Review of Sterilization evaluated prospectively a total of 10,865 women who underwent tubal sterilization in medical centers in nine U.S. cities in 1978 to 1987. Women enrolled earliest in the study were eligible for up to 14 years of follow-up. A total of 143 true sterilization failures were identified. Conclusions include Tubal sterilization is highly effective but pregnancies may be more common than previously thought; the risk appears to vary by method of occlusion and technique. In general, the risk of pregnancy is greater for women sterilized at earlier ages. Pregnancy can occur for many years after sterilization and the more remote from sterilization it occurs, the more likely it is to be ectopic. The risk of ectopic pregnancy likewise persists and varies by age and method of occlusion; there were ectopic pregnancies identified in the 10th year of follow-up after all four methods of laparoscopic sterilization. Does Tubal Sterilization Cause Menstrual Abnormalities? A preliminary analysis found no menstrual changes attributable to sterilization within the first year or two after the procedure. Findings of changes at five years after the procedure could be attributable to ageing. A report based on an analysis of the final data set is pending. Available evidence argues against the existence of a post-tubal sterilization syndrome. Does Tubal Sterilization Increase the Risk of Hysterectomy? Although women undergoing sterilization were approximately four times more likely than their nonsterilized counterparts to undergo hysterectomy at 5 years after the procedure, the increase is likely to be attributable to non-biologic factors. What is the likelihood of Regret after Sterilization? The prevalence of regret increased with time since sterilization and was highest among women who were young at the time of the procedure.

WEDNESDAY, SEPTEMBER 6

RM3.04.02 US FDA PIVOTAL STUDIES WITH THE FILSHIE CLIP Gilbert Marcus Filshie, University Hospital of Nottingham, Queens Medical Centre, Nottingham, United Kingdom The Filshie clip was developed in conjunction with Mr D Casey with the support of the Simon Population Trust between 1974 and 1982. During this time over 12,000 prototype clips had been tested. The final model became available in 1982. Preparations for the FDA approval was subsequently sought and the final approval (PMA) was granted in 1996. The clip is made of titanium (ASTM Grades I and II) and silicone rubber (a medical grade silicone rubber). Both these materials have been extensively used clinically. Non-clinical laboratory studies included: microbiology, toxicology, minology, bi-compatability, stress, wear, shelf life and radio active effects on the silastic elastima. A review of the literature was also conducted. There were no significant adverse biological responses noted in the literature or on tests. Carcinogenic studies were conducted in 200 rats and 200 mice following the application of mini-Filshie clips. The results showed no evidence of carcinogenic activity resulting from the occlusion of the uterine horns in the animals. Eleven clinical investigations were conducted to demonstrate the safety and efficacy of the Filshie clip system. Four of these studies were pivotal ie they were large, multi-centre, prospective randomised, comparative trials involving the Filshie clip versus the Wolf (Hulka) clip, the tubal ring, applied laparoscopically (2 studies) and mini-laparotomy (2 studies). There were seven non-pivotal studies. Six thousand, one hundred and two women received the Filshie clip either as an interval procedure or in the puerperium and 3,095 of these were part of the pivotal studies. A summary of the pivotal studies is shown in Table I. 0.1% of women are reported to have a clip migration from the application site and of this total three women experienced expulsion of the clip but did not appear to have experienced any serious sequalae. I would like to acknowledge Professor Theodore King, Family Health International and Femcare Ltd for supporting these studies as well as the 40 investigators who contributed so diligently. Table I: Summary Data of all Clinical Studies Pivotal
Study1 Number Design2 Control Group Approach Filshie Control Treated Population Months of follow up No. of Centres Treated Population Overall3 Pregnancy Rates + SE _______________________ Filshie Control Statistically Significant Outcome Measures

6267 6267 ext

PRC PRC

Wolf Clip Wolf Clip

Laparoscopy Laparoscopy

622 298

625 301

12 24

4 2

0.002+0.002 0.010+0.007

0.010+0.004 0.028+0.012

None None

6266

PRC

Wolf Clip

Minilaparotomy

441

437

12

0.000+0.000

0.003+0.003

None

6265

PRC

Tubal Ring

Laparoscopy

916

909

12

0.002+0.002

0.002+0.002

Filshie group less likely to have surgical injury and less likely to have

6265 ext

PRC

Tubal Ring

Laparoscopy

356

347

24

0.007+0.005

0.003+0.003

pain during recovery

6264

PRC

Tubal Ring

Minilaparotomy

462

446

12

No pregnancies None

None

ext = extended protocol. The protocol was extended to 24 months for a subset of women PRC = prospective, randomised and controlled Gross cumulative life-table pregnancy rates + standard error through study protocol designated follow up period

RM3.04.03 FEMALE STERILIZATION FAILURE R. J. Stock, Portsmouth Naval Medical Center, Protsmouth, VA, United States There are more than 100 procedures described for female tubal sterilization. All the procedures are designed to permanently obstruct the

WEDNESDAY, SEPTEMBER 6
Fallopian tubes. They also all have related complications and reported failures. Sterilization failures may be categorized into 4 groups: 1) conception occuring prior to the surgical procedure; 2) the surgical procedure performed on a tubular structure other than the Fallopian tube; 3) and improperly performed surgical procedure on the Fallopian tube; or 4) the occurrence of tubo-peritoneal fistula formation or spontaneous anastomosis as a consequence of natural healing following a propely performed procedyre. The focus of this presentation will be on the latter 3 possibilities. Associated tubular structures are rarely mistaken for Fallopian tubes and are the result of incomplete operative exposure. Improperly performed procedures are most commonly associated with clip, ring of electrocoagulation techniques. These procedures involve specific knowledge and use of equipment, approach to the tube, and application to the appropriate section of the Fallopian tube. The failures in these cases are the results of incomplete obstruction/destruction of the tube. Segmental destruction of the tube by whatever means will result in a healing process that will tend to maintain a patent lumen. Usually the result will be a tubo-peritoneal fistula. However, if the two ends are in close proximity then spontaneous anastomosis may occur. The most successful sterilization procedures are those in which the segmental obstruction leads to fibrosis without separation, or tubal division with the uterine end of the tube buried beneath the peritoneum.

11
interventions aimed to treat urinary incontinence. Before such measures are introduced it is important that they are adequately tested for validity and reproducibility and it is important to recognise that such instruments cannot be used in isolation but must be included as part of an overall assessment, including subjective and objective parameters. UR3.02.02 DEVICES AND BEHAVIOURAL TECHNIQUES G. Willy Davila, Cleveland Clinic Florida Fort Lauderdale, FL, United States Treatment of urinary incontinence utilizing pelvic neuromuscular rehabilitative techniques makes rational sense, as the pathophysiologic basis for most types of incontinence and voiding dysfunction is based on neuromuscular dysfunction. Timed voiding and bladder drills have been demonstrated to be very effective as first line therapy for incontinent women, especially those with urge incontinence. Pelvic floor exercises by themselves are typically not effective due to the difficulty in identifying the levator musculature. Biofeedback-guided exercises have been demonstrated to be effective, especially in a motivated patient who performs exercises on a long-term basis. Functional electrical stimulation, initially thought to be a means of enhancing pelvic floor contraction strength, is primarily effective in women with urge incontinence. Multiple variables can be adjusted to individualize the utility of electrical stimulation for specific incontinence types. Devices used for the treatment of incontinence function by a variety of methods; external urethral obstruction, bladder neck elevation, and intraurethral valvular effect. Of those, intra-vaginal devices designed to elevate the bladder neck in a manner similar to anti-incontinence surgery have the highest degree of acceptance and usage. These are particularly useful in women who do not wish surgical therapy, or those in whom surgery may not be appropriate. Numerous effective non-surgical treatment options are available for women who suffer from urinary incontinence. Individualization of therapy is key to successful modality selection. UR3.02.03 TREATMENT OF GENUINE STRESS INCONTINENCE: MININVASIVE SURGERY Mauro Cervigni, "S. Carlo di Nancy" Hospital, Roma, Italy Type 1 and Type 2 Stress Urinary Incontinence (SUI) is defined as a urine leakage under stress associated with an urethral and bladder neck hypermobility. The actual world-wide concept is to create a support over a long period on which the hypermobile urethra can be compressed during abdominal straining. Up to now the gold standard for the treatment of SUI is the Burch procedure. Nevertheless its reliability and long-term efficacy (81% after 5 y. F-U), the modern trend of surgery is to obtain the same results of the traditional techniques with mini-invasive and day-surgery procedure. Needle suspensions were the first attempt of a less traumatic and mini-invasive approach. But recent papers on long-term discouraging resultsi (Kelly and Kirshbaum 91) suggested to find new techniques. Recently some groups have introduced the laparoscopy in the treatment of SUI. But, the sparse reports in the Literature, the short follow-up, the lack of a specific definition of the terms cure and improve and the complication rate raise some doubts on the advantages of these techniques on transvaginal techniques.. In 1982 Ulmsten postulated the hypothesis that the principal mechanism for urinary continence was related not only to the bladder neck, but also and mainly at the middle third of the urethra, were there is the location of the maximum intraurethral pressure. According to this hypothesis he proposed an ambulatory surgical procedure: Tension free Vaginal Tape (TVT), in which a Prolene mesh tape is positioned in local anesthesia below the middle third of the urethra. The advantages are numerous: 1. the patient awake has an intact pelvic floor reflex during cough maneuvers (extremely important for the evaluation of the degree of the tape tension). 2. The tape is positioned tension free, only loosely placed, without vaginal or bladder neck elevation, 3. this position create an urethral kinking only during stress, allowing a normal funneling of the bladder neck during. voiding with a positive effect on the onset of micturition.. The new technologies (Bone Anchors) combined with new concepts on physiopathology of continence (TVT.) are dramatically changing the surgical treatment of SUI. The near future might confirm these expectancies.

RM3.04.04 FEMALE STERILIZATION STERILIZATION REVERSAL S. Nair, Mount Elizabeth Hospital, Singapore Tubal sterilization has evolved over the years into minimally invasive laparoscopic approaches with less traumatic and tube preserving devices of tubal interruption (clips;rings). Due to the very small lumen size of the fallopian tube (500, um), the concept of microsurgery was initiated by Swolin (1967) who proposed the use of magnification and delicate instrumentation. Gomel (1977) and Winston (1977) independently proved the feasibility microsurgical sterilization reversal with resullts superior to macrosurgery. Pregnancy rates of 80% to 90% are achievable using microsurgical technique (Kim etal 1997). Most pregnancies occur within the first year (80%). The main prognostic factor for pregnancy is the age of the patient. The type of anastomosis and whether it is unilateral or bilateral has no statistically significant effect on fetrility results (Glock 1996). A commonly held niew is that the best fertility results after sterilization reversal when clips are used for tubal sterilization. Sieler (1983) however, reported that the type of sterilization procedure did not affect prognosis. The final length of the reanastomosed tube is an important prognistic factor (Silber & Cohen 1984; Kim etal 1997). The pregnancy rate was dismal in patients with a tubal length of less than 4 cm. Yet another revolution in microsurgery is the laparoscopic approach which provides a closed environment and utilizes patient positioning and pneumoperitoneum to obtain exposure without retractors / packing hence potentially reducing de novo adhesion formation. The advent of new ultra-micro laparoscopic instruments and the 3 chip CCD camera has enabled traditional microsurgery to be performed laparoscopically (Koh 1996).

UR3.02 INTERNATIONAL UROGYNECOLOGY ASSOCIATION SYMPOSIUM: INCONTINENCE UR3.02.01 QUALITY OF LIFE L Cardozo, Kings College Hospital, London, UK Urinary incontinence is a distressing condition which has been shown to adversely affect all aspects of the quality of life of those women who suffer from it. Various studies have been undertaken to try to measure the impact that incontinence has on normal daily living but the generic healthy questionnaires which are in current use are not specific enough to for this purpose. In recent years several new disease (incontinence) specific questionnaires have been developed which provide a more sensitive tool with which to evaluate the psychosocial impact of urinary disorders in women. The International Continence Society has recommended that quality of life be included as an outcome measure in all clinical trials of new

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UR3.02.04 THE SURGICAL MANAGEMENT OF RECURRENT STRESS URINARY INCONTINENCE J. A. Schulz, H. P. Drutz, Mount Sinai Hospital, Toronto, ON, Canada Recurrent stress urinary incontinence is a distressing problem. It scauses are multifactorial and the literatire continually provides suggestions for changes to the surgical approach. Over 200 surgical procedures exist for the treatment of stress urinary incontinence, and this leaves the practising surgeon with an overwhelming range of choice. This article will review current available techniques for the surgical treatment of recurrent stress urinary incontinence.

WEDNESDAY, SEPTEMBER 6
Follow-up of trainees with supportive supervision and a continuing education structure supports what has been taught. Supportive supervision provides feedback to the midwife or provider and the supervisor on performance of the midwife as well as retention of skills and knowledge. When problems with performance are identified, this information is fed into the continuing education component and contributes to the overall sustainability of the system. Conclusion: Begining in 1987, the Safe Motherhood initiative brought the magnitude and tragedy of women and infants dying in childbirth to the world's attention. The Life-Saving Skills program is one of the programs developed to decrease maternal and infant mortality and serious morbidity. SS3.03.03 COMMUNITY MIDWIFES - HOW EFFECTIVE ARE THEY? Ms.Yanne Annas, IBI, Jakarta, Indonesia One alternative solution decided by The Government of Indonesia to meet the high maternal mortality in the country was accelerate the midwifery training programme. Between 1989-1996 there are 3 midwifery programmes two basic midwifery programmes (Types A & C) and one post basic programme for instructors (type B). The quality of the graduates depended on many factors, among others, local situations, existing teachers & facilities and availability of clinical practice (in hospital & community). Focus of the midwifery programme at that time was more on quantity rather that on quality of the graduates. The government was in a hurry to place one midwife in each village (+ 65.000 villages). Several continuing education programme have been conducted to upgrade and improve the knowledge and skills of these midwives (community/village midwives). Many studies have been conducted on the community midwives, on their performances, their workload and also on their competence in technical skills. Even so, many community midwives are doing well in their respective village and they are integrated in the everyday life of the village. The main problem now, is that most of them are only on a 3 years contract with the government to work in the village (the government is not able to employ them on full-time basis as government employee). After 3 years they may extend their contract to three more years. But some also left the village after their contract expired and to find work else where. Data on how many of them are still working as a midwife or doing some other work, no accurate data is available yet. SS3.03.04 THE ROLE OF NATIONAL PROFESSIONAL ORGANISATIONS Christine Achurobwe, Uganda Private Midwives Association, Kampala, Uganda Objectives: The aim of the study was to: Identify roles and responsabilities for National Professional organisations. Encourage formation of National profesional organisations. Formulate National/Regional collaboration between organisations. Study Methods: Fifty percent (50%) questionnaires were distributed to members of two National Professional organisations to find out the role of their organisation: how they have assisted the country. Also how they have collaborated with other organisation outside the country. Results: Eighty percent (80%) of questionnaires were received back with what they thought was the roles or how they collaborated with other outside organisations. Conclusions: National Professional organisations are available resources which can be uterized and supported to expand National Programmes more especialy in community. My presentation will elaborate on what Uganda Women Medical doctors have done. The preservation will also indicate the need for National and regional National Organisation collaboration where we can build our roles and responsabilities by using National/Regional Experienced personnel to provide knowledge & skills to other organisations.

SS3.03 SAFE MOTHERHOOD: ENSURING SKILLED ATTENDANCE AT BIRTH SS3.03.01 SETTING MIDWIFERY STANDARDS: A MULTI-COUNTRY EXPERIENCE D. Sungkhobol, World Health Organization, Regional Office for SouthEast Asia, New Delhi, India. Maternal mortality and morbidity are a major public health concern in many countries of the World Health Organization South-East Asia Region, and the Region still accounts for 40 per cent of the worlds maternal deaths. Statistics reveal that more than 50 per cent of deliveries in the Region occur at home and are mostly assisted by unskilled attendants. Maternal health services in many countries in the Region are particularly inadequate. In response to the needs expressed by Member States, the Regional Office has developed Standards of Midwifery Practice for Safe Motherhood. The standards, which include management of selected obstetric complications and emergencies, were developed specifically for use in countries of the Region with their active involvement. They support evidence-based care and are intended to be prototype standards for adaptation according to countries needs. These standards were field tested in four countries of the Region where midwifery services are at different stages of development. The field test has demonstrated that by implementing the standards the quality of midwifery services has improved, client satisfaction has increased, and the competence and self-confidence of midwifery-trained personnel have been enhanced. The lessons learnt during this process were used in finalizing the standards. Several countries in the Region have now set their own midwifery standards by adapting the prototype standards. The use of these standards will assist countries in ensuring and enhancing the quality of midwifery services in order to address the problems of high maternal mortality and morbidity. SS3.03.02 IMPROVING LIFE SAVING SKILLS Joseph Taylor, Sandra Buffington, Diana Beck, Deborah Armbruster, Central Hospital, Koforidua, Ghana The Life Saving Skills (LSS) program was developed to meet specific needs identified in the field and is based on real-life experience of health care providers, particularly midwives and physicians. LSS responds to the needs of many countries by proving a practical, hands-on and systematic way to reduce maternal mortality and morbidity by training midwives, and other health care providers, to provide women with emergency obstetric services. The Life - Saving Skills Performance Improvement Approach It is critical for the improvement of the LSS program that a Performance Improvement Approach (PIA) to training be taken. A PIA implies not only the systematic development of a quality training program including preparation, competency-based training and follow-up, but also the development of a number of interlinking systems that support each other to produce an overall Training and Continuing Education System. This approach requires an investment of human resources during the set-up phase and the ongoing monitoring and support. By following this LSS Performance Improvement Approach to training, an in-service training and continuing education system can be designed that is focused on provider and community needs and reflects agreed upon clinical protocols.

WEDNESDAY, SEPTEMBER 6
SS3.04 GERMAN SOCIETY SESSION SS3.04.02 HEMATOPOIETIC TRANSPLANT POTENTIAL OF UNRELATED AND RELATED CORD BLOOD: EXPERIENCE OF THE EUROCORD/NETCORD BANK DSSELDORF T. Somville1, H. Rttgers2, W. Meier3, O. Bellmann4, A. Ring5, HG. Schnrch6, H. Streng7, H. Lehnen8, M. Kusche9, U. Rosseck10, G. Kgler11 and P. Wernet11. 1 Dept. of Gynecol. and Obstetrics H.-Heine-University Dsseldorf, 2 St.Antonius Wuppertal, 3EVK Dsseldorf, 4Florence Nightingale, Dsseldorf, 5AKH Viersen, 6 Lukashospital Neuss, 7Josefinum, Augsburg, 8Elisabeth Hospital Rheydt, 9Marienhospital Aachen, 10Dept. of Gynecology and Obstetrics Neuwerk, 11Institute for Transplant Diagnostics and Cell Therapeutics, H.-Heine-University Dsseldorf. To date, hematopoietic stem cells from cord blood (CB) have been employed in over 1500 allogeneic (sibling and unrelated matched and mismatched transplantations worldwide. The examination and standardization of unrelated and related cord blood derived stem cell preparations and banking as well as their biological characterization was initiated in Dsseldorf already in 1993. Hitherto a total of 4615 CB samples (4513 unrelated, 132 for directed donations within the family; mean volume 90+25 ml, total nucleated cells (NC) 10+5x108) from cord blood have been defined by hematological, immunological and microbiological criteria. These CB samples were collected from the umbilical cord vein immediately after vaginal full term delivery or cesarean section and stored frozen in liquid nitrogen. Only 5.0 ml of a CB sample is required for routine laboratory testing as there are HLA-class I typing, HLA-class II typing by sequence-specific oligonucleotide probes (PCR-SSOP), ABO typing, sterility control, assessment of progenitor- and stem cells by colony forming- assays, and CD34+ status as well as for CMV, Hepatitis B, C, HIV, Parvo B19 before releasing the CB unit for transplantation. With regard to viral infections maternal sera were tested for HBsAg , anti-HBc, anti-HCV,HIV-1-2, -HTLVI-II, -CMV and Syphilis. Within the last four years a total of 7400 preliminary searches, 920 extended unit reports were submitted to the CB bank Dsseldorf by fax or World Wide Web. Thusfar 102 unrelated and 3 related CB units were transplanted in over 40 different transplant centers world-wide. The median patient age was 6 years (range 0.3-48), the median weight 21kg (range 4-70kg). The majority of the patient suffered from ALL (n=36), JCML (n=1) AML (n=13), CML (n=8) and Lymphoma (n= 5), MDS (n=6), AA (n=5), FA (n=2); 29 patients had genetic and acquired diseases. All CB samples as well as the patients blood samples were typed in Duesseldorf for HLA-class I by serology confirmed by PCRSSP and by high resolution DNA typing for HLA-DRB1 and HLADQB1 alleles. 94% of the 105 patients receiving unrelated CB were mismatched at one or more HLA-loci. Until now 41 patients transplanted with unrelated CB from Dsseldorf were evaluable for engraftment with an overall engraftment rate of 84% with a median time of 23days (range 10-57 days). 49% of the transplanted patients are alive with a median follow-up of 320 days. SS3.04.03 NEW THERAPEUTIC APPROACHES IN CERVICAL CANCER PATIENTS A. Schneider and M. Possover, Dept. Gyn., University of Jena, University Hospital, Jena, Germany Objectives: The aim of the study was to investigate the effect of nerve sparing laparoscopic assisted radical vaginal hysterectomy (LARVH) type 3 for preservation of bladder function. Study Methods: 66 patients with cervical cancer FIGO Stage 1b1, 1b2, 2a, and 2b underwent LARVH type 3. In 38 patients only the vascular part of the cardinal ligament was transected at the pelvic side wall and the neural part was preserved. In 28 patients the conventional type 3 procedure with complete transection of the vascular and neural part of the cardinal ligament and at the pelvic side wall had been done. Results: There was no difference in peri- and post- operative complications between both groups. Bladder training by suprapubic catheter was stopped at postoperative day 11.2 in the patients treated by the nerve sparing techniques compared to 21.4 days in patients treated by the conventional technique (p=0.0007). Length of the parametrium measured on the fresh specimen was 6.8 cm for both groups. Conclusions: Nerve sparing LARVH type 3 allows preservation of the motoric function of the bladder without imparing radicalness of resection of the parametrium. SS3.04.05 FRONTIERS IN GYNECOLOGICAL ENDOCRINOLOGY Thomas Rabe, University Womens Hospital; Heidelberg, Germany

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Selectic topics - based on clinical trials mainly performed in Europe: Hyperandrogenism: workup according clinical feature; in cases with moderate and severe androgenisation an androgen producing tumor must be ruled out by serum testosterone (>1,5 ng/ml) and DHEAS (> 7 mg/ml); in infertility patients a 21-hydroxylase-deficiency must be suspected by 17-OH-progesterone > 4 ng/ml after ACTH stimulation test (25 IU i.m.) and verified by a gene sequenzing; if positive a screening of the partner and a dexamethasone therapy in early pregnancy until genetic diagnosis is recommended. Treatment option in non-infertility patients range from spironolactone, low dose OCs to OCs containing cyproterone acetate*), chlormadinone acetate*), dienogest*) or norgestimate (* not on the US market). Thrombophilia: increased risk for thrombosis by use of OC (up to 50200fold in patients with homocygous factor-V-Leiden mutation) as well as in HRT takers (2-3fold) (controls: 1/10 000). Family risk (history) for cardiovascular disease must be considered and if positive a screening is recommended for antithrombin III, protein-C, -S and APC-resistancy, exclusion of Factor-V-Leiden, and optional: homocysteine, lipids or carbohydrates. No differences in thrombophilia due to different progestagens used for OC and HRT. Contraception: New progestogens for oral hormonal contraception are or will be soon available: medrogestone (Wyeth), drospirenone (Schering). Progestogens with low androgenicity should be preferred. New 24-dayregimen with gestodene; clinical trials with Ocs containing natural estrogens. New ethinyl estradiol free oral hormonal contraceptives. The levonorgestrel releasing system (Mirena/Schering) has been accepted by more than 1.5 million users in Europe. Further innovations: vaginal rings, hormonal patches, implants and once-a-month injectable. HRT: 70 innovations (35 patches) are in clinical trials. Continuous, cyclic or intermittend use of progestogens might be selected for endometrial protection as well as a small levonorgestrel releasing IUS. Primary prevention of cardiovascular disease and Alzheimer must be prooven for ERT/HRT as well as their use following gynecological cancers. Breast cancer: HRT increases the chance the breast cancer diagnosis leading to a favorable prognosis and lower mortality when compared to non-HRT users. SS3.04.06 NEW PROCEDURES OF OVARIAN STIMULATION. Klaus Diedrich, Michael Ludwig, Department of Gynecology and Obstetrics, Medical University of Lbeck, Lbeck, Germany Ovarian stimulation is an essential part of each treatment cycle in assisted reproductive technology (ART). However, especially in IVF these ovarian stimulation procedures have different problems like the risk of ovarian hyperstimulation syndrome (OHSS), patients discomfort due to the length of the procedure, hormonal withdrawal symptoms or cyst formation. Using the new drug class of LHRH antagonists, some of these problems can be avoided or significantly reduced in their incidence. Ovarian stimulation can be integrated in a spontaneous menstrual cycle. With Cetrorelix (Cetrotide, ASTA Medica AG, Frankfurt, Germany & Serono International S.A., Geneva, Switzerland) the first antagonist was available. It could be shown in a prospective, randomized study, that the risk of OHSS was significantly reduced with Cetrotide compared to the long protocol. Prospective, randomized studies using Cetrotide as well as prospective studies using the antagonist Ganirelix (Orgalutran, Organon GmbH, Oss, The Netherlands) showed, that antagonists can be used with either urinary gonadotrophins or recombinant FSH with the same success rates. There is an ongoing debate, whether antagonist protocols might lead to lower pregnancy rates compared to agonist protocols in ovarian stimulation. Until now, no prospective randomized study could show a significant difference in pregnancy rates. A tendency towards lower pregnancy rates in antagonist protocols might be due to a bias in the studies and to a learning curve, which is necessary to yield optimal results with this new drugs. An open worldwide observational study using Cetrotide showed

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pregnancy rates in daily practice, which are in the range of the long protocol. In experienced centers no disadvantages for the patients could be seen, when Cetrotide was used instead of the long protocol. SS3.05 INTERACTIVE SESSION SS3.05 SOLVING THE DILEMMAS, AN OBSTETRICAL ISSUE (I AND II) Ernesto Castelazo-Morales, Instituto Nacional de Perinatologa, Mexico Cty, Mexico Preterm labor remains as a worldwide public health problem; lack of evidence and consensus over diagnostic and therapeutic issues still generate an enormous amount of controversy. This course is designed to review the way to approach this problem, confront different ways to handle it, hear the experts opinion and take a look at the evidence in an interactive session which includes case presentations. Main objects are to review etiology and epidemiology, identify risk, approach prevention, discuss management, anticipate potential complications, improve fetal outcome and consider delivery options. The course will start with a brief review lecture based on evidence followed by several short controversial case presentations covering different aspects of the topic; by electronic means the audience will have the opportunity to test its skills, compare and discuss them with the rest of the participants. PS3.01 PRESIDENTS SESSION PS3.01.03 PARTNERSHIPS FOR SAFE MOTHERHOOD: HOW MUCH IS A MOTHER WORTH? J. E. Thompson, University of Pennsylvania, Philadelphia, PA, United States This paper will address the power of partnerships in promoting Safe Motherhood globally and locally. Particular attention will be given to the role of the International Confederation of Midwives (ICM), FIGO, and WHO as partners in promoting the health of women and childbearing families throughout the world, including their participation with others on the Interagency Group on Safe Motherhood (IAG). Examples of these important partnerships will be drawn from joint efforts in upgrading the knowledge and skills of midwives through pre-Congress workshops, the promotion of Life Saving Skills in the developing world, and the setting of international competencies and standards for all those with midwifery skills who are vital in any effort to reduce maternal morbidity and mortality throughout the world. Skilled attendance at birth is one of the lessons learned from over 10 years of the global Safe Motherhood Initiative, and will be used as one example of the power of partnerships that promote the health of women. The discussion of the collaborative relationships between midwives and obstetricians at local, national, regional and global levels will focus on those aspects of this inter-professional relationship that promote the health of women with seamless, high quality, evidenced-based childbearing care from village through hospital, as needed. Discussion will highlight some of the inter-professional conflicts during the past decades as well as successes based on mutual respect, trust, and appropriate use of the unique competencies of both obstetricians and midwives in the care of women during their childbearing years. Examples from developed and developing nations will be used to answer the question, How much is a mother worth? The summary of this paper will focus on the values and ethics of Safe Motherhood, and the basic human rights that are needed by women in order to survive one of their most important roles in any society that of bearing and caring for the worlds children. Midwives and obstetricians working together can make a difference in lives of all the worlds women and families. PS3.02.02 CONTRACEPTION IN 2050 Professor R V Short, Department of Obstetrics & Gynecology, Royal Womens Hospital, University of Melbourne, Australia By 2050, the population of the world will be around 10 billion. Many developed countries will have falling populations, as the increasing costs

WEDNESDAY, SEPTEMBER 6
of educating children make childbearing prohibitively expensive, and as women choose to postpone marriage and childbearing for the sake of their careers. Improved sex education in school, and free availability of condoms, the oral contraceptive pill and emergency contraception will hopefully reduce the current high rates of teenage pregnancy and abortion. After achieving their desired family size, women will increasingly opt for forms of contraception like gestagen-releasing intrauterine devices that reduce menstrual blood loss, thereby avoiding the need for a hysterectomy as the menopause approaches. It seems unlikely that we will develop an effective hormonal or immunological contraceptive for men. The rising divorce rate is likely to make male and female sterilization less popular options. The situation in developing countries, where most of the population growth will be taking place, will be very different. The inexorable spread of HIV infection form Africa to Asia, with India as its new epicentre, will drastically reduce life expectancies, with early childbearing as the probable response. The condom is likely to remain the only contraceptive that offers protection against the rising tide of sexually transmitted diseases. Massive educational efforts will be needed among adolescents to increase condom acceptability and use. Loose fitting, re-usable plastic condoms might be more sensational and cost effective than the current latex varieties. They would also be more compatible with a range of new topical microbicides and HIV receptor blockers that should afford additional protection to men and women against sexually transmitted diseases. As abortion becomes legal in more and more developing countries, maternal mortality rates should fall. Cheap non-surgical means of female sterilization will also have an important role to play as desired family size continues to decline.

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FREE COMMUNICATIONS FC3.01 ASSISTED RERODUCTION FC3.01.01 BIRTH AFTER INJECTION OF SPERM AND THE CYTOPLASM OF TRIPRONUCLEATE ZYGOTES INTO METAPHASE II OOCYTES IN PATIENTS WITH REPEATED IMPLANTATION FAILURE AFTER ASSISTED FERTILIZATION PROCEDURES M-S Lee (1), C-C Huang (2), T-C Cheng (2), C-I Chen (1) (1) Dept. OB/GYN, Chung-Shan Medical and Dental College Hospital, Taichung, Taiwan. (2) Dept. Infertility, Lee Womens Hospital, Taichung, Taiwan. Objectives: To assess the technique of injecting a single sperm and cytoplasm obtained from tripronucleate zygotes into metaphase II oocytes for the treatment of patients with repeated implantation failure after ISCI or IVF. Study Methods: We studied patients with repeated implantation failure after ICSI or IVF. The metaphase II oocyte of recipients was injected with their husbands spermatozoa and cytoplasm aspirated from the tripronucleate zygotes of donors. Results: In total, 62 metaphase II oocytes from nine recipients were injected. Of the 62 injected oocytes, 3 (5%) degenerated and 43 (69%) had two pronuclei 18 hours after injection. Embryo development rate was 90.6% (39/43). All cleaved embryos were transferred into the uteruses of recipients. Four clinical pregnancies occurred in four recipients. Five healthy infants were born. Conclusion: Injection of the cytoplasm of tripronucleate zygotes may enhance the clinical pregnancy rate in patients with repeated implantation failure after ICSI or IVF.

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Study Methods: This Study was conducted in my private nursing home which is situated in rural area like Akluj, having population of 40 000. 50 cases have been selected for IUI in last year i.e. from 1st January 1997 to 1st January 1998. In all cases, basic workup was found to be negative. Follicular study was done by Transvaginal sonography & when follicle reaches to 19-20 mm, Inj. HCG 5000 I.U. given I.M. & IUI done. Results: Out of 50 cases, 12 patients conceived (24%). Out of 12 cases, 5 conceived at 3rd cycle (41.66%). Out of 12 cases, 2 premature delivery, 6 full term normal delivery, 2 lower segment caesarean section, 2 abortion at 2 months. Conclusions: Fifty cases were selected for IUI. In all above cases, basic workup was found to be negative. Follicular study was done by TV probe. Ovulation induction done by Clomiphane citrate in every case. When follicle reaches to 19-20 mm, semen sample prepared by HAM F10 media (0.5ml) injected in the uterine cavity by IUI canula. Patient was kept for 20 minutes in head low position. Out of 50 cases, 12 patients conceived (24% conception rate). This IUI is one of the best, non-invasive & economic method for unexplained infertility in rural set-up. FC3.01.04 MECHANICAL OR LASER HATCHING? J. Konc, K. Kany: Infertility and IVF Unit, St. John Hospital, Budapest, Hungary. Objectives: In the past few years two different trends spred worlwide at hathing to improve the implantation and pregnancy rates. The first method was mechanical hatching (AH) and later was used laser one (LAH). We use non-contact laser, the source of laser bbeam touches the zona pellucida tangentially only. The authors used the mechanical hatching and the non contact laser hatching too and they compared the efficience and safety of both methods. Study methods: From February 1998 to November 1999 the authors paralelly used both hatching methods. The authors used an infrared 1,48um diode laser (Fertilase, MTM, Montreux, Switzerland). Indications for LAH or AH were he age of 35 or above, and/or previously three times performed unsuccesful embryo transfer. At all women above 35 years LAH or AH was performed. Under the age 35 three or more unsuccesful embryo transfer gave indication for these interventions. The randomisation of the patients for using laser or mechanical hatching methode happened according to our two embriologists duty service, because one of our embriologists performed only mechanical and the other used only laser hatching. The study patients were divided in two groups according to the randomisation of our embriologists duty service. The Group 1 (LAH) consisted 330 patients, the Group 2 (AH) consisted 114 patients. The control Group 3 consisted 450 patients without hatching. Results: In Group 1 (LAH) the clinical pregnancy rate was 35,15% (116/330). In Group 2 (AH) clinical pregnancy rate was 25,4% (29/114) In the control Group 3 the pregnancy rate was 36,9% (166/450). The rate of major malformation was the same in the three groups. The rate of missed abortion in these groups was not different. Conclusions: By the help of non-contact laser hatching or with the mechanical hatching we were able to reach good clinical pregnancy rate. But there are some adventages of non-contact laser. The administration of non-contact laser hatching is quicker, simplier and easier. A diode laser will have adventages of giving reproducible result with a hole of defined diameter. The laser hatching method is also cheaper, and it spares the working time of the embriologists. FC3.01.05 THE REALITIES OF SETTING UP AN ASSISTED CONCEPTION TREATMENT PROGRAMME IN A DEVELOPING COUNTRY LIKE NIGERIA. R A Ajayi1, V N Bolton2 and J H Parsons2. 1The Bridge Clinic Limited, P O Box 70294 Victoria Island, Lagos, Nigeria. 2The Assisted Conception Unit, Kings College Hospital, Denmark Hill, Camberwell, London, United Kingdom, SE5 9RS. Objective: To outline the problems overcome in the establishment of an assisted conception programme in Nigeria. Design: A descriptive, longitudinal study.

FC3.01.02 IVF SUCCESS RATE FOLLOWING TUBAL STERILIZATION J. Horovitz, D. Sitko, M. Commenges, P. Rolland, A. Papaxanthos, D. Dallay. Maternity B-C, Hpital Pellegrin, Bordeaux, France Objective: Evaluate the success rate of vitro fertilization and embryo transfer (IVF-ET) in women who have undergone tubal sterilization for personal reasons but again desire pregnancy because of a change in their life, and compare the success rate for this group to that of a control group. Study Methods: Two groups of patients were studied, between March 1990 and October 1998, in the Maternity of the Teaching Hospital of Bordeaux. Group I consists of 37 couples where the wife underwent tubal sterilization mainly for personal reasons. This group had 56 IVFET. Group II is the control group and is composed of 237 couples where the wife is infertile because of tubal pathology only. This group had 404 IVF-ET. The following parameters were studied: age, previous fertility, number of ampullae of HMG, number of oocytes retrieved, number and quality of embryos, number of ongoing pregnancies (>= 12wg). Results: The statistical analysis of IVF-ET data was done using students t test and x2 test.
Tubal ligation Years Total number of ampullae Number of oocytes Total number of embryos Number of embryos C1 D1 Number of embryos transferred Ongoing pregnancies 34.5 30.7 5.5 3.5 1.44 2.44 16.7% (6) Tubal pathologies 31.7 40.9 6.7 4.2 1.65 2.45 17.7% (66) P value p = 0.000 /s p = 0.0025 /s p = 0.0230 /s p = 0.0821 /ns p = 0.95701 /ns p = 0.9570 /ns p = 0.875 /ns

Conclusion: Despite a past fertility rate of 89%, the patients of group I do not have a higher success rate than patients of group II (past fertility rate of 23%). The IVF-ET procedure success rate is not related to past fertility but rather to the age of the patient at the time of the procedure.

FC3.01.03 INTRAUTERINE INSEMINATION (IUI) IN UNEXPLAINED INFERTILITY IN RURAL SET-UP D. Satish, D. Sunetra, Doshi Ultrisound Clinic, Akluj, India Objectives: The aim of the study was to know the percentage of conception by IUI method, which is non-invasive & economic method for unexplained infertility in rural set-up

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Setting: The Bridge Clinic Assisted Conception Unit, Victoria Island, Lagos, Nigeria. Patients: Couples attending the Bridge Clinic Limited who require conventional in vitro fertilisation (IVF) and intra- cytoplasmic sperm injection (ICSI). Main interventions: A technology transfer IVF programme with a team from the Assisted Conception Unit of Kings College Hospital, London. Main Outcome measures. The number of treatment cycles carried out in the first operational year, the results of treatment and the problems that were successfully overcome in the setting up of the programme. Results: 81 ICSI treatment cycles and 26 IVF treatment cycles were carried out in the first year. 81 of these 107 treatment cycles had embryos transferred and there were 14 ongoing pregnancies, which include the first ICSI pregnancies in Nigeria. The ICSI programme had to be set up early because 75% of those requesting treatment required ICSI. The problems overcome include the high cost of treatment, infrastructural difficulties like power generation, difficulties in getting supplies and the social and cultural difficulties of accepting assisted conception treatment in a country with mass illiteracy. Conclusion: The difficulties of setting up an assisted conception programme in a developing country can be overcome with careful planning.

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number oocytes obtained, normal fertilization rates, number of embryos available for replacement, those replaced, implantation and pregnancy rates. Results: We have identified 105 patients who have uterine fibroids and are embarking on assisted conception treatment of which 59 patients to date have been treated. The control groups are those patients without fibroids who are treated during the same time interval. Both study and control groups are matched in age, duration of infertility, and basal serum FSH levels. The two groups are comparable in their response to stimulation with identical cancellation rates (10%). The mean number of oocytes obtained was 10.5 and 10.1 in the study and controlled groups respectively. The overall pregnancy and implantation rates were 11.1% and 8.9% in the study patients compared to 28.0% and 13.0% in the control group respectively (p=0.02 for pregnancy rate). Conclusion: Our study suggests that uterine fibroids are associated with lower implantation and pregnancy rates in assisted conception treatment. With more patients, we may be able to ascertain any differential effect of site and size of fibroids on the outcome of assisted conception.

FC3.01.08 ROLE OF PROLACTIN IN HUMAN REPRODUCTION K. Kaur, M. Singh, Dept. OB/GYN, Bombay Infertility Research Centre, Jalandhar, Punjab, India. Objectives: Prolactin may play a role in ovarian steroidogenesis and circumstantial evidence suggests that hyperprolactinaemia in women interferes with ovarian function, however the precise role of Prolactin in the selection and maturation of dominant follicle during ovulation is unclear. The present study was undertaken in an attempt to define this role. Study Methods: 150 infertile women with HSG evidence of bilateral patent tubes were divided into 2 study groups. In the 1st group of 100 patients controlled ovarian hyperstimulation (C.O.H.) was done with Clomiphene citrate and IUI was done. In the second group of 50 patients IVF was done and C.O.H. was achieved by use of Buserelin & Metrodin HP injection i.e. the standard long protocol. Serum Prolactin and Progesterone were checked on day 2 as well as 36 hrs after induction of ovulation with HCG in both groups of patients, while follicular fluid Prolactin and Progesterone were assayed in all the 50 patients undergoing IVF. Results: In the 1st group comprising of C.O.H. with C.C. + IUI, baseline Prolactin on day 2 was mostly found within normal limits while 36 hrs after HCG serum Prolactin was found equivalent to or less than that at the initiation of menstruation. While in the 2nd group (IVF group), where GnRH down regulation was done using Buserelin and then Metrodin HP was used as a full long protocol for induction of ovulation, there were paradoxical results, i.e. serum Prolactin on 34 hrs after induction of ovulation with HCG was much higher as compared to baseline and follicular fluid Progesterone 34 hrs after HCG was also considerably higher as compared to what one expects in preovulatory follicular fluid with respect to serum progesterone. Discussion: The paradoxical mid cycle rise of serum Prolactin and high follicular fluid progesterone suggest that exogenous GnRH and analogues cause Prolactin release from the Pituitary. Moreover, synchronized pulsatile release of Prolactin and LH has been observed when endogenous GnRH is increased as in postmenopausal women and in mid Luteal phase in response to Naloxone. The detailed mechanism by which Prolactin affects ovum maturation and has an effect on progesterone production is discussed.

FC3.01.06 ANALYSIS OF FETAL GROWTH, INFANT BIRTH WEIGHT AND 24 HOUR PHYSIOLOGICAL FUNCTION IN ASSISTED PREGNANCY (AP) VERSUS NON INTERVENTION PREGNANCY (NIP) M. A Omamo-Nyamogo, Dept. OB/GYN, Nyanza Provincial Teaching Hospital, Kisumu, Kenya Objectives: Demonstrate or exclude difference(s) in fetal growth and infant physiological fitness and birth in assisted pregnancy as compared to pregnancy without any from of therapeutic intervention. Study Methods: This was a case-control study in which 200 women with assisted pregnancy and 200 women who conceived and went through term pregnancy without any from of therapeutic intervention were recruited at 10 weeks and followed up to 24 hours after delivery following spontaneous labor at term. Results: The mean fetal weight during pregnancy and birth weight of 3 500g in AP were significantly higher than corresponding values in NIP. Caesarean section (c/s) rate was higher (9%) in AP than (7%) in NIP. In both groups, the leading indication for c/s was feto maternal disproportion. 24 hours physiological fitness assessed by respiratory function and reflex activity was similar in both groups. There was no difference in congenital malformations Conclusions: AP may be associated with slightly larger than average babies. The slight increase in c/s rate is statistically insignificant and fetal well being is preserved. Recommendation: Clients be cancelled appropriately and hospital staff instructed on meticulous monitoring of AP parturients.

FC3.01.07 PROSPECTIVE CONTROLLED STUDY OF THE EFFECT OF UTERINE FIBROIDS ON THE OUTCOME OF ASSISTED CONCEPTION TREATMENT Y. Khalaf, R. Hart, C.T. Yeong, H. Bickerstaff, R. Lawson, A. Taylor, P. Braude, Assisted Conception Unit, Guys and St. Thomas Hospitals Trust, London, UK. Introduction: The effect of uterine fibroids on the outcome of assisted conception has been the subject of recent debate. We set out to prospectively evaluate IVF&ICSI cycles in the presence of uterine fibroids. Materials & Methods: All patients from 1st of August 1999 to date were included in the study. Prior to embarking on a cycle of assisted conception all patients underwent a pelvic ultrasound scan. If a submucosal fibroid was suspected hydrosonography was performed and the fibroid resected if appropriate. The outcome of the subsequent assisted conception cycle was then analyzed. Multifollicular stimulation was carried out using either urinary or recombinant FSH. Buserelin acetate was used for down regulation in the long protocol. The study evaluated number of days of FSH stimulation, total amount of FSH used per cycle, cycle cancellation rates, number of preovulatory follicles,

FC3.01.09 PREMATURE LUTEINIZATION: DOES IT OR DOES IT NOT ADVERSELY AFFECT CLINICAL OUTCOME IN IVF-ET CYCLES? J.S. Younis, M. Matilsky, O. Radin, S. Bar-Ami, M. Ben-Ami. Reproductive Medicine Unit, Dept. OB/GYN, Poriya Hospital, Tiberias, Israel The etiology, pathogeneis, and effect on clinical outcome of premature luteinization (PL), in long GnRH-a IVF-ET cycles, is strongly controversial. Objectives: To examine whether PL, developing in long GnRH-a IVFET cycles, has any adverse effect on clinical outcome, and to study whether this phenomenon could be related to ovarian reserve.

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Study Methods: 76 consecutively seen women employing the long GnRH-a & hMG protocol for IVF-ET were prospectively evaluated. Basal hormonal ovarian studies were assessed in al women one month before starting the treatment. Patients were evaluated in their first cycle of treatment and were divided into those with (study group) and others without (control group) premature luteinization. Premature luteinization was defined as P/E2 ratio of more than 1 on hCG day*. Results: 21 (41%) of the women in the study population demonstrated PL (study group). Patients characteristics were similar in the 2 groups. Day 3 FSH levels were significantly higher in the study a compared to the control group, 9.33.1 and 6.71.9 mlU/ml, respectively. P levels on hCG day were significantly lower in the study compared to the control group, 1.90.7 and 1.20.6 ng/ml, respectively. Inversely, maximal E2 levels on hCG day were significantly lower in the study compared to the control group, 971566 and 2541921 pg/ml, respectively. In addition, the total amount of hMG dosage was significantly higher in the study compared to the control. Moreover, the number of follicles (14mm), oocytes and embryos achieved, were significantly lower in the study in contrast with the control group. Likewise, the clinical pregnancy rate was significantly lower in the PL group as opposed to controls, 13% and 42% respectively. Conclusions: Premature luteinization developing in the long GnRH-a cycles seems to adversely affect IVF-ET clinical outcome. Our results supports the notion that PL in this setting is related to low ovarian reserve. *Younis et al. Fertil Steril 1998:69;461-5 FC3.02.02 ROLE OF UROGENITAL MYCOPLASMA INFECTION IN IMMINENT ABORTION J. Peterek, Dept. OB/GYN, University Teaching Hospital, Warsaw, Poland.

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FC3.02 BACTERIAL VAGINOSIS FC3.02.01 RELATIONSHIP OF LACTOBACILLI TO GENITAL MICROFLORA RESPONSIBLE FOR BACTERIAL VAGINOSIS. A. Aroutcheva, J.Simoes, S.Faro, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, United States. Normal vaginal microflora is predominantly presented by Lactobacillus species that have the ability to regulate the growth of other vaginal flora by forming antibacterial products including lactic acid, H2O2 and bacteriocins. The clinical condition that is characterized by replacing Lactobacilli with Gardnerella vaginalis (Gv) and anaerobes is Bacterial vaginosis (BV). The purpose of the study was to determine the association between Lactobacilli and genital microorganisms detected in BV (Gv and anaerobes). Lactobacillus species were obtained from 35 gynecology patients. The lactic acid produced was tested biochemically and H2O2 formation was determined in MRS agar with horseradish peroxide. Bacteriocin activity were investigated in multilayer agar plate using indicator strains: Gv (20 isolates), Prevotella bivia, Bacteroides fragilis and Peptostreptococcus anaerobius (3 isolates of each). Lactic acid production ranged from 0.68-2.5mg/ml. H202 was positive in 82.8% of the organisms, but there was no correlation found between these parameters (P=0.992). The bacteriocin activity study demonstrated that 29 lactobacilli isolates inhibited the growth of 15 strains of Gv. Six strains of lactobacilli demonstrated zero activity, while five strains of Gv were not inhibited with Lactobacillus species. Only two Lactobacilli were inactive against all anaerobes. No statistical correlation between bacteriocin production, formation of lactic acid and H2O2 was found (P=0.33). Six H2O2-producer strains, were not able to inhibit growth of Gv. However, strains with a low production of lactic acid were found to be active against indicator strains. These findings conclude that Lactobacillus species differ from each other in their ability to produce defense factors, but each make a contribution to maintain normal vaginal balance.

Objectives: The aim of the study was to determine the incidence and importance of infections with M.hominis (M.h.) and U.urealyticum (U.u) in pregnant women with imminent abortion. Study Method: One hundred and four women, aged 18 30 years (mean age 24 years), in 7th 13th week of pregnancy with imminent abortion were divided into two groups: Group A 56 women with the first pregnancy, Group B 48 pregnant women in whom the previous pregnancy resulted in miscarriage or preterm labor. The diagnosis of infection by U.u. and M.h. was performed using Mycofast Evaluation 2 (International Microbio) test, based on hydrolysis of urea by U.u. and hydrolysis of arginine to ornitine by M.h.. The material for the studies was taken from the cervical canal. The results were analyzed statistically by chi2 test with Yates correction. Results: In Group A, U.u. infection was detected in 21.4% of cases. In Group B, U.u. infection was detected in 41.6% of cases and M.h. in 4.2% of studied subjects. In none of the studied patients, infection with both species of U.u. and M.h. was found. The difference of detected infections varied significantly in both groups (p<0.001). In 87 out of the group of 104 studied women, progressing pregnancy was observed and in 17 (16.3%) of cases, the pregnancy was ended in miscarriage which was dependent on the detected infections (p<0.002). Conclusions: Among the causes of imminent abortion, infections with U.u. and M.h. should be taken into consideration. Prophylactic examinations of pregnant women contribute to the detection of frequently asymptomatic or oligosymptomatic STD and make possible avoidance of pregnancy complications.

FC3.02.03 DOES BACTERIAL VAGINOSIS CAUSE CERVICAL INTRAEPITHELIAL NEOPLASIA? D.Boyle (1), S.Barton (2), J.Pollock (3), J.R.Smith (2), (1) Imperial College School of Medicine, Fulham Road, London, England, United Kingdom, (2) Chelsea and Westminster Hospital, London, England, UK, (3) Pollock and Pool Laboratories Ltd., Reading, Berkshire, UK. Previous research examining the relationship between bacterial vaginosis (BV) and cervical intraepithelelial neoplasia (CIN )has produced conflicting results, often failing to control for important confounding variables such as the presence of human papilloma virus (HPV). If BV produces carcinogenic nitrosamines, these might act independently on the cervix or, more likely, synergistically with oncogenic HPV. Women were recruited from two London hospitals. All underwent screening for sexually transmitted diseases, had cervical cytology performed and cervical cells saved for HPV testing. A subgroup had vaginal washings taken for analysis of nitrosamine content. BV was diagnosed by standard methods. 379 women were eligible for analysis:123 with BV and 276 without. Cervical cytology results showed that 12/123 women with BV had CIN whereas 20/256 women without BV had CIN. Specimens suitable for HPV testing were available for 285/379 women and were analysed by hybrid capture for the presence of high and low risk types of HPV. Nitrosamine analysis was performed on a total of 122 specimens: 36 BV positive and 84 BV negative. There was no causal relationship between BV and CIN even when high risk HPV was controlled for. Nitrosamine analysis showed no statistically significant difference between BV positive and negative specimens. This study did not demonstrate a causal relationship between BV and CIN or that BV organisms produce greater quantities of nitrosamines than normal vaginal flora.

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FC3.02.04 COITUS- RELATED VARIATIONS IN VAGINAL MICROBIAL FLORA A.S.Palakathodi AS (1), P.Thorsen (1), S.H.Ebrahim (2), D.Schendel (2), J.A.McGregor (1), G.J.Westergraad (1), (1) Odense University Hospital, Odense, Denmark, (2) C.D.C., Atlanta, GA, United States. Objective: To assess the association between coital frequency and vaginal microbial flora. Methods: The prevalence of microorganisms among pregnant women (Odense University Hospital, Denmark) who reported frequent coitus (7 episodes/ 4 weeks) were compared with that among who reported infrequent coitus (3 episodes/ 4weeks) at initial prenatal visit. Results: Of a total 2,927 pregnant women, the majority reported having coitus (any coitus: 89.2%; frequent: 22.8%; daily: 2.9%) and not using condoms (96.9%) in the 4 weeks before enrollment. Among those who reported no condom use, the prevalence of vaginal microorganisms was significantly high among women who had frequent coitus than women who had infrequent coitus for 8 of the 18 microorganisms (Bacteriodes species, Group B Streptococcus, Mycoplasma hominis, Ureaplasma urealyticum, Candida albicans, nospecific Candidas, Gardnerlla vaginalis, nonspecific anerobic bacteria). The prevalence of Chlamydia trachomatis, Trichomonas vaginalis and Enterococcus faecalis among women who had frequent coitus was slightly higher than those who had infrequent coitus. Conclusion: Frequent unprotected coitus increases vaginal colonization by microorganisms leading to altered vaginal ecology, and, thereby, may facilitate transmission of some infections.

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and persistent BV increased the risk for preterm deliveries or peripartum infections.

FC3.02.06 SCREENING AND TREATMENT OF BACTERIAL VAGINOSIS IN PREGNANCY TO PREVENT PERINATAL COMPLICATIONS R.P.S. Camargo, J.A. Simoes, J.G. Cecatti, Dept OB/GYN, School of Medical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil Objectives: To investigate the impact of a new intervention with screening diagnosis and treatment of bacterial vaginosis in a low risk pregnant women population to prevent perinatal complications. Study Methods: This was an operational research study performed at a Brazilian university hospital in Campinas, Brazil, between January 1997 and March 1999. The women were divided in two groups: 71 women with diagnosis but without treatment of bacteria vaginosis (before intervention) and 134 women with diagnosis and treatment of bacterial vaginosis during pregnancy (after intervention). Univariate analysis was performed with Qui square, Fisher and variance tests. Risk ratios with 95% confidence interval were calculated for the main dependent variables. Multiple regression analysis was used to compare the groups. Results: There was no difference between the groups except for the history of a treated urinary tract infection, higher for the group without treatment. The risk ratios of no treatment were significantly higher, 7.5, 4.3, 6.0 and 4.2 for preterm premature rupture of the membranes, preterm labor, prematurity and low birth weight, respectively. Prematurity occurred in 22.5% of the group without treatment and in 3.7% of the group with treatment. Preterm premature rupture of the membranes and preterm labor were associated with prematurity in multiple regression analysis. In the group without treatment, puerperal infection and neonatal morbidity were significantly higher. Conclusions: For bacterial vaginosis during pregnancy the treatment seems to decrease perinatal complications.

FC3.02.05 VAGINAL CLINDAMYCIN IS INEFFECTIVE IN PREVENTING PRETERM BIRTH AND PERIPARTUM INFECTIONS IN A LOW RISK POPULAITON WITH BACTERIAL VAGINOSIS: A DOUBLEBLIND PLACEBO-CONTROLLED MULTICENTER TRIAL M Kekki, T Kurki, J Pelkonen, M Kurkinen-Rty, B Cacciatore, J Paavonen. Dept. of Ob/Gyn, Univ. Hospital, Helsinki, Dept. of Ob/Gyn, Univ. Hospital, Oulu, Vihti Health Center, and Helsinki City Health Department, Finland. Objectives We wanted to study whether treatment of BV in early pregnancy decreases the risk of preterm delivery and peripartum infectious morbidity. Study Methods In this multicenter, randomized, double-blind, placebocontrolled intervention study, screening for BV was performed by vaginal Gram-stain from 5432 healthy women with singleton pregnancies during the first antenatal clinic visit at 10-17 weeks of gestation. Women with a history of preterm birth were excluded. BVpositive women were randomized to treatment with either vaginal clindamycin cream or identical placebo cream for seven days. Repeat Gram-stains were taken one week after the treatment and at 30-36 weeks of gestation. Preterm birth was defined as delivery before 37 gestational weeks. Peripartum infectious morbidity was defined as postpartum endometritis, postpartum sepsis, post-caesarean section wound infection or episiotomy wound infection, based on clinical examination and necessitating antimicrobial therapy. Results The prevalence of BV was 10% (565 of 5432). Of the BVpositive women 380 (67%) were randomized to the treatment arms. The primary cure rate was 63% (119 of 189) in the clindamycin group and 35% (64 of 184) in the placebo group (OR 1.8, 95% confidence interval 1.3-2.6). The overall rate of preterm deliveries was 5% (10/189) in the clindamycin group and 4% (7/191) in the placebo group (OR 1.4, 95% CI 0.5-3.9). The rate of peripartum infectious morbidity was 12% (22/189) in the clindamycin group and 18% (34/191) in the placebo group (OR 1.5, 95% CI 0.9-2.7). BV recurred in 11% (26/246) of women who completed all follow-up visits. The rate of preterm deliveries was 15% (4 of 26) in this subgroup compared with 2% (2 of 121) among women who remained BV-negative after the treatment (OR 9.3, 95% CI 1.6-53.5). The rate of peripartum infectious morbidity was highest (15 of 57, 26%) among women with persistent BV after the treatment and lowest (10 of 121, 8%) in women who remained BVnegative (OR 3.2, 95% CI 1.4-7.5). Conclusions Vaginal clindamycin did not decrease the rate of preterm deliveries or peripartum infections among women with BV. Recurrent

FC3.02.07 PREVALENCE OF BACTERIAL VAGINOSIS IN A CHILEAN POPULATION E. Castro, M. Domnguez, P. Navarrete, C. Plaza, M. Quintana, M. Cisterna, L. Cifuentes, R. Zemelman R. Depto. Obstetricia y Puericultura, Facultad de Medicina y Depto. Microbiologa, Universidad de Concepcin, Concepcin, Chile. Objetives: The aim of the study was to evaluate the prevalence of bacterial vaginosis (BV) in women attending at health centers in the Concepcin Talcahuano area, Chile. Study Methods: Six hundred fifteen women were included in the study. Women were randomly selected between April 1997 and April 1999, among those gave consent. The population was composed of 352 women using contraceptives, 140 pregnant women, 80 sex workers, 43 women attending in gynecologic clinics. A routine gynecologic speculum examination was performed on each patient. One sample was obtained from the lateral walls of the vagina with cotton swab. BV was diagnosed using the Nugent criteria. Results: It was found 31.3% (110/352) women using contraceptives with BV. No statistical difference was found between the occurrence of BV and the use of oral contraceptive or intrauterine device. It was found 19.3% (27/110) pregnant women; 37.5% (30/80) sex workers and 23.3% (10/43) women attending in gynecologic clinics with the syndrome. Conclusions: The prevalence of BV encountered deserves future studies related to prevention and treatment of this syndrome considering its complications. This investigation was supported by the Grant Direccin de Investigacin N 96.848.004-1.1, Universidad de Concepcin, Chile. FC3.02.08 THE TREATMENT OF BACTERIAL VAGINOSIS WITH POVIDONE-IODINE IN THE 1ST TRIMESTER OF PREGNANCY T.A. Starostina, H.M. Demidova, A.S. Ancirskaya, O.Yu. Azarova, Clinic of Obstetrics and Gynecology, Moscow Medical Sechenov Academy, Moscow, Russia. Recent investigations suggest the actuality of bacterial vaginosis treatment during pregnancy because this disease increases the risk of

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pregnancy failure, premature membrane rupture, chorionamnionitis and postpartum complications. Objective: To evaluate the efficacy of the bacterial vaginosis treatment by Povidone-iodine (EGIS) vaginal suppositoria in pregnant females. Study Methods: The study population consisted of 40 1st trimester (7-14 weeks of gestation) in patients with diagnosed bacterial vaginosis. Bacterial vaginosis was verified based on clinical picture, Gram stained microscopy and cultural investigation of vaginal smears. Patients were treated by Povidone-iodine (1 suppositorium per vaginum for the night) during the 7 days. 3 females were excluded from the study because of iodine allergy. Results: Of 37 cases, clinical recovery was detected in 31 (83.7%), with normal samples in 78.4% (29/37) 7-10 days after the finished treatment. Microbiological features of bacterial vaginosis remained in 21.6% (8) of cases. Candidosis vulvovaginitis complicated the treatment in 2 cases. Bacterial vaginosis relapsed in 6.8% of patients between the 29th and 32nd weeks of gestation and in 17.2% (5) of females 6 months after delivery. Conclusions: Our data suggest that bacterial Povidone-iodine is a highly efficient, well tolerated and easily applied drug without serious side effects. It allows us to recommend it for bacterial vaginosis treatment. Although the lack of experience of Povidone-iodine application, its use is promising for prevention of miscarriage and intrauterine fetal infection in female with bacterial vaginosis during the 1st trimester of pregnancy when the drug choice is restricted by teratogeneous effects opportunity. miscarriage were associated with prelabor spontaneous rupture of membranes. Conclusions: This conservative, yet locally radical procedure for a highly selected and counseled group of women who wish to preserve their fertility appears to offer a safe alternative to traditional radical hysterectomy in early invasive cervical cancer.

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FC3.03.02 INVASIVE CARCINOMA (CA) OF THE CERVIX: IMPACT OF RACE, COMORBID DISEASE ON PROCEDURE TYPE, COST AND LENGTH OF STAY (LOS) S.E.Brooks, A. Ghosh, J. Gardner, C.R. Baquet, T. Chen, University of Maryland Medical Systems, 405 W. Redwood Street, Baltimore, MD, United State, 21071. Objective: To examine the association of comorbid illness, race and insurance status on resource utilization and procedure type during admission for invasive ca of the cervix (ICD-9 180.0-180.9) in a statewide population based discharge database. Methods: Hospitalizations were classified into relatively homogeneous sub-groups based on diagnoses indicating a primary or secondary diagnosis of invasive cervical ca. Procedures during admission, oncologic sequelae and comorbid diseases were evaluated. Multivariate techniques controlled for age, race, insurance status, comorbid illness and oncologic sequelae. Result: The mean age was 49.5. Sixty per cent (606/1009) were white, 354/1009 (35 %) African American, 5% other. Alcohol and drug related disorders, hypertension and circulatory system disease were associated with up to 60% of admissions for surgical procedures. African Americans were 1.6 times more likely to undergo urgent/emergent admission (95% confidence limit 1.2,2.2), to have comorbid illness, p<0.01 and were more likely to undergo admission for radiation therapy rather than surgery p=0.001. The factors associated with the highest cost and length of stay were emergency admissions, oncologic emergencies, and circulatory system disorders but race was not a significant factor influencing these outcomes. Conclusions: Although there were racial differences in the types of procedures occurring during hospitalizations, there were no significant racial differences in cost of admission, or length of stay when multivariate analysis adjusted for age,insurance status and comorbid illness. The influence of comorbid illnesses, particularly alcohol and drug disorders, hypertension and heart disease on outcome warrants further study and intervention. FC3.03.03 LAPAROSCOPIC COMMON ILIAC AND PARAORTIC LYMPHADENECTOMY H. Al Sultan, Dept. OB/GYN, Aleppo Hospital University, Aleppo, Syria. Objectives: Pretreatment evaluation of common iliac and paraortic lymphnodes status for appropriate cervical cancer staging and realizing correct treatment with exact prognostic. Study Methods: A total number of 10 patients were studied between 1997-99, stage IIB, IIA, IB. All patients underwent firstly laparoscopic common iliac lymphadenectomy with frozen section. If lymphnodes were negative, we selected appropriate radical hysterectomy or radio therapy, but when lymphnodes were positive, we continued to make subinferiormesentric paraortic lymphadenectomy following appropriate treatment. Results: Five patients with FIGO stage IIB cervical cancer provide four from the same staging and one patient with common iliac and paraortic lymphnodes metastasis, another three patients with FIGO stage IIA provide common iliac lymphnodes negative adding another one patient with FIGO stage IB had also common iliac lymphnodes negative. All patients tolerated the procedures smoothly except one operation for stage IIB cancelled due to anesthetic problems. Main time of operation was 60 minutes. Conclusion: Laparoscopic common iliac and paraortic lymphadenectomy was feasible and effective surgical staging procedure in pretreatment evaluation of cervical cancer and elaborate suitable treatment.

FC3.02.09 TANTUM ROSA IN THE TREATMENT OF BACTERIAL VAGINOSIS DURING PREGNANCY Tioutiounnik V.L., Efimov B.A. Research Centre of Obstetrics, Gynecology & Perinatology, Moscow, Russia Objectives: Treatment of bacterial vaginosis (BV) during pregnancy is a very complicated problem, due to probably negative influence of most medicines on fetus. The aim of this investigation is the study of the efficacy of Tantum Rosa in pregnant patients with BV in second & third trimesters of pregnancy. Methods: 49 pregnants were observed. Diagnosis of BV was based on clinical, microbiological, microscopia data, and results of amine test and vaginal pH. Results: The warm solution (vaginal douche one-time bottle with 140 ml of solution - 140 mg of active substance), have been used two times a day - 10 days. 4 patients, beside BV, have had vaginal candidosis. We included in the treatment dafnegin vaginal suppositories, containing 100 mg of active substance) - 1 suppositoria for 6 days. Clinical recovery and normalization of laboratory data were noted in 46 (93.7 %) patients. The second part of treatment was appointment of eubiotics for 10 days (acilact, bifidum or lactobacterin, bifidin) - the medicines that restore the normal correlation of lactobacillus in vagina. Conclusions: Tantum Rosa is very efficacious for treatment BV during pregnancy. FC3.03 CERVICAL CARCINOMA: SURGERY AND PROGNOSTIC FACTORS

FC3.03.01 RADICAL TRACHELECTOMY IN EARLY STAGE CARCINOMA OF THE CERVIX: OUTCOME AS JUDGED BY RECURRENCE AND FERTILITY RATES T. Mould, J.H. Shepherd, D. Oram, Dept. OB/GYN, St. Bartholemews Hospital, London, UK. Objective: To assess the recurrence and fertility rates in women with early stage invasive cancer of the cervix treated by radical trachelectomy. Study Method: Review of on-going research program and direct contact with all women to confirm pregnancies and outcome. Results: 27 women had been treated by trachelectomy. There were no recurrences, and the mean follow-up was 23 months (range 6 60 months). Of 13 women trying to have a baby, 8 had conceived with a total of fourteen pregnancies and 6 live births. 2 were still trying and 3 were experiencing sub-fertility. There were five premature deliveries and one late miscarriage. Four of the preterm births and the late

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FC3.03.04 THE FIRST TWO CASES OF ABDOMINAL RADICAL TRACHELECTOMY EFFECT ON MENSTRUATION, OVULATION AND FERTILITY M.Al-Kurdi, Dep. Ob/Gyn, M.Harris, Dep.Pathology, Hinchingbrooke Hospital, Huntingdon, Cambridgeshire, UK. Objectives: The aim of this case report is to assess feasibility to carry out successfully the procedure, effectiveness and its effect on myometrium, endometrium, menstruation, ovulation and fertility. Study Methods: Case report on two abdominal radical trachelectomies were performed on two women at age 36 and 34 respectively. Results: Both women had stage Ib2, poorly and moderately differentiated squamous cell carcinoma of their cervix respectively. The women wanted to preserve their fertility. At 34 and 23 months respectively the two women are well and disease free. Conclusions: Abdominal radical trachelectomy is a possible and effective alternative treatment for cervical carcinoma stage Ib2. The effects of the procedure on the myometrium, endometrium, menstruation, ovulation and fertility are discussed. FC3.03.05 RESULT OF THE TREATMENT OF STAGE IA CERVICAL CARCINOMA BY COLD KNIFE CONISATION A.Basta, K.Pitynski, M.Strama, A. Szczudrawa, Jagiellonian University, Kopernika 23, Krakow, Malopolska, Poland, 31-501. Objectives: Minimal invasive surgery begin more and more popular in gynecological oncology. The aim of the study was evaluation of treatment results of stage Ia cervical carcinoma with the use of cold knife conisation. Study methods: The study group included 54 women aged 25 41 years with stage Ia it is 48 women with stage Ia1 and 6 women with stage Ia2 who were diagnosed and treated in our Department in the years 1982 1994. Stage of cervical carcinoma was settled in colposcopy evaluation and histological examination of colposcopy directed biopsy specimens. Treatment and follow up results were analyzed. Results: Specimens without involvement of any margins were obtained in 45 (93,8%) patients with stage Ia1, and 5 (83,3%) women with stage Ia2 cervical cancer. Absence of neoplastic cells involvement into vascular space was found in all patients with stage Ia1 and in 4 (78,6%) cases of stage Ia2. Out of the 3 patients with stage Ia1 and involved margins in 2 cases subsequent hysterectomy and in one case reconisation were performed. In one patient residual disease and in one women carcinoma in situ were revealed. In 2 cases of stage Ia2 with vascular space involvement subsequent radical hysterectomy and pelvic lymphadenectomy were performed. Non of that patients had lymph node metastases. One of them had residual disease. Conclusions: Cold knife conisation gives satisfactory results in treatment of cervical cancer in Ia1 stage. In selected cases can be also practical at young women in stadium Ia2. FC3.03.06 DETECTION OF OCCULT TUMOR CELL DEPOSITS IN LIPOSUCTION ASSISTED RADICAL HYSTERECTOMY IN CERVICAL CANCER: FIRST RESULTS U. Fischer, Dept. OB/GYN, L.-C. Horn, Institute of Pathology, J. Einenkel, M. Hckel, Dept. OB/GYN University of Leipzig, FRG Objectives: Recently, Hckel et al. (AJOG 1998;178:971-6) have been described a modification of Wertheim-Meigs operation, termed liposuction-assisted nerve-sparing extended radical hysterectomy (LANS-RH) to improve radicality accompanied by preservation of pelvic splanchnic nerves. The aim of this study was to identify occult tumor cell deposits (OTCD) in additional resected pelvic tissue. Study Methods: The liposuction specimens of 20 patients, treated by LANS-RH, were step sectioned, H&E-stained and investigated immunohistochemically, using the cytokeratine antobodies MNF 116 (DAKO, Hamburg, FRG) and AE1/AE3 (Boehringer, Mannheim, FRG). For visualisation the AEC-method was performed. Results: In 6 patients the liposuction material represented small lymph nodes on H&-E-stained slides. In one of these cases OTCD were seen in

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a subcapsular lymphatic vessel. Two cases showed OTCD in liposucted fatty tissue and in a small vessel on immunohistochemistry, respectively. Conclusions: In accordance to earlier reports of breast cancer patients, the detection of OTCD can be improved by immunohistochemistry. Additionally, the LANS-RH, as a modification of classic WertheimMeigs procedure, is capable to remove tumor burden pelvic tissue and may be reduce risk of recurrence. Probably post-operative adjuvant therapy can be omitted in patients treated by LANS-RH. But, actually the follow up times of these cases is to short to draw any conclusions. FC3.03.07 IMPROVEMENT OF HPV DETECTION RATE ON CYTOLOGICAL SMEARS BY PCR IN SITU HYBRIDIZATION Y.H. Xiao, S. Sato, Y. Yokoyama, Y. Saito, Dept. OB/GYN, Hirosaki University School of Medicine, Aomori, Japan Objectives: To assess the HPV detection value of PCR in situ hybridization (PISH) in cytological uterine cervical smears by comparison with florescence in situ hybridization (FISH) and immunohistochemical staining (HIS). Study Methods: From 1985 to 1995, a total of 162 archival Papanicolaous smears of uterine cervices were available from 54 women before they were histologically confirmed as cervical severe displasia (SD) (n=17), microinvasive cervical cancer (Ic) and cervical carcinoma in situ (CIS) (n=37). Three smears of each patient were selected and randomized into three groups for HPV detection by means of FISH (Ns=54), PISH (Ns=54) and IHS (Ns=54), respectively. We analyze the HPV detection rates in the groups of various histological lesions and the total HPV detection rates by three methods. Results: In SD group, PISH showed 58.8% positive incidence, which was significantly higher than FISH (23.5%) (P < 0.05), but was no different with IHS (47.1%). In Ic and CIS group, PISH showed 73.0% positive incidence, which was significantly higher than FISH (43.2%) (P < 0.01), while IHS showed 67.6% positive incidence, which was also significantly higher than FISH ( P < 0.05). About the total detection rate, PISH (68.5%) and IHS (61.1%) were all significantly higher than FISH (37.0%) (P < 0.01 and < 0.05), but were not different from each other. Conclusions: PISH can improve the HPV detection rate in morphologically intact cells on uterine cervical cytological smears comparing to FISH and IHS. The PISH technique, possessing high sensitivity and specificity, will become a practical method to perform in situ analyses of nucleic acid molecules and cytological screening simultaneously.

FC3.03.08 IMPACT OF TUMOR LOAD IN SURGICALLY TREATED HISTOLOGICALLY STAGED EARLY CERVICAL CANCER: MULTIVARIATE ANALYSIS OF 568 PATIENTS L.-C. Horn, G. Raptis, Inst. of Pathology, University of Leipzig, Germany, U. Fischer, K. Bilek, Dept. OB/GYN University of Leipzig, Germany. Objectives: The purpose of the study was to evaluate the prognostic impact of tumor load and histology in pT1b cervical cancer (CC). Study Methods: 568 patients with histologically staged operative treated CC were cured in a period of 17 years. All cases with pelvine lymph node metastases (LNM) received postoperative radiation. Morphologic parameters, like tumor size (</> 4cm), intratumoral LVSI, grading, relative depth of invasion (RDI), peritumoral inflammatory response (PIR), patients age and histologic type were correlated to prognosis, using Chi2- and Cox-regression-analysis. Results: The 5-year-suvival-rate (5-YSR) of pT1b1 tumors with a RDI of >66% of the cervical wall declined from 86.9 to 79.3 (p=.0093). In pT1b2-CC RDI showed no prognostic impact. The recurrence rate in the latter tumors with LVSI was significant higher (p=.012). All poorly differentiated (G3) pT1b-CC in general and those with pelvine LNM have had a poor prognosis, but not in cases without LNM. T1b-tumors with large tumorload (>4cm) showed a poor prognosis, even when LNM were recognised (5-YSR: pT1b1: 87.8%, pN0 90.8%, pN1 70.9; pT1b2: 64.7%, pN0 85.2, pN1 37.4%; p=.0009). In multivariate analysis pelvine LNM, tumor size, LVSI and tumor grading reached statistic significane (p<.01) regarding overall survival, but the tumor type, RDI, PIR and patients age showed no prognostic impact. In cases without LNM only

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LVSI reached prognostic significance. In cases with pelvine LNM tumor size and grading (p<.03) were prognostic indicators. Conclusions: High tumor load in operative treated pT1b-CC represents a strong prognostic factor, even in separate analysis of node negative and positive patients. Large tumors, especiallly cases with pelvine LNM represent a high risk group and may represent candidates for (neo-) adjuvant multimodal therapy. FC3.03.09 MODIFIED TECHNIQUE OF RADICAL SURGERY FOR CARCINOMA CERVIX FIFTEEN YEARS EXPERIENCE C.N. Purandare, N. Gada, L. Bhosle., J.A. Lopez. Grant Medical College, Mumbai, India. Objectives: 1. To present our experience with modified technique of radical surgery for carcinoma cervix in 140 patients using Purandare's modified vaginoabdominal approach. 2. To study the 5 year survival rates and complicaton rates of surgery. Study Methods: The technique was carried out in 140 cases who were suffering from carcinoma cervix upto stage IIa and early stage IIb. Surgical technique included: 1. Vaginal dissection of the cuff of vagina of 1cm wide margin with growth free area. 2. Distal cuff closed by nonabsorbable suture and remaining vagina packed and closed by absorbable suture. 3. Abdominal dissection carried out consisting of Radical Werthiem's Hysterectomy with transperitoneal lymphadenectomy with bilateral Internal iliac artery ligation. Results 1. None of the patients had wound infection, pelvic infection, abscess formation, vaginal cuff cellulitis or thromboembolic phenomenon. 2. Overall early morbidity rate was 7.6%, 3. Incidence of urinary fistula was nil, 4. The recurrence rate was 5%, 5. The 5 year survival rate was 92%. Conclusion: We find this technique extremely useful in that the postoperative complications are infrequent and relatively minor, while clinical control of the tumor appears excellent.

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countries each year, more than half a million women die from maternal causes. Most of these deaths could be prevented not only by providing appropriate medical care immediately, but also by offering family planning counseling and services which could prevent many future unintended of family planning information; services and appropriate counseling are well known factors for offering effective and safe contraceptive methods. Study Methods: This is a retrospective study of women who received family planning services at Lade Hardinge Medical College & S.S.K. Hospital from 1/8/1998 to 31/7/99. Results: 2 269 cases underwent operative family planning procedures, out of which 1 745 were the total number of sterilization (76.7%). The pre operative complication rate was 0.9% and the postoperative complication rate was 4.9%. The sterilization failure rate was 1.1%. Conclusions: As population scientist and healthcare provider, we must redouble efforts to eliminate or significantly reduce barriers to contraceptive use in developing countries and promote an integrated healthcare service which is accessible, acceptable and can easily be molded to suit different social, cultural and religious settings. FC3.04.03 BARRIERS TO CONTRACEPTIVE UPTAKE IN THE STATE OF ORISSA (EASTERN INDIA) S.Kar, Obs&Gyn, Kar Clinic, A-32, Unit 4, Bhubaneswar, Orissa, India751001 Objectives: Aim of the study was to a)identify the factors that limit uptake of contraceptives amongt couples in urban and peri-urban areas of Orissa.b)role of providers in giving family planning advice and their level of knowledge. Study Methods: The study covered 4800 respondents, of which 2302 were relevant to the objectives of this study. 1532 were women, 366 were men. Following methods of investigations were used: structured and un-structured interview, depth interview, focus group discussion, observation and dummy client. Medical, paramedical practitioners and medical retail outlets were randomly selected for observation. Three study teams of four investigators each carried out field work for 10 weeks. Detailed computer analysis of data was carried out. 'Ethnograph' a package for qualitative analysis of computer data was used. This study was carried out with funds from the British Department For International Developement (DFID) Results: 40-50% of women had not heard of the condom or IUCD. More than 50% of men had'nt heard of the IUCD. Most had heard of the OCpill, but majority did not know anything else about it. Level of knowledge about characteristics of contraceptives was very low. Providers were substantially responsible for miscomunication. Most women have little or no opportunity to seek information or advice regarding contraception. Conclusions: Poor uptake and utilisation of modern methods of contraception is mainly responsible for the uncontrolled rise in population of developing countries.There is a large potential demand for spacing methods and lack of knowledge is a more important barrier to adoption than hostile views to specific methods. Efforts on a massive scale are needed to promote awareness, availability and utilisation of modern methods of reversible contraceptives.

FC3.04 CONTRACEPTION FC3.04.01 FEMCAP, A NEW BIRTH CONTROL METHOD A. Shihata, Scripps Instittution of Med. & Science, 14058 Mira Montana Dr., Del Mar, California, United States, 92014. Objective: To develop a safe, effective and acceptable woman-controlled barrier contraceptive device that minimize the transmission of STDs. Study methods: Silicone rubber was chosen because it is hypoallergenic, inert, durable, and easy to clean. The FemCap was designed to fit the anatomy of the cervix and vagina. It is shaped like a sailor hat. While its dome covers the cervix, its rim fits into the vaginal fornices and covers the vaginal vault, and its brim conforms to the vaginal walls. A unique groove, facing the vaginal opening was designed to store microbicidal spermicide that trap and kill the sperm and STD organisms. Result: A new contraceptive barrier device is developed that is safe, effective, acceptable, and may minimize the transmission of STDs. Conclusion: The FemCap could fulfill the primary objective of developing a woman-controlled barrier contraceptive device. The FemCap will be used in conjunction with microbicidal spermicide, hence may fulfill the secondary objective of reducing the risk of transmission of STDs. FC3.04.02 ADVERSE EFFECTS ON THE REPRODUCTIVE HEALTH OF WOMEN S. Mukherjee, Dept. OB/GYN, L.H.M.C. & S.S.K. Hospital, New Delhi, India Objectives: As the next millennium approaches, the current world population of 5.9 billion will continue to increase by 81 million per year93% of which will come from the developing countries. In developing

FC3.04.04 ACCEPTABILITY OF POSTPARTUM IUD (PPIUD) H. T. Salem, M. A. Kamel, S. A. Mohamed & O. M. Shaaban, Dept. OB/GYN, Faculty of Medicine, Assiut University, Assiut, Egypt Objectives: To study the factors affecting the acceptability and performance of 3 groups of postpartum IUD insertion (postplacental, predischarge and trans-cesarean). Study Methods: A total of 1880 and 1661 women were counseled antenatally and postpartum for PPIU insertion. According to women acceptance IUD (CuT 380) were inserted postplacental (within 10 minutes after placental deliver) in 60 women, predischarge (within 48 hours after delivery) in 74 women, trans-cesarean (before closure of the uterine incision) in 54 women and interval (after the end of purperium) 55 women. All the subjects were followed up monthly for careful pelvic examination and ultrasonographic scanning. Results: Out of 3541 women counseled, 1024 (28.9%) accepted the idea of PPIUD. Only 264 (7.5%) accepted the immediate postpartum

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insertion. The mean age and parity of the acceptors were 33 years and 4.3. The net cumulative continuation rates were 69, 72, 84 and 80 per 100 women for the post placental predischarge, trans-cesarean and interval IUD insertions respectively. Complete or partial expulsion was the main cause of discontinuation (8.4%). No perforation or pregnancy occurred in this study. Conclusion: With proper counseling and training immediate postpartum IUD insertion can be valid option in postpartum family planning. It is safe, effective and with minimal side affects. FC3.04.05 ATTITUDES TOWARDS CONTRACEPTION IN PAKISTAN F. Maqsood, R. Sohail, F. Zaman, Dept. OB/GYN, Postgraduate Medical Institute/Services Hospital, Lahore, Pakistan. Objectives: To assess awareness of women regarding contraception, available facilities and contraceptive practices. To analyze the influence of social, religious and cultural beliefs affecting attitudes. Study Methods: 1000 married women, aged 15-45, attending the antenatal and gynecological clinics were interviewed, a questionnaire was filled out and the data was analyzed. Results: 80% of the women attending the antenatal and gynecological clinics were in favor of using contraceptive methods to limit their family size, however, 70.4% of the women interviewed were not using any form of contraception. Those not practicing contraception had parity above 4. 48% had knowledge about contraceptive methods and their availability, 34% had no knowledge and awareness regarding them, while 15%, despite having knowledge, were not aware of their availability. 60% were using barrier method. Religion, considered to be a major factor, influenced only 30% of the women, who believed that contraception is prohibited in Islam. Conclusion: Contraceptive prevalence rate is very low and religious, social and cultural beliefs are important operative factors. Desire for male offspring plays a significant role in increased family size. There is need for greater efforts by family planning services to enhance awareness and ensure availability of facilities. FC3.04.06 NEW METHOD OF PUERPERAL TUBAL STERILIZATION IN DEVELOPING COUNTRIES. B.Dhorepatil, Shree Maternity Home, Siddharth Mansion, Nagar Road, Pune 411 006, Maharashtra, India, 411006. Objective: To improve the acceptence of post-partum tubal sterilization in private practicing gynecologist in developing countries. Study Methods: The present methods of post-partum sterilization used in developing countries ie.India is open tubal ligation.The approach of laparoscopy for tubal sterilization (bipolar cauterization & cutting the tube at isthmic region) in immediate post-partum period is used in this study to improve the acceptence for permanent contraception which is the need in developing country like India. In this study 50 cases were included for a period of one year. The proper consent was taken & procedure explained. Results: The procedure was well accepted by all the patients.No extra hospitlization required.There were no significant complications occured.There were no failures in this study though the period is short. Conclusions:This has improved the acceptence of purperal sterilization in private practice.

WEDNESDAY, SEPTEMBER 6
Results: 166 participants (41.5%) were using contraception. All used natural methods in addition to other methods. The association between using birth control and each of old age, high level of education and low family income was significant. Religious beliefs and low expectation of success of birth control were the reasons given by non-users. 85% of subjects did not accept sterilization without medical indications nor contraception before the first pregnancy. 26% of women believed that contraceptive methods could be purchased over the counter and 78% were unaware that they could be used for treatment of gynecologic diseases. 42.5 % of women thought that the age limit for using contraception in women was 40 years. 48.7 % of users had menstrual disturbances and all were most bothered by the inability to pray. Conclusion: Contraception is not commonly used by UAE women because of social traditions, religious beliefs and lack of information.

FC3.04.08 NORPLANT CONTRACEPTIVE SUBDERMAL IMPLANTS: FIVE YEARS EXPERIENCE IN ANKARA, TURKEY Hale Aktun, Hakan R. Yalcin, Perran Moroy, Oya Gokmen Zekai Tahir Burak Womens Health Education and Research Hospital, Family Planning Clinic, Ankara, Turkey Objective: To assess the efficacy, safety and acceptability of norplant implants. Study design: A prospective study conducted in the family planning clinic, Zekai Tahir Burak Womens Health Education and Research Hospital, Ankara, Turkey from 1994 to 1999. Norplant is one such, based on the use levonorgestrel capsules which inroduced into womens arms, produce a daily secretions of hormones and have from two to five years effect. Results: This report summarized five years experience with the subdermal levonorgestrel implants in 711 women. The mean age of the patients was 21.22.4. Menstruel disturbances ranging from amenorrhea to menorrhagia, were the majr side effects and were present 327 (45.9%) of women during the five years. These disturbances resulted in 15 removals, medical complications, including headache, desire for pregnancy etc. were the principal reasons for another 39 removals. Conclusion: The efficacy, safety and acceptability of the implant suggests that norplant is one of the most effective and practical forms of contraception for any women who wants long term, continuous yet reversible contraceptive options.

FC3.04.09 THE DETERMINANTS OF THE CHOICE AND USE OF FERTILITY REGULATING METHODS IN GEORGIA K. Kuparadze, L. Baramidze, Zhordania Institute of Human Reproduction, Tbilisi, Georgia. Objectives: The aim of the study was to assess the characteristics of women who do not use modern contraception (abortion clients) versus users of modern contraceptive methods (age, religion, education, profession, income, medical and reproductive history, smoking, past experience with abortion and contraception, future plans and etc.) Study Methods: Data were collected using semi-structured interviews with clients and providers, using pretested questionnaires. One hundred ninety women for contraception (C) and 194 women coming for abortion (A) included in this study. Results: Most of the patients are 25-34 years old. The average age of the patients is 27. In group A, considerable number of patients 43percent, 8 were with high education. At the moment of survey 27% of patients have no children yet, 20% comes on school children/students. In this group, 39.3% prefer to use condom, 36.3-IUD. 63.4% had the induced abortion before but for group C (96.6%) was using contraceptive after abortion. For group C, majority of patients were using contraceptive pills 80% and 8.9% condom. Most of women in group A (75.9%) have not felt any discomfort using modern methods of contraception. Mostly is concern pills 69.2%, then condom 30.8% and IUD 15.4%. Conclusions: Education level and life conditions in both groups are similar, which manifests lack of information (mass media, gynecologist, sex education) for those who prefers abortion to contraception.

FC3.04.07 KNOWLEDGE AND PRACTICE OF CONTRACEPTION AMONG UNITED ARAB EMIRATES WOMEN. S.Ghazal-Aswad, D.Rizk, S.Al-Khoori, H.Shaheen, Faculty of Medicine & Health Sciences, UAE University, PO Box 17666, Al-Ain, United Arab Emirates. Objectives: To determine the knowledge and practice of contraception among United Arab Emirates [UAE] women. Methods: UAE women at risk of pregnancy defined as married, aged 1544 years and had previously born children, were randomly selected from the community (n=200) and health care centers (n=200). Subjects were interviewed about their contraceptive practice using a structured questionnaire.

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FC3.05 EFFECTS OF HRT

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Study Methods: In an open, multinational, multicenter, non-controlled phase III study, 1501 women aged 52-65 years with postmenopausal symptoms were treated with Klimodien for 12 treatment cycles (48 weeks), with assessments of efficacy, safety, tolerability (adverse events) at 8, 24 and 48 weeks. Efficacy was assessed using the Kupperman Index. Safety assessment included transvaginal sonography, endometrial biopsy, mammography, physical and gynecological examination, vital signs, prothrombotic factors and routine laboratory safety parameters. Results: Kupperman Index improved with increasing duration of treatment, accompanied by improvement of self-reported well being. Individual climacteric symptoms, such as hot flushes and pychonervous disorders, also improved. The most pronounced improvement was seen in HRT-nave patients. The incidence of breakthrough bleeding declined over time, resulting in complete amenorrhea in 86.2% of the patients after 12 cycles of treatment. Furthermore, total and LDL cholesterol levels decreased and HDL cholesterol levels increased. Decreases in alkaline phosphatase, pyridinoline, and desoxypyridinoline demonstrated that dienogest did not affect the inhibitory action of extradiol on bone resorption. Endometrial thickness remained almost constant and the incidence of serious endometrial findings was similar to that of untreated women. Conclusions: Continuous combined substitution with Klimodien is effective, safe and well tolerated in postmenopausal women. The hybrid progestin dienogest does not abolish the estrogen benefits of Klimodien.

FC3.05.01 ENDOMETRIAL HYPERPLASIA WITH TIBOLONE (LIVIAL) L. Schmaltz, M. Albernaz, E. Souza, Dept. OB/GYN, Hospital Materno Infantil de Goinia, Goinia, Brazil. Objectives: To question the endometrial security after long term Tibolone use. Study Methods: Case report of 3 cases of endometrial hyperplasia during Tibolone medication. Results: The first placebo controlled trials suggested almost an endometrial protection, showing no stimulation and bleeding not greater than placebo. Most studies had only one year follow-up and there are very few described cases of Tibolone associated hyperplasia, until now. We describe 3 cases of private office, that developed endometrial hyperplasia, tow of them with focal atipias, after on year or more of Tibolone. The patients were 54 years old, more than 1 year menopause, werent obese, had normal exams, except for a type II controlled diabetes and had 5 mm endometrium before and HRT (Hormone Replacement Therapy). Case 1 had only one month of combined estrogen during HRT, and two of them had used oral or local estrogen before Tibolone, but all had endometrium less than 6 mm and stayed amenorrheic for more than 1 year before bleeding and hyperplasy diagnosed by transvaginal sonography, hysteroscopy and biopsy. Conclusion: We need more studies with long-term follow-up and Tibolone interaction to confirm it is safe to the endometrium. Until then, doctors must control endometrial stimulation with Tibolone like any other HRT. FC3.05.02 SUBCUTANEOUS EXTRADIOL IMPLANT AS A REGIMEN FOR HRT IN MENOPAUSAL ESTROGEN DEFICIENCY S. Suhonen(1), L. Anttila(2), R. Punnonen(3), E. Varila (3), I. Rauramo (4), T. Salmi(2) (1) Dept OB/GYN, Helsinki City Maternity Hospital, Helsinki, Finland. (2) Turku University Central Hospital, Turku, Finland. (3) Tampere University Hospital, Tampere, Finland. (4) Leiras Oy, Helsinki, Finland Objectives: To investigate the efficacy and safety of the subcutaneous estradiol implant (E2) treatment for menopausal estrogen deficiency. Study Methods: This was an open, non-comparative, multi-center study in 37 peri- and 61 postmenopausal women. Two implants, each containing 70 mg E2, were inserted at study entry under local anesthesia in the subjects upper arm and the treatment was used for 24 months. Oral MPA (10mg) for 10 days/month was used to oppose endometrial stimulation. S-E2 concentrations were measured and the relief of climacteric symptoms was evaluated by using Kupperman index. Results: The treatment compliance was high: 85 (86.7%) out of 98 subjects completed the 24 months follow-up. The steady state E2 concentration (192.0 pmol/l) was reached in 7 days remaining at an acceptable level for up to 24 months. Relief of menopausal symptoms was successful: the median Kupperman index declined from entry to three months by 64% and 80% and to 24 months by 100% and 90% in the peri- and postmenopausal groups. The most common adverse events were headache and breast tenderness. 10 out of 13 discontinuations were due to adverse events. Conclusions: Subcutaneous E2 implant is an effective and safe long-term treatment method for HRT in menopausal estrogen deficiency. Patient compliance is high since daily or weekly administration is not needed.

FC3.05.04 WHAT IS COMING AFTER HORMONE REPLACEMENT IN WOMEN AND MEN? CONSIDERATIONS FROM THE ENDOCRINOLOGIC AND PHARMACOLOGIC POINTS OF VIEW REGARDING HORMONE DISPLACEMENT M. Oettel (1), W. Elger (1), M. Obendorf (1), V. Patchev (1), U. Schumacher (1), B. Winkelmann (2) (1) Dept. Research and Development, Jenapharm GmbH & Co. KG, Jena, Germany. (2) Herzzentrum Ludwigshafen Medizinische Klinik B, Ludwigshafen, Germany. The near future of hormone replacement in women is strongly influenced by the development of selective estrogen receptor modulators, estrogen sulfamates, and selective progesterone receptor modulators. New developments for hormone replacement in men refer to tissue specific androgens (selective androgen receptor modulators) and non-feminizing estrogens. A new approach could be hormone displacement. On the basis of our own epidemiologic data the age-related reductions of the secretion of estrogens, androgens, DHEAS and their clinical consequences will be discussed. The secretion of cortisol and progesterone (at least in men) is not age related. Therefore, a relative hypercortisolism and a progesterone/testosterone imbalance occurs. The potential therapeutic value of selective antiglucocorticoids will be presented as well as the different approaches to the modulation of non-classical progesterone action. FC3.05.05 COMPARATIVE BIOAVAILABILITY OF TWO TRANSDERMAL DEVICES OF 17-b- (ESTRADIOL TD760 AND OESCLIM50) IN POST-MENOPAUSAL VOLUNTEERS D. Deprez (1), G. Blanchot (1), A. Renoux (2), D. Chassard (2) (1) Institut de Recherche Pierre Fabre, Boulogne, France. (2) Groupe CEPHAC-ASTER, Paris, France. Objective: To compare the pharmacokinetic profiles and the relative bioavailability of estradiol and estrone after a 2-week application of TD760 applied once weekly versus Oesclim50 applied twice weekly. Study Methods: Single center, open labelled, randomized, two 14 day period cross-over study in 36 healthy post-menopausal women with FSH 40 IU/I and plasma estradiol < 45 pg/ml. A wash-out period of one week was observed between the two treatment periods. Blood samples were collected for each treatment period before patch application (TO) and every 12/24 hours from D8 to D15 as well as 1, 2, 4 and 12 hours after last patch removal on D15. Plasma estradiol (E2) and estrone (E1) were assayed by GC/MS. Cmax Tmax, Cmin, AUC168-336h, Cav, PTF and E2/E1

FC3.05.03 EFFICACY AND SAFETY OF A COMBINATION OF 2 MG ESTRADIOL VALERATE PLUS 2 MG DIENOGEST IN POSTMENOPAUSAL WOMEN T. Graser (1), T. Romer (2), F. Walter (1), M. Oettel (1) Medical Research Dept. Jenapharm GmbH & Go. KG, Germany. Jena and Clinic OB/GYN, University of Cologne, Germany. Objectives: To evaluate the efficacy, safety and tolerability of continuous combined hormone replacement therapy (HRT) with 132 valerate plus 2 mg dienogest).

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ratio for Cav were calculated. Local and general tolerability was assessed throughout the study. Results: TD760 provided stable plasma concentrations of E2 and E1 fluctuating around a mean Cav of 52.1 pg.ml-1 (range: 16.2 144.4). The significantly higher Cav observed with Oesclim50 (83.9 pg.ml-1, range: 28.5 312.8, CI 90% of [0.66; 0.73]) resulted from higher peaks reached twice a week and were associated with slightly more estrogenrelated AEs. E2/E1 Cav ratios were close to the physiological premenopausal ratio for both devices. Tolerability was good; the most frequent adverse events (AEs) were mainly observed with Oesclim50 (12 AEs reported by 7 subjects vs. 8 AEs reported by 5 subjects) and were estrogen-related (breast pain, pelvic inflammation). The same number of subjects presented with pruritus for TD760 and Oesclim50 (4 per group). Conclusions: Application over a week of matricial TD760 led to plasma concentrations of estradiol and estrone fluctuating within the physiological range of concentrations observed in pre-menopausal women.

WEDNESDAY, SEPTEMBER 6
In these studies EMATE was used as a positive control. In addition the effect on sulphatase activity in endometrium cells ECC-1; HEC 1A) was studied. Results: Tibolone and its metabolites do not inhibit sulphatase activity in the two bone cell lines, but in breast cells a strong inhibition was observed. EMATE has a stronger inhibitory effect in breast cells than in bone cells. These results suggest the sulphatase enzyme is differently modulated in these two cell types. Partial inhibition was observed in the endometrial cells. The lower observed inhibition may be due to the presence of a high level of sulfotransferase activity in the endometrial cells. Conclusions: From these results we conclude that tibolone and its metabolites show tissue selectivity with respect to sulphatase inhibition. The inhibition of the enzyme as seen in breast and endomerial cells may serve a lower stimulation of these tissues by tibolone FC3.06 PREGNANCY - PATHOPHYSIOLOGY FC3.06.01 ROLE OF HEPARAN SULFATE PROTEOGLYCAN ON PLACENTAL THROMBOXANE PRODUCTION M. Yamaguchi, T. Ikenoue and N. Mori, Department of OB/GYN, Miyazaki Medical College, Miyazaki, Japan Objectives: In this paper, we sought to investigate the mechanism how antithrombin III (AT III) stimulate placental prostaglandin and thromboxane (TX) production. Study Methods 1) Identification of the heparan sulfate proteoglycan (HSPG) of the placental tissue: We tried to identify HSPG of the placental tissue collected from 4 cases by immunohistochemical technique. For this purpose, 10E4 antibody (detect intact HSPG, including perlecan and syndecan), 3G10 (detect digested HSPG; DHSPG) and BB4 antibody (detect syndecan 1) were used for first antibody. 2) Effect of AT III of placental TX production: Placental tissue was incubated with Dulbeccos PBS with or without AT III. TX concentration of the medium was measured by enzyme immunoassay. 3) Effect of heparitinase digestion on placental TX production: HSPG of the placental tissue was digested with 0.25mU/ml heparitinase for 30 min. TX production by the placental tissue was determined by enzyme immunoassay. Results 1) HSPG was strongly positive in capillary endothelial and interstitial tissue of the chorionic villous tissue. Syndecan 1 was strongly positive in trophoblast and positive in endothelial cell of the chorionis villous arteriole. 2) DHSPG was not detected in chorionic villi. In heparitinase treated tissue, HSPG and syndecan 1 were not detected. DHSPG was stained in the heparitinase treated chorionic villous tissue 3) AT III increased TX production by the placental tissue 4) Heparitinase digestion did not alter basal placental TX production. However, TX production was decreased in heparitinase treated tissue with AT III stimulation Conclusions 1) We could stain the HSPG of the placental tissue. Especially, we showed the presence of syndecan 1 of the trophoblase. 2) At III stimulated TX production of the placental tissue, (at least, in part) by HSPG related mechanism.

FC3.05.07 THE EFFECT OF TWO DIFFERENT HORMONE REPLACEMENT THERAPY REGIMENS ON POSTMENOPAUSAL SYMPTOMS A. Elfituri (1), M.S.Elmahaishi (2), H.Chrystyn (1), (1) University of Bradford, School of Pharmacy, # 22, Quayside Lodge, London, England, United Kingdom, SW6 2UZ, (2) Misurata Teaching Hospital, Main Street, Misurata, Libya. Objectives: To evaluate the effects of two different Hormone Replacement Therapy (HRT) regimens, a sequential regimen of 17-B estradiol with dydrogesterone, and a continuous regimen of tibilone. Study methods: 80 healthy women with postmenopausal symptoms, 1224 months since their last menstrual period, were enrolled in a 6-month prospective study. Participants were randomly prescribed two different preparations: the first group (n=30) received a monthly-bleed HRT; 17B estradiol 2 mg tablets sequentially combined in one tablet with dydrogesterone 10 mg for 14 days of each cycle (Femoston, Solvay Pharma). The second group (n=50) received a bleed-free HRT; tibilone 2.5 mg tablets once daily (Livial, Organon). The presence and severity of short and intermediate-term postmenopausal symptoms were reported at baseline and after 3 and 6 months of treatment. Observed side effects, if any, and patient compliance were recorded. Results: A total of 53 women completed the 6-month study period, 22 of the first group and 31 of the second group. Participants, in both groups, experienced a significant improvement after the third month of treatment. The observed symptoms were relived by the end of the study period, with no significant differences between the groups. Women who completed the study period showed their satisfaction and compliance to the used medications. No significant side effects were recorded. Conclusions: Tibilone, without the need for withdrawal bleeding, similar to 17-B estradiol, relieves short and intermediate-term postmenopausal complaints.

FC3.05.08 SULPHATASE INHIBITION BY TIBOLONE PREVENTS STIMULATION OF BREAST AND ENDOMETRIUM H.J.Kloosterboer and M.E.de Gooyer, N.V. Organon, Oss, The Netherlands Objectives: Tibolone is a tissue specific agent due to tissue selective metabolism of the compound. Estrogenic metabolites of tibolone are formed in the liver and intestine and are responsible for the effects on bone whereas formation of the delta-4 isomer, a progestagenic metabolite, in the endometrium opposes the estrogenic action on this tissue. The majority of the estrogenic metabolites is in the inactive sulphated form. Previous studies have shown that tibolone diminishes tumor growth in the DMBA model. This effect may be due to a lowering of estrogenic compounds by sulphatase inhibition. Such an inhibition may not occur in bone, because it would lower the estogenic response on bone. This means that tibolone or its metabolites must show tissue selective inhibition. In order to test this hypothesis the effect of tibolone and its metabolites on sulphatase activity in breast cells (T47D) and osteoblast-like cells (MG63; HOS TE 85) were tested. Study Methods: Cells were incubated with estrone sulphate and the amount of intracellular estrone plus estradiol was assessed using HPLC.

FC3.06.02 DOES PLASMINOGEN ACTIVATOR INHIBITOR 1 (PAI-1) CONTROL TROPHOBLAST INVASION ? A STUDY OF INTRAUTERINE, TUBAL AND MOLAR PREGNANCIES. C. Floridon, L. Sunde, JG. Westergaard, SG. Thomsen and B. Teisner. Dept. OB/GYN and Pathology, Odense University Hospital, Denmark. Objective: Urokinase plasminogen activator, its receptor and the inhibitor PAI-1 are involved in proteolysis and remodelling of maternal tissue during implantation. Ectopic and molar pregnancies are abundantly associated with excessive placental invasion and necrosis. This study evaluate subcellular PAI-1 at the implantation site, basal plate and placental bed in normal, tubal and molar pregnancies.

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Study Methods: PAI-1 was analysed by immunohistochemistry in 50 normal, 50 tubal and 100 cytogenetically verified molar specimens from 1st, 2nd and 3rd trimester pregnancies. Results: Basal plate and placental bed extravillous interstitial trophoblasts as well as vascular trophoblasts were focally PAI-1 positive. In the decidua, PAI-1 was located within the cytoplasm of noninvaded stromal cells. By contrast, when decidual invasion was established, PAI-1 was seen membrane-associated or confined to the extracellular matrix. Only a few stromal cells distant from the implantation site were PAI-1 positive and decidualization was not present in tubal pregnancies. Conclusions: The present data indicate that PAI-1 is a marker of specific invasive trophoblast cells within the maternal decidua. Moreover, stromal cellular lack of PAI-1 in ectopic pregnancies or excessive decidual necrosis in molar pregnancies seems to be associated with an uncontrolled placental invasion. We speculate that trophoblast invasion is primarily regulated by signals from decidual cells. FC3.06.03 THE RELATIONSHIP BETWEEN FETAL ANTIGEN AND INTERLEUKIN MESSENGER RNAS IN MATERNAL PERIPHERAL BLOOD T. Tamura, T. Okuda, C. Kato, H. Kojima, M. Fukuoka, T. Yamamoto, H. Honjo, Dept. OB/GYN, Kyoto Prefectural University of Medicine, Kyoto, Japan. Objectives: This study was designed to examine the immunological interactions between fetus and the mother during pregnancy. We examined the relationship between the amount of fetal antigen flowed into maternal peripheral blood and the maternal immunological responses measured by the quantitative analysis of IL mRNAs in peripheral blood cells. Study Methods: With informed consent, peripheral blood was obtained from pregnant women (n=450) and non-pregnant women (n=62). Total RNA was prepared for RT. By quantitative RT-PCR method, we measured the expression amount of fetal hemoglobin gamma china (HbF-) mRNA as a representative fetal antigen. The relative expression ratio of HbF- chain, IL-8, IL-18 and IL-4 mRNAs against b actin mRNA were measured. Results: In pregnant women, the expression of IL-8 and IL-18 mRNAs were suppressed and significantly lower than those in non-pregnant women, but between IL-8 or IL-18 mRNA and HbF- mRNA, there were significant positive correlations, respectively (IL8 and HbF: R=0.50, p<0.01) (IL18 and HbF: R=0.44, p<0.01). On the contrary, the expression of IL4 mRNA in pregnant women was significantly higher than in non-pregnant women, but no significant correlation was observed with HbF- mRNA. Conclusions: In maternal peripheral blood cells, we could observe two kinds of immunological changes. The both were induced by pregnancy. One was influenced by the amount of fetal antigens flowed into maternal peripheral blood, but another was independent of it. It was suggested that there were two different mechanisms of immunoreactions in maternal peripheral blood cells.

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also compared fetal birth weight, length, weight/length, and ponderal index. In addition, we measured the maternal prepregnancy body mass index, pregnancy weight gain, relative weight gain, and body mass index at delivery. Results: No correlations were found between maternal and cord leptin levels. Maternal leptin concentrations were significantly higher than cord leptin concentrations (p<0.0005 for the male and female newborns and the total group). Maternal leptin correlated with birth weight (Spearmans p = 0.183; p = 0.031). Fetal leptin correlated with birth weight (p = 0.665; p = 0.0001), length, (p = 0.490; p = 0.0001), poderal index (p = 0.260; p = 0.002), and weight/length (p = 0.625; p = 0.0001). No significant differences in leptin were observed between female and male infants. Conclusion: The fact that there is no correlation between maternal and cord leptin is consistent with the hypothesis of a non-communicating, 2compartment model of fetoplacental leptin regulation. FC3.06.05 UMBILICAL ARTERIAL BLOOD GLUCOSE CONCENTRATION, pH, BASE DEFICIT AND BLOOD GASES IN PRETERM, GROWTH RETARDED AND NORMAL INFANTS. R. Rukaria-Kaumbutho, Dept. OB/GYN, University of Nairobi M. Cortina- Borja, Department of Statistics, University of Oxford and C. Redman, Nuffield Dept. OB/GYN, University of Oxford, John Radcliffe Hospital. Objective: To determine the relationship between the pH, base deficit and glucose concentration in the umbilical arterial blood taken at caesarean delivery. Study Methods: Umbilical arterial pH, base deficit, glucose and blood gases were routinely assessed in 216 fetuses delivered by elective caesarean section at the High Risk Pregnancy Unit of the John Radcliffe Hospital in Oxford. The gestation, birth weight, reason for delivery, outcome and demographic factors were determined. Cases with insulin dependent or gestational diabetes mellitus, multiple pregnancy were excluded. Results: The mean gestation at delivery was 232 days (SD 27), with a range of 169-294. The arterial glucose was 2.68 mmol /l (SD 1.21), the mean pH was 7.23 (SD 0.09) and the mean base deficit was 4.52mm/l (SD 3.50). There was a significant linear correlation between the umbilical arterial pH and base deficit (t =16.524, P=0.000). The umbilical arterial glucose and PO2 increased significantly with gestation (P<0.005) while the base deficit decreased. (p<0.005). Eighty four (38.9%) infants were SGA with birth weight less than the 3rd centile. SGA fetuses were found to be hypoxaemic, acidaemic, hypercapnic, and hypoglycaemic. Although glucose concentration by itself was not found to be a determinant of base deficit, hypoglycaemic fetuses were not able to generate high base deficit when there was concomitant hypoxaemia. Conclusion: Therefore the interpretation of fetal acid base balance must take into account the glucose concentration in order to avoid missing foetal distress. FC3.06.06 CLINICAL REPRODUCTOLOGY PROBLEMS OF NEWBORNS G. Ouchakova, S. Yolgina, Dept. OB/GYN, Kemerovo State Medical Academy, Kemerovo, Russia. Objectives: Reproductive system has been formed morphologically by the moment of birth. Complicated pregnancy, extragenital pathology in a mother affect unfavorably the reproductive system of a fetus and thus of a newborn. The aim of the study was to investigate the reproductive system of newborns in a physiological course of pregnancy. Study Methods: The content of FSH, LH, testosterone has been studied on the delivery of 31 healthy women at the age of under 30 by the radioimmunologic method with a set of Byk Mallinckrodt and 11-OKS fluorometric method. Among those under study there were 20 boys and 11 girls. All babies were born with 8-9 points according to the Apgar score. External genital organs of boys and girls were formed appropriately. Results: Low content of FSH has been determined in mothers and newborns: both girls and boys. The LH content in boys is high and obviously exceeds serum LH in girls. Testosterone content in boys does

FC3.06.04 MATERNAL SERUM AND CORD BLOOD LEPTIN IN NORMAL PREGNANCY T. Lam1, I. Schulz-Lobmeyr1, B.W. Hartmann1, O. Preyer1, P. Wagenbichler2 1 University of Vienna Medical School, Dept. OB/GYN, Vienna, Austria 2 Ignaz-Semmelweis-Frauenklinik, Vienna, Austria Objective: Based on the hypothesis of a non-communicating, 2compartment model of fetoplacental leptin regulation, out aim was to determine whether there is a difference in maternal leptin concentration and cord blood concentration in normal pregnancies. Study Methods: In an observational study, we included one hundred and thirty-nine pregnant women identified as having an uncomplicated pregnancy. Blood samples were collected immediately after delivery. Leptin was measured by radioimmunoassay, and its relationship to fetal and maternal anthropometrics was assessed by Spearman correlation. Differences in maternal and cord blood leptin levels between male and female infants were tested with the Mann-Whitney-U-test. Maternal and cord blood leptin were compared by the Wilcoxon Signed Rank test. We

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not differ from that of girls. 11-OKS in mothers serum is high and does not depend on a babys sex. Conclusions: The study testifies sex differences during the reproductive system formation in newborns. Readiness of the system to extrauterine life is formed by the moment of birth. Received statistic data of honadotrophic and some steroid hormones can be applied as indexes while assessing the state of reproductive system of newborns. FC3.06.07 PLASMINOGEN ACTIVATORS AND PLASMINOGEN ACTIVATOR INHIBITORS IN MYOMETRIUM OF PREGNANT WOMEN M. Uszynski, K. Maciejewski, J. Kuczynski, The Rydygier Medical University, Bydgoszcz, Poland. Objectives: The aim of the study was to find out whether myometrium can produce and export fibrinolytic components to the blood stream via utero-placental circulation. Study Methods: The study group consisted of 32 women in the 36-40th week of gestation with some gestational complications (pre-eclampsia in 11 cases) or complicated labor (intrauterine asphyxia in 21 cases). 10 non-pregnant women were the control group. During the cesarean section, strips of myometrium were obtained from the lower segment of the uterus, and the tissue extract was prepared. In extracts of myometrium, and in blood plasmas, the following components of fibrinolysis were measured: tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), plasminogen activator inhibitor 1 (PAI-1) and plasminogen activator inhibitor 2 (PAI-2). An ELISA method was used. Statistical analysis was performed using a t-Student test. Results: The contents of the fibrinolytic components in myometrium were as follow: tPA 46.60 33.63 ng/lg, uPA 17.18 4.36 ng/lg, PAI-1 731.38 370.63 ng/lg, PAI-2 814.71 23.58 ng/lg. In the blood of pregnant vs. non-pregnant women: tPA 9,30 4.30 ng/ml vs. 4.44 2.97 ng/ml; uPA 0.70 0.34 ng/ml vs. 0.48 0.16 ng/ml; PAI-1 48.50 16.08 ng/ml vs. 19.08 8.2 ng/ml; PAI-2 - 177.14 56.12 ng/m vs. 1.80 1.86 ng/ml. Conclusions: It is generally acknowledged that placenta is the main source of fibrinolytic components. Our results show that myometrium of pregnant women may be considered to be an additional source of fibrinolytic components.

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FC3.06.09 THE EFFECT OF RECURRENT HYPOXIA-REPERFUSION ON LIPID PEROXIDATION IN THE FETAL LAMB BRAIN: A PATH ANALYSIS M.S. Rogers (1), C.C. Wang (1), H.G. Murray (2) (1) Dept. OB/GYN, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong. (2) Dept. OB/GYN, Hepean Hospital, Penrith, Australia. Objectives: To determine the effects of variable recurrent oxidative stress on lipid peroxidation in the fetal brain. Study Methods: Setting: The Westmead Hospital Vivarium, University of Sydney and the Dept. OB/GYN of the Chinese University of Hong Kong Plasma lipid peroxide concentrations were measured in acutely exteriorized fetal lambs under graded hypoxia induced by intermittent total umbilical cord compression in 30-, 60- and 90-second occlusions with diminishing recovery periods of 3-, 2- and 1-minutes. Results: A rapid and profound rise in fetal cartoid artery organic hydroperoxide (OHP) concentrations, but drop in fetal jugular venous concentrations was found intermittent 30-second occlusions, with minimal fetal arterio-venous differences. Arterio-venous differences appeared under severe hypoxic stress from 60-second occlusions onwards. Path analysis of the changes in OHP concentration between arterial perfusate and venous drainage of the brain confirmed strong direct associations from the variables occlusion length and duration of experiment, with moderate indirect associations through changes in oxygen saturation and in hypoxanthine concentration. Conclusions; The analysis supported the causal model as defined: occlusions leading to hypoxia with a rise in hypoxanthine; reperfusion during intervals between occlusions leading to the accelerated production of xanthine and uric acid and the generation of oxygen free radicals, which, in turn, are responsible for the rise in lipid peroxidation. FC3.07 FIBROIDS FC3.07.01 ARTERIAL EMBOLIZATION: A NEW TREATMENT OF UTERINE MYOMATA IN YOUNG WOMEN J.H. Ravina (1), A. Aymard (2), N. Ciraru-Vigneron (2), J. Clerissi (2), J.J. Merland (2) (1) Dept. OB/GYN, Clinique Spontini, Paris, France. (2) Dept. OB/GYN, Facult St. Louis Lariboiserie, University of Paris VII, Paris, France. Objective: Nonsurgical treatment of symptomatic uterine myomata by particulate arterial embolization in young women. Study and Methods: 59 women, aged 21 to 37 years, with symptomatic uterine myomata in whom surgery was initially planned after having received precise information chose embolization. The size, the number and the place of myomata were determined by pelvic ultrasound subseral and submucosol pediculed or sessile myomata were excluded. Performed under neurolept and local anesthesia, this interventional vascular radiology technique is designed to induce necrosis of myomatous tissue. After retrograde transfemoral introduction of the catheter (4 to 5 F), the left and right uterine arteries are successively catheterized. Ivalon particles are injected by free flow until devascularization. It is important to preserve ovarian blood supply. Results: 55 patients were able to be evaluated. Complete resolution of symptoms was obtained in 51 cases and 4 failures were observed. Bleeding resolved in all but two patients. A marked reduction in the size of the myomata was observed as it was complete (7 cases) or greater than 80% in 27 out of 45 cases. The mean volume of single or dominant myomata was 83 cm3 before embolization versus 9 cm3 after embolization. 5 pregnancies were observed. The effects of embolization on fertility are discussed. Conclusion: The very encouraging results of this preliminary series of 59 cases (92.5% success) suggest that embolization, a new minimally invasive technique, can replace myomectomy in young women.

FC3.06.08 INHIBITION OF PLATELET AGGREGATION BY RAT TROPHOBLASTS P.K. Mehrotra (1), R. Tewari (1), M.P. Singh (2), S. Farheen (1), and M. Dikshit (2) (1) Division of Endocrinology, Central Drug Research Institute, Lucknow, India (2) Pharmacology, Central Drug Research Institute, Lucknow, India Objectives: The aim of the study was to determine the effect of suspended rat trophoblast cells on the adenosine diphosphate (ADP) induced platelet aggregation. Study Methods: The trophoblasts were isolated from ectoplacental cone (EPC), a preplacental tissue highly rich in there cells, developed in rat embryo on day 12 of pregnancy. The platelet rich plasma was obtained from adult male rats. The trophoblasts were preincubated (37oC, 30 min), suspended in the medium and re-incubated with platelet rich plasma (PRP) for 3-5 min. Results: It was noticed that the cell at 5-7 X104 concentration inhibited ADP-induced platelet aggregation. But when the concentration was increased to 1-2 X 105 cells, proaggregatory phenomena was observed. However, there was no response when fixed trophoblasts or live endometrial stromal cells were incubated with PRP. Conclusions: Findings indicated that the aggregation inhibition response was cell specific and concentration dependent The nature of inhibitory or stimulatory factor is, however, not yet established.

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FC3.07.02 SUCCESSFUL TREATMENT OF UTERINE FIBROIDS WITH INTERSTITIAL LASER PHOTOCOAGULATION Rowan J Connell, National Medical Laser Centre & Department of Obstetrics and Gynaecology, University College London, UK Alasdair Gordon, Department of Obstetrics and Gynaecology, University College London, UK. Alfred Cutner, Department of Obstetrics and Gynaecology, University College London, UK Stephen G Bown, National Medical Laser Centre, Department of Surgery, University College London, UK Objective: Interstitial laser photocoagulation (ILP) is a technique for destroying lesions in solid organs, using low power laser energy to gently coagulate the target tissue with no surface effects, and therefore no collateral damage. Our aim was to assess ILP as a minimal access technique of treating symptomatic uterine fibroids. Study Methods: This study was carried out at a London teaching Hospital. Twelve women with symptomatic uterine fibroids (3-12 cm diameter) were recruited. Under laparoscopic control, 1-4 pre-charred, bare tipped 400mm laser fibres from a semiconductor laser (805nm) were inserted into fibroids through Tuohey needles and activated simultaneously, each delivering 3.5W for 300 seconds. Fibroid volume was measured preoperatively and during follow up with MRI. This treatment is in contrast to laser myolysis (which uses powers up to 50W). Results: We have MRI follow-up of 17 treated fibroids, with diameters ranging from 4.5 cm to 11.5 cm (volumes 41 mls to 668 mls), in 12 women with a mean age of 41 years (range 33-48 years). There were no complications and recovery was comparable to that after laparoscopy. Fibroid volume as a percentage of the untreated volume was a mean of 175% (81-276%) 1 week after ILP; 93% (range 40-144%) at 4 weeks; 41% (range 15-58%) at 20 weeks; 23% (range 18-32%) at 32 weeks; and 28% (range 20-36%) at 52 weeks, and 18% at 80 months. ILP is safe, it successfully shrinks fibroids and the shrinkage appears to be sustained. Conclusion: ILP is a successful minimal access technique, which can be used to safely treat uterine fibroids.

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FC3.07.04 MINIMALLY INVASIVE PERCUTANEOUS LASER ABLATION OF UTERINE LEIOMYOMAS. Law. P, Dept. Obstetrics & Gynaecology/Interventional MR, ICSM@St.Marys, London, UK. Gedroyc. W, Dept. Interventional MR, St.Marys Hospital, London, UK. Regan. L, Academic Dept. Obstetrics & Gynaecology, ICSM@St.Marys, London, UK. Objectives: To develop an effective and accurate method for thermal ablation of uterine fibroids using an open interventional magnetic resonance (MR) scanner to guide percutaneous insertion of laser fibres and to monitor the extent of uterine fibroid coagulative necrosis during treatment. Study methods: Thirty women with symptomatic fibroids and completed families were recruited from the gynaecology clinic at St. Marys Hospital, London, to undergo percutaneous laser ablation. Four MR compatible needles were placed percutaneously under MR guidance through the anterior abdominal wall into the centre of the targeted leiomyoma. Four bare laser fibres were then inserted into the leiomyoma via the outer needle sheaths. A diode laser heat source of five watts per fibre was used with a four-way splitter.Tissue effects of thermal ablation were monitored throughout the procedure with realtime image processing software. (RTIP) Results: Three months after laser ablation, targeted leiomyoma volume had decreased by 37.5%, which was maintained at six months. Total menstrual blood loss was measured before and after laser ablation in five women with a mean decrease of 39.2%. Women reported symptomatic improvement after laser ablation using a validated gynaecological outcomes questionnaire. Conclusions: Preliminary work with percutaneous laser ablation suggests that this minimally invasive day case procedure may offer an alternative to traditional surgical treatment for symptomatic uterine fibroids. FC3.07.05 MYOMETRIAL RESECTIONS: PRELIMINARY REPORT OF A UTERINE-CONSERVING PROCEDURE FOR MYOHYPERPLASIA I. Babarinsa, M. Oladokun, I. Adewole, Dept. OB/GYN, University of Ibadan, Ibadan, Nigeria. Introduction: Myohyperplasia in our limited experience, occurs discretely, or in association with uterine fibroids or adenomyosis. The definite treatment for myohyperplasia is hysterectomy, but the option is not acceptable to women desirous of continuing childbearing or menstrual function. Study Method: We evolved this technique following the occasional need to restore uterine form following enuclation of huge myomas. A midline anterior uterine incision was the only approach. No tourniquet was applied or vasopressin used. The myometrium was carefully resected, short of the endometrium and reconstituted with scrosal closure all using vicryl sutures. Results: Eight women had the procedure over 3 years. Five patients had myohyperplastic uteri, three in association with fibroids. Menstrual function was unaltered in 5, one patient had hypomenorrhea and another had irregular cycles. One patient got pregnant and was delivered by an elective cesarean section. Conclusion: Myometrial resection is an easily learnt procedure, acceptable to patients and worth considering in settings where hysterectomy for myohyperplasia has hitherto been the practice.

FC3.07.03 HAEMOSTASIS DURING LAPAROSCOPIC SURGERY: A COMPARATIVE STUDY A.M. Badawy, A. L. Magos*, Departement of OB/GYN, Mansoura University, Egypt. *Consultant Obstetrician and Gynaecologist, The Royal Free Hospital, London, UK. The objective of this study is to determine the proper haemostatic method to be adopted during laparoscopic surgery. This study comprised 213 patients undergoing laparoscopic hysterectomy, oophorectomy and salpingectomy for various indications whom were randomly allocated to bipolar electrosurgery, Endo GIA 30 stapler or pre-tied sutures as primary methods of haemostasis. The three study groups were compared in regard to many details such as operative time, blood loss, postoperative discomfort, bowel function, medications, hospitalisation, resumption of activity and return to work. The study showed that bipolar electrodesiccation is an effective, rapid, cheap and relatively safe haemostatic technique for almost all laparoscopic procedures. It was effective in securing large pedicles such as infundibulo-pelvic ligament and uterine vessels. Bipolar coagulation was also useful for ablation of endometriosis, for bloodless adhesiolysis and opening the peritoneal pouches. Bipolar electrodesiccation was of comparable speed to staples and significantly more rapid than sutures in most of the procedures. Bipolar coagulators have the versatility to be used in various situations especially in emergency conditions and have the capacity to cope with the developing challenges of endoscopic surgery. We have not had major complications from electrosurgery. We can confidently recommend bipolar electrosurgery as the primary method of haemostasis for most of laparoscopic procedures. Bipolar electrosurgery should be an essential part of the armamentarium of any endoscopist.

FC3.07.06 EXPERIENCE WITH MYOMECTOMY M. Sammour, H.Sammour, Dept. OB/GYN, Ain-Shams Faculty of Medicine, Cairo, Egypt. During the years 1991-1998, 582 myomectomies were carried in a Private Institute. The mean age was 32.6 years and the mean parity 2.4. The operation was carried n 26 unmarried females. Cervical myomas constituted 8.5% broad ligament myomas 2.8%, 3 cases of peritoneal myomeas and the rest were corporeal. Submucous leiomyomas were present in 22.6% of the cases while the interstitial myomas were present in 74.2% and the subserous in 36.5%. Single myoma in 32.5% of cases while 2-5 myomas accounted to 47.5% of cases while multiple myomas above 5, were seen in 20% of our series. During myomectomy the cavity

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was explored in 35% of the cases with reconstruction and preservation of the endometrial surface. Pregnancy rate after myomectomy was the highest in between the single interstitial and subserous myomas. The lowest pregnancy rate in between the submucous myomas with exploration and reconstruction of the endometrial cavity. Closure of the serous layer after myomectomy and drainage of the pelvic peritoneal cavity for at least 48 hours after the operation have improved our results concerning the postoperative adhesions an the pregnancy outcome. Not a single case of rupture myomectomy scar was encountered during subsequent delivery after myomectomy. The highest pregnancy rate occurred during the first year after myomectomy. FC3.07.07 DISTRIBUTION OF TWO PROGESTERONE RECEPTOR ISOFORMS IN UTERINE LEIMYOMA Lihui Wei, Z. Tu, J. Wang. Dept. GYN, Peoples Hospital, Beijing Medical University, Biejing, P.R. China, 100044. Objectives: Human progesterone receptor(hPR) has two isoforms, hPRA and hPR-B, and hPR-B has a longer NH2 terminus and function differently from hPR-A. Thus, the relative expression of hPR-B/hPR-A is likely to be important for the action of progesterone. To investigate the role of two isoforms in generation and progression of leiomyoma, their distribution and ratio of messenger ribonucleic acid and protein in leiomyoma and myometrium were detected. Methods: Leimyoma and adjacent normal myometrium from 30 uteri, which were excised for leiomyoma, were used for location and quantification of hPR-A and hPR-B protein. Immunohistochemistry and western blot were applied respectively. 23 pairs of mRNA out of the 30 cases were quantification by RT-PCR. Results: (1)Both hPR-A and hPR-B are nuclear receptors. (2)Concentrations of hPR-(A+B) and hPR-A in leiomyoma were higher than those in myometrium (P=0.0415, Pa=0.000563). (3)Both isoforms are presented in leiomyoma and myometrium , with a consistent dominance of hPR-B over hPR-A (P=2.97*10-12, P=1.19*10-15). (4)hPR-B to hPR-A ratio is much lower in leiomyoma than that in myometrium (P=0.0388). (5)More protein expression of hPR-A in secrete stage than that in proliferative stage, not only in leiomyoma but also in myometrium (P=0.0368, P=0.0236). (6)mRNA of hPR-B and mRNA of hPR-A are both more in leiomyoma than those in myometrium. Conclusions: Abnormal distribution of hPR isoforms may cause myometrium cell responds to progestin abnormally, that may be one mechanism of leiomyoma generation. hPR-A has a closer relationship with leiomyoma than hPR-B do, and may plays an important role in physiological change of myometrium. FC3.07.08 CONSERVATIVE MANAGEMENT OF FIBROIDS WITH LONGTERM COMBINATION OF GnRH-a AND LOW DOSE STEROIDS M. Mamopoulos, J.M. Tzafettas, D. Delkos, P.Petropolous, B. Karayiannis, G.Tektsides, G. Kalogeros, N. Klearchou, S. Anapliotis, Dept. OB/GYN, University of Thessaloniki, Thessaloniki, Greece. GnRH-a have been used for the measurement of estrogen dependent conditions like fibroids, endometriosos, dysfunctional uterine bleedings, endometrial hyperplasias and more recently for advanced stages of gynecological cancers. This treatment, though has been hampered by the associated unpleasant climacteric symptoms and its time limitation, due to the risk of osteoporosis. Objective: The aim of this study was to evaluate the beneficial effect of long-term use of GnRH-a on the size of a fibroid uterus and to assess the prevention of osteoporosis and the amelioration of the climacteric symptoms with the parallel use of HRT treatment, in view of the fact that complete down regulation of the ovaries is not necessary in such cases. Study Methods: In a prospective, randomized study, 36 patients (aged 34 51) with fibroids that required surgical treatment, due to their size or persistent bleeding, underwent treatment with leuproreline (Elityran, TAKEDA) and Trisequence (Novo-Nordisk) from the 3rd month onwards and for an indefinite period. Prior to the treatment all patients were subjected to clinical examination, serum bone metabolism tests and ultrasound assessment, repeated every 3 months. Radiological determination of bone mineral density was repeated every 12 months.

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Results: The duration of the treatment so far, has been 169 months (726). Significant reduction of the uterine size was noticed within three months and remained for the rest of the treatment. Except for five patients for whom the treatment had to be discontinued due to resistant menorrhagia, this was well tolerated by the rest. The bone metabolism markers, after an initial deterioration around the 3rd month of the therapy, showed a definite improvement afterwards. The same was recorded for the BMD in the lumbar spine. There was no significant change in the HDL levels. Conclusions: The creation of a well balanced combination treatment with GnRH-a and the parallel use of low dose estrogen in the form of HRT treatment might be a successful alternative to the surgical management of fibroids and other estrogen dependent conditions, especially in women of relatively younger age or those patients not suitable for surgical management. FC3.08 CURRENT TOPICS IN GENERAL GYNECOLOGY FC3.08.01 TISSUE RESPONSE TO THE STOP DEVICE: A NEW APPROACH TO TRANSCERVICAL STERILIZATION C.S. Carignan, Stanwood Associates, 392 Stablers Church Road, Parkton, MD USA 21120; T.C. Wright, Dept. OB/GYN Pathology, Columbia University, 630 W 168th St., NY, NY USA 10032; STOP Investigator Group, Conceptus, 1021 Howard Ave., San Carlos, CA USA 94070 Objective: To examine the histological response to the new STOP transcervical intrafallopian device in a multi-center prehysterectomy study to evaluate the likelihood of the device remaining in the tube and to support its proposed mechanisms of action: loss of normal tubal architecture and occlusion of the tube. Study Methods: The STOP device was inserted hysteroscopically in 50 fallopian tubes of 28 women who were scheduled to undergo a hysterectomy. The women wore the devices from 8-99 days. At the time of hysterectomy, the fallopian tubes were removed, embedded in methyl methacrylate and sectioned to observe the resulting local tissue response to the device. Results: All devices that were properly placed remained in the tube. On histological examination, acute and chronic inflammatory cells; loose and dense fibrosis; and smooth muscle cells, migrating in between the coils of the device and the PET fibers, characterize the reaction with properly placed devices. In women who wore the devices for a longer time, the response is more marked with denser fibrosis, migration of smooth muscle cells, and signs of early neovascularization. In all cases the reaction is limited to the area immediately surrounding the device and does not extend past the distal end of the device nor deep into the wall of the tube. Conclusion: The localized tissue response and notable absence of any normal tubal architecture at the site of implantation is believed to contribute to the contraceptive effectiveness the STOP device and to the long-term anchoring of the device. FC3.08.02 PREGNANCY AFTER FAILED TUBAL STERILIZATION IN TEHRAN, IRAN A. Mehdizadeh, A. Akbarian, H. Movahedi, E. Shirazi, R. Alaghehbandan, Dept. OB/GYN, Iran University of Medical Sciences, Nyayesh Street, Sattarkhan Avenue, Tehran, Iran Objectives: Worldwide, tubal sterilization is the most commonly chosen form of contraception by women who have completed their desired childbearing. Also this method is accepted by most of married women in Iran. Although pregnancy after tubal sterilization is uncommon, it can occur. This study was carried out to determine the incidence of pregnancy after tubal sterilization in Tehran, Iran. Study Methods: A register-based retrospective study was conducted in the teaching hospitals affiliated to Iran University of Medical Sciences in Tehran during 1992-98. A total of 2000 tubal sterilization were performed during the period of study. We entered all information regarding the number of sterilization failure and type of procedure. Results: The patients' age ranged from 22 to 49 years (mean, 33.8). Their parity ranged from 1 to 14 (mean, 4.7). Of 2000 patients 1900 (95%) had tubal sterilization by laparatomy and 100 (5%) by

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laparoscopy. The overall sterilization failure rate was 0.45% (9/2000) after 7 to 31 months of sterilization (mean, 9.6). There were 7 (0.35%) surgical failures (those who were pregnant after the procedure) and 2 (0.1%) administrative failures (those who were pregnant at the time of surgical procedure). All 9 women had intra-uterine pregnancy and no ectopic pregnancy was found. The sterilization failure rate was 3% (3/100) for laparoscopic methods and 0.3% (6/1900) for laparatomic sterilization. The pregnancy rate was 0.6% (4/663) in the group who had had a pregnancy terminated with their sterilization while 0.3% (5/1337) among those who their sterilization and termination of pregnancy were separately performed. Conclusions: Our study showed that tubal sterilization failure rate to be lower comparing to the most previous reports. Our failure rate was mainly attributed to the intra-uterine pregnancies. It should be stressed that preoperative pregnancy testing to be done before tubal sterilization. The sterilization failure rate in laparoscopic methods was higher than non-laparoscopic sterilization. Sterilization failure highly associated with combination of sterilization and termination of pregnancy. FC3.08.05 BONE MINERAL CONTENT AFTER A 12 MONTH-PERIOD TREATMENT WITH A CONTINUOUS COMBINED HORMONAL REPLACEMENT THERAPY. Sauerbronn, A.V.D.; Fonseca, AM; Bagnoli, VR; Assis, JS; Guerra, DMM; Halbe, HW & Pinotti, J. Dept. Ob/Gyn, So Paulo University Medical School, So Paulo, Brazil

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FC3.08.03 USE OF PLASTIC SURGICAL TECHNIQUES IN RECONSTRUCTIVE GYNECOLOGY V. Chitale, M. Chitale, Chitale Clinic, Solapur, Maharashtra, India. Objectives: There are many problems in day to day Ob/Gyn practice that can be better solved by using plastic and reconstructive surgery. Study Methods: 1) Dehisced episiotomy wound was treated by doing split thickness skin grafting by exposure method. 2) Web contracture of the fourchette was treated by Z plasty. 3) Transverse vaginal septum was treated by Double cross plasty. 4) For congenital absence of vagina treated by lining the cavity by split thickness skin graft: the use of a special mould (Condom-U-foamcatheter mould) will be emphasized. Results: Results were satisfactory. Conclusions: Plastic and reconstructive surgery has an important contribution to offer for difficult Ob/Gyn problems.

Objectives: The aim of this study was to evaluate the bone mass as well as clinical effects of a continuous combined HRT schema on climacteric women. Study Methods: 20 postmenopausal women aged 45 58 years, with time of menopause varying from 14 to 120 months, received a preparation with 28 tablets containing each one, 2 mg of estradiol and 1 mg of noretisterone acetate, during 12 consecutive months. We evaluated climacteric symptoms, Quetelet Index, blood pressure, and bone densitometry. Results: There was a good control of climacteric symptoms during treatment; the highest rate of irregular bleeding was 25% at cycles 5 and 6; at the end of treatment, 85% of patients were amenorrheic, Quetelet Index (Kg/m2) remained unchanged (baseline = 26.56 3.97; 12 months = 26.74 4.26 Mean SD); bone densitometry (standard deviation) remained unchanged at lumbar spine (baseline =1,541,38; 12 months =1,571,12) and decreased at femoral neck (baseline =0,681,43; 12 months =0,831,40); blood pressure (mmHg) remained unchanged (systolic / diastolic: baseline = 118 10.56 / 75.5 8.25; 12 months = 123.5 17.85 / 77.5 9.66). Conclusions: The continuous combined HRT preparation evaluated presented both good cycle and climacteric symptoms control. Mineral bone mass was maintained stable at lumbar spine, but decreased at femoral neck. General tolerability was good, and Quetelet Index and blood pressure remained within baseline rates.

FC3.08.06 INCIDENCE OF VAULT HAEMATOMA AFTER VAGINAL HYSTERECTOMY AND ITS CORRELATION WITH POST OPERATIVE MORBIDITY A.H. Khosla, J. Sen, S. Kumari, Dept. OB/GYN and Radiology, PGMIS, Rohtak, Haryana, India. Objectives: To study the incidence of vault haematoma and its relationship with postoperative pyrexia, drop-in hemoglobin and postoperative stay in patients undergoing vaginal hysterectomy and pelvic floor repair for uterovaginal prolapse. Study Methods: Prospective study of 72 patients undergoing vaginal hysterectomy with repair in one unit of Dept. OB/GYN, PGMIS, Rohtak, India from Jan. Dec 1998. Pelvic peritoneum and vault were closed and all patients received prophylactic antibiotics. Transabdominal and transvaginal ultrasonography was done for vault haematoma on postoperative day 3 or 4. Routine postoperative monitoring was done by staff blinded to the ultrasound findings. Tests for significance done were c2 and two sample T-test. Results: Four (5.55%) of the 72 patients had a vault haematoma (Group 1). Of these, 2 (50%) had low grade pyrexia. Of the 68 patients with no vault haematoma (Group II), 6 (8.82%) had low grade pyrexia. The mean drop in hemoglobin was 1.33 grams/dl in group I and 1.43 grams/dl in group II. The mean hospital stay was 8.4 days in group I and 10.5 days in group II. Conclusions: The incidence of vault haematoma was 5.55% in this study compared to 25% (Thomson et al) and 95% (Kuhn et al) in other studies. There was a significant increase in low grade pyrexia but no statistically significant drop in hemoglobin or prolonged hospital stay in these patients. Ultrasound detection of vault haematoma does not add to the postoperative care of patients of uterovaginal prolapse where all pedicles can be extraperitonealized during vaginal hysterectomy.

FC3.08.04 SELF-ADMINISTRATION OF CYCLOFEM ONCE-A-MONTHINJECTABLE CONTRACEPTIVE TROUGHOUT UNIJECT DEVICE IN MEXICAN WOMAN. A. Morales-del Olmo, J.Garza-Flores, G.Perez-Palacios, Ministry of Health, Homero 213, DF, Mexico, 11750. Once-a-month injectable contraceptives are well accepted in Mexico; since its incorporation to the National Family Planning Program in 1994, Cyclofem (medroxiprogesterone acetate 25 mg and estradiol cypionate 5 mg) formulation, has demonstrated its high efficacy, safety and acceptability. Nowadays, one of each five new acceptors of any contraceptive method, select this formulation in Mexico. Objectives. To compare acceptability and continuation rates of monthly injectable contraceptive Cyclofem in the new prefilled injection disposal Uniject. Study methods. A multicentred, prospective and comparative clinical trial was conducted by governmental health institutions in Mexico. Seven hundred and eighty healthy women were randomly allocated in two comparative groups; group I, included women who attend the clinic once-a-month to receive contraceptive via Uniject by the service provider; and group II, included women who were trained in selfadministration and were provided with 6 doses and instructed to apply them monthly at their home. Results. After life-table data-analysis, the study confirmed the proposed hypothesis that continuation rates are significative higher in group II, where injectable self-administration was performed. Furthermore, autoaplication was preferred by participating women. Conclusions. The high acceptability and safety of injectable contraceptives, was confirmed demonstrating the high compliance of parenteral administration. This study provided the elements to incorporate the new injection prefilled disposal to the contraceptive options available in Mexico.

FC3.08.07 STAGE TREATMENT OF PATIENTS WITH BENIGN EPITHELIAL TUMORS OF OVARIES (BETO) V. Nagornaya, V. Marichereda, Dept. OB/GYN, Odessa Medical University, Odessa, Ukraine. Objectives: To reveal the optimal volume of operation and necessity of post-operative treatment of patients with BETO based on the analysis of

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function of the hypothalamic-pituitary-ovarian system and the system of proteolyctic enzymes. Study Methods: Radioimmune assay, immunoenzyme (FSG, LG, PRL, estradiol, progesterone), biochemical (acid, alkaline proteases, their inhibitors) methods. Results: For 467 women of 17 40 years of age the level of hormones and enzymes was determined in peripheral blood and enzymes in tissues of ovaries before the operation in the 1st three months, and 1,2,3 and more years postoperatively after BETO removal, performed as enucleation of tumor, resection or removal of the ovary. Three versions of a hormonal dysfunction, rising of protease level, except elastase, and decrease of inhibitor level have been revealed. For many patients these dysfunctions are maintained after the operation and are determined by the scope of the performed operation. In 19.27% of patients, tumors are recurrent, in 58.24% these are benign tumors of uterus, mammary gland. For their prevention corrective therapy was conducted postoperatively. Within 4 years of the follow-up, recurrence of tumors has not been noticed. Conclusions: The treatment of the patients with BETO should be done in 2 stages. Stage I: operation at optimal scope (tumor enucleating), Stage II: corrective hormonal and enzyme therapy. FC3.08.08 OUTCOME OF PREGNANCIES ASSOCIATED WITH INTRAUTERINE CONTRACEPTIVE DEVICE. EXPERIENCE FROM THE THIRD WORLD A. Ashmag, B. Ahmed, H Fawzi, Sudan Fertility Care Association, Police Hospital, Dept. OB/GYN, Khartoum, Sudan Between January 1985 and January 1991, 200 women aged 18-38 years old were fitted with Copper T intrauterine device (I.U.C.D.). Insertion of the I.U.C.D. was performed immediately after menstruation by the author and a trained midwife. The women were instructed to self-check the I.U.C.D. tail after each menstrual period. All the women were examined after six weeks and were followed-up every six months. During this period, 150 women were lost to follow-up and 37 accidental pregnancies occurred (Cumulative net pregnancy of 2 per 100 women). Thirty-five pregnancies were intrauterine and two were ectopic. All women with intrauterine pregnancies elected to continue with their unplanned pregnancies, as termination of pregnancy is not socially acceptable. Most of the accidental pregnancies occurred during the 18 months of use. The I.U.C.D. was extracted during the pregnancy in only two women. The incidence of spontaneous abortion was doubled when the I.U.C.D remained in utero. The chance of preterm birth was increased. There were no recognizable congenital anomalies detected in this series. FC3.08.09 POSTMENOPAUSAL OSTEOPOROSIS CURRENT TRENDS IN DIAGNOSIS AND MANAGEMENT K. Mukherjee (1), G. Ganguli (1), A. Tripathi (1), K.D. Tripathi (2) (1) Dept. OB/GYN, MLN Medical College, Allahabad, U.P., India. (2) Dept. Orthopaedics, MLN Medical College, Allahabad, U.P., India Objectives: The aim of the study was to diagnose the postmenopausal osteoporosis and to evaluate the role of alendronate & Vit D3 metabolite in osteoporosis management. Study Methods: One hundred and fifty postmenopausal women attending out patient department of SRN Hospital, MLN Medical College, Allahabad, India were included in this study. Bone Marrow Density was measured by Dual Energy X-ray Absorptiometry (DEXA). The women who have BMD at least below mean for adults were randomised to oral administration of alendronate (10mg/day), Calcitriol (0.25ug twice daily) and plain calcium (placebo) (500mg twice daily) and followed up by measurement of bone marrow density at six month intervals up to two years. Results: In our study group only 9.33% of the women were found to be having normal bone marrow density. 40% were in osteopenic range, 33.32% were osteoporatic and 13.33% were severely osteoporotic. BMD was increased by 3.6% and 1.8% in alendronate treated and calcitriol treated groups respectively at 2 years. The safety and tolerability of both were comparable with those of the placebo. Conclusion: Dual Energy X-ray Absorptiometry is a sensitive and convenient method to diagnose postmenopausal osteoporosis.

WEDNESDAY, SEPTEMBER 6
Management with alendronate and calcitriol progressively increases bone mass and is generally a well tolerated treatment for osteoporosis in postmenopausal women. FC3.09 CURRENT TOPICS IN GYNECOLOGY FC3.09.01 CLINICAL TRIAL OF IMMUNOTHERAPY WITH PATERNAL MONONUCLEAR CELLS FOR UNEXPLAINED RECURRENT MISCARRIAGE F. A. Saad, A. Al-Hilali*, Department of Obstetrics and Gynecology and Department of Laboratory and Blood Bank*, Hamad Medical Corporation, Doha, Qatar. Objectives: The purpose of this study was to evaluate the effect of immunotherapy with paternal leukocytes for the treatment of unexplained recurrent miscarriage. Study Methods: During the period from December 1994 to January 1998, we immunized 86 women with >2 miscarriages, with about 0.5x109 paternal mononuclear cells. Another 63 recurrent miscarriers, who conceived during the same period, were used as controls. Results: There was no overall positive effect of paternal leukocyte transfusion. However, among women with >3 miscarriages, the success rate was significantly higher in the treatment group (p<0.01) compared to the controls (83.9% versus 51.7%). On the other hand, in the subgroup of women with history of only two miscarriages, the success rate was significantly higher in the control group (p<0.05) than in the study group. We found significantly higher success rate (90%) in the group immunized during pregnancy compared to (60%) in the group immunized before pregnancy (p<0.05). Conclusions: Alloimmunization with paternal leukocytes showed a positive effect in a subset of women with >3 miscarriages. The therapeutic effect found in this study compared with other studies may rely on the use of a greater dose of leukocytes injected. This treatment should not be offered to patients with history of only two miscarriages and preferably it should be performed as early as possible during pregnancy. FC3.09.02 HOW UNIVERSAL ARE MEDICAL ETHICS AND LAW? AN EXAMPLE IN THE PERMISSIBILITY OF SURROGACY S.I.M.F. Ismail, Dept. OB/GYN, Singleton Hospital, Swansea, UK Objectives: This study evaluated whether a single code of medical ethics and law could be applied to all countries worldwide or a flexible approach is needed to match varied backgrounds. It made this evaluation in relation to surrogacy, upon which the position of Western and Muslim counties vary considerably, as an illustration of how best to handle moral differences as part of international co-operation in health care. Methodology: The study relied on published literature and theoretical considerations. It considered rationality, relativism as well as tolerance as approaches to reconcile both stands on surrogacy. The study also explored legal grounds for adaptation to local factors that vary between societies and looked at different legal position on surrogacy. Results: Moral disputes in health care are subjective, such that looking at the rationale of different stands on surrogacy or evaluating them in relation to local features can not be made in an objective way and tolerance of varied views is preferred. This might have to be restrained whenever human suffering ensues, though it is difficult to reach an agreed definition of such suffering. Likewise, a single legal code is unlikely to suit all societies and law is better tailored to the place where it is to be applied. Conclusions: It is difficult to agree on a single code of medical ethics and law as moral diversity will necessitate a degree of flexibility.

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FC3.09.03 HERPES SIMPLEX VIRUS IN INFERTILE COUPLES: DNA SEQUENCE OF PCR PRODUCT N. El Borai (1), M. Araki (2), E. Naumova (3), M. Inoue (4), S. Kato (5), K. Yamamura (2), M. Yamamura (1) 1) Dept. Mol Life Sc., Tokai University School of Medicine, Isehara, Kanagawa, Japan. 2) Gene Tehnology Center, Kumamoto University, Kumamoto, Japan. 3) Tufts university School of Medicine, Boston, MA, USA. 4) Sanno Hospital, Tokyo, Japan. 5) Dept. PED, Tokai University School of Medicine, Isehara, Kanagawa, Japan. Objectives: To confirm the presence of the herpes simplex virus DNA detected in semen and menstrual blood of infertile couples by sequencing the PCR (polymerase chain reaction) product. Study Methods: A specifically designed PCR assay with nested primers was used to test (1) the menstrual blood of 25 infertile and 4 fertile women, (2) semen from 157 infertile and 25 fertile men, and (3) 50 cord blood samples as control. The PCR product of positive samples was sequenced. Results: The control virus sample herpes simplex 1 Tomioka strain gave positive results with both the first PCR reaction and the second PCR using the nested primers. The second PCR reaction with nested primers allowed the detection of low titers of virus, in 48% menstrual blood samples and 24% semen samples of infertile subjects. None of the samples form fertile subjects or cord blood were positive. The sequence of the PCR product of the infertile samples were the same as the published sequence of HSV-1, but differed form the HSV-1 Tomioka strain. Conclusions: The PCR product of semen and menstrual blood samples were the same as the published sequence of herpes virus 1 but different from the control virus Tomioka strain. The results confirm the importance of excluding herpes virus as the reason for infertility before more specialized treatment is undertaken. FC3.09.04 HRT FOLLOWING HYSTERECTOMY D.K. Chakrabortti, Dept. OB/GYN, KMC Research Institute, Calcutta, India. Objectives: The aim of this study is to evaluate the rationality of undertaking hormone replacement therapy (HRT) to women following surgical menopause. The sudden drop of endogenous estrogen level is accompanied by menopausal symptoms resolved to a great extent by HRT. Study Methods: The study comprises interviewing women prehysterectomy and 1 to 5 years after operation with respect to their experiences while using HRT, adherence to therapy, perceptions of effectiveness in relieving symptoms and appearance of new problems. The type of hormone prescribed, changes in serum FSH, E2, Lipid profile, breast tenderness/lump and vaginal cytohormonal changes evaluated. This is a prospective study of 200 cases of abdominal hysterectomy for non-malignant indications among pre-menopausals. Results: Out of 200 cases 178 (89%) required HRT within 3 months of operation. In 22 cases (11%) hormone profile remained normal till 1 year mostly where ovaries preserved. Conclusions: HRT is recommended for most women following hysterectomy even when ovaries are retained. Study also revealed loss of ovarian hormonal functions in the majority (60%) within 3 months to 1 year where ovaries retained during operation.

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earlier to the arrival of an ovum in the AFT, the short-lived Y-sperms would perish, meanwhile, the waiting show-moving longer-lived Xsperms would fertilise the ovum on its arrival. A total of 385 couples - 375 wanting a son each, and 10 daughters, were registered. Baring two, others wanted a child of the opposite sex to the one(s) they had. BBT & U/S monitoring of follicle growth data was used to advise the first coitus of the cycle for conceiving a child. Results: 200 couples have conceived a child of their choice. 6 aborted (6 sex was not ascertained). Excluding -6- abortions, the success rate was 98% for a child of the desiteed sex. Conclusions: The "Barthakur's Theory of Waiting" needs serious consideration world wide. In the countries where gender preferences are strong, it will help to curb gender linked forticide, infanticide, population growth and improve mother & child health.

FC3.09.06 HORMONE REPLACEMENT THERAPY (HRT) AND BREAST DISEASE Pereira, PAA; Fonseca, AM; Pasqualotto, EB; Bagnoli, VR; Penteado, SRL; Ramos, LO & Chnee, LH. Dept. Ob/Gyn, So Paulo University Medical School, So Paulo, Brazil. Objective: The objective was to evaluate the prevalence of breast diseases in menopausal women submitted to hormone replacement therapy (HRT). Methods: A total of 47 women who had abnormalities on mammography during their follow-up were included in this retrospective study. Patients ages ranged from 41 to 70 years (mean age of 57,8 years). Patients were divided into 2 groups: Group I (n = 23) patients whose previous mammography was normal, and Group II (n = 24) patients whose previous mammography showed benign changes. Results: In group I we observed 9 cases of microcalcifications, 12 cases of breast node, 1 case of spike lesion and 1 case of undetermined mammography finding. No malignancies were found in this group. The mean period of HRT administration in this group was 4,46 years. HRT discontinuation occurred in 6 cases. In group II we observed: a) 10 patients had benign nodes beforehand with regression of the lesion in 3 case, and no changes were found in 7 cases; b) 10 patients had initially fibrocystic disease. One of them had breast cancer, 1 node with atypical proliferation, 2 cases with sparse microcalcifications, 5 normal and 1 case with benign node; c) 2 patients had microcalcifications beforehand without changes during the follow-up; d) 2 patients had spike nodes beforehand with the diagnosis of breast cancer in 1. In group II discontinuation of treatment occurred in 7 cases and the mean period of HRT was 4,4 years. Conclusions: In the group that received HRT and had initial normal mammography only benign findings were observed in the follow-up. In the group with benign lesions from the beginning, we observed 2 cases of cancer, 1 of atypical proliferation.

FC3.09.07 THE PREMENSTRUAL SYNDROME AND ITS CLINIC IN DIFFERENT AGE GROUPS OF WOMEN Shevchuk T.V., Bodryagova O.I., Regeda S.I., Zakharenko N.F. Institute of Pediatrics, Obstetrics and Gyneacology, Kiev, Ukraine Objective: The aim of study was to follow the peculiarities of PMS in different age groups. Study Methods: Three groups of patients were recruited into the study: 28 women of 18-29 years (I group), 32 women of 30-35 years (II group) and 30 women of 36-45 years (III group). The study was carried out on the base of complaints, clinical and ultrasonic investigations. We estimated 47 clinical symptoms of PMS in the lutein phase of cycle with the Moos R.H. menstrual-distress questionnaire. Clinical gradation of different forms of PMS (neuropsychic, edematous, cephalalgic and crisis) was based on Smetnik classification. According to the number of symptoms, their intensity and duration we determined the forms of PMS (light or severe), its stage (compensated, subcompensated, decompensated) based on gradation of Kuznetzova S. Results: The symptoms of PMS appeared 5,82,4 days before menstruation (I group), 6,13,0 days (II group), 7,34,7 days (III group) p<0,05. The most prolonged illness was reported in neuropsychic and edematous forms (12,43,8 and 9,83,5 days accordingly) of PMS. The assessment of age peculiarities of PMS revealed that in early

FC3.09.05 BARTHAKUR'S THEORY OF WAITING: GENDER CHOICE BY NATURAL INSEMINATION 1. Geeta Shroff OB/GYN, Nutech Mediworld (Ferti, Clinic), New DelhiIndia. 2. Vera Hingorani, AIIMS & Batra Hospital MRC, New Delhi, India Objectives: To clinically test the application of "Barthakur's Theory of Waiting", gender choice could be made through natural insemination. The speedier short-lived Y-sperms would fertilise the ovum if the first of the cycle coitus took place when an ovum was waiting in the Ampulla of the Fallopian Tube (AFT), otherwise, if it had taken place hours/days

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reproductive period (I group) prevailed the cephalalgic form (46,4%), in the active reproductive age (II group) - neuro-psychic form (68,9%) and in the late reproductive period (III group) - neuropsychic (40%) and crisis (30,05%) forms. Conclusions: The results of study have revealed the clinical peculiarities of PMS in different age group. It should be considered for the development of the individual program of treatment of PMS. FC3.10 MATERNAL MEDICAL DISORDERS FC3.10.01 PREGNANCY IN SICKLE CELL DISEASE K. Al-Mulhim, King Farad Hospital, Al-Hofuf, Saudi Arabia. Objectives: Aims of the study were to assess risk involved in pregnancy among sickle cell disease patients (SCD) in Al-Hassa region of Saudi Arabia. Study Methods: Retrospectively records of 64 SCD, 54 sickle cell trait (SCT) patient admitted during 1997-98 were analyzed and crossmatched with 84 controls admitted during the same period. Criteria for SCD was based on absence of HbA1, HbS more than 40 percent and presence of HbA2 and HbF. Age, gravidity, parity, birth weight of fetus, mode of delivery, sickle cell crisis, blood transfusion and HbS percentage were taken into consideration. Statistical analysis was done using and Epi-Info cartridge. Results: Mean age in SCD, SCT and controls was 26.3, 26.8, 27.6 years respectively. Mean gravidity of SCD group was 4 which was significantly (p<0.05) lower than 5.1, 5.2 in SCT and control groups. Mean birth weight of fetus in SCD was 2856 grams, which was significantly (p<0.001) lower than in SCT controls (3168 & 3268 gms.). Cesarean section was required by 25.0% of SCD patients as compared to 93% in SCT patients. Blood transfusion was required in 43.8% of SCD patients. There was no maternal mortality and only one abortion in SCD patients. Mean HbF concentration in SCD patients was 25.6%. Conclusions: High HbF concentration could be responsible for mild manifestation of SCD and better outcome of pregnancy among SCD patients in Eastern region of Saudi Arabia.

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1. Bouillon R., Naesens M., van Assche F.A. et al. Thyroid function in patients with hyperemesis gravidarum. Am J Obstet Gynecol 1982; 143: 922-926 2. R K H Chin and T T H Lao. Thyroxine concentration and outcome of hyperemetic pregnancies. Br J Obstet Gynecol 1988; 95: 507-509 3. Rhodes VA, McDanial RW. The Index of Nausea, Vomiting and Retching: a new format of the Index of Nausea and Vomiting. Oncology Nursing Forum 1999; 26(5): 88994.

FC3.10.03 ASSOCIATION BETWEEN LOW BIRTH WEIGHT AND MATERNAL ANEMIA IN VENEZUELAN PREGNANT WOMEN G. Pea (1), G. Comunin (2), A. Mart-Pea (1), (1) Clinical Epidemiology Unit, Universidad de Carabobo, Miami, FL, USA. (2) Ciudad Hospitalaria Dr. Enrique Tejera, Valencia, Venezuela. Background: The anemia is main hematological complication during pregnancy. Maternal anemia has been considered as a risk factor for low birth weight (LBW). Studies regarding association between maternal anemia and LBW are not known in Valencia, Venezuela. Objective: To determine the association and its magnitude between LBW and anemia in pregnant women in their third trimester and at labor. Design: An incident case-control study was conducted using 2 controls per case. Setting: Maternidad Dr. JL Facchn de Boni, Ciudad Hospitalaria Dr. Enrique Tejera. A tertiary hospital in Valencia, Venezuela. Patients: A total of 543 pregnant women (Cases: 181, controls: 342) Main Outcome Measure: Association between LBW (<2500 g, WHO) and maternal anemia (<11g/L, WHO) (Odd Ratio OR-). Methods: Logistic regression was used to evaluate the data. Likelihood ratio test was done for model comparison. Results: Maternal anemia was found to be significantly associated with LBW (OR: 2.2, 95% CI = 1.5 to 3.2, P =0.001) after adjusting for age, placental abruption and premature rupture membranes. Conclusion: In Valencia, Venezuela, maternal anemia at the end of the third trimester of pregnancy, at labor, was found to be associated with an increased risk of LBW.

FC3.10.02 HYPEREMESIS GRAVIDARUM RELATIONSHIP BETWEEN SEVERITY OF VOMITING AND THYROID FUNCTION R.K.H. Chin, K.Y. Lee, C.Y. Li, Department of Obstetrics and Gynaecology, Caritas Medical Centre and Princess Margaret Hospital, Hong Kong, China Objective: To study the association between thyroid function and severity of nausea and vomiting in patients with hyperemesis gravidarum Study Methods: The association between abnormal thyroid function and hyperemesis gravidarum has been well-documented (1). In about a third of hyperemic patients both total thyroxine and free thyroxine levels were raised (2). Whether thyroxine levels were related to the severity of nausea and vomiting, however, has not been adequately studied. A major issue in the interpretation of previous studies has been the use of different methods to qualify and quantify nausea, vomiting and related symptoms. In the present study, the Rhodes Inventory (3) which is recommended by The International Consensus on Standards for Studying the Efficacy of Pharmacological and Non Pharmacological Therapies for Nausea and Vomiting of Pregnancy was used as a standard for the study of this condition. On admission, hyperemic patients filled in the Rhodes Inventory questionnaire and thyroid function tests were also performed. Correlation between thyroxine levels and the Rhodes Inventory was performed. Results: Twenty-six patients admitted to hospital with hyperemesis gravidarum between December 1998 and September 1999 were studied. They aged between 19 38 (mean 27). All patients were either expecting their first or second baby. The nausea and vomiting scores were from 8 to 34 and do not correlate with the thyroxine levels. Conclusions: There was no correlation between the severity of nausea and vomiting and thyroxine levels in patients with hyperemesis gravidarum. References :

FC3.10.04 TREATMENT OF IRONDEFICIENCY ANEMIA IN PREGNANCY USING IRON PROTEINSUCCINYLATE SUPPLEMENTATION. S.Sifakis, E.Angelakis, E.Papadopoulou, E.Vardaki, E.Kolibianakis, Y.Koumantaki, E.Koumantakis, Dept of Obstetrics and Gynaecology, University of Crete, Heraklion, Crete, Greece. Objectives: Approximately 75% of all anemias diagnosed during pregnancy are due to iron deficiency. The purpose of this study was to evaluate the effectiveness of proteinsuccinylate iron supplementation in the treatment of iron deficiency anemia during pregnancy by assessing the alterations of various clinical and hematological parameters. Study Methods: 100 pregnant women with confirmed iron-deficiency anemia were studied. Hemoglobin levels below 11.5, 10.9 and 10.3 g/dl were used for anemia diagnosis during 1st, 2nd and 3rd trimester of pregnancy respectively. The determination of anemia type as well as differential diagnosis was performed by Hb electrophoresis, determination of MCV MCH, MCHC, reticulocyte count and plasma levels of iron, ferritin and vitamin B12 in some of the cases. A dosage of 1600-mg iron proteinsuccinylate per os was administered to each woman daily. Follow up included determination of various clinical and hematological parameters every two months. T-test for paired samples was used for statistical analysis Results: The iron supplementation improved the levels of Hb, Hct, MCV, MCH, and serum ferritin (p<0.05) as well as fatigue, lethargy, tachycardia, tachypnea, pallor, glossitis and cheilitis related to anemia. No adverse or side effects other than constipation and epigastric pain (in some cases) were observed. There was no statistical significant change in the levels of WBCs, PLTs, RBCs, and MCHC. Conclusions: The proteinsuccinylate iron is an effective, low cost, treatment of iron deficiency anemia during pregnancy with minimal adverse or side effects. In addition it may contribute to the prevention of severe anemia in pregnancy which may lead to severe growth retardation as well as fetal prematurity.

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FC3.10.05 PREGNANCY AND HEREDITARY SPHEROCYTOSIS A REPORT ON TWO CASES T. Tantanasis, P. Tampakoudis, K. Tsatalas, E. Vlachaki, D. Kelartzis, S. Mantalenakis, 1st Dept. OB/GYN, Aristotelian University of Thessaloniki, Greece. Objectives: As there is little information with regard to pregnancy complicated by hereditary spherocytosis (HS) we report on 2 patients with this disorder who had a total of 5 pregnancies. Study Methods: Particularly, patient I suffered from HS since early childhood; the course of HS was mild therefore no splenectomy was carried out. In her history, she had two 1st trimester abortions; lastly she presented with twin gestation complicated by hemolytic crises. At week 34 cesarean section was performed due to premature rupture of membranes; both newborns were clinically normal. Patient II underwent at age 10 a splenectomy. Her course was thereafter uneventful. She had two completely normal pregnancies and she delivered at term giving birth to two normal infants. Conclusions: Apart from the afore-mentioned report, it was a further target of the current article to deal with problems related to the coincidence between HS and pregnancy; therefore an overall review of the literature has been incorporated. FC3.10.06 ADMINISTRATION OF RECOMBINANT HUMAN ERYTHROPOIETIN (rHu-Epo) IN ANEMIC PREGNANT WOMEN E. Cardamakis, T. Hatzis, V. Tsapanos, N. Linardos, H. Mantouvalos, V. Tzingounis, Dept. OB/GYN, University of Patras, Rio, Mitera Maternity and Surgical Center, Athens, Greece. Objectives: The purpose of the study was to determine the effectiveness and safety of the rHu-Epo (Eprex, Janssen-Cilag) administration in anemic pregnant women. Study Methods: Pregnant women with Ht levels 30% at the 36th week of pregnancy were divided in two comparable groups (for age, Ht levels before delivery, and gestational age at delivery, p>0.1. Group A (n=85) received 200 iu/kgr rHu-Epo s.c. twice weekly 1600 mg iron protein succinylate per os (Legofer, Elpen) daily and Group B (n=80) received only the same dosage of iron. Hb and Ht levels were evaluated weekly, blood pressure daily. Moreover blood analysis was performed at the neonate blood units that were transfused, fatigue, weakness, headache, nursing problems, postpartum complication and side effects were record. Results: Table I. Ht Levels between the groups before and after treatment.
Eprex+Iron (Group) Ht 36th week Ht 38th week Ht at Delivery 28.48+5.8 (26.2+29.6) 30.67+7.41 (29.7-33) 33.54+2.85 (30-36) Iron (Group B) 28.94.4.8 (26.8-29.9) 27.4+5.95 (24-29.7) 30.10+3.43 (27-34) P 0.545 <0.001 <0.001

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acid complex (Inj-Jectofer) was given in first 50 cases 5 amps daily were given on tow consecutive days, but because of too much side affects in rest of 100 cases 3 amp IM was given daily. Side effect were evaluated. Results: Maternal mortality due to anemia for past 5 years was 30.8%, 27.6%, 57.1%, 6%, 12.7% respectively. 16.6%, 73.3%, 10% were suffering from severe, moderate and mild anemia respectively, 80% patients reported to hospital in 3rd trimester. Severity is more in multigravida, illiterate, lower socioeconomic group. Worm infestation is a major causative fator 87.9%. Malaria was present in 21.2%, 61.3% were suffering from hypochromic anemia. 100 cases who received 3 amps of Jectofer daily had minimal side effects like dry retching which was insignificant and required no specific treatment. Nausea and vomiting observed in later does only. Improvement seen on follow up was remarkable and encouraging with the average Hb% rise 4-6 gm%. Conclusions: In developing countries this may be one of the effective and acceptable method of treating anemic pregnant women to reduce maternal and neuronatal morbidity and mortality. FC3.10.08 THYROID HORMONAL PROFILE DURING PREGNANCY IN INDIAN WOMEN A.Kumar, N.Gupta, Maulana Azad Medical College, 13-B, Ber Sarai, New Delhi, Delhi, India, 110016. Objectives: The aim of the study was to evaluate the thyroid function during pregnancy. Study Methods: Sixty consecutively registered primigravidas were included. Pregnant women with known metabolic and/or medical disorders were excluded. Thyroid function tests, i.e., total triiodothyronine (T3); total thyroxine (T4) and thyroid stimulating hormone (TSH) were estimated by radioimmunoassay technique. Results: The mean age and weight of the subjects was 22 years and 55.34 kg respectively. Of these, 75% were using iodised common salt. Normal refrence ranges are - T3: 1.2 to 3.1 nmol/L, T4: 78.5 to 151.9 nmol/L, TSH: 0.5 to 5.0mIU/ml. The mean T3 values estimated were 2.05 nmol/L, 2.51 nmol/L and 2.92 nmol/L in the first, second and third trimester respectively. The mean T4 values estimated were 120.0 nmol/L, 168.47 nmol/L and 173.5 nmol/L in the first, second and third trimester respectively. The mean TSH values estimated were 1.67 mIU/ml, 1.96 mIU/ml and 2.98 mIU/ml in the first, second and third trimester respectively. Even though none of the patients were symptomatic, 5 (8.3%) were found to have elevated TSH. This suggests that they could be having asymptomatic hypothyroidism. Conclusions: A careful vigilance is required by the obstetrician to detect asymptomatic hypothyroidism during pregnancy, especially in iodine deficient areas. FC3.10.09 CORRECTION OF FETAL STATE IN PREGNANT WOMEN WHO UNDERWENT SURGICAL TREATMENT ON THYROID GLAND WITH SUPERIMPOSED PRE-ECLAMPSIA J.Davydova, V.Dashkevich, E.Mikhaylenko, Institute of Pediatrics, Obstetrics and Gynecology, 8 Manuilsky str, Kiev, Ukraine, 252050. Within 14 years after the radiation catastrophe in Ukraine we use to observe the trend to increase of fertile age patients number with different pathology of thyroid gland, which demanded the surgical intervention. One of the most spread complications in case of routine treatment of postoperative hypothyroidism is the early development of superimposed preeclampsia which leads to placental insufficiency and disorders of fetal well-being. According to this the advanced therapy of this pathology appears to be acute. Target. To study the efficacy of Sermion (Nicergoline, Pharmacia &Upjohn,USA) in patients underwent surgical treatment of thyroid gland with the gestation period complicated by superimposed preeclampsia. Materials and methods. We observed 28 women with total and subtotal resection of thyroid gland. We prescribed Sermion 30 mg per day within 14 days. We studied the levels of maternal estriol, placental lactogen in blood serum, time average velocity (TAV) and blood volume (Q) in uterine and funic arteries in color Doppler US before and after the treatment. Results. In pregnant women after the implemented treatment we managed to reduce the systolic blood pressure on 20,8 + 5,8 mm Hg, the

Table II. Clinical Conditions during Puerperium Eprex+Iron Iron P Anemia (Ht28%) 0 10 <0.001 Transfusions Fatigue 0 11 <0.001 Weakness 1 16 <0.001 Headache 4 12 0.021 Nursing Problems 3 13 0.004 Conclusions: Subcutaneous erythropoetin administration is rapidly effective in decreasing the risk of transfusions increasing the Ht levels and decrease the incidence of major maternal problems associated with anemia during puerperium.

FC3.10.07 EVALUATION OF THE EFFECT OF IM INJECTABLE IRON (BOLUS DOSE) IN ANAEMIC PREGNANT PATIENTS V. Agrawal, R. Agrawal, Dept. OB/GYN, G. R. Medical, Gwalior, India. Objectives: Anemia is a major cause of maternal mortality in India till today. The aim of the study is to investigate the effect and complications of IM perenteral iron (3 amp daily) in anemic pregnant patients. Study Methods: 150 patients were included in this study. Each patient was investigated for degree, type and cause of anemia. Inj. Sorbital citric

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diastolic - on 10,0 + 8,7 mm Hg. We stated the improvement of TAV and Q indices in uterine and funic arteries (p<0,05), the mild increase of estriol level in maternal blood serum. There was no evidence for significant increase of placental lactogen levels. Conclusions. Sermion implementation in pregnant women underwent surgical treatment of thyroid gland with superimposed preeclampsia and fetal hypoxia is efficient: resulting the reduction of resistance and spasm of vessels we managed to improve the maternal-placental blood circulation and to achieve the optimization of transport and endocrine placental functions.

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Results: FHR and FPO data from the FPO sensor will be correlated with FHR and auscultation data. Cord pH and Apgar scores will be compared to FHR and FPO showing determining sensitivity and specificity of fetal distress. All clinical decisions are based on FHR patterns and clinical judgement. All FPO saturations at or below 40% are discussed with the clinician, but at present there are no plans to use FPO for clinical decisions. This is an ongoing study approved and in progress at our hospital with promising results. Our latest data will be presented, particularly those cases that combine FHR and FPO, that reassure and predict fetal wellness as evidenced by neonatal exams and cord pH. FC3.11.03 FETAL PULSE OXIMETRY DURING LABOR WITH FETAL HEART RATE ABNORMALITIES. M. Butterwegge, Dep. OB/GYN, Marienhospital Osnabrueck, Johannisfreiheit 2-4, 49074 Osnabrueck, Germany Objectives: Routine electronic fetal monitoring intrapartum results in an increase of operative deliveries. Measuring fetal oxygen saturation (FSpO2) during labour is a new technique currently under development. Important points of all studies is the fetal condition at birth (Apgar, acidbase and neurological status) compared with oxygen saturation. Study Methods: Conventional FHR monitoring plus pulse oximetry (Nellcor,USA) were measured during labor in 189 cases. 67 scalp pH were indicated in times of non-reassuring or pathological FHR pattern. Simultaneous readings of FSpO2 and FBS obtained before birth were compared to the neonatal status. This study will demonstrate the relationship between the measured FSpO2 values and gold standard methods to assess fetal well- being, fetal blood sampling (FBS) and fetal heart rate (FHR) scoring. Results: At a 7.13 threshold for fetal scalp pH and 30% for fetal oxygen saturation the predicitive value of fetal pulse oximetry was similar to that of fetal blood analysis. Correlation was found between decrease of scalp-pH, the duration of low FSpO2 (p< 0.001) and depressed fetal outcome (p< 0.01).There were few cases of false positive and negative cases. Transient fetal saturation values < 30% are common during uncomplicated labor and did not predict fetal outcome. If prognostically unfavourable additional criteria with variable decelerations increase, a tendency towards decreasing FspO2 is recognisable. Conclusions: These data demonstrate that this new technique allows to reduce obstetrical interventions without altering neonatal outcome. In cases of reducing SpO2- levels during labor an association to fetal compromise and metabolic acidosis can be observed. FC3.11.04 GUIDELINES FOR THE USE OF FETAL PULSE OXIMETRY DURING LABOR AND DELIVERY. M.Khnert (1), M.Butterwegge (2), B.Seelbach-Goebel (3), G.C.DiRenzo(4), (1) University of Marburg, Pilgrimstein 3, Marburg, Hessen, Germany, 35033, (2) Marien Hospital, Osnabrueck, NDS, Germany, (3) University of Wuerburg, Wuerzburg, Bayern, Germany, (4) Universita Degli Studi di Perugia, Perugia, Italy. Objectives: FSpO2 monitoring of fetal oxygenation is an adjunct to conventional CTG monitoring and clinical assessment in cases of nonreassuring fetal heart rate. Study Methods: Fetuses in labor with pathological fetal heart rate pattern CTG plus FSpO2 monitoring of fetal oxygenation was done in four centers of Europe in appr. 1000 cases. Fetal scalp pH was checked for a baseline assessment, labor managed according to appropriate pH protocol. Results: The use of FSpO2 monitoring can resolve clinical uncertainty about the current state of fetal oxygenation. If the FSpO2 is > 30% the fetus is presumed to be adequately oxygenated at present. This does not exclude the possibility of pre-existing acidosis from a prior period of hypoxia. No additional scalp pH sampling is needed if the FSpO2 remains > 30%. If the FSpO2 remains below 30% for more than 10 minutes, fetal oxygenation may not be adequate and the fetus may be at risk for hypoxic injury. If fetal scalp blood sampling is easily and rapidly available, the impact of fetal hypoxia sufficient to cause acidosis may be confirmed with scalp pH. Conclusions: This paper provides guidelines for the use of fetal oxygen saturation by pulse oximetry (FSpO2) monitoring in clinical practice.

FC3.11 NEW APPROACHES TO FETAL MONITORING FC3.11.01 A NEW METHOD OF COMPUTER AIDED ANALYSIS OF COLOR CODED SONOGRAPHY OF THE HUMAN PLACENTA N. Kahn, H. Joern*, M. Baumann, S. Gerke*, J. Bosmann*, I. Wurdack, H. Schmid-Schoenbein, W. Rath* Institute of Physiology, Rhenish-Westfalian Technical University Aachen, Germany Department of Obstetrics and Gynecology, Rhenish-Westfalian Technical University Aachen, Germany* Objective: Starting from the hypothesis that IUGR represented flow inhomogeneity, we developed and validated a new method for computerized analysis of sonographic power Doppler data during the second half of the pregnancy. Materials and methods: The texture of flow distribution can be visualized using power Doppler sonography (Toshiba 270, data recorded using DVR-Sony). To extract this information, the time series were processed using a program of own design. In counting the color pixels in a given frequency range, allows to construct a power-time-diagram (water fall diagrams). Using arbitrary intensity units, the FFT of flow related signals are used to generate spectra. Results: Contrary to conventional haemodynamic rationale, high signal intensity was identified as sign of pathology: low signal intensity within the parenchymum was clearly identified as signum of physiological intervillous flow. Experiments corroborating this interpretation were performed with isolated human placenta specimen in vitro. This preliminary conclusion allows to interpret repetitive power Doppler signal during the course of normal and pathological placentae. In an informal clinical observation, the haemodilution resulted in augmentation and more homogenous distribution of low power signals, interpreted as success in avoiding perfusion mismatch. Using quantitative ratios (high power intensity/low power intensity), the rehomogenization can be quantified. Conclusions: Homogeneity analysis of power Doppler data allows to distinguish normally distributed and maldistributed intervillous blood flow: quantitative parameters not only allow to identify IUGR, but the success of a therapy. FC3.11.02 FETAL MONITORING BY A NOVEL NON-INVASIVE DEVICE FOR MEASURING OXYGEN SATURATION A.Hasenburg (1), D. Waterman (1), D. Vogelgesang (1), D. Siker (2), D.G. Kieback (1) (1) Dept. OB/GYN, Freiburg University Medical Center, Freiburg, Germany. (2) Dept. OB Scientific, Germantown, Wisconsin, USA. Objectives: Fetal heart rates (FHR) monitoring has been accepted for assessing fetal distress. However, FHR does not translate to specific abnormal patterns predicting cord blood pH. Attempts to incorporate intrauterine fetal pulse oximetry (FPO) or fetal oxygen tension were unsuccessful. This study will investigate the use of FPO compared to FHR monitoring. Maternal acceptance of the sensor, percentage of valid data acquisition times, and cord pH values will be analyzed. Study Methods: Paturients with labor of less than 30 minutes anticipated births will be monitored with a FPO sensor placed, during a vaginal exam via the cervix with intact membranes (preferably) against the fetal torso. Parturients with premature rupture of membranes, premature labor, low lying placenta, placenta praevia or abruption, vaginal bleeding, acute infection, polyhydramnios, oligohydramnios, fetal distress, uterine congenital abnormalities are excluded from the study.

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The guidelines were developed from the authors extensive clinical experience with an N400 fetal pulse oximeter during labor. continued. Current data of 1141 cases show a significant reduction of operative interventions in the CTG + ST arm (n=43) compared to the CTG arm (n=71), along with a reduction in the number of babies with metabolic acidosis (CTG + ST arm n=2, CTG arm n=11). Conclusion: These data confirm the results of the Plymouth trial and supports the ability of CTG + ST to safely reduce the number of operative interventions. FC3.11.07 INTRAPARTUM FETAL PULSE OXIMETRY (IFPO). THE TWO YEAR CZECH EXPERIENCE A. Roztocil, Dept. OB/GYN, Masaryk University, Brno, Czech Republic.

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FC3.11.05 THE RELATION BETWEEN METABOLIC ACIDOSIS AND FETAL ARTERIAL OXYGEN SATURATION DURING LABOR B. Seelbach-Gbel1, M. Khnert2, M. Butterwegge3, Dep. OB/GYN, University of Wuerzburg1, Marburg2, Marienhospital Osnabrueck3, Johannisfreiheit 2-4, 49074 Osnabrueck, Germany Objectives: The present study compares fetal arterial saturation (FSpO2) with the change of Base Excess (BE) and lactate concentration in fetal blood from one fetal blood sampling (FBS) to the next in order to find criteria to exclude or predict the development of fetal metabolic acidosis by fetal pulse oximetry during labor. Study Methods: FSpO2 was measured with an N-400 and FS 14-B sensor in 135 deliveries with pathological heart rate and FBS was performed to exclude pre-existing acidosis. The change of pH, BE and lactate concentration (LC) were calculated between two adjacent blood samplings. The duration of low (<30%), medium (30-60%) and high FSpO2 (>60%) was measured between adjacent FBSs and correlated to the change of pH, BE and LC by Spearmans correlation. ROC analysis was performed to define an critical threshold value. Results: A highly significant correlation was found between the decrease of pH and the duration of low FSpo2 (p<0.0001) and medium FSpO2 (p<0.01). The decrease of Base excess of the increase of Lactate were correlated to duration of low FSpO2. No significant decrease of pH (>0.05 pH unit) and BE (>3mMol/l) corresponding to an increase of Lactate concentration by more than 2 mMol/l was observed unless FSpO2 was < 30% for at least ten minutes. Conclusions: The development of metabolic acidosis seems predictable by intrapartum pulse oxi-metry measurements. No significant worsening of the acid base status and no significant increase of lactate concentration are to be expected unless FSpO2 is < 30% for at least 10 minute.

FC3.11.06 RANDOMIZED CONTROLLED TRIAL OF CTG VERSUS CTG + ST ANALYSIS OF THE FETAL ECG I. Amer-Whlin (1), K. Marsal (1), H. Noren (2), C. Hellsten (3), Swedish STAN Study Group (1) Dept. OB/GYN, University Hospital, Lund, Sweden. (2) Dept. OB/GYN, University Hospital, Gothenburg, Sweden. (3) Dept. OB/GYN, University Hospital, Malmoe, Sweden. Objective: ST waveform analysis of the fetal electrocardiogram during labor is validated as a new means to provide diagnostic information of the fetal condition. Basically, an increase in T wave amplitude identifies a situation where the fetus is utilizing its prime defense activation of the sympathetic system with enhanced myocardial performance and glycogenolysis. The opposite functional response is seen with ST segment depression (biphasic ST waveforms) negative T waves, thus indicating a fetus not capable of fully responding. The Plymouth trial (Westgate et al, Am J Obst Gynec, 169, 1151, 1993) focused on the ability of the then newly developed STAN system to safely reduce the number of operative interventions for fetal distress. This primary aim was fulfilled. Lately, refinements in digital signal processing has allowed much enhanced signal quality and automatic assessment of ST changes. It was therefore decided to conduct a second randomized trial of CTG only versus CTG + ST to verify the ability of CTG + ST to reduce the incidence of cord artery metabolic acidos (pH<7.05 and BDecf>12.0 mmol/l) and the number of operative deliveries for threatening asphyxia. Study Methods: Four Swedish labor wards were equipped with the new STAN system (Neoventa Medical, Gothenburg). Term singleton pregnancies were enrolled after a decision had been made to apply a single spiral scalp electrode. Clinical action was guided by conventional CTG interpretation and computerized ST waveform assessment (ST log). All ECG data was stored in both arms of the trial. After staff teaching and training the trial commenced in January 1999. Results: During the initial 6 months of the trial, obstetric management continued to be based on CTG rather than CTG + ST. Six cases with ST changes and subsequent metabolic acidosis at birth convinced the staff of the potential value in ST assessment and after retraining the trial

Objectives: The aim of the study was to evaluate the attitudes towards IFPO and its impact on perinatal results (decrease of C. Section rate) in 10 maternity centers. Study Methods: 18.8% of births in the Czech Republic in 1998 took place in the delivery wards disposing with IFPO monitor N-400. A questionnaire comprising 18 questions was sent to the heads of the maternity centers. None of them refused the collaboration. Results: (1) The manipulation with the machine: easy (60%), rather easy (40%) (2) The insertion of the sensor: easy (40%), rather easy (60%) (3) Indications for fetal SpO2 measurements: fetal hypoxia 277 (67.5%), stained amniotic fluid: 84 (22.0%), other indications: 30 (7.5%). Total 401 measurements. (4) Side effects-pain: 0, unpleasant feelings 0-100%, maternal, fetal injury and or infection:0 (5) Duration of insertion: 15-77 min, mean value 37.5 min (6) False negative results: 1 (0.3%), false positive results: 22(5.5%) (7) Decrease in C. Section rate from the indication of acute fetal hypoxia stated by means of CTG monitoring: mean value 50.3% (8) The attitudes of the health care providers towards IFPO: positive: 62.5%, rather positive 30.0%, rather negative 7.3%, negative 0. (9) The method is a positive contribution to the obstetrical practice: yes 90%, rather yes 10%, no 0. Conclusions: IFPO proved to be an easy method in the accurate diagnosis of acute fetal hypoxia and it decreased the C. Section rate performed from the indication of acute fetal hypoxia diagnosed by means of CTG tracing. It has no serious side affects and is well accepted by the patients and the obstetric ward staff. FC3.11.08 FETAL PULSE OXIMETRY (FPO) WAS OBTAINED 80% OF TIME DURING LABOR; CAN FPO REDUCE C-SECTION RATES? D. Siker+, J. Waters+, A. Lopez*, and O. Borre*, +Cleveland Clinic Foundation, 9500 Euclid, Cleveland Ohio, USA - 44195 *Department of OB/GYN University of Cartagena, Rafael Calvo Maternidad, Cartagena, Colombia, South America. Objectives: Our intrauterine fetal pulse oximetry (FPO) and fetal heart rate (FHR) studies at Rafael Calvo Maternity Hospital have now exceeded 150 births using a correlated FPO/FHR intrauterine sensor. In this study neonates most at risk for hypoxemia during labor and delivery were studied using a FPO/FHR sensor to assess maternal and physician acceptance of FPO. Study Methods pilot report of our most recent 7 parturients. Parturients in active labor and intact uterine membranes were selected because their FHRs were non-reassuring by auscultation and intermittent abdominal ultrasound (GE Logic1000). After informed consent, the FPO sensor was positioned beyond the cervix against the fetal torso away from the placenta. Results: Although labor analgesia was withheld, parturients reported minimal pain during insertion of the sensor. Labor duration was from 0.6 3 hours. No membranes were ruptured during placement of the sensor. Summary data (Mean Standard Deviation) was FPO% = 6611; FHR = 12926; lowest FHR = 7218; lowest FPO% = 4513. Significant FHR decelerations were noted in all patients but none had a FPO reading of less than 40% for any sample epoch. Six infants had complicated nuchal cords noted at birth. Patient # 7 was rushed to an emergent Csection with a FHR in the 60s with a mean FHR of 98 during a 40minute labor. However, since her FPO tracing was never below 65%,

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she was allowed to deliver vaginally in the OR. Her babys Apgar 1min.=9/ 5min.=9). Conclusions: With FPO data consistently present 80% of the time, cesarean section was avoided in this group. Maternal and physician acceptance of the current smaller sensor was excellent. In these parturients sensor placement was easy, with little discomfort, and with no episodes of bleeding, chorioamnionitis, or rupture of membranes; we are encouraged to expand our studies. To date (n=153) parturients with normal FPO (Sat%= 4580) have delivered normal infants. Four severely depressed babies in this cohort had extended (>3 minute) FPO epochs below 35%. FC3.11.09 ANTENATAL FETAL ECG MONITORING OUR HOSPITALS EXPERIENCE A Wong, SW Seng, GSH Yeo. Department of Maternal Fetal Medicine, KK Womens and Childrens Hospital, 100 Bukit Timah Road, Singapore 229899 Objectives: The aim of our study was to determine the efficacy of the non-invasive fetal ECG monitoring system in predicting an adverse pregnancy outcome in full-term low risk antenatal women. Study methods: 309 consecutive patients attending the Obstetric Day Care Center for cervical priming were recruited. The fetal ECG monitoring system was used to obtain an average ECG complex from an abdominal tracing. The mean and standard deviations of the ECG waveform was measured and calculated. Results: The occurrence of T wave inversion, ST elevation and T/QRS ratios was correlated against outcome measures such as the APGAR scores, neonatal special care and ICU admissions, and caesarean section or instrumental delivery for fetal distress. There was a statistically significant trend toward more neonatal special care admissions with poorer T/QRS scores. No significant difference was found in the occurrence of T wave inversion and ST elevation with neonatal outcomes. Conclusion: The fetal ECG provides a new avenue for research into antenatal fetal monitoring. Our study did not find the antenatal fetal ECG useful in predicting an adverse outcome in a low risk population. Further studies are needed to determine if it is a useful tool in the high-risk population. FC3.12 PREGNANCY AND LABOR FC3.12.01 FIVE YEAR REVIEW OF INDUCTION OF LABOR IN PATIENTS WITH A PREVIOUS LOWER SEGMENT CESAREAN SECTION A. Adolph (1), L. Brydon (2), J. Thiel (2) (1) Dept. OB/GYN, Royal University Hospital, Saskatoon, Saskatchewan, Canada. (2) Dept. OB/GYN, Regina General Hospital, Regina, Saskatchewan, Canada. Objectives: The study reviews the safety of the use of vaginal prostaglandin (PGE2) gel for induction of labor with a previous lower segment cesarean section (LSCS). Study Methods: We conducted a retrospective review of 877 patients delivering at the Regina General Hospital between January 1992 and December 1997. Patients with a previous lower segment cesarean section on spontaneous labor were used as controls. Five groups were analyzed; Spontaneous labor, Spontaneous labor with augmentation, Syntocinon induction, PGE2 induction, PGE2 induction requiring Syntocinon augmentation. Primary outcome measures include uterine rupture and/or dehiscence. Secondary outcomes include cesarean section, instrumentation, length of first and second stage and neonatal outcome. Results: PGE2 gel induction in patients with previous LSCS had statistically significant increase in uterine rupture and/or dehiscence (p<0.02), as well as increased cesarean section rate (p<0.04). Comparing PGE2 gel with Syntocinon for induction of labor, there was an increased rate of rupture/dehiscence when PGE2 was used, this was also statistically significant (<0.03). Conclusion: PGE2 gel induction in patients with a previous LSCS is unsafe. PGE2 gel compared with Syntocinon for induction also appears to be less safe. Syntocinon augmentation of spontaneous labor is less

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likely to cause a rupture than Syntocinon augmentation after PGE2 gel. If induction of labor is indicated, other methods should be considered.

FC3.12.02 MORE THAN ONE PREVIOUS CESAREAN SECTION DOES NOT EXCLUDE A TRIAL OF LABOR W.A. Spaans (1), L.M.E. van der Vliet (1), O.P. Bleker (1), E.A.M. Rell-Schorer (2), J. van Roosmalen (2), (1) Dept. OB/GYN, Academic Medical Center, Amsterdam, The Netherlands. (2) Dept. OB, Leiden University Medical Center, RC Leiden, The Netherlands Objectives: The aim of the study was to investigate pregnancy outcome of women with a history of multiple previous cesarean sections (MPCS). Study Methods: All medical records of women with a history of MPCS who gave birth during a 10 year period (1988-1997) in two large teaching hospitals in the Netherlands were studied. Results: During the study period 30, 132 women gave birth at the two centers, with a cesarean birth rate of 14.8%. there were 242 women with a history of MPCS: 188 (77.7%) delivered by elective repeat cesarean section, 54 (22.3%) had a trial of labor, of whom 45 (83.3%) had a vaginal birth. Women with recurring indication had less often a trial of labor than women with a non-recurring indication had less often a trial of labor than women with a non-recurring indication (OR 0.30; 95% CI 0.15-0.62). Three uterine ruptures occurred after previous lower segment cesarean sections without maternal or perinatal mortality; one during a trial of labor and a hysterectomy was necessary, one in a uterus bicornis planned for elective repeat cesarean, and one suddenly at 30 weeks pregnancy without any sign of labor. In the study group was no maternal mortality. Maternal morbidity did not differ between women with an elective repeat cesarean or a failed trial of labor. Women with a vaginal birth after cesarean needed less often a blood transfusion. Perinatal mortality was not related to the mode of delivery. Conclusion: An elective repeat cesarean section is not the only answer to a woman with more than one previous cesarean section. A trial of labor can be a safe option for a selected group of women.

FC3.12.03 IS THERE A RISK OF INTRA UTERINE FETAL DEATH IN UNCOMPLICATED SINGLETON POST TERM PREGNANCY? E.G. Tamale-Sali, Dept. OB/GYN, Ahmadi Hospital, Ahmadi, Kuwait. Objectives: The purpose of this study was to examine the hypothesis that there is a risk of intrauterine fetal death in uncomplicated post term pregnancy. Study Methods: This was a retrospective study involving 283 patients with uncomplicated singleton pregnancy. Only patients with a prior ultrasound scan for dating before the 20th week of gestation were included. During the same period, a study of all cases of intrauterine fetal deaths on or after the 28th week of gestation was also made. Results: In the post term group, the mean age was 27.1 (range 16-44), mean parity 2.9 (range 0-11). The mean fetal weight was 3539.5 mg (range 2130-5170 mg). The mean post term gestation was 298.5 days (range 295-325). The cesarean section rate for fetal distress was 7.4%, that for instrumental delivery 4.6%. Meconium stained liquor incidence was 24.7% and the induction rate was 13%. There were neither intrauterine nor neonatal deaths in this group. All the 115 intrauterine deaths that occurred in the other group happened prior to the 290th day of gestation. The mean fetal weight was 2248 (range 670-5150 mg). Most of the pregnancies had an associated complication. Conclusion: Post term in uncomplicated singleton pregnancy appear to have little or no risk at all of intrauterine fetal death. Therefore induction of labor in these patients should be based on other factors other than post term provided a good follow up is assured or is in place.

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FC3.12.04 EFFICACY OF DROTAVERINE AND VALETHAMATE BROMIDE IN ACTIVE MANAGEMENT OF LABOR B. Goswami, B. Goswami, M. Sarkar, B. Biswas, Dept. OB/GYN, Chittaranjan Seva Sadan College of OB/GYN, Calcutta, India. Objective: Shortening the duration of first stage of labor by reducing cervical resistance. Study Methods: Active management of labor was conducted in 300 demographically similar subjects divided into three groups of 100 cases each: Group 1: Oxytocin + Drotaverine Group 2: Oxytocin + Valethamate Bromide Group 3: Oxytocin alone (Control Group) Comparative analysis was carried out with regards to the rate of cervical dilation per hour, duration of first stage of labor, side effects and safety of the drugs on fetomaternal outcome. Results: In primigravid parturients, the rate of cervical dilation per hour was 2.71 1.41, 2.391.69 and 1.351.01 cm in Group 1, 2 & 3 respectively. The duration of first stage was 174.790.76, 196164.02 and 344.7257.28 minutes respectively. A similar trend was observed in multiparas. The difference between the values in Group 1 and 2 was not statistically significant, but that with Group 3 was highly significant. Conclusion Both Drotaverine and Valethamate Bromide were observed to accelerate the first stage of labor by enhancing cervical compliance. FC3.12.05 ACTIVITY OF HEXOKINASE GLUCOSE 6 PHOSPHATE DEHYDROGENASE AND GLUCOSE 6 PHOSPHOTASE IN PLACENTA FROM PATIENTS WITH RHEUMATIC HEART DISEASE E.E. El-Hassan, Maternity Hospital, Port Sudan, Red Sea State, Sudan. Objectives: The aim of this study is to investigate the activity of the enzymes: hexokinase, glucose 6- phosphate dehydrogenase and glucose 6 phosphate in placenta from patients with rheumatic heart disease after delivery. Study Methods: 62 patients with rheumatic heart disease (RHD) and 40 normal women were included in this study. Hexokinase activity studied by the method of Slein M. et al. (1950), glucose-6- phosphate dehydrogenase by the method Glock G. and Maclean p. (1953) and glucose-6-phosphotase by Swanson method (Swanson M.A. 1950). Nonorganic phosphate by Baginski method (1960, 1967) and protein content by the method of Ehersmann B. et al (1973). Enzyme activity expressed in micromole of reduced NADP for one minute per one gram of protein. Results: This study showed that the activity of the studied enzymes varies in a wide range. Four types of enzymatic changes have been noticed in placental homogenates from patients with RHD. Type I: characterized by normal hexokinase, significant increase in glucose-6-phosphate dehydrogenase activity and significant decrease of glucose 6- phosphotase. It was found in 22 patients with compensated (Ho) RHD. Type II: characterized by significant increase of hexokinase and glucose 6- phosphate dehydrogenase and more reduction in glucose 6phosphotase activity. It was seen in 18 patients with decompensated RHD (H1). Type III: This had been found in 15 patients with severe decompensation. (H2) and characterized by significant increase in the activity of the three studied enzymes, the increase is significant even if it is compared with type I and type II. Type IV: in this group the characteristic elevation of glucose-6phosphate dehydrogenase, seen in all other three types, was not only absent, but there was significant reduction of glucose 6- phosphate dehydrogenase activity. The gluscose-6- phosphotase remained normal while the hexokinase activity was raised. This type was found in only 7 patients, 3 of them were in Ho and 4 in H1. 5 out of the 7 patients had active rheumatism. Clinical analysis showed that complications of labor due to abnormal uterine contractility were more seen in patients with type III and type IV. Low birth weight and low Apgar score noticed mainly in patients with type III enzymatic changes. Conclusions: Hypoxia caused by heart decompensation and active rheumatic process seem to be the most important factors affecting the activity of the studied enzymes.

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Changes in glucose 6-phosphosphete dehydrogenase is the prominent feature of enzymatic disturbances which might have an impact on the generation of NADP essential for protein and hormone synthesis. Management of patients with RHD should aim to prevent cardiac decompensation and activation of rheumatism by prophylactic treatment. FC3.12.06 BIRTHS AND PERINATAL CARE IN FINLAND AND ESTONIA FROM 1992-1996 - CONVERGENT DIFFERENCES? H. Karro, Dept. OB/GYN, University of Tartu, 36 Lossi street, Tartu, Estonia, 51003; M. Gissler, National Research and Development Center for Welfare and Health, P.O. BOX 220, Helsinki, Finland, 00531; A.Tellmann, Institute of Experimental and Clinical Medicine, 42 Hiiu street, Tallinn, Estonia, 11626; E. Hemminki, National Research and Development Center for Welfare and Health, P.O. BOX 220, Helsinki, Finland, 00531. Objectives: The aim of the study was to describe the differences in childbearing, in maternal care and in perinatal outcome in Finland and Estonia. Study Methods: Registry study using the data from the Finnish and Estonian Medical Birth Registries for years 1992 to 1996 (in total 324 021 and 74 297 births respectively). Results: Compared with Finnish mothers, Estonian mothers were younger, had fewer multiple births, less prenatal care and fewer interventions during pregnancy and delivery. The intervention rates increased in both countries, but this increase was more rapid in Estonia. The infant outcomes were poorer in Estonia, but the differences between Estonia and Finland decreased during 1992 to 1996. Conclusion: Changes in maternal backgrounds and improvements in prenatal care and in availability of appropriate equipment and technology may have caused improved maternal and infant health in Estonia, but this should be further investigated.

FC2.12.07 MATERNAL AND PERINATAL OUTCOME IN PREGNANCY INDUCED HYPERTENSION J.D. Tank, D.K. Tank, A.M. Chati, E. Saldhana, P. Chikal, Ashwini Maternity and Surgical Hospital, Mumbai, India. PIH remains the single most obstinate cause of maternal mortality and morbidity. This is a retrospective study in which cases over the past 5 years are studied. Patients who satisfied the ISSHP criteria for the diagnosis of PIH were included in the study. Patients whose fetuses had congenital abnormalities, patients with multiple pregnancies, associated medical disorders like diabetes, etc., were excluded from the study. All patients had a uniform pattern of antihypertensive drugs (either alfa methyl dopa or nifedepine) administered depending on the severity of the PIH. The incidence of eclampsia in our study was 2.5% of all patients with PIH. All eclamptics were given magnesium sulfate as per the Pritchards regime. The main outcome measures studied are a) gestational age at delivery and mode of delivery, b) maternal morbidity and mortality, and c) perinatal morbidity and mortality. The outcome was also studied with respect to the regime used for eclampsia.

FC3.12.08 ANGIOPROTECTOR GINKOR FORT IN COMPLEX TREATMENT OF PREGNANT WOMEN WITH VARICOSE DISEASE AND PLACENTAL INSUFFICIENCY. B.L. Gurtovoy, N.V. Ordzhonikidze, Research Center of Obstetrics, Gynecology & Perinatology, Russian Academy of Medical Science, Moscow, Russia The objective of the study was to investigate the therapeutic efficacy of the angioprotective drug GINKOR FORT in treatment of varicosis of the lower extremities in pregnant women with infection of viral and/or bacterial etiology. Thirty patients in the III gestation trimester were included in the study. It was found that administration of GINKOR FORT (2 capsules x 3 times a day in the course of 30 days) provided elimination of varicosis symptoms, such as pain, heaviness, or discomfort in the lower extremities, nocturnal paresthesia, and cramps in most patients (96.6%). Tissue edema was also eliminated, which was manifested as significant

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decrease of medullar volume. Dynamics of hematological parameters, such as pO2, pCO2 and level of blood saturation with oxygen proved that oxygen-carrying function of blood was enhanced. Hemorheological status of the patients was normalized. US-investigation revealed improvement of blood circulation in popliteal artery, as well as in the blood vessels of mother-placenta-fetus system. Action of GINKOR FORT was not associated with any adverse side effects. Thus, the results of the study provided evidence that use of GINKOR FORT in treatment of varicosis in pregnant women with infection of viral and/or bacterial etiology is justified pathogenetically.

WEDNESDAY, SEPTEMBER 6
FC3.13.02 CHORIONIC VILLUS SAMPLING AFTER THE FIRST TRIMESTER. M. Podobnik, S. Ciglar, M. Podgajski, B. Gebauer, Dept. OB/GYN, University Hospital Merkur, Zagreb, Croatia Objectives: The purpose of this article was to evaluate the association between late CVS (placental biopsy) and complications between sampling and delivery. Study Methods: Late chorionic villus sampling under ultrasound guidance was carried out in 2600 (86,7 %) cases in the second trimester and 400 (13,3 %) cases in the third trimester of pregnancy. Out of 3000 late CVS, 684 (22,8 %) were performed because of suspicious ultrasonographic findings. In the 500 patients between 13 and 16 weeks of gestation color Doppler was used to investigate the uteroplacental and fetal vessels before and after late chorionic villus sampling. Results: In 24 patients (0,8 %), complications between sampling and delivery were found. There were only nine (0,35 %) spontaneous abortions four to six weeks after late chorionic villus sampling. We found 156 (5,2 %) chromosomal abnormalities. In the group with suspicious ultrasonic findings (684 cases) we found significant oligohydramnios in 300 (43,8 %) and significant polyhydramnios in 150 (21,9 %), and 105 (15,4 %) had chromosomal abnormalities. Among the 156 patients with chromosomal abnormalities, ultrasonographic findings in 85 (54,4 %) were detected after 20th week of pregnancy. There were no significant differences in mean pulsatility indices between uteroplacental and fetal vessels before and after late chorionic villus sampling. Preliminary data for twenty trisomic fetuses indicate an abnormally increased umbilical PI and abnormally decreased middle cerebral artery PI. Conclusions: Late CVS is a safe method of prenatal diagnosis for highrisk couples and does not significantly affect the outcome of pregnancy.

FC3.12.09 OUTCOME OF PROLONGED LABOR: A STUDY OF 100 CASES IN A PERIPHERAL MEDICAL COLLEGE HOSPITAL BANGALADESH R. Maliha, B. Mala, Dept. OB/GYN, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangaladesh. Objectives: To observe the causes and outcome of prolonged labor among the patients admitted with this problem in Mymensingh Medical College Hospital, Mymensingh, Bangaladesh. Study Methods: This study was undertaken in Mymensingh Medical College Hospital between January and December 1998. We defined prolonged labor as one lasting for more than 12 hours. All patients admitted with labor pain lasting for more than 12 hours were brought under this study. The aim was to study 100 cases. Results: The main causes of delay were due to abnormal uterine action 415, Relative fetal causes 40%, C.P.D. 11%, Absolute Fetal causes 2% and birth canal causes 7%. The mode of delivery of these 100 patients was cesarean section 40%, forceps delivery 21%, destructive operation 17%, spontaneous vaginal delivery 16%, internal podalic version 4%, breech extraction 2%. Maternal mortality was 3% and perinatal mortality was 21%. Conclusion: Prolonged labor is associated with high maternal and perinatal morbidity and mortality. It is a preventable condition since proper antenatal and intranatal care can prevent this problem in our country. Unfortunately, most of the pregnant women of our country do not receive any antenatal care; as well, a majority does not receive intranatal care either since only 6% of deliveries occur in hospitals. For this reason, prolonged labor still remains a major problem in our country. Proper antenatal and intranatal care needs to be implemented without delay to prevent these disasters. FC3.13 PRENATAL DIAGNOSIS FC3.13.01 PREGNANCY OUTCOME USING FETAL NUCHAL TRANSLUCENCY AT 10 TO 14 WEEKS E.Horner, W. Holzgreve, I.Hsli, S.Tercanli, Dept. OB/GYN Womens University Hospital, Basel, Switzerland Objectives: To evaluate the incidence of chromosomal and non chromosomal defects and the pregnancy outcome with the nuchal translucency (NT) measurement. Study methods: A prospective study with 1355 consecutive NT measurements between 10 and 14 weeks gestation with a crown-lump length (CRL) between 26 and 84 mm. Risk calculation was estimated with NT measurements in relation with maternal age and CRL (adjusted risk), and the outcome of all our cases was documented. Results: In 83/1355 (6,1%) cases NT was 2,5 mm (group A). Fetal karyotype was abnormal in 33 (39.8%) cases. In 8 cases with NT2,5mm and normal karyotype, other sonographic anomalies were detectable and confirmed postnatally (e.g. exencephaly, LCHADdeficiency). In fetuses with NT < 2,5 mm (group B) an abnormal karyotype was diagnosed in 2 cases (trisomy 21, ring chromosome 22) and 22 cases with non chromosomal abnormalities were detected. Analyzing our data an unfavorable outcome was seen in 49,4 % in group A, and 1,9 % in group B (p< 0,001). Conclusions: Our results confirm the most recent findings, that the NT is an important marker to detect chromosomal defects. Besides a high incidence of chromosomal anomalies there are frequently also other associated anomalies which justify a continuous sonographical follow up.

FC3.13.03 CHORIONIC VILLUS SAMPLING FOR PRENATAL DIAGNOSIS IN ZAGREB: EXPERIENCE WITH 3000 CASES M. Podgajski, M. Podobnik, Z. Duic, B. Gebauer, Dept. OB/GYN, University Hospital Merkur, Zagreb, Croatia Objectives: This study comprises data from 3000 women allocated to transcervical CVS (TC-CVS), transabdominal CVS (TA-CVS) and transvaginal CVS (TV-CVS). We have assessed the efficacy of transabdominal CVS compared with transcervical CVS and transvaginal CVS, and examined factors that have been implicated in causing spontaneous abortion. Study Methods: Over a ten years period 3000 women underwent chorionic villus sampling at 9-12 weeks of gestation, by transcervical, (500 patients) transabdominal (2400 patients) and transvaginal technique (100 patients). Transvaginal color Doppler was used to investigate the uteroplacental and fetal vessels in 500 pregnancies between 11 and 12 weeks of gestation (400 TA-CVS and 100 TC-CVS) before and after CVS procedures. Results: Five hundred (16,7 %) patients underwent transcervical CVS (TC-CVS) and spontaneous abortion after TC-CVS occurred in five cases (1,0 %). Two thousand and four hundred (80,0 %) patients underwent transabdominal CVS (TA-CVS) using a 20 gauge spinal needle and abortion after TA-CVS occurred in ten cases (0,4 %). One hundred (3,7 %) patients underwent transvaginal CVS (TV-CVS) using a 20-gauge needle and abortion after TV-CVS occurred in three cases (3,0 %). The spontaneous abortion rate after CVS procedures was 0,6 %. One hundred twenty (4,0 %) cases showed chromosomal aberration. The spontaneous abortion rate was lower among cases allocated to TA-CVS after 11 weeks of gestation. There were no significant differences in mean pulsatility indices (PI) between maternal, fetal and intraplacental circulation, before and after CVS procedures. Conclusions: Transabdominal CVS has lower fetal loss rate than transcervical and transvaginal CVS.

WEDNESDAY, SEPTEMBER 6
FC3.13.04 ANALYSIS OF FETAL DNA FROM A MATERNAL PERIPHERAL BLOOD BY LECTIN _ PCR - SSCP M. Shinya (1), A. Okamoto (1), M. Saitou (1), Y. Akiyama (2), H. Sagou (2), M. Kitagawa (2), T. Tanaka (1), (1) The Jikei University School of Medicine and National Okura Hospital, Nishi-Shinbashi 3-258, Tokyo, Japan, 105-8461, (2) National Okura Hospitak, Tokyo, Japan. Objectives: Fetal nucleated cells in maternal peripheral blood are noninvasive source of fetal DNA for prenatal genetic diagnosis. However, the number of fetal cells present in maternal peripheral blood is few. Therefore, fetal cell enrichment is generally considered necessary to allow detection and subsequent genetic analysis of the rare fetal cells. In this study, we performed fetal cell separation from maternal blood using galactose / galactosamine - specific Lectin to concentrate fetal nucleated red blood cells (FNRBCs) , and we also performed Polymerase Chain Reaction - Single Strand Conformation Polymorphism ( PCR - SSCP) for paternal diagnosis. Methods: Fetal cell separation was performed using galactose / galactosamine - specific Lectin on PV-LA coated slide. Approximately 20 cells consisting of a NRBC and its surrounding cells were collected using the Micromanipulator (NARISHIGE Co.) and the Laser micromanipulator (ZWEISS Co.). DNA analysis was performed using 2 STS markers (D13S270, D18S474) by PCR - SSCP. Results: A specific band was detected in mixed DNA at the concentration of 1: 20 by PCR SSCP analysis. Four out of 5 cases were informative at both or either at D13S270 and / or D18S474 loci (80%). Paternal specific bands were detected in all informative cases (100%). Conclusions : Lectin - Laser Micromanipulation - PCR - SSCP method may contribute the development of prenatal diagnosis.

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Study Methods: During the period November 1996 to November 1998, fetal nuchal translucency was measured on 2683 women between 10-14 weeks of gestation. Women were considered high risk if the calculated risk was greater than 1 in 100 or nuchal thickness was above the 95th centile for a given crown rump length. Second trimester (16 to 20 weeks) maternal serum biochemical screening (Triple test - Fetoprotein, b subunit of hCG and unconjugated estriol), was performed in women who opted to have second screening after negative nuchal scan. A serum screening risk of greater than 1 in 250 was considered high risk. Results: 74 (2.8%) women were referred to tertiary center for invasive procedure following high-risk NT results. Screening with nuchal translucency detected eight out of eight (100%) fetuses with Trisomy 21 and 13 of 16 (81%) aneuploid fetuses. The positive predictive value of NT in detecting Trisomy 21 was 10.9% with a false positive rate of 2.5%. 1057 women had a triple test as a further method of screening following negative NT scan. There was no case of Downs baby in this group. The positive predicative value of Triple test was 0% with a false positive rate of 4.3% (46 of 1057). Conclusion: The value of second trimester serum screening for Trisomy 21 in a population of women identified as low risk by NT screening remains unclear. The data presented do not refute a case for second trimester maternal serum biochemisty following a negative NT screen; however, they certainly do not prove that it confers any benefit.

FC3.13.05 FREQUENCY AND STRUCTURE OF FETAL ANOMALIES IN VORONEZH I. Tchembartseva, N Tchembartseva, Dept. OB.GYN, Voronezh Medical Academy, Voronezh, Russia. The widespread of fetal anomalies all over the world had led to its thorough study. According to Russian researchers, evidence of the frequency of fetal anomalies is between 1.5% to 3% and 25-26% of perinatal mortality is caused by it. Objective: Frequency study of fetal anomalies in Voronezh from 1995 to 1998. Methods: Retrospective clinic and statistical analysis of individual medical cards of the pregnants, deliveries and newborns from 1995 to 1998. Results: In 1995, fetal anomalies were detected in 12 newborns (0.7%), from the total amount of 1691 newborns, while in 1996 50 infants (2.4%) from 2073 newborns. In 1997, 1682 were born with 54 having fetal anomalies (3.2%), in 1998 55 newborns (3.3%) had fetal anomalies from 1688 newborns. The structure of the fetal anomalies was the following: Cardiovascular anomalies -35 newborns (63.6%); support-locomotion system anomalies 10 (18.2%); urogenital system anomalies 4 (7.3%); brancho-pulmonary system anomalies 1 (1.8%); gastrointestinal anomalies 1 (1.8%). Downs syndrome was observed in 2 cases (3.6%) and 2 (3.6%) newborns had multiple fetal anomalies. Conclusions: Fetal anomalies in Voronezh reveal a distinct tendency to be increasing. This indicates that the concerned problem is of crucial importance and needs a number of prophilactic measures to reduce the frequency of this pathology.

FC3.13.07 RISK FIGURE FOR FIRST TRIMESTER MATERNAL SERUM BIOCHEMICAL SCREENING FOR DOWN'S SYNDROME IN FINLAND. Marko Niemimaa*, Mikko Suonp1, Maija Seppl1, Antti Perheentupa*, Seppo Heinonen, Aimo Ruokonen1, Markku Ryynnen*. Departments of Obstetrics and Gynecology and Clinical Chemistry, Oulu* and Kuopio1 University Hospitals, Wallac OY, Turku, Finland Objectives. With the growing recognition of the frequency and importance of congenital disorders and with current social trends toward smaller families and delays in childbearing, prenatal diagnosis has an important role in the management of most pregnancies in the western countries. Both the mothers and the medical profession wish this testing could be carried out reliably already in the first trimester. We wished to set up Finnish medians for free b-hCG and PAPP-A, and nuchal translucency in the first trimester and determine the risk figure for trisomies at a 5% screen-positive rate. Study methods. Written informed consent was obtained from all women before being enrolled in the study. Blood samples were drawn in participating centers between the 10th and 14th week of gestation. Wallac analyzed serum samples. The laboratory was provided with the following patient information: date of birth, weight, first day of last menstrual period, gestational age by ultrasound (if available), diabetic status, use of insulin, and the number of fetuses. Serum samples were analyzed by Wallac and the adjusted estimated risk for Down syndrome was calculated using Wallac 1T program. Results. Serum PAPP-A and b-hCG concentrations were analyzed in 1,461 pregnancies. In the screenees, a total of 139 women (9.5%) had the adjusted estimated risk of at least 1 in 250 for Down's syndrome. The outcome of pregnancies in the all the women screened is not yet known. Until now one trisomy 21 and 18 has been identified. From these only the trisomy 18 was detected: both analytes were low, PAPP-A 0.6, bhCG 0.1 and NT 3.8 MoM ( the risk figure was 1:10). Conclusions. The risk figure at a 5% screen- positive rate is in Finland 1:120. The number of samples and known outcomes is still too small to figure out the Fp and Fn. The study is going on. We have now Finnish medians and the cut-off figure for invasive testing. Our aim is to further validate this form of prenatal screening of chromosomal anomalies during the first trimester.

FC3.13.06 SCREENING FOR TRISOMY 21: THE SIGNIFICANCE OF A POSITIVE SECOND TRIMESTER SERUM SCREENING IN WOMEN WITH LOW RISK NUCHAL TRANSLUCENCY SCAN A, Sau (1), K. Langford (2), B.Auld (3), D. Maxwell (2) 1) Dept. OB/GYN, Medway Hospital, Bromley, Kent, UK. 2) Dept. of Fetal Medicine, Guys Hospital, London, UK. 3) Dept. OB/GYN, Conquest Hospital, St.Leonard-on-Sea, UK. Objectives: To assess the efficacy of second trimester serum screening in detecting Downs syndrome in a population with a prior low risk NT (nuchal translucency) scan.

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FC3.13.08 MORPHOLOGIC OBSTETRIC ULTRASOUND INDICATIONS AND DIAGNOSTIC FINDINGS OF EXAMINATIONS PERFORMED IN A REFERENCE HOSPITAL F. Dib A. Berezowski, G. Duarte, R. Yano, F. Costa, S. Cuhna, Division of Fetal Medicine, High-Risk Prenatal Care and Ultrasonography, Dept. OB/GYN, Clinic Hospital of Ribeirao Preto Medicine Faculty, University of So Paulo, So Paulo, Brazil Objectives: To establish the profile of fetal abnormalities that exist in the population assisted at an Universitary Hospital. Study Methods: From January to December, 1998, 176 pregnants were referred to an Universitary Hospital to be submitted to a morphological obstetric ultrasound examination. Results: Most of fetuses were anatomically normal. The most common abnormalities were from central nervous system, followed by genitourinary tract abnormalities and multiple malformations. A complete table listing all diagnostics is available for presentations. Conclusions: Most of fetuses were anatomically normal. The most common abnormalities were from central nervous system, followed by genito-urinary tract abnormalities and multiple malformations. Under any suspected abnormality detected by routine ultrasound examinations the patient must be referred to a specialized center to confirm the diagnostic. Most of indications for morphological ultrasound had revealed normal fetuses, so this exam must be performed by well trained professionals only. According to many reports the central nervous system and the genito-urinary tract abnormalities were the most frequent.

WEDNESDAY, SEPTEMBER 6
FC3.14 PROLAPSE AND PELVIC FLOOR REPAIR FC3.14.01 SACROSPINOUS LIGAMENT FIXATION OF THE PROLAPSED VAGINAL VAULT FOLLOWING HYSTERECTOMY U. Aufderhaar, A. C. Almendral, W. Holzgreve, A. Dellas. Dept. Obstetrics & Gynecology, University Hospital, Basel, Switzerland Objectives: The purpose of this study was to assess the results of the sacrospinous ligament fixation for the treatment of vaginal vault prolapse following hysterectomy. Study Methods: Between 1979 and 1996 sixty-three women underwent a reconstructive operation due to vaginal prolapse following abdominal or vaginal hysterectomy. Sacrospinous ligament fixation was carried out in all women in combination with operative correction of either cystoand/or rectocele. Results: Recurrent vaginal prolapse occurred in only one woman 3 years after the operation. Temporary nerve damage was observed in two patients. Six women reported urine loss due to stress incontinence following sacrospinous ligament fixation. Conclusions: Vaginal vault suspension to the sacrospinous ligament avoids major abdominal surgery and allows the surgeon to correct coexistent cystocele and rectocele. Sacrospinous ligament fixation of the prolapsed vaginal vault should be carried out with colposuspension if a masked urinary stress incontinence is preoperatively detected. FC3.14.02 INDICATIONS, OPERATIVE TECHNIQUE, AND OUTCOME OF VAGINAL SACROSPINOUS COLPOPEXY: A PROSPECTIVE OBSERVATIONAL STUDY OF 230 CASES OF VAULT AND UTEROVAGINAL PROLAPSE M. Hefni, T.A. El-Toukhy, Dept. GYN, Benenden Hospital, Kent, UK. Objective: To identify the indications, determine the operative and long term follow up outcome of sacrospinous colpopexy and to demonstrate the safety of the technique. Methods: Between September 1993 and February 1999, 230 women underwent transvaginal sacrospinous colpopexy. 128 women (55.6%) had previously undergone one or more pelvic operation, 102 (44.%) had post hysterectomy vault prolapse, and enterocele was present in 172 (74.7%). Uterus was conserved in 36 women either because they were over 65 years old or in young nullipara. Patients data were collected prospectively at the time of initial recruitment, during hospital stay and at the end of each follow-up visit following surgery. Results: The main indications of sacrospinous colpopexy were vault prolapse, procidentia, second degree uterine prolapse if the vaginal vault remains at or bellow the hymenal ring at the completion of hysterectomy and as main management of enterocele. The mean blood loss was 82 ml (range 15 to 800). One patient (0.4%) had a rectal injury during dissection of the recto vaginal space. There were no incidental bladder or ureteral injuries. During the mean follow up period of 15 months there was 7 cases of recurrences vault prolapse , a success rate of 97%, 12 (5%) recurrent symptomatic cystocele, 33 (14%) asymptomatic cystocele. There was 6 recurrences of rectocele but only one was symptomatic. There was no recurrence of enterocele. All sexually active women were maintained there sexual function with adequate vagina except two women needed Fentons procedure. 43% reported improvement in sexual function one year after the operation. Fourteen women presented with symptoms of fecal incontinence, 9 (64.3%) women reported cure and 4 (28.6%) improvement of their symptoms. Conclusions: This study demonstrated the safety of the technique with variety of indications and high success rate. Vaginal sacrospinous colpopexy maintains the vaginal apex at its normal level, the normal anatomical angle of the vagina over the levator plate and the sexual function, it is very valuable technique to correct level I defects (Cardinal ligaments and paracolpium) and should replace the traditional vaginal hysterectomy and repair for procidentia and advanced utero vaginal prolapse.

FC3.13.09 FIRST-TRIMESTER NUCHAL TRANSLUCENCY AND SECONDTRIMESTER SERUM SCREENING FOR FETAL DOWNS SYNDROME Y.H. Lam(1), C.P. Lee(1), S.Y. Sin(2), H.S. Wong(3), R. Tang(4), M.H.Y. Tang(1), S.F. Wong(5), (1) Dept of OB/GYN, University of Hong Kong, Tsan Yuk Hospital, Hong Kong, China (2) Kwong Wah Hospital, Hong Kong, China (3) Princess Margaret Hospital, Hong Kong, China (4) Pamela Youde Hospital, Hong Kong, China (5) Tuen Mun Hospital, Hong Kong, China Objectives: The efficacy of second-trimester maternal serum hCG and AFP screening for fetal Downs Syndrome is well established. We investigated the use of first trimester screening by nuchal translucency (NT) either in isolation or in combination with maternal age and second trimester serum markers. Study Methods: All pregnant women attending the obstetric clinic before 15 weeks of gestation were recruited. An abdominal and/or vaginal ultrasound examination was performed at 10-14 weeks to measure the fetal crown-rump length, bi-parietal diameter and NT. The NT measurements were not disclosed and acted upon. All women had serum AFP and hCG test at 15-20 weeks. The risk of having a Downs syndrome birth was calculated taking into account the maternal age, weight, AFP and hCG level. Amniocentesis was offered if this assigned risk was 1:250 or if maternal age was 35. Results: Between January 1997 and February 1999, 13 453 women were recruited (25% 35 years of age). 656 defaulted the serum test at 10-15 weeks after recruitment and these were excluded from analysis. NT increased with gestational age and a log-linear model fitted the data well (NT median=100.0051x gestational day 0.2377). All the NT were converted to multiple of the median (MoM). Of the 12 717 pregnancies analyzed, 32 were affected by Downs syndrome. The log means and SDs of NT MoM for affected and unaffected pregnancies were 0.22, 0.18 and 0, 0.12 respectively. NT MoM was not correlated with age, AFP MoM and hCG MoM. At a false positive rate of 5%, the detection rate of Downs Syndrome by NT alone, NT + age, serum hCG + AFP + age and NT + serum hCG + AFP + age were 56%, 67%, 78% and 87% respectively. Conclusions: First trimester NT and second trimester AFP, hCG test can be used in combination to provide an effective method of screening for Downs Syndrome.

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FC3.14.03 PROPOSAL FOR A WORLDWIDE, USER-FRIENDLY CLASSIFICATION SYSTEM FOR PELVIC ORGAN PROLAPSE SE Swift, RM Freeman, E. Petri, U. Ulmsten. Standardization of Terminology Committee, International Urogynecology Association (IUGA) Objective: The IUGS standardization of terminology committee was approached by the International Federation of Gynaecologists and Obstetricians to review the current literature on pelvic organ prolapse classification systems and describe a simple, reliable and reproducible system that could be recommended for worldwide use. Materials and Methods: A review of the published literature on various prolapse classification systems was done to assess the current state of scientific study regarding various classification systems. We also developed and sent out a questionnaire to selected members of the International Continence Society (ICS) to query their opinions regarding several current systems in use. We asked whether or not they were using the pelvic organ prolapse quantification (POPQ) ICS system, the halfway system and the New York system. We also asked for comments regarding the use of the various systems. Results : In reviewing the literature, only the halfway system and the POPQ system had been investigated to determine their intra- and interexaminer reliability. They were both deemed reliable. Also, it was observed that the POPQ system is gaining recognition as the standard for scientific literature in studies regarding pelvic organ prolapse. The questionnaire results demonstrated that individuals were using a multitude of systems with no clear consensus. Only 20% of the members of ICS polled were using the POPQ system despite the fact that the ICS membership endorsed it as the standard pelvic organ prolapse classification system. The most common reason cited for not using the POPQ system was that there were difficulties in learning and teaching the complexities of this system. The committee then developed a simplified version of the POPQ that retained the ordinal staging system of the POPQ. The simplified version continues to require description of the anterior, apical and posterior segments of the vagina but only requires one point for each segment. Also, it allows for continued use of the familiar terms cystocele, rectocele, and enterocele. The proposed system is as follows: Stage 1: Prolapse that descends to within one centimeter above the hymenal remnants. Stage 2: Prolapse that descends to the introitus defined as one centimeter above or below the hymenal remnants. Stage 3: Prolapse that descends past the introitus but does not represent complete vaginal eversion or complete procidentia uteri. Stage 4: Complete vaginal vault eversion or complete procidentia uteri. Conclusion: There continues to be no consensus regarding a classification system for pelvic organ prolapse. There is a need for a simple, user-friendly classification system which will allow for accurate description of prolapse for physicians worldwide. The IUGA Standardization Committee proposes this simplified version of the POPQ system and recommends further study to determine its usefulness and reproducibility. FC3.14.04 HYSTEROSUSPENSION THROUGH ABDOMINAL APONEUROTIC FASCIA FLAPS AS CONSERVATIVE TREATMENT OF UTERINE PROLAPSE V Vavala, A. Monaco, E. Solima, G. Matonti, L. Muzii*, A. Scribanti Ob/Gyn Dept. Ospedale degli Infermi, Biella, Italy *Ob/Gyn Dept. Libero Istituto Universitario Campus Biomedico, Rome Italy Objectives: The authors describe a conservative surgical technique of hysterosuspension by means of flaps developed from the aponeurotic abdominal fascia in patients with severe hysterocele. Material and Methods: Forty-one patients, aged 26 to 41 years, underwent the technique described. Patients were followed for a mean period of 5.5 years to evaluate possible recurrence. No intra- or postoperative complication occurred. Results: All the patients were satisfied with the surgery. After a followup ranging from 2 to 23 years (mean : 5.5), only two patients necessitated further surgery, one for cystocele that developed three years after the initial procedure, and one patient underwent total abdominal hysterectomy for multiple myomas six years after the procedure. In two

41
patients, a normal intrauterine pregnancy was carried to term and delivered vaginally. Conclusions: The present series suggests that a conservative technique of hysterosuspension to abdominal fascia flaps can be offered to patients who express their desire of preserving the genital anatomy. The technique presented here appears to be safe and effective in the conservative treatment of genital prolapse. FC3.14.05 OPERATIVE MANAGEMENT OF POST-HYSTERECTOMY VAGINAL PROLAPSE AND INCONTINENCE G. Ohlenroth, M. Butterwegge, Dep. OB/GYN, Marienhospital Osnabrueck, Johannisfreiheit 2-4, 49074 Osnabrueck, Germany Objectives: Complete genital or vaginal prolapse affects a large number of middle aged to elderly females. Satisfactory correction of prolapse has been a challenge to the pelvic surgeon for many years and multiple operative vaginal or abdominal methods are described. Study Methods: A retrospective analysed examination was carried out in patients with posthysterectomy vaginal vault prolapse. Two hundred fourtyeight patients, aged 48 to 90 years (mean age 71), underwent abdominal fixation using Williams and Richardsons method and Burch procedure in cases of stress incontinence in 76 cases. Conjunction with enterocele repair (92 patients), vaginal hysterectomy (56 patients), or both (46 patients). Results: Two hundred eleven patients were followed up at a mean of 23.3 months (range 6.5 to 39). Recurrence of enterocele or vault prolapse occurred in 3 patients (1.2%; 3/248) All patients who had preoperative stress incontinence were cured of leakage. Complications were rare, and there were no instances of vaginal foreshortening, urinary retention, vaginal skin necrosis, bladder perforation, or rectovaginal fistula. Neither dyspareunia nor stress urinary incontinence were seen as complications of our procedures. The patients who were sexually active have begun having normal sexual intercourse again. Conclusions: Our survey confirms the information and the good result of this technique in the treatment of the total vaginal dome prolapse. The operation allows a secure fixation of the prolapsed-vault of the vagina with nearly optimal anatomic and functional restoration of the vagina. FC3.14.06 MORBIDITY OF ABDOMINAL, VAGINAL AND LAPAROSCOPIC HYSTERECTOMIES Mkinen J. et al., Department of Obstetrics and Gynecology, University Central Hospital of Turku, Turku, Finland Objectives: The aim of the study was to evaluate the influence of the type of surgery, abdominal, vaginal or laparoscopic, in causing or avoiding certain complaints is, however, controversial. Study Methods:We conducted a prospective nationwide study comprising all hysterectomies for benign disease performed in Finland during 1996. An evaluation of the operation-related morbidity, common surgical details, operative complications and short-term outcome up to 3 months were compared between the types of operation. Results: A total of 10110 hysterectomies, including 5875 abdominal, 1801 vaginal and 2434 laparoscopic operations showed a low rate of overall complications, 17.2 %, 23.3 % and 19.0 %, respectively. Between the three groups, the laparoscopic approach was associated with the longest operation time and the shortest hospital stay and sick leave. Infections were most common complications with the incidence of 10.5 %, 13.0 % and 9.0 % in the abdominal, vaginal and laparoscopic group, respectively. The most common type of infections was urinary tract infections with the highest rate in the vaginal group (7.3%). The most severe type of hemorrhagic events (intra-abdominal bleeding) occurred in 2.1, 3.1 and 2.7 % in the abdominal, vaginal and laparoscopic group, respectively. Ureter injuries had a predominance in laparoscopic group (RR 7.2 cf. abdominal) while bowel injuries were most common in vaginal group (RR 2.5 cf. abdominal). Surgeons who had performed over 30 laparoscopic hysterectomies had a significantly lower incidence of ureter and bladder injuries (0.5 and 0.8 %, respectively) than those who had performed 30 or less operations (2.2 and 2.0 %, respectively). A decreasing trend of bowel complications was seen also with increasing experience in vaginal hysterectomies. Conclusions: This large series of hysterectomies provide novel rates of morbidity that a gynecologist can face when performing either

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abdominal, vaginal or laparoscopic approach. It also proves the importance of the experience in reducing severe complications, especially in laparoscopic and vaginal hysterectomies. FC3.14.07 SURGICAL TREATMENT OF VAGINAL PROLAPSE AFTER HYSTERECTOMY V. D. Petrova, S.N. Buyanova, M.N. Ioseliani, A. A. Popov, Moscow Regional Scientific Research Institute of Obstetrics and Gynecology, Moscow, Russia. Objectives: To define the optimum methods of surgical treatment of vaginal prolapse after hysterectomy. Study Methods: We have operated on 65 patients because of the recurrence of prolapse. Of these 65, 24 developed recurrent prolapse after vaginal hysterectomy and 41 after abdominal. 27 patients suffered stress incontinence (tipe I-II of ICS). All patients were operated upon: aponeurotic vaginopexy (abdominal or laparoscopic approach). In 27 women, this operation was supplemented with Berchs operation. The restoration of the pelvic diaphragm was essential. Results: 3 years later, the results of the operation were satisfactory. 2 years later, the prolapse (rectocele) was recurrent in 5 patients (7.7%). Stress incontinence recurred in 3 patients, 2 years later (11.1%). Conclusions: The aponeurotic vaginopexy (or MESH-vaginaopexy) was the most effective method for correction of the recurrence of prolapse. It was obligatory for the patients with stress incontinence to be treated with a combination of operations.

WEDNESDAY, SEPTEMBER 6
Mayer with the application of the suturing device; 73 - after WilliamsonRichardson-Krasnopolsky technique with flaps aponeurosis; 54 - after ventrofixation of the cervix or vagina; 60 - after Manchester operation. The follow-up results showed the recurrence of prolaps in 1 patient after vaginal hysterectomy, in 2 patients after fixation with flaps aponeurosis and in 1 patient after ventrofixation of the cervix. All these patients underwent sacrocolpopexia with good results. The choice of surgical intervention in PU depends on the age, occupation, stage of the disease, concomotant gynaecological pathology, the presence of urinary incontinence. Our results lead to the conclusion, that the method of choice for PU of II-III stages for elderly patients is vaginal hysterectomy by Mayer, in young patients - is fixation (uterus, cervix, vagina) of flaps aponeurosis or sacropexia. For PU of I-II stages with elongation of the cervix Manchester operation.

FC3.15 TECHNIQUES IN CESAREAN SECTION FC3.15.01 COMPARATIVE STUDY: CESAREAN (CS) VERSUS VAGINAL DELIVERY (VD) - DOES A MODIFIED TECHNIQUE OF CS HAVE AN EFFECT ON MATERNAL MORBIDITY? D. Fauck (1), M. Naett (1), J.H. Ravina (2), (1) Dept. GYN, Clinique Sully, Maison Laffitte, France. (2) Dept, OB/GYN, Clinique Spontini, Paris, France. Maternal morbidity is known to be higher after CS than VD. The two major causes are infections and consequences of late mobilization due to wound pain. We have used a latero-vertical incision of rectus abdominalis fascia, which provides less pain and better port-operative comfort. In addition we have used an extraperitoneal technique as described by Norton to minimize the role of infection. During 36 months we performed 200 CS. Each CS was matched in a comparative study with the closest VD following or preceding. All CS and all VD were considered, without sub-groups. The studied factors were: blood loss, infection, analgesia, pain, intestinal passage, mobilization, and hospitalization. The result in our study shows that maternal morbidity and discomfort are not increased by extraperitoneal CS with vertical aponevrosis incision comparing to VD. FC3.15.02 IS CATHETRIZATION ESSENTIAL FOR CAESAREAN SECTION? H. Senanayake, University of Colombo, Kynsey Road, Colombo 08, Sri Lanka. Introduction: Catheterization of the urinary bladder is considered an essential safety precaution for caesarean section (LSCS). It may increase the risk of urinary tract infection (UTI) and discomfort to the mother. Objectives: To determine the feasibility and safety of performing caesarean section without urethral catheterization Method: The study was conducted in two phases. The first phase included 50 subjects who voided urine within an hour before elective LSCS. They were catheterized for the duration of surgery. The volume of urine collected in the bag at the time of entry into the peritoneal cavity (Volume A) and at the end of surgery (Volume B) was measured. In the second phase of the study 200 women underwent elective LSCS without catheterization. The degree of distension of the bladder was noted. Results: The average of volume A was 25.5ml. (SD= 11.4) and that of volume B was 42.8 ml. (SD= 24.3). These volumes could be contained in spherical spaces whose diameters are 4.0 and 4.8cm respectively. In the second phase of the study without catheterization, the bladder was not filled to be visible above the symphysis pubis in 129. In the other 71 it was visibly filled, but was completely covered by Doyen's retractor. None of the second group had UTI, damage to the bladder or postoperative urinary retention. Conclusions: During elective LSCS without a urinary catheter, the bladder does not distend to a volume that compromises ease of surgery or safety. Catheterization for LSCS as a routine is unnecessary.

FC3.14.08 SURGICAL TREATMENT OF PROCIDENTIA A. Y. Goldina, S. M. Semyatov, A. O. Dukhin, Dept. OB/GYN, Maternity Hospital N 25, Russian Peoples Friendship University, Moscow, Russia. Objectives: This study was undertaken to evaluate the effectiveness of surgical treatment of procidentia (P) in menopausal and postmenopausal women. Study Methods: During 1995-1999, 113 patients with P aged 62-91 years old were performed the Le Fort operation, which in some cases was combined by the reconstruction of the levator ani group. Results: Pre-operative investigation detected that all patients were not sexual active, 62 complained of sense of heaviness and foreign body in perineal area, 18 had difficulties with micturition and defecation and trophic ulceration was diagnosed in 58 women. There were marked various accompanying somatic diseases (arterial hypertension, bronchial asthma etc). Before operation all patients underwent thorough clinical investigation, received procedure improving the trophics of vaginal walls, got treatment of trophic ulceration and somatic diseases. 90 patients were operated on under epidural anaestesia.. In 23 women the Le Fort operation was performed in combination with levatoroplasty because of expressed incompetence of the pelvic floor muscles and it allowed to prevent the displacement of anterior wall of rectum in all cases. For long-term coaptation of wound surfaces the synthetic absorb suture were used. Postoperative period was uncomplicated in all patients. Follow-up (for five years) showed any no case of relapse of the disease. Conclusions: The Le Fort procedure especially carried out with the levatoroplasty is the optimal method of surgical treatment of P and provides the improvement of quality of life in menopausal and postmenopausal periods.

FC3.14.09 SURGICAL CORRECTION OF UTERINE PROLAPSE. G.Savelieva, L.Kappusheva, B.Baisova, Dept.OB/GYN, Russian State Medical University The prolaps of the uterus (PU) has makes up a significant portion among gynecological diseases. PU occurs not only in older age? but also in young women. Surgical intervention is the optimal method of tratment of PU. There have been suggested about 500 types of operations, but recurrence rate may be from 2,3 to 33%. Follow-up results of 427 patients operated on for PU (the age ranges from 31 to 82) have been analysed: 263 after vaginal hysterectomy by

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FC3.15.03 SINGLE LAYER CLOSURE OF CAESAREAN SECTION - A COMPARATIVE STUDY. E. Lodh, P. Bhattacharjee, Indira Gandhi Memorial Hospital, Krishnanagar, Agartala, Tripura, India Objectives: The aim was to introduce a safe simple and cost effective technique of Caesarean section. Study methods: The study was conducted at IGM Hospital, Agartala, India. In the study group 5000 women underwent Caesarean section in single layer closure technique and another 5000 cases (controlled group) had section in conventional method. Both the groups included primi and multi-gravida, elective and emergency cases with similar indications in same age group. Technique - A transverse skin incision is made 2.5 - 3 cm above the symphysis pubis. A nick is made in the rectus sheath which is stretched cranially and caudially. A hole is made with finger in the parietal peritoneum which is widened. Lower segment is incised. Delivery of baby and placenta done as usual. Uterine wound is closed in single layer with continuous unlocked suture. Visceral peritoneum is repaired. Parietal peritoneum is not stitched. Rectus sheath and skin are stitched as usual. Results: In the study group mean operative time is 23 minutes. Operative blood loss is minimal, IV fluid requirement is less, ambulation is earlier. Incidence of PPH, Postoperative pain and morbidity is much less and the hospital stay is shortened. Conclusions: Patients operated in this technique has faster post-operative recovery and are better able to take care of their babies. The single layer technique should be included in text book.

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Results: The mean (SD) operation time was shorter in the new method group as compared to standard method group, 14.55.5 minutes and 31.48.1 minutes, respectively (p<0.05). The postoperative morbidity is similar in both groups of patients regardless whether the operation was performed using the new method or the standard one. The mean (SD) hospital stay was similar, 5.12.5 days and 6.81.3 days, respectively (p=0.62). Conclusion: Both methods are equivalent in maternal morbidity. We emphasize the simplicity, efficacy, and safety of the new (Laniado) method for low isthmic transverse cesarean.

FC3.15.06 SINGLE-LAYER REPAIR OF THE UTERINE INCISION IN CESAREAN SECTIONS, A VERY SAFE AND TIME SAVING TECHNIQUE. C. Baruah, Dept. OB/GYN, OIL India Hospital, Duliajan, Assam, India. Objectives: The aim of this study was to assess the effectiveness of single-layer repair of uterine incision in cesarean section in both elective as well as emergency cases. Study Methods: Two hundred and fifty-six cesarean operations were performed using continuous locked single layer stitch using No. 1 polyglactin suture material to repair the uterine incision. Out of these 148 (57.9%) cases were emergency operations and 108 cases (42.2%) were elective. 190 cases (74.3%) were first cesarean, 40 cases (15.7%) were repeat cesarean, and 16 cases (6.3%) were repeat cesarean for the third time. Patients were discharged from hospital as early as 4 days to 10 days. Patients were observed for any fever, pain, signs of infection and particularly PPH and evaluated again at 2 weeks, 1 month and 3 month intervals when ultrasonography was done to see the uterine scar. Results: Out of 256 cases, only 2 cases (0.8%) had severe PPH which was treated conservatively. In the rest, the post-operative period was uneventful. 35 women conceived again within 6 months, in whom termination of pregnancy was done in 15 (5.9%) and 20 (7.9%) of the women had full term pregnancy. Out of them, 14 women (5.5%) went for repeat cesarean. In no case was there any weakness in ultrasonography or rupture of uterine scar. Incidence of placenta accreta was nil. Conclusion: Single layer repair of uterine incision in cesarean section is very effective which saves time without any short and long term complications.

FC3.15.04 SINGLE LAYER VS- TWO LAYER CLOSURE OF UTERUS DURING CAESAREAN SECTION AN INSTITUTIONAL EXPERIENCE B. Mukhopadhyay, Dept. OB/GYN, Calcutta Medical Research Institute, Calcutta, India. Objectives: Closure of a low transverse cesarean incision with one layer is associated with less per operative complications and post-operative morbidity compared with the traditional two-layer closure. Study Methods: A prospective randomized controlled study was performed in our institution during the period January 1997 to October 1999. A total of 412 women were randomized to closure of a low transverse cesarean section with one continuos layer of non-locking number 0 vicryl suture or two continuos layers with the first one locked. Preoperative and post-operative outcome were then compared. Results: A significant decrease in operating time and post-operative fabrile morbidity was found for the singe layer closure (p<0.01). No differences were found for operative blood loss or post-operative hysterographic evaluation of the scar. Conclusions: Continuous no-locking, single layer closure of the uterus is not only expedient but also promises a safer post-operative course.

FC3.15.07 EVALUATION OF MATERNAL MORBIDITY AND PERINATAL MORTALITY IN DIFFERENT TYPES OF CESAREAN SECTIONS A.A. Youssef, A.M.Sabra, N.M. Fahmy, H.A. Abdel-Hafize, Dept. OB/GYN, Assiut University Hospital, Assiut, Egypt. Objectives: The study was done to determine the relation of maternal intrapartum and postpartum complications and the newborn complications to the type of cesarean section. Study Methods: The study was prospective and included 400 pregnant women undergoing cesarean section (CS); 131 women (32.8%) had undergone elective CS (group 1); 239 women (59.8%) had undergone selective CS (group 2) and 30 women (7.5%) had undergone CS after neglected labor or failure of instrumental vaginal delivery. Results: Regarding the maternal intraoperative complications the incidence of intraoperative hemorrhage was 26% in group 3, 16% in group 1, 15% in group 2, the difference was statistically higher in group 3 than in group 1 and group 2. The incidence of postoperative maternal febrile morbidity and urinary tract infection in group 3 was statistically higher in group 3 than in group 1 and group 2. The perinatal mortality rate was 20% in group 3 compared to 11.4% in elective cases and 7.9% in selective cases, thus perinatal mortality rate in group 3 was significantly higher than in elective and selective cesarean section. Conclusion: Cesarean section carried out after neglected labor or after failure of instrumental vaginal delivery had significant maternal morbidity and perinatal mortality than elective and selective cesarean section.

FC3.15.05 COMPARISON OF NEW (LANIADO) AND STANDARD TECHNIQUE FOR LOW ISTHMIC TRANSVERSE CESAREAN S. Lurie, M. Feinstein, Y. Mamet, Dept. OB/GYN, Laniado Hospital, Netanya, Israel. Objective: To evaluate the efficacy and maternal morbidity of a new method for low isthmic transverse cesarean. The highlights of the new method are: Pfannenstiel incision, blunt expansion of subcutaneous tissue and the fascia, blunt expansion of subcutaneous tissue and the fascia, blunt opening of the parietal peritoneum, vertically, no intraperitoneal swabs, blunt expansion of the uterus, double layer closure of the uterus, nonclosure of visceral and parietal peritoneum, continuous non-locking suture of the fascia and nonsuturing of the subcutaneous tissue. Methods: The study group included all patients who underwent a first cesarean by new method during the 1998 (n=51). The control group included patients who underwent a first cesarean by standard method during the same year matched for age (within two years), parity (primiparous vs. multiparous) and gestational age at delivery (within one week) (n=51).

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FC3.15.08 MYOMECTOMY IN COURSE OF CAESAREAN SECTION Wojciech Kazimierak, Maria Brzozowska, Teresa PajszczykKieszkiewicz, Medical University of Lodz, Lodz, Poland The study was performed in the group of 144 women with uterine myomas delivered by cesarean section between 1986 and 1999 year. The study group was divided on three subgroups: the first one consisted of 22 cases of the uterine myomas, which were the only indications to the cesareansection because of pain, location making the normal delivery impossible, large size or necrosis confirmed by ultrasound; the second one consisted of 45women with small uterine myomas (to 40 milimeters in diameter) recognized during the pregnancy, who were delivered by cesarean section because of the other indications three subgroup consisted of 77 women with small size uterine myomas recognized in the course of cesarean section done because of the other indications (their location making an ultrasound detecting during the pregnancy impossible). The small size uterine myomas were enucleated as a whole. The large size uterine myomas were removed by progressive dismemberment - this method reduces the possibility of the intraoperative hemorrage. The good hemostasis was achieved fast owing to an application the continuous suture through all layers of the site of the myoma removal. The hemoglobine concentration in blood measured in the second twentyfour hours post operation, time of hospitalization following the operation and incidence of high temperature were compared with control group. No significant difference between these parameters in the both groups was confirmed. The myomectomy in the course of the cesarean section does not influence the incidence of the postoperative complications. This procedure seems to be of profit to the patients, because it allows them to avoid the next operation. FC3.15.09 CRITICAL ANALYSIS OF MATERNAL DEATHS FOLOWING CAESAREAN SECTION S. Sapre, S. Surana, Dept OB/GYN, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India Objective: The aim of the study was to investigate the causes of death after caesarean and suggest remedies to reduce the number of deaths. Study Methods 72 maternal deaths following caesarean from January 1994 to December 1998 were analyzed. Results: Out of 20 293 deliveries in K.R.H. 4646 (22.9%) delivered by caesarean section 0.72 (1.5%) died following caesarean section. On analysis, 90.3% unbooked, 97% from rural population and 93% emergency caesarean. Indications of operation were obstructed labor 29%, eclampsia 23%, sepsis 20.8%, anemia 20.8%, hemorrhage 8.3% and embolism 8.3%. Conclusion: Majority of deaths can be avoided by proper utilization of 3Es Essential antenatal care, early detection of complications and efficient emergency services, with creation of awareness of maternal health, safe delivery by trained person at periphery with prompt transport facilities, adequate blood transfusion. FC3.16 ABDOMINAL HYSTERECTOMY

WEDNESDAY, SEPTEMBER 6
hysterectomies were carried out by experienced surgeons, and at the end of surgery identical wound dressings were placed on the lower abdomen irrespective of hysterectomy route. Carers and patients remained blind to route of surgery until the day of discharge. The time of discharge was the primary end-point and was patient determined. Results There were no significant differences in peri-operative patient or surgical characteristics. Vaginal hysterectomy was associated with a reduction in hospital stay compared to abdominal hysterectomy (median stay 3 days vs 5 days, p < 0.01). In addition patients undergoing vaginal hysterectomy had reduced analgesic requirements (75.4 mg vs 131.4 mg morphine equivalent, p < 0.01), shorter need for intravenous hydration (25.3 hours vs 32.7 hours, p <0.05), and faster return of bowel action (median 3 days vs 4 days, p <0.001). They also returned to normal domestic activities (median 5 weeks vs 8 weeks, p = 0.03) and work (median 7 weeks vs 11.5 weeks, p < 0.01), and completed their recovery (median 8 weeks vs 12 weeks, p=0.02) more quickly. Conclusions: Vaginal hysterectomy is associated with significant benefits in terms of reduced hospital stay and improved patient recovery and as such should be considered the route of choice in the majority of cases.

FC3.16.02 CLOSURE VERSUS NON-CLOSURE OF PERITONEUM AT ABDOMINAL HYSTERECTOMY AND SHORT-TERM MORBIDITY: A RANDOMIZED STUDY A.W.M. Afify, M.E. Ibrahim, A.B.M Al-Nashar, Dept. OB/GYN, Banha University Hospital, Nasr City, Egypt. Objective: To compare closure and non-closure of the visceral and parietal peritoneum at abdominal hysterctomy with respect to short-term post-operative morbidity. Study Methods: Prospective controlled study included 86 women undergoing elective abdominal hysterectomy and were randomly assigned to one of three groups: visceral and parietal peritoneum open (Group A, n=34), visceral peritoneum open (Group B, n=24) or peritoneum closed as control (Group C, n=28). The main outcome measures were operative time, febrile morbidity, analgesia required, ileus, unassisted ambulance and hospital stay. Results: Population characteristics were similar between the three groups. The operative time of the study group A was significantly less than the study group B and control group C and the study data indicates that febrile morbidity was significantly related to operative time length. The control group C had non-significant less wound infection and dehiscence and urinary catheterization compared to the other study groups. The study groups A and B had less non-significant would hematoma, cystitis, ileus and blood transfusion compared to the control group. The study groups A and B had significantly less febrile morbidity compared to the control group and the mean number of analgesic doses required and time to oral intake were significantly higher in the control and study group B compared to study group A. Conclusion: Non-closure of the peritoneum at abdominal hysterectomy is advantageous and not associated with increased incidence of shortterm morbidity. So we advocate the use of the non-closure of the visceral and parietal peritoneum technique at abdominal hysterectomy which is simpler than the traditional peritoneal closure technique.

FC3.16.01 RANDOMISED, PROSPECTIVE, DOUBLE-BLIND COMPARISON OF ABDOMINAL VERSUS VAGINAL HYSTERECTOMY Tariq Miskry, A. Magos, NSW, Australia Objectives Although vaginal hysterectomy is feasible in the majority of patients undergoing surgery for benign indications, most hysterectomies world wide are done abdominally with the exception of cases of genital prolapse. One reason cited for this practice is a lack of controlled evidence in favour of vaginal surgery. We report a prospective randomised comparison of vaginal with abdominal hysterectomy in women suitable for either approach. Methods 36 patients attending the University Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK were recruited and randomised in the operating theatre immediately prior to surgery. All

FC3.16.03 RANDOMISED TRIAL OF TOTAL VERSUS SUBTOTAL HYSTERECTOMY: POSTOPERATIVE COMPLICATIONS. H.Gimbel, Dept.OB/GYN, Hvidovre Hospital,Denmark , V.Zobbe, B.Andersen, Dept.OB/GYN, County Hospital of Roskilde, T. Filtenborg, Dept.OB/GYN, County Hospital of Slagelse, K.Jacobsen, C. Srensen, K. Toftager-Larsen, Dept.OB/GYN, County Hospital of Hillerd, E.M.Madsen,Dept.OB/GYN, County Hospital of Gentofte, N.Mller, K. Sidenius, Dept.OB/GYN, County Hospital of Glostrup, A. Rosgaard, Dept.OB/GYN, County Hospital of Holstebro, M. Vejtorp, H.Clausen, Dept.OB/GYN, County Hospital of Herlev, B.Ottesen, A.Tabor, Dept. OB/GYN, Hvidovre Hospital, Denmark. Objectives: The aims of this study are to assess the effect of hysterectomy with and without conserving the cervix on postoperative complications, bladder, bowel and sexual function, pelvic pain, descensus of the vaginal top/cervix uteri, vaginal bleeding and psychological well-being.

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Study Methods: This multicenter Danish, randomized trial included women undergoing hysterectomy for benign disease from 1 April 1996 to 31 April 2000. The sample size was estimated as 320 women based on the assumption that subtotal hysterectomy reduces the incidence of urological complications by 10% (test of significance at 5% level, power 80%). The endpoints are postoperative complications, bladder, bowel and sexual function, pelvic pain, descensus of the vaginal top/cervix uteri, vaginal bleedings and psychological well-being. These are measured by validated, questionnaires filled out by the women before and 8 weeks, _ year, one, five and 10 years after the operation. Information about postoperative complications was collected by files filled out by the operating gynecologist. The automatic randomisation procedure was computer generated using block randomisation and stratification by center and ovarian status. An independent datamonitoring committee (DMC) has supervised the study. Their interim analyses regarding postoperative complications and urinary incontinence have not caused the study to be stopped. Results: As 300 patients have been included by 15 January 2000, recruitment for the study is estimated to be finished by May 2000. Data regarding the complications during the first eight weeks after the operation will be presented. Conclusions: present data from the first randomised trial of total versus subtotal hysterectomy. FC3.16.04 THE TECHNIQUE, SAFETY, AND COST-EFFECTIVENESS OF MINIMAL INVASIVE ABDOMINAL HYSTERECTOMY (MIAH) USING STANDARD LAPAROTOMY EQUIPMENT F. Lee, C. Gupta, Dept OB/GYN, University of Manitoba, Winnipeg, Manitoba, Canada Objectives: To demonstrate the technique, safety, and cost effectiveness of MIAH. Study Methods: One hundred and fifty-two women with non-malignant disease who were not suitable for vagina hysterectomy were included in this study. Hospital stays were compared with hysterectomies done by open laparotomy, vaginal and laparoscopic assisted vaginal hysterectomy (LAVH) techniques. Results: One hundred and twenty-seven women had TAH and 25 women had sub-total abdominal hysterectomy by choice. Spinal anesthesia was used in 122 women. The average weight of women was 69 kg with 40 women ranging form 80 to 160 kg. Sixty-five women had previous major abdominal surgery. Average weight of uterus was 183 grams, ranging from 44 to 1400 grams. Average surgical time was 54 minutes. No major complications encountered. Average length of hospital stay was 2.2 days compared to regional hospital stay of 4.4 days for abdominal hysterectomy, 3.5 days for vaginal hysterectomy and 2.7 days for LAVH. Conclusions: The technique of MIAH using standard open surgery equipment is safe, decreases patient morbidity and is cost effective. FC3.16.05 TOTAL LAPAROSCOPIC HYSTERECTOMY VERSUS TOTAL ABDOMINAL HYSTERECTOMY: A CONFRONT OF 101 VS 100 CASES IN A PROSPECTIVE RANDOMIZED STUDY G. Cucinella, G. Gugliotta, B. Adile, Dept. OB/GYN, Villa Sofia Hospital, Palermo, Italy. Objectives: In this prospective randomized study, 101 cases of laparoscopic hysterectomy (LH) were compared to 100 cases of the traditional abdominal hysterectomy (AH). Patients were enrolled in this study from January 1997 and September 1999 at our Dept. of OB/GYN, Villa Sofia Hospital. Materials and Methods: The criteria for choosing LH were generally based on uterus volume which should not exceed that of 18 weeks pregnancy. The indications were the same for both LH and AH included: abnormal uterine bleeding or menorrhagia in 30 pts, enlarged uterus with myomas in 60 pts, pelvic pain in 27 pts, abnormalities of pelvic floor in 15 pts and adnexal mass in 19 pts. The study was randomized and patients had given their informed consent to undergo either LH or AH. Blood loss during LH was calculated as the difference between the volume of liquid introduced and the volume of liquid aspirated during the operation. Post-operative pain was assessed in three days after surgery using the visual analogic scale

45
(VAS) from 0=no pain to 10=max pain. A temperature of 38C starting from the second post-operative day was considered as post-operative fever. The following parameters were also evaluated: post-operative drop of hemoglobin (Hb) complications, duration of post-operative stay. Results: The average time employed for LH was about 104.1 26.98 min (range 72-163). Average intraoperative blood loss was significantly lower in LH as opposed to AH, with lower first post-operative day Hb drop in the pts who underwent LH (table I). It was never necessary to convert LH to abdominal. Patients who underwent LH had less intense post-operative pain than pts in the group of AH (table II). Post-operative complications in the LH group were fever in one pt. And a ureteralvaginal fistula diagnosed 10 days after surgery in one patient, for which it was necessary to introduce a ureteral splint. In the AH two cases of hematoma of the vaginal cuff and 4 cases of fever. Table I : Comparison of post-operative results of laparoscopic and abdominal operations Parameters Laparoscopic Abdominal P value hysterectomy hysterectomy T test (No. pts: 101) (No. pts: 101) Age 47.8 7.42 47.6 7.39 P-ns Body weight 62.71 4.49 64.14 4.52 P-ns Parity 2.27 1.48 2.35 1.42 P-ns Uterine weight (gm) 368 125.3 389 143.9 P-ns Blood losses (ml) 140 41.5 406 103.9 P<0.001 Post-operative day 1 Hb drop (gm/ml) 0.37 0.22 1.59 0.35 P<0.001 Post-operative stay 2.38 0.30 6.23 1.85 P<0.001 Data presented as mean SD ns = non-significant Table II: The comparison of postoperative pain for laparoscopic and abdominal hysterectomy Post-operative pain (VAS) Laparoscopic Abdominal hysterectomy hysterectomy Day 1* 4.1 1.2 6.9 1.8 Day 2* 2.3 1.6 5.41.3 Day 3* 1.00.7 3.10.9 Data are presented as mean SD *P <0.001 Conclusions: This study has demonstrated that after LH pts. recovered faster, had less pain and the incidence of complications was low.

FC3.16.06 ROLE OF SUPRACERVICAL HYSTERECTOMY IN THE TREATMENT OF MENORRHAGIA V Vavala, A. Monaco, E. Solima, G. Matonti, Ob/Gyn Dept. Ospedale Degli Infermi, Biella, Italy Objectives: to compare intraoperative and postoperative outcome of supracervical hysterectomy Materials and Methods: Between 1997 and 1999, 253 women underwent hysterectomy for unresponsive to medical treatment of menorrhagia at Ob/Gyn Dept.of Biella hospital. Of these operations, 58.7% were performed by Supracervical Hysterectomy. The remainder, were performed either by total abdominal hysterectomy or vaginal hysterectomy. Comparative data of these surgical techniques concerning patients' characteristics, blood loss, operating time, hospital stay, uterine weights, postoperatively used analgesics, bladder and rectal dysfunction were recorded Conclusion Supracervical hysterectomy patients showed a statistically significant reduction of intraoperative and postoperative complication rate. Bladder dysfunction symptoms were more frequent in patients submitted to total hysterectomy either laparotomic or vaginal.

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FC3.16.07 FAST TRACK HYSTERECTOMY C.Moeller, H.Kehlet, L.Schouenborg, B.Ottesen, S.G.Friland, C.Lund, Hvidovre University Hospital, Hvidovre University Hospital, Hvidovre, Denmark, DK-2650. Objectives: The purpose of this prospective, descriptive study was to identify factors limiting early discharge after hysterectomy in a fast track setting with emphasis on information, treatment of pain, early mobilization and early food intake. Study design: 1) Thirty-two unselected women were allocated to either abdominal hysterectomy (n=16) or laparoscopically assisted vaginal hysterectomy (LAVH) (n=16). The patients received the same information, care, advice and restrictions for the perioperative period except for an assumed one-day hospital stay in the LAVH-group and two days in the abdominal group. 2) Thirty unselected women were assigned for abdominal hysterectomy in an assumed one-day hospital stay. Postoperative mobilization, gastro-intestinal function, length of stay, time for resumption of normal daily activities and work were registered. Results 1) Median hospital stay was 1 day (1-3) after LAVH and 2 days (2-4) after abdominal hysterectomy. Work was resumed after median 23 days in the abdominal group and after 28 days in the LAVH-group (NS). 2) Median hospital stay was 2 days (1-4). Work was resumed after median 19 days and leisure activities were resumed median 14 days after the operation. Conclusions: The study questions the proposed advantages of shortened hospitalization and convalescence after LAVH compared with abdominal hysterectomy, since a fast track setting reduced the need for hospitalization and convalescence. Further studies with active rehabilitation are needed to demon trate differences between laparoscopic and open hysterectomy.

WEDNESDAY, SEPTEMBER 6
Study Methods: One hundred and thirty women were included in this prospective study where surgery was successfully completed by minilaparotomy hysterectomy (Group A), thirty women of tubal recanalization and tuboplasty (Group B) and thirty women of surgery for ectopic pregnancy (Group C). Results: The mean operating time, day of mobility, starting normal diet and discharge from hospital were 45 minutes, 65 minutes, and 30 minutes; 18 hours, 12 hours, and 10 hours; 2 days, 1.5 days, and 1.4 days; 3.8 days, 3.2 days, and 3.1 days respectively in the three groups. Mean blood loss was 120 ml, 38 ml, and 375 ml and blood transfusion was required in 4, 0, and 24 cases respectively in the three groups. The post operative complications were fever in 5, 2, and 3 cases, paralytic ileus in 2, 0, and 2 cases, UTI in 4, 3, and 2 cases, urinary retention in 3, 2, and 1 cases and wound infection in 2, 1, and 2 cases respectively in the 3 groups. Conclusions: The minilaparotomy appears to be a safe and effective technique for various gynecological surgeries. FC3.17 DIABETES AND PREGNANCY FC3.17.01 INTRAPARTUM GLUCOSE-INSULIN INFUSION AND NEONATAL METABOLIC PROFILE IN GESTATIONAL DIABETES MELLITUS S. Ilic, L. Jovanovic, D. Pettitt, K. Hugo, Samsun Medical Research Institute, Santa Barbara, California, USA. Objectives: The main objective was to evaluate the impact of glucose and insulin infusion intrapartum in women with gestational diabetes mellitus (GDM) on neonatal metabolic outcome. Methods: Ten insulin requiring women with GDM received an intravenous glucose-insulin infusion throughout labor and delivery (Group 1) in order to achieve stable maternal glucose concentrations, and 31women did not (Group 2). Glucose control was followed by HbA1c and glucose profiles in all 41 GDM throughout pregnancy. At birth, glucose, C-peptide, insulin and leptin were measured in maternal and cord blood. Neonatal glycemia was followed for 24 hours after birth. Results: Both groups maintained excellent glucose control (HbA1c = 4.9 0.1, and 5.20.1, respectively for Group 1 and 2). At delivery, maternal glucose concentration was significantly lower (p=0.0018) in the Group 1 (94.84.1 mg/dl), than in the Group 2 (121.44.7 mg/dl). Cord glucose concentrations did not differ between groups, however, five neonates in the Group 2 and none in the Group 1 had hypoglycemia at birth (difference in proportions = 0.16, 95% confidence interval=0.030.29). Mean maternal and fetal C-peptide and insulin concentrations and maternal leptin did not differ between groups. However, 4 of 5 neonates who experienced hypoglycemia at birth had an insulin concentration of 2 or more standard deviation above the mean (in the range 26.99-35.39mU/ml). Neonatal cord blood showed higher leptin concentrations (t=1.8260, p=0.044) in the Group 2 (19.08 ng/ml) than in the Group 1 (12.51 ng/ml). No newborn in either treatment group demonstrated macrosomia, intrauterine growth restriction, or fetal abnormality. Conclusions: Even excellent diabetes control through pregnancy is not sufficient to prevent neonatal hypoglycemia and hyperleptinemia. Tight balance achieved during labor and delivery is equally important for achieving good neonatal metabolic outcome. In the presence of excellent antepartum glucose control, tight regulation of the intrapartum maternal glucose concentration will minimize neonatal hypoglycemia and hyperleptinemia. FC3.17.02 CAUSE OF FETAL DEATH IN MOTHERS WITH GESTATIONAL DIABETES I. Colon (1), D.Singer (2), K.Adamsons (3), (1) Harvard Medical School, 75 Francis Street, Boston, Massachusetts, United States, 02115, (2) Women & Infants Hospital, Providence, Rhode Island, U.S.A., Dep. of Obstetrics and Gynecology, San Juan, Puerto Rico, U.S.A. There is no scientifically validated explanation for fetal death in late gestation among diabetic mothers. We propose that fetal hyperinsulinemia causes structural changes in the fetal liver, which produces umbilical venous hypertension, thus resulting in edema of villi, and compression of the intervillous space (IVS). Initially the diminution

FC3.16.08 TRIAL OF OPEN VERSUS CLOSED VAGINAL VAULT IN RELATION TO POSTOPERATIVE MORBIDITY AFTER ABDOMINAL HYSTERECTOMY A.Anwer, Dept. OB/GYN, Military Hospital of Rawalpindi, Islamabad, Pakistan. Objectives: The aim of the study was to evaluate and compare the results of two surgical techniques of abdominal hysterectomy; closed vaginal vault with single layer interrupted stitches versus open vaginal vault with continuous locking stitch. Study Methods: A prospective trial was carried out at Military Hospital Rawalpindi Pakistan. One hundred and forty two total abdominal hysterectomies were carried out. Patients were observed for complications during the postoperative hospital stay and reviewed 4-6 weeks later. Results: In seventy cases (Group A), vault was left open while in seventy-two cases (Group B), it was closed. Post-operative abdominal wound infection was seen in five patients (7.1%) of Group A and in seven patients (9.7%) of Group B. Febrile morbidity was recorded in 3.2% (Group A) and 4.8% (Group B). Vault granulation was observed in 15% and 12% respectively. A single case of vault abscess was seen in closed vault subjects. Vault haematoma was detected in three patients of Group A (4.2%) only. Conclusion: This study failed to show any advantage with regards to postoperative morbidity improvement with either of the techniques. However, vault haematoma seen in cases with vault open impresses upon the fact that vault collections can still occur laterally. A careful & thorough homeostasis remains a must. FC3.16.09 MINILAPAROTOMY TECHNIQUES FOR VARIOUS GYNECOLOGICAL SURGERIES J.B. Sharma, Dept. OB/GYN, MAM College, New Delhi, India. Objectives: The aim of this study was to assess the feasibility and safety of minilaparotomy (incision up to 6 cm) for various gynecological surgeries.

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of the IVS perfusion is tolerated, because of the facilitated means of the fetus of anaerobic glycolysis, but ultimately the fetus dies of progressive hypoxia. To test this hypothesis, hyperinsulinemia was produced in 10 fetal Rhesus monkeys by implanting insulin ejecting micropumps between 113 and 120 days of gestation (term= 167 days). After 3 weeks the fetuses were delivered by hysterotomy. Three fetuses had died on day 19, 20 and 21. Organs were subjected to morphometric and histologic examination. The hyperinsulinemic fetuses, as compared to controls had 34% increase in body weight, 61% increase in liver weight, and 67% in placental weight. Examination of liver revealed extensive infiltration with erythroblasts, cytoplasm of hepatocytes partly filled with neutral fat, and reduction of portal vessels. There was marked diminution of the IVS due to crowding and edema of villi, and proliferation of the throphoblast. We conclude that structural changes in fetal liver, and increased proliferation of the throphoblasts, caused by hyperinsulinemia, are responsible for umbilical venous hypertension, edema of villi, and a progressive decrease in the perfussion of IVS, leading to fetal death.

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For IET, its sensitivity was 93.1%, its specificity was 89.1%, positive predictive value of 65.9% and negative predictive value of 98.3%. Conclusion: Among the three tests, MAP showed the highest specificity but IET showed the best sensitivity, positive as well as negative predictive values. FC3.17.05 PREGNANCY OUTCOME OF DIABETIC PREGNANCY IN A DEVELOPING COUNTRY L.A. Banu, Dept. OB/GYN, Birdem Hospital, Dhaka, Bangladesh. Objectives: Effect of good ANC and meticulous control of blood sugar improves the pregnancy outcome of diabetic patient to a great extent. Study Methods: In this retrospective study, patients delivered from January 1995 to June 1999 taken the total number of patients delivered was 2994 of which Diabetic were 1405 (47.7%) and non-diabetic (52.3%). Results: Vaginal delivery occurred in 988 (33.5%) patients of which diabetic were 364 (36.8%) and non diabetic 634 (63.2%) and cesarean section was done in 1956 *66.5%) patients of which diabetic were 1041 (53.2%) and non-diabetic 915 (46.8%) patients. Most of the patients were in 20-39 years are irrespective of diabetic or non diabetic. The promising part is fetal condition. The average fetal weight was 3.2 kg, death within 7 days was only 51 (5.8%) amongst 873 babies sent to SCABU (special care baby unit). Main fetal complication were hypoglycemia (57.2%), preterm (47.2), LGA (34.9%), Jaundice (28.9%). Congenital anormaly was about 5%. Conclusions: This study was compared with some studies in Jamaica, Norway, Mauritius, Poland and Barcelona. CS rate was 46.7% in Jamaica, 45% in Norway, 59.7% in Barcelona and 66.7% in Bangladesh study. Hypoglycemia was found more in present study. Other parameters were non-significant. From the above study it has been said that regular systemic ANC and meticulous glycaemic control and the delivery facility with special baby care unit, the pregnancy outcome is satisfactory.

FC3.17.03 HOW USEFUL IS GLYCATED HAEMOGLOBIN IN PREDICTING THE OUTCOMES OF DIABETIC PREGNANCIES? P. Scriven (1), R. Searle (2), P. Sinha (3), F. Fairly (4), (1) Rotherham General Hospital, Moorgate Road, Rotherham, Yorkshire, United Kingdom, (2) Northern General Hospital, Sheffield, Yorkshire, UK, (3) Conquest Hospital, St Leonards on Sea, East Sussex, UK, (4) Jessop Hospital For Women, Sheffield, Yorkshire, UK. Objective: Glycated haemoglobin is the common assay of glycaemic control in diabetes and is frequently used as an indicator of potential maternal and neonatal morbidity. This study assesses the usefulness of HbA1c in predicting pregnancy outomes of type one diabetic mothers. Study Method: A retrospective analysis of 126 pregnancies of type one diabetic mothers who delivered between 1 January 1986 and 1 June 1998 at Jessop Hospital and Northern General Hospital, Sheffield. Glycated Haemoglobin was determined using a Pierce & Warriner Glycotest IItm system with an interassay coeffiecient of variability 0f 0.6%. A mean value for glycated heamoglobin was determined using at least three measurements from at least two trimesters. Outcomes measured: birth weight, gestational age at birth, perinatal morbidity (measured as an overall score) and mode of delivery. In order to compare birth weights of all infants it was necessary to normalise for gender and gestational age to give a birth weight ratio. Results were analysed by linear regression and Students t-test. Results: No statistically significant association was found between glycated haemoglobin and birth weight ratio, perinatal morbidity or mode of delivery. Conclusion: Given the poor predictive value of glycated haemoglobin should we be using other methods of assessing the diabetic pregnancy?

FC3.17.06 GAS CHROMATOGRAPHIC MASS SPECTROMETRIC ANALYSIS OF URINARY SUGAR AND SUGAR ALCOHOLS DURING PREGNANCY. M. Tetsuo (1), C.Zhang (2), H. Martsumoto (3), J. Ishimatsu (4) (1) Dept OB/GYN, Tetsuo Hospital, Nagasaki, Japan. (2) Matsumoto Institute of Life Sciences, Kanazawa, Japan. (3) Mils Clinic, Kanazawa, Japan. (4) Dept OB/GYN, Kumamoto City Hospital, Jumamoto, Japan Objectives: Since carbohydrates metabolism during pregnancy is considered to be diabetogenic, our interest was concentrated on evaluating the metabolic deviation by assessing the excursion and fluxed of urinary sugar and sugar alcohols during normal pregnancy and pregnancy with abnormal carbohydrate metabolism. Study Methods: Subject included 353 women with normal pregnancies, 48 women with suspected abnormal carbohydrate metabolism as defined by urinary glucose values and 41 non-pregnant women served as control. After urease treatment of urine, trimethylsilyl derivative of glucose, sorbitol, fructose, myo-inosito and 1.5 anhydro D glucitol (1.5-AG) were quantified by using capillary gas chromatography-mass spectrometry computer system. Results: The urinary glucose level declined with statistical significance in the first trimester of pregnancy, and was unchanged in the second and third trimesters. Sorbitol level increased in the first trimester and steadily increased as the pregnancy progressed. Fructose and myo-inositol levels increased in the first trimester and remained unchanged in ht second and third trimesters. 1.5-AG level increased transiently in the first trimester and the declined. The compared to that in pregnant women (p<0.01), while concentrations of sugar alcohols are significantly higher in pregnant women (p<0.001 for sorbitol. Fructose, myo-inositol and 1.5AG). The level of each sugar and sugar alcohols in women with abnormal glucose metabolism increased and the standard deviation because wider with advancing gestation. Conclusions: The results suggest that the changes of the levels of urinary sugar and sugar alcohols may reflect a mild alteration in carbohydrate metabolism that goes undetected by conventional diabetic indicators.

FC3.17.04 THE PREDICTIVE VALUES OF THREE CLINICAL TESTS IN PREDICTION OF GESTATIONAL HYPERTENSION N. Zainal Shah, I. Abdul Samad. N.N. Aung, Dept. OB/GYN, University Hospital, Sains Malaysia, Seremban, Malaysia. Objectives: To determine the predictive values of three clinical tests, namely, roll over test (ROT), mean arterial pressure (MAP) and isometric exercise test (IET) for predicting gestational hypertension. Study Methods: This was a hospital-based survey involving 158 pregnant women. Each woman had all three clinical tests performed on her. Then they were followed up by their own obstetricians. Neither the patients nor their obstetricians were aware of the results of these tests. Data on outcome of their pregnancies were collected only after their deliveries. Using 2x2 table, predictive values for gestational hypertension were calculated for each test. Results: Out of 158 pregnant women, 129 were normotensive, 27 had gestational non- proteinuric hypertension and 2 had gestational proteinuric hypertension. None of them developed gestational proteinuria or eclampsia. For ROT, its sensitivity was 55.2%, its specificity was 78.3%, positive predictive value of 36.4%, and negative predictive value of 88.6%. For MAP, its sensitivity was 41.4%, its specificity was 94.6%, positive predictive value of 63.2%, and negative predictive value of 87.8%.

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FC3.17.07 CORRECTION OF SPECIFIC AUTOIMMUNE DISORDERS FOR PREGNANT WOMEN WITH DIABETES MELLITUS V. Petrukhin, T. Budikina, F. Burumkulova, A. Poletaev. V. Gurieva, N. Volkova, Moscow Regional Scientific Research Institute of OB/GYN, Moscow, Russia Objectives: As shown in our previous experiments, for diabetic women is characteristic the increased levels of insulin (AT-1) and its receptors (AT-2) antibodie3s. These antibodies, linking the factor of growth of nerves, conduct to the disturbances in the nervous system of a fetus and newborn. The aim of our work was estimate the efficiency of different methods of correction of these autoimmune disorders and improving the pregnancy outcome. Study Methods: 126 diabetic pregnant women with increased serum levels of AT-1 and AT-2 (measured by an original method on a basis of immunofermentic assay) were divided into 4 groups depending on a kind of received treatment. 42 pregnant women received the heparinum inhalation, 28 system enzymotherapy (wobenzym), 26 the specific desensitizing therapy by insulin and 30 only strictly metabolic control. Results: The management of heparinum and wobenzym has resulted in a decrease of the serum contents of AT-1 and AT-2 on 60-65% from initial levels. Usage of insulin as specific desensitizing therapy also has resulted in a decrease of studied antibodies on 62%. In group with only strictly metabolic control the levels of antibodies significantly did not vary. The positive influencing of selected methods of therapy on gestation and neurological status of newborns is marked. Conclusions: The therapy, lowering specific serum immunoreactivity in diabetic pregnant women, allows to achieve the better outcome of pregnancy for fetus and newborn and to optimize tactics of management.

WEDNESDAY, SEPTEMBER 6
FC3.17.09 HAVING INSULIN THERAPY IN INADEQUATE GLUCOSE TOLERANCE S. Djordjevic, M. Gojnic, S. Petkovic, T. Mostic, University of Belgrade, Clinical Centre of Serbia, Institute for Gynecology and Obstetrics, Belgrade, Yugoslavia. Objectives: The aim of this study was to present the necessity of making frequent test of glucosae intolerance in high risk pregnancies. Study Methods: Last year we started to make routine repetition of oral glucosae tolerance test (OGTT) in pregnancies. We looked after postpranduial glicemia in all women. We made the diabetic diaet and in some cases insulin therapy. Results: In 81.25% (13 women of the 16 examined) the test was pathological at the end of the second trimester, and in the first one it was normal. In 76.9% of pathology second test, we gave insulin to future mothers and in only 23% diabetic therapy was adecvate. Conclusions: We wanted to suggest that the necessity of routine repeated OGTT, in cases when it was normal in first trimester and a more frequent use of insulin in those cases.

FC3.18

ENDOMETRIAL AND OVARIAN CANCER PROGNOSTIC MARKERS

FC3.17.08 ASSOCIATION BETWEEN GLYCOSYLATED HEMOGLOBIN IN THE FIRST TRIMESTER OF PREGNANCY AND MAJOR FETAL MALFORMATIONS V. Mazneikova, S.Ivanov, K.Todorova, P.Popivanova State University Hospital of Obstetrics and Gynaecology Maichin Dom, Sofia, Bulgaria Objectives: The aim of the study was to evaluate the incidence of major congenital malformations among unselected pregnant women with insulin-dependent diabetes mellitus and to determine whether a consistent association can be demonstrated, after adjustment for maternal age and White classification, between glycosylated hemoglobin (HbA1c) values in the first trimester of pregnancy and fetal outcome (major malformations). Study Methods: The retrospective study comprised 180 unselected pregnancies complicated with pre-existent insulin-dependent diabetes mellitus admitted to the High Risk Pregnancy Department between 1995 and 1999. The patients were referred from regional hospitals which did not fulfill the guidelines for the management of pregnancy in diabetic women. Only 2% of pregnancies were planned. All diabetic patients had HbA1c determinations in the first trimester of pregnancy. Women with gestational diabetes were excluded from the study. Results: Among 180 pregnancies, 121(68%) resulted in a liveborn infant, 27 (15%) aborted spontaneously, five (2%) resulted in stillbirth, and 27(15%) were terminated. Of the terminations, twenty were for congenital malformation. The prevalence of congenital malformations varied between 13 and 15% compared with 2% in the general population. Relative risk calculations indicated a highly significant and consistent correlation between HbA1c values above 7% and major fetal malformations after adjustment for differences in maternal age and White classification. Conclusions: In an unselected population the infants of women with preexistent insulin dependent diabetes mellitus have a 6-8-fold greater risk of a congenital malformation than infants in the general population. Our data support a clinically significant and consistent relationship between fetal malformations and HbA1c in the first trimester of pregnancy of mothers with pre-existent insulin-dependent diabetes mellitus.

FC3.18.01 ASSOCIATION OF CYCLIN D1 GENE (CCND1) POLYMORPHISM AND CLINICAL OUTCOME IN EPITHELIAL OVARIAN CANCER K.K.Dhar, R.E.J.Howells, C.W.E.Redman, P.W.Jones, R.C.Strange, A.A.Fryer, P.R.Hoban. Centre for Cell and Molecular Medicine, University of Keele School of Postgraduate Medicine, North Staffordshire Hospital, Stoke-on-Trent, UK, Department of Obstetrics and Gynaecology, City General, Stoke-on-Trent, UK, Department of Mathematics, Keele University, Staffordshire, UK. Objectives: The cyclin D1 gene (CCND1) contains a frequent polymorphism (A/G substitution) within the splice donor region of exon 4. CCND1 Genotype is associated with clinical outcome in non-small cell lung cancer and squamous cell cancer of the head and neck. In this study we investigate the influence of CCND1 genotype on clinical outcome in 138 women with epithelial ovarian cancer. Study Methods: CCND1 genotypes were identified from peripheral blood DNA by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) analysis. Patients CCND1 genotypes were compared with clinical details, tumour characteristics, response to chemotherapy, progression free interval and survival data. Results: The frequency of CCND1 genotypes in the cases and 191 unrelated women controls were similar (p=0.29). We observed no correlation between the genotypes and FIGO stage, amount of residual tumour, differentiation and histological type of the tumour and response to chemotherapy. There was no significant difference in overall survival and progression free interval (PFI) among patients with different genotypes. Analysis of data from patients who responded to postoperative chemotherapy revealed that women with CCND1 AA genotype was associated with early disease progression (p=0.020, HR 4.58, 95% CI 1.27-16.48) and reduced survival (p=0.026, HR 4.48, 95%CI 1.19-16.79) compared to that of CCND1 AG and GG genotypes. Conclusion: These data show that CCND1 genotype does not influence overall prognosis in epithelial ovarian cancer, however, it is associated with disease progression following initial response to chemotherapy.

FC3.18.02 TYPE III AND TYPE I COLLAGEN METABOLITES AS PREDICTORS OF PROGNOSIS IN OVARIAN CANCER M. Simojoki*, M. Santala*, J. Risteli**, L. Risteli**, A. Kauppila* * Dept. OB/GYN, Oulu University Hospital, 90220 Oulu, FINLAND **Dept. Clin. Chemistry, Oulu University Hospital, 90220 Oulu, Finland Objectives: The aim of the study was to investigate the usefulness of aminoterminal propeptide of type III procollagen (PIIINP) and carboxyterminal telopeptide of type I collagen (ICTP) in relation to CA 125 in predicting prognosis of ovarian cancer patients. Study methods: Fifty-six women with epithelial ovarian cancer were studied through PIIINP, ICTP and CA 125 determinations from serum samples collected before operation and three, six, nine and 12 months

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after operation. The follow-up time was three years. The patients were divided in two groups: patients who were alive three years after the surgery, and patients deceased. The variables were compared using the Mann-Whitney U-test, c_-test and multivariate Cox regression analysis. The survival analyses were carried out using the Kaplan-Meier method. Results: Before the operation the frequency of high serum PIIINP (P=0.034) and ICTP (0.002) concentration was significantly higher of the patients with a poor prognosis than of the patients with a good prognosis. This did not apply to the CA125 (0.2029). At nine and 12 months, there were significantly more patients with high PIIINP (P= 0.007, = 0.005, respectively), ICTP (<0.0001, =0.0005) and CA125 (=0.007, =0.0001) concentrations in the group of poor prognosis than in the group of good prognosis. In the Kaplan-Meier survival analysis, the preoperative, nine-month and 12-month PIIINP (P= 0.0422, =0.0062, = 0.0062, respectively) and ICTP (P= 0.0004, <0.0001, = 0.0005) concentrations distinguished the patients with good prognosis from the patients with poor prognosis, while as to the CA125, the difference could only be seen at the nine- and 12-month follow-up (P= 0.0003, =0.0004). In the multivariate analysis on preoperative specimens, the ICTP was the only independent and significant determinant of the clinical outcome of ovarian cancer. Conclusions: The preoperative PIIINP, and the ICTP in particular, are better than the CA 125 in the prediction of clinical outcome in ovarian cancer, whereas during the year following the operation these variables complement each other in this function. FC3.18.03 IMMUNOCYTOCHEMICAL LOCALISATION OF SOMATOSTATIN RECEPTOR SSTR1 AND SSTR5 EXPRESSION IN OVARIAN TUMORS G.H. Hall (1), L.W. Turnbull (1), I. Richmond (2), L. Helboe (3), S.L. Atkin(4) (1) Dept. Radiology, University of Hull, Hull, UK. (2) Dept. Histopathology, Castlehill Hospital, Cottingham, UK. (3) Dept. Medical Anatomy, The Panum Institute, Copenhagen, Denmark (4) Dept. Medicine, University of Hull, Hull, UK. Objectives: The potential role for antiangiogenic compounds in therapy of ovarian tumors has been suggested by the relationship between vascular endothelial growth factor expression and poor prognosis. Somatostatin analogues are a group of antiangiogenic compounds already in clinical trials in other malignancies. This study aims to examine SSTR1 and SSTR5 expression in ovarian tumors. Study Methods: Archival specimens of 28 ovarian tumors of mixed histological type were dewaxed, microwaved, blocked and incubated with rabbit polyclonal antibodies raised against SSTR specific peptides. Signal was amplified with biotinylated tyramide and visualized by the HRP-StrepABC method with DAB. Staining was graded by intensity independently by two observers. Results: 18/28 (64%) tumors showed strong or medium staining of epithelium or stroma, for either one or both SSTR1 and SSTR5. Strong epithelial staining was demonstrated with both SSTR1 and SSTR5 in 4/28 (14%) patients and for either SSTR1 Or SSTR5 in 9/28 (32%) cases. Stromal staining occurred in 6/28 (21%) of cases which was subjectively stronger for SSTR1. 4/28 (14%) of specimens showed moderate staining of intratumoral vessels with SSTR1 and none showed similar with SSTR5. 10/28 (36%) tumors showed either mild or no staining. Conclusions: Over 50% of ovarian tumors demonstrate expression of either SSTR1 or SSTR5. This indicates a potential role for somatostatin in the molecular biology of ovarian carcinoma, and a potential role for subtype specific somatostatin analogues in the therapy of these tumors. Further work will examine the expression of the other receptor subtypes and correlate the results with histology and prognosis. FC3.18.04 PROGNOSTIC AND PREDICTIVE VALUE OF P53/WAF-1 EXPRESSION IN EPITHELIAL OVARIAN CANCER S.Fracchioli (1), E.P.Diamandis (2), M.Massobrio (1), D.Katsaros (1), (1) University of Turin, via Ventimiglia, 3, Turin, Italy, 10126 (2) University of Toronto, Toronto, Ontario, Canada.

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Objectives: This study was designed to determine whether patients who received adjuvant chemotherapy for epithelial ovarian cancer could be stratified into groups with different prognosis based on the immunoassay-quantified expression levels of two proteins the p53 tumor suppressor and its downstream mediator WAF1 (p21/CIP1/SDI1) rather than by conventional immunostaining. Methods: The concentrations of both proteins, measured in ovarian tumor extracts from 120 patients, by an immunofluorometric assay developed by the authors (p53) and by a commercially available immunoassay (WAF1), were also compared between groups differing on the basis of treatment response. Results: Whereas p53 levels were elevated in patients with advanced stage disease (p=0.02) or poorly differentiated (p=0.03), suboptimally debulked tumors (p=0.02), as well as in patients who failed to respond to chemotherapy (p=0.03), statistically significant association between concentrations of p53 and WAF1 were not found. Although also not significantly associated with treatment response and clinicopathologic markers of prognosis, WAF1 expression was suggested to be reduced in more advanced disease. Univariate analysis showed that p53 concentrations above the median indicated higher relative risks (RR) for relapse (p=0.04) and death (p<0.01) and provided evidence for a doseresponse effect between p53 concentrations and risks for relapse (p=0.04) and death (p<0.01). Multivariate analysis confirmed these observations (RR=1.50; p=0.05 for relapse and RR=1.92; p=0.03 for death). Conclusions: p53 expression was an independent indicator of prognosis in ovarian carcinoma patients treated with adjuvant platinum-based chemotherapy, and was associated with responsiveness. Prognostic and predictive implications of WAF1 expression in our patients, however, could not be demonstrated. FC3.18.05 IDENTIFICATION OF DIFFERENTIALLY EXPRESSED mRNA IN NORMAL, HYPERPLASIA ENDOMETRIUM AND ENDOMETRIAL NEOPLASM Lihui Wei, Y. Meng, J. Wang. Dept. GYN, Peoples Hospital, Beijing Medical University, Biejing, P.R. China, 100044. Objectives: The aim of the study was to investigate the related gene of endometrial carcinoma. This should help us a better understanding of the mechanisms of transformation. Study Methods: Individual mRNA species from normal and neoplastic endometrium obtained from the same patient were comparatively studied by exploiting the Differential Display methodology. The mRNAs were isolated from the tissues, reverse transcribed to cDNA,and then amplified by PCR. The PCR products were displayed on a polyacrylamid gel by silver staining and the differentially expressed bands were retrieved and reamplified. Subsequently we screened each of these sequences from normal endometrium and endometrial carcinoma, selected four sequences named T1.7,T2.7,T3.8 and N2.11for further analysis. Results: cDNA homology was analysed by searching through GenBank sequence databases and indicated that T1.7 (438bp)is no significant sequence homology with any sequence of known function, the other sequences is partially homology with other cDNA sequences. Homology of T2.7,T3.8 and N2.11 are 85%,24.3% and 97.3% respectively. Further study appears that T1.7 recognizes an mRNA which is expressed more abundantly in endometrial carcinoma than hyperplasia endometrium, not expressed in normal endometrium. We are studying the distribution of the T1.7 in the other normal tissues and tumoral tissues. Conclusions: T1.7 is a new EST. It expressed more abundantly in endometrial carcinoma than hyperlasia endometrium,not in normal endometrium. After we study the ditribution of it ,we will search the whole length of gene through RACE.

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FC3.18.06 ALTERATION OF CD44 AND CADHERINS EXPRESSION: POSSIBLE ASSOCIATION WITH AUGMENTED AGGRESSIVENESS AND INVASIVENESS OF ENDOMETRIAL CARCINOMA M. Leblanc (1), C. Poncelet (1), D. Soriano (1), F. WalkerCombrouze(3), P. Madelenat (2), J.Y. Scoazec (4), E. Darai (1) (1) Service de Gyncologie, Hpital Htel-Dieu, Paris, France. (2) Service de Gyncologie-Obsttrique, Hpital Bichat-Claude Bernard, Paris, France. (3) Service dAnatomie et Cytologie Pathologiques, Hpital BichatClaude Bernard, Paris, France. (4) Laboratoire de Biologie Cellulaire, INSERM U327, Paris, France. Objective: Cadherins and CD44 isoforms are transmembrane glycoproteins with diverse functions in cell-cell and cell-matrix interactions and may be a determinant of metastatic and invasive behavior in carcinomas. Study Methods: The immunohistochemical expression of cadherins and CD44 in a tissue sample from 15 normal endometrium and 33 endometrial adenocarcinomas were examined. The immunohistochemistry analysis was performed by using the monoclonal antibody HECD-1 against E-cadherin, the polyclonal antibody against N-cadherin, the monoclonal antibodies 2C5, binding to CD44s and all the variants encoded by exons 3 to 10, 3G5, specific for CD44-v3 and 2F10, specific for CD44-v6. Results: E-cadherin and N-cadherin expressions were statistically lower in endometrial adenocarcinoma than in normal endometrium (P=0.0001) and (P<0.001) respectively. In contrast, an overexpression of CD44 isoforms (P<0.01) and CD44-v3 (P<0.01) expressions was found in endometrial adenocarcinomas as compared with normal endometrium. No difference was noted for CD44-v6. An association was found between a decrease in E-cadherin expression and the occurrence of metastasis and recurrent disease. An association was found between CD44 overexpression and lymph space involvement and myometrial invasion. Conclusion: Our results suggest that cadherin and CD44 expressions in endometrial carcinomas may have both diagnostic and prognostic value. Alteration of CD44 seems to be related o local invasion. While alteration of E-cadherin seems to be associated with dissemination of the disease.

WEDNESDAY, SEPTEMBER 6
was 60.12% (11.3-92.3%). We correlated the PCNA index with stage, grade and myometrial invasion and we did not find any difference (P<0.001). Conclusions: The PCNA index was higher in patients with endometrial adenocarcinoma and the difference was statistically significant. Intense PCNA expression was not significantly associated with others prognostic indicators including stage, grade and myometrial invasion. FC3.18.08 SIGNIFICANCE OF VASCULAR ENDOTHELIAL GROWTH FACTOR EXPRESSION IN OVARIAN CARCINOMAS G. Shen (1), M. Ghazizadeh (2), (1) Dept. OG/GYN, Beijing Hospital, Beijing, China. (2) Dept. Mol. Pathol., Institute of Gerontol., Nippon Medical School, Kawasaki, Japan. Objectives: The purpose of this study was to investigate the significance of vascular endothelial growth factor (VEGF) expression in relation to the established clinicopathological features and prognosis of ovarian carcinoma. Study Methods: Paraffin tissue sections from 64 ovarian carcinomas, 13 borderline and 17 benign ovarian tumors were immunostained for VEGF using affinity-purified polyclonal antibody. RT-PCR was used to assess the differential expression of VEGF mRNA isoforms in frozen tissues from normal ovary and a number of benign and malignant ovarian tumors. Results: Of the malignant, borderline, and benign ovarian tumors, respectively, 2 (3%), 4 (31%) and 16 (94%) were negative, 31 (48%), 7 (54%) and 1 (6%) had low expressions, and 31 (48%), 2 (15%) and 0 (0%) had high expressions of VEGF. Nested PCR amplification of cDNA prepared from frozen sections showed that the predominant isoforms were VEGF121, 165, and 189 in ovarian adenomas and carcinomas. A high VEGF expression was associated with disease stage (p=0.002), histologic grade (p=0.0004), and patient outcome (p=0.0002). The survival of patients with high VEGF expression was significantly worse than those with low and negative VEGF expression. In a multivariate analysis, disease stage and VEGF expression were independent prognostic indicators. Conclusions: These results suggest that high VEGF expression plays an important role in the tumor progression and may bean independent prognostic factor for patients with ovarian carcinomas.

FC3.18.07 EXPRESSION OF PROLIFERATING CELL NUCLEAR ANTIGEN (PCNA) IN ENDOMETRIOID ADENOCARCINOMA M. G. Giusa-Chiferi, W. J. Goncalves, M. T. Seixas, E. C. Baracat, Dept. OB/GYN, So Paulo Federal University, So Paulo, Brazil. Objectives: The am of this study was to investigate the value of immunohistochemical staining for the cell cycle protein proliferating cell nuclear antigen (PCNA) in patients with endometrioid adenocarcinoma and if the PCNA index could be related to other prognostic indicators including stage, grade, and deth myometrial invasion. Study Methods: We studied 77 patients with postmenopausal bleeding treated at Sao Paulo Hospital Paulista School of Medicine 0- Sao Paulo Federal University. All patients were submitted to transvaginal ultrasound, histeroscopy and endometrial biopsy. When the results showed adenocarcinoma, the patient was submitted to surgery (Abdominal exploration, TAH-BSO, Omental biopsy, peritoneal washings and pelvic lymph node biopsy). PCNA index was studied by using an immunohistochemical technique (PC10 avidin-biotin method) using the paraffin blocks. A computerized image analysis system (IMAGELAB) was used to determine the percentage of nuclear area stained. Results: The average age was 63.13 (46-88) years. We found 33 (42.86%) patients with endometrioid adenocarcinoma, 22 (28.54%) polyp and 22 (28.54%) atrophic endometrium. Among these 33 patients with adenocarcinoma, 23 (69.7%) had diagnosis of Stage I disease, 5 (15.15%) Stage II disease and 5 (15.15%) Stage III disease. Among these 33 patients 21 (63.64%) had diagnosis of grade 1, 10 (30.30%) of grade 2 and 2(6.06%) of grade 3. We also found that 20 (60.61%) patients have less than 50% of myometrial invasion and 13 (39.39%) have more than 50% of myometrial invasion. The mean of PCNA index between patients with atrophic endometrium was 2.49% (0.09-12.14%) with polyp 8.89% (0.01-26.25%) and for endometrioid adenocarcinoma

FC3.19 CURRENT TOPICS IN GYNECOLOGY FC3.19.01 RETROSPECTIVE ANALYSIS OF 195 CASES FOR TREATMENT OF ABNORMAL UTERINE BLEEDING TO COMPARE CLINICAL AND ECONOMIC OUTCOMES Jay Berman, Wayne State University School of Medicine, Southfield, MI, United States Study Objective: To compare clinical and economic outcomes for abdominal hysterectomy, rollerball ablation and endometrial ablation using the Hydro ThermAblator* (HTA*). Study Methods: Retrospective analysis of 20 abdominal hysterectomies, 50 roller ball ablations and 125 treatments with the HTA. Patient follow up is 12 months. One hundred ninety five women (ages 30-50) with abnormal uterine bleeding. All women underwent pretreatment testing. Endometrial pretreatment was administered for roller ball or HTA treatments. Treatments occurred in hospitals and hospital run surgery centers. Abdominal hysterectomy, roller ball ablation or endometrial ablation using the HTA. Summary: Clinical outcome measurements, including efficacy and safety; the mean direct cost per case, including operating room time, anesthesia, and equipment; and indirect costs, including recovery and lost productivity, for abdominal hysterectomy, roller ball ablation and the HTA treatment will be compared.
# of cases 20 50 125 Efficacy Safety (Intra/Postoperative Complications) Time (ave min.) Direct Cost/case 100% 12 60 9742.03*730.35 85% 6 35 4912.50*560.66 94% 4 23 4967*500.98

Hysterectomy RB Ablation HTA* Ablation

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Conclusion: Treatment with the HTA is a safe and effective treatment for menorrhagia that may reduce economic costs and risk associated with the procedure when compared to abdominal hysterectomy and roller ball ablation. Additional long-term post treatment follow up data must be gathered. FC3.19.02 ALTERNATIVE MANAGEMENT OF MENORRHAGIA WITH LEVONORGESTREL RELEASING INTRA-UTERINE SYSTEM (LNG-IUS) Ibrahim, MN, Sinha, P, Michelle Mammom, Conquest Hospital, St-Leonards-On-Sea, United Kingdom Objectives: To assess the efficiency, side effects, patients satisfaction and outcome after insertion of the Mirena coil in-patients with menorrhagia after failed medical treatment. Study Method: Retrospective case note analysis, 65 patients were included in this study between 1st November 1998 to 31st October 1999. Follow up was arranged after 6 weeks, 3 months, 6 months and 12 months. During the follow up patients satisfaction was noted by giving a set of questionnaires including associated undesirable side effects. Results: Significant improvement in menstrual flow was noted in 40 patients (61.5%). There was no symptomatic improvement in 6 patients (9.2%). Out of these 6 patient 4 had prolonged bleeding and out of these: 1 had endometriosis, 2 had an ovarian cyst and 2 had hysterectomy after 11 months. Indications for hysterectomy were adenomyosis and endometrial polyp. The symptoms did not improve in one of the patients because the coil had been expelled, (the patient being excessively obese). Six patients did not attend for follow up on enquiry they were happy. Thirteen (29.3%) are still awaiting their first follow up after insertion. Conclusion: Most patients had their menstrual flow reduced. The commonest side effects were prolonged spotting which carried on for up to 10 months in some patients. Patients with adenomyosis and endometrial polyp had not achieved the desired effect. Despite being a small study, it does suggest that the Mirena coil is the treatment of choice before surgery. It should be noted however that proper counselling is still important and that we recommend proper uterine examination is performed before any treatment is undertaken. FC3.19.03 THE EFFICACY OF A 125 MG/DAY REGIMEN OF FLUTAMIDE IN MAINTAINING THE CLINICAL RESULTS IN HIRSUTE WOMEN. S. Venturoli, A. Bagnoli, F. M. Colombo, B. Ravaioli, F. Vianello, F. Mancini. Institute of Reproductive Physiology and Pathology, University of Bologna, Bologna, Italy Objective: To evaluate the safety and efficacy of a 125 mg/day regimen of flutamide in maintaining the clinical results previously achieved using higher doses, in women suffering from hirsutism. Study Methods: Forty-three women suffering from several etiological hirsutism were enrolled in the study. Six dropped out of the study. The women received 250 mg/day of flutamide as an initial treatment for 12 months. Subsequently they received 125 mg/day of flutamide for an additional 12 months as a maintenance treatment. Hirsutism was evaluated by the Ferryman-Gallwey score, and hair diameter and hair growth rate were determined by a special image analysis processor (IBAS: sensitivity of 0.001 mm). Biochemical, clinical and hormonal parameters were evaluated in basal conditions and every 2-6 months. Results: The initial treatment period produced a significant decrease in the hirsutism score (-50%), hair diameter (-21%) and hair growth rate (41%). At the end of the maintenance treatment period, the hirsutism +score further decreased, and hair diameter and growth rate were confirmed. Free Testosterone (-44%), Androstenedione (-28%) and 17-P (-36%) levels progressively decreased up to a maximum level at the end of the maintenance treatment period. T (-25%) and DHAS (-27%) levels did not further decrease after the initial treatment period, while DHT (21%) and DHA (-37%) levels, after the decrease observed in the initial treatment period, showed an increase during the maintenance treatment period thus suggesting a reduction of the suppressive effect. During the initial treatment period, very few transient side effects were observed but

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four subjects (9%) registered an increase of aspartate aminotrasferase and alanine aminotrasferase and dropped out. During the maintenance treatment period, no subjects registered side effects or complications. Conclusions: Satisfactory management of hirsutism with flutamide seems to be represented by an initial treatment period using 250 mg/day followed by a long maintenance treatment period using 125 mg/day, once satisfactory results have been obtained with higher doses. FC3.19.04 THE EFFECTS OF TWELVE MONTH USE OF A GESTODENE/ETHINYLESTRADIOL CONTRACEPTIVE PILL BY PREMENOPAUSAL WOMEN ON LIPID AND LIPOPROTEIN METABOLISM AND HEMOSTATIC PARAMETERS I.H. El-Nashar (1), G.H. Sayed (1), M. El-Kabsh (2), A. Nasr (1), M.M. Shaaban(1), Departments of (1) OB/GYN and (2) Clinical Pathology, Assiut University Hospital, Assiut, Egypt Objectives: To study the effects of a 12-month use of a low-dose combined gestodene-containing combined oral contraceptive (COC) preparation on serum lipids, lipoproteins and some hemostatic parameters. Study Methods: One hundred premenopausal women above 40 used a COC preparation containing ethinylestradiol 0.03 mg plus gestodene 0.075 mg for 12 months. An age-matched comparison group of 50 women used the T-Cu-380 intrauterine contraceptive device (IUD). Blood samples were taken at admission and after 3, 6 and 12 months of use. Statistical analysis was determined by Student t-test and X2 test. Results: No statistically significant differences between the 2 groups were observed at admission. Pill use resulted in a significant reduction in vasomotor symptoms and Apolipoprotein-A after 12 months of use. Triglycerides increased significantly after 12 months of use. Antithrombin-III activity showed an early and sustained decrease. The COC group showed a significant increase in a2-antiplasmin after 6 and 12 months of use. The IUD group showed no significant change in any of the measured parameters. Conclusion: Use of the gestodene containing low-dose COC by women over 40 favorably changes a number of parameters of cardiovascular risk mainly increased HDL cholesterol and Apolipoprotein-A but may otherwise result in some unfavorable changes, mainly reducing antithrombin-III levels. FC3.19.05 MAJOR SYMPTOMS OF PREMENSTRUAL TENSION (PMS) ARE REDUCED BY FEMAL, A HERBAL PRODUCT. K. Winther (1), E. Shytte (2), E. Rein (2), C. Hedman (3) (1) Dept. of Clinical Chemistry, Gentofte Hospital, Copenhagen, Denmark (2) Institute for Clinical Research, Kolding, Denmark (3) Sahlgrenska Biomedical Innovation Centre, Gothenborg, Sweden Objectives: The presents randomized, double-blind, placebo-controlled, cross-over study aimed to test if Femal, a natural product containing pollen pistil and grain extract, PI 82, from the plant family Graminea, an extract, GCFEM, form pollen of the plant Secale Cereale, Royal Jelly, which is produced by working honey bees and finally a small amount of vitamin E, can influence mayor symptoms of (PMS). Study Methods: 32 woman, 20-54 years of age (mean 39.4) with regular menstrual cycles and no signs of depression, all having the diagnose of PMS for a mean period of more than 10 years, were included. Two tablets of Femal, each containing 90.9mg of the active ingredients or two placebo tablets of similar taste and size were given twice daily for two menstrual cycles. Then the group initially receiving Femal was changed to placebo and vice versa. At the end of each of the two treatment periods, premenstrual weight gain and PMTS self and observer rating scales were evaluated. Likewise tension, irritability, edema and general feeling of well being were tested using visual analogue scales. Results: Femal reduced weight gain by 60%, p<0.001, and PMTS self and observer rating scales by more than 35%, p<0.05. A decline in tension, irritability and edema and an increase in well being by more than 40%, p<0.05 was also observed during Femal treatment. Conclusions: The present data suggest that women suffering from premenstrual tension symptoms can benefit from Femal.

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FC3.19.06 EFFECTS OF ESTROGEN REPLACEMENT ISOLATED AND ASSOCIATED WITH GESTRINONE IN OOPHORECTOMIZED ADULT RATS WITH EXPERIMENTAL ENDOMETRIOSIS VR Lobo; E Schor; EC Baracat; CE Lang; V Freitas; MJ Simes; JM Soares Jr; G Rodrigues de Lima. Department of Gynecology - Escola Paulista de Medicina, Federal University of So Paulo, So Paulo, Brazil. Objective: The aim of this work was to analyze the effects of conjugated equine estrogens and gestrinone in oophorectomized adult rats previously submitted to endometrial implants. Study Methods: 50 adult female rats in which an endometrial implantation was made on the lateral abdominal wall. After four weeks a new laparotomy was achieved where implant sizes were measured, followed by bilateral oophorectomy. After six weeks, the animals were randomly divided into five groups: G I (n=10) received 0,5 ml/day of propylenoglycol (control), GII (n=10) received CEE (50 mg/day), GIII (n=10) received CEE (25 mg/day), G IV (n = 10) received CEE (25 mg/day) associated with gestrinone (2,5 mg/day); GV (n = 10) received CEE (50 mg/day) associated with gestrinone (2,5 mg/day). All animals were daily treated for 21 consecutive days by subcutaneous route. After this period the animals were submitted to a new laparotomy and the implants were measured and resected for light microscopy analysis. Results: The results showed a meaningful growth of endometrial implants group GII, which presented as vesicles with clear liquid content. Light microscopy showed the presence of endometrial tissue containing stroma, glands and well-developed cysts. There was regression of implant in groups GI, GIII, GIV and GV, and its localization was possible only due to the presence of surgical material. Conclusion: Only 50mg CEE promote growth of endometrial implants and gestrinone opposed the CEE effects.

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FC3.19.08 THE EFFECT OF LONG-RELEASED LEVONOGESTREL ON BONE DENSITY OF REPRODUCTIVE WOMEN S. He, Reproductive Medical Center, National Research Institute for Family Planning, Beijing, China Objectives: The aim of the study was to evaluate the effect of longreleasing levonorgestrel only on the bone density and bone metabolism of reproductive women who used Implant type I, II and Norplant for three years. Study methods: Eight women who used LNG Implant and forty-three controls were recruited into the cross-section study. Except general states, calcium intake, movement and private habits, to compare the mean level of serum E2, biochemical indicators of bone metabolism: serum calcium (Ca), phosphate (P), alkaline phosphate (ALP) and osteocalcin (BGP); concentration of calcium (Ca), OH-praline (HYP) and cretonne (Cr); and the mean value of the bone density at middledistal forearm. Results: The mean levels of estrogen (E2) were lower at normal level in three groups and was no significant difference compared to the control group. The period formation of bone peak in all groups was 30-40 years old. There was no line-relationship between mean level E2 and BMD in three groups except control group. The changes of BMD. Ca/Cr and Hyp/Cr in women who used Norplant was suggested the bone absorption to be slight strengthens. Conclusions: Long-released LNG implant type I, II and Norplant for three years were no significant effect on BMD and other indicators of bone metabolism in women comparing with control. It was safe on bone metabolism in reproductive women. FC3.20 OBSTETRICS: LABOR FC3.20.01 USING THE MEDICAL AUDIT TO IMPLEMENT GUIDELINES FOR INDUCTION OF LABOUR T.A. Mahmood, H. Mousa, C.K. Tan, Dept. OB/GYN, Forth Park Hospital, Kirkcaldy, Scotland, United Kindgom The incidence of induction of labor is steadily rising. Inappropriate use of prostaglandins can not only increase the risk of iatrogenic fetal distress but also of emergency cesarean delivery and therefore has been cited as an important contributing factor towards subclinical care. (CESDI 1997; Why Mothers Die, 1998-UK). Clinical guidelines facilitates implementation of evidence based practice. Objectives: The aim of this study was to determine whether implementation of guidelines for induction of labor could reduce induction to delivery interval. A medical audit cycle was used to demonstrate the delivery of a high quality evidence based health care. Study Methods: A retrospective audit of 380 consecutive case notes where labor had been induced in 1995 was carried out to identify inconsistencies in clinical management. New strategies for labor induction directed pre-induction cervical priming and use of low dosages of vaginal prostaglandins were developed and implemented. The effect was monitored prospectively during 1996, 1997, and 1998. Results were analyzed with X2 test. Results: A total of more than 2000 women were studied. They all had a viable singleton pregnancy, a cephalic presentation, no uterine scar and a gestational age greater than 37 weeks. They all had their labors induced. After management change, a significantly higher proportion of women had pre-induction cervical priming (change from 20% to 85%, p<0.0001). Although a significantly reduced amount of prostaglandin gel was used, there was a significantly reduced induction to delivery interval (p<0.001), with no increase in cesarean rate. Conclusion: Implementation of guidelines on induction of labor significantly shortened induction to delivery interval.

FC3.19.07 METHOTREXATE IN THE THERAPY OF SYMPTOMATIC UTERINE LEIOMYOMAS Aleksandar Zivanovic, S. Arsenijevic, M. Brkic, S. Djukic-Dejanovic, Sazdanovic P. Clinic of Gynecology and Obstetrics, Clinical-HospitalCenter, Kragujevac, Yugoslavia Background: Abnormal bleeding occurs in about one third of patients with symptomatic uterine myoma. Estradiol increases a number of glandular mitosis in endometrium. Binding of thimidin in endometrium increases during follicular phase. Methotrexat is an antimetabolite drug that inhibits enzyme dihydrofolat-reductase. Due to that cells have a lack of reduced folan acids and therefore there is no possibility for synthesis of thimidin. The aim of this study is to evaluate effects of subendometrial methotrexat injections in perimenopausal women with sympthomatic myoma uteri, on menstrual bleeding and volume of myomas. Methods: Twenty premenopausal women with myoma uteri were analyzed. Methotrexat was applied as subendometrial injection in follicular phase, in dose of 5 mg/2ml per cycle during three menstrual cycles in total dose of 15 mg. The Pictorial Blood Loss Assessment Chart (PBAC) was used to assess the level of menstrual flow, before, through and after therapy. The volume of myoma before and after therapy was measured with Aloca 640 ultrasound. Results: Analysis of mean values of PBAC score before therapy and a second cycle showed a statistically significant decrease in menstrual flow (t=11.49, p<0.001). The most evident difference between a mean value in PBAC scores was observed before and after therapy completition (t=20.47, p<0.001). The difference in volume of myomas before and after therapy was tested by Wilcoxon pair sample test. The volume of myomas was diminished with statistical significance of z=3.17, p=0.0015. Conclusion: These preliminary results suggest that methotrexat can be useful in the treatment of perimenopausal women with symptomatic myoma uteri. Key words: Uterus, Leiomyoma, Methotrexat, and Therapy.

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FC3.20.02 SHOULDER DYSTOCIA IN A BUSY OBSTETRIC UNIT H.J.A. Carp1, S. Kees1, V. Margalit2, E. Schiff2, S. Mashiach2, 1 Herzelia University, Herzelia, Israel 2Department of Obstetrics & Gynecology; Sheba Medical Center, Tel Hashomer, Israel Objectives: To assess the incidence and complications of shoulder dystocia in a busy obstetric unit and whether they could be avoided. Study Methods: Review of the notes of patients with shoulder dystocia between 1966-1969 to determine whether macrosomia, diabetes, height of the head at full dilatation, length of the second stage and instrumental deliveries could have predicted shoulder dystocia. Fetal asphyxia, brachial plexus injury, and the manoevres used to free the shoulders were assessed, and the incidence of injury according to the manoevre. In cases of Erbs palsy, we tried to determine whether the experience of the attendant affected the outcome, and whether these cases could have been avoided. Results: There were 56 cases of shoulder dystocia in 24,000 births. 59% occurred after spontaneous delivery. McRoberts manoevre was used in 48 deliveries, but sufficed as a solitary procedure in only 9 cases. The addition of suprapubic pressure was sufficient for 25 patients, 27 when bilateral episiotomy was also used. Corkscrew procedures were required in 12 patients. Midwives were involved in 35 cases. They required assistance in 27 of these cases. Senior staff were called to intervene in 25 cases, and were involved in another 13 cases where they carried out the delivery. Macrosomia above 4000g was only a feature in 20 infants, and diabetes in 6 infants. Signs within labor such as the height of the head or length of the second stage were not helpful. There were 13 cases of Erbs palsy. Seven after vacuum delivery and six after spontaneous delivery. Eight of these cases were associated with McRoberts procedure and suprapubic pressure, two with no procedure, and three with the corkscrew procedure. Conclusions: Certain cases of shoulder dystocia can be prevented by cesarean section. However, even if all infants above 4000g had been delivered by cesarean section, there would still have been 36 cases of shoulder dystocia. If the ultrasonic estimated weight were used to select patients for cesarean section, only 7 cases would have been diagnosed. Therefore, there will always be unexpected cases of shoulder dystocia.In order to lessen the degree and incidence of fetal injury, labor ward staff are urged to become as familiar as possible with these techniques.

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FC3.20.04 INTRAVENOUS NITROGLYCERIN IN THE MANAGEMENT OF RETAINED PLACENTA P. Chedraui, D. Insuasti, Dept. OB/GYN, Enrique Sotomayor Maternity, Guayaquil, Ecuador Objectives: Evaluate the efficacy, safety and optimal dose of nitroglycerin (NTG) in the management of retained placenta and its effects on hemodynamics parameters. Study Methods: 30 patients in third stage of delivery with retained placenta were studied in a prospective experimental manner, to receive intravenous nitroglycerin for the management of retained placenta. We studied maternal, labor and neonatal data. Results: The average time of the procedure was 5.31.1 min. with a range dose of 50 to 200 mcg of NTG. The systolic and diastolic blood pressures fell by a mean of 8.5mmHg and 7.33 mmHg respectively. (p<0.05) Although there were differences statistically significant in the hemodynamic parameters, this was not true clinically, and there were no complications. Conclusions: Intravenous NTG at a dose of 200 mcg or less is SAFE, EFFECTIVE and PREDICTABLE in the management of retained placenta and could obviate the need of general anesthesia.

FC3.20.05 MISOPROSTOL: AN EFFECTIVE ALTERNATIVE TO OXYTOCIN FOR LABOR INDUCTION IN TERM PREMATURE RUPTURE OF MEMBRANE AND UNFAVORABLE CERVIX T.S. Thach (1), S. Jamulitrat (2), V. Chongsuviwatong (3), A. Geater (3), T.D. Pham (1) (1) OB/GYN Hospital, Ho Chi Minh City, Vietnam. (2) Songklanagarind Hospital, Hat Yai, Songkla, Thailand. (3) Epidemiology Unit, Prince of Songkla University, Songkla, Thailand. Objective: To test the hypothesis that vaginal misoprostol is an effective and safe alternative to oxytocin for inducing labor in women with premature rupture of membrane (PROM) at term and unfavorable cervix. Study Methods: The randomized, controlled trial was carried out at Hungvuong OB/GYN Hospital, Vietnam. 172 eligible subjects were randomly assigned to receive either misoprostol or oxytocin. 25 mg misoprostol was placed in the posterior vaginal fornix. Subsequent doses after 4-hour intervals were only given if uterine contractions were not sufficient. Oxytocin was administered intravenously by a standard increment infusion protocol. Study subjects were closely monitored during intra- and postpartum period. Interval from start of induction to vaginal delivery and infection complications were primary outcomes. Survival analysis was carried out to take the occurrence of cesarean delivery into account. Results: There were no significant differences with regards to labor duration, intra- and postpartum complications and neonatal morbidities. The interval from induction to vaginal delivery, adjusted for cesarean section, was similar between the two study group (Hazard ratio = 1.06 and 95% confidence interval (CI)=0.54, 2.06). Chorioamnionitis was diagnosed slightly more frequently in the misoprostol group (risk ratio=1.7; 95% CI:0.6, 4.4; P=0.29). Conclusion: Vaginal misoprostol at the conservative dosing regimen could be taken into consideration as an alternative to intravenous oxytocin for induction of labor in term PROM associated with unfavorable cervix. Both treatments give similar induction-to-vaginal delivery interval and similar complications. Further study is required to address the rare outcomes, namely neonatal long-term morbidity and mortality.

FC3.20.03 INTRAVAGINAL MISOPROSTOL IN INDUCTION OF LABOR ON VIABLE CHILD AFTER 38 WEEKS OF AMENORRHEA: RETROSPECTIVE STUDY OF 63 CASES K. Salihy, A. Desroches, P. Megier, Dept. OB/GYN, Regional Hospital, Orleans, France. Objectives: Retrospective clinical study about efficacy and safety of intravaginal misoprostol in induction of labor on viable child after 38 weeks of amenorrhea. Study Methods: The population is composed of 63 paturient women with a singleton pregnancy having benefited by an induction of labor in the Department of OB/GYN of the Regional Hospital of Orleans. Main indications were prolonged pregnancy and fetal macrosomia. 50 mg of misoprostol were applicated intravaginally every 4 hours (with a maximum of 5 doses), without any dispensation of oxytocin. Statistical analysis of data was realized with c2 test and Fischer test, using SPSS software. Results: Only one failure of induction was observed. 62 patients were delivered during the 24 hours following the first application of misoprostal (H O ). Two doses were sufficient for 74.5% of patients. The interval between H O and the beginning of labor was 6.023.41 hours. The interval between H O and the delivery was 10.194.03 hours. The cesarean section rate was 22.2%. The cesarean section rate for abnormalities of the fetal heart rate was 16%. A tachysystole was observed in 12.3% of cases. Seven neonates needed care in neonatal unit. No side-effects of misoprostol was noted. Conclusion: Intravaginal misoprostol in induction of labor on viable child after 38 weeks of amenorrhea offers a satisfactory efficacy and safety. The rage of abnormalities of the fetal heart rate and of cesarean sections seems higher in cases of immature uterine cervix, with a Bishop score inferior or equal to four.

FC3.20.06 RASPBERRY LEAF TABLETS AND THEIR EFFECT ON LABOR AND BIRTH OUTCOMES M. Parsons, Dept. OB, Westmead Hospital, Sydney, Australia. Objectives: The aim of the study was to investigate the effect of the raspberry leaf herb, consumed in tablet form by nulliparous women from 32 weeks gestation until birth, on their labor and birth outcomes. Study Methods: One hundred and ninety healthy, nulliparous women were included in this double-blind, placebo-controlled, randomized,

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observational study which was conducted at one hospital in Sydney, Australia. Mothers whose baby was delivered by cesarean section were excluded from analysis of some variables. Results: Although not statistically significant, on average mothers in the raspberry leaf group had a slightly shorter gestation period (in days) [MRx=278.95, Mc=280.35, t(156)=1.07, p=29], and length of time in first stage of labor (in minutes) [MRx=291.11, Mc=431.67, t(122)=1.08, p=28] Conclusions: The raspberry leaf herb, consumed in the form of tablets at the rate of 2400mg per day was found to shorten labor with no known side effects.
Study group N=315 (%) 5 (1.6) 2 (0.6) 0 0 1 (0.3) 3 (0.9) 18 (5.75) 12 (3.8) 5 (1.6) 42 (13.3)

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Control group n=10,852 (%) 98 (0.9) 11 (0.1) 43 (0.4) 11(0.1) 65 (0.6) 43 (0.4) 488 (4.5) 412 (3.8) 152 (1.4) 1159 (11.6) p NS NS NS NS NS NS NS NS NS NS

Placental abruption IPFD PPH Uterine rupture Retained placenta Manual lysis Vaginal tears Fetal distress Vacuum deliveries Cesarean sections

FC3.20.07 THE INFLUENCE OF UMBILICAL VEIN OXYTOCIN ON BLOOD LOSS AND LENGTH OF THE THIRD STAGE OF LABOR N. Jovanic, N. Lazic, S. Savic, S. Sibincic, Clinical Centre - Banja Luka, Dvanaest beba 2, Banja Luka, Republic of Srpska, Bosnia and Herzegovina, 78000. Objectives: The aim of the study was to investigate the effect of transumbilical technique of oxytocin application. Study Methods: Blood loss and duration of the third stage of labour were monitored in four groups of thirty patients each. The third stage of labour in Group 1 patients was physiologically managed. Patients in Group 2 were injected 30 ml. of 0,9% solution of NaCl into umbilical vein. Patients in Group 3 were injected 30 ml. of 0,9% solution of NaCl with 10 IU of oxytocin. Patients in Group 4 were injected 30 ml. of 0,9% solution of NaCl with 20 IU of oxytocin. T-test was done as a statistical method on significance level of 0,01. Results: Application of 10 IU or 20 IU of oxytocin through umbilical vein leads to statistically shortened third stage of labour (p < 0,01) and statisically significant decreased blood loss in the third stage of labour (p < 0,01). Dose increase of oxytocin for 100% no relation to neither duration of the third stage of labour (p > 0,01) nor blood loss in the third stage of labour (p > 0,01). Conclusions: There were no complications during the applications of oxytocin through umbilical vein.The transumbilical technique of oxytocin application has unjastifyably rarely used in the third stage of labour although it is easely accesible, simple, painless and safe.

Conclusions: Ripening of uterine cervix in grandmultiparous patients with vaginal PGE2 was not associated with a higher rate of peripartum complications. Therefore, the use of PGE2 in grandmultiparous women for ripening of the cervix should be considered relatively safe. FC3.20.09 ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR - A COMPARATIVE STUDY Jasmine Rajwani, Khadilkar, Survana, Grant Medical College - Cama and Albless, Government Hospital, Mumbai, India Objectives: The aim of the study was to compare the effect of intramuscular methergin, intra-umbilical vein oxytocin and intramuscular prostaglandins in the management of third stage of labor. Study Methods: A study was carried out on 120 patients of normal labor. Patients were selected randomly and divided into three groups: Group1- 40 patients were treated with injection methyl ergometrine 0.2mg intramuscular following delivery of the placenta, Group2- 40 patients were treated with instillation of 5 units of oxytocin in 10ml of normal saline into the umbilical vein, Group3 - 40 patients were treated with injection prostaglandins 250mg intramuscular. Pre and post delivery estimation of haemoglobin and packed cell volume was done, duration of third stage and amount of blood loss was noted. Results: The amount of blood loss in patients with intramuscular prostaglandins was less, average of 4% as compared to 7% with intraumbilical vein oxytocin and 9% with use of intramuscular methergin. The duration of third stage was less with use of prostaglandins as compared to the other groups. Conclusion: Use of prostaglandins was most effective in reducing amount of blood loss in third stage of labor as compared to intraumbilical vein oxytocin and intramuscular methergin. However, intraumbilical vein oxytocin was particularly useful in cases of pregnancy induced hypertension, heart disease patients and it seems to be a promising treatment for retained placenta obliviating the risk involved in the procedure of manual removal of placenta. FC3.21 HRT: CENTRAL NERVOUS SYSTEM AND OTHER EFFECTS

FC3.20.08 RIPENING OF THE UTERINE CERVIX IN GRANDMULTIPAROUS WOMEN WITH PROSTAGLANDINS E2: PERIPARTUM COMPLICATIONS AND SAFETY T. Silberstein, S. Eyal, Z. Ben Aroya, M. Hallak, D. Yochai, M. Katz, M. Mazor, Dept. OB/GYN, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel. Objective: To determine whether the use of vaginal prostglandings E2 (PGE2 ) for ripening of uterine cervix in grandmultiparous (parity 5 or more) women is associated with a higher rate of peripartum complications. Study Methods: We included 11,167 grandmultiparous women, who delivered in our institution between the years 1989-1995. Ripening of the cervix with vaginal administration of 0.5 mg of PGE2 was performed in 315 women (study group). All patients were monitored for fetal heart rate and uterine contractions for 3 hours after PGE2 administration. Additional PGE2 doses were administered every 6 hours if indicated. The control group consisted of 10,852 grandmultiparous women who did not undergo ripening of the cervix by PGE2. Statistical analysis included chi square and Fishers exact test when appropriate; power analysis of major variables was >80% assuming a type one error rate of = 0.05. Results: No significant differences were found in any of the peripartum complications between the PGE2 treated patients and the control group.

FC3.21.01 THE EFFECT OF SHORT-TERM ESTROGEN REPLACEMENT THERAPY ON SLEEP A RANDOMIZED PLACEBOCONTROLLED DOUBLE-BLIND CROSS-OVER TRIAL IN POSTMENOPAUSAL WOMEN P. Polo-Kantola (1), R. Erkkola (1), K. Irjala (2), O. Polo (3), University of Turku, Turku, Finland (1) Dept. OB/GYN (2) Dept. Clin. Chem. (3) Dept. Physiol. Objectives: To evaluate the effect of estrogen replacement therapy (ERT) on subjective and objective sleep quality in postmenopausal women and to assess the predictive factors involved. Study Methods: A 7-month prospective, randomized, double-blind, cross-over study consisting of two 3-month treatments with estrogen and the placebo treatment with one months wash-out period in-between. Out of 71 recruited women, 62 completed the follow-up. Subjective sleep quality was evaluated with 8 visual analogic scale (VAS) statements. For objective sleep quality measurement all-night

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polysomnography and static-charge-sensitive bed (SCSB) were assessed. Self-reported climacteric symptoms for 14 days were also carried out. Serum E2- and FSH-levels were controlled. Results: ERT effectively alleviated climacteric symptoms, such as hot flushes (p<0.001), sweating (p<0.001), sleep complaints (p<0.001), headache (p=0.002) and depression (p=0.055). ERT improved sleep quality, facilitated falling asleep and decreased nocturnal restlessness and awakenings (p<0.001). The subjects were less tired in the mornings and in the daytime (p<0.001) on ERT. These effects were associated with alleviation of vasomotor symptoms (r range 0.27-0.55), alleviation of somatic symptoms (palpitation and muscular pain r range 0.26-0.36) and alleviation of mood symptoms (r range 0.28-0.37) on ERT. In polygraphic sleep studies altogether 11,570 arousals were observed. ERT decreased the frequency of movement arousals, while increasing the frequency of EEG arousals. Regardless of the treatment sleep efficiency, sleep latencies and distribution of various sleep stages remained similar. Conclusions: ERT significantly diminished sleep complaints among postmenopausal women. Alleviation of climacteric symptoms is the most important predictive factor for the beneficial effect of ERT. ERT improves objectively measured sleep quality by alleviating the frequency of movement arousals without having any effect on sleep architecture. Because of these beneficial effects, ERT should be considered as a treatment of choice for postmenopausal sleep complaints. FC3.21.02 CEREBRAL GLUCOSE METABOLIC RESPONSE TO PREMARIN AND EVISTA IN HEALTHY POSTMENOPAUSAL WOMEN J.T. Metz, L.H. Kinnunen, M. Cooper, Micro Inc., Chicago, IL, USA. Objective: We sought to determine the effects of Premarin and Evista on regional cerebral metabolism of glucose (rCMglu). Study Methods: In a double-blind crossover study, eight normal healthy female subjects (aged 63-78) received, for two weeks each, Premarin (0.625 mg/day), Evista (60 mg/day) and placebo. At the end of each two week period, subjects participated in an FDG/PET study. Metabolic images were analyzed to reveal areas in which either drug differed significantly from placebo. Results: While no differences in overall cerebral metabolism behavioral stare, or mood were observed, both drugs produced effects on CNS rCMglu. Premarin significantly increased relative rCMglu in right frontal and temporal cortices, and decreased relative rCMglu in left frontal cortex. Evista increased relative rCMglu in right frontal cortex and thalamus, and decreased relative rCMglu in parietal and temporal cortices. Conclusions: Estrogens CNS effects, including protection against dementia and other cognitive dysfunctions, are likely to be mediated through, or indicated by, the metabolic changes induced in cerebral regions by Premarin. Because Evista had different CNS effects, its behavioral consequences are likely to be different.

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placebo were observed beginning at Week 3 for the 2.5 g dose and at Week 6 for the 1.25 g dose. Overall, both doses of ESTROGEL Gel were well-tolerated with a low incidence of unrelated serious adverse events. Conclusions: Overall, ESTROGEL Gel was shown to provide effective relief of postmenopausal vasomotor symptoms. ESTROGEL 2.5 g was the most effective dose in alleviating the frequency of hot flushes, compared to placebo. The 1.25 g dose, however, also demonstrated improvement over placebo and should be considered the starting dose for symptomatic patients

FC3.21.04 COMPARATIVE EFFECTS OF PREMARIN, EVISTA, AND PLACEBO ON SLEEP ARCHITECTURE, SLEEP QUALITY, AND HOT FLUSH FREQUENCY IN POSTMENOPAUSAL WOMEN M, Scharf, R. Stover, J. Withrow, D. Berkowitz, Center for Research in Sleep Disorders, Cincinnati, Ohio, USA. Objectives: The purpose of the study was to evaluate and compare the effects of Premarin, Evista, and placebo on sleep efficiency and quality in postmenopausal women who complain of night sweats and hot flushes. Study Methods: Thirty subjects between the ages of 45 and 60 who were at least 6 months post menses and who had complaints of at least one episode of hot flushes per night were enrolled in a single, blind, placebo controlled trial. All subjects maintained daily diaries during a two-week period followed by 4 weeks of treatment with Premarin, 0.625mg, Evista, 60mg, or placebo administered 2-4 hours prior to bedtime. The diaries were checked to assess sleep quality and frequency of hot flush events. The first three nights of both the placebo baseline and the treatment periods were spent in the sleep laboratory. Split screen audiovisual recording was carried out to allow for simultaneous observation of polysomnographic data and the patients verbal report of hot flush/night sweat events. Data were analyzed using an analysis of covariance that corrects for baseline differences between the groups. Results: Patients on Premarin showed less wake after sleep onset with the total number of awakenings significantly below that of the placebo group (p<0.005). The decrease in awakenings was in part due to the decrease in the number of nocturnal hot flush events. Patients receiving Premarin showed a significant reduction in the overall number of hot flushes per day compared to the placebo (p<0.001) and to Evista (p<0.005) as well as the number of nocturnal hot flush events recorded in the laboratory compared to placebo (p<0.05) and to Evista (p<0.05). No differences were noted in hot flush frequency in the laboratory or at home between patients receiving Evista or placebo. Daytime physical function measured by the Quality of Life Questionnaire was perceived as diminished on Evista compared to placebo or Premarin. Conclusions: Premarin reduces but Evista maintains daily hot flush frequency in postmenopausal women. Concomitantly, the reduction in hot flush events with Premarin is accompanied by fewer nocturnal awakenings. Daytime physical function was perceived as worseon Evista compared to Premarin or placebo after 4 weeks of treatment. Poor nocturnal sleep can significantly impact on quality of life issues.

FC3.21.03 EFFICACY AND SAFETY COMPARISON OF ESTROGEL GEL AND PLACEBO IN THE TREATMENT OF VASOMOTOR SYMPTOMS D.F. Archer, for the ESTROGEL Study Group; Eastern Virginia Medical School, Norfolk, VA, United States Objectives: This was a randomized, placebo-controlled, double-blind, multicenter study of the efficacy and safety of ESTROGEL Gel 1.25 g and 2.5 g daily for the treatment of vasomotor symptoms in menopausal women. Study Methods: Postmenopausal women who experienced a minimum of 7 daily or 60 weekly moderate-to-severe hot flushes were randomly assigned to ESTROGEL Gel 1.25 g, 2.5 g or placebo once daily for 12 weeks. Efficacy was evaluated from the frequency of hot flushes. Safety was assessed by a battery of physical and laboratory examinations and recording adverse events. Results: Among 221 women randomized (75 to 1.25 g, 73 to 2.5 g, and 73 to placebo), the mean percent change in the frequency of hot flushes decreased in both ESTROGEL Gel dose groups from Weeks 1 to 12 (1.25 g dose: 26.7% to 74.6%; 2.5 g dose: 26.9% to 82.3%; placebo: 26.2% to 56.7%). Statistically significant differences from

FC3.21.05 EFFECTS OF TRANSDERMAL HRT ON VASOMOTOR SYMPTOMS USING EITHER A SEQUENTIAL REGIMEN OR A CONTINUOUS COMBINED REGIMEN M. Notelovitz (1), M-P Dain (2) (1) Women Institute Research Center Inc America. Gainesville, Florida, United States. (2) Rhne-Poulenc Rorer, Antony, France. Objectives: To evaluate the efficacy and tolerability of sequential estradiol/norethisterone acetate (E2/NETA) transdermal therapy (Estalis Sequi) and continuous combined E2/NETA transdermal therapy (Estalis), in reducing moderate-to-severe post-menopausal vasomotor symptoms compared to placebo alone, were evaluated. Study Methods: Two separate, randomized, double-blind, multicenter, quality of life (QoL) studies were done over 12 weeks. In both trials, healthy post-menopausal women (age 40-70 years) with an intact uterus and with at least 8 hot flushes per day, were assigned to one of four treatment groups, a transdermal patch containing either placebo or one of three different regimens of E2/NETA. Sequential therapy consisted of

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a transdermal patch releasing 17 b-estradiol (E2) 50 mg/day alone for days 1 to 14 of each cycle and a combination E2/NETA patch releasing E2 50 mg/day plus NETA 140, 250 or 400 mg/day for days 15 to 28 of each cycle. Continuous combined therapy consisted of transdermal E2/NETA 50/140, 50/250 or 50/400 (mg/day hormone delivery), applied every 3.5 days. Vasomotor symptoms, patch tolerance and adhesion were rated by a patient questionnaire. Results: Transdermal E2/NETA as either sequential or continuous combined therapy significantly reduced the mean number of hot flushes and sweating (from 8 to <1/day, p=0.001), reduced sleep disturbances and improved sexual function, with all trial dosages, compared to placebo. Conclusion: Both regimens significantly reduced vasomotor symptoms. The QoL of post-menopausal women can be effectively improved by treatment with either of these regimens of transdermal E2/NETA. Patch tolerance and adhesivity were both excellent for each regimen.

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E2 50 mg/day and sequential transdermal E2/NETA delivering NETA 250 or 400 mg/day or continuous transdermal E2 50 mg/day (Estraderm TTS) plus sequential oral dydrogesterone 10 mg/BID for 14 days in a 28-day cycle during 24 weeks; 1 group received a continuous E2/NETA patch delivering 50 mg E2 and 140 or 250 mg/day NETA or 2/1 g/day oral E2/NETA for 24 weeks. Results: The studies showed a much lower incidence of endometrial hyperplasia with transdermal E2/NETA than with E2 alone. All studies showed that the incidence of hot flushes and sweating declined from baseline. All patches were well tolerated and treatment-related adverse events and urogenital bleeding were comparable between treatment groups. Conclusions: Continuous combined and sequential transdermal E2/NETA was comparable to transdermal E2 alone, Estraderm TTS plus oral progestin and oral E2/NETA for reducing vasomotor symptoms amongst postmenopausal women. The studies shoed a much lower incidence of endometrial hyperplasia with E2/NETA than with E2 alone. FC3.21.08 EFFECT OF TRANSDERMAL CONTINUOUS COMBINED ESTRADIOL/NORETHISTERONE ACETATE VS ESTRADIOL ALONE ON QUALITY OF LIFE IN POSTMENOPAUSAL WOMEN S. Shumaker, The Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA. Objectives: To investigate the effects of three doses of norethisterone acetate (NETA) administered together with estradiol (E2) in a continuous combined regimen vs. transdermal E2 alone on quality of life (QoL) in postmenopausal women. Study Methods: In a 1-year, multicenter, randomized, double-blind, parallel-group study a total of 625 healthy post menopausal women aged 40-70 years with an intact uterus were randomized into four treatment groups: E2 50 mg/day, with one of three doses of NETA 140, 250 or 400 mg/day (50/140, 50/250, 50/400) compared with E2 50 mg/day alone. Study endpoints were selected QoL parameters. Effects on vasomotor symptoms and genital bleeding were also monitored. Results: In all treatment groups sexual arousal improved from baseline to study endpoint. Sleep disturbances decreased significantly from baseline to endpoint in all E2/NETA groups (50/140, p=0.050; 50/250, p=0.036 and 50/400, p<0.001). Improvements in urinary incontinence and cognitive function were significantly greater in the 50/400 group compared to those receiving E2 alone (p<0.001). The E2/NETA combination patch demonstrated effects comparable to E2 alone with respect to vasomotor symptoms. During cycles 10, 11 and 12, the percentage of women who were amenorrheic decreased to 35% in the E2 50 group and increased to 39% in the 50/250 group and to 44% in the 50/400 group. The percentage of women who were amenorrheic showed little change in the 50/140 group (48 to 53%). Conclusions: Overall the combined E2/NETA patch improved QoL in postmenopausal women. E2/NETA combination HRT (Estalis) has been shown to have greater benefits on QoL parameters than transdermal E2 alone. FC3.21.09 ANTIDEPRESSANTS AND HORMONAL REPLACEMENT THERAPY IN TREATMENT OF DEPRESSIVE DISORDER CAUSED BY POST-OVARIOECTOMY. Y. Svetlana (1), S. Vera (1), K. Galina (2), K. Valery (2), (1) Research Centre of Ob\Gyn & Perinatology, Oparino 4, Moscow, Russia, 117815, (2) Moscow Institute of Psychiatry, Moscow, Russia. Objectives: The goal is the study of effective of using antidepressants and hormone replacement therapy (HRT) in the treatment depressive disorder caused by postovarioectomy. Study Methods: Pharmacological, psychometric methods with specially developed map, Hamilton's dials of anxiety and depression. Results: In 57,5 % cases dysthymia was diagnosed, in 22,5 % cases depressive episode (easy and middle degrees of Redness) was diagnosed (ICD-10). During the treatment of HRT somatovegetative disorders were reduced (group A). During the initial use of tianeptine (25 mg), sertraline (50 mg) mood disorder was decreased (group B). Conclusion: Influence on the pathogenic mechanisms of depression makes different class of medicines use effective.

FC3.21.06 THE INFLUENCE OF HORMONE REPLACEMENT THERAPY ON THE AGE-RELATED CHANGE IN COGNITIVE PERFORMANCE. E.L.Lkkegaard (1), A.T.Pedersen (1), P.Laursen (2), I.P.Loft (2), S.Larsen (2), T.Jrgensen(2), (1) Hvidovre University Hospital, Kettegrd All 30, Hvidovre, Denmark, DK-2650, (2) Copenhagen County Centre of Preventive Medicine, Glostrup University Hospital, Denmark. Objective: To analyze over an 11-year observation period the impact of hormone replacement therapy(HRT) on age-related changes in a broad spectrum of cognitive functions and to assess if women choosing HRT are characterized a priori by better cognitive function. Study Methods: The analyses were based on data from a longitudinal prospective sub-cohort of 226 women from a large population-based study. A psychological examination was performed twice, 11 years apart applying a computer-aided test technique - the Cognitive Function Scanner, including 28 cognitive parameters. The final analyses comprised 126 "never users" of HRT, 40 "current users" at follow-up and 30 "future users", defined as women who started HRT subsequent to baseline registration during the eleven-year observation period. These groups were compared according to cognitive performance using multivariate statistical methods to adjust for confounding factors. Results: A tendency that current users of HRT exhibited a less pronounced decline in cognitive function over an eleven-year observation period compared to "never users" was found. This tendency was, however, only significant for three parameters of the comprehensive applied battery of cognitive tests. We also found a general tendency that women subsequently choosing HRT are characterized by better cognitive function at baseline. Conclusions: It appears that HRT postpones the age-related decline in specific areas of cognitive function. However, women choosing HRT are characterized by better cognitive functioning a priori, which might induce a potential selection bias.

FC3.21.07 EFFICACY OF TRANSDERMAL STRADIOL/NORESTHISTERONE ACETATE VS. OTHER HRTS ON VASOMOTOR SYMPTOMS IN POSTMENOPAUSAL WOMEN H. Burger (1), D.F. Archer (2), M. P. Dain (3) (1) Prince Henrys Institute of Medical Research, Monash Medical Centre, Victoria, Australia. (2) Dept. OB/GYN, Eastern Virginia Medical School, Norfolk, VA, USA. (3) Rhne-Poulenc Rorer, Antony, France. Objective: To compare the efficacy of continuous combined and sequential transdermal estradiol/noresthisterone acetate (E2/NETA) HRT (Estalis and Estalis Sequi) vs. transdermal E2 and oral progestrin and oral E2/NETA (Kliogest) on vasomotor symptoms and endometrial hyperplasia in healthy postmenopausal women. The primary endpoint was the incidence of endometrial hyperplasia. Study Methods: 4 separate randomized, double-blind studies, over 400 women with 3 hot flushes/day received the following HRT regimens: 2 groups received either a patch releasing E2 50 mg/day or a combination E2/NETA patch delivering E2 50 mg/day and either 140, 250 or 400 mg/day NETA for 52 weeks; 1 group received transdermal

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FC3.22 HYSTEROSCOPY: DIAGNOSIS FC3.22.01 OUTPATIENT DIAGNOSTIC HYSTEROSCOPY WITH HYDRODILATATION M. A. Siddig Dept. OB/GYN Royal Cornwall Hospital, Truro, Cornwall, UK Objectives: To evaluate the success, indications, complications and results 286 diagnostic hysteroscopies performed with hydrodilatation (without anaesthesia) in a district general hospital. Design: Retrospective analysis of hysteroscopy charts between 1996 and 1998. Setting: Royal Cornwall District General Hospital, Patients: 286 patients referred for outpatient diagnostic hysteroscopy for different indications. Intervention: Diagnostic hysteroscopy was performed in 86% of patients without anaesthesia or cervical dilatation. Hydrodilatation technique was used by increasing the pressure of the infused saline to 200cm H2O. The hysteroscope was introduced under direct vision using a camera. Results: The most common indication for hysteroscopy was PMB (26.5%). Hysteroscopy was successfully performed in 90.9%. In 86% of women we accessed the uterine cavity with hydrodilatation technique under direct vision without premedication, local anaesthesia or cervical dilatation. In 39.8% intrauterine pathology was diagnosed and in 10% further surgical treatment in the form of hysterectomy was carried out. The most common cause of failure was cervical stenosis (61.4%). Conclusion: Diagnostic outpatient hysteroscopy with hydrodilatation and introduction of the hysteroscope under direct vision is feasible in overwhelming majority of cases without local anaesthesia. The low complication rate and the high detection rate for intrauterine pathology justifies performing this procedure in the office as routine in the new century. FC3.22.02 THE ACCURACY OF HYSTEROSCOPIC VISUAL IMPRESSION FOR DIAGNOSING ENDOMETRIAL COMPLEX ATYPICAL HYPERPLASIA OR CANCER G. Del Priore, S. Feinstein, F.S.Williams, A. Lui, NYU School of Medicine, 530 First avenue, suite 9R, New York, NY, United States, 10016. Objective: The aim of the study was to determine the accuracy of hysteroscopic visual impression (HSC) for diagnosing endometrial complex atypical hyperplasia (CAH) or endometrial cancer (CA). Methods: Using the medical record and pathology department databases from 1994 to 1998, we identified all patients diagnosed with CAH or CA. Those patients who had also had hysteroscopy with dilation and curettage (HSC D&C) as part of their work-up are the subjects of this study. Results: There were approximately 700 patients with either CAH or CA, 44 of which had a HSC D&C. Medical records were available for all of them. Patient ages were between 23 and 87 years with a mean of 58.1. Uterine size was between 4 and 13 weeks with a mean of 6.8. The indication for HSC D&C was abnormal uterine bleeding in 54.5%, a suspicious prior office biopsy in 20.5%, abnormal sonogram in 13.6%, other in 4.5% and not specified in 9.1%. The pre-operative diagnosis was rule out cancer or CAH in 26.8%. This number did not change after HSC. However, in two patients, the pre-operative diagnosis of CAH or cancer was changed to an incorrect benign diagnosis. In two other patients, who had not been diagnosed pre-operatively with CA or CAH, visual impression under hysteroscopy led to these correct diagnoses. The operative findings were reported as completely normal in 7.3% and various other benign findings were reported in 82.9%. The preoperative diagnosis was changed by hysteroscopic appearance in 9.8% of cases. Compared to final pathologic diagnosis, the intra-operative HSC detection of CA or CAH (sensitivity 26.8%) added nothing to the preoperative clinical impression (sensitivity 26.8%). Conclusions: The operative impression based on HSC appearance rarely matches the post-op pathologic diagnosis of CAH or CA. Cancer is missed by HSC even when the clinical scenario suggests malignancy. We found that physicians are not more likely to correctly predict CAH or CA with HSC information. Further study is needed. However, the data suggests that hysteroscopy is of little benefit in diagnosing CAH or CA. FC3.22.03 INTEROBSERVER VARIATION IN THE ASSESSMENT OF HYSTEROSCOPIC IMAGES J. Bernardes, M. Martinho, P. Xavier, J. Monsanto. Departamento de Ginecologia e Obstetrcia, Hospital de S. Joo, Faculdade de Medicina do Porto, Portugal

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Objective: Evaluation of interobserver agreement in the assessment of hysteroscopic images. Methods: Sixty consecutively recorded hysteroscopic video-tapes with good quality image were selected, obtained with a 5 mm Hamou II hysteroscope and saline as distension media. The tapes were reviewed by three experienced specialists in hysteroscopy, who were asked to detect and identify intra-cavitary lesions as polyps, myomas, neoplasia, adhesions, malformations and IUD and to classify the endometrial pattern as atrophic, proliferative, secretory or hyperplastic. For statistical analysis, the proportions of agreement (PA) and the k statistic, with 95% confidence intervals (95%CI) were used. Results: Interobserver agreement was excellent regarding the detection of intra-cavitary lesions (PA=0.86, 95%CI 0.84-0.89; K=0.79, 95%CI 0.70-0.89), but only fair to good in the classification of the endometrial pattern (PA=0.65, 95%CI 0.61-0.69; K=0.49, 95%CI 0.40-0.59). Conclusions: A good agreement between specialists is found in hysteroscopic detection of intra-cavitary lesions, but less so in the classification of endometrial patterns. Care should be taken in the interpretation of endometrial patterns as obtained through the hysteroscope, as this may not be very reproducible. FC3.22.04 CLASSIFICATION OF MICROHYSTEROSCOPIC IMAGES AND THEIR CORRELATION WITH HISTOLOGICAL DIAGNOSES J.E. Dotto, B. Lema, Instituto Argentino de Diagnstico, Buenos Aires, Argentina. We have suggested a method for the systematic classification of hysteroscopic images based on our experience with 1436 hysteroscopies and their corresponding biopsies. Images are classified as follows: normal hysteroscopy, benign disease, low risk hyperplasia, high-risk hyperplasia and carcinoma. There is a strong correlation between the classification of images and the histological diagnosis; in the first two groups the correlation was present in every case; there were some false positives and false negatives in the low and high risk hyperplasias and carcinomas, the causes of which have been analyzed. If this classification system is used for the diagnostic exploration and submitted to the final histological diagnosis it can be useful for a systematic approach to hysteroscopic findings and to improve communication between specialists involved in a case. It is based on the degree of hysteroscopic suspicion aimed at the early detection of endometrial cancer and its precursor lesions. Correlation between microhisteroscopy images and histopatological confirmation
N.H. N.H.I. B.D. L.R.H. H.R.H. CARC Total Histopath. Confirm. N.H.I.: L.R.H.: CARC: S.H.: NORMAL HYSTEROSCOPIC IMAGE LOW RISK HYPERPLASIA CARCINOMA SIMPLE HYPERPLASIA B.D.: H.R.H.: N.H.; C.H.: BENIGN DISEASE HIGH RISK HYPERPLASIA NORMAL HISTOLOGY COMPLEX 1040 0 0 0 0 1040 B.D. 0 290 10 0 0 300 S.H. 0 0 60 4 0 64 C.H. 0 0 0 11 0 11 CARC. 0 2 0 0 19 21 TOTAL IMAGES 1040 292 70 15 19 1436

HYPERPLASIA The correlation was significant (p<0.001) Cramer V correlation coefficient = 0.925 The Lambda coefficient = 0.96

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FC3.22.05 NATIONAL SURVEY OF OUT-PATIENT HYSTEROSCOPY IN THE UK L. Rogerson, S. Duffy, Dept. OB/GYN, St. Jamess University Hospital, Leeds, UK. Objectives: The investigation of women with bleeding using outpatient hysteroscopy has been established in a number of units in the UK. The benefit to patients and the Health Service is currently under review. The extent to which outpatient hysteroscopy is available to patients is not clear, possibly due to preferred alternative clinical practice. In 19941995 over 100,000 diagnostic procedures were undertaken for menorrhagia in England alone, with only 30,000 of these performed in the out-patient setting. This survey is designed to explore the current practice in relation to outpatient hysteroscopy with staffing levels, training facilities and equipment used with the underlying reasons as to why it may not be in use. Study Methods: We sent postal questionnaires to all consultant gynecologists in the UK with no reminder sent for non-responders. Results: Of 1148 questionnaires sent 629 were returned (55%) response rate, a previous study in 1996 initiated at Bradford in the UK had a response rate of 43%. The findings relating to the differing practices will be presented in detail but 48% of respondents had an interest in minimal access surgery. 54% had out-patient hysteroscopy available to them and of the ones with no facility 76% would like it instituted. Conclusions: Out-patient hysteroscopy is widely available and in the units where it is not, there is a significant desire for the facility to be initiated. There is a huge variation in equipment, facilities and staffing for out-patient hysteroscopy.

WEDNESDAY, SEPTEMBER 6
FC3.22.07 DOES THE "Y" IN OUT-PATIENT HYSTEROSCOPY MATTER? P. Quinn, P. Mc Gurgan, P O'Donovan, MERIT Centre, Bradford Royal Infirmary, U.K. Objectives: Evaluate the preconceptions and perceptions of patients having out-patient hysteroscopy, with emphasis on their attitudes towards the gynaecologist's gender. Study methods: Prospective anonymous questionnaire used before and after the procedure for women referred to an out-patient hysteroscopy clinic in a district general hospital, where the surgeon was randomly allocated, and blinded to results. Results: Out patient hysteroscopy was performed on 77 patients, (38 and 39 patients had a male or female surgeon respectively). The two groups of patients were similar in age, parity, ethnicity, referral source and pre-medication use. Fifteen (39%) of the patients allocated to a male, and 9 (23%), of the patients allocated to a female would prefer a female hysteroscopist. This was not statistically significant (p= 0.12), no patients expressed a preference for a male. Gender preference had no significant effect on pre-operative anxiety (p=0.58), or procedure discomfort (p=0.76), or satisfaction (p=0.28). Patients treated by a male were more likely to state that the procedure would have been improved by having a female surgeon (p=0.054). Conclusions: The preference rates for gender are comparable to other published studies. Patients treated by operators of different genders do not have any difference in discomfort or satisfaction scores, but women treated by men perceive that the procedure would be improved if they were treated by a female operator. For future practice, women should be given a choice of gender were practical, however it does not appear to have any effect on discomfort or satisfaction. FC3.22.08 RANDOMIZED PLACEBO CONTROLLED TRIAL TO ASSESS THE ROLE OF LIDOCAINE AEROSOL SPRAY IN OUTPATIENT HYSTEROSCOPY D. Soriano, S. Ajaj, T. Chuong, B. Deval, A. Fauconnier. E Dara, Service de Gyncologie, Hpital Htel-Dieu, Paris. France. Objective: We conducted a randomized, placebo-controlled trial to assess the efficacy of lidocaine spray during outpatient hysteroscopy in reducing the procedure pain and to identify risk factors for this discomfort. Study Methods: One hundred twenty one patients undergoing outpatient hysteroscopy were randomly assigned to have application of lidocaine spray or placebo to the uterine cervix, during outpatient hysteroscopy. Main Outcome Measures was the evaluation of pain during hysteroscopy on a visual analogue scale. Results: There was no statistically significant difference between the study and the control groups in the mean SD age of the patients, the rate of nulliparity, postmenopausal state, the need for cervical dilation, or in the percentage of women using hormone replacement therapy. The indications for diagnostic hysteroscopy were similar in the two groups. Women in the anesthetic group had statistically significant less pain during the procedure in comparison with women in the placebo group 2.2 1.9 and 3.7 2.5 respectively (p<0.0004). Women with abnormal uterine findings (endometrial cancer, submucose myoma, endometrial polyp, or intra-uterine adhesions) had a significantly higher pain score than women with normal cavity 2.2 1.9 and 3.2 2.4 respectively (p<0.002). The use of aerosol anesthesia and normal uterine findings were independently associated with less pain. No procedure had to be abandoned due to excessive pain or development of complications and no women required hospital admission. Conclusion: Women treated with lidocaine spray experienced significantly less pain. Abnormality of the uterine cavity may be associated with higher degree of pain during hysteroscopy. Further evaluation of this finding is needed.

FC3.22.06 FLEXIBLE OUTPATIENT HYSTEROSCOPY AT A DISTRICT GENERAL HOSPITAL: PATIENT'S PAIN RELIEF AND SATISFACTION WITH A COMBINATION OF ORAL AND LOCAL ANALGESIA. A C Paul, Bangladesh Medical College, Dhaka, Bangladesh. M A Debono, Dept. OB/GYN, Halifax General Hospital, Salterhebble, Halifax, U.K. Objectives: To study the effect of oral diclofenac and lignocaine spray to the cervix on level of patients pain relief and satisfaction during outpatient flexible hysteroscopy. Study Methods: From July 1998 to October 1999, patients having outpatient flexible hysteroscopy were invited to participate into this prospective study and 160 of them agreed. For analgesia, they had oral diclofenac and local lignocaine spray. Hysteroscopy was performed with a 3mm flexible hysteroscope. The data was collected from a standardized data collection form filled by the patients immediately after and at 15 minutes of the procedure. A visual analogue chart was used to document pain as mild, moderate and severe. To assess their satisfaction, patients were asked whether they would consider this procedure in future. Results: The most common indication for hysteroscopy was abnormal vaginal bleeding. There were 51(31%) postmenopausal and 59(36%) perimenopausal women with abnormal vaginal bleeding. During the procedure, 44 (27%) women had no pain and in 63(39%) the pain was mild. Moderate pain was complained by 46(29%) and in 7 (4%) the pain was severe. Hysteroscopy was completed in 157(98%) and 155(96%) had endometrial biopsy. At 15 minutes after hysteroscopy, 90(56%) complained of no pain. Mild, moderate and severe pain was reported by 47(30%), 18(11.25%) and 5 (3%) of the women respectively. If required for them, 156(97.5%) of the women will consider this procedure in future. Conclusions: Outpatient hysteroscopy with oral diclofenac and lignocaine spray to the uterine cervix is a well tolerated procedure and highly appreciated by the patients.

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FC3.22.09 DIAGNOSTIC WORK-UP AND THERAPEUTIC MODALITIES FOR PERSISTENT DYSFUNCTIONAL UTERINE BLEEDING (DUB) M. Salah, M. Fathalla, H. Abdel-Aleem, I. El-Nashar, A. El-Samman, Dept. OB/GYN, Faculty of Medicine, Assiut University, Assiut, Egypt. Objectives: To evaluate a diagnostic work-up for DUB consisting of D&C biopsy, diagnostic hysteroscopy, ultrasound examination, Doppler and screening for thyroid, liver and blood diseases. Secondly, to compare between the results of hysterectomy versus endometrial ablation. Study Methods: 82 patients with DUB who failed to respond satisfactorly for a reasonable trial of medical, hormonal treatments and several D&Cs, were evaluated using the items of the diagnostic workup. Treatment options (hysterectomy versus endometrial ablation) were compared using computer package software (SPSS). Results: Uterine polypi were diagnosed definitely by ultrasound only in 28.5% suspected in 5% and false negative results in 21.5% of cases. Doppler indices were lower in cases with hyperplasia than proliferative endometrium. Positive findings on hysteroscopy were found in 31 cases (polyps in 41.9%, submucous fibroids 29% and polypoidal endometrium in 12.9%). Thyroid disorders were found in 30 cases (3.6%) and blood diseases in 3 (3.6%). 38 cases were treated with hysterectomy and 38 with electrosurgical ablation. Intraoperative and postoperative morbidity are higher in the hysterectomy group. Postoperative hospital stay and pain are less in the ablation group. Conclusions: D&C has a false negative rate of 37.8%, hysteroscopic examination proved to be an excellent method for detection of intracavitary lesions. Transvaginal sonography is a single non-invasive method of detection of gross uterine and ovarian abnormalities but has a limited value in the diagnosis of small polypi. When the Doppler indices were higher (85) the presence of simple hyperplasia was <10% and there were no organic lesions. Hysterectomy is an ultimate choice for treatment of bleeding problems with an excellent satisfaction rate (>90%). However, it is associated with relatively high morbidity and is considered an overtreatment for benign conditions. Endometrial ablation is an attractive, alternative line of treatment with less morbidity and reasonable satisfaction rate of 80%.

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Results: High malignancy risk HPV types were found in 29% of cases. After logistic regression analysis we found out that significant risk factors for high malignancy risk HPV types was sexual debut <18 years OR 2.07 CI (1.35-3.17); > 1 partner/year OR 2.17 CI (1.42-3.34); smoking OR 2.73 CI (1.64-4.55); important risk factors were other STDs e.g. syphilis OR 1.89 CI (0.46-7.89). Conclusions: Risk factors for high malignancy risk HPV types are similar to the risk factors for other STDs.

FC3.23.03 THE ROLE OF HUMAN PAPILLOMAVIRUS TESTING IN CERVICAL SCREENING. Paraskevaidis E1, Koliopoulos G1, Paschopoulos M1, Kontostolis E1, Zikopoulos K1, Pappa L2, Malamou-Mitsi M2, Kalantaridou SN1, Georgiou I3, Kitchener HC4, Lolis DE1. 1 Gynecologic Oncology Unit, Department of Obstetrics and Gynecology; 2Department of Cytopathology; and 3Laboratory of Molecular Biology, Department of Obstetrics and Gynecology, University of Ioannina School of Medicine, University Hospital, Panepistimiou Avenue, 45500, Ioannina, Greece, 4Department of Obstetrics and Gynecology and Reproductive Health Care, St Marys Hospital, Manchester, UK Objective: To investigate whether human papillomavirus (HPV) testing should be performed as a screening test along with Papanicolaou (pap) smear for the detection of cervical intraepithelial neoplasia (CIN) lesions not detected by pap smear. Study Methods: HPV typing by using semi-quantitative PCR/ELISA (subtypes 16/18 and 31/33) was performed in 1000 women who were self-referred for routine Pap-smear. Women were further referred for colposcopy following a smear indicating squamous intraepithelial lesions (SIL) or positive HPV testing. Large loop excision of the transformation zone (LLETZ) was performed in all the women with cytologic and colposcopic findings of SIL. Shallow loop excision of the transformation zone was performed in women with positive HPV testing and colposcopic impression of SIL. Results: Pap smear examination was suggestive of HPV infection in 22.3% of the women, CIN1 in 2.1%, and CIN2/3 in 1.8%. LLETZ was performed in 64 cases. Histologic evaluation revealed HPV infection in 3 cases (5%), CIN1 in 34 (53%), and CIN2/3 in 27 (42%). Positive HPV typing was found in 46 (6%) of the remaining 738 women. Shallow loop excision of the transformation zone was performed in 11 of the above 46 women due to colposcopic impression of SIL. Histologic examination revealed HPV infection in 6 cases (55%), CIN1 in 4 (36%), and CIN2/3 in 1 (9%). Overall, pap test detected 94% of the cases with CIN (61 out of 66) whereas HPV typing detected 6% (5 out of 66). Conclusions: In a screening program, pap test detected 94% of women with CIN. HPV typing resulted in the identification of 6% of women with CIN which would have been missed by standard cytologic screening. Randomized trials are required to determine the role of HPV testing in cervical screening.

FC3.23

LOWER GENITAL TRACT: INTRAEPITHELIAL NEOPLASM

FC3.23.01 AVALIATION OF THE CERVICAL AND VAGINAL INTRAEPITHELIAL NEOPLASIAS FOUND IN 3105 COLPOSCOPIES REALIZED IN CLASSES A AND B WOMEN S.K. Alperovitch, D. Alperovitch, Paulist Association of Medicine, So Paulo, Brazil. Objective: The objective in this work is the study of frequency of CIN and VAIN in 3.105 colposcopies realized in classes A and B women in Saint Paul City. Study Methods: The diagnosis was done by histopathological examination obtained by directed biopsies. Results: We found 06 cases of CIN (3 CIN I) and 03 cases of VAIN (2 VAIN I). Conclusions: We concluded that in class A and B women the frequency of CIN and VAIN occur in 0.19% and 0.09%, and the use of colposcopy is important in cervical cancer prevention.

FC3.23.02 RISK FACTORS FOR HIGH RISK HPV TYPES AMONG 18-35 AGED WOMEN R. Nadisauskiene, M. Kliucinskas, T. Spukaite, Z. Padaiga, Dept. OB/GYN, Kaunas University of Medicine, Kaunas, Lithuania. Objectives: The aim of the study was to evaluate risk factors for the patients with high malignancy risk HPV types between 18-35 year old women. Study Method: 475 women participated in the cross sectional study. Non-anonymous questionnaire with structured and open questions was used, gynecological examination, Pap smear, Schiler test were done; HPV was detected by Hybrid Capture testing.

FC3.23.04 PAPANICOLAOU TEST RESULTS AND COLPOSCOPY FINDINGS IN WOMEN WITH BACTERIAL VAGINOSIS J. Sisovic1, A. Georgijevic2, S. Djukic-Ivancevic2, M. Bujko3 1 1 Gynecology Department of Outpatient Clinic Vozdovac, Belgrade, Yugoslavia 2 Institute of Microbiology and Immunology, School of Medicine, University of Belgrade, Yugoslavia 3 Institute of Public Health, School of Medicine, University of Montenegro, Podgorica, Yugoslavia Objectives: The aim of the study was to investigate what are Papanicolaou test results and colposcopy findings in women with bacterial vaginosis (BV). Study methods: Ninety-six women of reproductive age were examined in the Gynecology Department of one Belgrade Outpatient Clinic. The pregnant women were excluded. Each woman was examined gynecologically and with the colposcope, and for every woman the Papanicolaou test was done and also microbiological analysis of her vaginal secretion. Diagnosis of BV was made by Nugent criteria. Using Nugent scoring system women were divided into three groups: women with BV, women with intermedial vaginal flora and women without BV.

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The data were statistically analyzed using &#967;2-test and Fishers exact test. Results: Twenty (21%) of examined women had BV. Among them six (30%) had normal colposcopy findings compared to 86% (56 vs 65) of women without BV (p<0.01). Vaginal hyperemia with vaginal discharge were found in 30% (6 vs 20) of women with BV and in 4% (3 vs 65) of women without BV (p<0.01). Chronical cervicitis had 15% (3 vs 20) of women with BV and 2% (1 vs 65) of women without BV (p<0.05). Leukoplakia was found in 20% (4 vs 20) of women with BV and in 3% (2 vs 65) of women without BV (p<0.05). Papanicolaou test results of all 96 (100%) examined women showed normal findings (p>0.05). Conclusions: Women with BV have more often some pathological colposcopy findings such as leukoplakia, chronical cervicitis and vaginal hyperemia with vaginal discharge compared to women without BV. Papanicolaou test results are normal for women with BV and for women without BV.

WEDNESDAY, SEPTEMBER 6
discharge (NETZ 9 days, LLETZ 12 days, cold knife,13 days, p=0.008) and f) success rate after single treatment (NETZ, 97.1%, cold knife 85.7%, LLETZ 71.4%). Conclusion: NETZ was associated with fewer problems during surgery and a higher success rate after single treatment. LLETZ had a higher rate of residual disease, and cold knife a higher rate of conversion to general anesthesia. FC3.23.07 RELATION BETWEEN SEXUAL PRACTICES AND HUMAN PAPILLOMAVIRUS (HPV)INFECTION IN THE OROPHARINGEAL CAVITY EPITHELIUM P.C.Giraldo (1), A.K.Gonalves (2), F.Ribeiro (1), D.Ayrton (1), S.Witkin (3), (1) University of Campinas/UNICAMP, Alexander Flemming, 101, Campinas, So Paulo, Brazil, 13083-970, (2) Federal University Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, (3) Weill Medical School of Cornell University, New York, NY, United States. Objective: To check the frequency of HPV in the oral cavity of women diagnosed with genital HPV infections and correlate it to sexual practices. Material and Methods: HPV infected women (102) were investigated for evidence of HPV in the oral cavity by means of Pap- smears. The subjects were questioned about sexual practices, STD history and smoking. HPV diagnosis in the oro-pharynx was based on the presence of Koilocitosis and Discariosis on the cytological smear. Results: Oral and anal sex were practiced by 66.6% and 51.9% of the cases, respectively. HPV in the oral mucusa was confirmed in 22 cases (21.5%), in 31 cases (30,4%) there was a cytological suspicion of HPV and the remaining 49 women were HPV negative. Oral and Anal sex was practiced by 72.2% and 63.6% respectively of the oral HPV positive women. A history of privious STD was stated in 27.2% versus 34.7%, smoking in 18.1% versus 24.5% and the presence of tooth cavities in 63.6 versus 75.5% of the HPV+ and HPV- respectively, in the oropharynx. The statistical analisis, using two-tailed Fisher exact test showed no significant differences with regards the practice of oral sex (p=. 61), anal sex (p= .23), tooth decay (p= .39) and smoking (p= .76) comparing oro-pharyngex HPV + and - women. Conclusion: The data suggests a high frequency of HPV in the epithelium of the oro-pharynx of women with genital HPV. The practices of oral and anal sex do not seem to influence the carriage of HPV in the oro-pharynx

FC3.23.05 SIGNIFICANT INFLAMMATION IS NOT NECESSARY FOR CLEARANCE OF EXTERNAL GENITAL WARTS BY IMIQUIMOD RL Miller, TL Fox, HB Slade, M Smith, MA Tomai, 3M Pharmaceuticals, St-Paul, MN, USA. Objectives: Imiquimod (IQ) is new immune response modifier which is available for the treatment of external genital and perianal warts (EGW). The associations of significant inflammation with the clearance of EGW was examined. Study Methods: In two randomized, placebo-controlled trials patients applied IQ 5% cream three times/week until total wart clearance, or for a maximum of 16 weeks. Results: In a Phase III trial, patients with mild or no erythema at the treatment site had a complete clearance rate of 47% (29/62) and patients with moderate or severe erythema, 57% (25/44). In mechanism of action, study, treatment of EGW with topical IQ demonstrated cytokine induction. Biopsies were taken at baseline, wk 6 and end of treatment from IQ (n=16) or placebo (n=3) patients. RT-PCR using specific primers showed relative increases from baseline for mRNA levels of cytokines and cell markers and decreases in HPV gene products. PCR showed a decrease in HPV DNA copies/cell. All IQ treated patients had >75% reduction in wart area and seven totally cleared their lesions. Three of these seven had mild erythema. One IQ patient had an 88% reduction in lesions and no erythema. Increases in mRNA for proinflammatory cytokines did not correlate with clearance of lesions. Conclusion: Local erythema is often seen during clearance EGW lesions by IQ but significant inflammation is not necessary for clearance of the lesions. FC3.23.06 A RANDOMIZED PROSPECTIVE STUDY OF COLD KNIFE, LARGE LOOP EXCISION AND NEEDLE EXCISION OF THE TRANSFORMATION ZONE FOR TREATMENT OF CERVICAL INTRAEPITHELIAL NEOPLASIA A L. Sadek, O. Istre, G B. Trolle, Dept. OB/GYN, Hedmark Central Hospital, Elverum, Norway, and H. A. Schitz, Dept. OB/GYN, Vestfold Central Hospital, Tnsberg, Norway. Objectives: To compare Needle excision of the transformation zone (NETZ), in which a new, specially designed diathermy needle is used, with Large loop excision (LLETZ) and Cold knife for the treatment of CIN. Study Methods: A prospective study was done on 105 women with histologically verified CIN. They were randomized to three groups, each of 35 patients. Surgery was done under local anesthesia as outpatient procedures. There were no statistically significant differences between the groups. Follow-up time is three years; all patients were evaluated at 3, 6, 9, 12, 18, 24 and 36 months after surgery. Descriptive statistical analysis, one way Anova and Pearson c2 statistics were used. Results: The following statistically significant differences between groups were seen: a) mean operating time including anesthesia (NETZ 7.4 minutes, LLETZ 8.6 minutes, cold knife 17.7 minutes, p=0.001), b) conversion to general anesthesia (NETZ 11%, LLETZ 22%, cold knife 37%, p=0.04), c) free resection margins (NETZ 85%, LLETZ 37%, cold knife 68%, p=0.002), d) residual disease (NETZ 2%, LLETZ 28%, cold knife 14%, P=0.006), e) mean postoperative duration of vaginal

FC3.23.08 TOPICAL TREATMENT OF HPV GENITAL INFECTIONS USING RIBAVIRIN YES OR NO V. Stanimirovic1, B. Stanimirovic2, D. Nikolic3, A. Nikolic4 1 Galenika R&D Institute, Belgrade; 2 GYN/OB Clinic Narodni front, Belgrade; 3 Clinical Center "Bezanijska kosa", Belgrade; 4 Clinical Center "Dragisa Misovic", Belgrade Objectives: Ribavirin, a nucleoside similar to guanosine, has both virustatic and immunological potentials. The objectives of this prospective study (Phase IIb) were to assess the efficacy and predict the level of response to ribavirin in patients with HPV genital infection (types 6 and 11), as well as to determine the safety of topically administered ribavirin in these patients. Study Methods: Fifty eligible patients with detected early clinical and subclinical forms of HPV infection (types 6 and 11) involving skin, mucosa and lower genital tract (LGT) were evaluated in this open, individually-controlled study. The following diagnostic methods have been used in detection and verification of HPV changes: clinical observation, cytology, colposcopy, virology (in situ hybridization). The 28-day treatment period was succeeded by a 28-day follow-up period. During the treatment period 7.5% ribavirin cream was applied four times a day to HPV changes. The regression of the symptoms and signs of the disease was monitored in the course of both periods. Results: In 96% of patients a partial clinical and/or laboratory response was noted. The regression of local symptoms associated with the infection (burning, pain, pruritus) started on Day 8 of the treatment in 50% of patients, while at the end of the treatment period none of the patients had the above symptoms. During and after the treatment period

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no local or systemic adverse effects were reported resulting from ribavirin administration. Conclusions: Topically applied ribavirin has an effect on regression of the clinical manifestations of HPV genital infection. Further studies are required (with new dosage and pharmaceutical forms) in order to elucidate fully the relationship between ribavirin and HPV genital lesions. FC3.23.09 CERVICAL COLPOSCOPY, CYTOLOGY AND HISTOLOGY: REVIEW OF 3605 RECORDS Uma Devi.K., U.D.Bafna., V.K.Ahuja., E.Vallikad, Kidwai Memorial Institute of Oncology (KMIO) Bangalore, India The case records of 3605 women underwent Colposcopy at the department of Gynaecologic oncology between January 1989 and December 1997 has been reviewed.All women without any obvious malignant lesion of the cervix were examinedwith the colposcope. An attept has been made to correlate colposcopic observations with Cervical Cytology and Histology. Majority (86.2%) were above the age of 30 years and 86% belonged to lower socioeconomic groups. The Cervical smears were taken in 3114 women, reported as class I and II in 88.7 % and has reported as class III and above in 10.7%. The colposcopic observations were graded using Coppleson's classification. A satisfactory colposcopic examination could be performed in 56.79%, Grade I changes were observed in 29.37% and only 4.75% had Grade III changes. A normal Transformation Zone was seen in 19.5% women, Grade I changes were assosciated with smears of class I & II in 92.8% and histology of Normal or Inflammatory in 82.8%. Grade III changes were assosciated with smears of class III and in 14.45% and histology of CIN III or Invasive Cancer in 84.4%.

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FC3.24.02 ACTUAL INTAKE DURING LABOR IN THE NETHERLANDS. LACK OF CALORIC INTAKE LEADS TO A HIGHER RISK OF AN INSTRUMENTAL DELIVERY. H.C.J. Scheepers, M.C.J. Thans, P.A. de Jong, G.G.M. Essed, S. Le Cessie, H.H.H Kanhai., Leyenburg Hospital, The Hague, The Netherlands Objectives: In the Netherlands, women are in most cases, allowed to eat and drink. In this study the actual intake of nutrients during labor is studied and related to the course of the delivery. Methods: Dutch midwives (n=32) and gynecologists (n=34) included each 5 consecutive nulliparous women, who were asked to write down what caloric intake they had during delivery. 213 women (65%) could be evaluated. A multivariate logistic regression model compared spontaneous deliveries with instrumental deliveries due to a non progressing second stage. Caloric intake, duration of labor, fetal presentation and weight, the use of pain medication, a high versus low risk delivery and spontaneous start of labor versus induced labor were used as prognostic factors. Results: During labor, 38% of the women had intake other than water, of whom 74% ate solid food. Women without caloric intake had a higher probability of an instrumental delivery due to a non progressing second stage, even after adjusting for the other prognostic factors. Conclusion: Caloric intake during labor results reduces the chance of an instrumental delivery because of a non progressing second stage. Solid food, contributes less to the available energetic substrate, if it remains in the stomach, and is in case of aspiration more damaging. Therefore, the use of caloric liquids is probably preferable. FC3.24.03 INSTRUMENTAL DELIVERY: AN EXPERIENCE AT A TEACHING HOSPITAL IN NEPAL R. Jha, L. Shrestha, M. Singh, M. Dongol, Dept. OB/GYN and Pediatrics, Tribhuwan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal. Objectives: The aim of the study was to compare vacuum extraction with forceps delivery and evaluate its role in modern obstetric practice. Study Methods: Tribhuwan University Teaching Hospital serves about 210,000 patients annually and is one of the tertiary care hospitals in Nepal. In a five year period (April 1995 to April 1999) a total of 13,333 Nepalese women delivered out of which 239 (1.7%) women had an instrumental vaginal delivery at term in the Obstetrics unit of Tribhuwan University Teaching Hospital, were studied. Out of this number 101 had forceps delivery while 138 had vacuum extraction. Results: The vacuum delivery rate fluctuated between 0% and 1.7% while the forceps delivery rate fluctuated between 0.2% and 1.4%. During this time period the cesarean section rate had steadily increased from 10% to almost 16%. With the exception of fetal distress there were no significant differences found in the indication for forceps delivery and vacuum extraction. Both consultants and residents seemed to use vacuum extraction more than forceps deliveries. The reapplication station position and cervical dilation differ in both infants delivered by vacuum extraction had higher incidence of neonatal jaundice, transient cosmetic deformities including chignon and cephalhematoma. Whereas infants delivered by forceps had skin ecchymoses /abrasions and subconjunctival hemorrhage more frequently. Apgar scores in infants born by vacuum extraction did not differ from those of infants delivered by forceps. Vacuum extraction has gradually assumed more prominence than forceps delivery in our unit in the study period. There was no maternal mortality in the groups. Conclusion: Forceps delivery was associated more with genital tract trauma, whereas vacuum extraction had a higher incidence of cosmetic deformations and neonatal jaundice. Many women and their babies have benefited from this timely and expertly performed procedure. Thus, there is a continuing role for the judicious use of instrumental assistance in modern obstetric management.

FC3.24 MANAGEMENT OF LABOR FC3.24.01 ASSESSMENT OF LIFE SAVING SKILLS (LSS) IN VIETNAM NL Sloan1, B Winikoff1, DT Hieu2, NTN Ngoc3, C Quimby4, G Fassihian1 1 Population Council, New York, NY United States; 2 Ministry of Health MCH/FP, Hanoi, Vietnam; 3Hung Vuong Hospital, Ho Chi Minh City, Vietnam; 4American College of Nurse Midwives, Washington, D.C., United States. Objective: To assess whether LSS training of clinicians in primary and first referral care facilities and providing EOC equipement and supplies improves delivery care. Study Methods: A controlled quasi-experimental study in Bac Thai and Lam Dong provinces, rural Vietnam, was conducted. LSS training centers were created in Hanoi and Ho Chi Minh City. Qualified practitioners from primary health facilities and district hospitals received two weeks of intensive competency-based LSS training, LSS manuals and midwifery kits. Obstetricians from district hospitals received a oneweek LSS and one-week refresher cesarean training. Essential equipment and supplies were provided. Data were collected in intervention and comparison facilities over 12- to 20-months on the management of deliveries. Results: The intervention improved detection of life-threatening obstetric conditions at primary care facilities and district hospitals but only improved their management (including referral) at district hospitals. Conclusion: Primary health care facilities may see too few patients to maintain skills required for EmOC. To improve referral to secondary health facilities, less comprehensive courses should be evaluated in primary health facilities.

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FC3.24.04 CONSERVATIVE POLICY OF INDUCTION OF LABOR IN UNCOMPLICATED POSTDATED PREGNANCIES S.Chakravarti, B.Goenka, Dept. OB/GYN, Vivekananda Institute of Medical Sciences, Calcutta, India. Objectives: To assess the outcome of induction of labor after completing 42 weeks of gestation in uncomplicated postdated pregnancies as opposed to the established policy of routine induction within 41 weeks. Study Methods: Over a period of one year, 231 primigravidae fulfilled the selection criteria of low risk, uncomplicated post dated pregnant patient with confirmed dates. 117 of these patients were randomly allocated to the study group. The remaining 114 patients were managed as per established protocol of induction within 41 weeks of pregnancy. In the study group, fetal surveillance was done by daily fetal movement count (DFMC) and biophysical profile (BPP) and ultrasonography (USG). Patients undelivered at 42 completed weeks of gestation were induced following cervical ripening, if indicated, by prostaglandin E2 gel. Results: 54 patients out of 117 (46%) had spontaneous onset of labor during the period of study and the rest had to be induced. 94 (84%) patients achieved vaginal delivery, 48 in the spontaneous onset group and 46 in the induced group. 8 patients were delivered by forceps and 20 patients underwent cesarean section (7 in the spontaneous onset group and 13 in the induced group). In 114 patients, who served as controls, 29 (25.4%) were delivered by cesarean section. Neonatal mortality and morbidity were unaltered in this group of 231 patients. Conclusions: If DFMC and fetal BPP by USG are unsatisfactory, one may well wait until 42 completed weeks in an otherwise uncomplicated postdated pregnancy even without the help of antenatal fetal cardiotocography. Furthermore, this policy helps in reducing the cesarean section rate.

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Taichong. For estimation of pain we used Visual Analog Scale (VAS) on 4 cm, 7 cm, and 10 cm of cervical dilatations. Results: On 4 cm on cervical dilatation, pain was lower in treated group (t=2.20; p<0.05); on 7 cm (t=3.60; p<0.001); on 10 cm (t=4.23; p<0.001). Apgar score in 1st min. was higher in treated group (t=4.47; p<0.001); in 5th minute there were no differences between the two groups. All women had vaginal delivery. There was no difference between the groups in length of first stage of labor. Conclusions: EA had no side effects on labor, women and fetus. EA has a better analgesic effect than Meperidine (in given dose). EA has a sedative effect. EA can be used for induction of labor. FC3.25 OBSTETRIC AND GYNECOLOGY HEALTH DELIVERY

FC3.25.01 MAKING THE GRADE ON WOMEN'S HEALTH: A NATIONAL AND STATE-BY-STATE REPORT CARD M. Berlin (1), S.Ginsburg (2), M.Greenberger (3), (1) University of Pennsylvania, 423 Guardian Drive, 915 Blockley, Philadelphia, PA, United States, 19104, (2) The Lewin Group, San Francisco, CA, United States, (3) National Women's Law Center, Washington, D.C., United States. Objectives: The mission of the Report Card is to provide a national and state-by-state overview of U.S. women's health to be used by policymakers, researchers, and advocates in creating public policy to promote the health of women. This project assesses the overall wellbeing of U.S. women and identifies steps to maintain and improve their health. Study Methods: The Report Card uses a definition of health that emphasizes well-being as consistent with that of the Beijing's Fourth World Conference on Women and the U.S. Healthy People 2010 (HP2010) objectives. The Report Card uses a set of health status and policy indicators to rate how well the U.S. and it's states are addressing the needs of women. The health indicators go beyond the reproductive needs of women; they provide a common metric for women's health researchers and comprise the analytic foundation for the Report Card. These health indicators are linked to policy analyses and measures of public investments in women's health. Results: Health status indicators describing the spectrum of health conditions from mortality and morbidity to prevention and wellness have been chosen. Companion policy indicators that support and ameliorate health conditions have been selected. Important gaps in data collection, availability, and analysis have been identified and described (including race/ethnicity, age, geography, and literacy issues). Conclusions: By regularly reporting on women's well-being, the Report Card serves as a policy and advocacy tool to improve U.S. women's lives. Over time we will monitor and incorporate trends and investments in women's well-being. FC3.25.02 MATERNAL SATISFACTION WITH THE METHOD OF DELIVERY IN PREGNANCY Y. Sajjad (1) C. Nwosu (1), H. Hamed (1), G. Ramsden (2) (1) Dept. OB/GYN, Whiston Hospital, Merseyside, UK (2) Warrington Hospital, Merseyside, UK Objectives: The aim of the study was to assess maternal satisfaction with the actual method of delivery compared to the womans choice. Study Design: Three thousand four hundred and fifteen pregnant women were recruited in pregnancy prior to the onset of labor. Women were asked to complete a questionnaire indicating their preferred method of delivery if given the choice. Following delivery, they were asked to complete another questionnaire indicating their satisfaction and to what degree they feel they contributed to the method of delivery. Results: 3,197 women (93.6%) felt they had influenced events to a high degree in labor and delivery and were therefore very satisfied with the outcome and method of delivery. 164 (4.8%) women felt that labor and the method of delivery was all right, having contributed to some degree to events while 54 (1.6%) women were not satisfied. Majority of the unsatisfied women had not been granted their wish for delivery by cesarean section.

FC3.24.05 SHOULD THE PARTOGRAM BE ADAPTED FOR TERM VAGINAL BREECH DELIVERIES? I. Babarinsa, M. Oladokun, A. Adeyemo, I. Adewole, Dept. OB/GYN, University of Ibadan, Ibadan, Nigeria. Introduction: Active management of labor is traditionally practiced with cephalic fetal presentation. The use of a partograph is believed to prevent prolonged labor. Few papers have documented experience with breech labors managed with aid of a partograph. Study Methods: This was a 10-year comparative prospective study of the partographic documentation of labors between babies presenting cephalic and by the breech. Augmentation was not done in either group. All partographs were retrieved and 10 variables extracted. Analysis was with EPI-INFO version 6.0. Results: Two hundred and nine (209) consecutive breech presenting babies were compared with (209) cephalic presenting babies. Mean duration of entire labor was shorter in breech (OR 2:1:8), but duration of second stage was shorter in cephalic. Five minute Apgar scores were similar, but 1-week of life status was worse for breeches (OR 0.75:1). Conclusions: Intrapartum care of breech presenting babies using the standard partograph will require major validation, modification and adaptations related to estimated fetal weight. FC3.24.06 ELECTRO-ACUPUNCTURE FOR PAIN CONTROL IN LABOR M. Dunjic. M. Jevremovic, B. Dunjic, N. Sulovic, S. Stanisic, P. Momcilov, Dept. OB/GYN University Clinic, School of Medicine, Pristina, Belgrade, Yugoslavia. Objectives: The aim of this study is to estimate the role of Electroacupuncture (EA) as an ancient healing art and proven analgesic method on pain in labor, uterine contractions and the fetus. Study Method: In this study are included 36 women in the treated group and 20 women in the control group. In the treated group we used only EA as a uterotonin and for sedation and analgesia during labor. In the control group we used Oxytocin as a uterotonin and Meperidine 100mg for analgesia. For EA we used metal needles and WQ 10DI electroacupuncturoscope. We used next acupuncture points: Baihui, Sishencon, Shenmen, Hegu, Sanyinjiao, Ciliao, Zusanli, Guanyuan and

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Conclusion: The majority of women are satisfied with their method of delivery as long as they feel they have been involved in making the decision of the method of delivery. FC3.25.03 SOME ASPECTS LINKING INDONESIAN AND BALINESE TRADITIONAL CULTURE TO HUMAN REPRODUCTION I.B.G. Manuaba, Suwiyoga, P. Kemara, Dept. OB.GYN, School of Medicine, University of Udayana, Bali, Indonesia. Indonesia has a long and rich historical tradition. Hinduism, Buddhism and Islam add to the populations understanding of human life. According to these religions beliefs, life begins at conception and carries a moral status that must be protected and cared for. Any activity that disturbs this developing life form is considered murder (ahimsa karma), according to basic philosophies (Pancacrada). According to Indonesian traditional culture, all life consists of four brothers: membranes, amniotic fluid, placenta/retroplacental circulation and the fetus itself all of which need antenatal care. Traditionally, to create the best quality of human being, the time for procreation must be individually selected (Suputra). Episodes from the Mahabratha, a Hindu holy book, specifically describe the care of the fetus and newborn for the Hindu Dharma population of Indonesia. Aspects of Indonesian cultural experience can also speak to assisted reproduction technology and surrogate motherhood. Also discussed are comparisons between Ausculapious original writings and findings from the Ayur Vedic, the original Hindu medical texts.

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FC3.25.05 KNOWLEDGE AND PRACTICE (KAP) ABOUT MATERNAL HEALTH AND NUTRITION G. Mahmud, K.Iqbal, Y.Hasebe, T.Nakasa, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, Objectives: Baseline information about maternal health indices is scarce in Pakistan and no such local data is available. The ICT (Islamabad Capital Territory) area was chosen by the JICA/PIMS MCH Project as model area for long term evaluation of training programme for Maternal Health Education. Methodology: A comparison between two samples before and after (Pre & Post) design witha control group was used to evaluate the training program in Rural ICT. The study area was divided into two. Intervention areas were Rawat and Jhang Sayyadan. Control areas were Bhoker, Gagri, Tumair and Chirah. Study Population: All women delivered within the last three months. Open ended questionnaire was designed, pretested and modified before administration. 10 doctors and nurses were trained for the interviews in the respondent's home with the help of local lady health workers (LHWs). Data entry and analysis was done by using SPSS and Excel. Results: 257 confinements within last three months. Study period was May 24 to June 5, 1999. 66.3% of women were of 20-29 years in the intervention and 59.3% in the control group. 62.7% of women had 1-3 children. 55% were illeterate. 14% never seek antenatal care. 41.1% saw a health personnel less than 3 times. 90% of women were seen at least once by LHW. 61% were home deliveries. 50% by Traditional Birth Attendant (TBA) and only 11% by Lady Health Visitors (LHV). Majority never used contraception. Conclusion: Large gaps exists between Knowledge and Practice about Maternal Health. FC3.25.06 IMPACT OF SOCIAL MOBILISATION ON MATERNITY CARE IN A RURAL AREA OF BANGLADESH S. Chowdhury, F. Rahman, F. Islam, MQ. Hassan, A. Rahman, N. Begum. Institute of Child and Mother Health, Matuail, Dhaka, Bangladesh. Objectives: The study aimed to evaluate the impact of Social Mobilisation on Maternity Care in a rural community of Bangladesh. Study Methods: It was a community trial in which a social mobilisation was launched in an area of about 30,000 population for one year and another similar area was kept as control. In each area 150 randomly selected pregnant women were interviewed at pre and post intervention periods. Social mobilisation programme included advocacy and group meeting, rally, enter-education by folk songs and video. After intervention the outcome variables regarding maternity care were compared between study and control area. Results: The change in the mothers attitude towards the utilisation of Antenatal care (ANC) services was found significantly higher in intervention area than control after social mobilisation (29% vs 4%, p <.001). Again ANC service utilization improved 43.1% from base line in intervention area compared to 7.5% in control. Although no significant increase in the proportion of hospital delivery was observed as a result of social mobilisation, there was a dramatic increase (from 19% to 42%) in the proportion of trained delivery attendants in intervention area compared to no change in the control. An over all 12% decrease in the proportion of delivery complications from baseline to after SM at intervention area compared to only 4% decrease in control (p<.001). Conclusions: Social mobilisation programme is effective in improving the maternity care in the rural area of Bangladesh.

FC3.25.04 DIFFERENCES IN KNOWLEDGE AND ATTITUDE TOWARDS THE RISK APPROACH STRATEGY AMONG HEALTH AND HOSPITAL-BASED PERSONNEL IN MALAYSIA K. Shamsuddin(1), S. Selvaraju(2) (1) Dept. of Community Health, University Kebangsaan, Faculty of Medicine, Kuala Lumpur, Malaysia (2) Family Health Development Division, Ministry of Health, Kualalumpur, Malaysia Objectives: The aim of this study was to compare the knowledge and attitude of the risk approach strategy in maternal health care as practices by the government public health personnel. Study Methods: A cross sectional survey of different categories of health staff working in the public health and the hospital sectors was conducted in 1997. Data was collected through self-administered questionnaire distributed to staff working in different health facilities in 16 randomly selected health districts in Peninsular Malaysia. Results: Based on weight analysis, there were 1473 and 1522 health and hospital-based staff respectively participating in this survey. Both health and hospital-based staff are highly awareness of the existence of risk approach strategy in maternal care in Malaysia (99.3% versus 97.3% respectively). 95.1% of health-based personnel have relatively high knowledge of the strategy compared to 77.7% among hospital-based staff. With regards attitude towards the risk approach strategy compared to 77.6% of hospital-based staff reported that there were no monitoring system for the strategy. Among those who reported problems in the implementation of the strategy, very few reported lack of training as a problem. Among health-based staff, lack of support especially low feedback from the hospital staff had been identified as a problem, while for hospital-based staff, differences in management and practice had been identified as a problem in the implementation of the risk approach strategy. Conclusions: The risk approach strategy requires close cooperation between the health and hospital-based personnel in managing maternal health care for high-risk mothers. Both heath and hospital-based staff have high awareness and positive attitudes towards the strategy. However, knowledge of the hospital-based staff on the risk approach as practiced by the health-based staff is rather low and problems identified by health and hospital-based are different. Steps must be taken to bridge their differences.

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FC3.25.07 A REVIEW OF DEATH CASES FOLLOWING MEDICAL TERMINATION OF PREGNANCY IN MAHARASHTRA WITH SPECIAL REFERENCE TO IMPLEMENTATION OF M.T.P. ACT1971 IN MAHARASHTRA M. Mandakini (1), C.K. Bazpande (2) (1) Public Health Dept., Govt. of Maharashtra, Mumbai, Maharashtra, India. (2) Health Services, Mumbai, Maharashtra, India. Objectives: In India, abortions were prohibited unless medically indicated to save pregnant women until1 971, when the Medical Termination of Pregnancy Bill was passed. Until then, as per Indian Panel Code (45 of 1866), the termination of pregnancy was an offence. In Maharashtra until December 1999, around 2270 M.T.P. centers are registered and approx. 130,000 M.T.P. Procedures are performed every year. The study was conducted to assess the impact of M.T.P. Act in providing the safe abortion of the women. Study Methods: In the last ten years, 52 cases of M.T.P. deaths were reported in Maharashtra with a total no. of 2270 M.T.P. centers approved. Results: By critical analysis of M.T.P. program in State it was observed that M.T.P. is a predominating urban program. Performance-wise, 55% of the cases were performed in metropolitan cities of Bombay and Pune, 30% in other municipal areas and the rest (15%) in rural areas. In 52 cases of death reported, 40% of cases were done by unqualified doctors. 38% of the cases were reported from District Hospitals, 22% of the cases from teaching institutes. The number of deaths reported in the 2nd trimester abortion was 54.4%. The total number of legation case done along with M.T.P. was 42.5%. Detailed inquiries were conducted in all the death cases. Conclusion: A conclusion is drawn to take major steps to improve the implementation of M.T.P. program in the state. To make these facilities more accessible at the rural level, abortion kits, trained personnel and hired services of expert gynecologists in the area are provided (Govt. of India guidelines). To upgrade one equip government institutions in rural and district places. To motivate the N.G.O. for approval M.T.P. centers and smooth reporting of all cases, also the death cases. FC3.26

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OBSTETRIC PRACTICE

FC3.26.01 ACCESS TO MIDWIFERY CARE IN THE U.S.: FINDINGS FROM THE SECOND NATIONAL SURVEY OF NURSE-MIDWIFERY PRACTICE Deanne Williams1, L.L. Payne2, L.M. Koontz3. 1 American College of Nurse-Midwives, 818 Connecticut Ave, NW #900, Washington, DC, 20006, USA; 2 Boston University School of Public Health, Boston, MA; 3 Maternal and Child Health Bureau/HRSA, Rockville, MD. Objectives: to determine selected characteristics of certified nursemidwives in US; impact of managed care on women and CNMs; and involvement of CNMs in federal and state funded MCH programs Study methods: 6,365 CNMs surveyed, 40% response rate. Data analyzed using SPSS and QSR NUD*IST software. Results: On average, CNMs were 45 y/o with 10 yrs experience. 87% were in clinical practice. From 1992 to 1997, number of uninsured clients increased from 8% to 16%; non-white clients increased from 40% to 50%; and care in rural settings increased from 21% to 26%. 29% of clients were less than 20 y/o, 21% were over 35 y/o. Of the respondents, 51% reported changes in health care financing had negative impact on practice. Fewer than 25% were directly involved in federally funded MCH programs. Conclusions: Between 1992 -1997, the national CNM data base increased from 4,303 to 6,635 and the number of births recorded went from 185,005 to 258,227. During this time, a large portion of care by CNMs was for women who were more likely to have limited access to health care. Many CNMs believe that the system of health care financing limited access to services for women and hindered their ability to provide the midwifery model of care. CNMs had limited interaction with state MCH and Medicaid programs.

FC3.26.02 IMPROVING OBSTETRIC PRACTICES IN UPPER EGYPT A. Abdel Megdeid, R. Gipson, T. Coles, John Snow Inc, Cairo, Egypt. Objectives: The overall objective of the HM/HC results Package is to provide an integrated package of services for the reduction of maternal and perinatal mortality in high risk groups and in the population of Upper Egypt. HM/HC Project activities focus primarily on the district and community level as the sites for implementation. Study Methods: The Healthy Mother/Healthy Child Project (HM/HC), MOHP completed an assessment of health need as well as training and management support need in Upper Egypt Governorates based on the criteria in essential maternal and child health service standards and monitoring checklists. Governorate, district and facility management teams have been trained in how to use these service standards to monitor and improve the quality of essential service provision. The use of service standards and monitoring checklist is a practical means of governorate, district and facility health level teams to assess the quality of service provision, plan for improvement, implement and monitor steps to improving services against the criteria in the standards. The HM/HC Project has developed management systems as well as a competency-based training program development process which meet the need to strengthen the quality of service provision. The system and training methodology can be disseminated and replicated more widely throughout the MOHP service system, the private sector as well as through medical and nursing educational institutions. Results: Service standards and monitoring checklists are practical means for assessing the level of managerial and clinical competence in providing essential maternal and child health service. The development of these tools followed a systematic process: 1. Health and training needs assessed, 2. Competency-based job analysis completed, 3. Clinical protocols developed, 4. Management systems materials developed, 5. Management and service provider teams trained in requisite skills. Conclusions: For the quality of services to comply with the criteria in the service standards, facilities had to be renovated, equipment procured and distributed, governorate, district and facility level management teams established and trained, the supervisory and training infrastructure strengthened, service providers trained to a level of clinical skill mastery.

FC3.25.08 REPRODUCTIVE HEALTH IN FEMALES OF THE ARAL SEA AREA D. Alieva. Dept. of Surgical and Conservative Gyn., Research Institute of OB/ GYN, Tashkent, Uzbekistan Objectives: Anthropogenic impact of unfavorable factors of the drying Aral Sea, worsened social and economic life conditions resulted in substantial health deterioration of the Aral Sea area population. In this connection the epidemiological investigation undertaken was aimed at studying a reproductive health in females of the region. Study Methods: Bacterioscopy and colpocytological studies as well as questionnaires were used to identify the health status in 120 females of a fertile age, 86 of which were 19 to 35 yrs old, 34 females older than 36 yrs. Results: The questionnaire study revealed a high incidence of extragenital diseases. Every second female suffered from inflammation of the gastroenteric and urinary tracts, chronic bronchitis and endocrine disorders. Inflammation of the vulva and vagina as disbiosis and bacterial vaginosis were noted in 110 females. Diseases of the neck of the uterus in the form of erosion and pseudoerosion, inflammatory processes of the uterus were registered in 29 females (24.2%), uterine appendages in 58 (43.3%), menstrual function disturbances in 24 cases (20%), amenorrhea in 2 (1.7%), primary sterility in 7 (5.8%), secondary sterility in 8 subjects (6.7%), uterine hypoplasia in 2 females examined. Ptosis of the internal sex organs, colporrhexis and perineal laceration were noted in 22 (18.3%) females. Conclusions: The results of the study dictate the need in undertaking measures to restore a reproductive health in females of the Aral Sea area.

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FC3.26.03 COMMUNITY BIRTH ATTENDANT IN BANGLADESH A.B. Bhuiyan (1), F. Begrum (2) (1) OGSB Maternity Hospital, Dhaka, Bangladesh. (2) Dept. OB/GYN, Sir Salimullah Medical College, Dhaka, Bangladesh. Objectives: To review the situation of Community Birth Attendant in Bangladesh. Study Methods: Review of literature and situation analysis. Results: In Bangladesh annual expected number of deliveries are 32, 49, 520; of which 95% are home delivery. Maternal Mortality Rate is 4.3 per 1000 live births and maternal morbidity is about 20 times of mortality. Only 5% of complicated cases receive medical care at institution level. Only around 15% of deliveries were conducted by trained health workers. The community is mostly served by TBA. They were supposed to offer clean birth practices but studies show that there is not much change even after training. Under this circumstances Government of Bangladesh (GOB) has responded to the WHO guideline for community midwives and intended to developed skilled birth attendant at the grassroots level. The Obstetrical and Gynecological Society of Bangladesh (OGSB) was given the responsibility to frame to the curriculum and training guide for community midwife. It has already been developed by OGSB and GOB is in the process of implementing the training of community midwives. Initially 250 FWV (Family Welfare Visitors/ Paramedics) are trained for six months at district hospitals. OGSB with the technical expertise and credibility of establishing Emergency Obstetric Care (EOC) at all level is entrusted with the community midwife program by GOB. Conclusions: Bangladesh is already in the process of implementing Skilled community Birth Attendant. The professional society has got tremendous role in supporting the GOB program particularly in reproductive health/pregnancy care. FC3.26.04 CERVICAL RIPENING WITH PROSTAGLANDINS AFTER PREVIOUS CESAREAN SECTION Z. Tth, O. Trk, J. Lukcs, Dept. OB/GYN, University of Debrecen, Hungary. Objectives: The aim of the study was to analyze the outcome of deliveries after previous cesarean section with special concern to cases in which for unfavorable cervix cervical ripening by local prostaglandins needed to be applied. Study Methods: This is a retrospective analysis of 468 cases out of a total of 7112 deliveries during the last 2 _ years at our department. Elective repeat cesarean section was performed in 90 cases for maternal and/or fetal indication. These cases were excluded from the study. The rate of repeat cesarean section was analyzed in cases with spontaneous onset of labor and in cases after induction of labor. Results: In the group of 214 women commenced into labor spontaneously the cesarean section rate proved to be 40%. In 126 cases with premature rupture of membranes cesarean section was performed in 39,6%. In 26 cases of the latter group with an unfavorable Bishop score dinoprotone gel was applied for cervical ripening. In this way the frequency of cesarean deliveries was reduced to 35%. Out of the 38 cases, 8 women with a Bishop score 5 delivered vaginally. In the 30 pregnancies with unripend cervix Prepidil gel was applied. In this group the cesarean section rate could be reduced to 50%. No severe complication due to prostaglandins was observed. Conclusions: Our data support that under strict criteria locally administered prostaglandins can safely and effectively be applied in patients with a history of previous cesarean section. This practice might further decrease the number of repeat cesarean sections. FC3.26.05 EFFECTIVENESS OF TRADITIONAL BIRTH ATTENDANTS L. M. Sibley, T. A. Sipe, Prime-American College of Nurse-Midwives, Washington DC, United States TBAs remain a major workforce in maternity care in developing countries. Yet, after more than three decades, evidence in support of TBA training is still limited (WHO, 1992). Although TBAs have been shown to favorably impact on neonatal mortality (Levitt, 1997), their

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current impact on reducing maternal mortality is uncertain (Fortney & Smith, 1997; UNICEF, 1997). A meta-analysis of TBA training effectiveness is currently being conducted to determine the effect of training on TBAs and on pregnancy outcomes. To date, 57 documents published or written between 1974 and 1997 have been admitted into the meta-analysis as a result of the five-staged literature search strategy and review process. The 57 published and unpublished documents concerning TBA training evaluation contained 70 separate studies from 24 countries. Six separate coding forms were developed to code 147 substantive, methodological, and outcome variables. Each study was coded by a team of two trained research assistants who met on a regular basis to resolve discrepancies. Effect size coding and calculations are currently in progress. The majority of the outcome variables are reported as proportions, thus effect sizes will be calculated using the arcsine transformation (Lipsey 1990). An unweighted effect size mean, as well as an n-adjusted effect size mean, for each category of outcome variable will be calculated (Hedges & Olkin, 1985). Homogeneity tests will be conducted on the distributions of effect sizes to check for variability. Sensitivity analyses will be conducted to explore variability in effect size distributions. (Greenhouse & Iyengar, 1994). There are 4 TBA attributes (knowledge, attitude, behavior, advice) and 23 MCH content areas being investigated, as well as maternal and newborn outcomes. Preliminary results show, for example, a medium weighted mean effect size for knowledge and a small effect size for behavior and advice regarding maternal risk factors and problems needing referral. References: Fortney, J. & Smith, J. (1997). Traditional birth attendants: A bibliography. Research Triangle Park, N.C.Family Health International. Greenhouse J. B., & Iyengar, S. (1994). Sensitivity analysis and diagnostics. In H. Cooper & L. V. Hedges (Eds.), The handbook of research synthesis (pp. 383-398). New York: Russell Sage. Hedges, L.V., & Olkin, I. (1985). Statistical methods for meta-analysis. Boston: Academic Press. Levitt, M.J. (1997, April). When the training of TBAs is cost effective: Trained TBAs and neonatal essential care in South Asia. In:A. Costello and D. Manandhar (Eds.). Improving health of the newborn infant in developing countries: Conference draft. (Kathmandu Mother and Infant Research Activities (MIRA) and Institute of Child Health, University College, London Medical School, UK. Compilation of papers for the conference held in Kathmandu, Nepal UNICEF (1997). Report on the consultation on attendance at birth: community birth attendants. Health Section, Programme Division, UNICEF/New York, June 9-10, 1997. World Health Organization. (1992). Traditional birth attendants: A joint WHO/UNICEF/ UNFPA statement. Geneva: World Health Organization FC3.26.06 A NEWER APPROACH TO PRE-INDUCTION SCORING G. Radhakrishnan, N. Vaid, Rashmi, University College of Medical Sciences & GTB Hospital, Shahdara, Delhi, India Prolonged pregnancies are mostly associated with unfavorable cervix, thus making the universally accepted Bishop Score unsuitable. Increased uterine activity, which can predict preterm labor, may also influence inducibility in postterm pregnancies. Objectives: To evaluate a new Pre-induction scoring system incorporating uterine activity (UA) in predicting inducibility and to compare it with Bishop Scoring (BS) in cases of prolonged pregnancies. Patients and Methods: 75 patients with uncomplicated singleton pregnancies at 41-42 weeks gestation underwent pre-induction evaluation by BS and the new scoring system which incorporates: (a) Cervical effacement, (b) cervical dilatation, (c) station of presenting part, along with (d) parity, (e) number of uterine contractions in 10 minutes and (f) strength of contraction expressed as area under the contraction curve. Variables (a), (b) & (c) were scored 0-3 and (d), (e) & (f) were scored 0-2 making the total score to be 15. Interval from induction to full dilatation, and the total oxytocin required were compared for the two scores. Results and Conclusions: 73.33% cases had a poor BS of 5 or less and 66.66% cases had a score of 6 or less by the new scoring method. Patients with a score >6 by the present system had a significantly shorter labor and decrease in total oxytocin requirement as compared to those

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with a BS >5. With further evaluation of this scoring method, cervical ripening methods may be obviated in many cases.

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FC3.27.02 DETECTION OF EPITHELIAL OVARIAN CANCER IN ASYMPTOMATIC POSTMENOPAUSAL WOMEN S. Skates (1), R. Knapp (2), I. Jacobs (3), (1) Massachusetts General Hospital, Fruit Street, Boston, MA, United States, 02114, (2) Brigham & Women's Hospital, Boston, MA, United States, (3) St. Bartholomew's Hospital, London, United Kingdom. Objectives: To determine whether utilizing the Risk of Ovarian Cancer Algorithm (ROCA) using serial CA 125 levels for the preclinical detection of ovarian cancer increases the specificity, sensitivity and predicative value sufficiently to be considered for clinical utilization. Study Methods: Serum CA 125II samples were assayed from 5,500 women in a Stockholm series and 22,000 women postmenopausal in a London series, Using statistical modeling, we developed a method for calculating the serum level for each woman over time to estimate the risk of ovarian cancer, The ROCA combined the four variables; age, initial assay (intercept), serial assays over time (exponential slope) and assay variability. Data is divided into training and validation sets. The training set is used to develop the algorithm which differentiates cancer and noncancer. Validation set validates the algorithm and calculates the number of false positives. Results: Thirty five ovarian cancers developed and the ROCA detected 30. The sensitivity and specificity is 85% and 99.7%. The positive predictive value is 16% for the assay alone without the addition of ultrasound. Conclusions: On the basis of the ROCA, women can be allocated to one of three groups: normal ROCA *0.05%, annual assay; intermediate ROCA 0.05%-4.0% repeat assay; elevated ROCA >4.0% refer TVS.

FC3.26.07 THE EFFECT OF INTRACELULLAR Mg2+ IN PRE-ECLAMPSIA Ana Mitrovic, Milan Djukic, Snezana Rakic, Nikola Antic Clinic of Gy and OBS/Narodni Front, Medical Faculty, University of Belgrade, Yugoslavia Approximately 2-10 % of pregnancies are complicated by preeclampsia.The pathophysiology of preeclampsia is general arteriolar constriction and increased vascular sensitivity to pressor peptides and amines. The etiology of preeclamsia is unknown. We examined (105 gravids) prospectively the corelation between intra and extracelullar magnesium deficit and Uterine artery Doppler in women with preeclampsia. We used bilateral early diastolic notch at 24 weeks as the definition of an abnormal waveform (circulatory parametars-Pi, Ri, of gravids art.utrina were excluded). For evaluation of RBC and plasma magnesium and calcium level we used AAS-atomic apsorption spectrophotometry. According to our results, in majority of cases, we determinated significatly low level of intracellular magnesium 0,86 +0,22 mmol/l in group with bilateral notch, and positive corelation between bilateral notch,intracelular magnesium deficiency, increase level of intracelullar calcium (0,63 + 0,18 mmol/l) and preeclampsia. These results support hypothesis that disbalance of intracelullar electrolites, expecially intracelullar magnesium and calcium are strong determinants of risk of preeclampsia because these facts could cause grater excitability of vascular smooth muscle contraction.

FC3.27 OVARIAN CANCER MANAGEMENT FC3.27.01 SUPRACERVICAL HYSTERECTOMY: QUESTIONNAIRE OF THE SOCIETY OF GYNECOLOGIC ONCOLOGISTS MEMBERSHIP R.Chalian (1), R.Smith (2), M.Silverstein(1), G.Del Priore(1), (1) NYU Medical Center, New York, New York, United States, (2) Imperial College, London, United Kingdom. Objectives: To determine the opinion of the Society of Gynecologic Oncology membership on supracervical hysterectomy (SCH). Methods: A one-page questionnaire was mailed to all members of the SGO as listed in the 1998 Directory. Possible responses were listed as categories of ranges therefore medians, modes and ranges are reported below. Eight hundred, sixty-one questionnaires were sent out. Results: To date, 303 have been returned (41% response rate); 20.4% were women and 79.6% male. Women were significantly younger with a median range of 36-40 yrs vs 46-50 yrs for men (Kolmogorov-Smirnov 2-Sample Test p<.001). Median time from medical school graduation was 14-18 yrs for women vs 24-28 yrs for men(p=.001). Hospital setting was reported as "urban" by 93% and "teaching" by 84% of respondents. There was no difference by gender in the number of hours/week spent seeing patients (median range 11-20hrs/wk) and 79.4% seeing between 20-60 patients/wk; 13.4% saw 60 patients/wk. The mean number of hysterectomies/month was 6.8 for female oncologists and 6.2 for male physicians (p=.51). The majority, 91%, reported having performed a SCH with 76% of both genders stating that they considered performing a SCH because it "decreased operative morbidity" while 7.8% sited "preservation of sexual function". When presented with a case of suboptimal debulked ovarian cancer, 50% reported that they would perform a SCH while 99.8% would not consider a SCH in a patient with endometrial cancer. Of the oncologists who did not perform SCHs, 91% did not do so because it had "no additional benefit" and 46% cited an increase risk of cervical neoplasms. There was no difference in any response based on gender or type of hospital setting. Conclusions: The majority of gynecologic oncologists have performed a SCH. Consensus opinion suggests it may be reasonable in cases of suboptimal ovarian cancer but rarely an option in endometrial cancer. Concern regarding cervical neoplasms continues to be an issue although the potential benefits of a SCH are also acknowledged. Given the diversity of opinion, a randomized clinical trial may be feasible.

FC3.27.03 SERUM ALPHA L-FUCOSIDASE ENZYME ACTIVITY IN OVARIAN AND OTHER FEMALE GENITAL TRACT TUMORS H. Abdel-Aleem(1), A. Sabra (1), A. Ahmed (1), M. Zakhari (2), M. Soliman (2), H. Hamed (1). (1) Dept. OB/GYN, (2) Dept. of Biochemistry and Radiology, Faculty of Medicine, Assiut University, Assiut, Egypt. Objectives: To assess the value of serum a-L-fucosidase as a tumor marker in the diagnosis of ovarian and other female genital tract tumors. Study Methods: One hundred and fifty-one patients were studied; 101 had different genital tract tumors [malignant ovarian tumors (48), carcinoma of the cervix (13), endometrial carcinoma (6), carcinoma of the vulva (6) and benign tumors (28)]. Fifty healthy females acted as controls. Serum a-L-fucosidase activity was determined in all patients and controls. Serum CA 125 level was also determined in patients with malignant ovarian tumors. Results: Patients with malignant ovarian tumors showed the lowest level of a-L-fucosidase activity in comparison to other malignant and benign tumors of the female genital tract and also in comparison to controls. The majority of ovarian carcinoma patients (90%) had a serum level of < 275 u/ml of a-L-fucosidase activity, while more than 90% of the controls and other genital tumors had a serum level of > 275 u/ml. The sensitivity and specificity of serum a-L-fucosidase activity in diagnosing epithelial ovarian tumors were 88.5% and 98%, respectively (using a cut-off level of < 275 u/ml). The corresponding figures for CA 125 were 96.2% and 100% (using cut-off level of > 35 u/ml). Conclusions: Serum a-L-fucosidase enzyme activity can be useful as a tumor marker in diagnosing advanced malignant epithelial ovarian tumors. Its sensitivity and specificity are comparable to CA 125. However, there is a lack of data to support its usefulness in the diagnosis of early stage disease (Stage 1). The cost of doing the test is one-third that of CA 125 and the test can be more widely applied in developing countries.

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FC3.27.04 LYMPHADENECTOMY IN PRIMARY CARCINOMA OF THE FALLOPIAN TUBE M. Klein (1), A. Rosen (2), A. Graf (3), M. Lahousen (4), (1) Dept. GYN, Hanusch Hospital, Vienna, Austria, (2) SMZ Ost., Vienna, Austria, (3) LKH Salzburg, Salzburg, Austria, (4) University Graz, Graz, Austria. Objectives: The bad prognosis of primary carcinoma of the Fallopian tube is ascribed to early lymphogenous metastasis. Due to the rarity of cases, there exist only few and divergent results on the importance of lymphnode metastasis in the relevant literature. Thus, our study aimed at detecting the incidence of lymphnode metastases and their influence on overall survival, as well as at evaluating the therapeutic effect of radical lymphadenectomy. Study Methods: We studied 109 cases in a retrospective multi-center analysis. Group I (n=38) consisted of patients who were subjected to radical pelvic and para-aortic lymphadenectomy in addition to TAH, BSO and omentectomy. The control group II (n=71) underwent the same surgical procedures but without radical lymphadnecetomy. Results: In group I 42.1% showed lymph node metastases. Lymphatic dissemination was observed only after the carcinoma had spread beyond the organ (intra-abdominal stage II); the incidence of lymphnode metastases rose significantly (p=0.02) with growing intraperitoneal tumor masses. Pelvic and para-aortic metastases occur simultaneously. If radical lymphadenectomy is performed (group I) the median survival time increases to 43 months compared to 21 months in group II (p=0.095). Conclusions: Correct staging is obtained only on the basis of pelvic and para-aortic lymphadenectomy. Radical lymphadenectomy in tumors of equal size may markedly prolong survival.

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stable over the last three decades in developed countries, increasing incidence has been reported in developing countries. The aim of this study was to determine the frequency of epidemiological risk factors among epithelial ovarian cancer patients. Study Methods: The records of 203 patients with epithelial ovarian cancer who were treated at four gynecologic oncology centers in Tehran, during the 10 year period from 1989-1998 were reviewed. Demographic data and associated risk factors were investigated. Results: The median age of diagnosis was 47 years (range, 17-81 years). 61% of patients (124/203) were in the 30-60 age group. 46.3% of patients (94/203) were diagnosed as having serous tumors, 22.1% (45/203) had mucinous tumors, 20% (40/203) had unclassified adenocarcinomas, and 4% (8/203) had endometrioid carcinoma. The median parity was 3, and 15.7% of patients (32/203) were nulliparous women. 88% of patients (179/203) did not use oral contraceptives. The most common blood group was group O (35%), followed by group A (31%) and group B (19%). The rate of tubal ligation was 3% (6/203). In 11.3% of patients positive family history for gynecologic malignancies were found. The most common presenting symptoms were abdominal pain (43%), abdominal swelling (21%), palpable mass (14%), and vaginal bleeding (13%). Conclusions: Our study showed that the median age of the patients to be lower comparing to the most various reports. Also it seems that the rate of factors associated with decreasing in risk is relatively low. However, further investigation through large epidemiological studies is required. FC3.27.07 PREDICTIVE VALUES OF SERUM TETRANECTIN AND CA125 IN OVARIAN CANCER. C. Hgdall1,5, E. Hgdall2,4, J. Blaakaer3, L. Christensen2, E. Glud2, J. Vuust4, B. Nrgaard-Pedersen5, J. Bock1 and S. Krger Kjaer2*. Dept. Gyn/obst, Rigshospitalet, Copenhagen1 Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen2, Dept. Gyn/obst, Aarhus University Hospital, Skejby3, Lab. Mol. Biology4 & Dept. Clin. Biochemistry, Statens Serum Institute, Copenhagen, Denmark5 (*Principal investigator). Objectives: The aim of the study was to evaluate the predictive values of serum tetranectin (TN), CA125 and a mathematical index, based on the two serum markers, in a possible screening setting for ovarian cancer (OC) Study methods: In the MALOVA study blood samples were collected from 1331 healthy control women and pre-operatively from 124 patients with a borderline ovarian tumor, 106 with a FIGO stage I OC, 39 stage II OC, 225 stage III OC and 58 with a stage IV OC. The stage related distributions of TN and CA125 were examined by Mann-Whitney and the Spearmans correlation tests. Sensitivities and specificities were evaluated by receiver operator curves (ROC). Results: Significant differences were found between respectively the TN and CA125 levels in every of the above mentioned tested subgroups (median controls: TN 12.7 mg/l, CA125 8.7 U/ml; Borderline: TN 11.2 mg/l, CA125 24.8 U/ml; Stage I: TN 9.6 mg/l, CA125 46 U/ml; Stage II: TN 8.8 mg/l, CA125 269 U/ml; Stage III: TN 8.0 mg/l, CA125 569 U/ml; Stage IV: TN 6.3 mg/l, CA125 622 U/ml. Highly significant correlations were found between TN, CA125 and stage. In the ROC analyses TN and CA125 supplemented each other in all stages. For stage I an increase in sensitivity was found from 30% for CA125 alone to 43% for the index at a specificity of 99.8%. Conclusions: TN is highly correlated to the stage of OC. TN and CA125 supplement each other, resulting in an increase in sensitivity without any decrease in specificity, when the variables are used in a mathematical index. TN may be valuable in a panel of tumor markers for OC screening.

FC3.27.05 VALIDITY OF COMPLETE PARAAORTIC LYMPHADENECTOMY IN APPARENT STAGE I (pT1) OVARIAN CARCINOMA S. Sakurai, Y. Shimizu, S. Umezawa, K. Shimizu, T. Kato, K. Hasumi, Dept. of Gynecology, Cancer Institute Hospital, Tokyo, Japan. Objectives: To assess the validity of paraaortic lymphadenectomy in apparent stage I (T1 of TNM classification) ovarian carcinoma. Study Methods: Clinicopathologic analyses were made on 119 consecutive patients (pts) with pT1 ovarian carcinoma who underwent systematic pelvic and paraaortic lymphadenectomy up to the upper level of renal vessels in addition to hysterectomy, radical bilateral adnectomy, and omentectomy from January 1989 to December 1998. Results: The average number of pelvic (PLNs) plus paraaortic lymph nodes (PANs) removed was 66.5 (range: 32 to 110). The incidence of positive lymph nodes (LNs) by T subdivisions was 12.2% (7/57) in pT1a, 66.7% (4.6) in pT1b, 25% (14/56) in pT1c, and thus 21.0% (25/119) in pT1 ovarian carcinoma. The sites of LN metastasis were PANs alone in 15 pts and both PLNs and PANs in the remaining 10 pts. Thus, all of 25 LN positive pts had positive PANs. The sites of PANs involved in 25 pts were located between the bifurcation site of inferior mesenteric artery (IMA) and the renal vein. Of 25 LN positive pts 11 had a solitary LN involvement and the sites were limited to PANs superior to the IMA. The LN positive rate by histopathologic grade (G) was 1.6% (1/61) in G1, 27.0% (10/45) in G2, and 66.7% (14/21) in G3. The LN positive rate by histologic type was 44/4% (8/18) in serous, 80% (4/5) in transitional, 3/2% (1/31) in endometrioid, 24.4% (10/41) in clear cell, and 8.7% (2/23) in mucinous carcinoma. Conclusions: The results indicate that PANs superior to the IMA is a primary site of LN involvement of ovarian carcinoma. The high positive rate of LN involvement, especially in high grade and chemo-resistant clear cell type, validates a complete PALA in apparent stage I ovarian carcinoma. FC3.27.06 REVIEW OF OVARIAN CANCER IN TEHRAN, IRAN M. Ashrafi, R. Alaghehbandan, S. Tavajjohi, Dept. OB/GYN, Iran University of Medical Sciences, P.O. Box 19395-4644, Tehran, Iran Objectives: Epithelial ovarian cancer is the most lethal of gynecologic malignancies. Although the incidence of ovarian cancer has remained

FC3.27.08 MALIGNOMAS OF FALLOPIAN TUBE R. Radosavlievic, J. Popovic-Lazic, R. Maglic, E. Garalejic, N. Antic, B. Stanimirovic, B. Terzic, J. Milosevic, Dept. of Pathology, University of Belgrade, OB/GYN Clinic Narodni Front, Belgrade, Serbia, Yugoslavia. Objectives: The aim of this study is to analyze the frequency and type of the primary-malignomas of the fallopian tube.

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Study Methods: Retrospective analyses were conducted on material obtained from operated patients in the OB.GYN Clinic Narodni Front in Belgrade, Serbia form 1993 to 1998 for primary neoplasm of the fallopian tube. We analyzed the age of the patients, location ad histological type of the tumors and presence of metastases. Results: In our study, we analyzed 563 patients. Among them we found 11 (1.99%) with primary neoplasm of the tube, 4 (36%) were malignant and 7 (64%) were benign. The average age of the women was 55 years (36 to 69 years). The most frequent malignancy was serous papillary adenocarcinoma (3) and one case of squamous cell carcinoma. Two adenocarcinomas were moderately differentiated and located on the right tube (one with metastases in the ovaries and the other without). One adnocarcinoma was well differentiated, at the right fimbria and with metastases on the omentum, colon and ovaries. Among the benign tumors, the most frequent were leiomyoas 3 (2R and 1L), 3 adenomatoid tumors (1R and 2L) and one mature teratoma on the left fallopian tube. Conclusions: The most frequent malignomas are serous papillary adenocarcinoma. Average age of patients is 55 and the location with the worst prognosis is on the fimbria. The frequency of the primary neoplasm of the uterine tube is in correlation with literature data.

WEDNESDAY, SEPTEMBER 6
Conclusions: Patients with recurrent miscarriage have a higher incidence of small for gestational age babies, preterm delivery, cesarean section and perinatal loss. These patients represent a population at high risk of obstetric problems and close surveillance in the antenatal period is therefore advisable. FC3.28.02 TREATMENT OF UNRUPTURED ECTOPIC PREGNANCY WITH METHOTREXATE A UK EXPERIENCE M. Sau (1), A. Sau (2), J.K. Roberts (3), W.O. Goldthorp (3) (1) Dept. OB/GYN. Stafford General Hospital, Stafford, UK. (2) Dept. OB/GYN, Medway Hospital , Gillingham, UK. (3) Dept. OB/GYN, Tameside General Hospital, Ashton-U-Lyne, UK. Objectives: To evaluate the effectiveness and complication rates of multiple dose of systematic methotrexate in the treatment of unruptured ectopic pregnancy in a District General Hospital. Study Methods: Twenty-six cases of ectopic pregnancy treated with methotrexate were analyzed retrospectively. A diagnosis of ectopic pregnancy was made by estimating the serum b hCG (human chorionic gonadotropin) level, transvaginal scan and/or diagnostic laparoscopy. All women were counseled and informed consent was obtained before methotrexate treatment. The success rates and adverse effects of methotrexate treatment, subsequent tubal patency and fertility rates were analyzed. Results: Out of 26 cases, 27% f women were primigravida and 19% had previous ectopic pregnancy. The mean pre-treatment human chorionic gonadtrophin level was 2931.97572.5 miu/ml. All but four patients had laparoscopy for confirmation of diagnosis. The majority of women (73%) received four doses of methotrexate, two women received two doses, four received three doses and one had five doses of methotrexate. All 26 women responded to methotrexate. The mean time to resolution was 22.915.8 days. There were no major side effects from chemotherapy. Three (11.5%) women showed elevated level of AST on the eighth day, which returned to normal within 48 hours of completion of therapy. Post treatment hysterosalpingograms demonstrated tubal patency on the ipsilateral side in 75% of women. Of those attempting to achieve pregnancy, 66% became pregnant, 95% intrauterine and 5% ectopic. Conclusion: Our results support the use of systemic methotrexate, which is a safe and effective treatment for unruptured ectopic pregnancy. It also preserves future reproductive performances. FC3.28.03 A RANDOMIZED STUDY OF CONSERVATIVE MANAGEMENT VERSUS SURGICAL UTERINE EVACUATION FOR INCOMPLETE MISCARRIAGE (INTERIM ANALYSIS) T.A. Mahmood, K.I. Shehata, K.J. Thong, Forth Park Hospital, Kirkcaldy, Scotland, UK. Evacuation of the uterus remains the management of choice for women presenting with spontaneous incomplete miscarriage during the first trimester of pregnancy. Two small studies (Mansur,1992; Neilson, 1995) have reported that retained products of conception (volume <15 mm) can be managed conservatively. However there remains a concern about infectious morbidity and effects on subsequent fertility. This study was funded by the Chief Scientists Office, Scottish Home and Health Department, Edinburgh. Objectives: The aim of this randomized study is to compare surgical uterine evacuation versus conservative management of women with incomplete miscarriage with gestation less than 13 weeks. Study Methods: In order to demonstrate that infectious morbidity is not significantly increased following conservative management, 500 women need to be randomized into one of the management regimes. Women in both groups are screened for infection and observed prospectively for many weeks. So far 287 women have been randomized, 154 to the conservative management and 133 to the surgical evacuation group. Results: So far 14 women required surgical procedures for persistent uterine bleeding, 9 (6%) in the conservative group and 5 (4%) had reevacuation in the surgical group. 29 patients needed antibiotic treatment for suspected upper or lower genital tract infection, 15 (10%) in the conservative group and 14 (11%) in the surgical group. Data will be presented on return to ovulation, pregnancy rates and quality of life.

FC3.27.09 SURGICAL ULTRASONIC TUMOR ASPIRATION IN ADVANCED OVARIAN CANCER. P. Bratila, O. Nicodin, N. Niculescu, Gynecological Clinics, Central Military Hospital of Bucharest, Bucharest, Romania Objective: To evlaute the efficency of tumor cytoreduction using an ultrasonic surgical suction device in cases of ovarian cancer. Materials and Methods: The Cavitron Ultrasonic Surgical Aspirator (CUSA) was used for removal of superfical metastatic lesions found at the time of hysterectomy, omentectomy and removal of other adnexal organs. This method of cytoreduction was used in 56 patients selected during February 1997 through June 1999. Study patients averaged 62 years of age and were diagnosed with ovarian cancer, the majority of which were stage IIIC. Results: CUSA was used to aspirate tumor fragments from the diaphragm, liver, stomach, small bowel, bladder, sigmoid and rectum without any organ injury. A pre and post operative ultrasound evaluation was performed on the removed tumor. The meat time of use was fifteen minutes and there were no intraoperative complications. Conclusions: CUSA cytoreduction facilitated the removal of primary tumor as well as metastatic lesions. This technique helps reduce the potential for resection of extragenital organs and facilitated chemotherapy application. Overall, it improved survival rates and patient quality of life. FC3.28 PREGNANCY COMPLICATIONS FC3.28.01 OBSTETRIC AND NEONATAL OUTCOME AFTER RECURRENT MISCARRIAGE: A RETROSPECTIVE OBSERVATIONAL STUDY S. Jivraj, B. Anstie, F. Fairlie, T. Li, Dept. OB/GYN, Jessop Hospital for Women, Sheffield, England. Objectives: To determine the obstetric and neonatal outcome in women with a history of recurrent miscarriage. Study Methods: Women who attended the recurrent miscarriage clinic at the Jessop Hospital between 1st January 1992 and 30th June 1998 were studied. Those who progressed beyond 24 weeks gestation were included in this study. There were 178 deliveries in this group. Their outcome was compared with a background population of 24,699 deliveries for the same period of time (1992-1998). Outcome measures studied were: incidence of hypertension, diabetes, small for gestational aged babies, preterm delivery rate, mode of delivery and perinatal mortality rate. Chi squared test was used for statistical analysis. Results: The incidence of hypertensive disorders (7.3%) and diabetes (1.7%) was not significantly different from the control population. Preterm delivery rate (13.3%), incidence of small for gestational age (13%), emergency cesarean section rate (18%), elective cesarean section rate (18%) and perinatal mortality rate (2.5%) was significantly higher (p<0.05) in the recurrent miscarriage population than the control population (4%, 2%, 10.2%, 6.5% and 1% respectively).

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Conclusion: The interim results of the study so far suggest that expectantly managed women had a similar outcome to surgical evacuation of the uterus. FC3.28.04 HYSTEROSCOPY IN THE EVALUATION OF PATIENTS WITH RECURRENT PREGNANCY LOSS (RPL) G. Ventolini (1), R. Samlowsky (2) (1) Dept. OB/GYN, Good Samaritan Hospital, Cincinnati, Ohio, USA. (2) Dept. Fam. Pract. Med., U.C., Cincinnati, Ohio, USA. Introduction: The purpose of this study was to determine the prevalence of structural uterine defects (SUD) in patients with RPL attending a large family medicine practice and o determine the effectiveness of the therapeutic intervention. Materials and Methods: This prospective cohort study from 10/95 to 10/98 included 23 patients, ages 23 to 35 (mean age 28.1 years) with otherwise unexplained three or more 1st trimester miscarriages and no live births. All couples were not tobacco or alcohol users and had normal cytogenetic examinations and testing. Their jobs were unrelated to chemical handling. All patients underwent a complete history, physical examination and hysterosopy with directed biopsy. They had normal values for: complete blood count, sedimentation rate, urinalysis and culture, (GC, Chlamydia, Syphilis, Hepatitis B, HIV), Lupus anticoagulant, anticardiolipin antibodies, progesterone and pelvic ultrasound. Results: Fourteen patients (60.9%) had normal hysteroscopy (with biopsies), nine patients (39.1%) had SUD as follows: five patients (21.8%) had intrauterine adhesions, two patients (8.7%) had septated uterus, one patient (4.3%) had submucosal myoma and one patient (4.3%) had multiple factors. After appropriate therapy of the SUD seven patients (77.8%) achieved successful pregnancy and two patients (22.2%) had recurrent miscarriages. The normal hysteroscopy group had eight patients (57.1%) with recurrent miscarriages, two patients (14.3%) with infertility and four patients (28.6%) achieved successful pregnancy with no further therapy. Conclusions: The prevalence of SUD in our studied population was 39.1%. The rate of live birth pregnancies in these patients after appropriate treatment was 77.8%. Since SUD are the most treatable causes of RPL, these patients should be identified early after other potential causes of RPL are eliminated.

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Conclusions: There is insufficient evidence available to date to support medical or expectant care for the management of incomplete miscarriage. Further randomised trials are needed to enable the risks and benefits of the different approaches to be fully assessed.

FC3.28.06 A PROSPECTIVE RANDOMIZED CONTROL TRIAL COMPARING MEDICAL AND SURGICAL TREATMENT FOR EARLY PREGNANCY FAILURE C. Demetroulis, E. Saridogan, D. Kunde, A.A. Naftalin, Dept. OB/GYN, Newham General Hospital, London, England. Objectives: To assess the effectiveness of single dose misoprostol administered intravaginally compared to surgical evacuation for the treatment of early pregnancy failure. Study Methods: Eighty women with a diagnosis of early pregnancy failure were randomized to study and control groups. 800mg of misoprostol was administered vaginally in the study group patients. The control group patients had surgical evacuation of the uterus under general anesthesia. Success of treatment, side effects as assessed during, immediately after and ten days after treatment, and patient satisfaction were recorded. Results: Intravaginal misoprostol was successful in 82.5% of the patients. None of the control group patients required a repeat evacuation. The number of patients who experienced significant abdominal pain following treatment did not differ between the groups. The duration of pain was shorter in the control group, however, they required more analgesics during this short period. The number of patients with significant vaginal bleeding, the duration or severity of bleeding did not show any significant difference between the groups. All thirty-three patients in the study group who had successful treatment expressed satisfaction, whereas 58% of the study group did so. Conclusion; This randomized control study demonstrated the efficacy and safety of the administration of 800mg of misoprostol intravaginally for the management of early pregnancy failure.

FC3.28.07 A RANDOMIZED CLINICAL TRIAL COMPARING ORAL AND VAGINAL MISOPROSTOL FOR MEDICAL EVACUATION OF SPONTANEOUS ABORTION S.M.W. Pang, T.K.H. Chung, Dept. OB/GYN, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China Objectives: To compare the efficacy and side effects of vaginal versus oral misoprostol in the management of spontaneous abortion. Study Methods; Two hundred and one women with incomplete abortion were randomized to receive either oral or vaginal misoprostol for medical evacuation (800 mcg for 2 doses, 4 hours apart). The subjects were reviewed the next day after treatment and 2 weeks later for evidence of retained product of conception and side effects of the treatment. The efficacy of uterine evacuation and the short-term side effects of the two treatment regimes were compared with chi-square test and Mann-Whitney U test. Results: The efficacy of uterine evacuation of oral and vaginal misoprostol was comparable (64.4% vs. 61.1%, p=0.62). There was a significantly lower incidence of diarrhea (13.6% vs. 65.3%, p 0.01) with the use of vaginal misoprostol. Conclusions: Vaginal misoprostol was as effective as oral misoprostol in medical evacuation of patients with spontaneous abortion. There was also a significant reduction in the incidence of diarrhea with the use of vaginal misoprostol. We believe that vaginal misoprostal should be considered a better regime than oral misoprostol for medical management of spontaneous abortion. FC3.28.08 THE USE OF PERIDURAL CATHETER IN SHUNTING FETAL SURGERY M. Saito, C.R. Arajo, E.C. Marinai, L.A.B. Martins, P.T. Oliveira, L.A. Silva, J.C. Massoneto, Faculdade de Cincias Mdicas de Santos, So Paulo, Brazil. Objective: To evaluate the use of peridural catherer to shunting fetal pleura effusion and urinary tract obstructions.

FC3.28.05 AN EVIDENCE-BASED APPROACH TO THE MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE J. Shelley, Centre for the Study of Mothers' and Children's Health, La Trobe University, Melbourne, Victoria, Australia Background and objectives: Improvements in medical care, e.g. antibiotics and ultrasound, and the improved health status of women, mean that the basis for surgical evacuation of the uterus following first trimester miscarriage may no longer apply. This paper reviews the evidence on the effectiveness of two other management approaches, synthetic prostaglandins and expectant care. Study Methods: All randomised trials examining medical or expectant management of incomplete miscarriage were identified from MEDLINE searches or citations in other articles. The trial methods were summarised and results meta-analysed where possible. Results: There were seven randomised trials of management of spontaneous miscarriage: four comparing synthetic prostaglandins to curettage, two comparing expectant care to curettage, and one comparing prostaglandins to expectant care. The total number of women randomised to curettage was 448, 496 received prostaglandins and 184 had expectant care. Almost all the studies had fewer than 100 women in each treatment arm. There was considerable heterogeneity between studies in eligibility criteria, dosages, definitions and timing of outcome assessments. Metaanalysis of results was not possible. Rates of successful evacuation with curettage were 97 to 100%, with misoprostol 13%, 50.5% and 100%, and with expectant management 76% and 79%. Only one study reported psychological outcomes, two reported later reproductive outcomes, and only one economic evaluation was located.

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Methods: Between January 1994 and July 1999 we performed fetal shunting in 16 cases of fetal anomalies, 9 cases were due to urinary tract obstruction and the others to pleural effusions. Initially, the peridural catheter was prepared as described by Leite and Cabral to change your original form and transform in a pigtail (as a Rodeck Catheter). Cannla with a trochar were substituted by a peridural needle. The procedure was guided by ultrasound and after the tip of the needle had reached the fluid collection the guide of the needle was removed and then the catheter was then inserted inside the needle. After the introduction of the half of the catheter, the tip of the needle is moved until the amniotic cavity and then with the proper guide were pushed out. Once the catheter was placed, ultrasound monitoring indicated weekly detecting any displacement or blockage. Results: In all 16 cases the catheter was sited in desired position. In two cases, the monitoring established that the catheter was displaced and a second catheter was then introduced. After one week, in one case we identified that the catheter was displaced and blockage in two others. The ultrasound monitoring that the catheter was functioning support by the reduction of the volume of the pleural effusion or the urinary tract obstructions. Indeed the reduced number of the cases we believe that these methods can be used as an alternative way to fetal shunting. FC3.28.09 FETAL CORTICOTHERAPY M. Saito, L.A. Silva, A.C. Silva, F.L.P.S. Souza, G.R. Maniov, A.L.S. Pontes, J.C. Massoneto, Faculdade de Cincias Mdicas de Santos, So Paulo, Brazil. Objective: Report 4 cases of fetus submitted to intra-muscular and intraperitoneal corticotherapy. Case report: Case 1 CSA, 22 years old, 29 weeks gestational age. Case 2 MSO, 18 years old, 24 weeks gestational age. Case 3 AFS, 32 years old, 33 weeks gestational age. Case 4 MSD, 32 years old, 24 weeks gestational age. All patients were in their first pregnancies and all of them were sent by the diagnosis of anencephaly. The ultrasound scan excluded other associated abnormalities and confirmed the suspected malformation. All patients were submitted to cordocentesis to evaluate the fetal karyotype and hematalogic parameters. The results were normal in 4 cases. In the 3 previous cases were injected 0.3 mg/kg of dexamethasone in the buttock region of the fetus and in the last case, it was injected the same dose but intra-peritoneously. One of the fetus that was injected in the buttock region was dead a week later the procedure. After the birth of the 4 fetus, we observed that there were no alterations in the puncture local in all cases. The case in which the fetus was injected intra-peritoneously, there was an increase in lecitine/esphingomieline concentrations, a week after the procedure had been done. Discussion: The administration of corticostheroids directly into the fetus had been reported in cases in which there is maternal contra-indication of the procedure. The intra-muscular injection had been correlated with local complications (tissual necrosis). The intra-peritoneal injection had been rarely related. In our cases, in spite of the death of one of the fetus, we had not observed any local puncture complication. The increase in lecitine/ espphingomieline concentrations may justify the efficacy of this type of preocedure.

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nephrostomy drainage, the ureteral catheterization has much less side effects. There is no use of x-rays or general anesthesia. The patients can be treated fast, effective and without pain. Ultrasound is sufficient to control the position of the ureteral catheter. Sometimes and exchange of the ureteral catheter is necessary after four weeks. The termination of pregnancy can be avoided by this procedure. Conclusions: In all cases, the termination of pregnancy was not necessary. Only a few hours after the ureteral catheterization patients realized a relief of their discomfort. The high motivation for this method is based on the elegant videocystoscopical technique with minimal local anesthesia. The pigtail ureteral catheterization has completely displaced the invasive methods of acute hydronephrosis in pregnancy in our hospital. FC3.29.02 THE INFLUENCE OF ANTIBIOTICS IN PRETERM LABOR ON THE INHERITED INFECTION RATE IN NEWBORNS P. Oszukowski, A Pieta, M. Nowak, Polish Mothers Memorial Hospital Research Institute, Lodz, Poland. Objectives: The purpose of this study was to evaluate the influence of antibiotic therapy in women with preterm labor and intact membranes on the incidence of inherited infection in their newborns. Study Methods: Our prospective randomized study group comprised of 154 women selected by the following criteria: singleton pregnancy, gestational age below 36 weeks, intact membranes, regular uterine contractions (at least one every ten minutes), cervical dilation < 4 cm, no signs of infection at admission. We applied the expectant management with the use of tocolysis (intravenous: verapamil and salbutamol). Patients were monitored with frequent vital signs, fetal heart rate evaluation and blood tests (e.g. C-reactive protein, white blood cell count). The further inclusion criterion was delivery within 14 days from admission. Antibiotics (amoxicillin/clavulanic acid) were administered as a result of randomization. Inherited infection of newborns was established on the physical examination, chest X-ray film, blood and urine culture, blood morphology and serum C-reactive protein. Results: Antibiotics were administered in 63 women. In 91 patients expectant management didnt include antibiotic therapy. There were no statistically significant differences between these two groups of women according to gestational age at delivery (mean +/- SD: 31.7 +/- 3.4 vs. 32.7 +/- 2.9 weeks), birth weight of their newborns (1686 +/- 568 vs. 1863 +/- 626 grams) and 1 minute Apgar score (6.3 +/- 2.5 vs. 7.1 +/2.2). The incidence of inherited infection in newborns of women who received antibiotics was 36.5% (23/63) and didnt differ significantly from inherited infection rate 31.9% (29/91) in the non-prenatal antibiotics group. Conclusions: Our data revealed that antenatal antibiotic therapy didnt increase the incidence of inherited infection in newborns of women with preterm labor and intact membranes.

FC3.29

PREGNANCY PATHOLOGY

FC3.29.03 CIRCULATING LEVELS OF TBARS AND VITAMIN E AS PRECLINIC PREDICTIVE AGENTS OF PREGNANCY-INDUCED HYPERTENSION AND GESTATIONAL DIABETES. Galimberti D. M., Joao M., Fernandez C.A., Cortelezzi M., Carames V., Holland M. and Aparicio N. J. Obstetrics Department T. Alvarez Hospital, Aranguren 2701, Buenos Aires Argentina Diabetes Mellitus and arterial hypertension are associated with oxidative stress, but the temporal association between lipoperoxidation markers and plasma s antioxidant activity and the clinical development of gestational diabetes (GD) and pregnancy-induced hypertension (IH) is still not known. Objective: to determine the circulating levels of TBARS and vitamin E in healthy primigravidas at the moment of the first consult. Material and methods: 91 (healthy at the moment of incorporation) primigravidas (age between 17 and 32 years) were incorporated at the moment of the first consult (between the 8th and 12th week of pregnancy). Blood was extracted from each one of them during the first, second and third trimester of pregnancy (8th to 12th , 22nd and 32nd week of pregnancy, respectively). The patients were controlled clinically on a weekly basis since incorporation until delivery. TBARS levels were determined in each sample (intraassay variation 4.7% and interassay 6.9%) (in mmols/l) as well as vitamin E (intraassay var. 4% and interassay 6.1%) (in mmols/l). Results: 85 patients had a normal

FC3.29.01 THE PIGTAIL URETERAL CATHETERIZATION A PERFECT MINIMALLY-INVASIVE THERAPY OF HYDRONEPHROSIS IN PREGNANCY G. Schindler, U. Retzke, R. Illing, H. Graf, Dept. OB/GYN Zentralklinikum Sudthuringen, Suhl, Germany. Objectives: The aim of this study was to assess the use of pigtail ureteral catheterization in cases of acute hydronephrosis in pregnancy in comparison with other worldwide commonly applied procedures. Study Methods: From 1988 through 1999, we retrospectively identified 38 pregnant women suffering from hydronephrosis. The indication, the procedure and the relevant results for mother and child are demonstrated. Results: In comparison to formally performed procedures treating acute hydronephrosis in pregnancy like operative or percutaneous

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gestation, whilst 6 of them developed induced hypertension between the 27th and 32nd week, and 2 of them, besides, developed gestational diabetes. TBARS levels in normal primigravidas were (mean SD) 2.00 0.22, 2.11 0.53 and 1.92 0.39 respectively for the three trimesters; the maximun and minimun figures being 1.4 and 2.87. The respective values for vitamin E were 29.0 5.8, 27.1 4.9 and 29.3 6.4 for the three trimesters with an absolute minimun of 21.0 and an absolute maximum of 48.1. Four out of the six patients who had induced hypertension (two of them with GD) presented TBARS levels clearly high (between 3.3 and 5.66 mmols/l) already in the first trimester and all of them presented high levels in the 22nd week, maintaining this until the 32nd week. Vitamin E scores were low (less than 12.0) in all the patients with IH except one. Conclusions: a) TBARS and vitamin E levels were determined in the three trimesters of normal primigravidas; b) the values were similar to the ones found in a healthy population of eumenorrhoeic women; c) The gestants who finally had induced hypertension ( 2 of them with associated DM) presented clearly high levels of TBARS and, in most of them, low levels of vitamin E preceding by several months the manifestation of the clinic signs; d) The determination of circulating levels of TBARS and, eventually, vitamin E, could well be useful for a preclinical prediction of a late development of induced hypertension and gestational diabetes. e) A discussion of these results in view of the current concepts of the mechanism of development of IH will be performed. FC3.29.04 ENDOTHELIAL FUNCTION FOLLOWING GESTATIONAL DIABETES MELLITUS M.M. Hannemann, W.Liddell, A.C. Shore, J.E. Tooke, Dept. Vascular Medicine, University of Exeter, UK. Objectives: Previous gestational diabetes mellitus (GDM) confers a 3050% risk of Type 2 Diabetes Mellitus (NIDDM), which is characterised by endothelial dysfunction. The aim was to investigate the presence and nature of endothelial dysfunction prior to the development of NIDDM. Study Methods: 17 GDM women were matched with controls for body mass index, menstrual cycle phase, smoking, age, blood pressure, and lipid profiles. All were normally glucose tolerant. Tests of endotheliumdependent and independent vasodilatation were performed:(i) Maximum dorsal foot skin hyperaemic response to a standard thermal stimulus, measured by laser doppler fluximetry, (ii) vasodilatory responses of forearm skin to iontophoresis of acetylcholine and sodium nitroprusside, measured by laser doppler perfusion imaging, and (iii) ultrasound estimation of brachial artery flow mediated (FMD) and nitrate (GTN) induced dilatation. Results: (i) Maximum hyperaemia (Subjects(S) =1.15(0.73-1.73)V median(range) v. Controls(C)=1.5(0.7-2.29)V; p=0.02), (ii) Iontophoresis of acetylcholine(S=1.59(0.32-2.55)V v. C =1.79(0.722.06)V ; p=0.81) and sodium nitroprusside (S=1.39(0.8-3.14)V v. C=1.41(0.34-2.19)V ; p=0.68). (ii) Brachial FMD (S=1.65(-0.5-9.07)% v. C=2.77(0.63-6.6)% ; p=0.42) and GTN-induced dilatation (S=9.16(6.64-20.91)% v. C=8.9(3.94-22.09)% ; p=0.43). Conclusions: Maximum hyperaemia, which differed significantly, is a complex indicator of vascular function, including that of endothelium. The other tests, more specific to the endothelium, did not differ. Thus GDM patients have a diminished microvascular dilatory reserve compared to controls, but this is not explained in this study by dysfunction of ACh-, shear-mediated, or vascular smooth muscle pathways. FC3.29.05 OUTCOME OF SINGLETON BREECH PRESENTATIONS IN WOMEN TREATED WITH ORAL SALBUTAMOL AS A TOCOLYTIC AGENT M.O. Okoronkwo, St Michaels Hospital for Women, Umuahia, Nigeria. Objectives: The aim of the study was to determine out-come of singleton breech presentations (SBPs) in women treated with oral Salbutamol at 26 37 weeks gestation. Study Methods: This randomized prospective study involved three hundred and fourteen consecutive women with SBPs: 157 women treated with oral Salbutamol (as sulphate) 4 mg thrice daily for seven days and 157 control women on bed rest. Results: 133 spontaneous cephalic versions (SCVs) (84.7%) were recorded in treated women vs 29 SCVs (18.4%) in control women (P=0.51). Incidence of SBPs at term was 0.6% in treated vs 2.5% in control women. Conclusions: This study revealed association between SBPs and premature uterine contractions. It has enabled us to understand more about mechanism of SBP and possible measures against it.

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FC3.29.06 STUDY OF PLASMA FIBRINOGEN LEVEL AND FIBRIN MONOMER POLYMERIZATION FUNCTION IN PRE-ECLAMPSIA M. Y. Gao, S. Q. Liao, L. Zhou, A. N. Rao, L. Z. Zhang, Dept. of OB/GYN, The Second Affiliated Hospital of Guangzhou Medical College, Guangzhou, China. Objectives: The aim of the study was to investigate the changes of plasma fibrinogen (Fbg) level and fibrin monomer polymerization function (FMPF) in preeclampsia. Study Methods: Fbg and FMPF were determined by Actualase Hydrolyzed Fibrinogen and Calculator Automatic Detection System in 80 cases or normal pregnancy (37-40 Wks) as control and in 20 cases of severe preeclampsia (37-40 Wks). Results: In the severe preeclampsia (1) The Fibrin Monomer Polymerization Reaction Speed (FMPV) was 0.8980.110. (2) Maximum attraction luminosity (Amax) was 0.5730.060. (3) Fibrinogen concentration of 797(73 (mg/dl). (4)FMPV/Amax was 1.9920.180. (5) Reaction delayed time (DT) was 174 (sec). The plasma Fbg level and the FMPF value were significantly higher than that of the controls (p<0.05). The higher value of the FMPF along with the increased level of Fbg in patients with preeclampsia may have some significance in predicting preeclampsia. FC3.29.07 TRANSVAGINAL COLOR DOPPLER STUDY OF THE SUBTROPHOBLASTIC BLOOD FLOW IN EARLY PREGNANCY A. Persona-Sliwinska, J. Brazert, R. Biczysko Department of Gynecology and Obstetrics, Karol Marcinkowski University of Medical Sciences, Pozna, Poland Objectives: The aim of this study was to compare the values of resistance index (RI) and pulsatility index (PI) in subtrophoblastic vessels of the uteroplacental circulation and the maternal serum concentration of progesterone and _-hCG in normal and threatened abortion first trimester pregnancies. Study Methods: We have analysed 89 pregnant women between 5th and 12th weeks of pregnancy - 32 with threatened abortion as a test group and 57 with normal intrauterine pregnancy taken as controls. In all patients transvaginal ultrasound with pulse color Doppler was performed. The RI and PI values were calculated for radial and spiral arteries. The concentration of progesterone and _-hCG in maternal serum were evaluated by immunoassays. The results obtained were analysed by means of the following statistical methods: t-Student, Mann-Whitney, Pearsons correlation. Results: There was statistically significant difference between RI and PI in normal and threatened abortion pregnancies only for spiral arteries in 11th to 12th weeks of pregnancy (p<0,01; p<0,05). Hormones concentrations were within normal ranges in all patients in the control group. In the tested group in 40,63% of patients the level of progesterone was abnormal, in 37,5% of patients the level of _-hCG was abnormal. There was statistically significant difference between serum progesterone concentration in the tested group and controls from 5th to 12th week of pregnancy (p<0,001) and between serum _-hCG concentration from 7th to 12th week of pregnancy (p<0,001). Conclusions: The combination of Doppler blood flow analysis in spiral arteries and hormones evaluation in the maternal serum performed in the first trimester may be useful for the early selection of high risk pregnancies which require intensive fetal monitoring.

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FC3.29.08 OBSTETRIC AND PERINATAL OUTCOME OF PREGNANCIES WITH TERM LABOR AND MECONIUM-STAINED AMNIOTIC FLUID S.M. Ziadeh , E. Sunna, F. Abu-Kteish, Dept. OB/GYN, Dept. of Pediatrics, Jordan University of Science and Technology, Amman, Jordan. Objective: To determine prospectively the risk of adverse neonatal outcome among infants born through clear or Meconium-stained amniotic fluid (MSAF). Setting: Princess Badeea Teaching Hospital, North Jordan. Study Methods: We compared prospectively the outcomes in 390 term singleton cephalic presentation with meconium and controls comprised similar women but with clear AF (400). Intervention: Most babies born through MSAF, though oropharyngeal suction as soon as the head was delivered followed by immediate intratracheal intubation and suctioning in infants depressed at birth. Results: Virtually meconium staining of the amniotic fluid was significantly associated with poor neonatal outcome in all outcome measures assessed. FHR abnormality was significantly increased with Mod Thick meconium (P=0.01) and thin meconiium alone was not associated with adverse outcome except respiratory distress. Severe fetal acidemia at birth (PH7.00) increased from 5 per 1000 to 10 per 1000 with meconium (P<0.001). Apgar score 3 at 1 min and 5 min was significantly increased with meconium (p<0.001 and <0.003 respectively). Meconium Aspiration Syndrome (MAS) was significantly more common with Mod-thick meconium, and those with clear AF. The need for mechanical ventilation or oxygen support was relatively similar between infants with clear AF, thin stained fluid, and mod-thick fluid who were not suctioned, but was significantly greater among suctioned infants (P<0.01). Cesarean delivery increased with mod-thick meconium from 7 to 14% (P<0.001). Perinatal mortality increased from 2 per 100 births with clear amniotic fluid to 10 per 1000 births with meconium (P<0.001).

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PANELS RT3.01 QUINACRINE NONSURGIAL STERILIZATION RT3.01.01 QUINACRINE NON-SURGICAL FEMALE STERILIZATION IN BANGLADESH S.N. Bhuiyan, R. Begum, Dept. OB/GYN, Chittagong Medical College Hospital, Chittagong, Bangladesh. Objective: To evaluate the efficacy, safety and acceptability of transcervical applications of quinacrine along with other adjuvant as ampicillin and ibuprofen for sterilization. Design: Cohort study. Setting: Family planning clinic in Chittagong Medical College Hospital, Bangladesh. Clients: Seven hundred and fifty normal women who requested sterilization and volunteered for this method. Interventions: Several different protocols were tried over the years from October 1989 to April 1999. Each woman received one or two insertions of 180 mg or 252 mg quinacrine with adjuvant such as ibuprofen 55.5 mg and ampicilin 125 mg. Supplementary contraception was oral contraceptive pills, barrier methods of medroxyprogesterone for 3 months. Details of each protocol will be described in text. Results: The gross pregnancy failure rate for 180 mg cases (N=489) was 4.4% compared to 1.5% for 252 mg cases (n=261). There were no serious complications and side effects were transient. Conclusions: Quinacrine non-surgical sterilization is a safe acceptably effective method when two insertions of 252 mg quinacrine with medroxyprogesterone for 3 months supplementary contraception is used. RT3.01.04 QUINACRINE STERILIZATION AMONG HIGH RISK WOMEN A. Sarin, Aastha Medical Center, Patiala, India

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Conclusions: Quinacrine sterilization is a safe option for women who are sure they desire no more children.

Objectives: A nonsurgical method of female sterilization is needed because many women are at high risk of complications for standard surgical methods, especially in developing countries. Also, some women who desire sterilization refuse it for fear of surgery. To meet these special needs, we initiated a trial of quinacrine sterilization (QS). Study Methods: A trial of a nonsurgical sterilization method involving transcervical insertion of 252 mg quinacrine as pellets by a modified IUD inserter plus 50 mg of diclofenac in the proliferative phase of the menstrual cycle was initiated among 134 women requesting sterilization at a medical school family planning clinic. This insertion was repeated a month later and a 150 mg injection of depo medroxyprogesterone was administered at time of the first insertion. Results: Among 134 women of reproductive age entering this trial, 92 were considered high risk for surgery, 27 refused surgery and 15 were cases of failed surgical sterilization. Mean follow-up was 3.46 years. No pregnancies or serious complications were experienced. The main side effect was menstrual irregularities, probably due to depo medroxyprogesterone. Conclusions: QS is a suitable option for women at high risk of surgical complications.

RT3.01.02 QUINACRINE STERILIZATION: ASSESSMENT OF SAFETY AND EFFICACY J. Lippes, School of Medicine, State University of New York at Buffalo, Buffalo, New York, USA Objectives: To assess the safety and efficacy of a method of nonsurgical female sterilization. Study Methods: Review of literature, including www.quinacrine.com, and unpublished reports known to the author. Results: No deaths have been reported in over 100,000 quinacrine sterilizations performed in 25 countries. Major complications are 1/50th that reported for surgical sterilization. Ectopic pregnancy risk is similar to that following surgical sterilization. Follow-up for 19 years shows no increased risk of cancer. Pregnancy failures are 1 to 2 per 100 women after 2 years of use. Conclusions: Quinacrine sterilization should be an option for all wellinformed women who desire no more children

RT3.01.05 QUINACRINE STERILIZATION: ENDOMETRIAL ASSESSMENT BY VAGINAL ULTRASONOGRAPHY CRC Ferreira, DRB Magalhaes, MZ Hanan, DC Ferreira, Faculdade de Medicina da UFMG, Belo Horizonte, Brazil Objectives: To observe endometrial thickness before, during and after transcervical administration of quinacrine for nonsurgical sterilization. Study Methods: 80 women out of a planned study of 150 women requesting sterilization at the family planning clinic of a medical school hospital in Bela Horizonte, Brazil volunteered to participate in this study. Each received 2 consecutive monthly transcervical insertions of 252 mg quinacrine as pellets delivered by a modified Copper T IUD inserter in the proliferative phase of the menstrual cycle. Follow-up visits were scheduled at 1, 3, 6 and 12 months. Transvaginal pelvic ultrasonography was performed before, during and after insertions and at each follow-up visit. Results: Of 80 subjects admitted in the study, transient side effects were noted as follows: headache 4 cases, light bleeding 12, mild abdominal pain 12, vaginal pruritis - 8, and yellow vaginal discharge for 7 to 10 days 64. No major complications, infections or pregnancy failures were noted. A decrease in endometrial thickness was observed during the first 6 months, which corresponds to incidence of oligomenorrhea. Conclusions: Quinacrine sterilization was found safe and acceptable when offered as an option to women requesting sterilization. A decrease in thickness of endomentrium and oligomenorrhea appears to be transient over a 6-month period.

RT3.01.03 QUINACRINE NON-SURGICAL FEMALE STERILIZATION: EXPERIENCE IN CHILE V. Trujillo, San Jos Hospital, Santiago, Chile J. Zipper, University of Chile, Sotero del Rio Hospital, Santiago, Chile A. Dabancens, Faculty of Medicine, University of Chile, Santiago, Chile S. Guzman, Regional Hospital of Valdivia, Valdivia, Chile Objectives: To evaluate the safety and efficacy of quinacrine nonsurgical sterilization from experience in 3 hospitals in Chile. Study Methods: Clinical data for 2592 Chilean women receiving quinacrine sterilization involving 2 or 3 transcervical insertions of 252 mg quinacrine in the proliferative phase of the menstrual cycle between 1977 and 1998 in three public hospitals are analyzed. Results: For the 2592 women receiving quinacrine sterilization, cumulative life-table pregnancy rates per 100 women at 10 years varied from 5.2 to 6.9. The addition of intrauterine antiprostaglandins as adjuvants did not affect these rates. Physicians and midwives showed similar efficacy. No birth defects among pregnancies carried to term were detected. There were 9 ectopic pregnancies (0.34%) among a total of 119 pregnancy failures, which is similar to our experience with IUDs and lower than for surgical sterilization. There were no life threatening complications and side effects were mild and transient.

RT3.01.06 QUINACRINE STERILIZATION: APPROPRIATENESS FOR PRIVATE PRACTICE AND SERVICE PROGRAMS M. Hanson, Private Practice OB/GYN, Minneapolis MN, USA Objectives: To assess risks and benefits of quinacrine sterilization (QS), a nonsurgical method for women. Study Methods: Literature review, including www.quinacrine.com, of QS, which involves transcervical application of quinacrine 252 mg in the proliferative phase of two consecutive menstrual cycles. This is compared to laparoscopic surgical sterilization in the USA. Results: The present protocol for QS shows an estimated pregnancy failure rate of one per 100 women at 2 years of use, which is approximately twice that of surgical sterilization. On the other hand, QS has a much lower incidence of side effects and serious complications and there are no reported case fatalities for QS in over 100,000 cases,

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whereas for surgical sterilization in industrialized countries, as the USA, the incidence is 3 per 100,000 procedures. Long-term sequelae of QS, such as risk of cancer and birth defects appear to be very remote and ectopic pregnancy risk among pregnancy failures is not higher than for surgical sterilization. Obviously, the cost of QS is lower than for surgical sterilization. Conclusions: QS should be an option for any woman who is sure she wants no more children. This method is now appropriate for use in private practice and service programs in the USA, where it is legal for this off label use on prescription filled by compound pharmacists.

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V3.01 VIDEO SESSION: MISCELLANEOUS TOPICS V3.01.01 VAGINAL ADNEXECTOMY FOR BENIGN OVARIAN CYST AT VAGINAL HYSTERECTOMY S. S. Sheth, Sheth Nursing Home, Breach Candy Hospital, Mumbai, India Objectives: Vaginal surgeon to consider adnexectomy for a benign, mobile ovarian cyst at vaginal hysterectomy without laparoscopic assistance. Study Methods: Pre-operative, clinical examination under anesthesia, imaging and tumor marker indicated that the ovarian pathology was benign and freely mobile in 80 women of 40 years and above, scheduled for hysterectomy. Adnexectomy was performed at vaginal hysterectomy. Laparoscopy was performed to evaluate the pelvic findings in 8. They are then compared with 115 cases with benign adnexal pathology subjected to total abdominal hysterectomy with bilateral salpingooophorectomy. Results: All 80 had successful vaginal hysterectomy with adnexectomy for ovarian cyst and prophylactic oophorectomy on the opposite side without difficulty and complication. Laparoscopic assistance was not taken in any of the cases. Laparotomy was performed in 3 as frozen HP study revealed malignancy. When compared with the abdominal approach, morbidity, hospital stay and cost were significantly reduced with more rapid recovery. Conclusions: Vaginal approach is effective, reduces morbidity and spares opening of the abdomen as well as laparoscopic assistance. It is the least invasive. V3.01.02 WATER DELIVERY A DIFFERENT CHOICE G. Acosta-Osio, Dept OB/GYN, Metropolitan University & Hospital, Barranquilla, Colombia Objectives: The aim of this there is to show to our colleagues the obstetricians world wide what the water delivery is, how the pregnant woman may give birth, and giving birth in a different way. Study Methods: A video showing three water deliveries is presented. During the presentation an explanation will be given on how relaxed the woman feels, how lukewarm water favors the stretching and dilation of muscular fascicles, the moment of episiotomy, if necessary, the fact that there is no risk of harm for the baby or the mother, and that the puerperium care is similar to the one given in a conventional delivery. Does this type of delivery reduce the cesarean incidence? Conclusions: Water delivery is another choice where the mother decides how she wants to deliver her baby, enjoying it with the family, making the delivery an enriching and pleasant experience, free of traumas and fears. V3.01.03 PREGNANCY COMPLICATED BY HUGE UTERINE MYOMA PRAEVIA SURVEILLANCE, DELIVERY AND THERAPY V. Pazin, S. Rakic, N. Antic, B. Damnjanovic, S. Dragojevic, T. Moskovic, OB/GYN Clinic Narodni Front, Belgrade, Yugoslavia Objectives: Our intention was to present our way of conduction, surveillance and therapy of this extremely complicated high-risk pregnancy from the early postconceptional period until myomectomy several months after delivery. Study Methods: A 34 years old primigravida showed in 4-th week of gestation complicated by myoma located in isthmico-cervical region of anterior uterine wall, 7 cm in diameter.After thorough consideration we decided to continue the pregnancy under intensive surveillance.We used bimanual, ultrasonographical, color-Doppler and biochemical examinations as often as neccessary.When uterine contractions have occured, bed rest and three-week permanent intravenous tocolysis has been performed, followed by peroral tocolytic therapy.Long-term antibiotic treatment has been ordered to solve intermitent febrile state and leukocytosis due to possible intraamnial infection or tumor necrosis.Caesarean section was the only way of delivery in case of huge myoma praevia, enlarged to 15 cm in diameter, filling the whole minor pelvis.Myomectomy was performed several months after delivery. Results: Fortunately, we have got healthy baby and the uterus prepared for the new high-risk pregnancy as the results.

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Conclusion: Intensive surveillance and perinatal care using all means of up to date technology in diagnostics and therapy of very complicated higd-risk pregnancy can oftenly be granted by perinatal success, which means healthy baby and happy mother.

V3.01.04 MYOMECTOMY IN THE COURSE OF PREGNANCY Wojciech Kazimierak, Teresa Pajszczyk-Kieszkiewicz, Medical University of Lodz, Lodz, Poland Presence of myomas in pregnancy may be dangerous for the normal development of fetus and the course of pregnancy. They may affect normal blood circulation in the placenta, distort the shape of uterus, and lead to fetal hypotrophy and compression. Myomas are frequent sources of complaints in pregnancy, causing pain and uterine contractions, which may lead to premature labour. In our clinic, we qualify such patients for operation only when the risk for a mother or fetus is greater with therapeutic treatment. Myomectomy in pregnancy is performed in the following cases: - Severe pain with peritoneal signs. - Position of the mayoma above the placenta, which impairs blood supply. - Indenation into the uterus with compression of the fetus. Between 1986 and 1999 we have opereted 23 pregnant women with uterine myomas: 14 primigravidas and 9 multipara. Surgery was done between 11th and 31st weeks of pregnancy. The size of enucleated myomas. Varied from several to 20 cm, with tumors over 10 cm prevailing. In 23 operated women 20 pregnancies terminated after 36 weeks: 22 healthy children were delivered. There was one case of twins. Conclusions: Enucleation of myomas in pregnancy is relatively safe procedure, nevertheless it should be proceded by thorough analysis of indications and conditions. Operation in pregnancy enables further proper course of pregnancy till term and removes complaints connected with the presence of tumor. New generation of absorbable sutures enables proper technique of sewing with good hemostasis and renders better endurance of site removedmyoma.

V3.01.05 SAVE THE MOTHER S. Chowdhury, F. Islam, A K M Shahabuddin, H. Hasan, Shaheen. Institute of Child and Mother Health, Matuail, Dhaka, Bangladesh. Objective: The video has been prepared to create awareness about some factors of maternal deaths and to encourage the family of pregnant women for maternity care Study Methods: The script of the video was written with targeting primarily the pregnant womens family and secondarily the heath care providers of grass root level. Policy makers were also considered as tertiary target audience during its preparation. Story based on a fact of a pregnant women, Momotaz Begum. Momotaz Begum, wife of Solimuddin a farmer of a rural area of Bangladesh, was on her fifth pregnancy with labour pain. The labour was prolonged for more than 24 hours with two sun rises. At that time she was attended by an untrained birth attendants, mother and mother in law. Momotaz was exhausted and extremely tired because of her prolonged labour However at the end of 24 hours she managed to deliver on baby. But following that she started post partum haemorrhage. Then Momotazs mother requested Solimuddin to ask for a doctor to rescue Momotaz. Then started the delays in transporting the patient from home to hospital. But at last Momotaz Begum passed away living all the arrangements and planning made for her. That was they end of part one and at this point a new couple entered at the scene. This couple had regular ante-natal care and delivery care and at the end a happy mother with a healthy baby. Results: The video was well accepted by the audience. Conclusions: The messages of the video include ensure antenatal care for all pregnant women, provide extra food during pregnancy, and if labour pain prolonged for 12 hours refer the woman to hospital.

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V3.01.06 PATIENT SAFETY: A HUMAN FACTOR ANALYSIS OF A COMPLICATED VENTOUSE DELIVERY B.L.Pedersen, Dept. OB/GYN, Copenhagen University and Cooperation Hospital, Hvidovre, Denmark. Objectives: A ten minute video of a complicated ventouse delivery is presented.The video was taped by a relative to the delivering woman. A 24 year old nullipara presents 12 days postterm after an uncomplicated pregnancy. After 8 hours of labor she is fully dilated but there is no further progression in spite of oxytocin augmentation. When the patient has pushed for morethan one hour the midwife calls in the obstetrician who decides to deliverthe child by ventouse. The position of the head is +1, the rotation is not described. The ventouse slips of six times and the obstetrician pulls during 23 contractions before one of the midwifes calls in the chief obstetrician who delivers the child after a moderate shoulderdystocia. The distressed asfyxiated child develops severe braininjuries. Study method: The video is analyzed according to human factor analyses of latent and active failures. Results: The analysis raises some questions that all department should deal with in order to prevent a similar case. These includes : When should a vaginal operative delivery be tried, should there be a maximum time from applying vacuum on the ventouse and until delivery, should there be a maximum number of pulls, when should a midwife call in a more senior obstetrician etc. Conclusion: In order to improve patient safety all adverse event should be analyzed in order to prevent similar cases. Departments might learn from adverse events in other departments.

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V3.01.07 VIDEO-PRESENTATION ON MANAGEMENT OF SHOULDER DYSTOCIA R. Deshpande, Dept. OB/GYN, Shri Banshankari Hospital, Solapur, Maharashtra, India Objectives: To study the effect of learning shoulder dystocia drill on the model of baby and the pelvis and its effect on the management. Study Methods: In the year 1991-1999, 4450 women at term, in labor were studied, 5 cases of shoulder dystocia were noted. Two groups were studied. Group A, between 1991-1995, when the drill was not applied and Group B between 1995-1999 when drill was practiced on the model. Results: All the babies (3) in Group B were saved without any long term morbidity and mortality, by application of Woods-Screw Maneuver. Conclusion: By practicing the shoulder dystocia drill on baby-pelvis model, management of shoulder dystocia can improve and reduce neonatal morbidity and mortality.

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POSTERS P3.01 ANTENATAL CARE AND DIAGNOSIS P3.01.01 ACARDIAC TWINS: A REPORT OF SIX CASES B. Ben Romdhane, A. Masmoudi, L.Smaili, A. Mabrouk, M.B. Chanoufi, F. Zouari, H. Chelli, S. Gaigi, Dept. Fetopathology, Center of Maternity and Neonates of Tunis, Tunis, Tunisia. Objectives: The aim of this study was to determine the frequency of acardiac fetuses in our institution, to precise the means of prenatal diagnosis and the neonatal management of this malformation. A review of the literature is made. Study Methods: We reviewed retrospectively six cases of acardiac fetuses diagnosed in the Center of Maternity and Neonates during a period of 7 years (January 1993-December 1999). The diagnosis was made or suspected by ultrasound examination and confirmed by autopsy in all the cases. Results: The prevalence of this malformation was estimated to 1/8000 births. Prenatal ultrasound examination finding a cardiac abnormality in one of the twins was carried out at an average term of 30 weeks. The diagnosis was evident before birth only in one case: ultrasound examination showed no heart area at all. In the other cases, the diagnosis was suspected by the absence of cardiac pulsation in a living fetus. Three cases of acardius acephalus and three other cases of acardius ancepts fetuses were found on autopsy. The prognosis of the pump-twin was worse in 4 cases (3 neonatal deaths and 1 intrauterine death). The two other babies developed a congestive cardiac failure. Conclusion: The diagnosis of acardiac fetus in twin pregnancies must be suspected on ultrasound when this latter show no cardiac pulsation especially if another malformation is associated. The development of the normal twin must be regularly evaluated by repeated ultrasound examination.

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P3.01.03 DETERMINATION OF FETAL LUNG SURFACTANT MATURITY BY A SIMPLE CROMATOGRAPHIC PROCEDURE A. Bazarra(1), A. Castro(2), J. Aguilar(2) 1) Health Sciences, University of La Coruna, La Corua, Spain 2) Medicine, University of La Corua, La Corua, Spain Objectives: Analyzing fetal lung phospholipids in a basic laboratory with efficacy and efficiency using a simple and cheap method. Study Methods: 173 samples of amniotic fluid were analyzed from 148 pregnant women, between the 25 and 44 weeks of gestation age. For detection of phospholipids two dimensional thin-layer cromatography was used, by means of a technique simplified by us, we do not use the rotavapor, the precipitation with cold acetone, the aspiration bell of the double beam densimeter. We have only checked the presence or fosfatidilglicerol absence. Lecithin/sphingomyelin ratio was measured by planimetry. For the statistical analysis the program BMDP was used. Results: In normal gestations phosphatidylglycerol was detected for first time to the 35 weeks and 3 days of gestational age. No newborn suffered the respiratory distress syndrome when the phosphatidylglycerol was detected in the amniotic fluid. In 7 cases without detecting phosphatidylglycerol, the newborn did not develop respiratory distress syndrome. Specificity 98.1%. Positive predictive value 85.7%. With a cutoff for the lecithin/sphingomyelin ratio of 3.1 there is no respiratory distress syndrome (p<0.001). Conclusions: With a cheap and simple technique that can be carried out in any elementary laboratory, a control of the fetal lung maturity is possible. And so, to prevent the respiratory distress syndrome with exactitude, precision, efficacy and efficiency avoiding big cost of hospitalization facilities and expensive instruments.

P3.01.02 AMNIOTIC FLUID BILIRUBIN DELTA EXTINCTION AS A PREDICTOR FOR INTRAUTERINE INTRAVASCULAR TRANSFUSION IN SECOND TRIMESTER FOR ERYTHROBLASTOSIS FETALIS L.J. Mirkovic (1), D. Plecas (1), M. Popovic (2), N. Radunovic (1), V. Milenkovic (1), M. Radovic (1) (1) Institute of Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Yugoslavia. (2) National Blood Transfusion Institute, Belgrade, Yugoslavia. The severeness of fetal anemia and initiation of intrauterine transfusion treatment were analyzed on basis of the numeric value of delta extinction per 450 nm of amniotic fluid bilirubin (DE 450 nm) in this period 18-32 weeks of gestation in 40 Rh-alloimmunized pregnant women. The validity of the extrapolation of Liley risk zones in second trimester was studied and the fetal hematocrit values (fetal blood obtained by cordocentesis) were correlated with the DE 450 nm values. The numeric DE 450 nm value indicates the existence of a hemolytic process but it is not a reliable indicator of fetal anemia. By extrapolation of Liley risk zones in the second trimester of pregnancy is not a reliable predictor of severity of fetal anemia. Chemical determination of amniotic fluid bilirubin cannot be used as an independent diagnostic and prognostic parameter of fetal anemia. Anamnestic data, Coombs Rh-antibodies titer, ultrasound monitoring, chemical and spectrofotometric determination of amniotic fluid bilirubin, are complementary diagnostic and prognostic methods for prompt cordocentesis. The need for intrauterine transfusions is assessed on the fetal hematocrit values, which are the method of choice in treatment of severe fetal hemolytic disease.

P3.01.04 EVALUATION OF THREE SCREENING TESTS FOR PREGNANCY INDUCED HYPERTENSION IN SECOND TRIMESTER OF PREGNANCY A. Barua, S. Kumar, S. Mittal, V. Dadhwal. Dept. OB/GYN, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Objective: To evaluate Doppler flow study of uterine arteries in second trimester of pregnancy for prediction of pregnancy induced hypertension and its comparison with roll over test and isometric exercise test. Study method: Prospective, non-randomized study included 111 nullipara attending antenatal clinic at AIIMS Hospital, New Delhi. Each subject underwent isometric exercise test before 20 weeks and roll over test between 20-28 weeks. Doppler flow study of u Results: Out of the 111 subjects, 13 had developed PIH. Of the 18 subjects with positive isometric exercise test, 5 developed PIH (X2=0.67, p=0.0540, OR=4.09, 95% CI=1.16-14.41) and out of 27 patients with positive roll over test, 3 developed PIH (X2=0.0 Conclusion: Doppler flow study of uterine arteries in second trimester was found to be a better test for prediction of PIH than isometric exercise test or roll over test. P3.01.05 INDUCTION OF ANTENATAL PERIVENTRICULAR LEUKOMALACIA BY HEMORRHAGIC HYPOTENSION IN THE CHRONICALLY INSTRUMENTED FETAL SHEEP K. Okuyama, T. Matsuda, K. Cho, Y. Kobayashi, T. Kishida, T Kusaka, S. Fujimoto, Dept. OB/GYN, Hokkaido University School of Medicine, Sapporo, Japan Objectives: The purpose of this study was to determine whether systemic hypotension induced by rapid withdrawal of fetal blood would induce periventricular leukomalacia in the brain of premature fetal sheep. Study Methods: At 110 days of gestation, catheters were placed in fetal superior vena cava, inferior vena cava, and distal abdominal aorta and 3 electrodes were fixed to fetal chest wall by means of hysterotomy. At 113 days of gestation, systemic hypotension (mean blood pressure <30mmHg) of fetus was induced by withdrawing approximately 35% of fetoplacental blood volume in hemorrhage group (n=6), whereas isovolemic exchange transfusion was carried out in control group (n=4). Physiologic parameters were monitored periodically during experiments.

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Six days after the insult, fetal brains were removed and processed for histologic investigation. Results: Five of 6 fetuses in the hemorrhage group exhibited periventricular white-matter lesions, consisting of nodular coagulation necrosis or diffuse axonal swellings, or both. There were accumulation of activated forms of microglia-macrophages and migration of phagocytizing macrophages in necrotic foci. Immunohistochemical staining revealed anti-Alzheimer precursor protein A4 expression in these lesions. None of fetuses in control group developed central nervous system lesions. Conclusions: Antenatal hemorrhage hypotension apparently induced brain lesions in the chronically instrumented fetal sheep similar to those of periventricular leukomalacia in human neonate. It should be suggested that fetal hypotension plays an essential role in the pathogenesis of periventricular leukomalacia in premature fetuses. P3.01.06 PECULIARITIES OF FREQUENCY AND SPECTRUM OF CHROMOSOME ABERRATIONS IN THE EMBRYOS OF RADIOPOLLUTED TERRITORIES Olena V. Kravchenko, Bucovinian State Medical Academy, Chernivtsi, Ukraine With the aim to estimate genotoxicity of the environmental pollution we have studied the frequency and spectrum of chromosome aberrations in embryoes on the territories suffered from Chornobyl disaster. Human embryo lymphocytes were received from the cellular suspension of the liver tissue after artificial abortion (80 embryoes - polluted area, 20 control area). This method enables us to observe chromosome changes which appear in a certain ecological surroundings excepting the factor of cultivation influence. The analysis of the level of chromosome aberrations revealed that the number of aberrant metaphase plates in embryoes and fetuses of the polluted regions exceeded data of the control population (7,0 + 0,57%, 3,78 + 0,5%), p<0,05; besides, both indices of chromosome (2,15 + 0,32%, 0,64 + 0,12%) and chromatid elisions (5,0 + 0,48, 3,14 + 0,46%) p<0,05 were higher. As to the structural changes of chromosome aberrations according to the sex of embryoes and fetuses we have determined that metaphase plates with chromatid elisions of several chromosomes were more frequently admitted with 46XY karyotype. In ecologically polluted region substantial difference in the frequency of metaphase plates with circular chromosomes in the male embryoes (46XY - 8 cases, 46XX - 2 cases) was found, that is the most objective radio-induced cytogenetic marker. Thus, mutation changes in embryoes and fetuses in the region suffered from the consequences of Chornobyl disaster are much higher that of average-population indices and are indicative of chemical and radioactive influence as well. From our point of view it is the sensitivity of embryo cells that should be a criterion in the estimation of possible harmful substances concentrations considering their high genetic risk. P3.01.07 PERINATAL OUTCOME AMONG SHORT STATURED WOMEN IN NEPAL R. Jha (1), D.S. Malla (1), A. Rana (2), (1) Maternity Hospital, Thapathali, Kathmandu, Nepal. (2) Dept. OB/GYN, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Objectives: The study was conducted to determine the effect of maternal short stature on perinatal outcome. Study Methods: It was a prospective study of 360 women admitted in Maternity Hospital, Thapathali for the management of labor over a period of 35 days. All the women fulfilled the inclusion criteria primigravida, sure date of last menstrual period, singleton viable cephalic fetus of 28 weeks of gestation and without any complication. Maternal height and weight at the time of delivery and a detail history was taken. Nature of labor, mode of delivery and complications were noted. Weight of fetus, admission in special care baby unit (SCBU), morbidity and mortality were noted. Results: The study has identified 144 cm stature as high risk height for Nepalese women. Mothers 144 cm in height had one and half times higher chance of preterm delivery in comparison to women 145 cm

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(11.29% vs. 6.71%). Mothers 144 cm height had 2.29 times more risk of giving birth to low birth weight babies. 11.29% of babies born to short mothers (144 cm) were severely asphyxiated at 1 minute of birth in comparison to 2.6% among mothers 145 cm in height. Babies of short mothers had a higher rate of admission in SCBU in comparison to babies of taller mothers (20.96% vs. 0.67%). Conclusions: It has been found that maternal height is significantly associated with perinatal outcome. Short statured mothers are at a higher risk of poor perinatal outcome and therefore, need early identification, special care and delivery in a well-equipped hospital.

P3.01.08 PRENATAL DIAGNOSIS OF A CASE OF LETHAL DWARFISM A.Desroches, P. Megier, Y. Le Brun Keris, Unit of Ultrasonography of Dept. OB/GYN, Pluridisciplinary Center of Prenatal Diagnosis, Regional Hospital, Orleans, France Objectives: Prenatal diagnosis of a case of lethal dwarfism and followup of the pregnancy after refusal of a medical termination of pregnancy. Study Methods: A 23 year old gravida 2 para 1 benefited by a systematic ultrasonography at 22 weeks of amenorrhea. We observed a micromelia, with telephone-receiver-shaped femoral bones and a severe thoracic hypoplasia. The forehead was high and bulging. We laid down the diagnosis of lethal dwarfism. The couple was informed by the obstetrician and the pediatrician about the lethal prognosis of the malformation. They did not choose the medical termination of the pregnancy because they are Muslim. The psychological escorting was difficult by fact of a linguistic barrier. Results: The ultrasonographic follow-up showed the persistence of the abnormalities, the apparition of a polyhydramnios, a macrosomia and an hyperdeflection of the fetal head. In spite of repeated information with translators, we think that the couple failed to appreciate the severity of the fetal prognosis. We realized a cesarean section at 39 weeks of amenorrhea on account of a fetal-pelvic disproportion. The female child died just after her birth on account of an acute respiratory distress. Her weight was 2850g. The macroscopical examination confirmed the prenatal diagnosis. A radiological study was realized before the burial. Conclusion: Prenatal diagnosis of lethal dwarfism is easy. This observation shows the difficulty of prenatal diagnosis in patients who are not used to investigation techniques and the consequences of their results.

P3.01.09 PRIMIGRAVIDAS-HOW DO THEY GET INFORMATION ABOUT THE DIFFERENT MODES OF PAIN RELIEF IN LABOUR AND WHEN DO THEY DECIDE ON THE MODE OF PAIN RELIEF. Y Sajjad*, T Sajjad+, *Dept Of Ob & Gyn, Warrington General Hospital, Warrington, + Dept of Anaes & Pain Relief, Royal Liverpool Uni Hospital, Prescot Street, Liverpool, United Kingdom. Objectives: 1. To determine the source or sources from which the primigravidas obtain information about the different methods of pain relief in labour. 2. To investigate what percentage of primigravidas, have chosen the mode of pain relief before the onset of labour (during pregnancy). 3. To investigate, what percentage of primigravidas chooses the mode of pain relief, after admission to labour ward. 4. To determine the single most important person, who influences the choice of pain relief. 5. The involvement of husband / partner in helping the primigravida in choosing the mode of pain relief. Study Design: This is a prospective, ongoing study being carried out at Arrowe Park Hospital, Wirral, Liverpool, United Kingdom. It has been approved by the Hospital Ethical committee and informed consent is obtained from each patient. The patients are requested to fill a questionnaire within 36 hours of delivery. This information will be correlated with patient's level of education and employment status. Conclusions: The study will help us in determining, firstly the sources primigravidas use to gain information about different modes of pain relief available in labour. Secondly, we will be able to find out when would be the best time to deliver information about different modes of pain relief in labour to the prospective first time mothers, and lastly who would be the best person to effectivelydeliver this information.

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P3.01.10 THE EARLY EXTERNAL CEPHALIC VERSION (ECV) TRIAL: A RCT OF ECV BEGINNING AT 34 WEEKS VS DELAYED ECV BEGINNNING AT 37 WEEKS GESTATION FOR SELECTED BREECH PREGNANCIES. E.K.Hutton, M.E.Hannah, E.D.Hodnett, K.Kaufman, K.Amankwah, for the Early ECV Trial Group, University of Toronto, ON, Canada. Funded by MRC, Canada Objective: This multicentre RCT will recruit 232 women to determine if, for selected women with a fetus in breech presentation, an early ECV beginning at 34-36 weeks gestation will decrease the likelihood of non cephalic presentation at birth when compared to delayed ECV that is not initiated until 37-38 weeks gestation. Study Methods: There is good research evidence to support delayed ECV beginning at 37 weeks gestation. However the success rate of delayed ECV is poor among nulliparous women and those with a frank breech presentation, particularly in North America and Europe. The selection criteria for entry to the study will ensure that only those women who may potentially benefit from the early ECV procedure will be included. The inclusion criteria: 1. nulliparous women with any breech presentation or multiparous women with a suspected frank breech presentation 2. live singleton fetus 3. gestational age between 34 and 36 weeks. The exclusion criteria: 1.contraindication to labour or vaginal birth 2. any contraindication to ECV 3. any contraindication to early ECV 4. plans to move to a non-trial centre prior to delivery. Prior to undertaking an appropriately sized RCT to assess the effect of early vs. delayed ECV, in selected women, in terms of need for CS or risk of fetal complications, we believe that we first need to prove that early ECV will result in a clinically important decrease in the number of non-cephalic presentations at birth. The primary outcome of this trial, therefore, is the rate of non-cephalic presentation at birth. Additional outcomes include, 1.CS, 2. serious fetal complications, 3. preterm birth (<37 weeks) and 4. womens views. Results: Recruitment has begun at three Canadian centres with 20 women enrolled as of January 25, 2000. An additional 10 centres in Canada and the UK are awaiting recruitment or local ethics approval. Other interested centres, are welcome to contact Early ECV Trial c/o MIRU (FAX 416-351-3771; email eileen.hutton@utoronto.ca) P3.01.11 THE EFFECT OF ABORTION ON OUTCOME OF SUBSEQUENT PREGNANCY M. Ghaffarnejad, M. Hejazi, F. Ebrahimi, Dept. OB/GYN, Mirza Kuchakkhan Hospital, Tehran University of Medical Sciences, Tehran, Iran. Objectives: The aim of the study was to investigate the effect of one or more spontaneous abortion on subsequent pregnancy outcome. Study Methods: In a historical cohort study, we evaluated the effects of one or more spontaneous abortion on subsequent pregnancy outcome. 1693 pregnant women were classified in three groups: 1100 without any prior pregnancy, group (1) 550 with history of one spontaneous abortion (G2Ab1), group (2) 43 with two or more prior spontaneous abortion and no other prior pregnancies. We collected data through interview, patients records and physical examination. We matched the patients according to their age, subgroups, history of chronic disease, drug administration, radiation during current pregnancy and familial marriages. Then we compared adverse outcome of present pregnancy in group 1 and 2 with the women without prior pregnancy. The data was analyzed with chi-square and Fissures exact methods. Variables: Premature labor, prolonged rupture of membrane, abruptio placenta, placenta previa, pre-eclampsia, eclampsia, low birth weight, stillbirth and difficult delivery. Results: We resulted that history of one spontaneous abortion had no effect on subsequent pregnancy except in prolonged rupture of membrane (p<0.0001), but history of two or more abortion significantly affects occurrence of stillbirth (RR=29, p=0.003) and placenta previa (RR=8.5, p=0.03). Conclusions: These findings suggest that women with history of two or more spontaneous abortion need special prenatal care. P3.01.12 THE IMPACT OF PRENATAL DIAGNOSIS (PND) ON THE OCCURRENCE OF CHROMOSOME ABNORMALITIES AND OBSTETRICAL PRACTICE Y. Y. Yang, S. Y. Ho, P. T. Chang, M. C. Chao, Dept. OB/GYN, FooYin Hospital, Taiwan, R.O.C.

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Objectives: To measure the impact of PND on the incidence of all types of chromosome abnormalities resulting in improved obstetrical outcome. Study Methods: The study population consisted of 875 pregnant women in 1999, undergoing chorionic villus sampling and amniocentesis for prenatal diagnosis, who were maternal age 35 years or older, positive screening test (over 1/270) for Down syndrome, an abnormal fetal ultrasonographic scan or an increased risk of chromosomal fetal abnormality. Cell culture with in situ method, karyotype analysis at least 20 cells. Results: (1) A total of 875 patients were included in this study, of which 2.63 % (23 cases) were chromasomally abnormal. The incidence of autosomal trisomies was 1.37 % (12 cases), sex chromosome abnormality was 0.8% (7 cases), balanced translocation 0.45% (4 cases), and 3 cases of culture failure. (2) The indications of PND are mostly due to abnormal serum marker (417 cases, 47.6%) and advanced maternal age (324 cases, 37%); These results are associated an increase in the number and proportion of chromosome abnormal fetus detected (8 cases and 13 cases respectively) and slight decrease in the prevalence of chromosome abnormalities among live births. (3) Suspected fetal pathology categories increased in frequency (129 cases, 15%). While Sonography abnormal fetus category still remained low in frequency (5 cases, 0.5%). (4) The proportion of first trimester tests performed with chorionic villus sampling decreased significantly. Conclusions: A wide-ranging screening program of pregnant women has to be used to significantly reduce the birth of chromosome abnormal fetus. Further, we can offer patients early trimester detection for karyotyping or genetic diagnosis resulting in the option of safer pregnancy termination which will improve the obstetrical outcomes.

P3.01.13 THE USE OF INTRAVAGINAL MISOPROSTOL FOR INDUCTION OF LABOR D. Casagrandi Casanova, Havana, Cuba Abstract: Misoprostol, a synthetic drug analog of prostaglandin E1 has been used to provoke cervical ripening and induction of labor. The aim of this study was to evaluate the efficacy and safety of intravaginal for labor induction. A total of 198 pregnant women were included in the study and fractionated doses (25 microgram) of misprostol were applied every three hours until a maximum of four doses or beginning of labor. The most common indications for induction of labor were premature rupture of membranes (28%), post-datism (21%) and pregnancy induced hypertension (19.5%). 45.5% of patients started with uterine contractions in the first hour after vaginal application of misoprostol. Normal cardiotocography was observed in 96 cases (48%), 46 (23%) had tachysistole and 17 (8.5%) had variable decelerations. Oxitocin infusion was used in 64 patients (32.3%), almost always after the fourth dose of misoprostol. The cesarean section rate was seen in 5 patients (2.5%). No maternal side effects and neonatal adverse effects were noted. We conclude that intravaginal misoprostol admiinistration with low doses is an effective method for labor induction, but further investigations should be done to evaluate its real safety. P3.01.14 USE OF RANDOM URINE PROTEIN/CREATININE RATIO TO ESTIMATE PROTEINURIA IN PREGNANCY A.M.B. Ongkiko Cagayan,Quezon City, Philippines Objective: To determine whether random urine protein/creatinine ratio can be used to determine proteinuria in pregnancy. Design: Prospective study assessing accuracy of quantitation of proteinuria. Setting: Intensive Maternal Unit of the Department of Obstetrics and Gynecology of Philippine General Hospital.

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Population: Pregnant women admitted to the hospital. Method: Three random urine specimens and 24-hour urine collection were ordered for 90 subjects. Random urine protein/creatinine ratio and estimated total urine protein were compared with the 24-hour urine protein. Main Outcome Measures: Correlation of random urine protein/creatinine ratio and estimated total urine protein with the 24-hour urine protein excretion; 2. Sensitivity, specficity, positive and negative predictive values of random urine protein/creatinine ratio for significant and nephrotic-range proteinuria. Results: Log random urine protein/creatinine ratio and log estimated total urine protein showed good correlation with log 24-hour urine protein (r=0.70 to 0.80; p=0.0001). A log/log transformation of data was necessary due to the wide variability of values. A protein/creatinine ratio >300 mg/g was the discriminant value for significant proteinuria, with sensitivity and specificity of 70-80% and a positive predictive value of 90%. However, its negative predictive value was only 20-30%. A protein/creatinine ratio >3000 mg/g was the discriminant value for nephrotic-range proteinuria, with sensitivity, specificity, and negative predictive value of 80-90% and positive predictive value of 70%. Conclusion: Random urine protein/creatinine ratio may be useful in determining proteinuria in pregnant women. Because of large standard deviations associated with this method, caution must be taken in applying overconfidence to the values obtained with this technique. P3.02 CERVIX P3.02.01 ABNORMAL PAP SMEAR IN ADOLESCENCE Tacla , M.; Tubaki , M.E.; Schwarzschild , M.M.S.; Luca , P.D.; Meniconi , M.C.; Barrueco , A.K.; Lopes, E.A.; Duarte , M.I.S. Laboratrio Fleury - So Paulo - Brazil Objective: The purpose of this retrospective study is to evaluate the age distribution of cytologic abnormalities in adolescence and its correlation with the histopathologic findings. Material and Methods: Between January 1994 to December 1999, 3.483 cervicovaginal smears from upper and middle class adolescents ranging from 11 to 19 years old , that were referred to Laboratrio Fleury , were taken. 155 smears were identified as abnormal . Colposcopy, vaginoscopy and/or colposcopically directed biopsy were performed in 110 adolescents. Results : Table I: Cervicovaginal Smear Age Distribution
Total of Age 11 12 13 14 15 16 17 18 19 Age 14 15 16 17 18 19 Cervicovaginal Smears 13 15 24 55 146 312 669 956 1293 LSIL 1 6 11 31 42 53 Abnormal Smears 1 6 12 31 44 61 HSIL 0 0 1 0 2 8 Percentage of Abnormal Smears (%) 1.8 4.1 3.8 4.6 4.6 4.7 TOTAL: n = 155 1 6 12 31 44 61 0.6 % 3.9 % 7.7 % 20 % 28.4 % 39.3 %

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abnormalities. Screening of cervical intraepithelial neoplasia among adolescents is essential to avoid the early evolution of this disease.

P3.02.02 CERVICAL CANCER IN PEMBROKESHIRE SINCE NATIONAL CANCER SCREENING PROGRAMME: IS SCREENING DISINVESTMENT DESIRABLE? S.N. Roy, W.M.Clow, J.Hall, Withybush Hospital, Dept. of Obstetrics & Gynaecology, Haverfordwest, Pembrokeshire, United Kingdom, SA 61 2PZ. Objectives: In the light of possible screening disinvestment, to assess the presentation of Cervical Cancer in Pembrokeshire since the starting of National Screening Programme (1988). Study Methods: Retrospective study of Cervical Screening history of patients diagnosed with Cervical Cancer in Pembrokeshire between 1988-1998. The screening coverage of the population was also assessed during the same period. Results: Screening coverage in Pembrokeshire was only 45% in 1988. This rapidly escalated to 81% in 1991 and stayed around 85% since 1993. Total 83 patients developed Cervical Cancer. Ten of these were above the age of 65 at 1988 and therefore not included in screening. The highest incidence of Cervical Cancer was in women who were never screened. A large number of cases were detected at the time of first call for screening (29). In the 'recal' programme, there were 7 interval cancers. Five of these were diagnosed because of 'unscheduled' smears. Six cases in this group (30%) would have not been diagnosed if screening was curtailed at the age of 50 for well screened patients. Conclusion: The present policy of 3 yearly screening till the age of 65 should be continued in Pembrokeshire. P3.02.03 CONIZATION - POSTOPERATIVE COMPLICATIONS M. Temelkovski, M. Trajanova, J. Kostadinov, A. Sopova, Special Gynecology and Obstretrics Hospital, Skopje, Macedonia Cervical conization is a rapid and relatively save surgical procedure. The advance is both, diagnostic and therapeutic. Analyzed were154 conization cases performed in two techniques. Patients were between 28 and 54 years old, and different pregnancies and births number. 90 patients (59%) had two, 17 (11%) had three and the remaining 32 (21%) more than 3 children. 41 (27%) had 2 artificial abortions and 46 (30%) had one. Indications were: unsatisfactory colposcopy following abnormal cervical smear, colposcopy prediction of early invasion or suspicion of cytology invasion, early invasion on direct biopsy, positive endocervical curettage, cytology discrepancy with colposcopy or direct biopsy and recurrent disease following previous ablative therapy. The operative technique is classical conization; hemeostasis obtained with a circular suture in 70 % (108 cases) and Shtrumdorf suture 30% (46). Postoperatively was ordinated for 3-5 days: cephalosporin, sulfonamide or tetracycline. Complications occurred in 7,79% (12 patients). Postoperative hemorrhagy within 1 to 10 days appeared: 0-2 days 1 (0.64%); 3-5th 3 (1.94%); 6-8th 2 (1.29%); 9-10th 2 (1.29%), postoperative cevicitis l (0.64%), urinary infections 3 (1.94%) and one had adhesions of the cervical channel. Preoperative findings were: CIN III in 98 cases (63.63%), CIN II in 32 (20.77%); suspicious invasion in 24 (15.58%). There was a high correlation between pathohystological results and preoperative findings with the postoperative diagnosis in 93% (143) cases, and the conization technique associated with the postoperative complications revealed no differences with the literature.

Table II: Abnormal Cervicovaginal Smear Age Distribution

101 cervical biopsies were performed resulting in: 1 Condiloma Acuminatum , 2 Condiloma Acuminatum + CIN II , 9 Chronic Cervicitis, 45 Chronic Cervicitis + HPV , 1 Endocervicitis , 38 CIN I and 5 CIN II. Conclusion: The importance of these data is to establish the correlation between the age distribution of abnormal cytology and histopathology in the screening of cervical cancer and evaluate the severity of these

P3.02.04 DETERMINING THE COST EFFECTIVENESS OF MASS SCREENING FOR CERVICAL CANCER USING COMMON ANALYTIC MODELS S. Sato, G. Matsunaga, A. Yajima, Dept. OB/GYN, Tohoku University School of Medicine, Sendai, Japan. Objectives: To estimate the cost per life-year saved (cost-effectiveness ratio [CER]) for cervical cancer and to evaluate the influence of the decreased incidence upon the cost per life-year saved.

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Study Methods: We established hypothetical cohorts at 10 year intervals between 30 and 79 years of age, each of which consisted of 100.000 asymptotic female subjects, and estimated the cost and effect of single mass screening for cervical cancer. To investigate the influence of CER, we performed a sensitivity analysis of each item, including the consultation rate for further examination, prevalence rate and cost of medical treatment. Results: The estimated CER per one expected life-year of survival was lowest for subjects in their 30s and highest for those in their 70s. The difference between the two was more than five-fold. Sensitivity analysis was rarely affected by changes in the cost of medical treatment and the prevalence rate, but the effectiveness rate could be fairly affected by the consultation rate for closer examination. Conclusions: Mass screening for cervical cancer is acceptable in terms of economic effectiveness. Moreover, mass screening for cervical cancer could decreased the morbidity rate for scores of years thereafter.

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Methods: Four-hundred women submitted to traditional cone or Loop Electrosurgical Excision Procedures (LEEP) for cervical intraepithelial neoplasia (CIN) III were studied. Histological cone results were divided into: with residual lesion, who were indicated to hysterectomy and, absence of residual lesion. Epidemiological characteristics of population presenting residual lesions were analysed, concerning the year of surgery, to estabilish a possible epidemic distribution of the lesion, all over the years. Results: On cone histology, 321/400 (80.25%) patients showed absence of residual lesion and 79/400 (19.75%) residual lesions. During 1996, 23/79 (29.12%) were treated: 6/23 (26.09%) from 21 to 30 years old; 10/23 (43.47%) 31-40; 5/23 (21.74%) 41-50 and, 2/23 (8.70%) > 50 years old. Considering 1997, 18/79 (22.79%) patients in the same order: 3/18 (16.67%); 9/18 (59%); 4/18 (22.23%) and, 2/18 (11.11%). During 1998, 25/79 (31.65%) patients, in the same order: 4/25 (16%); 10/25 (40%); 6/25 (24%) and, 5/25 (20%). During 1999, 13/79 (16.46%) patients, in the same order: 3/13 (23.08%); 4/13 (30.77%); 4/13 (30.77%) and, 2/13 (15.39%). Conclusions: The majority of cases occurred from 21 to 40 years old, the highest rates (75.67%) being in 1997 and, the lowest ones (53.85%) in 1999. This fact reflects a protocol change, in which nowadays only indicates a conservative two-years follow-up for residual non-invasive lesions. P3.02.07 MANAGEMENT OF CERVIX UTERUS EROSION IN NULLIPAROUS WOMEN N. G. Pryadko, G. V. Belousov, Donetsk State Regional Center of Maternity and Child Care, Donetsk, Ukraine. Objectives: The aim of the investigation is to study the efficacy of shortwave therapy in young women having cervix uterus erosion accompanied by chlamydial infection based on colposcopic and morphologic evaluation of the cervix uterus epithelium condition. Study Methods: 32 women aged 16-25 were examined. Anamnesis was studied, gynecologic examination, clinical and bacteriological investigation of vaginal discharge, simple and extended colposcopy, histological investigation of cervix uterus tissue bioptates were done. Antibiotic therapy in combination with an isolated effect of short-wave therapy on biologically active acupuncture points was sued. Results: There were no die effect in patients after short wave therapy. In 33.3% of cases initial transformation epithelium was demonstrated. In 37.8% cases the ectopic area decreased because of the extension of transformation and formation lingualae zone mainly on the back lip of cervix uterus. By the 8th week from the beginning of treatment full epithelization was colposcopic diagnosed in 42.7% patients, in 32.4% of them stratified pavement epithelium was unripe, that demonstrated in segments with negative or feebly positive Shiller test. In 12 weeks full epithelization took place in 47.1% cases, in 36.8% of them Shiller test was positive. The treatment hasnt brought positive outcomes in 6(8.8%) cases. Conclusions: It is possible to explain obtained outcomes by modulating effect of electromagnetic millimeter wave range on natural processes of stratified pavement epithelium transformation. If there is and inflammation in a combination with antibacterial treatment, the shortwave therapy stimulates initial processes of stratified pavement epithelium regeneration and promotes decreasing of inflammatory responses in tissues.

P3.02.05 DIAGNOSTICAL-PREVENTIVE VALUE OF BILLINGS OVULATION METHOD FOR VAGINAL-CERVICAL PATHOLOGIES A.L. Astorri, G. Pompa, E. Terranera, E. Giacchi, A.Cappella. Center for Study and Research on Natural Fertility Regulation, Catholic University of the Sacred Heart, Rome, Italy Objectives: The Billings Ovulation Method (BOM) is one of the most modern and valid methods which allows a woman to regulate her fertility in a natural way by identifying fertile and infertile phases in her menstrual cycle through a self-observation of cervical mucus secretion. The visual observation of mucus and the recording of the sensation produced by the mucus at vulva (mucus symptom) are demonstrated to enable the woman to identify the beginning and the end of the fertile phase in menstrual cycle, as well as the day of maximum fertility (peak of the mucus symptom). This study analyzes the eventual diagnostical-preventive value of BOM for vaginal-cervical pathologies (VCP). Study Methods: A group of 72 BOM users has submitted to gynaecological examination because they observed an atypical pattern of the mucus symptom which did not appear to be imputable to an endocrinous disfunctional pathology (as it was observed by hormonal assays and basal body temperature assessment). In these patients, an accurate check of the low genital tract was performed through cytologic-colposcopic examination and vaginalcervical cultures. Results: In a significative average of cases an atypical pattern of mucus symptom leads to an early diagnosis of clinically remarkable VCP such as HPV and other sexually transmitted diseases (63,9%).After the physical and/or pharmacological treatment the symptom became normal or better. Conclusions: Our study confirms the importance of mucus symptom as a faithful indicator of cervical function and the BOM usefulness for an early diagnosis of VCP, some of them are frequently present as subclinical and asymptomatic forms. Nowadays, VCP have acquired considerable interest in health environment either for their diffusion (for instance in case of sexually transmitted diseases) and in relation to the possible difficulty of diagnosis and therapy as well as to their oncogenic potentiality and the prospective consequences on the womans health and fertility. P3.02.06 EPIDEMIOLOGICAL CHARACTERISTICS OF PATIENTS SUBMITTED TO HYSTERECTOMY FOR CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN) GRADE III, FROM 1996 TO 1999, IN A WOMEN'S REFERENCE CENTER OF SO PAULO, BRAZIL. M. Dos Santos, M.A. Gonalves, G. Ferreira, D. Ferreira, Hospital Prola Byington, rua Bergamota, 470/121A, So Paulo, Brazil, 05468000. Objectives: This study was developed in order to evaluate epidemiologically women submitted cone excision and, also the outcome of those who were submitted to hysterectomy because of residual lesions from 1996 to 1999.

P3.02.08 POSSIBLE TRIAGE SOLUTION FOR EQUIVOCAL PAPS C-L.Chang, Y-C. Yang, S-Y.Wang, C-C.Wu, Mackay Memorial Hospital, No 92, section 2, Chung-Shan North Rd, Taipei, Taiwan, 105. Objective: The reported frequency of high-grade CIN in equivocal Pap smears has been more than 10%. But testing for HPV as a triage proposal is still debated. In this study we try to use the alteration of microsatellite patterns predicting the clinical outcome of this wideranged population. Study Design: Patients with cytologic ASCUS who were followed periodically and have a conization as final outcome were enrolled. The exfoliated cells in initial cervical swab were subjected to compare with the normal stromal cells in paraffin-embedded tissue in each case by their microsatellite patterns.

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Methods: PCRs with 5 pairs of primer labelled with fluorescence (D3S1110, D3S1228, THRB, D3S1289, D6S291) was done using DNA extracted from exfoliated cells and control stromal cells. The size and number of PCR products were relatively defined by GeneScan. Ratio between two allelic bands was compared between normal and tumor cells to determine the loss of heterozygosity (LOH). RESULT: LOH or alteration in one locus and two loci as a marker for HISL showed 82.2% and 64.7% in sensitivity, 74.1% and 91.6% in positive predictive value, 61.5% and 92.4% in specificity and 72.7% and 66.7% in negative predictive value, respectively. Conclusion: Microsatellite alteration as a possible triage for equivocal Paps is better than HPV testing. Pathologically it is more related to late event in carcinogenesis rather than early event involved by HPV. P3.02.09 RETROSPECTIVE ANALYSIS OF MULTIPLE PRIMARY MALIGNANT TUMORS (MPMT): GENERAL CHARACTERISTICS AND PRINCIPAL ASSOCIATIONS. M.A. Gonalves, A.L.Pinto, F.Savoy, F.Laginha, Hospital Prola Byington, rua Bergamota, 470/121A, So Paulo, Brazil, 05468-000. Objectives: This work seeks to study Multiple primary malignant tumors (MPMT) focusing the main associated neoplasms, distribution according to time interval occurrence and, epidemiological characteristics of affected population. Methods: Twenty women harbouring MPMT attending on Oncology Service of Hospital Prola Byington from 1983 to 1999 were studied. Neoplasms were classified according to their occurrence as sincronic (till 6 months interval between tumors) and metacronic (more than 6 months interval among tumors occurrence). Tumors with similar histological features were excluded from the analysis. The following epidemiological characteristics were considered: age at the time of tumors diagnosis; neoplasm interval; parity; menopausal status. Results: From the total of neoplasms analysed, 19/20 (95%) was a double association and 1/20 (5%) was a triple one. Fifty per cent was sincronic and 50% metacronic. Breast-ovarian was responsible for 20% of associations, (75% metacronic, 25% sincronic); breast-cervix for 20% (100% metacronic); breast-endometrium for 15% (100% sincronic); endometrium-ovarian for 10% (100% sincronic); cervix-ovarian for 10% (50% sincronic, 50% metacronic) and others for 25%. Age at the first neoplasm diagnosis ranged from 34 to 81 years old (median 60), at the second diagnosis was from 38 to 81 (median 62.2) and, at the third one was 71 years old. Considering metacronic tumors, diagnosis interval varied from 1 to 13 years (median 5.2). Parity ranged from 0 to 16 deliveries (median 2.8). At the moment of the first tumor diagnosis, 75% of patients were at menopausal status. Conclusions: The most freqent organ involved in multiple tumors was the breast, in 55% of cases, probably due to embriologic or commom etiologic factors. Menopause seems to be directly related to MPMT appearance, thus, as a routine, it is very important to screen all menopausic women harbouring a breast neoplasm, for a second sincronic or metacronic tumor. P3.02.10 ROLE OF INTRAVAGINAL ISO SORBIDE MONONITRATE IN CERVICAL RIPENING PRIOR TO 1ST TRIMESTER MTP V. Agrawal, T. Batham, N. Jain, R. Agrawal, Dept. OB/GYN, G. R. Medical College, Gwalior, India. Objectives: The aim of the aim of the study is to evaluate the adequacy and side effects of pre treatment of intravaginal 40 mgm iso-sorbide nominitrate to ripen the cervix before first trimester termination of pregnancy. Study Methods: One hundred women scheduled for first trimester surgical termination were assigned to receive 40 mgm iso-sorbide mononitrate per vaginum 1/2hr. before surgery. Results were compared with women who received Inj. Prostodin 3 hrs. before surgery. Results: The study reveals that more women remained symptom free after iso-sorbide monosorbitrate that Inj. Prostodin (4/100 vs 53/100). Pre treatment with Prostodin resulted in abdominal pain in 25%, nausea 8%, vomiting 12%, diarrhoea 2%, whereas women developed headache after iso-sorbide mononitrate 4%. Cervical resistance was lower in Prostodin group than iso-sorbide mononitrate achieved 7.8 mm whole with Prostodin 8.48 mm. Intraoperative blood loss was lower after pre

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treatment Prostodin but no effect was observed after iso sorbide mononitrate. Conclusions: Vaginal administration of the nitric oxide donor isosorbide mononitrate can induce effecting ripening of human cervix. Women remained symptom free after it except in 4% women developed headaches.

P3.02.11 STUDY OF THE GLANDULAR ENDOCERVICAL EPITHELIUM CELLS FROM POST MENOPAUSED WOMEN RECEIVING HORMONAL REPLACEMENT THERAPY COMPARING A MORPHOLOGIC ANALYZES WITH PCNA IMMUNOEXPRESSION Marcos Ymayo, J. Robalta, J. Focchi, J. de Lima. Escola Paulista de Medicina - Federal University of So Paulo, Av. Brigadeiro Luiz Antonio, 2819 #8d, So Paulo, Brazil, 01401-902. Objectives: This study was undertaken to develop objective morphometric data on the cells of glandular epithelium collected from post menopaused women receiving hormonal replacement therapy (HRT). We analyzed the following outcomes: nuclear(NA) and cellular area(CA), nuclear(ND) and cellular major diameter(CD), nuclear(NV) and cellular volume(CV), epithelium thickness(ET) and PCNA immunoexpression (PCNA). Study Methods:10 cases with a mean age of 62.8 years were selected at The Federal University of So Paulo Escola Paulista de Medicina Ambulatory of Colposcopy . The oral HRT, was done with 0.625mg of conjugated estrogen for 28 days and 5mg of medroxyprogesterone acetate from the 14th to 28th day, which one had been exposure for a total of 84 days. Biopsies samples were obtained from the endocervix on day 0, 28, 56 and 84. The morphometric and PCNA data were analyzed . Results were statistically analyzed by descriptive parametric tests for the comparison of the means. Results: The results for each outcome from the absent of hormones to HRT 84 days is described: NA from 40.74 to 61.44mm2 (p<0.001), ND from 10.91 to 12.70mm (p=0.010), NV from 52.29 to 68.00mm3 (p<0.001), CA from 119.95 to 272.15mm2 (p<0.001), CD from 19.29 to 37.64mm (p<0.001), CV from 125.99 to 294.20mm3 (p=0.003), ET from 17.50 to 33.64mm (p<0.001) and PCNA from 15.97% to 55.47% (p<0.001). Conclusions: The cells increased the areas, major diameters, volumes and epithelium thickness after 84 days of HRT. We observed positive PCNA higher than 50% after 56 days. The above average cells measurements, in general, follow the positive PCNA raising, during the hormonal effects. P3.02.12 TAKING A SATISFACTORY CERVICAL CYTOLOGIC SMEAR A. Baheiraei (1), N. Jamshidy (2), M. Noorian (2), M. Pourheidary (1), A. Mehran (3), Z. Khakbazan (3), Tehran University of Medical Sciences, Tehran, Iran. (1) Dept. Midwifery, Faculty of Nsg. & Midwifery (2) Dept. of Pathology (3) Dept. of Vital Statistics Objectives: The aim of the study was to investigate the quality of cervical papanicolaou smears by teaching pap smear procedure to midwives. Study Methods: The study used a papanicolaou smear database of 1850 specimens collected in health and treatment center in Semnan Province in Iran. The proportion of pap smears with inadequate (absent endocervical cells), obscure and badfixation was determined before and after teaching. Results: The number of smears before and after teaching of papsmear procedure has been 950 and 900 sample respectively. Before teaching, of 950 smears, 3115 (33.16%) classified as unsatisfactory or satisfactory but limited (19.58% inadequate, 9.68% badfixation, 3% obscuring of cell specimens), after teaching of 900 smears (10.22%) were classified as unsatisfactory or satisfactory but limited (5.78% inadequate, 3.22% badfixation, 1.22% obscuring of cell specimens). Conclusion: Greater skill with smear sampling is associated with fewer unsatisfactory smears.

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P3.02.13 THE MANAGEMENT OF MILD CERVICAL DYSPLASIA DUE TO HPV INFECTION M. Grigore, G. Costachescu, A.C. Anton, I. Lupascu, Dept. OB/GYN, University of Medicine, Iasi, Romania. Objectives: The study is conducted in order to detect the appropriate management of the mild dysplasia of the cervix caused by HPV infection. Study Methods: In the period 01/02/97 to 01/01/99 we analyzed and treated 75 cases of mild cervical dysplasia caused by HPV (human papiloma virus) infection. The diagnosis of mild dysplasia was posed by citology combined with colposcopy and biopsy. Results: From those cases, 30 (40%) which had associated vulvar or vaginal HPV infection, underwent cervical local treatment with diathermocauthery and 45 (60%) cases were managed by expectancy. The one year follow-up after the initial exam and treatment shoed no significant differences between the two groups of patients regarding the recovery after HPV infection. Conclusions: In spite of those results, we recommend local treatment of all mild cervical dysplasia because of two reasons: cervical local treatment enhance local immunity (making the local treatment of other sites of HPV infection like vulva or vagina not necessary any more) and decrease the possibility of transmission of the disease during the intercourse (this way decreasing the possibilities of spreading the HPV infection).

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pap smear and colposcopy with biopsy, each patient applied 1 sachet of imiquimod by tampon overnight, 2 times per week for 8, 10, or 12 weeks. Repeat pap smear and colposcopy with biopsy were performed at 8 and 12 weeks. Patients with other cervical or vaginal pathology were excluded. Results: After 8 weeks of treatment, 18/90 patients had negative pap smears and colposcopy with biopsies. An additional 26/90 patients had normal pap smears but were acetowhite positive. These patients were treated for 2 more weeks. After 12 weeks of treatment, the 26 patients treated for 10 weeks had normal test results and the remaining 46/90 patients that were treated for 12 weeks also normalized. Almost every patient experienced one or more adverse reactions, which included vaginal and vulvar erythema (85%), erosion (25%), edema (20%), and burning (33%). Conclusions: The human papillomavirus is the primary etiological agent in external genital warts and cervical dysplasia/cancer. Imiquimod is an immune response modifier indicated for the treatment of external genital warts. Our data suggests that intravaginally administered imiquimod may be an effective therapy for the treatment of cervical dysplasia. However, long term, prospective studies are needed to assess the potential of this promising therapy. P3.03 CESAREAN SECTION 1 P3.03.01 AN ANALYSIS ON TIME-RESPONSE IN IMMEDIATE CAESAREAN SECTION G. Pandis, D. Gibb, Dept. of Women and Child Health, Kings College Hospital, London, UK. Objective: The aim of the study was to examine the time-response from decision to delivery by immediate caesarean section. Study Methods: A computerised database search for 1998 identified all immediate procedures. 50 obstetric records were reviewed with particular interest in the assessment of decision to delivery time, number of medical personnel involved in each assessment, neonatal outcome and maternal morbidity. Results: The mean internal decision to delivery time was 27.9 minutes. 37% of babies were delivered within 20 minutes. The mean internal assessment to decision time was 16 minutes with 72% of decisions being made within 20 minutes. This was independent of the number of doctors involved in each case. Preterm delivered comprised 40% of cases with 25% of them being <32 weeks. Mean Apgar score was 5.6 at 1 minute and 32% of babies had a cord pH <7.15. Half of neonates required admission and there was a correlation between need for admission and prematurity or low Apgar score at 1 min. Women spent an average of seven days in the hospital. Postoperative pyrexia was evident in 30% of cases, while half of the remaining women developed post-operative complications such as wound haematoma or pelvic abscess. Conclusion: Immediate caesarean section is associated with increased neonatal and maternal morbidity. Delivery within 20 minutes from decision is a difficult but realistic aim. Possible causes of slow response and potential time saving measures should be considered during the second phase (decision to delivery) of the overall response time (assessment to decision to delivery).

P3.02.14 THE MEASUREMENT OF CERVICAL ECTOPY: COMPUTERIZED PLANIMETRY VERUS CLINICAL ASSESSMENT C. Morrison, P. Bright, I. Yacobson, C. Kwok, Z. Pan, E. Wong, Family Health International, P.O. Box 13950, Research Triangle Park, N.C., USA, 27713. P. Blumenthal, S. Zdenek, Planned Parenthood of Maryland, 610 N. Howard St., Baltimore, M.D., USA, 21201 Objectives: To determine the reliability of cervical ectopy measurements made by computer planimetry and by clinical (visual) assessment. Study Methods: Women seeking contraceptive services at two health centers in Baltimore underwent a pelvic examination. After applying acetic acid, clinicians rated the relative size of ectopy by direct visualization and took cervical photographs using a 35 mm camera. Two independent raters measured the absolute and the relative size of ectopy using the digitized images and an analytic software program. Agreement levels between raters, between multiple readings by the same rater, and between the two measurement methods were quantified using the intraclass correlation coefficient (ICC) and weighted kappa (k). Results: Intrarater agreement for computer planimetry measurements was excellent for the absolute (ICC = 0.97; 95% CI 0.95-0.98) and relative (ICC = 0.89 95% CI 0.85-0.92) size of ectopy. Interrater agreement for computer planimetry measurements was also very high for the absolute (ICC = 0.83; 95% CI 0.76-0.88) and relative (ICC = 0.85; 95% CI 0.79-0.89) size of ectopy. Agreement levels between clinician assessment and computer planimetry for the relative size of ectopy were moderate (k=0.48; 95% CI 0.43-0.53) but somewhat higher when limited to measurements by a single, experienced clinician. Conclusion: Measurement of cervical ectopy by computer planimetry was highly reliable. Use of computer planimetry appears appropriate for evaluating the role of cervical ectopy in the acquisition of cervical infections. Clinical assessment of ectopy may be used when measurement by computer planimetry is infeasible.

P3.03.02 BREECH PRESENTATION - ANALYSIS OF MODE OF DELIVERY A. Havalda, B. Tibor, M. Borovsky, D. Mracnova, M. Korbel Dept. OB/GYN, Conenius University, Bratislava, Slovakia. Objectives: The aim of the study was to analyze the mode of delivery of breech presentation in 1994 1998 in the Bratislava region, to determine neonatal mortality and morbidity in non-malformed singleton infants delivered in breech presentation and identify a possible correlation between outcome on the one hand, and mode of delivery, parity and birth weight on the other. Study Methods: We analyzed 873 singleton breech deliveries of nonmalformed infants in the Bratislava region between 1994-1998. Process and outcome measure: mode of delivery, gestational age, birth weight, congenital malformations, intrapartum death, Apgar scores and early neonatal death. Results: A total of 252 (28.9%) infants were delivered vaginally, extraction was used in 49 (5.6%) deliveries, 301 (34.5%) were delivered

P3.02.15 USE OF IMIQUIMOD 5% CREAM IN LOW GRADE CERVICAL DYSPLASIA R.Chung Garay, L.Uribe, V.Moreno, D.Espinosa, Cervical Dysplasia Clinic, 2380-5 Hildago Ave, Guadalajara, Jalisco, Mexico, 44150. Objective: The aim of this study was to evaluate the safety and efficacy of intravaginally administered imiquimod 5% cream for the treatment of low grade cervical dysplasia. Study Methods: Ninety patients with a cytological and histological diagnosis of CIN I were enrolled in an open-label study. After a baseline

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by elective and 277 (30.0%) by emergency cesarean section. Infants delivered vaginally and by emergency cesarean section had higher rates of mortality (intrapartum and early neonatal death) and morbidity (low Apgar scores) when compared to those delivered by elective cesarean section. 73% of all primiparas and 52.5% of all multiparas were delivered by cesarean section. Conclusions: Vaginal delivery is associated with increased mortality and morbidity.

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P3.03.05 CESAREAN SECTION IN ECLAMPSIA AT A RURAL REFERRAL CENTER T. Deka, H. Kalita, R. Deka, Nalbari Maternity Hospital, Nalbari, Assain, India Objectives: The aim of the study was to investigate whether liberal cesarean section in eclampsia improves maternal & perinatal salvage. Study Methods: Fifty-five cases of eclampsia were included in the study, over a period of 4 years between Oct. 1995 to Oct. 1999. 30 were delivered by cesarean section (Group A) and 25 cases were delivered vaginally (Group B). Magnesium sulfate was the anticonvulsant and Nifedipine was used as the antihypertensive. All the cesarean sections were performed under general anesthesia. Results: -Incidence of cesarean section in the present study is 54.5% -Fit recurrence with Magnesium sulfate anticonvulsant regime is minimal -Maternal mortality is less in the patients delivered by cesarean section (3.3%) in comparison to vaginal delivery (12%). -Fetal salvage could be improved by early resort to cesarean section. PNMR-10% vs. 28% in Group A & Group B respectively. Conclusions: -Magnesium sulfate is an effective anticonvulsant in eclampsia -A policy of More section in eclampsia has improved the maternal and perinatal outcome

P3.03.03 CESAREAN SECTION (CS) WITH AUTOLOGOUS BLOOD/PLASMA TRANSFUSION (ABT/APT) CAN PREVENT POSTPARTUM COMPLICATIONS. S. Chermnich (1), I. Mogilevkina (2), I. Knurov (1) 1. Donetsk State Regional Center for Mother and Child Care, Donetsk, Ukraine. 2. Dept. OB/GYN, Donetsk State Medical University, Donetsk, Ukraine. Objectives: To study the benefit of ABT/APT in elective CS patients. Study Methods: Two-hundred and forty-four elective CS patients were included. ABT was performed in 150 pregnant women (I), APT in 34 women (II). Homologous blood transfusion was used in 30 (III) and no blood transfusion in 30 (IV) women. 3-4ml per kg was collected in ABT patients within 4-10 days before CS. 500-600ml of plasma was donated in donor plasmapheresis in third pregnancy trimester. Coagulation, hematological and immunological indexes were studied. Results: We did not find any negative hematological and hemodynamic changes after blood donation and plasmapheresis. No negative consequences were defined in fetus well being. Postpartum period in ABT/APT patients was characterized by significantly higher levels of Hb (I 109.93.1; II 108.83.0 ; III 105.23.2; IV 98.64.1 g/l), Ht (I 32.60.7; II 32.80.6; III 31.01.4; IV 29.61.0 g/l), erythrocytes (I 3.30.1; II 3.20.1; III 3.00.1; IV 2.90.1 T/l), and IgG (I 15.00.6; II 15.00.5; III 14.80.6; IV 13.00.6 g/l). 53% of group I and 55% of group II patients have had postpartum anemia (70% in group III and 80% in group IV). Puerperal infection was identified in 47% of group IV, 17% of group III and just 10% of group I and 6% of group II patients. Conclusion: ABT/APT are safe procedures for mother and fetus. Positive hematological and immunological changes in ABT/APT groups were accompanied by postpartum anemia as well as puerperal infection decline. P3.03.04 CAESAREAN SECTION- SAME PROCEDURE: THEN WHY DIFFERENT PRACTICES? M. Khaled. Dept. OB/GYN, Prince Charles Hospital, Merthyr Tydfil, CF47 9DT, UK. Objectives: This retrospective study was to compare the practice of Caesarean section in two nations to try and establish the possible reasons for the difference in practices Study Methods: The 1996 labour word records in the two selected units (one in UK and the other in the UAE) were studied in great detail. Data included all relevant information in the two units. Results: Remarkable differences in the rates (19% vs 10%) and indications for both elective and emergency Caesarean sections were identified in both units. All these differences were statistically significant. Maternal request, while being on the increase in the UK, it is growing in UAE. Previous Caesarean as an indication for repeat Caesarean noted to be significantly different in the two populations (42% vs 12%). Conclusions: Caesarean section rates and indication are different from one unit ton another. There is a wide variation in the practice despite same training. Population type is only one aspect but there are many reasons for the differences. The need for local , national and international protocols is required to standardize practice. Regular audit within each unit is essential in improving the quality of care given

P3.03.06 CESAREAN SECTION INDICATIONS IN THE PERINATAL CENTER N. Shpatusco, M. Shatalova, I. Mogilevkina, Dept. OB/GYN, Donetsk State Medical University, Donetsk, Ukraine. Objectives: To study indications for cesarean section in the perinatal center. Study methods: Retrospective cohort study of cesarean section case records had been performed at Donetsk Regional Center for Mother and Child Care in 1998. 366 cases (89.4%) were analyzed. All perinatal mortality cases were excluded. Results: Cesarean section rate was 20.7%. Among those, 86.1% (315) were at term, 13.7% (50) pre-term, and 0.5% (2) post-term. Hysterectomy was performed in 27 women (7.4%). Indications for cesarean section were divided into; mothers - 291 (79.3%), and fetus 75 (20.7%). Mothers indications included: contracted pelvis 5 (1.4%); obstructed labor 6 (1.6%); placenta previa 4 (1.0%); placenta abruption 19 (5.2%); previous cesarean section 47 (13.2%); cervix distocia 2 (0.5%); delayed labor 34 (9.3%); preeclampsia 55 (15%); common diseases 101 (27.7%); others 16 (4.3%). Fetus indications included: hypoxia 29 (8%); malpresentation 33 (9.1%); cord prolaps 3 (0.8%); IVF 6 (1.7%); others 4 (1.1%). Conclusions: Mothers indications were more often reason for cesarean section in the perinatal center. Among those common diseases were crucial. Preeclampsia was the second one followed by previous cesarean section and delayed labor. To decline cesarean section rate, vaginal delivery in both previous cesarean section and preeclampsia should be discussed. Hysterectomy in cesarean section patients is still a matter of great concern.

P3.03.07 COAGULATION DISTURBANCES DURING CAESAREAN SECTION (CS) AND THEIR PREVENTION BY INTRAOPERATIVE TRANSFUSION OF AUTOLOGOUS FRESH-FROZEN PLASMA (AFFP) S. Hodoroja, R. Comendant, U. Topor, Dept. OB/GYN, State Medical and Pharmaceutical University, Chisinau, Republic of Moldova. The normal activity of anticoagulant mechanisms is essential in preventing activation of clotting system during CS. This activation often progress to disseminated intravascular coagulation with subsequent development of hemorrhagic, as well as thromboembolic complications. The objective of out study was to examine coagulation disturbances during CS in pregnants with high risk factors of bleeding or thromboembolism (repeat CS in Association with preeclampsia, placenta

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praevia, grand multparity, obesity, gross varicose veins) and to asses the effectiveness of AFC transfusion in their prevention. Study Methods: In 56 patients with above mentioned risk factors coagulation parameters (fibrinogen, platelet count, APTT, thrombin clotting time, and antithrombin III activity (AT III) were measured during CS and the first 5 postoperative days. This group was compared with 58 patients who met the same criteria for hemorrhage and thromboembolism. In this group (II) in the III trimester of pregnancy 600-900 ml of AFFP was collected by means of plasmapheresis and used intaoperatively to restore coagulation inhibitor AT III and to stop depletion of clotting factors. Results: In the first group haemostasiological evidences of consumption coagulopathy detected at the end of CS (reduction of fibrinogen from 4.20.23 g/l to 2.70.21 g/l and platelets from 2407.610 /l to 1946.410 /l) were preceded by intraoperative reduction in AT III activity (73.51.2%). In the second group, after intraoperative transfusion of AFFP and size of AT III level to 86.42.2% (p<0.05) the consumption of coagulation factors was stopped (fibrinogen 3.840.36 g/l (p<0.05), platelets 2169.110 /l (p<0.05). AT III activity >80% in these patients was detected during all the first 5 postoperative days, while in the fist group AT III returned to normal values only on the fifth day after operation. Conclusion: Intraoperative transfusion of AFFP increases anticoagulant activity, prevents coagulation disturbances during CS and be effectively used to reduce the incidence of hemorrhages and thromboembolic complications in patients with high risk factors delivered by CS. P3.03.08 COMPARATIVE ANALYSIS OF OWN MODIFICATION OF MISGAV-LADACH (MML) AND PFANNENSTIEL METHODS FOR CESAREAN SECTION IN THE MATERIAL OF FETALMATERNAL MEDICINE DEPARTMENT PMMH-RI BETWEEN 1994-1999 P. Pawlowicz (1), J. Wilczynski (1), T. Stetkiewicz (2) (1) Dept. of Fetal-Maternal Medicine, Polish Mothers Memorial Hospital, Research Institute, Lodz, Poland. (2) Dept. of Gynecology and Menopause, Polish Mothers Memorial Hospital, Research Institute, Lodz, Poland. Objectives: Comparative analysis of modification of Misgav-Ladach (MML) and Pfannenstiel methods for cesarean section in the material of Fetal-Maternal Medicine Clinical Department of PMMH-RI between 1994-99. Study Methods: Study group consists of 242 patients. In all women from this group we performed cesarean section using modification of MisgavLadach method. Among all patients from control group (counting 285 women) we performed cesarean section applying Pfannenstiel method. To analyze clinical postoperative course in both groups we took into account several parameters. Results: Statistical analysis revealed that most of clinical postoperative course parameters had significantly better values in the study group in which we performed cesarean section using the modification of MisgavLadach method. Conclusions: The benefits of modification of Misgav-Ladach method, with less pain post-operatively and quicker recovery, are all a by-product of doing the least harm during surgery and removing every unnecessary step. This method is appealing for its simplicity, ease of execution and its time saving advantage.

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Methods: Retrospective analysis of data on 290 unselected patients who had term primary cesarean delivery during a twelve-month period was conducted. Eighty-four percent were residents of the district whereas the other 16% had been transferred from smaller health districts. Patient characteristics, indications for, and preventability of cesarean delivery was assessed by reviewers who were blind to the identity of the obstetricians. Results: Overall, 66 (23%) of the cesarean deliveries were deemed preventable: 41 (62%) of those cases were considered preventable by patients and 25 (38%) by obstetricians. The preventable cesarean section rate was significantly higher in Saskatoon residents as compared to nonresidents (24% vs. 13%; P< 0.05). The two main indications accounting for preventable cesarean sections were breech presentation and dystocia. Conclusions: The choice of patients and individual obstetricians normal practice appear to influence recourse to cesarean delivery. Addressing the perspectives on breech presentation and dystocia by obstetricians for clinical management and by patients for their choice may facilitate the proper utilization of cesarean delivery.

P3.03.10 FETAL SURVIVAL DESPITE UNRECOGNIZED UTERINE RUPTURE RESULTING FROM PREVIOUS UNKNOWN CORPOREAL SCAR M. Erman-Akar, Z. Yilmaz, O. Gkmen, Dept. OB/GYN, Zekai Tahir Burak Maternity Hospital, Ankara, Turkey. Cesarean scar rupture of a gravid uterus with unknown corporeal scar is common. Our case was a 35-year-old woman, gravida 2, para 1, presented at 38 weeks gestation. She was admitted to our hospital for routine follow-up. She had no signs or symptoms of labor. However, eight hours after the initial examination, she came back to the hospital with signs of shock and acute abdomen. Immediately, she was referred to surgery. Intraoperatively, a complete rupture of the classical corporeal incision was observed, but the fetus was enclosed within the anterior lying placenta. The fetus was delivered with one minute apgar score 3 and five minute apgar score 8. According to this case, we conclude that spontaneous uterine rupture of the classical uterine scar can be observed even without uterine contractions. So women with the possibility of previous classical uterine incision should be delivered once fetal maturity is documented. Key words: uterine rupture, classical incision, fetal survival.

P3.03.11 HYSTERECTOMY CAESAREA R. Ljubomir Ristic, P. Branislav, R. Goran, M. Ivana, M. Nemanja, Gynecology & Obstetrics Clinic, Belgrade, Yugoslavia. The authors, in the paper, presented results of hysterectomies during Caesarean Section at the Gynecology and Obstetrics clinic at Prishtina in the period 1989-1998. During this period there were 3870 deliveries at the Gynecology clinic of which 7274 (9.84%) were with Caesarean Section. At the same period they were 73 cases (1.00%) Hysterectomy during Caesarean Section. Authors analyzed the indications of hysterectomy: Abruptio placentae 7 (9.58%), Utery-placentae apoplexy 29 (39.72%), Placenta previa centralis 14 (19.17%), Placenta accreta 13 (17.80%), Ruptura utery completa post C.S. 6 (8.21%) and Atonio utery 4 (5.47%). The authors also show that the patients were operated in a very wicked condition by reason of abundant bleeding, presentation of developed infection and exhausted patients. Operative procedures presented a big risk with the intensive preoperative reanimation of patients, and the need of a surgeon with experience, and postoperative care. The results in this paper have shown that there were no serious complications in the cases and there were no cases of mortality.

P3.03.09 EFFECTS OF PHYSICIAN AND PATIENT PREFERENCES ON CESAREAN DELIVERY O.A. Olatunbosun, A. Ravichander, L. Edouard, R.W. Turnell, Dept. OB/GYN, Gynecology & Reproductive Services, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. Objectives: Despite and overall cesarean delivery rate below the national average, a wide range of variation exists between individual obstetricians rates at Saskatoon Health District. Our objective was to test the hypothesis that physician and patient preferences influenced cesarean delivery rates. We evaluated the preventability of cesarean delivery to determine the contribution of physician and patient factors.

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P3.03.12 OBESITY AT DELIVERY AND RISK OF CESAREAN SECTION: A TEN-YEAR EXPERIENCE D. Czukerberg, E. Charles Lampley Jr., J. Blankstein, Dept. OB/GYN, Mount Sinai Hospital, Chicago, Finch University Health Sciences, Illinois, USA. Objective: Obesity is a pervasive public health problem among women in United States and is associated with significant excess of morbidity and morality. The objective of this study was to determine if women with obesity at delivery are more likely to deliver by cesarean section compared to nonobese women. Study Methods: A search of all records of singleton deliveries of women who delivered only once a t Mount Sinai Hospital between January 1st 1987 and December 31st 1997 was done from the perinatal computerized database. The body mass index (BMI) at delivery (weight in kilograms divided by the square of height in meters) was calculated for each record. Records with: a) missing or inappropriate height and/or weight, b)BMI<12kg/m2, c) age<11 and > 47 years old, and d) birth weight <500 grams, were excluded. Obesity was defined as BMI30 kg/m2 at delivery. The relative risk of cesarean section of obese women compared to non-obese was calculated. Results: Total 20,372 records met the inclusion and exclusion criteria. Only 291 records (1.4%) were previously excluded. Forty percent of women (8,213) were obese at delivery and 60% were not (12,159). The cesarean section rate for the obese group was 16.9% (1391) compared to 9.6% (1178) for the non-obese group. The relative risk of cesarean section for obese women is 1.75 (95% confidence interval 1.63-1.88; P<0.00000001) compared to non-obese women. Conclusions: Obese women at delivery have almost twice the risk of delivering a singleton by cesarean section than non-obese women.

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pre- and post-surgery tocolythic therapy, monitoring the condition of the fetus. Results: None of the patients had miscarriages. No stillborns. While examining the area of the uterus from which nodes had been removed, no pathological changes were found. Conclusions: The myomectomy in pregnancy patients must in optimal size of gestation with tocolythic therapy. Delivery by cesarean section at 38 weeks.

P3.03.15 THE USE OF VACUUM EXTRACTOR IN CAESARIAN SECTION S.N. Tripathy, Dept. of OB/GYN, S.C.B. Medical College, Cuttack, Orissa, India Objective: As the C.S. rate is increasing and more elective C.S. are being done for liberal indications, the incidence of lhigh mobile head at he time of C.S. is very often encountered. It poses considerable difficulty to the operator, the options available to him or her are to employ fundal pressure and use considerable force to extract the head, or increase the incision, or apply forceps which slips most often. Invariably the incision gets extended and there is profuse haemorrhage. Vacuum extraction has got a lot of advantages over in a vaginal delivery. So the aim of the study is to evaluate the use of vacuum to deliver a difficult head in C.S. delivery. Study Methods: This prospective study was carried out in 100 cases where a floating head was encountered. All were elective, single ton, term pregnancies. Thirty-five cases were delivered by vacuum extraction, 25 cases by wriglys forceps, and 40 cases by fundal pressure. They were matched for age, parity, foetal wt and S.E. status. The statistical analysis was done by Odds Ratio. Results: The failure rate with vacuum and forceps were 2.8% and 12% respectively. (OR -0.21) with no significant maternal injuries (16% with forceps, 7.5% with fundal pressure, none with vacuum. Haemorrhage (a subjective assessment) was more in cases of forceps. The face and scalp injury was more in forceps, though the cephalohaematoma rate was more in vacuum as well as the maternal worry over chignon. (OR 3.7). Conclusion: The study has been made almost on a healthy population in the best place, best time, in optimum ideal conditions and done by the consultant. The series is small. A large no. of cases has to be done to give this instrument a place in C.S., In English Literature I could not find any one adoptin the instrument in C.S.

P3.03.13 RISK FACTORS FOR CESAREAN SECTION S.A.T. Essinger, A.A. Cunha, S.C. Machado, A.M.S. Catharino, Faculdade de Cincias Biolgicas e da Sade, Universidade Iguau Maternidade, Escola, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil. Objective: To identify the risk factors for cesarean section. Study Methods: Cross sectional study. From January 1st 1998 to May 31st 1999, 3926 deliveries were observed at the Hospital Universitrio (Universidade Iguau). The factors were those from the Birth Certificate: (maternal age, maternal education, number of prenatal appointments,sex, gestational age, multiple gestation). Results: The odds ratios were: sex OR=1.01 (CI 0.88-1.16); pre-term (22-36 weeks of gestational age) OR=0.98 (CI 0.70-1.36), reference 37 and over weeks; multiple gestation OR=3.38 (CI 2.09-5.48); maternal age: adolescence (19 years) OR-0.56 (CI 0.47-0.67), late pregnancy (>=35 years) OR=1.53 (CI 1.21-1.94), reference 20-34 years; prenatal appointments: 1-6 OR=1.11 (CI 0.83-1.50), >6 OR=2.18 (CI 1.63-2.91), reference no prenatal care; education: fundamental OR=1.72 (CI 0.833.66), high school OR=2.60 (CI 1.25-5.52); university OR=5.64 (CI 2.13-15.21), reference no education. Conclusions: The risk of cesarean section was associated with multiple gestation, late pregnancy, more than 6 prenatal appointments, and higher education. The adolescence was a protective factor. P3.03.14 SURGICAL TREATMENT OF ATYPIC MYOMA OF THE UTERUS DURING PREGNANCY T.N. Senchakova, I.I. Levashova, L.S. Logutova, S.N. Buyanova, Moscow Regional Scientific Research Institute of Obstetrics and Gynecology, Moscow, Russia. Objectives: To define the optimum surgical technologies, tactics, preand post-surgery treatment of atypic myoma of uterus during pregnancy. Study Methods: We have performed myomectomy on 23 pregnant women with atypical nodes of various locations and sizes (16-19 week gestation). At this stage of pregnancy placenta provides a lower risk of miscarriage. The peculiarities of handling such patients include: careful performance during surgery, meticulous hemostasis, optimal suturing,

P3.03.16 VESICO-VAGINAL FISTULA: IS THERE A SHIFT IN AETIOLOGICAL DETERMINANTS? E. P. Gharoro, C.O. Okonkwo, Dept of Obstetrics and Gynecology, University of Benin Teaching Hospital, Benin City, Nigeria Background: The occurrence of VVF is universal but the causative factor varies depending on the state of industrialization of the nation. Vesico-vaginal fistulas in the developed nation are rare but mainly occur as a result of gynecological operations or malignancy. However, they present a great challenge to the gynecologist. Objective: To investigate the localization and etiological factors associated with VVF at the University of Benin Teaching Hospital (UBTH) Benin, Nigeria Materials and method: Records on 96 patients treated by the authors at the gynaecological ward of the UBTH between January 1992 and December 1999 were analysed. Information extracted included data on socio-biological, demographic, and obstetric event of the antecedent pregnancy. These were subjected to statistical analysis using appropriate software. Results: The majority (92.7 %) of fistulas are obstetric in origin, while 5.21% were due to total abdominal hysterectomy and 2.08% due to post irradiation for advanced gynecological malignancy. 53(55.21%) had some form of obstetric operative intervention (forceps or vacuum extract, and or Caesarean section). Caesarean section contributed 23.96% to the total figure. Juxta-cervical fistula was the most frequent, next mid vagina and followed by vesico-uterine (32.98%, 24.47% and 19.15% respectively). Conclusion: These findings have shown that obstetrics surgical intervention by care providers is a major cause of VVF formation with particular reference to Caesarean section in our environment today. The

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incidence of fistulas due to gynecological operations and malignancy is on the rise.

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P3.04.03 EFFECTS OF TRIMONTHLY INJECTION OF DEPOMEDROXYPROGESTERONE ACETATE (DMPA) ON HORMONAL PROFILE NR Melo, RM Burgos, LM Pompei, W Muniz-Oliva, WM Ari, AZ Melo, HW Halbe, JA Pinotti, Medical School of So Paulo University, Brasil Objective: To study the effect of injectable contraceptive consisting of long-acting progestin on hormonal profile. Methods: Forty-six DMPA-user patients were studied retrospectively (average age, 44.4 y). They used 150 mg of DMPA every 3 months as contraceptive for at least 5 years (average use, 10.6 years). It was tested serum levels of FSH, LH, estradiol (E2), prolactine (PRL), testosterone (T), androstenedione (D4), dihydroepiandrosterone sulphate (DHEAS), T3, T4, TSH. One hundred and twenty six intrauterine-device-user women (IUD) (average age, 43.5 y), were the control group. Results: The mean values of the studied parameters are in the following table:
Group FSH IU/l DMPA 14.31 LH IU/l 6.98 9.66 E2 pg/ml 36.96 86.00 PRL ng/ml 5.94 7.61 T ng/dl 22.35 30.05 D4 ng/ml 1.19 1.26 DHEAS ng/ml 849.86 975.45 T3 ng% 126.08 123.58 T4 mcg% 9.86 9.92 TSH mcIU/ml 2.21 2.48

P3.04 CONTRACEPTION P3.04.01 A TWELVE MONTH EVALUATION OF CONTRACEPTION AND BREAST FEEDING PATTERNS IN WOMEN FROM A LOWER SOCIOECONOMIC BACKGROUND IN THE SOUTHWESTERN UNITED STATES W. Volker, T. Layton, J Hazen, J. Wrightson, R. Hernandez, Dept. OB/GYN, University of Nevada, School of Medicine, Las Vegas, Nevada, USA. Objectives: This study evaluated women who were patients of a womens clinic in Las Vegas, Nevada. This resident clinic offers complete obstetrical and gynecological care to all women with insurance, on Medicaid, or with no insurance. The goals were to identify and characterize these women, determine their breast feeding patterns, and evaluate contraception choice, compliance, satisfaction, and failure rates. Study methods: Retrospectively, 248 patients who were seen postpartum at their six week visit were identified. Of these, 101 women were sampled 12 to 14 months after their delivery date. Medical charts were reviewed. Patients were contacted by phone and information was obtained from a standardized questionnaire. Results: The clinic serves primarily minorities: 52% Hispanic, 10% black, 4% Asian/other, and 34% white. 53% of these patients had no insurance and 40% were on Medicaid. 78% of women received breast feeding information postpartum. 59% chose to breast feed with an average duration lasting only 2.2 months. Contraception was begun by 69% of women with 34% using OCPs, 23% Depo Provera, 12% condoms, and 9% underwent tubal sterilization. Failure rates were substantially high: 15% OCPs, 17% condoms, and 4% Depo Provera. Overall 11 of the 101 women were pregnant 12 months after delivery. Conclusions: In this predominantly minority, lower socioeconomic status population, these women breast feed for a very short period of time and had a high failure rate on contraception entirely related to noncompliance.

Control 13.46

The following parameters had differences with statistical significance: LH (p<0.05), E2 (p<0.001), T (p<0.01). Conclusions: Long-acting-progestin injectable had an important effect on sex steroids, with a very important decrease in E2 and a decrease in testosterone, being explained by central supression to release of pituitary hormones, so it was expected that levels of FSH was lesser in DMPA group, what have not occurred. Other androgens (DHEAS and D4) were less affected because their non-ovary production are more important than with testosterone. Prolactine was a little decreased, but the values were normal in both groups and without statistical significance. Thyroid hormones and TSH were not influenced by DMPA. P3.04.04 EFFECTS OF TRIMONTHLY INJECTABLE OF DEPOMEDROXYPROGESTERONE ACETATE (DMPA) ON BONE NR Melo, RM Burgos, LM Pompei, MTJ Sacilotto, W Muniz-Oliva, AZ Melo, HW Halbe, JA Pinotti, Medical School of So Paulo University, Brasil Objective: To study the effect of trimonthly injectable contraceptive consisting of 150 mg of depot-medroxyprogesterone acetate (DMPA) on bone mineral density. Methods: Forty-six DMPA-user patients were studied retrospectively. Their average age was 44.4 and they used DMPA as contraceptive for at least 5 years (average use duration: 10.6 years). The dose of DMPA was 150 mg every 3 months. Bone densitometry of lumbar spine and proximal femur was obtained of every patient in a Hologic QDR-4500A bone densitometer. The effect of DMPA on bone mineral density (BMD) of lumbar segment L1-L4, femur neck and total femur was studied comparing to a group of 126 intrauterine-device-user women (IUD), with average age of 43.5 years (control group). Results: The mean results of DMPA-group and control-group were: BMD of L1-L4 was 0.924 g/cm2 in DMPA group and 1.024 g/cm2 in control group, thus the DMPA group had a BMD 9.78% less than control group (p<0.001). Femur neck had 0.829 g/cm2 of BMD in DMPA users and 0.889 g/cm2 in control, a difference of 6.75% in DMPA users (p<0.05). Finally, total femur had a BMD of 0.890 g/cm2 in DMPA group and 0.951 g/cm2 in control, so a difference of 6.52% of BMD in DMPA group (p<0.05). The differences in all these parameters had statistic significance. Conclusions: The DMPA used as a trimonthly injectable contraceptive for several years (at least 5) was associated to a lesser bone mineral density in lumbar segment and proximal femur than in control group. This fact may be explained by the inhibition of pituitary-ovarian axis with reduction of ovarian steroids.

P3.04.02 CLINICAL EXPERIENCE OF CU-T380A IUCD INSERTED WITHIN 12 HOURS AFTER ABORTION M. Rocca, Dept OB/GYN, Shatby Maternity Hospital, Alexandria, Egypt. Objectives: To assess the clinical performance of Cu-T380A IUCD inserted within 12 hours after evacuation of the uterus in cases of first trimester spontaneous abortion. Study Methods: Three hundred women who consented to use an IUCD after abortion and have no contraindication for IUCD application had the Cu-T380A IUCD inserted before they were discharged from the hospital (maximum 12 hours following evacuation of the uterus). All women were asked to come for follow-up visits every 3 months for the first year after the IUCD insertion. Results: 39 women did not attend for follow-up and were excluded from the study. No cases of uterine perforation or acute pelvic infection were reported during the IUCD application. After one year of use there was one case of pregnancy and 5 cases of expulsion. 46 women reported bleeding and pain and they were severe enough to necessitate removal of the device in only 14 cases. Twelve women opted to remove the IUCD because of the desire for another pregnancy. The continuation rate after one year of application was 87.7%. Conclusions: IUCD insertion in the immediate post-abortion period is as safe and effective as the interval IUCD application. This contraceptive option should be available in all health care sites that offer the abortion services.

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P3.04.05 EFFECTS OF TRIMONTHLY INJECTABLE OF DEPOMEDROXYPROGESTERONE ACETATE (DMPA) ON CARBOHYDRATE METABOLISM NR Melo, RM Burgos, LM Pompei, WM Ari, W Pinheiro, AZ Melo, HW Halbe, JA Pinotti Medicine School of So Paulo University, Brasil Objective: To study the effect of trimonthly injectable contraceptive consisting of 150 mg of depot-medroxyprogesterone acetate (DMPA) on carbohydrate metabolism. Methods: Forty-six DMPA-user patients were studied retrospectively. Their average age was 44.4 and they used DMPA as contraceptive for at least 5 years (average use duration: 10.6 years). The dose of DMPA was 150 mg every 3 months. To evaluate carbohydrate metabolism, it was obtained Quetelet's index, abdomen-gluteus ratio, glycemia, serum insulin and glycoside-hemoglobin. It was used a group of 126 intrauterine-device-user women (IUD), with average age of 43.5 years, as control to comparison. Results: The mean results of DMPA-group and control-group were: Quetelet's index was 27.79 in DMPA users and 27.41 in control group. Abdome-gluteus ratio was the same in both groups (0.94). Glycemia was lesser (92.13 mg/dl) in DMPA than in control (96.11 mg/dl), but it was normal in both groups (normal between 70 and 110 mg/dl). Serum insulin was 15.24 mcIU/ml in injectable group and 15.65 mcIU/ml in control, but in both it was normal (less than 20 mcIU/ml). Finally, glycoside-hemoglobin was 6.06% in the study group and 6.18% in control group. The differences between the two groups, when present, had not statistic significance. Conclusions: The DMPA used in a trimonthly injectable form with doses of 150 mg did not affect adversely the studied carbohydrate metabolism parameters.

WEDNESDAY, SEPTEMBER 6
Medical center. 800mg of buccal misoprostol was given for cervical preparation. Dilatation and evacuation was then performed using manual vacuum aspiration primarily to remove amniotic fluid and placenta. Fetal parts were removed as necessary with appropriate forceps. Results: Complete abortion was effected in 100% of cases. No cases required resorting to an electric vacuum source. In all cases, the cervix was adequately prepared to allow either the immediate introduction of a size 14 mm suction cannula or could be easily dilated to allow passage of same. Procedure time was not significantly different when manual vacuum source was used than that for procedures in which an electric vacuum source was used. Conclusion: Although manual vacuum aspiration (MVA) is known to be safe and effective for termination of pregnancy in the first trimester, this report indicates that it can also be safely and effectively used in 2nd trimester procedures. This is important for settings where electric vacuum sources are either unavailable, unreliable, or cannot accommodate the large bore equipment required for D&E procedures. Similarly, the use of misoprostol to provide cervical preparation, was effective and offers an alternative in settings where laminaria are not available. MVA and buccal misoprostol should be more widely investigated for this purpose. P3.04.08 EVALUATION OF LIPIDIC PROFILE IN TEENAGE LONG TERM USERS OF ORAL HORMONAL CONTRACEPTIVE C. Guazzelli, P.C. Lindsey, F.F. Arajo, R.M. Santana, R. Mattar, M. Barbieri, L. Kulay Jr., Family Planning Service, Federal University of So Paulo, EPM, Brazil. Objectives: In adolescence, the beginning of the association of factors of risk for cardiovascular diseases is frequently observed. In this period of life important transformations occur, such as changes in food ingestion and physical activity habits, initiation to smoking, alcohol abuse and sex. Such modifications can have repercussions throughout life, the most hazardous of which leads to arterosclerosis. Early commencement of sexual activity combined with the frequent use of oral hormonal contraceptives by teens has concerned specialists, mainly if used for long periods. Oral hormonal contraception has widespread use among teenagers because of its high effectiveness, facility of use and also due to benefits related to the menstrual cycle, dysmenorrhea and acne. Bearing in mind the importance of this subject, we decided to investigate the effects of monophasic combined OHC containing 30 mg of etinilestradiol and 75 mg of gestodene over teenagers lipidic metabolism. Study Methods: 33 young women aged 14 to 19 years, users of OHC for a period of three years were evaluated. These parameters were analyzed: total cholesterol, HDL-C, LDL-C, VLDL-C, triglycerides, Castelli I and II risk indices. These exams were performed before starting OHC and one, two and three years after utilization of the method. Results: Statistical analysis showed an increase in total cholesterol, HDL-C, LDL-C, VLDL-C and triglyceride levels when compared to the initial values of one, two and three years of utilization of OHC. Indeed, the averages didnt exceed normal ranges. No significant statistical variation in Castelli I and II indices was found. Conclusion: The use of combined monophasic hormonal oral contraceptive containing 30 mg of etinilestradiol and 75 mg of gestodene over a period of three years causes an increase in total cholesterol levels, its fractions and triglycerides. These data emphasize the importance of evaluation of lipidic profile before and periodically during the use of OHC in order to get better follow-up and prevention of cardiovascular diseases. P3.04.09 EVALUATION OF THE EFFECTIVENESS AND ACCEPTABILITY OF THE DIAPHRAGM AS CONTRACEPTIVE METHOD NR Melo, RM Burgos, LM Pompei, ML Elluf, P Nicolau, LO Ramos, JA Pinotti, Medicine School of So Paulo University, Brasil Objectives: To evaluate the contraceptive effectiveness and the acceptability of diaphragm. Methods: They were retrospectively studied 44 women that used the diaphragm as contraceptive method, and 84.1% used spermicide gel associately. Everyone received exhausting orientation for correct way of employment of the method. The time of use varied from 10 to 121 months (average: 45.3 months), being equal to 124.6 woman-years.

P3.04.06 EFFICACY AND SAFETY OF A LOWDOSE MONOPHASIC COMBINATION ORAL CONTRACEPTIVE CONTAINING 100mg LEVONORGESTREL AND 20 mg ETHINYL ESTRADIOL IN WOMAN 35 AND OVER A. DelConte (1), D. F. Archer(2), (1) Wyeth-Ayerst Research, St. Davids, PA, USA. (2) Jones Institute for Reproductive Medicine, Norfolk, VA, USA. Objective: To evaluate the efficacy and safety of a low-dose, 21-day combination oral contraceptive containing 100mg of levonorgestrel (LNG) and 20 mg of ethinyl estradiol (EE) in women 35 and older. Study Methods: Women (1,708) age 15 and older with regular menstrual cycles were administered a 21-day combination oral contraceptive containing 100 mg LNG/20mg EE for 3 years. The efficacy and safety of the OC was evaluated in a subset of 218 women age 35 and older. Results: During 3,859 cycles evaluated for efficacy, 1 pregnancy occurred (Pearl index = 0.34). This is consistent with the Pearl indexes compiled from other studies with 100 mg LNG/20 mg EE (range 0.2 to 0.9). Breakthrough bleeding (with or without spotting) occurred in 11.3% of the cycles, and spotting alone occurred in 11.5% of the 3,859 cycles evaluated. The two most common adverse events cited as reasons for discontinuation were hypertension (3% of subjects) and metrorrhagia (2%). Conclusions: Overall, the results of this study demonstrate that the lowdose, monophasic regimen of 100 mg LNG/20 mg EE offers effective contraception, acceptable cycle control, and good tolerability in women age 35 and older.

P3.04.07 EFFICACY OF MISOPROSTOL CERVICAL PREPARATION AND MANUAL VACUUM ASPIRATION FOR EARLY SECOND TRIMESTER TERMINATIONS C.S. Todd, M.E. Soler, L.D. Castleman, M.K. Rogers, P.D. Blumenthal Johns Hopkins Bayview Medical Center, Baltimore, MD, U.S.A. Objective: To determine the efficacy of using manual vacuum aspiration for abortion up to 18 weeks gestation after cervical preparation with misoprostol. Methods: Subjects were obtained from a case series of over 100 patients presenting for dilatation and evacuation at Johns Hopkins Bayview

WEDNESDAY, SEPTEMBER 6
Insertion of the diaphragm happened between 5 and 180 minutes before coitus (average: 47.9 minutes) and removing happened between 6 and 18 hours after (average: 8.3 hours). Results: There were 2 not-wanted pregnancies during the use. Therefore, the failure rate was of 1.61 per 100 woman-years. Only 2 patients did not manage to learn how to use diaphragm (4.5%) and 4 ones did not like the method (9.1%). Six women told to feel the diaphragm (13.6%), being uncomfortable to 5 ones (11.4%). Two patients (4.5%) told discomfort during coitus and 11 ones told the partner felt the diaphragm (25%), but only 5 of them referred that there was uncomfortable (11.4%). Four women referred that there was interference in the rhythm of the sexual relationship (9.1%), but just one told decrease of libido (2.3%). The use of spermicide gel caused discomfort to 12 patients of 37 that used it (32.4%). Urinary symptoms occurred in 13 of 44 patients (29.5%). Conclusions: Diaphragm associated to spermicide gel is effective when patients received a good orientation. Patient and her partner's acceptability is high. P3.04.10 IS THE INTRAUTERINE DEVICE APPROPRIATE CONTRACEPTION FOR HIV-INFECTED WOMEN? C. Morrison, D. Weiner, C. Kwok, Family Health International, P.O. Box 13950, Research Triangle Park, N.C., USA, 27713 C. Sekadde-Kigondu, S. Sinei, D. Kokonya, Dept. OB/GYN, University of Nairobi, Nairobi, Kenya Objectives: The World Health Organization and the International Planned Parenthood Federation recommend against use of intrauterine devices (IUDs) in HIV-infected women due to concerns about pelvic infection and female-to-male HIV transmission. We investigated whether the risk of complications is higher in HIV-infected women than in uninfected women in the 2 years following IUD insertion. Study Methods: 649 women (156 HIV-infected, 493 HIV-uninfected) in Nairobi, Kenya who requested an IUD and met local eligibility criteria were enrolled. We gathered information on IUD-related complications including pelvic inflammatory disease (PID), removals due to infection, pain or bleeding, expulsions, and pregnancies at 1, 4, and 24 months after insertion by study physicians masked to participants HIV status. Cox regression was used to estimate hazard ratios (HR). Results: Complications were identified in 94 of 636 women returning for follow-up (14.7% of HIV-infected, 14.8% of HIV-uninfected). Incident PID was rare in both infected (2.0%) and uninfected (0.4%) groups. Multivariate analyses suggested no association between HIV-1 infection and increased risk of overall complications (HR=1.0; 95% CI 0.6-1.6) adjusted for marital status, study site, previous IUD use, ethnicity, and IUD insertion problems. Infection-related complications (any tenderness, IUD removal for infection or pain) were also similar between groups (10.7% of HIV-infected, 8.8% of HIV-uninfected; p=0.50), although there was a nonsignificant increase in infectionrelated complications among HIV-infected women with IUD use longer than 5 months (HR=1.8; 95% CI 0.8-4.4). Neither overall nor infectionrelated complications differed by CD4 (immune) status. Conclusions: HIV-infected women often have a critical need for safe and effective contraception. The IUD may be an appropriate contraceptive method for HIV-infected women with ongoing access to medical services. P3.04.11 LONG TERM FOLLOW UP OF PATIENTS BEING STERILISED USING THE FILSHIE CLIP WITH LOCAL ANAESTHESIA IN A FAMILY PLANNING CLINIC SETTING G. M Filshie, Dept OB/GYN, University of Nottingham, Nottingham, UK The Family Planning Association Clinic, Nottingham, offered both male and female sterilization procedures as well as contemporary family planning methods. This study recruited patients for female sterilization from March 1982 to June 1992. During this time 464 patients were counseled and 30 of these sere excluded. Of the 434 patients who were operated on, 278 have so far been followed up. 13 cases required general anesthesia, 8 electively and 5 were transferred from local anaesthetic to general anaesthetic because of pain or failure of insufflation. Patients were followed up by postal questionnaire or telephone consultation. Major problems included one shot-term failure due to miss-application

89
of a chip and one patient who received a small bowel injury following the insertion of the Verres needle. The procedure was acceptable to both patients and staff. The Methodology, intra partum findings and subsequent surgery will be discussed.

P3.04.12 SMOKING REDUCES THE EFFECT OF ORAL CONTRACEPTIVES E.E. Andreasen, K. Hindsoe, B. Andersen, Dept. OB/GYN, Kolding Hospital, Denmark, Europe. Objectives: The aim of the study was to investigate the use of oral contraceptives among women referred to an induced abortion and correlated to their smoking habits. Study Methods: Prospective study of 854 women referred to induced abortion, and all were registrated consecutively during 3 years. Results: The participation-rate was 97.3% = 831 women, and the rate of smokers = 51%. We found that 35% had used their contraceptive methods in a regular way, but became pregnant nevertheless (group A). Another group of 33% had forgotten to use their contraceptives for a few days and became pregnant by an accident. The rest = 32% of the women did not use any methods. In group A, 55 women had used oral contraceptives 100% correctly, and here we found a rate of smokers = 87%, and this is significantly different from the smoking-rate of 51% among the 831 women in the study population. Conclusions: This study shows, that smoking reduces the effect of oral contraceptives in a significant way (p<0.001 using the chi-square test).

P3.04.13 TREATMENT OF DEPO-PROVERA CONTRACEPTION COMPLICATIONS V. P. Kvashenko, G. M. Adamova, I. L. Samarina, State Medical University, Donetsk, Ukraine. Objectives: The aim of the investigation is to analyze the efficacy Depprovera contraception (150 mg) for treatment of bleeding. Study Methods: 150 women aged 23-45 taken Depo-provera were examined. Women with bleeding during contraception were divided into two subgroups. In subgroup A women took tamoxifen 10 mg 2 times a day for 3-5 days, in subgroup B women took lo-femenal till bleedings stopped. Treatment efficacy was evaluated by sonography, endometrium aspitate and volume of hemorrage. Results: Hemorrhage had 38 (25.3%) patients. Bleeding stopped in the first cycle in 4 (20%) women on the 2nd day of tamoxifen taking, in 10 (50%) on the 3rd day, in 4 (20%) 4th day, in 2 (10%) 5th day. Bleeding was jugulated in the next cycle in 7 (36%) women on the 2nd 3rd day, in 1 (4%) 5th day. Bleeding stopped in the third cycle in 1 (4%) of women on the 2nd day of tamoxifen taking. In subgroup B bleeding stopped during the first cycle in 2 (11%) women in three days of lo-femenal taking, in 12 (67%) -in the 4-5 days, in 4 (22%) the dose was doubled because of treatment non-efficacy. Bleeding was jugulated in the next cycle in 8 (44.5%) women by proscribing lo-femenal 1 pill a day, in 4 (22%) 2 pills a day. Conclusions: Tamoxifen proscribing is effective for treatment of bleeding by for Depo-provera contraception. P3.04.14 USE OF NORPLANT-6 IN IMMEDIATE POSTPARTUM PERIOD AMONG ASYMPTOMATIC HIV-1 POSITIVE MOTHERS S. Taneepanichskul, C. Tanprasertkul, Dept. OB/GYN, Chulalongkorn University, Bangkok, Thailand. Objective: To study the bleeding patterns of Norplant-6 contracetpive implants in immediate postpartum asymptomatic HIV infection. Study design: Prospective descriptive study. Setting: Family planning clinic, Dept. OB/GYN, Faculty of Medicine, Chulalongkorn University. Subjects: 98 immediate postpartum asymptomatic HIV infection women who had vaginal delivery at gestational age 37 weeks or birthweight 2500 grams chosen for Norplant-6 subdermal contraception. Main Outcome Measure: After complete three months of use, we interviewed about their bleeding patterns and other adverse effects.

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Results: Eight-eight women completed the study. Irregular bleeding, amenorrhea and regular bleeding occurred in 55 (62.5%), 29 (33.0%), and 4 (4.5%) women, respectively. Others adverse effects were headache (10, 11.4%) and weight gain (10, 11.4%). No other serious side effects were found. Conclusion: Most of asymptomatic HIV infection women who used Norplant-6 subdermal contraception immediately postpartum had irregular bleeding pattern in the first three months.

WEDNESDAY, SEPTEMBER 6
P3.05.03 CHARACTER OF LOCAL METABOLIC CHANGES IN FOCI OF ENDOMETROID HETEROTOPIES L.V. Potapova, V.I. Grishchenko, N.A. Shcherbina, Dept. OB/GYN, State Medical University, Kharkov, Ukraine. Objectives: Particularly interesting in the study of endometriosis development are problems of the control and regulation of local homeostasis of tissues and mechanism of immune regulation. In this connection, the objective was to investigate the peculiarities of metabolic processes in endometrioid tissues and leukocytes of patients. Study Methods: The study was performed on endometrioid tissues and leukocytes of patients aged 22-47 with generalized forms of endometriosis. Intensity of free-radical oxidation of lipids in tissues as an indication of tissue-destructive processes, as well as metabolic activity of leukocytes was investigated. Results: In generalized forms of endometriosis, a reliable increase in the content of client conjugates and malone dialdehyde was observed, other examined parameters and lipid peroxidation (LPO) remaining within normal values and antioxidant activity (AOA) of tissue decreasing. The data obtained are indicative of development of chain reactions of freeradical oxidation, they becoming prevailing and uncontrolled by AOA system. Besides, activation of basic metabolic cycles and production of cytotoxic forms of oxygene in leukocytes were observed. Conclusions:lationship of LPO and metabolism in tissues and leukocytes apparently creates conditions for development of endometrioid heterotopies. P3.05.04 COMPARISON OF LEPRORELIN VS. LYNESTRENOL IN PATIENTS WITH ENDOMETRIOSIS P.-A. Regidor (1). M. Regidor (1), G. Lubben (2), E. Kienle (2), P. Fortig (2), A.E. Schindler (1) (1) Dept. of Gynaecology, University of Essen, Essen, Germany. (2) Takeda Pharma Germany, Aachen, Germany. Objectives: Comparison of leuprorelin acetate depot (LAD) 3.75 mg s.c./month vs. Lynestrenol (LYN) 5 mg p.o./b.i.d. regarding the efficacy and safety in patients with active endometriosis, r-AFS-score II-IV. Study Methods: Open prospective randomized single-center study. Results: For n=28 (LAD) and n=27 (LYN) patients r-AFS-points
First look laparoscopy Second look laparoscopy Number of progression
At diagnosis LAD LYN 34.1 26.7 Post-operative LAD 21.9 19.6 LYN 24.5 25.6 At diagnosis LAD 10.6 14.8 LYN 23.7 25.8 Post-operative LAD 3.8 9.3 LYN 8.5 16.5 LAD 1 LYN 8

P3.05 ENDOMETRIOSIS P3.05.01 BLADDER ENDOMETRIOSIS - REPORT OF TWO CASES S.K. Lam, Department of Gynaecology, Our Lady of Maryknoll Hospital, Kowloon, Hong Kong SAR, China Objectives: To report and review two cases of bladder endometriosis Report A 34 years old woman presented in 1990 with dysmenorrhoea. Laparotomy showed pelvic endometriosis, 4 cm right chocolate cyst and adhesions of the left fallopian tube and ovary. Right salpingooophrectomy (S.O.) was performed followed by a six-month course of progestogen therapy. She has recurrent endometriosis of the left ovary and total abdominal hysterectomy and left S.O. was performed in 1992. Premarin was given subsequently for hormone replacement. She complained of non-cyclical haematuria in 1998 and cystoscopy showed a 1 cm papilloma over the posterior wall of bladder. Biopsy confirmed endometriosis. Hormonal replacement was stopped and transurethral resection of the endometriotic nodule was performed. Repeat cystoscopy three months later showed no recurrence and hormonal replacement was restarted. She remained asymptomatic till now. The second patient 34 year old presented with dysuria one day before and one day after the period; there was no haematuria. In view of the coexisting dysmenorrhoea, laparoscopy was arranged. There was only minimal endometriosis over the left pelvic peritoneum. Cystoscopy showed a small patch of pinkish white flat submucosal lesion 0.5 cm at the trigone, likely to be endometriosis. Biopsy was not taken. Medical treatment was discussed but patient was reluctant and finally defaulted follow up. Conclusion: Bladder endometriosis is rare and a high index of suspicion is required for diagnosis.

P3.05.02 CAVATERM ENDOMETRIAL ABLATION, UTERINE TEMPERATURE DISTRIBUTION B. Friberg, Dept. OB/GYN, University Hospital, Lund, Sweden. Objectives: Cavaterm is a method for endometrial destruction by thermal coagulation. Before a new method is employed as a form of clinical routine treatment, it is important to know that it is safe. Study Methods: First, experimental studies were performed. Thereafter, since August 1993, the treatment has been used in our department. We have treated more than 230 out-patients. Results: No thermal effects on the outer uterine surface or on adjacent organs were found. There have been no immediate preoperative complications. In the first 60 women treated we performed measurements of balloon mean surface temperature and cervical mean temperature. Balloon mean surface temperature was 73.0 (range 55.0 84.8)C. Cervical mean temperature was 40.7 (range 27.9 50.0) C. Conclusions: A low mean temperature in the cervical region with its thin endometrium is essential in order to avoid thermal damage to the bladder wall. With the low mean temperature in the present series, where the temperature exceeded 43C in only 22% (13/60) of cases, and was above 45C in only one case, the risk of coagulation is low. Furthermore, the part of the catheter running through the cervical canal is now insulated. We found the Cavatermdevice safe for the patient.

Means
+/- S.D

31.4 24.3

Change of dysmenorrhoea after 6 months of treatment

Improved LAD LYN 23 14 No change 4 13 Deterioration -

Serum oestradiol levels of 28 LAD and 27 LYN patients

Pg/ml Oestradiol level before therapy LAD Means +/- S.D. 94.33 74.27 LYN 87.09 72.43 Oestradiol level after 3 months LAD 26.69 8.98 LYN 27.69 16.02 Oestradiol level after 6 months LAD 27.4 9.06 LYN 41.14 53.06

Conclusions: Leuprorelin is obviously more effective to treat an active endometriosis. The reduction of the r-AFS score is significantly higher in the LAD treated group (p<0.001, Mann-Whitney). A reliable suppression of the oestradiol level in all patients will only be achieved in patients treated with LAD. Improvement of dysmenorrhoea was more pronounced in the LAD group (p=0.017; U-test). Regarding endometriosis progressions LAD is more favorable.

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P3.05.05 CORRECTION OF IMMUNE DYSFUNCTION IN GYNECOLOGICAL PATIENTS BY LOCAL IMPULSIVE MAGNETIC FIELDS THERAPY O.N. Rogovaya, A.O. Khrebtov, Donetsk State Regional Center of Maternity and Child Care, Donetsk, Ukraine. Objective: The aim of the investigation is to study the local effect of impulsive magnetic field (IMF) as non-medicamentous procedure on separate links of the immune system in patients with genital endometriosis. Study Methods: 122 women aged 18-45 with genital endometriosis (main group 76; compared 46, control 30 gynecological healthy women). Cell immunity (CD3, CD4, CD8, CD22) and humoral immunity quotients (Ig G, A, M) were studied before, during and a month after the treatment. Results: It has been stated that genital endometriosis is revealed in CD4, and CD8, suppression and CD22 activation, and also factors of humoral immunity (on the whole, Ig M) in patients blood with I-II stages of endometriosis in 1. 2 1.6 times, III stage in 1.8 times, IV 2.1. Immune status disturbances correlate with changes in hormonal system depending on disease duration. For magnetic therapy IMF is used. Its place is field of uterus and uterine appendage plus spleen projection, time 15-20 minutes daily beginning on the 12-14th day of menstrual cycle. In comparison group treated with traditional hormonal therapy under danazol influence the number of CD3 CD4, and CD8 is decreased and CD22 is increased. In main group treated with both hormonal and magnetic therapy, immune status improved, the number of CD3 is increased by 12-14%, CD4 by 14%, and CD8, by 16%. CD22 is decreased by 12%. There were no side effects. Conclusions: Magnetic therapy can be used for complex treatment of patients with endometriosis for the local effect on separate links of the immune system.

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P3.05.07 EMBRIOTOXICITY AND IMMUNOLOGICAL MODIFICATIONS FROM WOMEN WITH ENDOMETRIOMAS UNDER TREATMENT WITH GnRH ANALOGS AND rIL-2 LEFT INTRACYST. MJ. Gmez-Torres, I. Velasco, A. Campos, R. Bermejo, P. Acin. Dept. OB/GYN and Immunology, School of Medicine, Miguel Hernndez University, Alicante, Spain. (Supported by FIS 97/0778). Objectives: The aim of this study is to analyse modifications in the embriotoxicity of serum from women with endometriomas under treatment with GnRH analogs and 600,000 IU of rIL-2 left intracyst, and the correlations with the immunological parametres. Study Methods: Serum from 20 women with endometriomas were analyzed before, during and after treatment. Embriotoxicity assays of serum were made with two-cell embryos CB6F1 of female mice. Lymphocyte populations (CD25, CD28, CD29, CD3, CD3-CD25, CD4, CD4-CD29, CD45, CD4-CD45, CD8) were analysed by flow cytometry and cytokines production (IL-1b, IL-2, IL-6, IL-8, IL-10, IL-12, IL-17) were evaluated by ELISA. Results: After treatment decreased the serum embriotixicity in those patients with whom rIL-2 was used. These women also had the cytokines productions and the levels of lynphocytes decreased, while cells CD45 decreased significantly in patients who did not receive rIL-2. Conclusions: The rIL-2 left intracyst decreased serum embriotoxicity of women with endometriomas and favoured the immunological response P3.05.08 EMBRIOTOXICITY OF PERITONEAL FLUID AND CYTOKINES PRODUCTION IN WOMEN WITH ENDOMETRIOSIS. MJ. Gmez-Torres, I. Velasco, A. Campos, P. Acin. Dept. OB/GYN and Immunology, School of Medicine, Miguel Hernndez University, Alicante, Spain. (Supported by FIS 94/0478). Objectives: Endometriosis is classically defined as the growth of endometrial cells at sites outside the uterus. It is common disease characterised by infertility, chronic pain and adhesion formation. We have assessed whether the peritoneal fluid from women with endometriosis is toxic to the mouse embryo early development in vitro. IL-6, IL-8 and INF-g well placed to play a key role in the extensive tissue remodelling required to accommodate menstruation, implantation and pregnancy. Study Methods: The subjects in this study were 42 women of reproductive age undergoing laparoscopy for suspected endometriosis. Embriotoxicity assay of peritoneal fluid was made with two-cell embryos CB6F1 of female mice. IL-2, IL-6, IL-8 and INF-g in peritoneal fluid were determined by ELISA. Results: Patients with high levels of cytokines in peritoneal fluid shown increased embriotoxicity on embryo development, in all concentrations used in vitro. This effect is dose-dependent (maximum toxicity was observed with cultures suplemented with 20% of peritoneal fluid), and we suspect that can affect to cytokeratin expression. Conclusions: There is a inverse relationship between, low levels of cytokines in peritoneal fluid and few embriotoxicity of this peritoneal fluid, and fertility of patients with endometriosis. P3.05.09 EXPRESSION OF P450AROM GENE IN ENDOMETRIOTIC IMPLANT LOCATED IN POSTOPERATIVE SCAR A.J. Jakimiuk, R. Tarkowski. L.P. Putowski. J.A. Jakowicki. Dept. Ob/Gyn, University School of Medicine. Lublin, Poland. Objective: The expression of P450AROM gene in the scar after cesarean section and episiotomy. Methods: The total RNA and DNA were extracted simultaneously from endometriotic samples. The P450AROM mRNA level was measured using quantitative RT-PCR. The results were calculated per DNA content in the sample. Results: The expression of aromatase gene has been detected in all endometriotic implants collected from the scar after cesarean section, however, the values were lower than in proliferative (75 pg RNA/ug DNA SEM 31.6) and secretive (162.5 pg RNA/ug DNA + SEM 14.6) endometrium. In the five cases the expression values were within the range 4.4 - 30.8 pg RNA/ug DNA and in one case the level of expression was close to that observed in proliferative endometrium. In a

P3.05.06 EFFICACY AND SAFETY OF LONG-TERM LOW-DOSE DANAZOL IN WOMEN WITH ENDOMETRIOSIS T. Adachi, A. Shionoiri, R. Saito, H. Ota, Dept. OB/GYN, Tokyo Womens Medical University, Tokyo, Japan. Objectives: The aim of the study was to investigate the efficacy and the safety of long-term low-dose danazol for women with endometriosis. Study Methods: Fifteen women, aged from 28 to 46 years old, were enrolled in this study with informed consent. Three had endometriosis after hysterectomy, 11 had uterine adenomyosis and/or ovarian chocolate cysts, and the remaining one patient had pneumothorax accompanying her periods. Patients were started on 400 to 200 mg/day of danazol for 8 weeks, and then maintained at 100 mg/day. The followup period ranged from 13 to 38 months, and the examinations, including gynecological examination, pelvic ultrasonography, evaluation of menstrual cycles, symptoms during periods, serum hormone levels, bone mineral density (BMD) measured by DEXA, were made at 27.18.8 months (MSD) from the initiation of this study. Results: Every patient had less pain or relief from other deleterious symptoms during periods. The size of the endometriosis decreased. Patients except those who had a hysterectomy had hypomenorrheic periods; irregular cycles with genital spotting were often observed for the first 3 months, followed by regular cycles of 25 to 40 days. Liver dysfunction was not observed. Relatively high E2, normal testosterone (T), low sex hormone binding globulin, and higher free-T were shown. BMD values, calculated by comparing with mean values of normal women at the same age, were represented as 101.310.3%. Conclusion: Long-term low-dose danazol for women with endometriosis was effective and safe.

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53-year-old woman with regular menses and with low level of aromatase expression the estimation of FSH (5 mlU/ml) and estradiol (120 pg/ml) excluded the menopause. The aromatase expression in endometriotic implants located in the scar after episiotomy was 6.6 pg RNA/ug DNA in one patient and it was not detected in the other one. Low serum estradiol was observed in the second case. Conclusion: The aromatase gene is expressed in endometriotic implant but its expression is much lower comparing to proliferative and secretive endometrium. P3.05.10 KI-67 EXPRESSION IN THE ENDOMETRIUM OF HEALTHY WOMEN AND PATIENTS WITH PERITONEAL ENDOMETRIOSIS V.A.Bourlev., S.V.Pavlovitch, N.I.Volkov, D.A.Stygar, Research Centre for Obstetrics, Gynecology and Perinatology, Moscow, Russia Objectives: The aim of the study was to investigate the expression of the proliferative marker Ki-67 in the endometrium of healthy women and patients with peritoneal endometriosis in the different stages of the menstrual cycle. Study Methods: Expression of the proliferative marker Ki-67 was evaluated in the stroma and glandular epithelium of endometrium from 6 healthy women and 25 patient with laparoscopically confirmed peritoneal endometriosis. Serial 5.0 mkm sections of endometrium had been performed and studied immunogistochemically using Ki-67 monoclonal antibodies (Immunotech, Marseille, France). The laboratory part of the investigation was carried out in the Department of Obstetrics and Gynecology of the Uppsala University, Sweden with scientific support of prof. B.Lindblom. Results: The percentage of Ki-67 positive cells in the stroma of endometrium from healthy women elevated from proliferative to late secretory phase. Expression of the marker in the gladular epithelium was minimal in the secretory phase. In endometriotic patients Ki-67 expression changes in the glandular epithelium were similar. Stromal maximal expression of Ki-67 was in the early secretory phase, and was 2 times higher than in healthy patients. In the late secretory phase Ki-67 expression was significantly lower in endometriotic patients both in the stroma and in the glandular epithelium. Conclusions :Revealed changes in the proliferative activity in the endometrium of patients with peritoneal endometriosis indicate on their possible role in the pathogenesis of this pathologic condition.

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P3.05.12 PREGNANCY COMPLICATED BY SPONTANEOUS RUPTURE OF UTERUS AND ENDOMETRIOSES AND OVARIAN ENDOMETRIOMA L.M. Lopes, R.A.M. Sa, I.B. Costa Jr., P.C. Gomes, P.R. Marinho, M.N. Ritto, A.L.M. Dourado, Dept. Maternal Fetal Medicine, Laranjeiras Clinica Perinatal, Rio de Janeiro, Brazil. Case Report: A 31 year-old Brazilian woman, gravida 1, Para 0, was admitted to Laranjeiras Clinica Perinatal at 26 weeks gestation with the chief complaint of mid-abdominal pain and vaginal bleeding. She had been treated with b-adrenergic for preventing preterm labor 45 days before admission. Physical examination revealed normal blood pressure and pulse. The fetal heart rate was 146 bpm and the size of the uterus was consistent with 26 weeks gestation. The significant laboratory findings included a hematocrit of 25% and hemoglobin of 8.2g/dl. A real-time ultrasound scan showed fetal biometry consistent with 26 weeks gestation, oligohydramnios, and 05 myomas. Doppler of fetal circulation was normal. Nausea, vomiting, hypotension, abdominal pain and vaginal bleeding began 12 days before admission. The initial clinical impression was abruptio placentae. Exploratory laparotomy was performed and upon opening the abdomen a sanguineous fluid was encountered. The uterus was elevated and multiple myomas were seen. In the posterior wall (occupying the cul-de-sac) was a chocolate-colored tumor and a uterine disruption. Both ovaries were adherent to the uterus with a chocolatecolored fluid-filled cyst measuring 15cm (on the left) and 20cm (on the right). She delivered by Cesarean a 2045g infant. Apgar 6. Hysterectomy and bilateral anexectomy was done. Histopatologic Observations: Uterine fibroids, adenomyosis and bilateral ovarian endometrioma. Follow up: Both mother and infant did well one year later.

P3.05.13 PSYCHOLOGICAL PECULIARITIES IN PATIENTS WITH ENDOMETRIOSIS L. Radzetskaya, A.Fomin, L.Suprun, Dept. OB/GYN, Vitebsk Medical University, Vitebsk, Belarus. Objectives: The aim of this study was to investigate the psychological peculiarities in patients with endometriosis. Study Methods: We used a modified Russian version of the Minnesota Multiphase Personality Inventory (MMPI) and Spilbergers test. We examined 54 patients with endometriosis and 23 controls. Results: We stated that patients with endometriosis had an elevated MMPI profile. Scale 5(M-F) had the lowest value 56,91,5 T-scores. The scales 8(Sc), 6(Pa), 4(Pd) and 7 (Pt) reached to 70 T-scores and even more (p<0.05). The scales 2(D) and O(Si) were higher than 65 Tscores (P<0.05). Scales of healthy controls were not higher than 30-60 T-scores. The psychological alterations directly related to the severity and duration of disease. Psychological disadaptation was registered in all patients with disease duration more than 6 years compared with only 20% of women with disease duration less than 2 years. The patients with mild endometriosis had less than 4 peaks of maximum 65 T-scores. The patients with severe endometriosis had at least 5-9 peaks of maximum 87 T-scores. MMPI profile did not depend on the endometriosis localization. The state of high anxiety in the patients was confirmed by results of Spilbergers test too. Conclusions: MMPI test demonstrated that patients with endometriosis were very anxious and had low possibilities of psycho-social adaptation. The results obtained allow us to assume a constitutional predisposition to forming the state of anxiety in such patients. P3.05.14 THREE-STEP THERAPY IN ENDOMETRIOSIS WITH DECAPEPTYL-DEPOT A. Keresztri, J. Daru, S. Koloszr, Z. Borthaiser, A. P., Albert SzentGyrgyi Medical University, Dept. OB/GYN, Szeged, Hungary. Introduction: The aim of the authors study was evaluate the relative safety and efficacy of triptorelin (Decapeptyl-Depot, FERRING) as primary treatment for endometriosis and obtain data about the ovarian

P3.05.11 POSSIBLITIES OF INSTRUMENTAL METHODS IN THE DIAGNOSIS OF ADENOMYOSIS O.M. Nosenko, V.K. Chaika, I.V. Vasilenko, Donetsk State Regional Centre for Maternity and Childhood Protection, Donetsk, Ukraine. Objectives: The aim of the study was to investigate the possibilities of instrumental methods in diagnosis of adenomyosis on the basis of comparison of instrumental data of patients investigation and histological investigation results of corresponding operative materials. Study Methods: 107 women were operated on for adenomyosis. Berfore operation hysterography, transvaginal sonography, hysteroscopy and miometriums hysteroscopic needle biopsy were carried out by the whole patient. The sections of operative materials were studied through light microscope. Results: The informativity of hysterography has made 5.6%, sonography 19.6%, hysteroscopy 11.1% and miometriums hysteroscopic needle biopsy 50.0%. That kind of informativity we explained with the following revealed histosructural features of adenomyosis: endometriotic lesions and glands in them with the sizes more than 1-2 mm were met accordingly in 29.0% and 19.6% of cases; endometriotic glands of the round form were prevailed in endometriotci lesions; the communication of large tubular endometriotic glands gaps with uterus cavity was met in 5.6% of patients; menstruate endometriotic lesions were met in 11.1% of supervisions; connective capsule around of endometriotic lesions was absent in the whole cases; the combination of adenomyosis with uterus myoma was met in 56.1% of cases. Conclusions: Low informativity of instrumental methods in the diagnosis of adenomyosis we connected with histostructural features of this pathology.

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and liver function during, and pregnancy rate in patients after the treatment. Materials and Methods: The authors used the gold standard in the management of endometriosis caused infertility. A total of 30 women aged 20-43 years (mean age, 28 years) had clinical symptoms of endometriosis. At the initial laparoscopy the disease was staged according to the American Fertility Society (AFAS) classification and the lesions surgically removed or electrocauterised. During the 6 months treatment patients were followed at monthly intervals, the nafarelin administered intranasaly everyday. The authors perform blood-sampling for CBC, chemistry t hormone assay at pre-admission, at 3rd, at 6th and at the 7th month of the treatment. The follow-up laparoscopy was performed within 6 weeks of the last GnRH administration. All the 30 patients were followed up for at least an additional 6 months and those attempting pregnancy for another 6 months. Results: The serum oestradiol level decreased in the postmenopausal level at the 3rd month of the treatment, and increased in the normal level after the 6th month treatment. No significant changes in the blood chemistry. The pregnancy rates were 33% (n=10), there were 1 spontaneous abortion and was no ectopic pregnancy. The GnRH analog eliminated dysmenorrhoea during the therapy, and significantly decreased the dyspareunia. The pregnancy rates were 34% (n=35), there were 4 spontaneous abortion and 1 ectopic pregnancy. Some of the side effects (hot flashes, night sweats, sleeping problems, headache, dizziness) reported during the tiptorelin treatment remained after treatment. Discussion :Nowadays, an attractive alternative method to treat endometriosis and preserve the fertility capability is the downregulation of pituitary-ovarian function by means of GnRH superactive agonists (GnRH-A), when the chemical alterations of the amino-acids at positions 6 and 10 produce synthetic derivatives of GnRH, that resist cleavage by endopeptidases but retain a high affinity for the pituitary GnRH receptor. Considering the high rate of spontaneous conceptions and the low abortion and complication rates, the combined therapy of GnRH agonists followed by laparoscopy removal of endometriosis represents a major step forwards in the effective treatment of sterility in patients with endometriosis. Conclusion: We conclude that hydralazine is a better choice for the treatment of pregnancy-induced hypertension.

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P3.06.02 AN ANALYSIS OF TEENAGE PREGNANCIES IN A TEACHING HOSPITAL IN MALAYSIA H.H. Siraj, N.N. Ismail, Dept. OB/GYN, National University Hospital of Malaysia, Kuala Lumpur, Malaysia. Objectives: To study the extent of teenage pregnancies and their obstetric outcomes in the Department of O&G, National University Hospital of Malaysia. Study Design: A cross-sectional study was designed to involve all pregnant patients under the age of twenty who delivered in the hospital (study group). Demographic data, antenatal and intrapartum progress as well as the pregnancy outcomes were studied. The group was then compared to a group of patients between the age of twenty to thirty-four of age (control group). Results: Seventy-eight patients under the age of twenty were delivered in the department throughout 1998. The incidence of teenage delivery was 1.9%. Only one patient was under sixteen years of age. There were significantly more teenage pregnancies which were unbooked throughout the pregnancy (neglected pregnancy), unemployed and unmarried. The proportion of Indian patients among the study group (14.1%) was significantly higher than in the control group (3.8%). There was no significant difference between the gestation at birth, mode of delivery, duration of labor and Apgar score of newborns between the two groups. However, the average birth weight of the newborns in the study group (2712 grams) was significantly lower than in the control group (2975 grams), p<0.05. Conclusions: Older teenagers (age 16 and above) comprised the majority of teenage deliveries in the department. The only significant poor obstetric outcome for the teenage pregnancies was the lower birth weight of the newborns. Although the study indicated that teenage pregnancies did not impose detrimental obstetric outcomes, it is obvious that there are many social factors and difficulties that need to be addressed and overcome.

P3.06 HIGH-RISK PREGNANCY P3.06.01 A COMPARISON OF THE EFFECT OF NIFEDIPINE AND HYDRALIZINE IN TREATMENT OF PREGNANCY-INDUCED HYPERTENSION F. Yassae. Department of Obstetrics and Gynecology, Taleghani Hospital, Shaheed Behesht University, Tehran, Iran. Objectives: The prevalence of hypertension during pregnancy and its sever complication led us to conduct the following study to compare the therapeutic effects and side effects of nifedipine and hydralazine in pregnant women with preeclampsia. Study Methods: In this sequential randomized trial, 37 inpatients referred to Mahdieh Hospital in 1995 with a pregnancy over 26 weeks were studied. Preeclampsia was dignosed based on a blood pressure over 140/90 mm Hg associated with proteinuria or generalized edema. Laboratory studies were conducted to differentiate sever preeclampsia. If blood pressure did not return normal after 24/48 hours resting, patients were sequentially assigned to one of two randomized groups. One group received 10mg nifedipine three times a day, and the other 10 mg hydralazine three times a day. This regimen was continued until delivery. Therapeutic effects were measured based on changes in systolic and diastolic blood pressure and termination of pregnancy, and the side effects studied were flushing, maternal tachycardia, and sever hypotension. Results: Nifedipine was given to 16 patients and the remaining 21 received hydralazine. The two groups were statistically similar regarding education, ABO and Rh typing, number of fetuses, age, weight, height, and number of previous pregnancies. Both drugs reduced hypertension, but changes in blood pressure were not significant in the nifedipine group (-4.4 13.8 and 8.5 16.8), while these changes were statistically significant in the hydralazine group (-5.8 7.1 and 9.6 11.2, P <0.001). No remarkable side effect or difference in the rate of pregnancy termination was observed in the two groups.

P3.06.03 ANTEPARTUM FETAL DEATH: OBSTETRICAL RISK FACTORS. E. Sheiner, M. Hallak, T. Oron, T. Silberstein1, I. Shoham-Vardi, M. Katz, M. Mazor. Dept Ob/Gyn and Epidemiology, 1Soroka University Medical Center, Ben-Gurion University of the Negev, BeerSheva, Israel. Objective: The incidence of antepartum fetal death (APFD) remains unchanged during the past 12 years. The objective of the study was to determine obstetrical risk factors for APFD. Study Design: Retrospective analysis of our perinatal database was performed. We included 68,870 singleton deliveries between the years 1990-1997. Fetuses weighting less than 1000 gram at birth and those with structural malformations and/or known chromosomal anomalies were excluded from the study. Results: The rate of APFD was 0.4% (246/68,870). The following obstetrical factors were found to be significantly correlated to APFD in a multiple logistic regression model: High parity (OR=1.3, 95% CI 1.11.5), lower gestational age (OR=1.1, 95% CI 1.1-1.3), IUGR (OR=2.6, 95% CI 1.4-4.8), gestational diabetes A2 (OR=2.3, 95% CI 1.1-5.0), oligohydramnion (OR=2.5, 95% CI 1.5-4.1), abruption placenta (OR=6.5, 95% CI 4.4-9.8) and meconium stained amniotic fluid (OR3.0, 95% CI 2.2-4.0). Conclusion: APFD was significantly associated with IUGR, oligohydramnion, gestational diabetes A2, multiparity, preterm deliveries, placental abruption and meconium stained amniotic fluid. These conditions should be carefully evaluated during pregnancy in order to decrease the incidence of APFD.

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P3.06.04 ANTIPHOSPHOLIPID SYNDROME, LONG-TERM TREATMENT WITH LOW MOLECULAR WEIGHT HEPARIN AND PREGNANCY OUTCOME. M.G. Genievskaya, A.D. Makatsaria. Department of Obstetrics and Gynecology, Sechenov Moscow Medical Academy, Bolshaia, Pirogovskaya St.2/6, Moscow, 119881, Russia. Thrombophilia and endothelial dysfunction plays crucial role in the pathogenesis of adverse pregnancy outcome in patients with APS. Pathogenically grounded therapeutic approach with minimum side effects, which is safe in outpatient base and convenient for patients, is to be determined. Under our observation were 55 women with confirmed APS. Among them 8 patients with heart pathology mitral regurgitation (1), aortic stenosis (1), mitral valve prolapse with regurgitation (5), artificial heart valves (1). Previous pregnancy loss varied from 2 to 6 (10 patients failed with other regimes). Lupus anticoagulant (LA) was assessed by dilute Russel Viper Venom Time (dRVVT) and APTT with platelets neutralization procedure. ACL (anticardiolipin antibody) IgM and IgG were detected by ELISA. 41 patients were positive for LA alone, 2 for aCL (in diagnostic titters) alone. In 12 cases both LA and aCL were detected. Increased level markers of thrombophiIlia such as TAT were detected in 32 cases (58%), FDP in 15 cases (27,2%). Platelets hyperactivation tests were positive in 30 cases (54%). Therapy included LMWH (Fraxiparine) alone from the moment of pregnancy detection (26 cases) or first antepartum visit at 12-16 weeks (29 cases). Dose was 150 ICU/kg 1 time/day s.c. While on therapy patients demonstrated positive dynamic markers of thrombophilias, normal and even decreased platelets activation tests. Thromboprophylaxis with LMWH continued 7-10 days postpartum with switch on oral anticoagulants or low dose aspirin. During observation no thromboembolic complications or fetal loss have been seen. No case of thrombocytopenia occurred. Complications included preterm delivery (6), mild/severe preeclampsia (4/2), more prominent in group with late onset treatment, slight vaginal bleeding at 6 week (1) and deep venous thrombosis postpartum in patient who refused oral anticoagulants due to breast feeding. Early onset treatment with LMWH (Fraxiparine) due to its positive influence on endothelium provides appropriate placenta development, reduces incidence of placenta insufficiency, IUGR and even preeclampsia and gives most promising results in APS pregnancy outcomes. P3.06.05 BETHAMETASONE AS INDUCTOR OF FETAL LUNG MATURITY IN PREGNANCIES WITH LATE DIAGNOSIS OF GESTATIONAL DIABETES VH. Ruz-Cervera, M. Ponce-Avila, JL. Garcia-Benavides, Hospital Angeles de las Lomas, Huixquilucan, Estado de Mexico, Mexico. Objectives: The purpose of the study was to evaluate the clinical evolution and rates of complications for patients with late diagnosis of gestational diabetes who received bethametasone to induce fetal lung maturity. Study Methods: We studied the cases of 23 patients with gestational age between 32-26 weeks and premature labor. Gestational diabetes was suspected for the presence of fasting hyperglucemia. In those patients was performed an oral glucose challenge test. Patients with negative lung maturity tests were metabolically stabilized, and after bethametasone 12 mg/day (two doses) was administered to induce fetal lug maturity. Results: There were no major medical neither obstetric complications is studied patients. In 80% of patients insulin was applied as maximum during these days after bethametasone treatment. On the other hand, only 13% of newborn babes develop mild respiratory distress. Conclusions: These data suggest that patients with late diagnosis of diabetes have a good prognosis when is performed an intensive treatment metabolic disturbances. In controlled patients, bethametasone can be used safely to induce fetal lung maturity.

WEDNESDAY, SEPTEMBER 6
P3.06.06 BIOCHEMICAL PARAMETERS IN AMNIOTIC FLUID IN PREGNANCIES COMPLICATED WITH INTRAUTERINE GROWTH RETARDATION J. Teliga, R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski, E. Romejko, K. Czajkowski, R. Szczecina Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objective: The aim of the study was to investigate fetal condition in pregnancy complicated with intrauterine growth retardation evaluating following parameters of amniotic fluid: glucose, bilirubin, total estrogen and human placental lactogen. There were also clouding test (absorption 570nm), foaming test and lecithin/sphingomyelin ratio performed. Study Methods: 36 pregnant women with IUGR (the studied group) and 72 women with eutrophic pregnancies (the control group) entered the study. The biochemical analysis of parameters listed above was performed. Results: All women were in the third trimester of pregnancy and there was no significant difference in mean gestational age between studied and control groups: 36.02.3 vs. 36.52.5 weeks respectively. Women in the studied group verses control group showed following concentrations in the amniotic fluid: glucose 1.210.41 vs. 1.770.64 micromol/l; p<0.001, biliruvin 2.911.54 vs. 1.500.72 micromol/l; p<0.001, total estrogen 2495500 vs. 2749769 nmol/l; NS, human placental lactogen 1363502 vs. 1700920 ng/ml; p<0.05, clouding test 0.2610.19 vs. 0.4340.32; p<0.01, foaming test 2.41.5 vs. 3.01.4 units; NS, L/S ratio 2.200.45 vs.2.300.45;NS. Conclusion: The decreased concentration of glucose in amniotic fluid of the studied group might be related to the acidosis and hypoxemia. The evaluated concentration on the bilirubin, low value of clouding test and human placental lactogen in the amniotic fluid might suggest fetal immaturity. Fetuses with IUGR showed maturation of the lungs adequate to the eutrophic ones. P3.06.07 CALCIUM THERAPY DURING PREGNANCY AND ITS EFFECT ON BLOOD PRESSURE, SERUM CALCIUM, SERUM URIC ACID AND PREGNANCY OUTCOME Z. Arshad, Shilpa, J. Ahmad, N.A. Sabzposh. Dept. OB/GYN, J.N. Medical College, Aligarh Muslim University, Aligarh, U.P. India. Objectives: To see if there is beneficial effect of oral Calcium Therapy (2gm/day) on blood pressure (B.P), serum calcium (SC), serum uric acid (SUA) and pregnancy outcome. Study Methods: Prospective study was conducted on 95 pregnant women. Thirty cases served as controls (gp-I) and 65 cases as study group (gp.II). Study was started at 16-20 weeks. All cases had normal B.P. at the start. Group-I was given 1gm and gp.II was 2gms of calcium per oral per day till delivery. Serum calcium, SUA were estimated at 1620, 28-32 weeks and at term. Results: A significant fall in B.P was observed in gp.II primigravidae as compared to primi- in gp.I. There was a fall in B.P in gp.II multigravadae as compared to gp.I multi- but was not significant. Preecampsia (PE) developed in 20% of gp.I and 6% of gp.II. At term serum calcium level fell in gp.I (P< 0.001) and increased in gp.II (P< 0.001). Women who developed PE in gp.II had less increase in serum calcium levels. SUA was lower at 16-20 weeks and increased in 3rd trimester in both gps (P< 0.001). At term mean SUA levels in normotensive women were 3.680.51 and 3.5 0.30 mg/dl for gp.1 and II (P<0.05) while PE cases it was 5.8 0.06 and 5.65 0.17 mg/dl for gp.I and II (P< 0.001). Intrauterine growth retardation was observed in 16% of gp.I and nil in gp.II, preterm births were 13% in gp.I and 4% in gp.II. Mean gestational age at births was more in gp.II than in gp.I (P< 0.001). Mean birth weight of babies was more in gp.II. Anti-hypertensive therapy was required in lesser number of PE cases of gp.II than gp.I. Conclusions: Two grams of calcium per day starting at 16-20 weeks of pregnancy and given till delivery lowers B.P, Pre-eclampsia and serum uric acid. It increases serum calcium levels and improves pregnancy outcome.

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P3.06.08 CONSERVATIVE TREATMENT OF CERVICAL PREGNANCY: CASE REPORT Slobodan Arsenijevic, A. Zivanovic J. Djuric, M. Brkic, A. Dimitrijevic The case of a 37-year-old woman presenting with cervical pregnancy is described. The both sides of lateral isthmico-cervical part of uterus was stitched by cremated catgut to temporary stop the circulation through descendent branch of artery uterine. Than the gestation sack is removed without incident. Key words: cervix, pregnancy, treatment P3.06.09 EVIDENCE FOR AN INTERRELATIONSHIP BETWEEN PREGNANCY AND MYELODYSPLASTIC SYNDROMES IN JAPAN K. Shimizu, J. Ishii, H. Osada, S. Doi, O. Eguchi, T. Nishiwaki, S. Sekiya, Dept. OB/GYN, Chiba University School of Medicine, Chiba, Japan. Objectives: Myelodysplastic syndromes (MDS) are a heterogeneous group of bone marrow disorders. We examined whether pregnancy could influence MDS. Patients and Methods: We retrospectively reviewed the charts of 1715 patients (pts) who delivered between 1995 and 1999. We found 5 pts with MDS, and compared these pts with 21 pts with MDS during pregnancy reported previously in the literature. Results: 4 of the 5 pts (age 20-29) were diagnosed with MDS during pregnancy. One pt was diagnosed as MDS derived from aplastic anemia, and another had a diagnosis of idiopathic thrombocytopenic purpura before pregnancy. All 5 pts in our review were defined as having refractory anemia without chromosomal abnormalities. All 5 pts showed both macrocytic anemia and thrombocytopenia, with Hb8.30.6 gm/dL and PLT422009000/mm3. The anemia and thrombocytopenia (PLT<20000) was found in 3 of the 5 pts. Severe hypertension was noted in 2 of the 3 pts with severe thrombocytopenia. Although all 5 pts clinically improved after delivery within 3 months, one pt developed thrombocytopenia and an increase of marrow blasts 4 months after delivery. Conclusions: The macrocytic anemia and thrombocytopenia being resistant to treatment during pregnancy suggest MDS, and bone marrow examination should be performed. The high incidence of severe hypertension in those with severe thrombocytopenia underlines the importance of aggressive management of MDS during pregnancy. Although the prognosis improved after delivery for our pts, further investigation is needed to evaluate the correlation between pregnancy and MDS.

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Conclusions: According to our experiment, it is expected that reactivated neutrophils stick to hemagioendothelium cell through medium of adhesive molecules and increasing production of activated oxygens and cytokine and that causes cell disorder, the basal pathologic physiology of preeclampsia and IUGR. P3.06.11 EXPRESSION OF PROTEIN THIOL/DISULFIDE OXIDOREDUCTASE FAMILY IN PREECLAMPTIC PLACENTA E. Shibata (a), K. Ejima (b), N. Toki, C. Koyama, M. Kashimura, (a) Dept. OB/GYN (b) Health Development University of Occupational and Environmental Health, Kitakyushu, Japan. Objectives: Recent studies have indicated that preeclamptic cases are affected by an increased oxidative stress. We examined whether oxidative stress is accelerated in preeclamptic placenta. Furthermore, we examined an expression of protein thiol/disulfide oxidoreductase family, which is antioxidant system and plays a crucial role in the regeneration of oxidatively damaged proteins. Study Methods: Seven placentas from severe preeclamptic patients and seven placentas from normal cases were studied. First, to explore whether oxidative stress is accelerated in preeclampsia, we examined the accumulation of HNE (4-hydroxy-2-nonenal) modified proteins, which is a marker of oxidatigve stress, by Western blotting analysis. Second, to examine protein thiol/disulfide oxidoreductases, we analyzed the expression of thioredoxin (Trx), thioredoxin reductase (TR), glutaredoxin (Grx), and protein disulfide isomerase (PDI) by Western blotting and immunohistochemistry. Result: Western blotting analysis revealed that the accumulation of HNE-modified proteins was enhanced in preeclamptic placentas. The expression of Trx, TR, Grx, and PDI was also enhanced in preeclamptic placentas. Furthermore, these proteins were mainly localized in trophoblast. Conclusions: Preeclamptic placentas showed an accelerated oxidative stress. Furthermore, as a protective mechanism, antioxidant family was induced in preeclamptic placentas. This study indicated that protein thiol/disulfide oxidoreductases may play an important role to preserve placental function against oxidative stress. P3.06.12 MAGNESIUM, CALCIUM, PHOSPHORUS AND RENAL FUNCTION IN PREECLAMPTIC WOMEN K. Czajkowski, P. Piekarski, E. Romejko, R. Smolarczyk, J. WojcickaJagodzinska, J. Teliga, T. Maciejewski, 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objective: The effect of preeclampsia on calcium-phosphorusmagnesium homeostasis in the third trimester of pregnancy was investigated. Methods: 38 women with preeclampsia (the studied group) and 30 healthy women (the control group) entered the study. All women were in the third trimester of pregnancy. Concentrations of calcium, phosphorus and magnesium were determined in the serum and diurnal urine. The biochemical assessment of renal function was also performed. Results: There was no significant difference in mean gestational age between studied and control groups (35.52.18 vs. 36.02.20 weeks). Women of the studied group presented blood pressure 169.511/1046.3 mmHg and proteinuria 4.722.17 g/24 hrs. Women of the studied group versus control group showed the following serum concentrations of: magnesium: 0.630.06 vs. 0.700.10 mmol/L, p<0.0001; total calcium 2.170.13 vs. 2.250.12 mmol/L, p<0.01; ionized Ca2+ 1.040.06 vs. 1.050.07 mmol/L, NS; inorganic phosphorus 1.620.17 vs. 1.310.22 mmol/L, p<0.001. The results in diurnal urine: magnesium 3.941.37 vs. 2.160.50 mmol/24 hrs, p<0.001; calcium 2.141.59 vs. 6.703.50 mmol/24 hrs, inorganic phosphorus 226.6 vs. 27.47.30 mmol/24 hrs, p<0.005; diurnal urine volume 901155 vs. 1265450 ml/24 hrs, p<0.001; urea 5.182.35 vs. 3.220.83 mmol/L, p<0.001; uric acid 40.59.04 vs. 19.03.6 micromol/L, p<0.001, K+ 4.350.53 vs. 4.200.20 mmol/L, NS; Na+ 1401.7 vs. 1383 mmol/L, p<0.01; Cl- 1091.53 vs. 1073 nmol/L, p<0.003. Acid-base balance: pH 7.400.036 vs. 7.4200.025, p<0.05; pO2 11.011.61 vs. 11.341.06 kPa, NS; pCO2 4.430.38 vs. 4.260.41

P3.06.10 EXAMINATION OF ADHESIVE MOLECULE EFFECT ON PREECLAMPSIA AND IUGR K. Nagahashi, T. Maemura, S. Kobayashi, R. Asami, M. Tanaka, H. Kubo, S. Hirakawa Dept. OB/GYN, Toho School of Medicine, Tokyo, Japan Objective: It has been reported that some kinds of adhesive molecules are participating to completion process of pregnancy and formation of placenta. We suppose that the adhesive molecules are also participating to complete preeclampsia and Intra Uterine Growth restriction (IUGR). Count the adhesive molecules, using antibodies of them, and compare it to that of non-pregnancy and latter term of normal pregnancy cases. Study Methods: We use neutrophils stratum of blood samples of pregnant women who complicate preeclampsia or IUGR. Cases which complicate infection and malformation are expected. We measured the fluorescence quantity of CD11a, CD11b, CD11c, CD18 adhesive molecules, which specific to neutrophils, using FAC scan (Becton Dickinson) and compare it to that of non-pregnancy and latter term of normal pregnancy cases. Results: Fluorescence quantity which measured by blood samples of pregnant women who complicate preeclamspsia (n=13) are 513.25 for CD11a, 498.62 for CD11b, 510.5 for CD18. And that complicate IUGR (n=16) are 468.6 for CD11a, 452.6 for CD11b, and 506.4 for CD18. These are significantly high rate compare to the cases of non-pregnancy (n=12) and normal pregnancy (p<0.01).

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kPa, p<0.05; base excess 2.970.34 vs. 1.81.2 mmol/L, p<0.001, standard HCO3- 21.50.99 vs. 23.01.2 mmol/L, p<0.001; total CO2 22.21.23 vs. 22.81.8 mmol/L, NS. Conclusions: There were marked disturbances in calcium-phosphorusmagnesium homeostasis observed in women with preeclampsia caused due to renal function impairment: hypomagnesemia, hypocalcemia, hyperphosphatemia, hypermagnesiuria, hypocalciuria. P3.06.13 MAGNESIUM, CALCIUM, PHOSPHORUS AND RENAL FUNCTION IN PREGNANT WOMEN WITH PRIMARY HYPERTENSION AND PROTEINURIA R. Smolarczyk, P. Piekarski, E. Romejko, J. Wojcicka-Jagodzinska, K. Czajkowski, J. Teliga, T. Maciejewski, 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objectives: The effect of primary hypertension with proteinuria on calcium-phosphorus-magnesium homeostasis in the third trimester of pregnancy was investigated. Methods: 22 women with primary hypertension with proteinuria (the studied group) and 30 healthy women (the control group) entered the study. All women were in the third trimester of pregnancy. Concentrations of calcium, phosphorous and magnesium were determined in the serum and diurnal urine. The biochemical assessment of renal function was also performed. Results: There was no significant difference in gestational age between the studied and the control groups (36.32.28 vs. 36.02.20 weeks). Women of the studied group presented blood pressure 16412/1016 mmHg and proteinuria 2.441.62g/24 hrs. Women of the studied group vs. control group showed following serum concentrations of: magnesium 0.650.085 vs. 0.700.10 mmol/L, p<0.05; total calcium 2.180.11 vs. 2.25.12 mmol/L, p<0.04; ionized Ca2+ 1.000.054 vs. 1.050.07 mmol/L, p<0.05; inorganic phosphorus 1.630.11 vs. 1.310.22 mmol/L, p<0.001. The results in diurnal urine: magnesium 3.290.76 vs. 2.160.50 mmol/24 hrs, p<0.001; calcium 2.421.43 vs. 6.703.50 mmol/24hrs, p<0.001; inorganic phosphorus 23.66.3 vs. 27.47.3 mmol/24 hrs, p<0.05; diurnal urine volume 1330426 vs. 1265450 ml/24 hrs, NS. Renal function parameters: creatinine 89.323 vs. 66.34.4 micromol/L, p<0.001; urea 4.981.83 vs. 3.220.83 mmol/L, p<0.001; uric acid 36.39.5 vs. 19.03.6 micromol/L, p<0.001, K+ 4.230.31 vs. 4.200.20 mmol/L, NS; Na+ 1432.4 vs. 1383 mmol/L, p<0.001; Cl- 1101.8 vs. 1073 mmol/L, p<0.001. Acid-base balance: pH 7.3910.025 vs. 7.4200.025, p<0.001; pO2 11.571.33 vs. 11.341.06 kPa, NS; pCO2 4.670.28 vs. 4.260.41 kPa, P<0.001; base excess 3.411.5 vs. 1.81.2 mmol/L, p<0.001, standard HCO318.81.62 vs. 23.01.2 mmol/L, p<0.001; total CO2 211.41 vs. 22.81.8 mmol/L, p<0.001. Conclusions: Marked disturbances in calcium-phosphorus-magnesium homeostasis in women with primary hypertension is related to proteinuria and renal function impairment. P3.06.14 MAGNESIUM, CALCIUM, PHOSPHORUS AND RENAL FUNCTION IN PREGNANT WOMEN WITH CHRONIC RENAL DISEASES AND PROTEINURIA R. Smolarczyk, P. Piekarski, E. Romejko, J. Wojcicka-Jagodzinska, K. Czajkowski, J. Teliga, T. Maciejewski, 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objectives: The effect of chronic renal diseases with proteinuria on calcium-phosphorous-magnesium homeostasis in the third trimester of pregnancy was investigated. Methods: 20 women (the studied group): 10 with chronic glomerulonephritis, 4 with chronic pyelonephritis, 1 with renal hypoplasia, 3 after reflux operation, 2 with nephrolithiasis and 30 healthy women (the control group) entered the study. All women were in the third trimester of pregnancy. Concentrations of calcium, phosphorous and magnesium were determined in the serum and diurnal urine. The biochemical assessment of renal function was also performed. Results: There was no significant difference in gestational age between the studied and the control groups (36.42.61 vs. 36.02.20 weeks). Women of the studied group presented blood pressure 16617/10412 mmHg and proteinuria 3.842.61g/24 hrs. Women of the studied group vs. control group showed following serum concentrations of: magnesium

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0.630.15 vs. 0.700.10 mmol/L, p<0.04; total calcium 2.190.11 vs. 2.25.12 mmol/L, NS; ionized Ca2+ 1.080.065 vs. 1.050.07 mmol/L, NS; inorganic phosphorus 1.550.21 vs. 1.310.22 mmol/L, p<0.01. The results in diurnal urine: magnesium 3.201.00 vs. 2.160.50 mmol/24 hrs, p<0.001; calcium 2.341.56 vs. 6.703.50 mmol/24hrs, p<0.001; inorganic phosphorus 21.67.6 vs. 27.47.3 mmol/24 hrs, p<0.01; diurnal urine volume 1089253 vs. 1265450 ml/24 hrs, NS. Renal function parameters: creatinine 137.022.1 vs. 66.34.4 micromol/L, p<0.001; urea 7.991.49 vs. 3.220.83 mmol/L, p<0.001; uric acid 41.0511.3 vs. 19.03.6 micromol/L, p<0.001, K+ 4.850.41 vs. 4.200.20 mmol/L, NS; Na+ 1422.5 vs. 1383 mmol/L, p<0.001; Cl- 109.22.1 vs. 1073 mmol/L, p<0.001. Acid-base balance: pH 7.3500.028 vs. 7.4200.025, p<0.001; pO2 11.041.33 vs. 11.341.06 kPa, NS; pCO2 4.790.31 vs. 4.260.41 kPa, P<0.001; base excess 5.451.68 vs. 1.81.2 mmol/L, p<0.001, standard HCO3- 18.81.62 vs. 23.01.2 mmol/L, p<0.001; total CO2 191.51 vs. 22.81.8 mmol/L, p<0.001. Conclusions: Chronic renal diseases with proteinuria are related to hypomagnesemia, hyperphosphatemia, hypermagnesuria, hypocalciuria, hypophosphaturia.

P3.06.15 PREGNANCY AFTER RENAL TRANSPLANTATION: EXPERIENCE IN SINGAPORE GENERAL HOSPITAL P.K. Tan, V. Anantharaman, A. Tan, Dept OB/GYN, Dept of Renal Medicine, Singapore General Hospital, Singapore Objectives: The aim of the study was to examine the overall outcome of pregnancy after renal transplantation in Singapore General Hospital (SGH). Study Methods: 22 women whose pregnancies after renal transplantation were jointly managed by the department of OB/GYN and Renal medicine in SGH between December 1986 and November 1998, formed the subjects of this retrospective study. Antenatal and postnatal details of the pregnancies for each woman were retrieved from their obstetric and neonatal records respectively. Results: Of the 34 post-transplant among the 22 women, 12 (35.2%) were unsuccessful because of 6 (50%) spontaneous miscarriages, 3 (25.0%) therapeutic abortions, 2 (16.7%) ectopic pregnancies and 1 (8.3%) stillbirth. The remaining 22 (64.8%) successful pregnancies were complicated by maternal anemia (63.6%), superimposed hypertension (45.5%), premature rupture of membranes (31.8%), urinary and lower genital tract infections (22.7% each), abnormal glucose tolerance test (13.6%), premature delivery (45.5%), low birth weight babies (45.5%) and intrauterine growth retardation (22.7%). 19 (86.4%) of the pregnancies were delivered by caesarean section and 3 (13.6%) by the vaginal route. There were no documented cases of multiple pregnancies, congenital anomalies or intrapartum or postpartum deterioration of renal function. Conclusions: Successful pregnancy is possible in women after renal transplantation. Such pregnancies are often associated with increased maternal and fetal morbidity and should be managed with a multidisciplinary approach in a tertiary center.

P3.06.16 PREVENTION OF P.E.T. P. Paul, Dept. OB/GYN, Narishikshaashram Hospital, Silchar, India. Objectives: The aim of this study is to prevent development of Preeclamptic Toxemia (P.E.T.)of pregnant women to reduce the morbidity and mortality of both mother and fetus. Study Method: 200 cases of primigravida of average wt and obese were selected for the study. At every antenatal visit, urine R.E., W.T., B.P. oedema were recorded along with other routine exams. From the beginning of pregnancy they were advised not to take butter, ghee, egg, milk, milk product, fried food, oily fish, fatty food, and use as little oil as possible during cooking. Strict advice was given to drink 6 10 glasses of water daily. Medication was given liberally to prevent constipation, acidity, indigestion. In a few cases, women developed edema around 24 30 weeks and were promptly treated with bed rest, reduction of carbohydrates and fatty foods in their diet. They responded well. Results: Not a single case developed high BP, albuminuria, or excessive gaining of WT.

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Conclusion: PET can be prevented with: a) dietary restriction of fatty food, b) liberal intake of water, c) constipation or any discomfort in the body may accelerate BP, thus precipitating toxemia. P3.06.17 PROPHYLAXIS OF THROMBOEMBOLIC COMPLICATIONS IN PREGNANT WOMEN WITH VEINOSE INSUFFICIENCY N.V. Ordzhonikidze, B.L. Gurtovoy, Yu.V. Boykova. Research Center of Obstetrics, Gynecology & Perinatology Russian Academy of Medical Science, Moscow The objective of the study was to investigate the therapeutic efficacy of the angioprotective drug GINKOR FORT in treatment of varicosis of the lower extremities in pregnant women with infection of viral and/or bacterial etiology. Thirty patients in the III gestation trimester were included in the study. It was found that administration of GINKOR FORT (2 capsules x 3 times a day in the course of 30 days) provided elimination of varicosis symptoms, such as pain, heaviness, or discomfort in the lower extremities, nocturnal paresthesia, and cramps in most patients (96.6%). Tissue edema was also eliminated, which was manifested as significant decrease of medullar volume. Therapeutic effect of the drug was achieved due to improvement of oxygen-carrying function of blood, as well as rehabilitation of patients hemorheological status. Positive dynamics of blood circulation in popliteal artery, as well as in the blood vessels of mother-placenta-fetus system, was also noted. Obviously, GINKOR FORT is an effective medication for treatment of varicosis in pregnant women in the III gestation trimester. P3.06.18 PROTEINS, LIPIDS AND RENAL PARAMETERS IN AMNIOTIC FLUID IN PREGNANCIES COMPLICATED WITH INTRAUTERINE GROWTH RETARDATION P. Piekarski, E. Romejko, R. Smolarczyk, J. Wojcicka-Jagodzinska, K. Czajkowski, R. Szczecina, 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objective: The aim of the study was to evaluate metabolic changes in amniotic fluid in pregnancies complicated with IUGR and physiological ones. The following parameters of amniotic liquid were investigated: total protein, albumin, total cholesterol, total fraction LDL, uric acid, urea, creatinine. Methods: Thirty-six pregnant women with IUGR (the studied group) and 72 women with eutrophic pregnancies (the control group) entered the study. The biochemical analysis of parameters listed above was performed. Results: All women were in the third trimester of pregnancy and there was no significant difference in mean gestational age between studied and control groups: 36.02.3 vs. 36.52.5 weeks respectively. Women in the studied group versus control group showed following concentrations in the amniotic fluid: total protein 4.31.5 vs. 6.02.5 g/l; p<0.001, total fraction LDL 0.2410.109 vs. 0.4500.334 g/l; p<0.001, albumin 23.184.35 vs. 42.0210.14 micromol/l; p<0.001, total cholesterol 0.210.08 vs. 0.250.23 mmol/l; NS, uric acid 79.129.1 vs. 76.726.8 micromol/l; NS, urea 8.73.3 vs. 8.03.1 mmol/l; NS, creatinine 188.330.9 vs. 200.732.7 micromol/l; p<0.05. Conclusions: The lowered concentrations of total protein, albumin,LDLcholesterol are noted in amniotic fluid in pregnancies complicated with IUGR. This might be an indicator of fetal malnutrition or immaturity. The decreased level of creatinine in amniotic fluid in IUGR might suggest a mild immaturity of fetal kidneys and/or might be related to the smaller fetal creatinogenic muscle mass compared to eutrophic pregnancy. P3.06.19 SEXUAL BEHAVIOR AS AN ETIOLOGIC FACTOR OF PREGNANCY HYPERTENSION E. Szabo, B. Kellner, Dept OB/GYN, Semmelweis Hospital, Kiskunhalas, Hungary

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Objectives: The aim of the study was to focus on the exploration of relationships between gestational hypertension and the length of sexual life, as well as the frequency and duration of sexual activity before the conception. Study Methods: Clinical data of 1010 successive patients managed, treated and delivered over a two-year period were collected from obstetrical records and interviews made with the patients. Results: Gestational hypertension developed in 11.9% of nulliparous, 4.7%in multiparous (with the same partners), and 24% among multiparous (women with new partners). Inverse relationship was found between the sexual activity, duration of cohabitation and the incidence of gestational hypertension (p<0.0001). Conclusions: The risk of developing hypertension is less dependent on nulliparity; rather, it is related to primipaternity. Repeated exposition to sperm antigens can lead to the evolution of a certain level of protection against pregnancy hypertension. The presumptive role of repetitive exposure to sperm antigens may influence the education of patients during preconceptional management.

P3.06.20 SIGNIFICANCE OF DETECTION OF LUPUS ANTICOAGULANT AND THROMBOPHILIA MARKERS IN PATIENTS WITH MISSED ABORTION BEFORE D@C D.G. Tsintsadze, N. Kamernitskaya, M.G. Genievskaya, A.D. Makatsaria, Dept. OB/GYN, Sechenov Moscow Medical Academy, Moscow, Russia. Objective: Patients with missed abortion due to circulation of lupus anticoagulant (LA) have double risk of thrombotic complication after D@C procedure as LA aggravate DIC and coagulation defects caused by long embryo retention in utero. Study Methods: We studied 47 women with missed abortion before D@C procedure. 27 patients (57.4%) were positive for lupus anticoagulant (LA). Among them based on history of thrombotic episodes, fetal loss syndrome and/or thrombocytopenia antiphospholipid syndrome (APS) was diagnosed in 21 cases (77.8%), 6 patients had positive LA without APS. Majority of patients with APS was under 30 years old. 2 patients had missed abortion after IVF/ET. Results: Lupus anticoagulant (LA) was assessed by dilute Russell Viper Venom Time (dRVVT) and APTT with platelets neutralization procedure (Stago, France). Increased level markers of thrombophillia such as TAT were detected in 13 cases, FDP in 9 cases. Platelets hyperactivation tests were positive in 13 cases. Therapy included infusion of fresh frozen plasma pre- and intraoperatively and low-doses heparin in post-op period for 7 days. Such approach prevented decompensation of DIC during D @ C and thromboembolic complications post-op. Conclusion: Detection of LA and thrombophilias markers in patients with missed abortion allows to perform timely and adequate correction of hemostasis defects and suggests appropriate management option for future pregnancy.

P3.06.21 THE EFFECT OF HYPERVENTILATION ON MATERNAL CEREBRAL BLOOD FLOW VELOCITY IN PREECLAMPTIC AND NORMAL PREGNANCIES: IS THERE EVIDENCE FOR AN ALTERED CEREBRAL VASOREACTIVITY? J. Zatik (1), T. Major (1), A. Jakrab (1), Z. Tth (1), B. Flesdi (2), University Medical School of Debrecen, Debrecen, Hungary. (1) Dept. OB/GYN (2) Dept. Anesth. and Intensive Care Objectives: The purpose of the study was to investigate cerebral arteriolar vasoreactivity function in preeclampsia. Study Methods: Preeclamptic and healthy pregnant patients had undergone transcranial Doppler sonography of the middle cerebral artery at rest and after 60 seconds of hyperventilation (HV). Systolic, diastolic and mean blood flow velocities of the middle cerebral artery were

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recorded. The percent change of the blood flow velocities after HV was calculated. Results: Mean blood flow velocity of the middle cerebral artery (MCAV) was higher in preeclamptic women as compared to healthy pregnants. No difference could be detected in percent change of middle cerebral artery blood flow velocities after HV between the two groups. Conclusions: There is no evidence of small vessel vasoconstriction among preeclamptic patients. The role of vasoconstriction of the large cerebral arteries and vasodilation of the resistance arterioles as well as a combination of these two pathomechanisms in determining cerebral blood flow in preeclampsia and eclampsia has to be investigated in further studies. P3.07 HUMAN SEXUALITY

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P3.07.01 A PAIN CONTROL COURSE FOR WOMEN WITH VULVAR VESTIBULITIS SYNDROME. Ph.Weijenborg, M.ter Kuile, Dept Psychosom Gyn & Sexology, Leiden University Medical Center, Leiden, The Netherlands Objectives: Evaluation of the effect of a pain control course for women with VVS. Study methods: 48 of 58 women with VVS (83%) completed a structured course on vulvovaginal pain control. During each course of twelve two-weekly sessions of two hours, 6-8 women could participate. The programme is based on cognitive- behavioural programmes for chronic pain and sex therapy. Different standardized questionnaires as well as a gynaecological examination were used to assess the effect of the course at pretreatment, posttreatment and three months follow-up. Results: At posttreatment women reported less pain in different sexual situations. They increased their internal locus of pain control and decreased their external locus of pain control; they perceived themselves as more effective in controlling and decreasing their pain; they reported lower levels of sexual problems. These results remained at follow-up. Moreover at posttreatment less painfull spots on the vestibule were observed. A decrease in the level of pain was associated with a decrease in sexual problems and an increase of perceived pain control at posttreatment. No significant association was found between changes in pain and the amount of painfull spots. Conclusions: A pain control course for women with VVS results in less pain during sexual activities, higher scores on the internal locus of pain control and perceived pain control and reduction of sexual problems.

P3.06.22 THE OPTIMIZATION OF CENTRAL HEMODYNAMIC PARAMETERS IN PYELONEPHRITIC PREGNANT PATIENTS I. Nikolskaya, N. Mazurskaya, I Tkacheva, I. Shouginin, V. Shepatov, Moscow Regional Scientific Research Institute of OB/GYN, Moscow, Russia. Objectives: The aim of the study was to investigate the central hemodynamic parameters in 159 pyelonephritic pregnant women without gestosis and the comparison of these characteristics to normal pregnant women. The parameters of blood circulation in 53 pyelonophritic patients with gestosis were also compared to gestosis patients, but without pyelonephritis. Study Methods: The methods of echocardiography and impedance rheocardiography by Kubicvek were used. Results: The pyelonephritic patients without gestosis were divided into three groups. I 45 gestational pyelonephritis patients, II-61 chronic pyelonephritis patients III 53 chronic pyelonephritis patients with other renal diseases (renal anomalies, hydronephrosis, urolitic disease, single kidney after operation). In the I group the hemodynamics parameters were the same as in healthy pregnant patients. In the II group these parameters had tendention of angiospasm. The III group patients had non significant peripheral angiospasm. The 53 pyelonephritic patients with gestosis had the most significant changes in their hemodynamics parameters in comparison with gestosis patients without pyelonephritis. Conclusion: These changes may be explained by the decrease of myocardial contratilyty in pyelonephritic patients as the result of infection process. The use of metabolic therapy and Chofitol optimized the hemodynamics parameters and myocardial contractility. P3.06.23 THROMBOPROPHYLAXIS WITH LOW-MOLECULAR WEIGHT HEPARIN AFTER CESAREAN SECTION IN PATIENTS WITH ANTIPHOSPHOLIPID SYNDROME (APS) S.G. Ismailova, V.O. Bitsadze, A.D. Makatsaria, Dept. OB/GYN, Moscow Medical Academy, Moscow, Russia. Objectives: APS an acquired thrombophylic state provided by the circulation of antiphospholipid antibodies (AA). It can be the cause of thrombotic event in patients, especially after cesarean section, which in itself is the high risk factor of thrombosis. Study Methods: We examined 20 women aged 22 32 years old with fetal loss syndrome and a history of thrombosis, who had operative deliveries. The control group consisted of 10 women in post-operative period. The signs of thrrombophyllia were revealed with special coagulation tests: TAT, F1 +2, prothrombin fragments. The LMWH (Fraxiparin) therapy began and continued during the whole pregnancy and was stopped a day before the surgery. After 8 hours postpartum, the LMWH therapy was restarted at the dosage of 0.3 (150 ICU/kg) once daily and lasted for 10 days under the condition of maintained lactation. Results: The LMWH (Fraxiparin) therapy was found to be effective and safe for thromnoprophylaxis in women with APS during postoperative period. All neonates wre born alive, without any sign of asphyxia. There were no hemorrhages or thromboembolic complications during the postoperative period.

P3.07.02 A PAIRED COMPARISON STUDY OF THE EFFECTS OF A BREATHABLE FEMININE HYGIENE PANTILINER VERSUS A TRADITIONAL NON-BREATHABLE PANTILINER ON REDUCING SKIN HYDRATION AND RELATIVE HUMIDITY A. Kanti (1), M. Bramante (2), S. Wang-Weigand (1), M. Roddy (1), F. Sarbaugh (1), A. Theil (1), E. Bookland (1). (1) The Procter & Gamble Co., Cincinnati, Ohio, USA. (2) Procter & Gamble GmbH, Schwalbach, Germany. Objective: Under continuously hydrated conditions, skin can be more sensitive to possible irritation. A new vapor permeable backsheet was developed and tested using a physiological forearm model to evaluate the effects of a breathable backsheet on skin hydration and relative humidity. Study methods: A paired comparison study was conducted using a forearm model with 16 women wearing pantiliners loaded with 0.5ml saline on each forearm for 6 hours. A double layer of cotton crotch material was placed on top of the pantiliners to simulate realistic wear conditions. Each woman wore a breathable pantiliner (Alldays Always Breathable Odor Control Pantiliner, Procter & Gamble) and a nonbreathable reference (Alldays Always Odor Control Pantiliner, Procter & Gamble) on the opposite forearm. Baseline transepidermal water loss measurements (TEWL, Dermalab) were taken after a 30 min acclimation period in a temperature (20-25C) and RH (405%) controlled room. After panelists wore the products for 5.5 hr, Relative Humidity (RH) and temperature were recorded at the center of covered test area (General Eastern Model 880) for 3 minutes. TEWL measurements were taken at defined intervals over a 15 min. period after product removal. Product weight was taken within 1 min. from product removal. Results: All parameters measured showed statistically significant differences (paired-t test, p<0.0001) from the non-breathable backsheet. The parameters evaluated included lower skin surface, water loss (SSWL) in the breathable pantiliner (area-under-curve at 15 min: 0.267 vs 1.201),lower RH and temperature in the breathable pantiliner (RH: 63.269% vs 89.131%; Temp: 83.037F vs 83.994F) lower TEWL in the breathable pantiliner (0.286 vs 1.335), and increased backsheet water loss in the breathable pantiliner (16.62 vs 1.557 g/m2/24hr). Conclusions :Breathable pantiliners reduce skin hydration and relative humidity as compared to non-breathable pantiliners. These results correlate well with superior comfort experienced by women during

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normal use (consumer research) and support breathable pantiliners suitability for daily use.

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P3.07.05 FLUOXETINE IMPROVES SOCIAL FUNCTIONING IN WOMEN WITH PREMENSTRUAL DYSPHORIC DISORDER (PMDD) J. Dillon (1), M. Steiner (2), R. Judge (1), E. Brown (3) (1) Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA. (2) McMaster University, St. Josephs Hospital, Hamilton, Ontario, Canada. (3) Eli Lilly and Co., Nederland, CO, USA. Objective: A previously reported, placebo-controlled multi-site trial found fluoxetine effective in mediating PMDD mood symptoms; these data are now used to determine fluoxetines effectiveness on social functioning in women with PMDD. Though cyclical mood disturbance is the pathognomonic feature of PMDD, impairment of social functioning frequently contributed to the severity of presentation. Methods: Social functioning was assessed in 320 PMDD patients who were randomized to fluoxetine 20 mg/day, fluoxetine 60 mg/day, or placebo. Symptoms were assessed by social impairment subtotals of the self-rated and observer-rated Premenstrual Tension Syndrome Scale (PMTS-SR, PMTS-O). Items rated on the PMTS-SR subtotal were: avoid social commitments, avoid family, cancel scheduled social activities, difficulty completing house/job routine, more accidents in daily housework/job, stopped seeing best friends and physical symptoms severe: unable to function. Outcome measures were change from mean baseline luteal phase scores to mean treated luteal phase scores. Results: Fluoxetine treatment (20 and 60 mg/day) statistically significantly improved social functioning compared with placebo treatment when measured on the PMTS-SR and PMTS-O social impairment subtotals (all analyses significant, p<.05). For all comparisons, 20 mg/day and 60 mg/day doses were not significantly different. Conclusion: Fluoxetine treatment was statistically significantly superior to placebo in improving frequently reported PMDD associated social functioning as measured by derived social impairment subtotals of the PMTS-SR and PMTS-O.

P3.07.03 DEVELOPMENT OF RELATIONSHIOP IN COUPLES AFTER ASSISTED REPRODUCTION A PROSPECTIVE LONGITUDINAL STUDY M. Wadsby (a), G. Sydsjo (b), (a) Division of Child & Adolescent Psychiatry, (b) Division of OB/GYN, Department of Health & Environment, Linkping University, Linkping, Sweden. Objectives: The purpose was to follow the development of relationship and parenthood in couples pregnant after IVF-treatment, and compare them with spontaneous primiparous couples. Furthermore, the study the childrens health, temperament and behavior in these two groups. Study Methods: Ninety primiparous couples pregnant after IVF, and an age-matched control group. Method used was the ENRICH Marital Inventory. The infants behavior was measured with the Baby and Toddler Behavior Questionnaire. Obstetrical and neonatal records were studied. Results: The vast majority of both men and women in both groups were satisfied with their relationship during pregnancy. When the children were 12 months old, no major changes in the ART-couples relationship were noted, while a significant decrease was present in the control group. No significant correlation between marital satisfaction/dissatisfaction and infants health temperament and behavior was noted. There were no differences in the obstetrical variables such as section rates and neonatal health status even though there were 14 duplex in the ART group compared to 2 in the control group. Conclusions: The birth of the first child implied no decline in ARTcouples satisfaction with their relationship a decline that was present in the control group. Surprisingly, duplex pregnancies had no negative impact on the medical variables or experience of the relationship.

P3.07.04 THE EFFECT OF A GROUP PROGRAMME ON FEELINGS OF PSYCHOLOGICAL DISTRESS IN WOMEN WITH THE MAYERROKITANSKY-KSTER-HAUSER SYNDROME Ph.Weijenborg, M.ter Kuile, Dept Psychosom Gyn & Sexology, Leiden University Medical Center, Leiden, The Netherlands Objectives:Evaluation of the effect of a group programme on feelings of psychological distress in women with the Mayer-Rokitansky-KsterHauser (MRKH) Syndrome Study Methods: Seventeen women, diagnosed as MRKH-women, participated in a semi-structured programme of seven sessions, dealing with different themes of the syndrome. The Symptom Check List-90 (SCL-90) was used to assess feelings of psychological distress. Measures were taken at the first visit 3 - 6 months before the group programme was started (pretest 0) , at the first (pretest ) and at the last group session (posttest). In this study the women were their own controls. Results: The posttest subscale scores for anxiety, depression, interpersonal sensitivity and the total score for psychological distress were significantly lower than the pretest-0 and pretest scores (p<0.05). No significant differences were found between pretest-0 and pretest subscale and total scores. Conclusion: A semi-structured group programme seems valuable in helping women with the MRKH-syndrome to deal with their psychological distress. - Paper is accepted for publication by the British Journal of Obstetrics and Gynaecology

P3.07.06 FLUOXETINE VERSUS SERTRALINE AND PAROXETINE IN MAJOR DEPRESSION: LONG-TERM CHANGES IN WEIGHT M. Fava (1), J. Rosenbaum (1), R. Judge (2), S. Hoog (2), D. Millard (2), and S. Koke (2) (1) Massachusetts General Hospital, Boston, MA, USA (2) Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, In, Usa Objective: To assess the effects to extended SSRI treatment on weight, and to examine whether different agents have differential effects. Study Methods: Patients with major depression were randomly assigned to fluoxetine, sertraline, or paroxetine. Patients whose symptoms responded within 6 to 12 weeks of active treatment continued treatment for a total of 26-32 weeks. The mean percent change in weight was analyzed, as was the number of patients who had 7% weight increase from baseline. Results: Paroxetine-treated patients experienced a significant weight gain, fluoxetine-treated patients had a modest, but nonsignificant decrease in weight, and sertraline-treated patients had a modest, but nonsignificant increase in weight. The number of patients who had >=7% weight increase was significantly greater for paroxetine compared with either fluoxetine or sertraline. Conclusion: Extended SSRI treatment is associated with different risks for weight gain. Patients treated with paroxetine experienced larger increases in weight, possibly due to the greater antocholinergic effects.

P3.07.07 SEXUAL FUNCTIONING DURING ACUTE AND CONTINUATION THERAPY WITH FLUOXETINE: A PROSPECTIVE ASSESSMENT David Michelson, Mark E. Schmidt Eli Lilly and Company, Lilly Research Laboratories, Indianapolis, Indiana, USA Background: Sexual dysfunction has been reported as an unwanted effect associated with SSRI therapy, but the nature and frequency of such effects have not been systematically characterized, not has the

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interaction of effects of mood improvement and specific drug effects on sexual function been adequately studied. Methods: Using a 4-item self-report assessment of sexual interest/desire, vaginal lubrication/erection, orgasm and overall sexual function, we studied depressed patients participating in a multi-center trial of acute and continuation fluoxetine therapy. Patients were evaluated at baseline, after 13 weeks of fluoxetine 20 mg daily, and during 25 weeks of continuation therapy with either fluoxetine 20 mg daily, fluoxetine 90 mg weekly, or placebo. Results: Acutely 557 patients on fluoxetine 20/day and during continuation therapy 181 fluoxetine 20/day, 181 fluoxetine 90/week, and 119 placebo patients were assessed. At baseline, mean reports of sexual function showed mild-moderate impairment of all aspects for both woment and men. After acute flouxetine therapy, overall sexual function was improved in 51.9% of women and 38.2% of men, unchanged in 34.5% of women and 42.7% of men and worsened in 13.6% of women and 19.1% of men. Worsening of orgasmic functions was modestly greater compared with other aspects (19.2% and 23.7% in women and men respectively). During 25 weeks of continuation therapy, changes in sexual function were not different between treatments for any aspect, and worsened sexual function in all aspects was strongly associated with worsened depressive symptoms. Conclusion: Sexual dysfunction reported prior to treatment tends to improve as mood improves during treatment with fluoxenine. Some patients (15-20%) experience worsened sexual function during acute treatment, and orgasm may be most affected. Worsening during longterm treatment is associated with return of depressive symptoms, and does not appear to be a drug-specific late-onset event.

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bleeding and 5% had normal loss. Nine months showed 47% with amenorrhoea, 38% with light bleeding and 7% with normal loss. At two years, 41% of those followed up had amenorrhoea and a further 41% had light periods Conclusions: Endometrial balloon ablation compares favorably with established techniques. It has a low capital cost and is safe and user friendly. Success rates for this procedure are good and patients satisfactions high.

P3.08.03 HYSTERO-FIBERSCOPIC MANAGEMENT IN DIFFICULT IUD REMOVAL J. Li, H. Fan, Dept. Family Planning, Peking OB/GYN Hospital, Beijing, P.R. China Objective: To assess the importance of flexible hysteroscope in complex removal procedure of IUD. Study Methods: Forty-eight women with the history of failed IUD removal or leaved part of IUD in uterus were treated by HYF-1T Hystero-Fiberscope with instrument under epidural anesthesia (less cases) or intravenous sedation (Dolatin). Results: All of the cases were managed successfully by Fiberscope HYF-1T without complications: 8 cases with incarceration in the cornu of the uterus, 12 cases with untramural incarcered partly, 14 cases with uterine or cervical cannel adhesion, 12 cases with rest of IUD, 10 cases with break of IUD, 4 cases with uterine hysteromyoma, 1 case with uterine malformation, another one just with uterine retroflexion. Only 3 cases without any problems, of course some cases got complicated (two or three problems). Conclusions: Hystero-Fiberscope is safe and easy to use, because the operation can be performed directively and exactly in which the neck neednt be expanded, and it is effective and useful due to tip deflection of 120o in two directions of maximum orientation accuracy so that complete examination and difficult IUD removal, which is almost anywhere in the uterus, could be made properly.

P3.08 HYSTEROSCOPY P3.08.01 COMPARISON OF THE TISSUE ALTERATIONS INDUCED BY ELECTRIC ENERGY AND BY SUTURE MATERIALS USED DURING LAPAROSCOPIC SUBTOTAL HYSTERECTOMY (LSH). A.S.Gasparov, P.A.Basanov, A.G.Melikian ; Dept.PEPR. Scientific Center for Obstet., Gynecol. and Perinat; 4, ak.Oparina street, Moscow, 117513, Russia. Objective: The aim of this study is to compare tissue alterations induced by electrocoagulation or by suturing used in LSH carrying out. Study methods: 100 women of the reproductive age (from 22 to 54 years) were included in this study. Every patient underwent LSH. All patients were divided in 2 groups: in 1 group electrocoagula-tion was used and suturing was selected for 2 group. Comparative analysis was performed using matching method (analogous gynecologic pathology and electrocoagulation or suturing). Results: Level of the tissue destruction products was reliably higher in 1 group, than in 2 group. Conclusion: Use of suture materials brings less tissue alteration than electrocoagulation performed during LSH in the case of the analogous gynecologic pathology. P3.08.02 ENDOMETRIAL BALLOON ABLATION WITH THE CAVATERM THERMAL BALLOON: RESULTS OF 69 CASES A. Alaily, Dept. of OB/GYN, Conquest Hospital, St.Leonards, East Sussex, UK Objectives: To determine the performance of Cavaterm, a relative new, safe and cost effective procedure that can treat menorrhagia without the need for surgery or drugs in women between the ages of 35-55 as day cases. Study Methods: The study is based on a balloon catheter that combines heat with pressure to destroy the endometrium and underlying myometrium. All women undergo pre-treatment tests, which include endometrial biopsy and hysteroscopy, and any contra-indications are excluded from this procedure. All patients had the procedure performed under general anaesthetic and were followed up at three, six and nine months and up to two years. Results: There were no complications of treatment. Sixty-nine patients were treated. Three patients had repeated ablations. 19% of patients had amenorrhoea at three months, 60% had light bleeding and 4 % had normal periods. At six months 40% had amenorrhoea, 42% had light

P3.08.04 HYSTEROSCOPIC SURGERY USING VERSAPOINT M. Paschopoulos, D. Lolis, E. Paraskevaidis, K. Zikopoulos, G. Adonakis, S. Kaladaridou, A. Kaponis, F. Avgoustatos, ObstetricGynecology Clinic, University Hospital of Ioannina, Opl. Poutetsi 2, Ioannina, Epirus, Greece, 45100. Objective: The aim of this study was the evaluation of electrosurgery using bipolar system ( Versapoint, Gynecare, J&J Co. ) in order to perform hysteroscopic surgery. Method: Hysteroscopic surgery was performed in 52 women, using the Bettochi System Hysteroscope ( Storz, Tuttligen, Germany, 3,5 mm diameter ). Normal saline was used for dilatation of the uterine cavity. The mean age of women was 32 years ( range 24-53 ). Results: Endometrial polyp was treated in 10 cases ( 5 cases under local anesthesia ), endometrial septum in 13 cases ( 6 cases under local anesthesia ), submucus fibromas in 13 cases, and endometrial adhesions in 16 cases. Conclusions: Hysteroscopic procedures using Versapoint is an effective and safe technique. The procedures may be performed under local anesthesia using normal saline. P3.08.05 PATIENT ACCEPTANCE OF MICROWAVE ENDOMETRIAL ABLATION UNDER LOCAL ANESTHESIA M.A. Ellard, T. Hayes, N.C. Sharp, Dept. OB/GYB, Royal United Hospital, Bath, UK. Objectives: To investigate patient acceptance of Microwave Endometrial Ablation (MEA) under local anesthesia (prilocaine/octapressin, Astra, UK) compared to general anesthesia. Study Methods: Randomized comparative study with 50 pre-menopausal women undergoing MEA. The main outcome measures were a pain score measured on a visual linear analogue scale (0-10) at 1, 4, 24 and 48 hours post procedure. Amount and type of post-operative analgesia use.

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Results: No patients required conversion from local to general anesthesia to complete the MEA procedure. Median pain scores at each time interval are shown below.
Time post MEA (hours) 1 4 24 48 Local Anesthesia 2.5 3.0 0.4 0.0 General Anesthesia 2.0 2.95 0.75 0.0

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showed different complications at BV-positive women: low birth weight, preterm birth, premature rupture of the membranes. Conclusion: The investigation showed high frequency of spreading of BV in pregnant women and clinically significant sequelae. All pregnant women with BV (high and low risk) should receive therapy for BV to prevent a possible complication.

There was less use of analgesia 1 hour post operatively in the local anesthesia group but at each subsequent time interval there was no difference in the use of codeine/paracetamol, non-steroidal antiinflammatory or opiate preparations. Conclusions: Prilocaine provides an effective block during the MEA procedure. There is no difference in pain scores between the two groups at each time interval. Local anesthesia appears as an effective alternative to general anesthesia providing the possibility of MEA being used as an office procedure.

P3.09.02 A NEW PROPOSAL TO THE HISTOLOGIC FINDINGS OF THE RECURRENT SUBAREOLAR BREAST ABSCESS (RSBA) L.F. Sampaio Neto, R. Hegg, P.H.N Saldiva, PUCSP Medical School, Sao Paulo, Brazil. Objectives: There is evidence that between 88.3% to 91.9% of smoking women have the RSBA. We suppose that the elastic system of the breast is affected by the elastase activation induced by the tobacco smoking. Study Methods: 54 breasts of RBSA patients were studied, 51 breasts of normal women served as control group. They were colored by the HE and Weigert resorcin to the morphometric study of its hytsological components and the elastic system. Results: The tobacco smoking was greatly related to the presence of RSBA (90.7%). The morphometric results revealed bigger area of connective tissue and less areas of adipose tissue in the RSBA group. Through the specific coloring for the elastic system, we found that the higher concentrations of elastic fibers took place around the ducts, especially in the RSBA population. Conclusion: These findings suggest that the ductile ectasia is related to RSBA and the concentration of elastic fibers around these ducts is bigger in the RSBA patients that could be related to elastic fibers disorder. P3.09.03 BACTERIOLOGY IN INFECTED ABORTION A. Farinati (1), C.O. Soler (2), G. Pagniez (1), L. Gliosca (1), J.Casellas (1), R. Guntin (2), E. Gambaro (2), J.Soutric (3), H. Arenoso (3), N. Caruso (3) (1) Centro de Estudios Microbiolgicos, Martinez, Argentina. (2) Dept. OB/GYN, Hospital Dr. Diego Paroissien, Isidro Casanova, Buenos Aires, Argentina. (3) Laboratoires Baga Sa, Buenos Aires, Argentina. Background: Abortion is the clinically diagnosed stoppage of pregnancy, before its 20th week. In Latin America around 800,000 women are admitted annually due to complications of provoked abortions (FLASOG 1997). Objective: To know what microorganisms (MO) are involved in infected abortions (IA) in order to determine an adequate empirical antibiotic therapy. Study Methods: In this prospective study, 45 patients (p) have been recruited so far. Before uterine scrape samples were obtained from endocervix (EC)/endomtrium (EM) and for blood cultures (BC). After the scrape: EM y BC. The etiology was attributable to germs categorized as vaginal flora (VF) when these were isolated from BC or EM only or with inflammatory response from both EC and EM. The isolation from EC and/ or EM was enough for the germs not considered as VF. The susceptibility of the isolates to the Amoxicillin+Sulbactam combination (Ax+Sb) was assessed. Results: Cultures (clt) from 33p. were positive (73.3%); in 17p. only one MO was isolated; in 16 p., two or more. 80% of the p. admitted previous abortive intervention and the remaining 20% did not, which does not allow us to state that they were spontaneous abortions or due to infection. All isolates were susceptible to Ax+Sb except 3 strains: 1 E. coli, 1 Enterobacter spp. And 1 Morganella morganii.
Microorganisms EC Enterobacteria* Gram (+) cocci # Anaerobes Otros 14 21 7 2 Before uterine scrape EM 15 22 5 4 BC 7 4 After uterine scrape EM 15 2 3 1 BC 4 1

P3.08.06 THE UTERINE CAVITY EVALUATION D. Prez, M. Pesaresi, R. Papera; GYN/OBS Division, Durand Hospital, Buenos Aires, Argentina. Objetives: Our purpose was to determine the role of four different tests in the diagnosis of abnormalities in the uterine cavity. Study Methods: In a prospective study, 61 patients showing different reasons for investigation, underwent transvaginal ultrasound, transvaginal ultrasonography, hysteroscopy and endometrial biopsy. Ultrasound and ultrasonographic findings were evaluated on the basis of final diagnosis by hysteroscopy and histologic examination. The sensitivity, specificity, positive and negative likelihood ratio were calculated. Hysteroscopic findings were correlated with the histology. Results: The transvaginal ultrasound demonstrated a sensitivity of 85% in diagnosing abnormalities in the uterine cavity and a specificity of 70%. The positive likelihood ratio was 2.8 and the negative likelihood ratio was 0.2 Ultrasonography demonstrated a sensitivity of 87% and a specificity of 90.4%. The positive likelihood ratio was 8.7 and the negative one was 0.1. Hysteroscopy was an excellent investigative tool for the uterine cavity. 32% of the studies were normal. It is important to point out that histological confirmation was obtained in only 23% of the cases of hysteroscopic observation of polyps. Hysteroscopic observation was unable to detect 50% of simply hyperplasias. Conclusions: Transvaginal ultrasound is an excellent first diagnostic method in the evaluation of the uterine cavity and for excluding other genital abnormalities. Both sensitivity and specificity of the different tests are influenced by the hormonal condition of women. Hysteroscopy as well as endometrial biopsy are the gold standards for uterine cavity evaluation.

P3.09 INFECTIONS IN OBSTETRICS AND GYNECOLOGY P3.09.01 A CLINICAL-MICROBIOLOGICAL STUDY OF BACTERIAL VAGINOSIS IN PREGNANT WOMEN AND CLINICALLY SIGNIFICANT SEQUELAE S. Tanchev, A. Chervencova, M. Sredcova, B. Plevneli, S. Pachcova, Dept. OB/GYN, Dept. Microbiology and Virology, Higher Medical University, Pleven, Bulgaria. Objectives: The aim of the study was to investigate the frequency of spreading BV in pregnant women at different stages of pregnancy and the results of the delivery among the positive group. Study Methods: We held a study of 106 pregnant women aged between 15 and 35, registered at the Pregnancy Consultation Office in Pleven. We used the clinical and microbiological methods. Results: About half of the women did not have data for vaginal discharge and microbiological analyses showed normal vaginal flora. Two thirds of the rest of the investigated women had data for candidiasis, bacterial vaginosis or both. Group B streptococci in significant quantity was found in five cases. Pregnant high-risk women (with a prior preterm birth) was five. The analysis of the delivery

*E. coli, Enterobcter spp, P. mirabilis, K. oxytoca, M. morganii. #E. faecalis, S. viridans, GBS, GAS, S. areus, S. epidermidis. Conclusion: The MO involved in this study on infected abortion are similar to the ones found by our group in a previous study on puerperal

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endometritis, in which Ax+Sb proved clinically effective as empirical therapy.

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immunocorrection therapy by viferon rectal suppositorians, the parameters of the interferonal status has achieved normal meanings. Conclusions: Complex antibacterial treatment of acute tube-ovarian inflammations in combination with viferon 500000 IU was found to have a significant effect in 94% of patients. P3.09.07 GNRH-AGONIST INDUCED OVARIAN CYSTS ASPIRATION: THEIR IMPACT ON CONTROLLED OVARIAN HYPERSTIMULATION AND PREGNANCY OUTCOME W. El Deeb, S. Farid, H. Assem, S. El Sahwi, International Fertility Center (IFC) Lauran, Alexandria, Egypt. Objective: To evaluate the impact of GnRH-a induced ovarian cysts aspiration on controlled ovarian hyperstimulation (COH) and pregnancy outcome. Study Methods: The design was a retrospective study. Patients and intervention: Eighteen patients form our IVF & ICSI program with who administration of GnRH-a failed to induce pituitary desensitisation as evidenced by both the presence of an ovarian cyst, and prolonged high oestrogen (E2) level. All patients underwent 23 cycles and had a baseline transvaginal sonographic evaluation prior to GnRH-a administration (Superfact, Hoechst, Frankfurt, Germany) O.3 ml two times daily S.C. starting from the second day of the menstrual cycle as a follicular phase long protocol. D10, inappropriate pituitary desensitization was considered if we have an ovarian cyst and prolonged hyperestrogenaemia. D11 we had 16 cycles in which transvaginal ultrasonographic guided cyst aspiration (TSVA) was performed, the rest of the cycles (7cycles) we had either very small cyst to be aspirated or persistent hyperestrogenaemia without cyst formation. D14 the patients were re-evaluated by ultrasonography and serum E2 concentration, HMG was stared when serum E2 was below 50pg/ml and routine follow-up of the patients until HCG administration. Main outcome measures: Ovarian responsiveness to subsequent COH and pregnancy outcome. Results: Out of the 23 cycles, 13 trials were completed (all had TSVA). Nine were cancelled due to ovarian irresponsiveness to COH and in one cycle a single injured oocyte was retrieved. We had four pregnancies and the pregnancy rate per transfer was 30% and 17% per cycle. This compares favorably with our concurrent pregnancy rate in the center. Conclusion: Aspiration of GnR-H-a induced ovarian cysts do not appear to interfere with COH and outcome. P3.09.08 PREVENTION OF VERTICAL HIV TRANSMISSION C. Manchese, O. Parada, M. Martinez, B.Chomski, R. Voita, R.H. Winograd, Dept. OB, Argenich Hospital, Buenos Aires, Argentina. Objectives: We sought to determine the decrease of perinatal transmission in pregnant women who are seropositive for the human immunodeficiency virus (HIV) that had been treated with antiretroviral drugs. Study Methods: We examined 85 newborns of mothers seropositive (HIV). During the period from 1995 to 1999 treated with the protocol 0.76 and other drugs. We evaluated several factors: 1. Condition clinical maternal 2. Antiretroviral drugs during the pregnancy; two or more drugs. 3. Rupture of the membranes 4. Delivery or cesarean section. Results: In the last 2 years (1998-1999), the 53 to 70% of the pregnant women (HIV) positive had in plasma HIV 1 RNA less than 5,000 copies/ml, and CD4 T cell count more than 200. During the period 1998-1999, the 42% of pregnant women HIV positive were treated with AZT associated to one or two drugs during the pregnancy. There was no difference respect the rupture of the membranes occurred less than 4 hours prior to delivery; we have 91% of patients in these conditions. Cesarean section was increased from 25% to 47% during 1999. Was significant the reduction of vertical transmission during the period (1998-1999), to the 6% incidence respect the period (1995-1997) in our maternity.

P3.09.04 BUSCHKE-LOWENSTEIN TUMOR OF THE VULVA: HOW WE CAN DO DIFFERENTIAL DIAGNOSIS WITH CONDYLOMA ACUMINATUM N.S. Carvalho, C.A. Maestri, E. Schunemann, R.P.G. Xavier, A. Bini. Dept OB/GYN, Clinic Hospital, Federal University of Parana, Parana, Brazil Giant condyloma acuminatum or Busche-Lowenstein tumor of the vulva and perinal regions is a uncommon entity that has not been extensively studied. Sometimes the appearance of common condyloma acuminatum with large size shown any doubts about the correct diagnosis. In this short communication, we discuss the clinical features, the histological criteria for diagnosis and methods of treatment available about this rare vulvar and perennial regions tumor. To illustrate the theme we show our experience with five cases about it.

P3.09.05 CHARACTERISTICS OF NEUTROPHIL SUPEROXIDE GENERATION IN HUMAN FETUSES H. Komatsu, K. Tsukimori, K. Hata, H. Nakano, Dept. OB/GYN, Graduate School of Medical Sciences, Kyushu University, Fukuoka, JAPAN Objectives: To investigate the defensive sysytem against bacterial infections in human fetuses, we studied neutrophil superoxide generation in fetuses and adults. Study Methods: After an appropriate informed consent, neutrophils were obtained from cord blood of neonates immediately after transvaginal delivery, which consisted of two groups: group I, 11 neonates (22 to 36 weeks gestation) and group II, 10 neonates (37 to 41). Ten healthy adults served as controls (group III). A SOD-inhibitable MCLA chemiluminescence assay was used to evaluate O2- production activity of neutrophils stimulated by PMA and fMLP. The [3H]fMLP binding assay was performed according to the modified method of OFlaherty et al. as previously described. Statistical analysis was performed using one-way ANOVA and Bonferroni test. Results: For PMA-stimulated O2- production activity of neutrophils, both group I (1.420.18_107cpm; meanSEM) and II (1.640.15_107) were significantly lower than group III (2.37_1070.22_107) (p<0.05), whereas no significant difference was noted between group I and II. In fMLP-stimulation, O2- production activity in group II (9.900.97_106) did not differ from group III (10.50.11_106). Group I (6.070.81_106) was significantly lower than the other groups (p<0.05). Scatchard analysis of [3H]fMLP binding to neutrophils demonstrated a tworeceptor site model in all groups. However, the number of high-affinity receptors per neutrophil in group I was lower than those in the other groups. Conclusions: These findings indicated that the fMLP-induced O2production activity of neutrophils in term fetuses, which was different from that in preterm fetuses, expressed the same level as that in adults by increasing the number of high-affinity receptors per cell. This evidence suggests that term fetuses acquire the defensive system against bacterial infections. P3.09.06 DISTURBANCES OF INTERFERONAL STATUS AND ITS CORRECTION BY VIFERON IN PATIENTS WITH ACUTE TUBEOVARIAN INFLAMMATORY DISEASES A.N. Strizhakov, V.V. Malinovskaya, J.A. Kagramanova, Dept. OB/GYN, Moscow Medical Academy, Moscow, Russia. Objectives: The aim of the study was to investigate the disturbances of interferonal status and to improve complex treatment of tube-ovarian inflammatory by viferon, which include human a2 interferon recombinantly and antioxidants. Study Methods: 50 women were included in the study of interferonal status in the blood serum. Results: 96% of the patients had deep decrease of interferonal status (aand g- interferon on 70%) after antibioticans only. After

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Conclusions: The prevention during the pregnancy with the protocol 0.76 and other drugs had reduced the vertical transmission by approximately two thirds. This is one of the most important variables to reduce the cases of pediatric HIV.

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P3.09.11 PREVALENCE AND RISK FACTORS OF STREPTOCOCCUS AGALACTIAE (GROUP B) COLONIZATION IN MOTHERS AND THEIR NEONATES AT SRINAGARIND HOSPITAL, KHON KAEN, THAILAND Y. Werawatakul, C. Wilailuckana, S. Taksaphan, J. Thinkumrup, Dept. OB/GYN, Khon Kaen University, Khon Kaen, Thailand. Objectives: To determine the carriage rate of streptococcus agalactiae (group B) in pregnant women at the onset of labor To find out the risk factors of streptococcus agalactiae (group B) colonization in mothers and neonates To evaluate the role in neonatal infection. Study Methods: 901 cases of pregnant women and their neonates were cultured for streptococcus agalactiae (group B) at labor room. Results: There were 56 cases (6.4%) of maternal colonization and 14 cases (1.6%) of neonatal colonization. Oral sex during pregnancy was a risk factor of streptococcus agalactiae (group B) colonization in mothers and their neonates. All cases of neonatal colonization did not have any clinical of neonatal infection. Conclusions: In this study we found lower prevalence of streptococcus agalactiae (group B) colonization in mothers and their neonates compared with western countries. P3.09.12 PROPHYLACTIC ANTIBIOTICS IN ABDOMINAL HYSTERECTOMY C. Chongsomchai (1), P. Lumbiganon (1), J. Anansuwanchai (1), J. Ounchai (2) (1) Dept. OB/GYN, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. (2) Dept. OB/GYN, Khon Kaen Regional Hospital, Khon Kaen, Thailand. Objective: To compare the efficacy of a single dose of ampicillin or cefazolin in preventing febrile and infectious morbidity after elective abdominal hysterectomy. Study Methods: A multi-center randomized controlled trial was conducted at Khon Kaen University and Khon Kaen Regional Hospital. Three hundred and thirty women undergoing elective abdominal hysterectomy were randomly allocated into each of the 3 groups: placebo, ampicillin or cefazolin group. These women received 3 cc. Sterile water or 1 gm. of ampicillin or 1 gm. of cefazolin intravenously according to the random assignment 30 minutes before the operation. Febrile and infectious morbidity, assessed by blinded independent evaluators, were used as main outcome measures. Results: Three hundred and twenty-one subjects were eligible for data analysis, 108 in placebo, 106 in ampicillin and 107 in cefazolin group. Febrile morbidity occurred in 12.0%, 13.2% and 11.2% of subjects in placebo, ampicillin and cefazolin groups respectively. Infectious morbidities were found in 26.9%, 21.7% and 10.3% of subjects in placebo, ampicillin and cefazolin groups respectively. The common causes of infectious morbidity were urinary tract infection, vaginal cuff infection and surgical wound infection. There were no statistically significant differences in febrile morbidity between the 3 groups. Regarding infectious morbidity, there was statistically significant difference between placebo and cefazolin groups (p=0.002). Among placebo and ampicillin, the result showed no significant difference (p=0.375). There was a statistically significant difference between cefazolin and ampicillin groups (p=0.023). Conclusions: Antibiotic prophylaxis should be considered in elective total abdominal hysterctomy to prevent infectious morbidity. Cefazolin appeared to be more effective than ampicillin.

P3.09.09 IMMUNOCORRECTIVE THERAPY IN COMPLEX TREATMENT OF PREGNANT WITH PLACENTAL INSUFFICIENCY AND HERPES VIRUS INFECTION Zaidieva Z.S., Tioutiounnik V.L., Ordzhonikidze N.V. Research Centre of Obstetrics, Gynecology & Perinatology, Moscow, Russia Objectives: To evaluate the efficency of immunocorrective therapy in complex treatment of placental insufficiency in pregnant women with herpes virus infection (herpes simplex virus infection and cytomegalovirus). Methods: 107 cases with disease relapses and asymptomatic elimination of virus were examined. Results: Discovered disorders in immune and interferon statuses allow to prescribe for these patients immunocorrective therapy. For this purpose we have used intravenous injections of immunoglobulin (250 mg/kg) 3 times a day in I, II and III trimesters of pregnancy. We have also used rectal suppositories with viferon (which consist of 150 000 ME alpha-2b interferon) 2 times a day for 5 days since 28 to 34 weeks of gestation. Viferon suppositories consisted of 500 000 ME of alpha-2b interferon have been prescribed 2 times daily after 35 weeks of gestation. Totally we use a 12 week courses of viferon for 5 days. Conclusions: It was found that this therapy leads to a firm normalization of immune and interferon status in pregnant women with herpes virus infection and improves the effect of complex treatment of placental deficiency in these patients.

P3.09.10 MECHANISM OF PLACENTAL DYSFUNCTION AND ABRUPTIO PLACENTAE IN INFLAMMATORY MOUSE PLACENTAL MODEL: OXIDATIVE STRESS AND APOPTOSIS K. Ejima(1), E. Shibata (2), H. Nanri (1), M. Ikeda (1), M. Kashimura (2), University of Occupational and Environmental Health, Kitakyushu, Japan. (1) Dept. of Health Development (2) Dept. OB/GYN Objectives: Recent studies have indicated that oxidative stress is one of the pathogenesis in preeclampsia and inflammatory diseases. In this study, we examined the expression of antioxidant system and the induction of apoptosis in mouse placenta exposed to lipopolysaccharide (LPS), which produces radical oxygen species. Study Methods: We used placentas from pregnant mice injected with LPS or saline as a control. We analyzed the occurrence of placental cell apoptosis and the role of Fas and Fas ligand (L) in that process in an LPS-induced inflammatory placenta. The accumulation of 4-hydroxy-2nonenal (HNE)-modified proteins, which is a marker of oxidative stress, and the expression of thioredoxin and thioredoxin reductase, which were antioxidant enzymes, were evaluated by Western blotting and immunohistochemistry. Results: Analysis of the isolated DNA in agarose-gel electrophoresis revealed a typical ladder pattern of bands consisting of 180-200 bp after LPS injection. Histochemical analysis using TUNEL revealed that nuclei positive for double-stranded DNA breaks were found in placentas exposed to LPS. Western blot analysis indicated that LPS increased the expression of Fas as well as Fas L in the placenta after injection, respectively. The cells expressing Fas as well as Fas L were identified as decidua and trophoblasts by immunohistochemistry and in situ hybridization. Furthermore, when the accumulation of HNE-modified proteins was assessed to evaluate the relation of oxidative stress elicited by LPS to the induction of apoptosis, again, decidua and trophoblasts were positive. Western blot analysis revealed that injected LPS enhanced the expression of thioredoxin and thioredoxin reductase. Conclusions: Oxidative stress may be involved in the occurrence of placental dysfunction and abruptio placentae.

P3.09.13 SPECIES SPECIFIC PREVALENCE OF VULVOVAGINAL CANDIDIASIS IN DIABETIC WOMEN V. Dadhwal, R. Goswami, U. Banerjee, N. Kochupillai, S. Mittal, Dept. OB/GYN/Microbiology/Endocrinology, All India Institute of Medical Sciences, New Delhi, India Objectives: To study the species specific prevalence of vulvovaginal candidiasis in diabetic women. Study Methods: Study comprised of 166 subjects, 78 patients with

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diabetes mellitus and 88 healthy controls matched for age and body mass index. All subjects were clinically assessed for symptoms and signs of vulvovaginal candidiasis. Discharge was collected from high vagina for direct microscopy and culture Glycemic, control was judged by total glycosylated hemoglobin. Pearson chi-square test was used for statistical analysis. Results: Overall 36 of 78 (46%) diabetic women shoed Candida growth on culture as compared to 21 of 88 (22%) healthy subjects (P=0.0025). The species isolated from diabetic patients were C.glabrata (39%), C.albicans (25%) and C.tropicalis (17%), C.albicans and C.haemuloni comprised 29% each in control group, none of control group isolated C.tropicalis (P<0.05). In the diabetic women, total glycosylated hemoglobin was significantly higher (P=0.001) in cases with vulvovaginitis. The sensitivity and specificity of clinical examination in predicting candida growth was 41% and 58% in diabetic patients and 25% and 78% in controls respectively. Whereas the sensitivity and specificity of direct microsocpy for predicting candida growth in diabetic patients was 58% and 93% and in control was 38% and 97% respectively. False negative results were predominantly due to nonalbicans species. Conclusion: The relative risk for vulvovaginal candidiasis n diabetics is 2.45 in this study. The risk was associated with glycemic control. Nonalbicans Candida cause infection in a high number of diabetic patients.

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P3.09.15 TREATMENT OF NONSPECIFIC VAGINITIS BY REPOPULATION OF VAGINAL FLORA WITH CULTURE OF SACCHAROMYCES CEREVISIAE C.A.Marques (1), M.Costa (2), J.C.Conceio (2), M.Vettore (2), M.Pedrosa (2), (1) Agamenon Magalhaes Hospital, Rua Ribeiro de Brito 573/6, Centro Empresarial Guararapes, Recife, Pernambuco, Brazil, 51021-310, (2) Federal University of Rio de Janeiro, Rio de Janeiro, Brazil. The objective of this prospective, open clinical trial was to evaluate the efficacy of repopulation of vaginal flora with Saccharomyces Cerevisiae (SC), an yeast with bactericide activity and production of B vitamins, in patients with nonspecific vaginitis. After informed consent and bacteriological diagnosis, 82 patients with nonspecific leukorrhea were treated with 7 days applications of the yeast solution. They were reevaluate within 30 days. It has been evaluated the smear, pH, symptoms and adverse events. The age varied between 19 and 75 years old with an average of 38,5. The results showed improvement of the symptoms in 58 patients (70,7%), no alteration in 21 (25,6%) and worsening in 3 (3,7%). Adverse events were verified in 14 patients (17%), mainly itching, burning and pruritus. We concluded that the repopulation of vaginal flora with SC is well accepted and improved the symptoms in most of the patients with nonspecific vaginitis.

P3.09.14 THE PECULIARITY OF PSYCHO-EMOTIONAL STATUS IN WOMEN WITH CHRONIC NON-SPECIFIC PELVIC IMFLAMMATORY DISEASES V.V. Podolsky, V.L. Dronova, Dept. of Family Planning, Institute of Pediatrics, Obstetrics and Gynecology, Kiev, Ukraine. Chronic non-specific infection of the female pelvis is one of the threats for the health and reproductive function of women. It is a well known fact that the conditions of life of modern women are changing, increasing the role of women in the decisions of socioeconomic problems, all of which intensify the psycho-emotional and stress load on the womans organism. The problems in the sphere of inter personality and sexual contacts in women with chronic inflammatory diseases of genitals are changing for the worse the psychoemotional status in these patients. Objectives: The purpose of our investigation was to study the peculiarity of psycho-emotional status in women with chronic non-specific inflammatory diseases of genitals. Study Methods: During our investigation we used a few psychological methods, such as modification of color test by Lusher, modification of variant of inter personality diagnosis by T. Liri and the scale of psychological stress by L. Rider. We examined 50 women with chronic non-specific inflammatory disorders of genitals. All of these women had the disorders in psycho-emotional status. The level of psycho-emotional stress correlated with the clinical characteristic and the age of the diseases. The highest level of psycho-emotional stress by the Riders scale registered in 40% of patients with the age of diseases before two years. The investigation of inter personality peculiarity in these patients showed that 10% of the women had the distrusting type of inter personality relations, 30% had envious and obedient type of inter personality relations, 44% had obedient and embarrassed type of inter personality relations. Results: We discovered that women with chronic non-specific inflammatory diseases had great psycho-emotional disorders, which correlated with peculiarity different ache during their sexual contacts, 15% had decreasing libido, 8.75% lost the libido, 11.25% had absence of satisfaction, 20% had decreasing of personal and character of diseases. Conclusion: The results of our investigation can improve the quality of medical treatment in these patients with the use of psychotherapy methods.

P3.09.16 VAGINAL AMEBIASIS Pangemanan WT, Dept. OB/GYN, Sriwijaya University, 1528 Basuki Rahmat Street, Palembang, South Sumatera, Indonesia. Objectives: The aim of this review is to report about Vaginal amebiasis case. Vaginal amebiasis is a very rare case, thus, it is difficult to find in newer literatures reported in US, China, Central America and in undeveloped countries. Case Report: A 50 year-old woman has been a widow for 20 years, has an occupation as a farm worker, resides on rural community that has a habit of relieving themselves in rivers, come with complain of white discharge with offensive odor, alongside with pain, and rash on her vagina. At first a vaginal malignancy was suspected. After a biopsy was done, and amebic cyst was found. Afterward, the patient was admitted into hospital care and was treated with oral metronidazole 3 x 500 mg and vaginal suppositoric metronidazole 2 x 1 gram and vaginal toilet twice a day. The patient was pronounced cured after 14 days of hospital care with negative culture result and no ameba found on vaginal swab. Conclusion: Vaginal amebiasis is a rare case and a problem on diagnosis is difficulties to directly make a correct diagnosis, while treatment can be done by giving metronidazol.

P3.10

INFERTILITY/ASSISTED REPRODUCTIVE TECHNOLOGY

P3.10.01 A COMPARISON BETWEEN QUARTER, PARTIAL AND TOTAL LASER ASSISTED HATCHING (LAH) IN SELECTED GROUPS OF INFERTILITY PATIENTS E. Mantoudis, B. Podsiadly, G. Venkat, A. Gorgy, E. Kelada, S. Rogers, and I. Craft, London Fertility Centre, 112a Harley Street, London, W1N 1AF, UK Objectives: LAH has been used in order to improve implantation rates in selected groups of patients. Total LAH was first introduced in our centre in June 1998, initial results did not meet our expectations and subsequently the technique was modified initially to partial LAH and finally to quarter LAH. In this study we analysed the results from the three types of LAH. Study Methods: A total of 322 cycles of laser assisted hatching were undertaken in our Centre between June 1998 and September 1999. The patients were divided into 3 groups, group 1 with total LAH, group 2 with partial LAH and group 3 with a quarter LAH. The patients were also divided into 4 categories according to their indication for LAH. Category A were patients over 37 years of age undergoing IVF/ICSI, category B were patients undergoing FER, category C were patients were women with more than 2 previous failures and category D were women who were poor responders. Statistical analysis was performed by

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means of logistic regression. Results: The pregnancy rate was 14.6% with a clinical pregnancy rate of 5.2% in group 1, 20.9% with a clinical pregnancy rate of 18% for patients in group 2 and 29.0% with a clinical pregnancy rate of 22.1% for patients in group 3. Conclusion: Overall there was firm statistical evidence that a quarter LAH is more effective in improving the pregnancy rate, when compared with partial and total LAH.

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sperm heads. Evidence of successful sperm delivery was found in all 56 ICSI oocytes; 25.0% (14/56) showed PCC, 17.9% (10/56) showed decondensed sperm heads, and 57.1% (32/56) showed intact sperm heads. Conclusions: This study suggested that about one-third of unfertilized oocytes exhibited chromosomal abnormalities. The difference of aneuploidy between IVF and ICSI oocytes needs further studies analyzing larger number of oocytes.

P3.10.02 A PROSPECTIVE RANDOMIZED CONTROLLED STUDY ON THE COMPARISON OF THE RESULTS BETWEEN THE DAY-3 EMBRYO TRANSFER AND DAY-5 BLASTOCYST TRANSFER T. Utsunomiya, C. Ikeda, K. Hirai, K. Hirotsuru, Dept. OB/GYN, St. Luke Clinic, Oita City, Japan. Objectives: To determine the effectiveness of day-3 and day-5 ET on the pregnancy and cancellation rate following in vitro fertilization (IVF) and intracytoplasmic sperm injection. Study Methods: One hundred sixty four cycles in patients (average age: 34 (25-45)) were treated by IVF and ICSI. All zygotes were cultured to day-3 in HTF for day-5 in Blastocyst medium or G1/G2 medium. Pregnancy rate and cancellation rate were compared between the groups of day-3 ET and day-5 ET. Results: The results were as follows: the pregnancy rate (cycles) of day3 ET was 18.3% and day-5 ET was 14.8%. The cancellation rate of day3 ET was 2.4% and day-5 ET was 25.6%. Conclusions: The pregnancy rate of conventional day-3 ET using HTF medium was better than the new method as day-5 ET using blastocyst stage culture medium. The theories of blastocyst stage culture and day-5 ET might be very good and ideal procedures. From our results, however, the condition of blastocyst stage culture should be discussed more. P3.10.03 CAUSES OF INFERTILITY IN INFERTILITY CENTER OF MASHHAD UNIVERSITY, IRAN FROM 1998 TO 2000 D.M. Dehghani, D.Z. Yousefi, D.H. Salare, D.M. Amere, Dept. OB/GYN, Ghaem Hospital, Mashhad University, Khorasan, Iran. Objectives: Evaluation of Causes of infertility in infertility center Mashhad University, Iran. Study Method: 1846 patients with infertility were evaluated with retrospective method. 1515 patients had primary infertility and 331 patients had secondary infertility. Result: 654 patients were with male factors and 715 patients had female factors and 248 patients with male and female factors and 238 patients with unexplained factors. Conclusion: Ovulatory disorder was the main cause for female factors, whereas varicocle the main cause for male factors. P3.10.04 CHROMOSOMAL ANALYSIS OF FAILED-FERTILIZED HUMAN OOCYTES RESULTING FROM IN-VITRO FERTILIZATION AND INTRACYTOPLASMIC SPERM INJECTION S. Kunthikom, O. Makemaharn, S. Suksompong, Dept. OB/GYN, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Objectives: The aim of the study was to evaluate the incidence of chromosomal abnormalities in failed fertilized oocytes derived from in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) procedure. Study Methods: 164 oocytes from 62 IVF patients and 64 oocytes from 32 ICSI patients were selected on the basis of availability of oocytes and staff. Chromosomal analysis was performed using the method described by Tarkowski. Results: 111 (67.7%) of the IVF and 56 (87.5%) of the ICSI oocytes were successfully karyotyped. Of 111 IVF oocytes, 73 (65.8%) exhibited normal haploid and 38 (34.2%) were abnormal. The abnormalities included 25 aneuploid (22.5%), 11 diploid (9.9%) and 2 structural anomalies (1.8%). Of 56 ICSI oocytes, 52 (92.9%) were normal haploid and only 4 (7.1%) were aneuploid. The sperm nuclei were observed in 43 IVF oocytes (38.7%), composed of 38 (34.2%) premature chromosome condensation (PCC) and 5 (4.5%) decondensed

P3.10.05 COMPARISON OF OVULATION INDUCTION WITH TWO DIFFERENT RECOMBINANT FOLLICLE-STIMULATING HORMONE PRODUCTS (PUREGON 50 AND GONAL F 75) FOR IN-VITRO FERTILIZATION N. Kanakas (1), T. Mantzavinos (2), K. Arvaniti (1), G. Creatsas (2) Euromedica IVF Unit, Athens, Greece. 2nd Dept. OB/GYN, University of Athens, Athens, Greece. Objective: Using the recombinant technology a new product of FSH has been widely introduced in the IVF programs. The purpose of this study was to compare the two commercially available recombinant FSH hormones regarding the IVF outcome and pregnancy rate. Study Methods: Retrospective data analysis between the two rec FSH hormones in an IVF centre. This study was carried out in 107 cycles (group A) receiving Puregon 50 IU (Organon, The Netherlands) and in 102 cycles receiving Gonal F 75 IU (Serono, Switzerland) (group B) who participated in a comparative study between June 1997 and December 1999. Ovulation was induced using the same short protocol of GnRH analogue (Buserelin, 1.2 mgr/day) and rec FSH was administered starting on day three of the cycle. Both products were administered intramuscularly. A similar number of patients had their oocytes feritilized with the classical IVF method and the intracytoplasmic method (ICSI) in both groups. The mean age of the patient was 34.77 years and 35.06 for group A and B respectively. Results: There were no statistical significant differences observed in the average number of ampoules administered per cycle (27.37 8.43 Puregon 50 IU and 28.69 9.7 Gonal F 75 IU), in the duration of treatment 7.97 1.59 days (Puregon 50) and 8.71 1.80 days (Gonal F 75), in the cancellation rate, in the oocytes recovery rate (6.06 4.3 Puregon 50 5.82 4.3 Gonal F 75) and in the number of embryos transferred between group A and B (2.7 2.02 and 2.59 1.73). No severe hyperstimulation was observed in both groups. Estradiol on the day of HCG administration did not differ between both groups (1435.21 931.6 pg/ml in Puregon 50 IU group compared to 1608 720.3 pg/ml, in Gonal F 75 group). Clinical pregnancy rates per embryo transfer did not differ between both groups (19.1% for group A and 20% for group B). Conclusions: Administration of the two different rec FSH products gave similar results in a significant number of cycles.

P3.10.06 DIMINISHED T CELL ADHESION TO EXTRACELLULAR MATRIX PROTEINS IN WOMEN WITH ANTIPHOSPHOLIPID ANTIBODIES M.Jerzak, W.Baranowski, J.Pajak, A.Gorski, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Weigla Street 12, Wroclaw, Poland, 53-114. Objectives: Recent data emphasize the important role of extracellular matrix (ECM) proteins in the regulation of T cell function. Evidence is accumulating that activation of the immune system can influence implantation and may be responsible for unexplained infertility and pregnancy loss. Our previous data suggest the association of abnormally high T cell adhesion to ECM proteins with recurrent spontaneous abortion (RSA). The aim of this study was to determine T cell adhesion to ECM proteins in antiphospholipid (APA) positive women. Study Methods: Thirty women with unexplained infertility, including women with RSA, and ten normal healthy women with the previous successful pregnancy outcome were studied. We investigated phorbol acetate myristate (PMA) and phytohemaglutinin (PHA) activated peripheral blood T cell adhesion to the following proteins of extracellular matrix: collagen IV (C-IV), elastin (E) and fibronectin (FN). APA concentration was measured by ELISA method. Results: We determined that PHA-activated T cell adhesion to C-IV and

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FN is significantly lower in APA positive women compared to APA negative women. Conclusions: Our data suggest the existence of disturbed T cell: ECM interactions in infertile women. Further studies are needed to determine the role of those abnormalities in reproductive failure. P3.10.07 EVALUATION, INCIDENCE AND OUTCOME OF I.U.I IN INFERTILITY CENTER, MASHHAD UNIVERSITY, IRAN, FROM 1997-1999 D.-H. Salare, D.Z. Yousefi, Dept OB/GYN, Mashhad University, Khorasam, Iran Objective: Evaluation incidence and outcome of I.U.I in infertility center, Mashhad university, Iran. Study Methods: 826 women who had I.U.I. were studied by retrospective analytic method. Results: In females, rate of pregnancy was mostly due to ovarian factors (26.4%) and lastly for tubal factors (9.9%) and multifactors (6.6%). Conclusions: I.U.I. is a cheap, good and available method that can be used in any center without much complication.

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urine. When the level in 17 neutral ketosteroids in 24-hour urine was higher than 38.6 1,4 Mk-mol the patients were given the evening _ tablet of dexametzon (0.005 mg) under the control of dehydroepinandrosteron: the women the basal temperature rose the doze of demetazon was lowered up to _ tablet. The worked-out tactics of treating allowed to achieve the rehabilitation of the reproductive function with 33.7% of patients, 62% of whom gave birth to mature children and 38% - to premature children.

P3.10.10 INFLUENCE OF THE DAYLIGHT ON QUALITATIVE CHARACTERISTICS OF SPERM IN PATIENTS WITH OLIGOSPERM S. Khmil, S Halnykina, A. Nychyk, B. Keisa, Dept. OB/GYN, Ternopil State Medical Academy, Ternopil, Ukraine. Objectives: Because of natural conditions the non-collision of spermatozoa with the light impelled us to learn the influence of the natural daylight on spermatozoa in patients with complicated oligosperm. Study Methods: We conducted a cytoluminestsentic test of spermatozoa of two randomized groups of patients with complicated oligosperm. All manipulations with sperm of patients (n=32) of the first group from gaining to investigation were kept in the dark (in the dark room). Sperm of patients of the second group (n=38) was taken and kept in room with natural daylight. The results of the investigation were made statistically, using Fishers criterion. Results: Spermogram of patients of the first group was characterized by the authentic increase (p<0.05) of quantity of spermatozoa, colored by acredine-orange in red colour. Conclusions: It is obvious that the aggressive action of the natural light against the background of exhaustion of compensatorily adjusted mechanism in patients with complicated oligosperm is detrimental to nuclear structures of spermatozoa. P3.10.11 MEDICAL TREATMENT FOR NONOBSTRUCTIVE AZOOSPERMIA MAY OBVIATE THE NEED FOR SPERM TESTICULAR RETRIEVAL N.Abdulwahid, Reproductive Endocrinologist, Amman, Jordan Objectives: Because multiple Testicular sperm extraction ( TESE) procedures can cause transient and permanent alterations in testicular function (Ostad et al, Urology 1998; 52:692). Therefore medical treatment for male infertility may play a role in Nonobstructive Azoospermia ( NOA) so as to avoid surgical sperm retrieval. Study Methods: This is a prospective study of 10 men with NOA treated with medical treatment for 3-6 months. Men investigated at time of presentation. And divided into 2 groups. Group 1 is 6 patients with testicular biopsy of Germ Cell Hypoplasia. This problem is due to Varicocel in 2 patients and idiopathic in 4 patients Age (mean+_sd) 37+7.8 Infertility duration 9.3+_7. Group 2 is 4 patients with testicular biopsy of Maturation Arrest .Age 41+_5.9.Infertility duration 14.3 +_5.6. All 10 men were treated by four medications (Tamoxifen 20 mg, Polljuven, Juvelon, Trental) for 3-6 months. Assisted reproductive techniques offered to all but refuse for financial reasons except ICSI done for 2 cases and IUI done for other 2 cases of group 1 only. Results: Group 1 Sperm retrieval from semen samples achieved in 5 out of 6 patients after 3 months medical treatments in all cases .One ICSI procedure was done using semen sample with successful fertilization but no pregnancy. The only azoospermic man ICSI was done with TESE for whom fertilization achieved but no pregnancy. As far as the other four patients whom refuse ICSI for financial reasons extended medical treatment up to 6 months resulted in one pregnancy with IUI and another spontaneous pregnancy with successful delivery in both those cases.Group 2 All those patients remain azoospermic at the end of 6 months medical treatments. Conclusion: Medical treatments have a role in NOA patients with Germ Cell Hypoplasia prior contemplating ICSI procedures.

P3.10.08 EVALUATION OF THE CERVICAL FACTOR IN INFERTILITY A.L.Astorri, G.Pompa, E. Terranera , A. Mancini*, A.Cappella Center for Study and Research on Natural Fertility Regulation * Institute of Endocrinology, Catholic University of the Sacred Heart, Rome. Objectives: A cervical factor of infertility has been widely proved. In fact, it could be recognizable in 15% of couples. However, an accurate evaluation of this factor of infertility is still at a preliminary level and so its real incidence is likely to be underestimated. The present study analyzes the cervical factor in a diagnostic-therapeutic protocol for infertility. Study Methods: The study of cervical factor has been carried out through cytologic-colposcopic examination and cervical cultures. For the evaluation of cervical function we have referred to the Billings Ovulation Method. It is one of the most recent and effective methods to evaluate cervical secretion through the woman's self observation. Results :Out of 187 couples in the protocol, 94 women (50,27%) showed a vaginal-cervical pathology (VCP). The highest concentration of VCP cases was found in the group of infertility due to couples factors (66 cases, equals to 70,21%). The study especially analyzes 45 patients resulted to show VCP as the only female factor, isolated (15 cases) or associated with male factor (30 cases). Conclusions: From our study results that the evaluation of the cervical factor of fertility comes out to be an important step in the screening of infertility and it may also be a contribution to the need for an accurate reproductive health care.

P3.10.09 INDUCTION OF OVULATION IN INFERTILE WOMEN BY INTRAVENOUS ADMINISTRATION OF PERGANDLI Z. Dubossarska, Dept. OB/GYN, Dnipropetrovsk State Medical Academy, Dnipropetrovsk, Ukraine. 20 women with infertility of endocrime genesis and 10 practically healthy women with retained reproductive function underwent complex investigation. Diagnostic program included not only tradidtional clinical but also hormonic investigation (the level of honadosteroic, steroid and corticosteroid hormones, cyclic nucleotides). The condition of prostaglandine system and complex investigatgtion of a sexual partner. 20 women were given pergandli for induction of ovulation according to the following scheme: pergandli3 ampules daily for 3 days, starting with the first day of menstrual cycle. Then 2 ampules a day during the following 9 days. We used US-monitoring, kept under control the cervical number and the content of estradioli in peripheral blood by the method of radiommune analysis. In addition we injected intramuscularly 10 000-30 000 units of prophasi once a day starting with 12th day of menstrual cycle, then added 10 000 units of prophasi injections on the 5th and 7th days after the increase of basal temperature. Special attention was paid to the androgens and their metabolits in the

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P3.10.12 OVULATION STIMULATION AND INTRAUTERINE INSEMINATION IN THE TREATMENT OF INFERTILITY M. Vasiljevic, N. Antic, M. Prorocic, E. Garalejic, S. Dragojevic, B.Arsic, O. Dzatic. Clinic of Gynaecology and Obstetrics "Narodni Front" University of Belgrade, Yugoslavia The aim of this study was to analyze the success rate of ovulation stimulation and intrauterine insemination in infertile patients whose ovulation was stimulated by three different protocols, and to determine the most successful of the protocols applied. Materials and methods: The study included 49 infertile patients of average age 32.3 years (25-34 years), with a mean infertility duration of 4.7 years (1-8 years). Infertility causes were: cervical factor, anovulation, male factor and unknown causes. For ovulation stimulation the following protocols were applied: In the first group of patients (n=18), follicle-genesis was stimulated with human menopausal gonadotrophins (Pergonal), the second group of 16 patients was stimulated by pure urinary follicle stimulating hormone (Metrodin); and the third group consisted of 15 patients who were stimulated with recombinant follicle stimulating hormone (Puregon).The cycle stimulation started on the fifth day of the cycle. Pergonal was administered in the dose of 150 IU, every other day. Metrodin was administered daily with 1 ampule of 75 IU, and Puregon with 1 ampule of 50 IU daily. The follow up of the follicle growth and development was done by vaginal ultrasonography, as well as determining the oestradiol concentration and lutenizing hormone in serum. Intrauterine insemination was done 24 hours after the administration of Pregnyl, and the sperm samples were prepared according to the swim up method. Results: In 49 patients 68 cycles were stimulated. Eighteen patients achieved pregnancy which means that the percentage rate per patient was 36.7%, and per stimulated cycle 26.7%. The pregnancy rate per patient in the different patient groups was: in the first group 22.2% (4 out of 18); 43.7% (7 out of 16) in the second group; and 46.6% (7 out of 15) in the third group. The pregnancy rate per stimulated cycle in the three groups was: 15.3% (4 out of 26) in the first group; 31.8% (7 out of 22) in the second group; and 35% (7 out of 20) in the third group of patients. Conclusion: The best results are achieved when cycles are stimulated with Metrodin and Puregon.

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Duration of procedure (15 20 on course) was 5 20 minutes. According to indications, the course was repeated up to five times with interval 1 2 months in period between menstruations. The effect of treatment was assessed by the kymopertubation and the histerosalpingography data (direction and percent of changes coincided). Results: Results of the employment of LLP are a restoration of the puterine tubes patency on 42.1 74.6% that is higher rate than without use of LLP. The effect of the treatment of primary infertility less than of secondary one (57.4 61.8% and 63.5 74.6% accordingly) and in bilateral pathology than in unilateral (63.1 - 71.0% and 61.1 67.9% accordingly). Single results of treatment were assessed in 1 3 years by questionnaire data of 216 women. Pregnancy had advanced in 98 patients (45.4%); 5 (2.3%) of them had miscarriages and 7 (3.2%) had extrauterine pregnancy; 203 women (39.4%) had labors with successful outcomes. Conclusions: So, LLP is effective method of the uterine tubes patency restoration. P3.10.15 SERUM CONCENTRATIONS OF INHIBIN AND ACTIVIN A DURING OVARIAN HYPERSTIMULATION WITH FSH G. Bartzke (1), F.W. Casper (2), R.J. Seufert (2), K. Pollow (2) (1) Dept. OB/GYN, Urei Surankenhaus, Rottweil, Germany. (2) Dept. Endocrinology, University of Mainz, Mainz, Germany. Objectives: Recently, it has been reported an increase in total immunoreactive inhibin levels after the administration of exogenous gonadotropins for ovulation induction. Study Methods: We have investigated serial changes in plasma concentrations of inhibin A, inhibin B, pro alpha C and activin A in 51 women undergoing stimulation with recombinant FSH bevor artificial insemination. Blood samples were collected at the early follicular phase, during stimulation with FSH, at ovulatory triggering and during the luteal phase of the menstrual cycle. Results: During stimulation and a day after ovulatory trigger, levels of both inhibins and pro alpha C are markedly increases, whereas activin A was largely unaltered. Statistical analysis demonstrated a close correlation between the number as well as the sonographic diameter of follicles and the inhibin response. Women with no Graaf-follicle showed unchanged serum levels of inhibins. Conclusions: The positive correlation observed between inhibin levels and the number of follicles larger than 15 mm suggest that inhibin may be useful as a marker of dominant follicle development in artificial insemination. Furthermore these data indicate that ovarian production of inhibins in women is gonadotropin-dependent. P3.10.16 THE COMPARISON OF NITRIC OXIDE AND MOTION CHARACTERISTICS OF TWO PREPARATION METHODS IN HUMAN SPERM: 3-LAYER PERCOLL AND PURESPERM METHOD G. J. Wu, D. C. Ding, Division of Reproductive Endocrinology, Dept. OB/GYN, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan, R.O.C. Objectives: To compare two different spermatozoa methods: three layers Percoll and Puresperm method with respect to recovery, motion characteristics and Nitric Oxide (NO) production of the supernatant after centrifugation. Study methods: Each of 39 semen specimens was divided and each aliquot was prepared using two methods mentioned above. The recovery rate and motion parameters were measured for each semen specimens (n=39) prepared with the two methods. The NO was measured with use the chemiluminscence method after centrifugation. Results: Recovery rate was higher in Puresperm method (45.428.7%). The other motion characteristics were improved than fresh semen samples. Hyperactivation of the sperm was improved in puresperm group comparing to the fresh sperm (Percoll:24.716.9%, Puresperm: 20.510.5% vs fresh: 9.29.2%). NO produced in the Puresperm was significantly lower than in the Percoll (0.240.3 uM vs 0.540.91uM)

P3.10.13 PRONE POSITION OF THE PATIENT AFTER LOCAL REPAIR OF V.V.F. S.A. Talukder, Dept. OB/GYN, Sher-E-Bangla Medical College, Barisal, Bangladesh. Objectives: The aim of the study was to investigate the effect of prone position on local repair of V.V.F. Study Methods: 10 V.V.F. patients were operated by local repair under spinal anesthesia in a district level hospital where anesthetist was not available. So anesthesia was given by the author himself. Later on an untrained nurse maintained the anesthesia. The assistants were also the untrained nurses in absence of trained doctors. Results: Out of 10 V.V.F. patients 9 cured completely. One patient was not cured due to blockage of the catheter. She was cured after three months in second attempt. Conclusion: Prone position after local repair of V.V.F. has a good effect on the success of the operation.

P3.10.14 RESTORATION OF THE UTERINE TUBES PATENCY BY EMPLOYMENT OF LOCAL LOWERED PRESSURE D.Y. Mirovich, I.G. Gerasimov, Research Institute of Family Medical Problems of Donetsk Government Medical University, Donetsk, Ukraine. Objectives: The local lowered pressure (LLP) was applied for restoration of the uterine tubes patency in women with different types of the tubeperitoneal infertility. Study Methods: The influence of LLP was exerted on small pelvis region and abdominal organs, limited from above by low brims of ribs and from below by upper third of hips. The pressure was applied on 75 mmHg lower than atmosphere one, in permanent and broken regime.

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Conclusions: Our data suggest that Puresperm method had a better recovery rate, but other motion characteristics are not to demonstrate any significant difference. The NO produced lower in the Puresperm preparation method may suggest the good quality of human sperm achieved is due to the decreasing NO production. P3.10.17 THE EFFECT OF ASPIRIN AND PREDNISOLONE ON INCREASING THE CHANCE OF IMPLANTATION IN WOMEN WITH AT LEAST TO FAILED IMPLANTATION CYCLES A.Aflatounian1,2,3, MA. Karimzaeh Meybodi2,3, SM Kalantar1,3, MH Amir Arjmand1,3 and M. Solimani1,3 1 Research & Clinical Centre for Infertility, 2Department of Obs. & Gyn. Medical Sciences University, Yazd-Iran. 3Madar Hospital for Women, Reproductive and Genetics Research Unit, Mahdieh Square, 89167, Yazd-Iran Objective: Although the fertilization rate in ART cycles are high, however, implantation rate is remained low. The aim of the study was to assess the effect of prescription of Asiprin / Prednisolone (ASP/PRE) on the time of embryo transfer on implantation rate. Prednisolone Study Methods: 38 women who had underwent at least previous two embryo transfer cycles without chemical pregnancy were enrolled in this study. The ART treatment cycles were done for these couples according to the cause of their infertility. From the first day of treatment cycles women undertake Aspirin (75mg/daily) and Prednisolone (10mg/daily) till the termination. Fertilization rate (FR), number of embryo transferred (ET) and pregnancy rate (PR) were assessed. Significant difference between cycles with (+) and without (-) (ASP/PRE) was analyzed by ANOVA using SPSS. Results: In four cycles embryo transfer was not performed. There was not significant difference between FR% in positive and negative cycles, 60.9% 7.9 and 75.5% 6.3 (mean SE), respectively (p>0.05). Also, fertilization rate was not significantly different between (+ASP/PRE) cycles (n=85) and (-ASP/PRE) cycles, 68.1 8.5 and 64.25 7.1, respectively (p>0.05). In 8 out of 34 (23.5%) cycles pregnancy was confirmed by positive b HCG and subsequently by sonography, one EP, 3 healthy babies was born in 3 cycles and 4 ongoing pregnancy. Conclusions: Our result showed that in the case of cycle's treatment with Aspirin and Pyrandazol increased the chance of implantation in patients with implantation failure. It would suggest to use Aspirin and Pyrandazol in patients with low or failure implantation history during ART treatment cycles.

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rate/systolic BP); the higher the meaning - the worse QOL (r=0,81). on 14 postoperative days - of preoperative preparation provided, including infusion, on indications - hemotransfusion and intraoperative blood reinfusion. In full-volume and non sufficient pre-op preparation: Emotional condition (4,30,2 and 6,50,1 points) and Physical Functioning (5,51,2 and 8,60,1 points), p<0,05. Conclusion: early hospitalization, fast diagnostic of EP, the rational preoperative preparation, the wide use of laparoscopy, that leads to surgery and hospital stay shortening - are the factors, that have a significant impact on patients QOL in early postoperative period.

P3.10.19 THE ROLE OF LAPAROSCOPY IN THE THERAPY OF INFERTILITY Z. Sleberenyi, A. Rucz, Dept. OB/GYN, Rethy Pal Hospital, Bekeslaba, Hungary. Objective: The problem of relatively expensive IVF methods call attention to the other procedures in the treatment of infertility. The laparoscope is an excellent instrument of these procedures and it is useful in smaller hospitals as well. Study Methods: The treatment of hydrosalpynx by laparoscopy is very simple: with monopolar hook-electrode the tuba is opened in Y form. After this procedure with the back of hook with little power coagulate the side of injury, turn it out. Then we have to see the endothel of tuba: if it is thin, discolored, it is better to perform salpingectomy and send the patient to the IVF center. The solution of PCO-sy is the simplest in the laparoscopic surgery of ovars.30-40 follicals are coagulated in each side with monopolar needl-electrode. Results: Laparoscopic myomenucleation is a difficult procedure. A more difficult thing is the right indication of operation. It is very important to inform exact the patient. We cannot leave out of consideration, that we often find big myoms in unfavorable places in pregnancies without complaints. At the same time during myomenucleation, we can get such bleeding that results hysterectomy. In the myomenucleation following pregnancy could happen silent uterus rupture as well. The patient must know it. First of all, by the operation, the environment of myom is infiltrated with POR 8 solution, then the uterus is opened with monopolar hook-electrode. It is very important to find the right layer quickly, then the blunt preparation. When we are in equator of myom, the patient must get iv.oxytocin After removing myom, we close the injury of uterus with forthrunning PDS stitch in the end PDS clips. Conclusion: The best instrument for the solution of endometriosis is the laser. Without laser, we can use monopolar needle-electrode as well. We can vaprise and preparate with it too. By retrocervical endometriosis, the surgeons right hand held the needle-electrode and with left hand he helps himself in the vagina. It is not comfortable, but very good method for preparation. The renaissance of tuba-recanalization is thanks to laparoscop.

P3.10.18 THE IMPACT OF NUMBER OF FACTORS ON QUALITY-OF-LIFE IN EARLY POSTOPERATIVE PERIOD AFTER SURGICAL TREATMENT OF ECTOPIC PREGNANCY. E.Kira, V.Bezhenar, I.Berlev, N.Ruhliada, Russian Medical Military Academy, Lesnoy st. 4-74, St.Petersburg, Russia, 194044. Objective: to estimate the influence of different factors on health-related Quality-of-Life in patients in early postoperative period after surgical treatment of ectopic pregnancy. Material: we evaluated the QOL with the help of our original questionnaire for QOL estimation after tubal surgery in 3 and 14 days after surgery. For all patients (n=92) we fulfilled the cross-match correlation of clinical data and QOL parameters, estimated the correlation (r) expression. The correlation was supposed to be statistically significant in r>0,7. Results: The correlation analysis performed has revealed the existence of following QOL dependencies: - of time to hospitalization; the longer that period, the worse QOL parameters in 3 days postoperation (r=0,846). The worst meaning was found in women, hospitalized later 72 hours since the first symptoms had appeared (Integral QOL Index =138,311,2 points Integral QOL Index = hospitalized later 72 hours since the first simptoms had appeared ()s) - of hospital preoperative stay; the longer the time before operation, the worse QOL in 3 and 14 days after it (r=0,712). - of laparotomy surgery length; the longer the operation - the worse the QOL in 3 and 14 days postoperation (r=0,711). For laparoscopic treatment there was found no significant correlation (r=0,073). - of hemodynamics, estimated with Allgevers shock-index (pulse

P3.10.20 THE ROLE OF TESTICULAR BIOPSIES IN SEVERE MALE FACTOR INFERTITY Gy. Bgyi,1, T. Kirsi2 1 Kenzy Hospital & Polyclinic, Department of Urology and 2 Department of Obstetrics and Gynecology, Infertility Unit, University Medical School of Debrecen, Hungary Objective: To assess the value of testicular biopsy during infertility workup. Materials and Methotds: We have evaluated 377 infertile men in our Department between January 1, 1994 and December 31, 1999. Out of these subjects 98 patients required testicular biopsy. The indications for these procedures are outlined in the WHO standard protokoll Results: In this study group 50 men (51%) were eligible for micromanipulation while 48 patients (49%) received medical treatment to improve the spermcount. Conclusion: Testicular biopsies are helpful to select patients with severe male factor infertility for appropriate therapy.

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P3.11 MATERNAL MORBIDITY AND MORTALITY

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P3.11.03 ACCURACY OF THE BLOOD LOSS ESTIMATION IN THE THIRD STAGE OF LABOR W. Prasertcharoensuk, U. Swadpanich, P. Lumbiganon, Dept. OB/GYN, Faculty of Medicine, Khon Kaen University, Khone Kaen, Thailand. Objectives: The aims of the study were to assess the incidence of postpartum hemorrhage in vaginal delivery and to assess the diagnostic performance of visual estimation in detecting postpartum hemorrhage. Study Methods: 228 [regnant women who had vaginal delivery at Srinagarind Hospital from Dec. 1, 1996 to Mar. 1, 1997. Blood loss through vagina following vaginal delivery was visually estimated and also directly measured. Postpartum hemorrhage was defined as blood loss of at least 500 ml. Results: The mean visually estimated blood loss was 263.81 ml (SD=152.06) whilst the mean measured blood loss was 362.89 ml (SD=298.85). The incidence of postpartum hemorrhage by visual estimation and direct measurement were 5.70% and 27.63% respectively. Visual estimation resulted in a 88.88% underestimation of PPH. The sensitivity, specificity and accuracy of visually estimated blood loss in detecting postpartum hemorrhage were 15.87%, 98.18% and 75.43% respectively. Conclusions: Visual estimation primary is very insensitive in detecting postpartum hemorrhage. Obstetricians should be aware of this underestimation and use other signs and symptoms in the management of third stage labor.

P3.11.01 A STEP FORWARD ON THE PATHWAY TO MATERNAL AND PERINATAL SURVIVAL: GUATEMALAS MOTHERCARE PROJECT (1994-98) E. Bocaletti, Institute of Tropical Medicine, VA, United States Objectives: Guatemala has a Maternal Mortality Ratio of 248 per 100,000 live births, the third highest in the Western Hemisphere. The majority of births take place at home with traditional birth attendants. The MotherCare Project aimed to bring the communities and health facilities together to save the lives of women and newborns. Methods: Recognition of life-threatening complications and their danger signs and where to go for help were emphasized during TBA training, broadcast by radio to communities, formed the basis for counseling during prenatal care, and were a major focus in the discussions with womens groups. Tutorial training followed by monthly supervisory visits, including sensitization to local birthing traditions strengthened their counseling and clinical skills. Outcome Measures & Results: Rural departments in project areas have witnessed increases in use rates of 50 to 77%. Met Need has doubled in project area hospitals (meaning a greater proportion of women having complications seek care). Equity has improved through increased use of EOC services by women. The confidence and skills of providers to perform high quality maternal and newborn care have significantly improved, and continues more than 2 years after completion of the training course. The trained providers and facility directors report an improved attitude toward providing care and working in a team, as well as providers enhanced ability to recognize problems early and to intervene skillfully. Conclusions: Nearly a third of the country has been reached by this community-based approach to reach women and newborns with essential obstetric services. The next steps are to sustain current activities and expand them across of the country.

P3.11.04 BURDEN OF ILLNESS-CHRONIC SEVERE ANAEMIA IN OBSTETRIC PATIENTS IN RURAL NORTH INDIA A.H. Khosla, K. Sangwan. Dept. OB/GYN. PGIMS, Rohtak, Haryana, India. Objectives: To collect relevant information about chronic severe anaemia (CSA) in the obstetric population of rural North India (Haryana) with a view to devise strategies which wil reduce maternal morbidity and mortality by focussing on the high risk population. Study Methods: A prospective study (Jan. to Dec. 1998) in which all pregnant patients with haemoglobin 6 grams/dl excluding those with acute blood loss i.e., abortions, antepartum and postpartum haemorrhage admitted to the department of obstetrics an gynaecology, PGIMS, Rohtak (Haryana) India were interviewed. Results: There were 5124 deliveries at PGIMS, Rohtak in the study period. There were 386 patients (7.53%) of CSA admitted who received a total of 1083 units of blood (mean 2.80 per patient). There were 2 maternal deaths due to CSA. A total of 246 of the 386 women could be interviewed in detail. The demographic features of these women (anaemic group) were compared with 100 pregnant women with haemoglobin >10 grams/dl (non anaemic group). In the amaemic group 81.7% were illiterate, 62.1% had no antenatal check up, 78.8% had no access to safe drinking water, 90.6% had no toilet facilities and used open fields for defecation; 63.0% reported having diarrhoea and abdominal pain off and on during pregnancy and 20.73% gave history passage of worms in the stools. 82% had no regular income and had a diet poor in protein, calories iron and calcium. All were vegetarians. The figures for the non anaemic group were illiterate 34%, antenatal check up in 76%, no toilet facilities in 55%, no safe drinking water in 38%, diarrhoea 6%, history of passage of worms in stool 2%. Conclusions: Pregnant women with no regular source of income, illiterate, without any public health facilities should be the beneficiaries of any programs for women and child health. These health interventions would be more cost effective comparing the cost of hospitalization, blood transfusions and DALYs (Disability Adjusted Life Years).

P3.11.02 A TWO YEAR REVIEW OF THE PATTERN OF MATERNAL MORTALITY AMONG MIGRANTS IN MALAYSIA Z. Shamsuddin, Dept. OB/GYN, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia. Objectives: The aims of the study were to investigate the pattern of maternal deaths among migrant mothers and to review its impact on the national maternal mortality statistics in Malaysia. Study Methods: This study was part of a detailed retrospective analysis of all maternal deaths occurring in Malaysia in 1995 and 1996 reported to the National Confidential Enquiries into Maternal Deaths. Deaths among migrants were identified and analyzed as a separate cohort. Results: In 1995 there were 251 maternal deaths with a MMR of 46.91/100,000 live births of which, 79 (15.5%) were migrant mothers. For 1996, 220 deaths were reported, with a MMR of 40.7/100,000, of which 40 (18%) were also migrants. Most of these deaths were Indonesians and Philippino migrants. Deaths were mainly from postpartum hemorrhage, obstetric pulmonary embolism and complications of pregnancy induced hypertension. Increased risks were associated with age 25-29, parity 1-5, poor uptake of contraceptives, failure to obtain antenatal care and late transfer to hospital. Conclusion: While a migrant status-specific MMR was difficult to obtain due to the lack of known denominators. Almost a fifth of the maternal deaths in Malaysia were migrants. Migrant mothers were certainly at risk of dying from PPH, OPE and PIH. Socio-economic factors clearly influenced maternal mortality, overriding both geographical and cultural differences. Illegal entry and lack of valid travel documents prevented migrant mothers from seeking antenatal care for fear of deportation despite the health care authorities relative indifference to citizenship status.

P3.11.05 CONSERVATIVE MANAGEMENT OF SPONTANEOUS ABORTION P. Busacchi, T.Perri, P.Pocognoli, C.Oliverio, C.Flamigni, University of Bologna, Via Massarenti, 9, Bologna, BO, Italy, 40138. Objectives: The aim of the study was to evaluate the benefit of a conservative therapy in spontaneous abortion. Study methods: We recruited 27 pregnancy patients admitted to our hospital with the diagnosis of spontaneous abortion. Their mean age was

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31.7 years and the mean period of amenorrhea at the time of abortion was 6.9 weeks. Each patient underwent an ultrasound examination (US) to asses that the endometrial thickness was < 12mm; blood samples were used to evaluate the hematic parameters (Hb-Ht) and the decrease of beta-hCG. The mean endometrial thickness was 5.3 mm; the mean betahCG value was 425.9 mU/ml. Each patient received, at discharge, a therapy consisting in uterotonic and antibiotic drugs, respectively for 5 and 3 days. The follow-up consisted in a US control and beta-hCG dosage a week after the discharge, beta-hCG and Hb-Ht dosage after two weeks; and US and b-hCG dosage after 4 weeks. Results: The mean value of beta-hCG at the third control has been remarkably reduced to 9.6 mU/ml. The mean value of endometrial thickness was 8 mm. In all cases, except one, the vaginal bleeding disappered during the therapy with no complications. Conclusions: Conservative therapy seems to be a good approach for patients with spontaneous abortion if opportunely selected.

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prolapse increased with parity up to 4 deliveries. Other types of birthtrauma found were functional damage of the anal sphincter muscle (3%) and vesico-vaginal fistula (0.1%). Symptoms of urinary incontinence were reported by 82 (7%) women. Conclusions: This large community-based study confirms a high prevalence of birth-trauma consistent with previous smaller studies in developing countries. The rate of urinary incontinence was lower than expected with this degree of uterovaginal prolapse and birth-trauma. Few women with prolapse complained of problems indicating that selfreport is a poor measure of the true prevalence of uterovaginal prolapse.

P3.11.08 GRAVID UTERINE RUPTURE - A MALAYSIAN EXPERIENCE IN KLANG K.L.Wong, W.K.Tan, K.Y.Ng. Tengku Ampuan Rahimah Hospital, Jalan Langat, Klang, Selangor D.E., Malaysia, 41200. Objectives: To determine the incidence, the etiological factors and fetomaternal outcomes of gravid uterine rupture. Study Methods: A 5 years (1995-1999) retrospective study of gravid uterine rupture to analyze the predisposing factors, clinical presentation, management, maternal and fetal complications. Results: Of the 77046 deliveries, there were 21 cases of uterine rupture, an incidence of 1:3669 deliveries. Majority of the cases identified were Malays (62%). However, the highest incidence was among the 'immigrants' from neighboring countries (1:2393 deliveries). Other predisposing factors include maternal age more than 35 years, grandmultiparity and previous uterine surgery. The two commonest clinical features were sudden fetal death and vaginal bleeding (both 52%). 14% of the cases were silent. Maternal morbidity was high (84%). Majority had DIVC (81%) and hypovolemic shock (67%). 71% had hysterectomy performed and all needed blood transfusion. 76% needed additional transfusion of DIVC regime. There was 1 maternal death and 8 perinatal deaths in this series. Conclusions: The incidence of uterine rupture has improved as compared to the incidence reported in 1991 in University Malaya Hospital. Factors contributing to this achievement include: (i) faithful adherence to the partogram (WHO, 1991) and early recourse to Caesarean section in suspected fetomaternal disproportion, (ii) reduction in the use of ECV, (iii) the improved health care facilities. However, injudicious use of oxytocics in cases with prior uterine surgery, poor contraception leading to grandmultipartiy and increased maternal age are still the crux of the problem. Majority of the cases survived despite the devastating complications. P3.11.09 GYNECOLOGICAL PROBLEMS AMONG HONG KONG CHINESE WOMEN IN THE FIRST THREE MONTHS FOLLOWING DELIVERY T.N. Leung (1), D.T.S. Lee (2), S.K. Yip (1), T.K. H. Chung (1), (1) Dept. OB/GYN and (2) Dept. of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China Objectives: To identify the common gynecological problems encountered by Hong Kong Chinese women in the first three months following delivery and test if their magnitude is related to their psychological well-being. Methods: 320 Chinese women who gave birth in the Prince of Wales Hospital, Hong Kong, were followed up at 3 months after delivery. Interviews were conducted using structured questionnaires. Gynecological problems, choice of contraception and feeding practice were recorded. The levels of general psychological well-being were also assessed using GHQ. Results: The mean age of the study group was 29.6 years. It took an average of 29.6 days for the lochia to disappear in the postpartum period but 13.8% of women had persistent lochia at 6 weeks postpartum. 83.4% of women had return of menstruation at follow-up and the mean time for the menstruation to return was 8.4 weeks. 22.8% experienced persistently increased menstrual flow while 10.5% of women complained of more pain during menstruation. The majority (67.8%) experienced some form of perineal pain but only 2.5% persisted at 3 months. 90.6% had resumed coitus at follow-up and the median time of resuming coitus was 49 days. Condom contraception was the most popular means of contraception (66.6%). Immediately after delivery,

P3.11.06 DESTINATION SAFE MOTHERHOOD INDIAN PERSPECTIVE S. Patwardhan, Dept. OB/GYN, Sai Seva, Pune, India. Objective: Increase awareness about the dangers a woman faces as she takes on the challenge of motherhood and how to prevent them. Study Methods: The message rides across the country as a series of bicycle rallies and sessions on Safe Motherhood. Symbol of Trust: Pedaling achieves instant rapport with the rural population. Visibility has played a major role in making Safe Motherhood a peoples movement. It is a live message for the urban population in eradicating pollution and enhancing fitness. Safe Motherhood and Cycling: Safe Motherhood primarily deals with Maternal Mortality. On a broader canvass, protecting the Mother Earth from pollution is also our responsibility. Hence pedaling. Simplicity: The concept of promoting Safe Motherhood with the use of a bicycle is simplicity personified. Savings: Both Safe Motherhood and Cycling result in substantial savings. The same is true for cycling. The minimal cost involved is a definite bonus. Unique features of Destination Safe Motherhood: Physical event with a social purpose, going close to the people we serve, generating goodwill, increased interaction between societies, participation by medicos form other branches and pathies and participation by motivated individuals from other walks of life are the unique features of this movement. It is the first time that lay people have taken such interest in understanding what Safe motherhood is. Many groups have begun in Maharashtra (India) using pedaling for this purpose. Conclusion: Destination Safe Motherhood has been a tremendous success in making Safe Motherhood a mass movement.

P3.11.07 EPIDEMIOLOGY OF INCONTINENCE, BIRTH TRAUMA AND UTERO-VAGINAL PROLAPSE IN RURAL WOMEN IN THE GAMBIA, WEST AFRICA C. Scherf1, G. Ekpo2, L. Morison3, G. Walraven1 1 Dept. Medicine, University of Wales, Cardiff CF14 4NX, UK 2 Medical Research Council Laboratories, P.O. Box 273, Banjul, The Gambia 3 London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E7HT, UK Objectives: To explore the epidemiology of incontinence, utero-vaginal prolapse and other signs of injury related to childbirth in a highly parous community in rural Gambia. Study methods: 1,151 women underwent gynaecological examination as part of a community-based survey of women aged 15 to 54 resident in 20 villages in The Gambia (see abstract Walraven et al.). Women with genital prolapse and/or incontinence were identified and classified into anterior, posterior or uterine prolapse with three different stages of severity. Results: Utero-vaginal prolapse was present in 488 (42%) of women; cystocele 25%, enterocele 14%, urethrocele 12%, rectocele 8% and uterine prolapse 7%. 13% of all women would have warranted surgical intervention (moderate, severe or symptomatic prolapse). 14% of those with any genital prolapse reported symptoms. This increased to 37% symptomatic women among the ones warranting surgery. Risk of

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38.1% had breast-feeding, but it was reduced to 8.4% at 3 months. A fear of insufficient milk production, sore nipples and inadequate rest were the 3 most frequent complaints among breast-feeding mothers. Forty-eight (15%) had a GHQ score of 5. There was no association between the GHQ score and the frequency of any of the gynecological problems. Conclusions: A significant portion of women had increased gynecological morbidity at 3 months after delivery, which cannot be attributed to psychological factors. P3.11.10 HELLP SYNDROME AND ACUTE FATTY LIVER OF PREGNANCY P. Vigil-De Gracia, Dept. OB/GYN, Complejo Hospitalario Metropolitano de la Caja de Seguro Social, Panama, Panama. Objective: To investigate the relationship of clinical and laboratory findings between HELLP syndrome (HS) and acute fatty liver of pregnancy (AFLP). Study Methods: Ten cases with AFLP and 75 with HS managed during the past 3.5 years were studied with emphasis on presenting symptoms, laboratory findings, maternal complications and neonatal outcome. Results: The main symptoms of HS were headache (75%) and epigastric pain (51%); in patients with AFLP were general malaise (100%), nausea and/or vomiting (70%), epigastric pain (70%) and jaundice (60%). Two maternal deaths occurred with HS (2.7%) and two with AFLP (20%). The perinatal mortality was 17.5% for HS and 18.2% for AFLP. DIFFERENTIATION OF HS AND AFTP
HS (76) Maternal age (yr) Gestational age (wk) Parity Platelets (x1000/mm3) LDH (IU/L) AST (IU/L) ALT (IU/L) Glucose (mg/dl) Total bilirubin (mg/dl) WBC (x 1000) Fibrinogen (mg/dl) Cholesterol (mg/dl) Triglyceride (mg/dl) Renal Failure (#) DIC (#) Ascites (#) Stay (day) Blood transfusions (#) 29.076.18 34.04.1 2.251.5 62.227.15 1398930 281311 202180 7617 1.360.7 175.3 482199 21073 247100 15 5 5 7.32.4 26 AFLP (10) 29.004.67 35.83.4 1.40.7 76.350.48 993407 444358 392247 3719 118.8 27.47.75 136120 7245 10154 9 7 3 13.15.0 8 SIGNIFICANCE NS NS P<0.006 NS P<0.02 NS P<0.04 P<0.00001 P<0.007 P<0.002 P<0.00001 P<0.00001 P<0.00001 P<0.0002 P<0.00001 P<0.048 P<0.005 P<0.01

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obstetric cause, six of these from haemorrhage. The indirect obstetric deaths were most commonly classified as caused by anaemia (4/9). Substandard obstetric referral health care, not recognising the severity of the problem at the community level, delay in starting the decisionmaking process to seek health care, lack of transport and sub-standard primary health care were all identified more than once as probable or possible contributing factors. Conclusions: This maternal mortality estimate is substantially lower than those generated in the same area in the 1980s (1,005 to 2,362 per 100,000 live births). In the early 1980s medical facilities and health professionals in the study area were limited, as was transportation and communication. This has improved greatly since then, and it is therefore very likely that improved availability of and access to essential obstetric care has played a major role in this reduction.

P3.11.12 LONGITUDINAL CHANGES IN VISCERAL FAT DEPOSITION DURING PREGNANCY T. Kinoshita, S. Fukaya, T. Saitou, K. Ootaka, M. Itou, Dept. OB/GYN, Toho University, Sakura Hospital, Japan. Objectives: To investigate whether pregnancy affects body-fat deposition of maternal body. Study Methods: Fifty women were enrolled. The thickness of the preperitoneal fat layer (P) and subcutaneous fat layer (S) were measured by ultrasonography during pregnancy. The P ratio was calculated as indicator of visceral fat deposition. Results :The correlation coefficient between PS ratio and gestational week was r=0.338 (g=0.341+0.009X, 95% CI 0.007, 0.011 p<0.0001). The PS ratio of 0.650.25 of the third trimester was significantly higher than those of the first and second (0.490.18, 0.520.20 respectively p<0.001). The PS ratio of postpartum was elevated (0.720.20) but did not reach statistical significance. The P thickness was correlated with the gestational week (r=0.159, 95% CI 0.08, 0.236, p<0.0001). No significant correlation between PS ratio and BMI was observed across the study period. The PS ratio in lean and obese women was observed in third trimester. There was no difference between lean and obese women. Conclusions: The visceral fat deposition increases during pregnancy. Pregnancy affects change of body-fat distribution of maternal body.

P3.11.13 MATERNAL DEATHS ASSOCIATED WITH CESAREAN SECTION IN ENUGU NIGERIA B. Ozumba, S. Anya, Dept. OB/GYN, University of Nigeria Teaching Hospital, Enugu, Nigeria Objectives: In view of the high maternal mortality ratios in Nigeria, we undertook to study factors associated with cesarean section fatalities at the University teaching hospital. Study Methods: Clinical records of twenty six maternal deaths following one thousand six hundred and eighty four cesarean sections over a six year period were studied. Maternal age, parity, indication for surgery, rank of surgeon and anesthetist, cause of death and perinatal outcome were noted. Epi info version 6 statistical package was used for analysis. Results: Cesarean section rate was 25.6% and the cesarean section fatality rate was 15.4 per 1000 operations. The mean age of the fatalities was 29.75.9 years and the mean parity was 2.32.4. 84.6% of deaths were associated with emergency cesarean section. Hypertensive disorders in pregnancy, prolonged obstructed labor, previous cesarean section and antepartum hemorrhage were associated with 96% of maternal deaths. Residents performed 96% of these operations. Perinatal mortality was very high (19%). Conclusions: Measures to reduce this unacceptably high maternal mortality rate include wider usage of improved antenatal care facilities. Greater consultant involvement in peri and intra-operative management of emergencies is recommended.

Conclusion: Our results suggest that AFLP have clinical and laboratory findings significantly different from HS. Thus, the diagnosis of AFLP and HS rests primarily on history, physical examination and laboratory data.

P3.11.11 IMPROVEMENT IN MATERNAL MORTALITY IN RURAL GAMBIA G.Walraven1, M. Telfer2, J. Rowley1, C. Ronsmans3 (1) Medical Research Council Laboratories, P.O. Box 273, Banjul, The Gambia (2) Divisional Health Team North Bank East, State Department for Health, Banjul, The Gambia (3) London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E7HT, UK Objectives: To estimate maternal mortality, its causes and contributing factors in a demographic surveillance area in rural Gambia Study methods: Maternal mortality is estimated from a reproductive age mortality survey of all deaths in women aged 15-49 between January 1993 and December 1998. Results: 18 maternal deaths were identified by verbal autopsy from the 74 deaths in women aged 15-49. Over the same period there were 4,245 live births which corresponds to a maternal mortality ratio of 424 per 100,000 live births. Nine of the deaths were attributed to a direct

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P3.11.14 MATERNAL MORTALITY AN AUDIT A.Boruah Madhab, S. Mahanta, Dept. OB/GYN, Pragati Hospital and Research Center, Sibsagar, India. Objectives: To determine the MMR and evaluate the reasons of mortality. Study Methods: Seven retrospective observational study. Setting: Records of four hospitals (2 government, 2 private) in the Sibsagar district of Assam, India. Methodology: Retrospective analysis of the hospital records to locate the total no. of live births, maternal deaths from November, 1992 to October 1999, and also to review the cause of death. Results: 86 maternal deaths were recorded during the observational study. Corresponding live births observed were 17 893 and the resultant maternal mortality ratio was 480. Post partum hemorrhage (36%) was the major killer in our study followed closely by unsafe abortion (30%). 94.18% (81/86) of these women were of lower socio-economic group and 43% (37/86) had no antenatal care what so ever. The delay in seeking care was evident from the records in all but seven women. The timing of deaths were 3 antepartum , 10 intrapartum and 47 postpartum. Emergency obstetric care was available at al the settings of the study. Conclusions: Maternal mortality is still rampant in this part of the globe. Poor socio-economic status is the single most important determinant. Status of the women must be improved upon if we are to achieve the goals of ICPD, 1994, Cairo Declaration.

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P3.11.16 MATERNAL MORTALITY IN A UNIVERSITY HOSPITAL IN TURKEY: 1995-1999 E.Malatyalioglu (1), F.F.Yanok (1), A.Yanok (2), A.Kk (1), (1) Ondokuz Mayos University, Samsun, Turkey, 55139, (2) SSK Samsun Hospital, Samsun, Turkey. Objectives: To determine the maternal mortality ratio and the causes of deaths in Ondokuz Mays University Hospital within the last five-year period. Study Methods: Direct and indirect obstetric deaths, as well as accidental or incidental deaths which occured during pregnancy or within 42 days after the termination of pregnancy were prospectively recorded between 1.1.1995 and 31.12.1999. Maternal mortality ratio was calculated as the number of direct and indirect obstetric deaths over the number of live births within the same time period. Results: During the study period, 35 direct obstetric, 7 indirect obstetric, and 1 incidental deaths were observed. Maternal mortality ratio was calculated to be 1088.9/100000 live births (42/3857). The leading causes of death were toxemia (n=16), hemorrhage (n=10) and infection (n=5). Conclusions: Maternal mortality ratio is unacceptably high in our institution. This is probably because Ondokuz Mays University is the only reference center in the Middle Black Sea region of Turkey, and high-risk pregnancies are referred here. Normal pregnancies and deliveries are generally witheld in the maternity hospitals. However, toxemia, hemorrhage and infection are the leading causes of death which may be largely prevented with proper antenatal and intrapartum care. P3.11.17 MATERNAL MORTALITY IN CARDIAC MOSCOW MATERNITY HOUSE A.I. Beilin, O.S. Alyautdina, V.O.Bitsadze, S.G. Belitskaya, A.D. Makatsaria, Dept. OB/GYN, Moscow Medical Academy, Moscow, Russia. Objective: The aim of the study was to establish the main causes of maternal mortality (MM) in our maternity house and to follow the structure of MM. Study Methods: There were more than 85,000 deliveries from 1964 to 1999 in our hospital, 32,000 of which were in women with cardiac pathology. 98 women died during this period. Results: The causes of MM in 60s 70s were cardiovascular diseases (75%), extragenital disorders (18%) and obstetric causes (7%). During the last two decades not a single obstetric cause was responsible for lethal outcome. The structure of MM has changed during the last ten years. It can be explained by changing of the pregnants associated diseases. Studies of patients with cardiovascular diseases underlined different types of thrombophylia that leads to thromboembolic complications, which became fatal for some women. In this particular group, Antiphospholipid syndrome and genetic forms of thrombophylia (factor V Leiden mutation, AT III deficiency) are diagnosed more often. We have applied the special coagulation tests to reveal the thrombophylic state in pregnant women with cardiac pathology. The therapy with low-molecular-weight heparin (Fraxiparin) was found to be of high benefit in thromboprophylaxis of such patients. Conclusion: But still high reserves are remained for improvement of situation: prenatal diagnosis and consultation, appliance of recent concepts of family planning in real practice, pregnancy planning and others.

P3.11.15 MATERNAL MORTALITY DURING HOSPITAL ADMISSION FOR DELIVERY: A RETROSPECTIVE ANALYSIS USING A STATEWIDE POPULATION DATABASE S. Panchal (1), A.M. Arria (2), S.A. Labhsetwar (3) (1) Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. (2) Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland USA. (3) St. Charles Hospital, Oregon, Ohio, USA. Objectives: There are currently no data available examining obstetric outcomes during hospital admission for delivery utilizing a statewide population database. The specific aims of this study were to (i) determine maternal mortality ratios from January 1984 through December 1997, and (ii) identify possible risk factors associated with maternal mortality. Study Methods: Data was extracted from January 1984 through December 1997 from the Maryland Uniform Health Discharge Data Set (UHDDS). A case-control framework was used to estimate the strength of association between suspected risk factors and outcomes. Results: During the study period there were 822,591 hospitalizations for delivery. There were 135 deaths resulting in an overall maternal mortality ratio of 15.9. Patients who died were significantly more likely to be African-American (60.7% versus 33.3%; OR=5.4, 95% CI=2.8310.1, p<0.001), or to have undergone a cesarean section (60.0% versus 26.7%; OR=5.3, 95% CI=3.10-8.98, p<0.001). The five most common diagnoses associated with maternal morality were preeclampsia/eclampsia, postpartum hemorrhage/obstetric shock, pulmonary complications, cerebrovascular event, and blood clot and/or amniotic embolism. Conclusions: By identifying at-risk groups for maternal deaths, potential opportunities exist for early intervention and preventative strategies aimed at decreasing maternal mortality. References: Maresh M. Quality in obstetrics and gynecology: The example of the enquiries into maternal mortality. J Qual Clin Practice 1998; 18: 21-28. Jacob S, et al. Maternal Mortality in Utah. Obstet Gynecol 1998; 91: 187-91.

P3.11.18 MATERNAL MORTALITY IN SO PAULO, BRAZIL: INVESTIGATION OF 5 YEARS K. Boyaciyan (1), C.E.P. Vega (1), L.C. Pazero (1), P.A.F. Marcus (1), R. Mattar (2), S.A. Barbosa (1) (1) Dept. OB/GYN, City Hall, So Paulo, SP, Brazil. (2) Dept. OB/GYN, Federal University of the State, So Paulo, SP, Brazil. Objectives: The aim of this study is to establish the maternal mortality rate (MMR) for So Paulo city over a 5-year period and to know the ethiology of these deaths. Study Methods: Revision of 323306 death certificates of S. Paulo city, from 1994 to 1998. A group of 2134 women from 10 to 49 years old

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whose deaths were apparently related to MM were separated. All these cases were evaluated through their medical reports and home visits. Analysis of the results was done according to the ICD (WHO 10th Revision) and to the number of live births (LB) in the same period (1065324 LB). Results: There were 711 cases of MM distributed as direct obstetric causes (336), indirect obstetric causes (245), non-obstetric causes (77) and late MM causes (53). Exclusion of 1312 cases from the total of 2134 was necessary after evaluation of data showing that they could not be considered as MM. Investigation is not yet complete for 111 cases. It was observed under the marked notification: 70.09% (239 cases undeclared as MM/418 declared). The most frequent direct obstetric causes were: preeclampsia-eclampsia (96 cases), hemorrhage (92), abortion complications (68) and puerperal infection (54). The most frequent indirect obstetric causes were cardiac diseases (61), bronchopneumonia (39) and chronic arterial hypertension (26). Conclusions: The MMR in the study was 54.53 deaths/100000 LB, which is considered high according to WHO. The main causes of MM are evitable and a program of prevention has to be implemented in our city. P3.11.21 POST-PARTUM HEMORRHAGE AS COMPLICATION OF DELIVERIES STIMULATED WITH OXYTOCIN A. Mladenovic, M. Milenkovic, G. Hajdukovic, Z. Mladenovic, KBC Zvezdara, Rifata Burdzevica 31, Belgrade, Serbia, Yugoslavia Serbia and Montenegro, 11000.

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P3.11.19 MATERNAL MORTALITY 10 YEARS REVIEW C. Karki, Dept. OB/GYN, CT House, Lalitpur, Nepal. Maternal mortality is still 10 times higher in developing countries than in developed countries. This study was carried out in Western Regional Hospital, Pokhara, Nepal from 1987 1996. Total number of deliveries during this period were 32,190. The 1st 5 year periods (1987-1991) figures were compared with the figures of next 5 years (1992-1996). MMR was declined from 173/100,000 live birth in group 1 to 124/100,000 live birth in group 2. A higher incidence of maternal death in younger age (30%) and nulliparous (35%) women were found in group 2 cases. About 70% of deaths were due to direct obstetrical causes and 30% due to indirect causes in both the groups. The incidence of sepsis, hemorrhage and toxemia remained the same in both the groups. Incidence of ruptured uterus, septic abortion and viral hepatitis remained the same in both the groups. P3.11.20 OBSTETRIC EMERGENCIES REQUIRING CRITICAL CARE G. Radhakrishnan, N. Vaid, Rashmi, N. Agarwal, University College of Medical Sciences & GTB Hospital, Shahdara, Delhi, India, 110095. Objectives: To review the clinical profile of obstetric patients requiring ventilatory support and evaluate the benefits offered by a multidisciplinary approach of these critically ill patients at GTB Hospital, Delhi, India Materials and methods: Records of 120 obstetric patients requiring ventilatory assistance in the critical care unit (ICU) at the GTB Hospital, between Aug 1993 and Dec. 1999 were analysed for indications and outcome of ICU treatment. Results: The indications for admission to the ICU were obstetric hemorrhage (50%), complications of PIH (34%) and sepsis (16%). As high as 75% patients with hemorrhage had reported to the hospital in shock. Hypertensive patients manifested uncontrolled seizures and / or hypertension or severe PIH with other complications. ARDS was the main indication for ventilatory support in cases with sepsis. The duration of assisted ventilation ranged 24 hours -48 days. The mortality rate was 30% with nearly 80% deaths occurring within 24 hrs. of admission and with the mortality directly correlating with the patients condition at admission. The morbidity ranged from fulminant bronchopneumonia in 5 cases, consolidation in 3 cases , to varying degrees of wound sepsis in 18% cases. Conclusions: Except for cases with sepsis, as most of the obstetric complications are inevitable, it is mandatory to have a team approach in managing these cases. Mortality is very high in the initial 24 hours, but the survival of patients requiring assisted ventilation beyond 48 hours is entirely dependent on the rigorous monitoring which only an ICU set-up can offer.

Objectives: The aim of the study was to investigate if postpartum hemorrhage appears more often in deliveries stimulated with oxytocin. Study Methods: Our study method was the retrospective revue of the data of deliveries during last four years. Results: There were 8453 deliveries in our hospital from 1996-1999. 4980 were stimulated with oxytocin. 45 of all were complicated with the postpartum hemorrhage (0,52%). Most of the women were primiparous (29 ; 64,40%). The average newborn weight was 3340 gr. The average duration of labor was 7 h 20`. V.E. was used in 3 cases (6,60%) and only one labor was with vertex presentation. In 2 cases (4,40%) the primmer diagnosis was FMU with consecutive development of DICK. Only one delivery was inducted with PGE2. In 28 cases (62%) there was need to treat anemia with blood transfusion. Conclusion: Our revue shows that there is no significant deference in occurrence of postpartum hemorrhage between deliveries stimulated with oxytocin (0,54%) and those who were not (0,52%) P3.11.22 PREGNANCY-RELATED CHANGES IN STANDARD LABORATORY PARAMETERS DURING NORMAL PREGNANCY W. Straube (1), E. Panzig (2), J. Luedemann (3), (1) Dept. OB/GYN, (2) Dept. Clin. Chem and (3) Dept. Epidem. & Social Med., Ernst Moritz Arndt University, Greifswald, Germany Objectives: The aim of this cross-sectional study was to investigate the effect of normal pregnancy on some standard laboratory parameters. Study Methods: Eight hundred and thirty-two healthy pregnant women were compared to a control group of three hundred and sixty-two healthy non-pregnant women. All the women were aged between 20 and 40 years. The following serum parameters were estimated: Liver enzymes, electrolytes, creatinine, white blood cells (total), hemoglobin and red blood cell indices, platelet count, coagulation factors and C-reactive protein as a marker of inflammation. All of the women came from the same region and all serum parameters were estimated in the same laboratory. Statistical significance was shown with non-parametric tests. Results: Some parameters increase to a different extent during normal pregnancy, such as white blood cells, fibrinogen and thromboplastin time. Some parameters decrease, e.g. hemoglobin, platelets, creatinin and serum calcium. A number of parameters are unchanged, e.g. CRP, PTT, uric acid, sodium, potassium and aminotransferases. Conclusions: The occurrence and the absence of physiological changes in laboratory parameters during normal pregnancy must be considered in the diagnosis of diseases during pregnancy.

P3.11.23 PROBLEMS RELATED TO REDUCING THE MATERNAL MORTALITY RATE IN INDONESIA A.Sofian, D. Lutan, D. Siddik, Dept. OB/GYN, Faculty of Medicine, University of North Sumatra, Indonesia. Currently, the Indonesian Maternal Mortality Rate (MMR) is at the high level of 390 per 100,000 births. Our challenge entering the year 2000 is to reduce Indonesias MMR to 225 per 100,000. The majority of maternal mortality in Indonesia was due to classical triad (hemorrhage 30-35%, infection 20-25% and eclampsia 15-17%) and other diseases that become worse because of pregnancy or childbearing. Health care and safe motherhood practices are being applied in the efforts to reduce MMR. These efforts include: increasing family planning programs (from 26% in 1976 to 61% in 1997), publishing and expanding the protocol for post-abortion treatment use the safe and effective vacuum manual aspiration (VMA) method, antenatal care services (more than 80%) and expanding referral systems, application of the WHOs partograph (in study of Dr. Pirngadi Hospital Medan decreased MMR from 0.44% to 0.06%). Although it is not enough yet, there were 18,900 midwives that had been distributed into rural area (the

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target is 50,000), because 65.3% of deliveries in the rural area were helped by Traditional Birth Attendants (TBAs). Training TBAs by village midwives and coordinating with administering department came to be one of the six basic elements of safe motherhood in Indonesia. The present economic crisis is predictable as holding back efforts towards safe motherhood and the programs to cut the MMR. An increase in family planning program drop out (example in DKI Jakarta province is almost 30% and in Kutai regency in east of Kalimantan province is 8.92% in 1998) will cause a baby boom and greater MMR in the future, particularly, deaths due to direct obstetrical causes and abortion. The economic crisis also causes use of untrained TBAs, rising risks and causing a predictable increase in MMR.

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moles. Nevertheless, B-HCG must be determined until negative since metastatic disease is always a possibility.

P3.11.26 SOCIAL PROBLEMS AND MATERNAL MORTALITY PAKISTANS PERSPECTIVE S. Saleem (1), S. Syed (2) (1) Hamdard University Hospital, Pakistan. (2) Sobhraj Maternity Hospital, Pakistan. Though there are many reasons for increase in mortality among childbearing women in Pakistan, yet, the social reasons are perpetuating the gloomy state of affairs. A series of interviews were conducted on women attending the antenatal and postnatal clinics in large maternity hospitals over a period of one year. It was recorded that lack of involvement of community, male members of family, poverty, illiteracy, gender bias and ignorance were the major contributing factors leading to maternal ill-health, pregnancy related complications and maternal death. These issues need urgent attention. This can be achieved through improvement in socioeconomic conditions, awareness, improvement in services and health education. This paper also discusses the plight of selected women who were the victims of unfortunate circumstances. Key words: Maternal mortality, gender bias, maternal health

P3.11.24 PUERPERAL PSYCHOSIS: SOCIODEMOGRAPHIC CHARACTERISTICS, OBSTETRIC EVENTS AND DISEASE PATTERN M. Mtawali, Dept. OB/GYN, Muhimbili University College of Health Science, Tanzania Objectives: To determine sociodemographic characteristics, obstetric events and disease pattern among women with puerperal psychosis. Study Methods: Sixty-seven women with puerperal psychosis were included in this Descriptive Hospital Based Study conducted between March and December 1998. Information was obtained using a structured questionnaire, physical and mental status evaluation with selected Laboratory Investigations such as Hemoglobin, Blood Slide for malaria parasite, endocervical swab for microbiological studies and ELISA test for HIV Antibodies. Data was entered and analyzed using EPI Info computer program number 6.4 May 1996 version. Results: Majority 95.8% of the women were primipara, married 44.8% with age less than 2 years (76%). Most of them were housewives and had attained primary level of education. Among those who were married, 59% received support from the partners but only 27% of them got satisfied. Majority had labored between 12 and 24 hours with spontaneous vertex delivery and a near birth weight of 3.4kgs. Most of the babies born were healthy. The commonest organic symptoms were headache, body weakness and abnormal vaginal discharge while the psychotic symptoms were affective in nature, 19% of the women had severe anemia and 42% moderate anemia. 24.3% had Falciparum malaria infection, 16.1% had a positive endocervical swab for Escherichia Coli infection and 16% had a positive HIV test. Conclusions: There is a need to conduct a case control study to determine its risk factors. P3.11.25 SEVERE PREECLAMPSIA AND HYPERTHYROIDISM ASSOCIATED WITH A PARTIAL HYDATIFORM MOLE AT 20 WEEKS GESTATION M.L. Caete, A.Sanchez-Dehesa, M.V. Bravo, J.C. Moreno, P. Rincon, Dept. OB/GYN, Hospital Virgen de la Salud, Toledo, Spain. Objectives: Partial hydatiform mole is a histopathologic entity characterized by focal trophoblastic proliferation and hidropic degeneration together with a coexisting fetus. We report a case in which clinical findings are unusual since preeclampsia and hyperthyroidism associated with large thecal luteal cysts and high B-HCG titers occur less frequently in patients with partial moles. Case report: A 27-year-old white female, gravida 1, para 0, at 20 weeks gestation, presented with gestational hypertension, legs oedema, proteinuria and elevated liver enzymes. An ultrasonographic examination revealed an abnormal hydropic placente and a growth retarded, microcephalic fetus with cerebral ventricular dilation, both ovaries were enlarged with thecal luteal cysts. Fetal karyotyping by funiculocentesis revealed a triploid fetus (69 XXX), B-HCG titers were greater than 500,000 IU/L. Further tests detected asymptomatic hyperthyroidism. A cesarean section was performed delivering a 190 g male fetus. After two months of follow-up, B-HCG titers were plateaud, requiring treatment with methotrexate. Conclusion: Partial hydatiform mole is usually diagnosed as missed or incomplete abortion. The complete clinical syndrome including preeclampsia before the 20th week of gestation, hyperthyroidism, large thecal luteal cysts and high B-HCG titers is highly unusual in partial

P3.11.27 TENDENCIES IN MATERNAL MORTALITY IN THE REPUBLIC OF UZBEKISTAN Sh.S. Mukhamedova. Dept. of Surgical and Conservative Gyn., Research Inst. of OB/ GYN, Tashkent, Uzbekistan Objectives: The aim of the investigation was to study the structure and clinical aspects of maternal mortality in the Republic of Uzbekistan within 1989 and 1998. Study Methods: A retrospective analysis of medical documentation of lethal outcomes was undertaken with the subsequent computer-assisted processing. Results: The study was undertaken to analyze 2,694 cases of maternal lethal outcomes within the mentioned period. The analysis demonstrated that 88.2% pregnant women in labor died at the gestation term of 28 weeks and more, 11.0% at the term of up to 28 weeks including mortality from abortion, 0.87% from ectopic pregnancy. The reasons for the death of pregnant females, those in labor puerperas died at the gestation term of 18 weeks were the following ones: bleeding in 29.1% of cases, septic postnatal diseases in 16.1%, gestosis in 15.4%, hysterorrhexis in 5,6%, embolism due to amniotic fluid in 3.1%. 14.7% females died due to extragenital diseases, in 13.0% cases the death was caused with reasons not related with their pregnancies (thromboembolitic complications in 32.3%, acute renal insufficiency in 30.4%, complications due to anesthesia and resuscitation mistakes in 18.3%, anaphylactic and hemotransfusion shock in 11.5% and 7.1% of cases respectively). In 3.0% of females lethal outcomes were due to uncertain reasons as autopsy was absent. The analysis demonstrated that 6.5% of females died pregnant, the other women died in the postnatal period, 28.5% of women died within the first 24 hrs and 55.0% during the first week after labor. According to an expert evaluation lethal outcomes were inevitable in 72.3% of the women died. Conclusions: The results of the study urge the necessity in development of effective ways in pregnancy, natal and postnatal follow-up to decrease maternal mortality.

P3.11.28 THE MANAGEMENT OF OBSTRUCTIVE UROPATHY IN PREGNANCY E. Alexopoulos, P. Sakellariou, S. Karpathios, G. Siampalioti, N. Kyritsis, M. Stathi, C. Papanicopoulos, K. Kakoullis, G. Pavlides, Alexandra Maternity Hospital, Athens, Greece Objectives: The aim of the study was to investigate the clinical efficacy of the insertion of a double J ureteral catheter in the management of patients with upper urinary tract dilatation secondary to obstruction.

WEDNESDAY, SEPTEMBER 6
Study methods: Symptomatic pregnant women who were treated for obstructive uropathy during the period 1988-1998 are included in this descriptive retrospective study. Results: Eighteen patients presented with symptomatology of urinary obstruction; eight of them suffeted from recurrent urinary tract infections. Whilst investigated an ultrasound scan performed, confirmed the presence of upper urinary tract dilatation. Their mean age was 26.8 years (ranging from 19 to 34 years) and the mean gestational age was 31.2 weeks (ranging from 29 to 35 weeks). When a double J ureteral catheter was placed patients symptoms regressed without any further serious complications for the rest of the antenatal period and labour. This self-sustained ureteral catheter was removed between 6th and 10th day postpartum. An ultrasound scan of the kidneys and urinary tract was performed after the removal of the catheter. The patients were followed up for twelve months with a repeat scan and intravenous pyelogram at 6 months postdelivery. Fifteen of them remained asymptomatic and three had minor urological problems. Conclusions: Dilatation of the upper urinary tract in pregnancy secondary to obstructive uropathy could be safely and effectively managed in selected cases by insertion of ureteral catheters in order to relieve patients symptoms and prevent renal insufficiency.

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between age of 20-30 years, illiterate with low socio-economic status, unaware of facilities of medical termination of pregnancy and contraceptives. All seven died within 72 hours of admission in hospital, due to septicemia (4), anemia (1), DIC (1), and renal failure (1). Conclusion: Female literacy, health education, counseling, dissemination of knowledge of contraceptives and MTP services, with increased number of trained doctors, availability of facilities in rural areas and utilization of services of safe abortion by women of remote areas, with early diagnosis of pregnancy and termination in first trimester, can remarkably reduce the number of mortality in the prime of life of women. P3.11.31 UNSCARRED UTERINE RUPTURE AFTER THE INDUCTION OF LABOR WITH MISOPROSTOL Sleyman Engin Akhan, Alkan Yldrm, Erkut Attar, Abdullah Turfanda, Department of Obstetrics and Gynecology, Istanbul University Faculty of Medicine, Istanbul, Turkey. Uterine rupture is an emergent situation that threats the life of fetus and mother. In this article we present a case of intrapartum rupture of intact uterus after using intravaginal misoprostol for cervical ripening and labour induction at term. The Case: A 30 years -old healthy women at 42 weeks of gestation was admitted to the hospital for induction of labor because of a low amniotic fluid index (4.3 cm.) and postmaturity. The obstetric history included two term pregnancies, and there was no other remarkable point. The initial Bishops score was two on admission. The first 25 mgr. misoprostol tablet applied to posterior vaginal fornix with 4 h intervals for a maximum of three times. 3h 45 minutes after the second dose of misoprostole the hyperstimulation was noted. Misoprostol withheld because of the tachysystole and variable decelerations, patient turned her left side and oxygen was administered. After 45 minutes atypical variable decelerations were deceased. However, tachysytol was persisted for consequent 1 h. The fetal heart rate was stable during this period of time. Cervix was 10cm dilated, vertex at +1station after 19 hours of the first misoprostol administration. Fetus developed bradycardia and vacuum extraction was performed. A 3630 gr infant was delivered with the Apgar scores of 4 and 7 for 1 and 5 minutes, respectively. The arterial cord blood pH was 6.926. After delivery of the placenta patient was taken to the recovery room for postpartum monitorization. Patient developed tachycardia and cyanosis 30 minutes after the delivery. Uterus was contracted but very mobile, therefore palpated above the normal localisation. Laparotomy was performed in emergency conditions. Approximately 2500-3000 cc haematoma localised in the retroperitoneal area was encountered. A 9-cm linear defect extended from right isthmus of cervix to the fundus of uterus was noted. Right uterine artery involved with this defect, the serosa was intact. Hysterectomy was performed, and right hypogastric artery was ligated. Totally 9 unite blood and 8 unite fresh frozen plasma was transfused. Patient and infant were discharged from the hospital 8 days after the operation. Conclusion: The development of this rare and catastrophic condition keeps its uncertainty, because uterine rupture can be developed in nulliparous. The physiopathology of the condition, factors that can effect the myometrium, the course of the rupture development are the major questions to be answered. Therefore, we decided that misoprostol only can not be the cause of the uterine rupture.

P3.11.29 THROMBIN GENERATION IS INCREASED IN WOMEN WITH TWIN PREGNANCIES VS WOMEN WITH SINGLETON PREGNANCIES S. Tamada, H. Minakami, A. Izumi, A. Ohkuchi, R. Iwasaki, S. Matsubara, T. Takayama, I. Sato, Dept. OB/GYN, Jichi Medical School, Tochigi, Japan. Objectives: Antithrombin III (AT-III) activity is likely to decrease in women with twin pregnancies compared with women with singleton pregnancies. It is not known whether thrombin generation is increased in women with twin pregnancies. Study Methods: 15 women with twin pregnancies and 208 women with singleton pregnancies were examined. Peripheral blood specimen for determinations of AT-III activity, thrombin-AT-III complex (TAT), and plasmin-a2 plasmin inhibitor complex (PIC) was obtained. Results: AT-III activity gradually decreased in twin pregnancies with advancing gestation (10411% at 27.31.6 weeks [n=10], 9619% at 31.81.1 weeks [n=15], 8610% at 35.31.0 weeks [n=24]), whereas it did not show a significant change in singleton pregnancies (10113% at 27.81.5 weeks [n=73], 9913% at 31.51.1 weeks [n=67], 9815% at 36.61.6 weeks [n=137]). TAT levels, 9.45.1 mg/L at 27.31.6 weeks (n=10) and 12.912.4mg/L at 31.81.1 weeks (n=15) in twin pregnancies were higher than those (5.42.4 mg/L at 27.81.5 weeks [n=73] and 10.922.3 mg/L at 31.51.1 weeks [n=67]) in singleton pregnancies, respectively. TAT level exhibited a significant negative correlation with AT-III activity (r=-0.44, p=.002) and a significant positive correlation with PIC level (r=0.41,p=0.005) in twin pregnancies, but not in singleton pregnancies. Conclusions: It is suggested that thrombin generation is increased in twin pregnancies as compared with singleton pregnancies. This may explain why AT-III activity is likely to decrease in twin pregnancies.

P3.11.30 UNSAFE ABORTION: MAJOR CAUSE OF MORBIDITY AND MORTALITY IN YOUNG WOMEN S. Sapre, V. Joshi, S. Yadav, Dept. OB/GYN, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India Objective: The aim of the study was 1. Investigate the cause of morbidity and mortality in unsafe abortions 2. Reasons of getting abortions done by untrained person, at unsafe places, by adolescent and young women Study Methods: 134 cases of unsafe abortions in last five years, 1994 to 1998 were analyzed in detail including seven deaths. Results: 134 cases analysis showed, 76% were adolescent (10-19 years) 24% (19-30 years), 70% of low socio-economic status, 85% from rural areas, 68% primigravida. 58 cases required laparotomy, 20 required repair of perforation of uterus, 3 cases ileal anastomosis, 16 cases drainage of abscess, in 12 cases subtotal hysterectomy done for perforation and sepsis. 7 cases died, 5 were primigravida. All cases

P3.12

MEDICAL AND SURGICAL COMPLICATIONS

P3.12.01 ABRUPTIO PLACENTAE AND EPH GESTOSIS B. Boskovski, J. Efremovski, J. Kostadinov; Special Hospital for OB/GYN Cair, Skopje (Macedonia) Objectives: The aim of our work is evaluation of connection between abruptio placentae and severe forms of EPH Gestosis together with factors from which it is caused. Study Methods: Our work includes 15 years material , from 1985-2000. It is analyzed: the age of patient, parity, body weight of fetuses, way of delivery and sex of fetuses.

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Results: There were 63853 childbirths in period of 15 years. Abruptio placentae occurred in 465 (0,73%) cases. In 38 cases or 8,6% abruptio placentae were associated with severe form of EPH Gestosis what mean that frequency rate is 11 time greater than in other pregnancies. Deliveries in 52,5% of cases with abruptio placentae and gestosis was finished with SC. 129 (28,01%) fetuses were dead before admitting in hospital. The mean age of the patient with this condition was 28,2 years. Conclusion: The analysis of data on our material is in conformity with results of other authors. Prognosis for mother and newborn depends on establishing diagnosis on time and appropriate therapy of EPH Gestosis. The severe forms of EPH Gestosis with abruptio placentae demanded urgent finishing of delivery and very often expose to danger life of mother and caused the dead of fetus. P3.12.02 ACTIVITY OF LACTIC DEHYDROGENASE (LDH), CREATINE KINASE (CK) AND GAMMA-GLUTAMYLOTRANSFERASE (gGT) IN THE COURSE OF INTRAHEPATIC CHOLESTASIS IN PREGNANCY K. Czajkowski, R. Smolarszyk, J. Wojcicka-Jagodzinska, P. Piekarski, E. Romejko, J. Teliga, A. Malinowska, K. Dragowska, The 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objectives: The activity of LDH, CK and gGT in blood serum of women with intrahepatic cholestasis in pregnancy was investigated. Diagnosis of intrahepatic cholestasis was based on anamnesis, clinical examination and laboratory tests. Study Methods: 41 women with intra hepatic cholestasis (the study group) and 30 healthy women (the control group) entered the study. All women were in the third trimester of pregnancy. The prevalence rate of intrahepatic cholestasis in pregnancy in our Department is 1%. All women of the study group presented an intensive pruritis and had negative hepatitis B antigen. The also presented negative results of laboratory tests. Clinical examination and anamnesis concerning other hepatitis. Results: There was no significant difference in mean gestational age between study and control group (35.12.8 Vs 36.03.0 weeks). The results of biochemical tests in study Vs control group: (1) total bilirubin 33.318.8 Vs 8.553.4 microMol/L; p<0.001, (2) direct bilirubin 25.614.2 Vs 1.7 1.7 microMol/L; p<0.001, (3) indirect bilirubin 7.72.22 Vs 8.553.4 microMol/L;NS, (4) alkaline phosphatase (AP) 168.461.2 Vs 96.8 14.9 IU/L; p<0.001, (5) heat-stable AP 99.838.7 Vs 64.120.9 IU/L; p<0.001, (6) bile acid 28.620.0 Vs 4.51.5 microMol/L; p<0.001, (7) AlAT 158100 Vs 53 IU/L; p<0.001, (8) AspAT 9731 Vs 83 IU/L, p<0.001, (9) de Ritis ratio AspAT/AlAT 0.610.31 Vs 1.60.4; p<0.001, (10) total protein 61.85.6 Vs 66.06.0 G/L; p<0.001, (11) albumine 45034.8 Vs 484.037.7 microMol/L; p<0.001, (12) FE++ 26.03.8 Vs 12.712.15 microMol/L; p<0.001, (13) total cholesterol 8.811.87 Vs 6.681.04 mMol/L; p<0.001, (14) total LDL 6.801.57 Vs 4.800.81 G/L; p<0.001, (15) LDH 21148 Vs 13433 UI/L; p<0.001, (16) CK 51.033 Vs 4514UI/L; NS, (17) G-GT 4922 Vs 238 UI/L; p<0.001. Conclusions: An increase of LDH is related to the significant impairment of hepatocytes. An increase of gGT confirms the retention of bile in intrahepatic ducts. CK does not present prognostic value in intrahepatic cholestasis in pregnancy. P3.12.03 HELLP SYNDROME ASYNTOMATIC GESTOSIS, EXORDIUM IN PUERPERIUM, EVOLUTION IN CID M.G. Mazza, D. Galea, G. Masciari, Dept. OB/GYN, General Hospital, Crotone, Italy. This syndrome can occur, as in our case, also in the course of asyntomatic gestosis in the early hours of puerperium growing in cid in a second time. Clinic Case: M.G. arrives at our observation at 38th week. At her arrival: the objective general and ostetric and urinic exams were normal, P.A. 120/80, HCT 39.6, MCV 89.5; MCH 30.5; MCHC 34.1; PLT 179/10^3/ul. The birth was done in the same day of the arrival. Soon

WEDNESDAY, SEPTEMBER 6
after the birth occurred in a spontaneous way after about 6 hours from the entrance the hospital, (alive and vital fetus, 3470 gr. P.A. 130/90) the clinic conditions showed a quick worsening with presence of abdominal bar ache of the arterial pressure with ipertensive crisis (180/110), subsequent eclamptic crisis with alterations of the following indexes of laboratory: a quick and drastic reduction of HCT (36.2) MCV (93.3) MCH (32.9) MCH (35.2); emoglobinuria, fragments of granular cylinders; a quick reduction of the pyastrinic count (33/103/ul); a strong increasing of the whole bilirubyna (4.05 mg/dl);an alteration of epatic enzymes with a strong increasing of GOT, GPT, CK, LDH levels; iperuricemia; rightness of the emocoagulative tests. Moved into the intensive therapy, the following day remarkable emocoagulative alterations appeared (HCT 33.2; MCV 87.9; MCH 31.4; MCHC 35.7; PLT 21/103/ul) becoming later cid (antitrombina III A 43.88%; antiplasmina 33.58%; product of phybrogen degradation>40 mml). Considerations: The H.S. according to us, can occur then the birth evolving in cid quickly, disegrecing with the data of literature where such a syndrome occurs in the course of the gestosyc pregnancy and it improves quickly after the birth. In our case the H.S. occurs in the hours following the birth matching to a worse of the symptoms of the gestosy, occurring the H.S. as essential element putting in evidence a gestosic syndrome up to then asyntomatic. The mother prognosis in spite of the seriousness of the clinic situations through which it occurred, is good, with a constant clinic improvement in the weeks following the birth.

P3.12.04 HYSTERECTOMY IN THE OBSTETRIC PRACTICE FOR THE PERIOD 1993-1998 N.D. Nicolova, Grueva, Dept. OB/GYN, The District Hospital, Rousse, Bulgaria. The Cesarean hysterectomy and the hysterectomy after vaginal delivery together with their indications, complications and the outcome for the mothers are observed during the period 1993-1998. The most common indications for Cesarean hysterectomy are: infected uterus, hemorrhage, myoma and cancer of the uterine cervix (80%). The hemorrhage and the rupture of the uterus (75%) are the main indications of hysterectomy after vaginal delivery. We had three fatal outcomes after hysterectomy following vaginal delivery. The authors recommend the organ-preserving approach. For the first time successful Cesarean hysterectomy was performed by Eduardo Porro 1876. Together with the hysterectomy after vaginal delivery, it is the most severe intervention, done in the surgical obstetric practice for the benefit of the mother. Materials and Methods: The hysterectomies were done over a period of five years in the dep. of obstetrics and gynecology in the District Hospital of Rousse. During that period we had 10 010 deliveries. Cesarean section was done on 550 cases. We did 10 hysterectomies - 7 Cesarean and 3 after vaginal delivery. The indications that led to hysterectomy were divided into 6 groups: 1.lnfected uterus 2.Primary hemorrhage 3.Secondary hemorrhage 4.Myoma of the uterus 5.Cancer of the uterine cervix 6.Rupture of the uterus We have studied the severe complications after the hysterectomy and the outcome of the mothers. Results: The rate of the hysterectomies over the studied period is.. The rate of the Cesarean hysterectomies is.. The rate of the hysterectomies after vaginal delivery is.. Groups Of Indications For Hysterectomy In The Obstetric Practice 1993-1998

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Table No.1
HYSTERECTOMY GROUPS OF INDICATIONS Infected uterus Primary hemorrhage Secondary hemorrhage Myoma of the uterus Cancer of the cervix Rupture of uterus TOTAL CESAREAN 2 2 1 1 6 AFTER VAGINAL DELIVERY 1 2 3

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P3.12.05 MATERNAL AND PERINATAL OUTCOME IN DIFFERENT GRADES OF ANAEMIA M. Malhotra, J.B.Sharma Ob/Gyn, MAM College, New Delhi, India Objectives: The aim of this study was to see the maternal and perinatal outcome in different grades of anaemia in pregnancy in a teaching hospital of New delhi. Study Methods:Four hundred and forty three women who delivered between January'99 to October'99 in Lok Nayak Hospital, New Delhi were assessed to observe the maternal and perinatal outcome in different grades of anaemia which included 123 (27.7%) of normal haemoglobin(Group A: Hb >= 11gms%), 214 (48.3%) mild anaemia (Group B: Hb 9-11gms%), 79 (17.8%) Moderate anaemia (Group C: 7-9 gms%), 27(6.09%) Severe anaemii (Group D Hb <= 7 gms%) Results: The parity was the highest and average gestational age the lowest in severe anaemia(Group D). The Caesarean section rate was highest in severe anaemia(7.4%) in contrast to 4.8%, 3.7%, 6.3% in normal, mild, moderate anaemia groups respectively. Instruemental delivery rate was also highest in severe anaemia(7.4%). Duration of labour was 5 hours, 6.2 hours, 4.8 hours and 9.5 hours in A, B, C, D respectively. Fetal weight decreased progressively with severity of anaemia being 2.5 Kgs in Group D. There were only two still births one each in moderate and severe anaemia. Conclusion: The perinatal outcome varies in direct proportion with severity of anaemia. P3.12.06 OSMOLARITY AND MICROALBUMINURIA IN THE COURSE OF INTRAHEPATIC CHOLESTASIS IN PREGNANCY R. Smolarczyk, K. Czajkowski, J. Wojcicka-Jagodzinska, E. Romejko, P. Piekarski, J. Teliga, A. Malinowska, K. Dragowska, The 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objectives: The osmolarity in blood serum and urine as well as the microabluminuria in women with intrahepatic cholestasis was based on anamnesis, clinical examination and laboratory tests. Study Methods: 38 women with intrahepatic cholestasis (the study group) and 30 healthy women (the control group) entered the study. All women were in the third trimester of pregnancy. The prevalence rate of itrahepatic cholestasis in pregnancy in our Department is 1%. All women of the study group presented an intensive pruritus and had negative hepatitis B antigen. They also presented negative results of laboratory tests, clinical examinations and anamnesis concerning other hepatitis. Results: There was no significant difference in mean gestational age between study and control group (35.83.1 Vs 36.03.0 weeks;NS). The results of biochemical tests in study Vs control group: 1. total bilirubin 29.615.4 Vs 8.553.4 microMol/L;p<0.001, 2. direct bilirubin 23.110.4VS 1.71.7 microMol/L;p<0.001, 3. indirect bilirubin 6.51.7 Vs 8.553.4 microMol/L;NS, 4. alkaline phosphatase (AP) 174.364.1Vs97.814.9 IU/L; p<0.001, 5. heat-stable AP 90.931.3 Vs 64.120.9 IU/L; p<0.001, 6. bile acid 25.418 Vs 4.51.5microMol/L;p<0.001, 7. AlaT 13991 Vs 53 IU/L; P<0.001, 8. AspAT 78440 Vs83IU/L; p<0.001, 9. de Ritis Ratio AspAT/AlAT 0.560.22 Vs1.60.4; P<0.001, 10. total protein61.14.8 Vs 66.06.0 G/L; p<0.001, 11. albumine 43930.4 Vs 484.037.7 microMol/L; p<0.001, 12. Fe++24.54.3 Vs 12.712.15 microMol/L; p<0.001, 13. total cholesterol 8.401.79 Vs 6.681.04 mMol/L; p<0.001, 14. total LDL 6.781.54 Vs 4.800.81 G/L; p<0.001, 15. osmolarity in serum 2844.16 Vs 2813,52 mOsm/KH H2O; p<0.005, 16. osmilarity in urine 567180.5 Vs 664208, mOsm/KG H2O; p<0.05, 17. microalbuminuria 40.39.8 Vs 114mg/24hrs; p<0.001. Conclusions: Disturbances in osmilarity and microalbuminuria are related to renal function impairment, therefore intrahepatic cholestasis in pregnancy should be considered as a general disease.

While in the group of the Cesarean hysterectomies the main indications are the infections of the uterus and the primary hemorrhage (total of 7 cases - 60%), in the group of the hysterectomies after vaginal delivery, the main indications are the primary hemorrhage and the rupture of the uterus (3 cases - 80%). Until 1995 there have been done 6 hysterectomies and during the second period- 4 hysterectomies. It is obvious from the table that this reduction is mainly due to the Cesarean hysterectomies - 3 cases, compared to the 2 cases during the second period. Pathology, Which Has Led To Caesarean Hysterectomy And Hysterectomy After Vaginal Delivery (1993-1998) Table No.2
DISEASE Hypo- and atonic uterine bleedings Infected uterus Rupture of the uterus Placenta accreta Myomautery Cancer of the cervix The Willebrandt disease Thrombocytopenia 2 1 1 1 1 1 HYSTERECTOMY 2

The previous Cesarean section leads to increased risk of pathology of the placenta and rupture of the uterus in the time of the next delivery. We have 3 cases with hysterectomy for uterine rupture - 2 cases after a previous Cesarean section and 1 case after inadequate treatment with uterustonics. In these 3 cases the hysterectomy was done on women, which had already fulfilled their reproductive program, an approach with which today we do not agree. We support the position of A.S.Slepih (1985) for the organ preserving intervention as a basic operative treatment. The cases with hypo- and atonic uterus show equal rates in occurrence and as an indication for hysterectomy. The both cases with infections of the uterus were from the described period 1993-1995. The new drug and surgical treatment approaches (partial suture of the abdomen with ampoxen, intraoperative lavage with antibiotics, postoperative intermittent irrigation with antibiotics of the uterine cavity after Cesarean section) lead to reduction of the relative share of this indication. We think that the myoma of the uterus can be an indication for hysterectomy mainly at the age of 40 and over for the Cesarean section delivery, especially for patients with multiple myomas. In our cases we did not have complications of the hysterectomy like: damage of the urinary bladder and the uterus, which we explain with the low relative share of the total hysterectomies and the well-performed traditional operative techniques. During the observed period there had not been fatal outcomes for the mothers. Discussion: The analysis of our data show that the hysterectomy in the obstetric practice, although rare, is not casuistry and it has its place as an intervention performed for the benefit of the mother. Good results are achieved by properly indicated and done operative intervention.

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P3.12.07 TBARS AND VITAMIN E AS PRECLINIC PREDICTIVE MARKERS OF PREGNANCY-INDUCED HYPERTENSION AND GESTATIONAL DIABETES. Galimberti D. M., Joao M., Fernandez C.A., Cortelezzi M., Carames V., Holland M. and Aparicio N. J. Obstetrics Department T. Alvarez Hospital, Aranguren 2701, Buenos Aires, Argentina Diabetes Mellitus and arterial hypertension are associated with oxidative stress, but the temporal association between lipoperoxidation markers and plasma s antioxidant activity and the clinical development of gestational diabetes (GD) and pregnancy-induced hypertension (IH) is still not known. Objective: to determine the circulating levels of TBARS and vitamin E in healthy primigravidas at the moment of the first consult. Material and methods: 91 (healthy at the moment of incorporation) primigravidas (age 17 to 32 years) were incorporated between the 8th and 12th week of pregnancy. Blood was extracted at 8th to 12th , 22nd and 32nd week of pregnancy, respectively. The patients were controlled clinically on a weekly intervalsm until delivery. TBARS levels were determined (intraassay variation 4.7% and interassay 6.9%) (in mmols/l) as well as vitamin E (intraassay var. 4% and interassay 6.1%) (in mmols/l). Results: 85 patients had a normal gestation, whilst 6 of them developed IH between the 27th and 32nd week; 2 of them, besides, developed gestational diabetes. TBARS levels in normal primigravidas were (mean SD) 2.00 0.22, 2.11 0.53 and 1.92 0.39 respectively for the three trimesters; the maximun and minimun figures being 1.4 and 2.87. The values for vitamin E were 29.0 5.8, 27.1 4.9 and 29.3 6.4 for the three trimesters (absolute minimun of 21.0 and absolute maximum 48.1). Four out of the six patients who had IH (two of them with GD) presented TBARS levels clearly high (between 3.3 and 5.66 mmols/l) already in the first trimester and all of them presented high levels at the 22nd week, maintaining this until the 32nd week. Vitamin E scores were low (less than 12.0) in all the patients with IH except one. Conclusions: a) the values of TBARS and Vit. E in the three trimesters were similar to the ones found in a healthy population of eumenorrhoeic women; b) The gestants who finally had IH ( 2 of them with associated DM) presented high levels of TBARS and, in most of them, low levels of vitamin E preceding by several months the manifestation of the clinic signs; c) The determination of TBARS and, eventually, vitamin E, could be useful for a preclinical prediction of a late development of induced hypertension and gestational diabetes. P3.13 MENOPAUSE

WEDNESDAY, SEPTEMBER 6

P3.13.01 A TWO-YEAR PROSPECTIVE RANDOMIZED TRIAL OF ORAL CONTRACEPTIVE AND HORMONE REPLACEMENT THERAPY ON BONE DENSITY, LIPID-LIPOPROTEIN AND COAGULATION PROFILES IN POSTMENOPAUSAL WOMEN N. Taechakraichana (1), K. Limpaphayom (1), K. Panyakhamlerd (1), S. Chaikittisilpa (1), T. Ninlagarn (2), N. Dusitsin (2) Dept. OB/GYN, Chulalongkorn University, Bangkok, Thailand Health Research Institute, Chulalongkorn University, Bangkok, Thailan. Objectives: The aim of the study was to investigate the effects of oral contraceptive (OC) and hormone replacement therapy (HRT) on bone mineral density (BMD), lipid-lipoprotein and coagulation profiles in postmenopausal women. Study Methods: 80 healthy postmenopausal women visited a menopause clinic at Chulalongkorn Hospital and were randomly assigned to a cyclic regimen of OC containing 30 mg of ethiyl estradiol and 150 mg of desogestrel or HRT containing 0.625 mg of conjugated equine estrogens 21 days per cycle and 5 mg of medrogestone 10 days per cycle for 24 months. BMD of lumbar spine and hip, lipid-lipoprotein and coagulation profiles were evaluated. Intention to treat analysis was done. Student ttest, general linear model (repeated measures) with Bonferroni comparison and analysis of covariate (ANCOVA) were used where it was appropriate. Results: After 24 months, BMD of lumbar spine, trochanter, intertrochanteric region and total hip significantly increased in both groups. Only OC treatment was associated with a significant increase in BMD of femoral neck and Ward triangle. Percent increases of BMD of lumbar spine, femoral beck and Ward triangle were significantly higher in the OC group than in the HRT group. Total cholesterol and lowdensity lipoprotein cholesterol significantly decreased in both groups. Only the OC therapy showed a significant increase in triglyceride level. There was no clinically significant changes of coagulation profiles in both groups. Conclusion: Both OC and HRT increased BMD of lumbar spine and hip with more obvious effects in the OC group. Both methods favorably affected these cardiovascular parameters during the 24 months of treatment.

P3.12.08 UNUSUAL PRESENTATION OF NON-PUERPERAL UTERINE INVERSION: A CASE REPORT B.R. Choudhury, Dept. OB/GYN, Sir Salimullah Medical College Hospital, Dhaka, Bangladesh. Objectives: The objective of my case report is to highlight the rapid diagnosis and prompt management of a rare gynecological emergency case. Study Methods: A rare case of noon puerperal or gynecological uterine inversion caused by large fundal myoma in a 40 years lady resulting in shock with intractable hemorrhage with lower abdominal pain was admitted in SSMC & Mitford Hospital, Dhaka, on 15-01-98 was reported. Results: After prompt diagnosis and resuscitation operation was done and patient quickly recovered and no complication occurred. Conclusions :Non-puerperal inversion of uterus is a rare event. In day to day clinical practice, puerperal inversion of uterus are met with acuteness and high mortality rate. This case was a gynecological emergency and management is discussed along with review of literature.

P3.13.02 CONTRACTION OF SMALL ARTERY IN PERIMETRIUM OF RAT UTERI AFTER TREATMENT WITH LH-RH AGONIST K. Hamasaki (1), Y. Doi (2), M. Seki (1), M. Kashimura (1), S. Fujimoto (2), University of Occupational and Environmental Health, School of Medicine, Fukuoka, Japan. (1) Dept. OB/GYN (2) Dept. Anatomy Objectives: The aim of this study was to compare ultrastructural alteration of the rat uterine vasculature after treatment with luteinizing hormone-releasing hormone (LH-RH) agonist to those of the oophorectomized rat. Study Methods: For experimental groups, adult female rats received either subcutaneous injection of LH-RH agonist (buserelin) or oophorectomy. Both experimental and control (untreated) groups were provided for scanning electron microscopic specimens using corrosion cast. Plasma ET-1 concentration was measured by ELISA in both groups. Results: Cast images showed the remarkable contraction of small arteries in the perimetrium of both buserelin-treated and oophorectomized rats. Plasma ET-1 levels significantly increased in the experimental rats when compared to that of the control ones. Conclusions: These findings indicated that treatment with either buserelin or oophorectomy induces the small artery contraction in the perimetrium as well as the increase in plasma ET-1 levels. Since ET-1 is known to regulate local blood flow by its potent vasoconstractive action, it seems that ET-1 may be one of the candidates that induce the arterial contraction.

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P3.13.03 EFFECT OF TRANSDERMAL ESTRADIOL/NORETHISTERONE ACETATE (ESTALIS SEQUI) VS. PLACEBO ON VASOMOTOR SYMPTOMS IN POSTMENOPAUSAL WOMEN R. Rebar (1), M. Notelovitz, (1) University of Cincinnati, Cincinnati, Ohio, USA. (2) Womens Research Centers Inc.,Gainsville, USA. Objectives: To evaluate the efficacy and tolerability of a sequential combination of estradiol/norethisterone acetate (E2/NETA, Estalis Sequi) versus placebo for relief of moderate to servere vasomotor symptoms in healthy postmenopausal women. Methods: In a 12-week double blind trial a total of 220 women with at least eight hot flushes per day during single-blind placebo therapy were randomly assigned to placebo or one of three doses of therapy consisting of a transdermal patch releasing E2 50mg alone for days 1-14 of each cycle and a combination patch releasing E2 50mg/day plus NETA 140, 250 or 400 mg/day for days 15-28 of each cycle. Vasomotor symptoms (including sweating and hot flushes), patch tolerance and adverse events were recorded for three 28-day cycles. Results: A total of 220 women completed the study. From baseline to endpoint, the change in mean hot flushes/day ranged from 9.3 to 9.7 in the E2/NETA groups compared with 5.5 in the placebo group (p<0,001). The incidence of adverse events was comparable with all three E2/NETA treatments and with placebo. With active patches only 4% to 7% of women experienced an application site reaction. Conclusions: Overall, a combination E2/NETA transdermal HRT administered in a sequential regimen was effective in treating moderate to severe vasomotor symptoms in postmenopausal women. Each E2/NETA treatment was significantly better than placebo in reducing daily hot flushes and sweating. Symptom relief was observed as early as week 2 of treatment.

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P3.13.05 EFFECT OF TRANSDERMAL ESTRADIOL AND NORETHISTERONE ACETATE HRT (ESTALIS) COMPARED WITH ESTRADIOL ALONE ON QUALITY OF LIFE IN POSTMENOPAUSAL WOMEN A.A. Licata (1), S. Shumaker (2), D.F. Archer (3), E.G. Luftkin (4) (1) Cleveland Foundation Clinic, Cleveland, Ohio, USA. (2) The Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA. (3) Dept. OB/GYN, Eastern Virginia Medical School, Norfolk, Virginia, USA. (4) Dept. Endocrinology, Mayo Clinic, Rochester, Minnesota, USA. Objectives: To compare continuous combined or sequential transdermal estradiol 50mg/day (E2 50) together with one of three doses of norethisterone acetate (NETA) 140, 250 or 400mg/day (50/140, 50/250 or 50/400) versus E2 50 alone on quality of life (QoL) in healthy postmenopausal women aged 40 70 years with an intact uterus. Study methods: An overview of two 1-year, multicenter, double-blind, randomized, parallel-group studies. In the first study, women received either a patch releasing E2 50 or sequential therapy consisting of an E2 patch for days 1 to 14 of each cycle and a combination patch releasing E2 50 plus, NETA 140, 250, or 400mg/day for days 15 to 28 of each cycle. In the other study, women received either an E2 50 patch or transdermal continuous combined E2/NETA delivering E2 50 and NETA 140, 250, 400mg/day. End-points for the two studies were selected QoL parameters measured on a point index scale. Results: QoL improved in all treatment groups from baseline to study endpoint. However, the E2/NETA 50/250 and 50/400 groups showed greater improvement than E2 alone in terms of sleep disturbance, urinary incontinence, cognitive function, sexual arousal and overall healthrelated QoL. Conclusions: A combination HRT patch* administering either continuous combined or sequential E2 50mg/day, together with either NETA 140, 250, or 400mg/day improved QoL in postmenopausal women. Transdermal E2/NETA appears to have greater benefits on certain parameters, such as urinary incontinence, cognitive function and sexual arousal than E2 alone. *Trademark: Estalis - continuous combined, Estalis Sequi sequential

P3.13.04 EFFECT OF TRANSDERMAL ESTRADIOL/NORETHISTERONE HRT VS. ESTRADIOL ON QUALITY OF LIFE IN POSTMENOPAUSAL WOMEN A.A. Licata (1), S. Shumaker (2), M-P. Dain (3) (1) Cleveland Clinic Foundation, Cleveland, Ohio, USA. (2) The Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA. (3) Rhone-Poulenc Rorer, Antony, France. Objectives: To investigate the effects of three doses of transdermal norethisterone acetate (NETA) estradiol (E2) administered sequentially vs. continuous E2, on quality of life (QoL). Study Methods: A 1-year, multicenter, double-blind, parallel-group study. The study included a total of 646 postmenopausal women with vasomotor symptoms aged 40-70 years with an intact uterus. Subjects received either transdermal estradiol 50mg/day, twice weekly for weeks 1 4 or transdermal E2 50mg/day twice weekly for weeks 1 2 followed by E2 50mg/day together with NETA 140, 250, 400 mg/day (50/140, 50/250, or 50/400) transdermally during weeks 3 and 4 of a cycle. Selected QoL parameters were measured on a point indices scale. Results: Within the groups receiving combined HRT, overall healthrelated QoL mean values improved from baseline to study endpoint compared with a slight reduction in patients receiving E2 alone. Values in the E2/NETA 50/250 group were significantly better than those in the E2 only group (p=0.011). Sexual function (arousal), sleep disturbance, depressive symptoms and cognitive function scores improved from baseline to study endpoint in all treatment groups. The 50/250 group had significantly better improvement in sleep disturbance scores than the E2only group (p=0.001). Conclusions: The combination patch administering E2/NETA* improved quality of life in postmenopausal women with an intact uterus. The 50/250 patch was significantly better at improving sleep disturbances and overall health-related QoL scores than E2 alone. *Trademark - Estalis Sequi

P3.13.06 EFFECTS OF HORMONE REPLACEMENT THERAPY ON APOPTOSIS AND BCL-2 AND P53 EXPRESSION IN THE SKIN OF POSTMENOPAUSAL WOMEN Assis, JS; Fonseca, AM; Sauerbronn, AVD; Sandoval, MP; Schivartche, PL; Bagnoli, VR & Pinotti, JA Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil Objective: To quantify apoptotic cells and the presence of proteins bcl-2 and p53 in the skin of postmenopausal women. Subjects and method: A total of 19 patients were included in this study. Patients were randomly allocated to either hormone replacement therapy (n = 10) or placebo pill (n = 9). Skin biopsies were performed before and 6 months after initiation of therapy. The tunnel reaction was employed to characterize apoptotic cells, and the immunohistochemical reaction for bcl-2 and p53 expression in the epidermis. Results: There was no difference in either group regarding to age, race, and duration of menopause. Hormone replacement therapy given for six months did not substantially interfere in the quantity of apoptotic cells. The reactions for the expression of proteins bcl-2 and p53 proved negative in both groups. Conclusions: We concluded that: (1) there were no statistically differences in apoptotic rates before and after treatment between groups; (2) there were no statistically differences in the apoptotic rates by the end of the 6th month of treatment between groups; (3) the expression of proteins bcl-2 and p53 proved to be negative in all aspects analyzed.

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P3.13.07 EFFECTS OF LONG-TERM HORMONE REPLACEMENT THERAPY (HRT) ON LUMBER BONE MINERAL DENSITY (BMD) N.H. Nagata, M. Nozaki, R. Egami, K. Koera, Dept. OB/GYN, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. Objectives: This study was designed to investigate whether it is possible to predict the effect of HRT on menopausal osteoporosis at the beginning of therapy utilizing retrospective data on the change in L2-4 BMD over eight years of HRT. Study Methods: 37 subjects who were on HRT (CEE 0.625 mg/day alone or combined MPA 2.5 mg/day) over 8 years were enrolled and had BMD measured every 6 months. The average HRT duration was 8.6 years (8 10 years). BMD was measured by DEXA (Hologic QDR1000W) before and during HRT (CV<1.0%). The correlation between an increase and decrease in BMD after long term HRT and 9 related factors were examined. We focused on the closest correlation of changes in BMD after one-year HRT and divided the subjects into three groups to examine the effects on BMD after long-term HRT. Group A: BMD increased more than 1% compared to pre-treatment value. Group B: Increase was less than 1%. Group C: BMD decreased more than 1%. Results: There was a significant correlation between the increase and decrease of BMD after long-term HRT and those changes of after one year of HRT, BMD before HRT and the period when BMD reaches a maximum. BMD increased significantly in both group A and B (22 out of 23 and 3 out of 4 cases, respectively, p<0.05). However the BMD of seven out of ten subjects in Group C decreased significantly compared to pre-treatment values (p<0.05). In Groups A and B, BMD was maintained by long-term HRT but not in group C. Conclusions: It may be possible to select the optimum duration of HRT by observing changes in BMD after one year of HRT in menopausal patients of osteoporosis.

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P3.13.09 EFFETCS OF RALOXIFENE VS. PLACEBO ON DEPRESSIVE SYMPTOMS IN NON-OSTEOPOROTIC POSTMENOPAUSAL WOMEN I. Pavo (1), F. Martenyi (1), D. Masanauskaite (1), N.B. Zharkova (2), S. Metcalfe (1), D.B. Muchmore (3) (1) Lilly Area Medical Center, Vienna, Austria. (2) Mental Health Research Center of the Russian Academy of Medical Sciences, Moscow, Russia. (3) Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA. Objectives: The aim of this study was to assess the effects of raloxifene (RLX) 60 mg/d on depressive symptoms in healthy, postmenopausal women enrolled in a 1-year osteoporosis prevention trial. Study Methods: One hundred and twenty eight healthy, postmenopausal women were enrolled in a phase 3, multi-center, randomized, doubleblind trial designed to compare the effects of RLX 60 mg/d vs. placebo (PL) on the bone mineral density. In a sub-study, 36 randomly chosen, clinically non-depressed patients were assessed for effective symptoms by an independent, blinded psychiatrist using the Hamilton Depression Rating Scale (HAMD) at study entry (baseline) and after 12 months (endpoint). The changes from baseline to endpoint were initially assessed using the paired t-test. When it was concluded that the data did not follow a normal distribution (Shapiro-Wilk test), the Wilcoxon signed-rank test was performed. Results: There was no significant differences in HAMD scores between treatment groups at baseline. In the PL group (mean age, 59.3; n=18), no significant changes from baseline to endpoint were observed in the total HAMD score (-2.04.14) and in the Depression (-0.441.38), Sleep (0.500.99), and General/Somatic (-0.061.43) sub-scores; a significant decrease in the Anxiety (-1.062.07; p=0.045) sub-score was observed for PL. Women in the RLX treatment arm (mean age 58.4, n=18) showed a statistically significant improvement in the total HAMD score (-3.224.39; p=0.006), as well as in their Depression (-1.001.88; p=0.037) and Anxiety (-1.391.65; p=0.002) subs-cores; no significant changes were observed in the Sleep (-0.561.65) and General/Somatic (0.281.36) sub-scores with RLX. The between group differences in each rating were not statistically significant. Conclusions: Results of this pilot study suggest that RLX may have beneficial effects on affective symptoms in postmenopausal women. P3.13.10 EFFICACY AND TOLERABILITY OF PREMARIN CREAM FOR ATROPHIC VAGINITIS IN ASIAN WOMEN M.F. Rhoa, (1), N. Raymundo (2), Y-C Bi (3), C-H Lai (4), S.L. Yu (5), S. Raman (6), K.Y. Leung (4), (1) Wyeth-Ayerst Global Pharm., St. Davids, PA, USA. (2) Manila Central Univ, Philippines. (3) Nanjing Jiangsu Provincial Hospital, P.R., China. (4) Chang Gung Memorial Hospital, Taipei, Taiwan. (5) Queen Elizabeth Hospital, Hong Kong. Objectives: To assess the subjective, cytological and clinical effects, tolerabilty and acceptability of Premarin Cream for the treatment of postmenopausal atrophic vaginitis in Asian women. Design: 151 postmenopausal women with clinical and cytological evidence of vaginal atrophy were enrolled at 9 centers in P.R. China, Philippines, Hong Kong, Taiwan, Malaysia and Singapore. Patients ere treated with 1 gram of Premarin Cream [0.625 mg conjugated estrogens/gram] applied intravaginally on cycle days 1-21 of a 28-day cycle, for 2 cycles. Gynecological evaluations and vaginal cytology smears were performed at baseline (BL) and on study days 21 and 49. Symptoms and patient acceptability were evaluated from daily diary cards kept by patients prior to, and throughout, treatment. Tolerability was assessed through physical exams, vital signs, adverse events, and study withdrawals. Results: Statistical analysis of the study is ongoing. Changes from BL to days 21 and 49 in vaginal cytology and the clinical gynecological exam are reported. Changes in the subjective signs and symptoms of atrophy from the diary cards are also reported, as well as changes in the total symptom score. Treatment acceptability and tolerability form BL to day 49 are performed and reported. Conclusions: This study provides data in Asian women about the efficacy of therapy for atrophic vaginitis. This trial not only yields data

P3.13.08 EFFECTS OF PROGESTIN DOSE AND TIME SINCE MENOPAUSE ON ENDOMETRIAL BLEEDING WITH CONTINUOUS COMBINED HORMONE REPLACEMENT THERAPY D.F. Archer, J.H. Pickar, Clinical Research Center, Jones Institute for Reproductive Medicine, Norfolk, VA, USA. Objective: To analyze the effects of progestin dose and time since last spontaneous menstrual period (LMP) on bleeding profiles with two continuous combined hormone replacement regimens in postmenopausal women. Methods: A randomized, double-blind, multi-center trial was conducted with 553 women recruited form 99 sites. Women received a continuous oral regimen of 0.625 mg/d conjugated equine estrogens (CEE) combined with either 2.5 mg/d or 5.0 mg/d medroxyprogesterone acetate (MPA) for 1 year (12 cycles). Results: After 1 year, more women in the 5.0 mg MPA group reported no bleeding (94%) compared with women in the 2.5 mg group MPA (90%; P<0.001). After 3 cycles for women 3 years or less from their LMP, 72.4% of women in the 5.0 mg MPA group did not experience bleeding compared to 59.0% in the 2.5mg MPA group (P<0.001). This trend was also noted after 6 months and 1 year; however, those differences were not statistically significant. For women more than 3 years since their LMP, 95% of women in the 5.0 mg MPA group and 91% in the 2.5 mg MPA group reported no bleeding after 1 year. Conclusions: The continuous combined regimen of CEE plus 5.0 mg MPA may be more suitable for women closer to the onset of menopause, or for women irritating therapy who are more likely to discontinue due to irregular bleeding. Thus the improved bleeding profile with this regimen may enhance HRT compliance particularly in the early cycles of therapy.

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concerning pre and post-treatment clinical findings in a large number of Asian women, but also renders descriptive data bout the specific subjective symptoms they report, and their tolerance and acceptance of local therapy for atrophic vaginitis.

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Conclusion: Estrogen therapy had no effect on clotting factors and no benefit on fibrinolysis, despite adequate metabolic control. The results could suggest a worsening on insulin resistance.
HDLCholesterol mg/dl Placebo CE 39 8 52 16* Glycated Hemoglobin % 8.61.4 7.51.2* Insulin -90 Insulin-120

P3.13.11 ESTROGEN THERAPY DID NOT IMPROVE CARBOHYDRATE METABOLISM (CHO) IN POSTMENOPAUSAL WOMEN WITH TYPE 2 DIABETES MELLITUS (DM). C Sztejnsznajd, MER Silva, NR Melo, A Nussbacher, RT Fukui, MRS Correia, RF Santos, OE Gebara, M Weingarten, S Lage, TRF Rocha, E DAmico, BL Wajchenberg, DM Rocha, MJM Ursich Medicine School of So Paulo University, So Paulo, Brasil Estrogen replacement therapy decreases the risk of cardiovascular disease (CVD) in healthy postmenopausal women, but there are few reports on diabetic women, known to have a greater prevalence of (CVD). Methods: The effect of CE on the CHO metabolism and lipid profile was assessed in 13 postmenopausal women with type 2 DM treated with sulfonylurea. Clinical data: age, 48-63yr; BMI, 24.7-32.2kg/m2; postmenopausal for 4-10yr; duration of diabetes, 3-16yr; hypertension, 4-10yr. After adequate metabolic control, a 4-month period of placebo and an equal period of conjugated estrogens 0.625 mg/d (CE) was performed. At the end of each phase, a lipid (fast) and an OGTT (75g) was done. Weight and blood pressure remained stable .No significant differences were seen on the levels of triglycerides, total cholesterol and LDL- cholesterol .On estrogen therapy there was a significant improvement (table) on HDL-Cholesterol and glycated hemoglobin. However, on the GTTO, the glucose response remained unchanged, although, significant higher insulin levels were seen at 90 and 120 min. Conclusion: Estrogen therapy had no benefit on glucose levels fast or after the glucose load, despite improvement on glycated hemoglobin. The results could suggest a worsening on insulin resistance.
HDLCholesterol mg/dl Placebo CE 39 8 52 16* Glycated Hemoglobin % 8.61.4 7.51.2* Insulin -90 Insulin-120

mU/ml 4328 569*

mU/ml 6145 7341*

* p<0.02

P3.13.13 HORMONE REPLACEMENT THERAPY IN THE PATIENT TREATED FOR ENDOMETRIAL CANCER M. Nozaki, H. Nagata, R. Egami, K. Koera, H. Nakano, Dept. OB/GYN, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. Objectives: Adenocarcinoma of the endometrium is considered to be an estrogen-dependent neoplasm and hormone replacement therapy (HRT) for patients even after surgical treatment has been contraindicated. However, various conditions due to estrogen lack, such as hyperlipidemia, osteoporosis and vasomotor symptoms, should be treated for quality of life. Study Methods: 176 patients undergoing primary treatment for surgical stage 1 and 2 after a one-year close observation were evaluated between 1986 and 1998. Their histological grades were G1 and G2. 23 patients received HRT (0.625 mg/day of conjugated equine estrogen were administered) and 158 patients had no HRT. In the group receiving HRT, the median age was 49 years (range 38 to 62 years) and 8 of these patients had received radiation therapy after surgery. None received chemotherapy. The duration of HRT was 12-78 months. All patients gave their informed consent to participate in this study. Results: In the group receiving HRT, cancer recurrence has not been seen. In the group without HRT, however, there have been 11 recurrences. The two groups are not significantly different (p<0.05). The group receiving HRT have improved symptoms of lack of estrogen, such as hot flush, night sweats, vasomotor symptom, vaginal atrophy, hyperlipidemia and osteoporosis. Conclusions: HRT appears to have been used safely after surgically treated stage 1, 2 and histological grade G1, 2 endometrial cancer.

mU/ml 4328 569*

mU/ml 6145 7341*

* p=0,02.

P3.13.12 FIBRINOLYSIS AND CARBOHYDRATE METABOLISM (CHO) WERE NOT IMPROVED WITH ESTROGEN THERAPY IN POSTMENOPAUSAL WOMEN WITH TYPE 2 DIABETES MELLITUS (DM). C Sztejnsznajd, MER Silva, NR Melo, A Nussbacher, RT Fukui, MRS Correia, RF Santos, OE Gebara, M Weingarten, S Lage, TRF Rocha, E DAmico, BL Wajchenberg, DM Rocha, MJM Ursich Medicine School of So Paulo University, Brasil There are few reports on the effects of estrogen replacement therapy on diabetic women, known to have a greater prevalence of cardiovascular disease (CVD), but it decreases the risk of CVD in healthy postmenopausal women. Methods: The effect of CE on the CHO metabolism, lipid profile and the hemostatic system, was assessed in 13 postmenopausal women with type 2 DM treated with sulfonylurea. Clinical data: age, 48-63yr; BMI: 24.732.2kg/m2; postmenopausal for 4-10yr; duration of diabetes, 3-16yr; hypertension, 4-10yr. After adequate metabolic control, a 4-month period of placebo and an equal period of conjugated estrogens 0.625 mg/d (CE) was performed. At the end of each phase, a lipid, a haemostatic profile (fast) and an OGTT (75g) was done. Weight and blood pressure remained stable. Results: No significant differences were seen on the levels of triglycerides, total cholesterol, factors V, VII and VIII, fibrinogen, PAI1, t-PA antigen, plasminogen, C-protein and anti-thrombin -III .On estrogen therapy, there was a significant improvement (table) on HDLCholesterol and glycated hemoglobin, although on the OGTT, the glucose response remained unchanged, but significant higher insulin levels were seen at 90 and 120 min.

P3.13.14 IMPLICATIONS OF TISSUE FACTOR IN MENOPAUSE AND EFFECTS OF HORMONE REPLACEMENT THERAPY A. Vilarino, A. Scazziotta, A. Tempone, G. Jacquier, L. Penalba, S. Pns, R. Wikinski, O. Contreras Ortiz, Dept. Climaterio, Bioqumica. Hospital Clinic, University of Buenos Aires, Argentina. Objectives: Tissue Factor (TF) exposure after arterial damage plays a role in the pathogenesis of acute ischemic coronary syndrome by initiating intravascular thrombosis formation. Study Methods: We studied 62 patients. Characteristics: Perimenopausal Women (PMW) (17), Age 45, 93, 3 BMI under 25. Postmenopausal women (PostW) (45) 55 6,5 under 25 Twenty patients received 17 Bestradiol 0, 05 two months and 17 Bestradiol 0.05 plus noretisterone acetate 0.025 for two months, cross over design. TF and Tissue factor pathway inhibitor (TFPI) were determined by Inubind from American Diagnostic. Results:
PMW TF TFPI 14, 2713, 54 69, 4029, 48 PostW 27, 1618, 77 92, 5557,09 Pvalue 0.0344 0.025

PMW TF TFPI 34, 3327, 91 108, 441, 08

PI 7, 789, 04 64, 4324, 67

PII 5, 449, 4 88, 420, 8

Pvalue 0.046, 0.029 0.073

Conclusions: The increase in tissue factor might be a predisponent factor for the development of thrombogenic disease.

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P3.13.15 INTERACTION BETWEEN RALOXIFENE AND VAGINAL PREMARIN OR REPLENS IN WOMEN WITH PRE-EXISTING VAGINAL ATROPHY EFFECTS ON SEXUAL ACTIVITY B. Kessel (1), R. Basson (2), A.V. Ciaccia (2), S. Siddhanti (2), L. Plouffe (2) (1) University if Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii, USA. (2) Lilly Research Laboratories, Indianapolis, Indiana, USA. Objective: Determine the effects of raloxifene HCI 60mg/d (Evista, Eli Lilly and Company), indicated for the treatment and prevention of postmenopausal osteoporosis, on sexual activity in women with preexisting vaginal atrophy who are taking vaginal Premarin cream or Replens vaginal moisturizer. Design: 187 naturally postmenopausal women with at least 2 signs of genitourinary atrophy were randomly assigned to one of four treatment groups: double-blind oral placebo or raloxifene 60 mg/day (RLX) with open-label vaginal Premarin cream (0.5 g/day; PRM) or Replens (REP). A 10 question Sexual Activity Questionnaire (SAQ; Thirlaway et al. Quality Life Res 1996; 5:81), which assesses sexual function of women with respect to activity, pleasure, and discomfort, was administered at baseline and at 3 month endpoint. Results: Mean age and years postmenopause at entry were 59 and 9.5, respectively, 104 women acknowledged being sexually active. There were no baseline treatmentgroup differences in the mean scores for any question. For most questions, the effects were small relative to the standard deviations, preventing detection of meaningful, consistent changes. For two questions relating to coital discomfort, both PRM and REP improved vaginal dryness and dyspareunia over the course of the study. Improvements in coital discomfort were as notable for raloxifene treatment as for placebo. Conclusion: Both PRM and REP are associated with improved SAQ scores for discomfort. RLX did not modify treatment response to PRM or REP. P3.13.16 MAMMOGRAPHIC PATTERN IN THAI CLIMACTERIC WOMEN R. Wattanayingcharoenchai, U. Theppisai, U. Udomsubpayakul, Dept. OB/GYN, Research Center, Ramathibodi Hospital, Bangkok, Thailand. Objectives: To study the breast imaging reporting and data system (BIRADS) mammographic category in climacteric women and its relation to age, menopausal status and parity. Study Methods: 1,001 climacteric women without hormonal replacement therapy, who had attended menopause clinic from March 1994 to November 1998, were included in this study. A screening mammogram and breast ultrasound that performed in all subjects were standard technique. The mammogram finding was interpreted using the recommendation of the American College of Radiology Breast Imaging Reporting and Data Systems (BIRADS). Chi-square test was used to analyze relationship of mammogram finding to age, menaopausal status and parity. Results: The age range of climacteric women were 40-75 years, which consisted of 22% premenopause, 33.8% perimenopause and 44.1% postmenopausal women. By using BIRADS category, 58.4% were in category 1, 36.5% in category 2, 2.8%, 2.0% and 0.3% in category 3, 4 and 5 respectively. Most cases of mammographic category 2 were dense breast, benign calcification, benign axillary lymph nodes, simple cysts, fibrocystic disease and fibroadenoma. All cases in mammographic category 3 had undergone mammogram and found no evidence of malignancy. The biopsy which was performed in 50% of cases in category 4 showed fibroadenoma and fibrocystic disease. 15% of women in category 4 underwent clinical examination and mammogram and the rest had lost follow-up. Only 1 in 3 cases in category 5 was intraductal carcinoma. The study had shown statistically relationship between mammographic category and parity, but no relation with age and menopausal status. Conclusions: In clinical practice, screening mammogram, using BIRADS category, can divide women into 2 groups: (1) category 1 and 2, whose mammograms are clearly normal and benign, require annual screening only; and (2) category 3, 4 and 5 need further management depending on the results of the mammogram. Moreover, the BIRADS category can help reduce unnecessary invasive procedure.

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P3.13.17 MENOPAUSE AS A DEMOGRAPHIC VARIABLE OF THE LOWBIRTH RATE ENVIRONMENTAL AREA M. Mirkovic (1), M. Bogavac (1), V. Grujic (2) (1) Dept. OB/GYN, Clinical Center of Novi Sad, Novi Sad, Yugoslavia. (2) Institute of Health Protection, Novi Sad, Yugoslavia. Objective: The aim of this study was to collect the data on the timing of menopause in the low-birth rate environmental area of the Yugoslav Province of Vojvodina. Study Methods: There were 175 women comprised in the study. The data on menopause was obtained by an inquiry introduced during a direct contact with the women. Results: The menopause in our materials occurs at 47 + 4.48 years. It most often occurs in the age group of 50.5 years. The menarcheal median is presented with 45.65 + 0.42. There are no significant differences in menarche timing between the native and newcomer populations in Vojvodina. Relative to the occupation, the menopause occurs later in the housewives (48.45 years) than in the workers (46.33 years). The longer length of service the later menopause timing (the length of service 0 - 10 years: the menopause occurring at 45 years; the length of service of more than 31 years: the menopause occurring at 47.11 years). Increased number of abortions affects earlier menopause: 5 and more than 5 abortions give menopause at 46.50 years. According to our data, the number of deliveries does not significantly influence the menopause timing. Earlier menarche gives later menopause: menarche at the age of 12 menopause at 49.42 years versus menarche timing at 18 years with the following menopause at the age of 45. Conclusion: 1. There are initial signs of postponing menopause timing in the Province of Vojvodina. 2. There is also a phenomenon of menarche acceleration. 3. Since 1989 the birth rate in Vojvodina has been negative. The specific fertility rates in the population over 34 years of age are irrelevant. Prolongation of the fertile period can, beside other factors, be of vital significance for Vojvodina the low-birthrate region in Yugoslavia.

P3.13.18 NATURAL ESTROGENS: A WAY TO IMPROVE WELFARE OF WOMEN IN POSTMENOPAUSAL PERIOD W. Kurach, C. Poduszczak, Dept. GYN, University Teaching Hospital, The Foundation for the Development of MMA, Warsaw, Poland. Objectives: The objective of the research was the evaluation of the influence natural estrogens on well being women in postmenopausal period. Study Methods: Forty women 58.2 years of age on average, at least 12 months after menopause. All patients underwent a continuous treatment without bleeding with Oestrofeminal from Mack oral pills containing 0.3 mg of estriol per pill. In order to assess the symptoms of climacteric syndrome five-group Greens scale was used. The intensity of complaints was assessed subjectively by the patient in the scale from 0 to 3 in six categories. Results: Within the six categories of climacteric symptoms the following results were obtained. (1) Psychological symptoms were diminished by 37% (2) Somatic symptoms were diminished by 42% (3) Vegetative symptoms were diminished by 37% (4) Anxiety and nervousness were diminished by 29% (5) Depression was diminished by 21% (6) The total point index in Greens scale decreased by 36% Conclusions: Natural estrogens dosed 0.3 mg per day is affective remedy diminishing climacteric symptoms by the 36% during the first three months of treatment. It seems to be particularly effective in treatment of psychological and somatic symptoms which accompany menopause.

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P3.13.19 PREVALENCE OF CLASSIC RISK FACTORS IN CLIMACTERIC WOMEN WITH CORONARY ARTERY DISEASE. E.R.G. Alexandre; D. Armaganijan, Department of Coronary Heart Disease, Dante Pazzanese of Cardiology Institute, So Paulo, Brazil. S.M.R. Rolim-Lima; J.M. Aldrighi, Department of Maternal-Infantile Health, Public Health School of So Paulo University, So Paulo, Brazil Objective: The incidence of coronary artery disease (CAD) increases during climacteric period. The aim of the study was to investigate the preval ence of the classic risk factors. Study Methods: Sixty-five patients (pts) were included for a period of fifteen months (98/10 to 2000/01), aged 37-64 years (mean = 51,69 + 7,13 years). They were divided into three age groups: Group I (GI) > 35 < 45 years; GII > 45 < 55 and GIII > 55 < 65. All of them have confirmed CAD by angiography. Results: The prevalence of the risk factors in the different groups are: GI (n = 13 pts): Familiar Antecedents = 61,5%, Hypertension = 92,3%, Hyperlipidemia = 69,2%, Tabagism = 84,6% and Diabetes = 38,5%; GII (n = 31 pts) Familiar Antecedents = 64,5%, Hypertension = 80,6%, Hyperlipidemia =74,1%,Tabagism=67,7% and Diabetes = 35,4%; GIII (n = 21 pts) Familiar Antecedents = 66,6%, Hypertension = 85,7%, Hyperlipidemia = 76,2%, Tabagism = 47,6% and Diabetes = 19%. Conclusions: The prevalence of familiar antecedents from CAD and hyperlipidemia was the same in the three age groups. The hypertension was the most prevalent in all groups, followed by tabagism and diabetes. There was a significant statistical difference in the prevalence of tabagism: in the group I. P3.13.20 RECOVERY OF MASS AND OF MUSCULAR TONE IN MENOPAUSE WITH HRT: PROSPECTIVE STUDY G.R. Lai, M.F. Careddu, F. Dore, B. Gigliotti The Authors have wanted study the modifications of the mass, of the tone, of the standard strength and of that specifies, of the femoral quadriceps in women in menopause in transdermal substitutive hormonal therapy versus that oral. I had selected 2 croups of 60 [ oral: A ] and 30 [ transdermal: B ] patients observed for 12 monthes across ultrasaund monitoring, isochinetics electromyography and isometric, electromyography against leg, test of Kotz. In the evaluation to 6 monthes the muscular mass, the tone, forces you/it and the ability of electrical transmission were grown of the 58-66% [group A] and of the 20-23% [group B ]: _>3.841. Thecheck to 12 monthes the result were of the 85-91% [group A] and of the 30-33% [ group B ]: _>6.635. In conclusion the therapies have statistically meaningful differences in the comparison of the maintenance and of the possible recover of the muscular performance, important element in the woman life quality in young menopause, of tall sociocultural level with life expectations of great quality.

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and early postmenopausal group. Furthermore, we found no correlation between skin thickness and chronological age. Conclusions: The decline in skin thickness of women entering menopause requires a period of time to undergo significant alterations and the study revealed a significant reduction of skin thickness as early as in the course of the early postmenopausal period.

P3.13.22 SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) AND HORMONE REPLACEMENT THERAPY (HRT) Chuery, ACS; Fonseca, AM; Pdua, MAF; Bagnoli, VR; Sauerbronn, AVD; Burgos, RM & Halbe, HW. Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil. Objective: To analyze clinical and laboratorial findings in patients with Systemic Lupus Erythematosus (SLE) submitted to hormone replacement therapy (HRT). Methods: Sixty-five menopausal women with SLE were included in this study. Age, initial complaint, Kuppermann Menopausal Index (KMI) and lipids screening were evaluated before and after 2 years of HRT. Patients were divided into 3 groups according to the HRT regimen used: Group A: association of estrogen and progestin (n = 31); Group B: estrogen therapy alone in patients submitted to hysterectomy (n = 7); and Group C: progestin therapy alone (n = 27). Results: The mean patients age was 46,4 years. The main complaint was hot flushes in 49,7%. No changes were found in the lipids screening. In Group A, 74,2% of the patients had clinical improvement, and 9,7% of cases had complications related to SLE. In Group B the clinical improvement was observed in 71,4% and no complication related to SLE were found. In Group C 74,1% had clinical improvement and 7,4% had complications related to SLE. Conclusions: During the follow-up time analyzed the majority of women had important improvement in climacteric symptoms, without clinical complications of Lupus with the introduction of HRT P3.13.23 THE DYNAMICS OF VEGETATIVE REGULATION OF THE HEART RATE IN PATIENTS WITH SURGICALLY INDUCED MENOPAUSE B. Ventskovsky, N. Yarotsky, Yu. Sirenko, O. Kupnovitsky, V. Zhegulovich, A. Senchuk, National Medical University, Kiev, Ukraine Objectives: To assess the changes of the blood pressure (BP) and heart rate variability after surgical menopause. Study Methods: 25 patients (average age 475 years) have been investigated before and in the 6-months period after ovaryectomy. Twofunctional 24-hours monitoring (ECG, BP) was performed with the use of system Cardioteus (Meditech, Hungary) before the operation and on days 3, 30 and 180 after operation. We have evaluated the daily BP profile, its average value and variability, and the indices of heart rate variability. Results: Vagotonic type of cardiac rhythm regulation was predominant before the operation together with the hypotension and low variability. From the 3rd day on after the surgery 55% of the patients have shown the increasing sympathetic component (group 1), while the remaining patients had vagotonic type (group 2). In 72% of group 1 this was followed by the rising of average BP. On the day 180th of the follow-up 45% of the patients from group 1 have developed the arterial hypertension. Conclusions: The investigation of the vegetative regulation of the cardiac rhythm makes possible the prediction of arterial hypertension on the background of sympatheticotonia in the early postoperative period.

P3.13.21 SKIN THICKNESS IN DIFFERENT MENOPAUSAL STATUS K. Panyakhamlerd, P. Chotnopparatpattara, N. Taechakraichana, A. Kukulprasong, S. Chaikittisilpa, K. Limpaphayom, Dept. OB/GYN, Chulalongkorn University, Bangkok, Thailand. Objectives: This study was performed to compare the skin thickness of Thai women in their premenopause, perimenopause and early menopause. Study Methods: 112 women between 40 and 60 years of age, visiting the menopause clinic, King Chulalongkorn Memorial Hospital, were divided into 3 groups: premenopause (N=31), perimenopause (N=35) and early postmenopause (N=46). Skin thickness was measured by ultrasonography using an Acuson 128 with a linear 7.5 MHz probe at the right great trochanter area. All tests were performed by the same radiologist. Each measurement was made six times before the mean was calculated. Results: The mean skin thickness in each group was 2.28 0.39 mm, 2.18 0.35 m, and 2.02 0.36 mm respectively. The skin thickness of women in the early postmenopausal group was significantly lower than those in the premenopausal group, but no difference was found between premenopausal and perimenopausal group nor between perimenopausal

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P3.13.24 THE EFFECT OF RALOXIFENE ON THE INCIDENCE OF SURGICAL INTERVENTION FOR PELVIC FLOOR RELAXATION S. Goldstein (1), P. Neven (2), S. Eckert (3), Y.L. Taylor (3), A.V. Ciaccia (30, L Plouffe Jr. (3) (1) Dept. OB/GYN, NYU Medical Center, New York, New York, USA, (2) Dept. OB/GYN, Algemene Kliniek St Jan, Brussels, Belgium. (3) Lilly Research Laboratories, Indianapolis, Indiana, USA. Objectives: Estrogen has been traditionally considered to have positive effects on pelvic floor relaxation, although no randomized, clinical trials have validated this perception. Pelvic floor relaxation has been associated with two SERMs to date, levormeloxifene and idoxifene. The objective of this analysis was to determine whether raloxifene increased the incidence of pelvic floor relaxation requiring surgical intervention, as compared with placebo. Study Methods: Safety data from 3 double-blind, placebo-controlled, randomized clinical trials of osteoporosis, which enrolled a total of 6926 postmenopausal women without prior hysterectomy treated for 36 months, were pooled for this analysis. Studies 1 and 2 enrolled younger (mean age =54.8; n=969), healthy postmenopausal women randomized to 30, 60, or 150 mg/day raloxifene or placebo. Study 3 enrolled older (mean age = 66.5; n=5957) osteoporotic, postmenopausal women randomized to raloxifene 60 or 120 mg/day or placebo. Indications for any reported pelvic surgeries were identified. Procedures performed for pelvic floor relaxation or urinary incontinence, including hysterectomies, were included in this analysis. Results: When considering all surgical procedures for pelvic floor relaxation, including hysterectomies, a total of 34 (1.5%) patients in the placebo group and 38 (0.8%) patients in the combined raloxifene groups underwent a surgical procedure for some type of pelvic floor repair. The relative risk for pelvic floor repair was 0.51 (95%CI: 0.32, 0.80). There was an overall statistically significant reduction in the incidence of procedures indicated for the treatment of pelvic floor relaxation in the combined raloxifene groups, as compared with the placebo group. (p=0.004). Conclusions: These findings suggest that raloxifene may help reduce the incidence of pelvic floor relaxation requiring surgery.

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Conclusions: Although ET-1 levels were not statistically affected during the course of the study, we propose that the significant decrease noted on carotid artery pulsatility index shows that tibolone has a positive effect indirectly on the peripheral vascular system in spite of significantly decreased HDL levels. P3.13.26 THROMBOPHILIC PROFILE OF CLIMATERIC AND MENOPAUSED WOMEN WITH VENOUS THROMBOEMBOLISM WHO ATTENDED THE GYNECOLOGY SERVICE OF SO PAULO UNIVERSITY HOSPITAL Margarido, PFR.; Junqueira, PA; Bagnoli, VR; Fonseca, AM; Halbe, HW; Pinotti, JA Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil Objectives: Evaluate the thrombophilic profile and risk factors associated of climateric and menopaused women with history of venous thromboembolic disease who attended the Gynecologi Service of So Paulo University Hospital. Methods: Between January 1997 and December 1999, 18 women with past history of venous thromboembolic disease were evaluated. The age ranged from 35 to 70 years. The diagnostic of the disease was based on mediacal history, past history of heparin and other anticoagulant use and doppler of venous sistem from lower limbs. A research for thrombophilic states for eligible cases was conducted based on the quantification of antithrombin III, proteins C and S, lupic anticoagulant and anticardiolipin anti-bodies (IgG e IgM) seric levels. The women were questioned about tabagism, use of hormone replacement therapy during the ocurrence of thromboembolism and other clinical conditions associated. The body mass index was calculated for all patients. Results: All 18 cases were considered as having a past history of thromboembolic disease. The median age was 49,9 years. Patients were diveded in 3 groups according to the first episode of the disease: 66,7% had venous thombosis; 22,2% had pulmonary embolism; and 11,1% had thrombophlebitis. The median age at the first episode was 43,6 (17-70 years). In 7 cases (38,9%) at least one associated thrombophilic factor was identified. Out of these cases, 4 (57,1%) were positive for lupic anticoagulant (1 was associated to protein S levels below the normal range and other was associated to IgG anticardiolipin anti-body); 2 cases (28,6%) were positive for anticardiolipin anti-body only; 1 woman (14,3%) was identified as carrier of protein C deficience. In relation to the associated risk factors 50% were found to be overweight (25>BMI<30); obesity (BMI>30) was found in 22,2%; and tabagism in 27,8%. In 6 cases (33,3%) the thromboembolic episode ocurred during hormone replacement therapy. In 3 of these cases there were found a thrombophilic state in later investigation Conclusions: As suggested by this study, BMI bigger than 25 and age over 40 years are important risk factors for the developing of tromboembolic disease. Among the cases wich develop the disease during hormone replacement therapy the prevalence of thrombophilic state may (can?) be as high as 50%.

P3.13.25 THE EFFECTS OF TIBOLONE ON PERIPHERAL VASCULAR SYSTEM Sleyman Engin Akhan, Blent Baysal, Esra Akgz, Abdullah Turfanda Department of Obstetrics and Gynecology, Istanbul University Faculty of Medicine, Istanbul, Turkey. Objective: The effect of tibolone, a synthetic steroid used in HRT, on the cardiovascular system and the biomolecular mechanism of this effect is not exactly known. The aim of this study, is to evaluate the effect of tibolone on the vascular system by evaluating its action on endothelin-1 (ET-1), the most potent vasoconstrictor agent, and its correlation with carotid pulsatility index and lipid profile. Materials and Methods: Our study group was composed of 32 women aged between 45 and 55 years with no systemic disease, who were postmenopausal for at least a year, have FSH > 40 IU/ml and have body mass index < 30 kg/m_. Initially, endothelin-1 and FSH levels, lipid profiles were measured and internal carotid artery Doppler USG was performed in all patients. All of these parameters were repeated after 6 months of tibolone use. Results were expressed as p value, mean starting valuestandart deviation vs. mean ending valuestandard deviation, Z value. Wilcoxon signed rank test was used during the statistical analysis and p value < 0.05 was accepted as statistically significant. Results: The average age of the patients was 49.53.5 years and the average postmenopausal age was 70.554.4 months. Twenty-five out of 32 patients have completed the study. The BMIs measured after the study was siginificantly increased (p=0.08, 26.363.73 vs. 27.063.3, Z= -2.66). After six months of tibolone treatment while HDL levels were significantly decreased (p=0.06, 48.327.3 vs.42.97.2, Z= -2.734), no significant change was observed in LDL levels (p=0.135, 158.219.98 vs. 154.5214.9, Z= -1.495). Although the decrease in ET-1 levels were not significant (p=0.819, 10.251.92 vs. 9.61.91, Z= -0.229), internal carotid pulsatility index measured after 6 months were significantlly decreased.

P3.13.27 TRANSVAGINAL COLOR DOPPLER SONOGRAPHIC EVALUATION OF THE UTERUS IN POSTMENOPAUSAL WOMEN ON DAILY RALOXIFENE THERAPY A. Chittacharoen, U. Theppisai, Dept. OB/GYN, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. Objective: To evaluate the effect of raloxifene on the endometrium and the uterus by transvaginal color Doppler sonography. Study Methods: The study group was composed of 33 asymptomatic postmenopausal women. All had been treated with raloxifene (60 mg/day) daily for 6 months. The patients underwent transvaginal color Doppler sonography before starting raloxifene and after treatment. The uterus was scanned by transvaginal ultrasound to evaluate endometrial thickness, echotexture and uterine volume. Color and pulsed Doppler ultrasound were used to evaluate the pulsatility (PI) and resistance (RI) indices of both uterine arteries. The mean values of the endometrial thickness, uterine volume and the PI and RI of the uterine arteries were used for statistical analysis. Results: The mean endometrial thickness (3.63 1.14 vs. 3.58 0.97 mm) and uterine volume (40.85 18.61 vs 37.93 19.76 ml) were not significantly different between starting treatment and after treatment

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(P>0.05). The mean value of the PI (3.42 1.54 vs 3.84 1.37) and RI (0.93 0.11 vs 0.98 0.10) of the uterine arteries were not significantly different between before starting treatment and after treatment (p>0.05). Conclusion: Daily therapy with raloxifene does not stimulate the endometrium, the uterus and uterine blood flow. P3.13.28 TREATMENT OF DRY EYES IN POSTMENOPAUSAL WOMEN WITH HORMONE REPLACEMENT THERAPY S. Chaikittisilpa (1), N. Taechakraichana (1), K. Panyakhamlerd (1), K. Limpaphayom (1), W. Tulvatana (2), Chulalongkorn University, Bangkok, Thailand. (1) Dept. OB/GYN (2) Dept. Ophthalmology Objective: The aim of the study was to investigate the effects of hormone replacement therapy on dry eyes in postmenopausal women. Study Methods: A prospective, randomized, placebo-controlled trial was conducted in King Chulalongkorn Memorial Hospital to investigate the efficacy of conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5 mg daily on tear volume in postmenopausal women. A total of 27 postmenopausal women were randomly assigned to receive the treatment, 13 cases with conjugated equine estrogen plus medroxyprogesterone acetate, 14 cases with placebo for 12 weeks. The tear volume was measured by Zone-Quick test before and after the treatment. The symptoms of dry eyes were recorded in visual analogue scale. The statistical analysis was unpaired ttest. Results: The two groups were not different in age, year since menopause, body mass index (BMI) or initial tear volume. The tear volume was significantly increased in the hormonal group after 12 weeks of treatment (P<0.05), but the placebo group was not. There was no significant difference between groups in the tear volume after the treatment. The eye symptoms were not significantly changed in both groups. Conclusions: The treatment of dry eyes in postmenopausal women with conjugated equine estrogen plus medroxyprogesterone acetate neither increased the tear volume nor improved eye symptoms within three months.

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control examination we found only one fetus, regularly developed, and in a separate amniotic cavity, a fetus without heartbeat with a small quantity of amniotic fluid in a bizarre position. Patient was immediately admitted in the hospital. Ultrasonographic examination, as well as routine laboratory analyses were repeated every ten days. After the 28th week of gestation we included a cardiotocographic (CTG) control every five days. In the 38th week the birth was finished by Cesarean section (indication for operation previous Cesarean section). A female child was born. After delivery, placenta was extracted with membranes which contained a dead fetus, 12 cm in length. After recovery which lasted seven days, the patient was dismissed in good condition with a healthy baby. Conclusions: An ultrasound examination proved to be of great help in making a diagnosis. It is very important to make a diagnosis in time, because if we do not do this, we will probably have great and heavy complications.

P3.14.03 ACTIVATED NITRIC OXIDE SYNTHASE EXPRESSION IN RECIPIENT'S PLACENTA FROM MONOCHORIONIC TWINS WITH TTTS M. Nobunaga1, M. Kanai1, T. Mizutani2, N. Suehara2, A. Nakajima3, R. Chin3, T. Nobunaga3, T. Kimura3, M. Koyama3, C. Azuma3, Y. Murata3 1 Kanai Women's Clinic, Osaka, Japan, 536-0004, 2Dept. OB, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan, 594-1101, 3Dept. OB/GYN, Faculty of Medicine, Osaka University, Osaka, Japan, 565-0871 Objectives; We investigated whether Nitric Oxide (NO), recognized to have various biological effects on mammalian cells, contributes to the pathophysiology of TTTS, which has an extremely high perinatal mortality and morbidity. Study Methods; Ten MD twin pregnancies without TTTS and 6 MD twin pregnancies with TTTS after 28 gestational weeks were studied._@ The concentrations of NO2-+NO3-, stable metabolites of NO, in amniotic fluid and umbilical plasma were measured. Western blot analysis and immunohistochemistory were also carried out to examine the expression of NOS in the placenta. Results; The NO2-+NO3- concentrations of amniotic fluid (24.0 _M) and umbilical plasma (58.5 _M) in 10 twins with TTTS were significantly higher than those of amniotic fluid (11.5 _M; p<0.01) and umbilical plasma (27.0 _M; p<0.005) of 8 MD control twins. Western blot analysis and immunohistochemistry revealed faint NOS I (ncNOS) protein in the syncytiotrophoblast of all of recipient, donor, and MD control twins and the expression of NOS II (iNOS) in the syncytiotrophoblast of MD twins with TTTS. NOS III (ecNOS) expressions in syncytiotrophoblast and endothelium of all of recipient, donor, and MD control twins were detected. The NOS III expression was three- to four-fold higher in donor's placenta compared with MD control twins. On the other hand, the protein of placenta from recipient twins expressed NOS III more than 10 times of MD control twins. Conclusions; We have demonstrated the elevated NO production in the placenta of MD twins with TTTS, suggesting that NO contributes to keep low vascular resistance and that the cytotoxicity of overproduced NO causes the high perinatal morbidity and mortality in TTTS twins. P3.14.04 ANTENATAL DIAGNOSIS OF TWIN-TWIN TRANSFUSION SYNDROME BY DOPPLER ULTRASOUND A. Hajric-Egic, Z. Mikovic, A. Cirovic, D. Filimonovic, V. Mandic, OB/GYN Narodni Front University Clinic, Belgrade,Yugoslavia. Objectives: The present study used Doppler ultrasound to analyze the usefulness of umbilical arterial velocimetry for predicting the risk of twin-twin transfusion syndrome. Study Methods: We studied 145 pairs of twins born at the Narodni Front OB/GYN University Clinic in Belgrade between January 1996 and June 1998. Eight of 145 pairs of twins had twin-twin transfusion syndrome. Using pulsed Doppler evaluation of the umbilical artery of each twin, the pulsatility index (PI) was used to evaluate the umbilical arterial waveforms. Results: Eight cases of twin-twin transfusion syndrome were diagnosed (5.5%). Four cases resulted in spontaneous abortion between 23-26

P3.14 MULTIPLE GESTATION P3.14.01 A CASE OF TRIPLET GESTATION COMPLICATED BY THE ANTENATAL DEATH OF TWO FETUSES AND THE SURVIVAL OF THE THIRD FETUS L. Zanotti, A. Contarini, A. De Rosi, Ospedale Civile S. Maria delle Croci, Ravenna, Italy. Case Report: A case of triplet gestation complicated by the antenatal death of two fetuses and the survival of the third fetus until the 32nd week. The two fetuses had monochorionic placentation. One of them died at the 22nd week, the second one at the 20th week. The surviving fetus had its own placenta. We adopted a conservative management until the fetal lung was mature with cortisonic, antibiotic, heparin and ritodrine therapy. Cesarean section was performed on the 32nd week. P3.14.02 ABNORMALITY OF TWIN PREGNANCY: FETUS PAPYRACEUS CASE REPORT N. Sulovic, M. Dunjic, S. Stanisic, L.J. Savic, Dept. OB/GYN, University Clinic, School of Medicine Pristina, Belgrade, Yugoslavia. Objectives: The aim of the work is to study the development of a twin pregnancy after one of the twins died in early pregnancy and the possible negative influence on the clotting system of pregnant women. Study Methods: Observation was done on patient DM, a 30 year-old housewife. She was observed from her first appearance at the department. Personal and family anamnesis was regular. She had one delivery three years ago with Cesarean section. Results: In the first ultrasonographic examination we found a twin pregnancy with obvious heartbeats of both twins. After two weeks on

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weeks and four in premature delivery between 28 and 35 weeks. Five of sixteen fetuses survived (mortality 69%). The differences in the PI (above 0.5) from twin-twin transfusion syndrome cases between 23 and 35 weeks, significantly exceeded those of the cases without this syndrome (p<0.05). Conclusion: The difference in PI umbilical artery seemed to predict the risk and prognosis of twin-twin transfusion syndrome, even before the onset of severe discordant growth and severe amniotic fluid disparity.

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the last twenty years no other case was mentioned in Romania. There is no possibility to state an etiological diagnosis. Embriologically, we defend the fusion theory (Winslow), proved by ORahilly (1998): gemelarity trouble during the 1st week.

P3.14.06 CERVICAL LENGTH MEASURED BY TRANSVAGINAL ULTRASONOGRAPHY IN TWIN PREGNANCIES M. Kudela, M. Prochzka, Dept OB/GYN, University Hospital, Olomouc, Czech Republic. Objectives: The aim of the study was to evaluate cervical length in twin pregnancies by transvaginal ultrasonography as a predictor of premature labor. Study methods: Thirty-two women with twin pregnancies without premature uterine contractions were evaluated by the means of vaginal ultrasound every second week between the 16th and 34th week of gestation. The length of the functional part of the cervix as well as the formation of funnellling was recorded. Signs of genital infection were also searched for. In case of cervical shortening below 25 mm before the 28th gestational week the patients were randomized for bed rest of cerclage (as a part of the CIPRACT project). Results: The mean length of gestation in the whole group was 35.5 weeks. Twenty-one pregnant women (66%) delivered after the 36th week. In the 23rd week of gestation the average length of cervix in those who delivered after the 36th week was 33.56.8 mm. The mean cervical length in the second group (delivery before the 36th week) was 21.65.5 mm. The difference was statistically significant (p=0.01). Genital infection (increased CRP, WBC, HVS and pH) in the latter group was found in 27%. The results of conservative treatment (bed rest) versus surgical treatment (cerclage) will be evaluated according to the COIPRACT protocol. Conclusions: Transvaginal ultrasonography seems to be a powerful diagnostic tool for assessing the risk of premature labor in twin pregnancies.

P3.14.08 ONE CHANCE OF DIAGNOSIS AND TREATMENT FOR UTERUS DIDELPHYS WITH UNILATERAL IMPERFORATE VAGINA COMPLICATED BY TRIPLETS PREGNANCY: CASE REPORT Chunping Jiang SheKou People's Hospital, Shenzhen, Guangdong, China (518067) Object: To summarize the artificial abortion characteristic of uterus didelphys with unilateral imperforate vigina complicated by pregnancy and learn more knowledge about the kind of cases. study methods: The clinical presentation of a case of uterus didelphys with unilateral imperforate vagina complicated by triplets pregnancy is analyzed and the literature from 1922 is reviewed. results: uterus didelphys with unilateral imperforate vagina is a kind of genitous anomaly.It includes a series of urogenital anomalies.So far its etiology and pathogenesis are unknow.There is no identical name and classification internationally.A lot of the kind of patients can't be diagnosed because its clinical presentation is not specific feature for the anomaly.It's artificial abortion process is more difficult and clinical pesentation after abortion is special.It gives a chance to diagnoses and treat. Conclusion: Artificial abortion is a chance of diagnosis and treatment when the case is complicated by pregnancy. P3.14.09 OUTCOME OF TWIN PREGNANCIES IN NORTH JORDAN S. Ziadeh, Dept. OB/GYN, Jordan University of Science and Technology, Amman, Jordan. Objective: The purpose of the study was to analyze the course of pregnancy and perinatal outcome of 386 twins. Study Method: Retrospective analysis of maternal and neonatal medical records of 386 twin pregnancies at Princess Badeea Teaching Hospital, North Jordan from January, 1996 to June, 1999. Results: During the study period, there were 3305 deliveries of which 386 were twin pregnancies (1/86). The gross perinatal mortality rate was 178 per 1000 twin births. The perinatal mortality rate for singleton births during the same period was 10 per 1000. Out of 772 twin babies, 108 were breech. Breech presentation was associated with the highest perinatal mortality rate (278 per 1000). 184 out of 386 twin pregnancies were preterm. The highest perinatal mortality rate occurred in the preterm group (184.78 per 1000). The neonatal mortality rate fell with increasing birth weight from 532 per 1000 at 1500g. to 16 per 1000 at 2500g. Regarding the association between modes of delivery and perinatal mortality, the highest mortality occurred with the babies whose births were by assisted vaginal delivery (144 per 1000). Conclusion: Prematurity and low birth weight were associated with high perinatal deaths. Various ways of reducing perinatal mortality associated with twin pregnancies, ranging from prophylactic use of betasympathomimetics to bed rest in prevention of preterm labor have been suggested. In Jordan, emphasis must be placed on adequate antenatal care and the increased use of ultrasound in modern obstetrics has resulted in earlier detection of twin pregnancies and greater supervision. Perinatal outcomes may improve by proper management of complications such as preterm labor, PIH, malpresentation. Keywords: Twin pregnancy, Neonatal outcome. P3.14.10 PERIPARTUM COMPLICATIONS OF UNDIAGNOSED TWIN PREGNANCIES S.A. Obed, Dept. OB/GYN, University of Ghana Medical School, Accra, Ghana. Objectives: The study was aimed at finding out why undiagnosed twins continue to be managed at delivery in a leading teaching hospital in

P3.14.07 DICEPHALIC CONJOINED TWINS A CASE REPORT F. Pricop, E. Crauciuc, M. Stavarache, D. Gafitanu, O. Masheh, 3rd Clinic OB/GYN, University of Medicine and Pharmacy, Iasi, Romania. Objectives: Presentation of one case of dicephalic conjoined twins, a are malformation with a frequency of 1/50,000 births in the world. Material and Method: The patient D.M.E., 25 years old, of urban medium, was hospitalized with the diagnosis: VI pregnancies, II births living infants, dicephalic fetus in complete pelvic presentation, activated birth, having 2 antecedent normal children and without a competent antenatal medical consultation. An emergency cesarean section was performed because of a fetus-pelvis disproportion, delivery departed, and the conception product was extracted: dicephalic conjoined twins, with a weight of 4100 g, size 46 cm, right cranial perimeter 35 cm, left cranial perimeter 36 cm, thoracic perimeter 40 cm, abdominal perimeter 35 cm, who lived for 30 minutes. The specimen has been investigated radiologically and echographically before dissection through a tomograph computer. Results: The anatomic examination showed: normality of cranial extremities (skull, soft parts and central nervous system); spines united in the oversacral lumbar segment; median lung aplasia in symmetry, lateral lungs were normal; heart with a sole ventricle and bifid at the atrial pole; aortic arch in symmetry, with right and left sub-clavicular arteries retro-visceral; a sole trilobate thymus; sole liver and milt; digestive duct doubled in symmetry, but located latero-lateraly at the level of the medi-enteric intestine; double pancreas and biliary vesicles in and two lateral kidneys, in normal position; sexual apparatus female sex with an important caudal appendage, located around a cavity with cloacal aspect. The hystologic examination did not show important modifications. Conclusions: The complex examination of the specimen allow us to state that the diagnosis is: dicephalus dibrahii dipus conjoined twins, during

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Ghana, the associated maternal and perinatal morbidities and how to reduce the incidence. Study Methods: The details of age, parity, antenatal care, maternal and perinatal complications of all 806 twin deliveries managed at the Korle Bu Teaching Hospital, Accra, Ghana in the two-year period from 1st Jan. 1997 to 31st Dec. 1998 formed the database. One hundred and eightyone of these undiagnosed twin cases at the time of delivery were matched against the 605 diagnosed for analysis. Results: The high incidence rate of 22.4% of twins delivered at the hospital were undetected before confinement was mainly due to poor antenatal care. There were significantly higher maternal and perinatal morbidities in the undiagnosed twins compared to those detected before delivery. Conclusion: Improving the antenatal care of patients managed at the levels A and B of the Primary Health Care System could enhance the detection rates of twin pregnancies, and a better maternal and fetal outcome. P3.14.11 TWINS AS A RISK FACTOR FOR GESTATIONAL OUTCOME R.A.M. S, R.B.R.G. Bornia, A.A. Cunha, N.R. Silva, M.J. Franco, J.E. Nejain, Dept. OB/GYN, Maternidade Escola, Faculdade de Medicina, Universidade Federal do Rio De Janeiro, RJ, Brazil. Objective: To assess multiple gestation as a risk factor for pregnancy outcome. Study Methods: The study design was a retrospective cohort. From Jan. 1, 1996 to Oct. 31, 1999, 5555 pregnancies were observed at the Maternidade Escola da UFRL/RIO/BRASIL. The inclusion criteria was gestational age >21 weeks. The study factor was a twin pregnancy. They were 172 (3.1%). Results: The multiple gestation, compared to singleton one, was a risk factor for pre-eclampsia. (RR=2.28, CI=1.68-3.10), eclampsia (RR=12.52, CI=2.45-64.07), pre-term delivery threat (RR=4.43, CI=3.12-6.29), hemorrhage in the 3rd trimester of pregnancy (RR=2.85, CI=1.03-7.83), premature rupture of membranes (RR=1.35, CI=1.071.69), lower gestational age (34.93.3 vs 38.42.8, -3.5 weeks, p<0.001) and lower gestational birth weight (2238 692 vs 3157 614, -919 g, p<0.001). Conclusions: Twin pregnancy is a risk factor for gestational outcomes associated with toxemia, pre-term delivery, premature rupture of membrane, lower gestational age and lower birth weight. P3.15 NEONATALOGY P3.15.02 BRAIN CIRCULATION AT NEWBORNS WITH PERINATAL PATHOLOGY N. Bashakin, A. Aksenow, I. Antipova, M. Troickaya Moscow Regional Scientific Research Institute OB/GYN, Moscow, Russia Objective: The aim of the study was to investigate parameters cerebral circulation (CC) at newborns with perinatal pathology. Study Methods: We used transcranial ultrasonic dopplerometrija arteria cerebri anterior (ACA) at 40 term infants in the age of 1-6 day (the scanner Aloka-650, transducer 5 MHz) at children with the complicated current of the perinatal period (basic group 32 children with neurology disease, hypotrophia, infants of diabetic mothers) and control group (8 healthy newborn). Results: Maximal value of systolic cerebral blood flow velocity in ACA at all newborn control group changed from 25.6 up to 51 cm/s. In time, 22 (71%) children of the basic group were lower 25.6 cm/s (p<0.001) and here have come 8 of 10 children of diabetic mothers. Minimal value of diastolic cerebral blood flow velocity in ACA also was authentically above at newborn control group (8.1 14.0 cm/s). The systolic-diastolic ratio (S/D), index of resistance (RI) at children of the basic group had the greater disorder of meanings (in the control an index S/D has made 2.71 3.92, RI o.63 0.74). At newborn with RI >0.75, it was marked more expressed neurology diseases with prevalence of an oppression of cerebral function , than at children with RI<0.75. Conclusions: Newborns with serious perinatal pathology need in the correction cerebral circulation diseases for decrease brain pathology.

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P3.15.03 CHOLESTEROL SIDE-CHAIN CLEAVAGE ACTIVITY IN HUMAN UMBILICAL CORD BLOOD ERYTHROCYTES IN VITRO K.L. Peh, A. Loganath, PCT Chew, YC Wong, SC Ng, University Dept OB/GYN, National University Hospital, Singapore, Republic of Singapore. Objectives: Our recent study on the enzymic ability of human umbilical cord blood erythrocytes to oxidize pregnenolone to progesterone raised the possibility whether these blood cells also possess the cholesterol C20, 22-desmolase ability to cleave the side-chain of cholesterol to produce pregnenolone and isocaproic acid, a rate-limiting step in steroidogenesis. Study Methods: Sonicated preparations of plasma-free erythrocytes at the range of total numbers between 59.8x109 and 66.9x109 obtained from umbilical arterial and venous blood collected from women (n=6; age 26 to 39 years) following spontaneous vaginal delivery from uncomplicated pregnancies at term (37 to 41 weeks) were incubated with [26-14C] cholesterol as substrate. The content of leucocytes was persistently very low (<0.0005%) in the incubates. The controls were heat-denatured preparations of cord blood erythrocytes. Using the reverse-isotope dilution procedure, [14C] isocaproic acid was characterized from the incubates. Results: Radiochemically pure p-bromophenacyl ester of isocaproic acid was obtained in all the 6 incubations with viable cord blood erythrocytes with specific activities ranging between 7.3 and 50.2 dpm/mg. Such a metabolite was not evident in the controls. Characterization of [14C] isocaproic acid is a reflection of the fact that the multienzyme desmolase system specific for the oxidation of the terminal 6 carbon atoms of the side-chain of cholesterol exists in the viable preparations. The efficiency of enzymic conversion spanned from 8.9x10-2 to 6.1x10-1%. Conclusions: The results reveal the presence of C-20, 22 desmolase enzyme system capable of conversion of [26-14C] cholesterol to [14C] isocaproic acid and pregnenolone in the cord blood erythrocytes. The evidence in vitro indicates that a potential for in situ production of pregnenolone exists in these erthrocytes. The evidence in vitro indicates that a potential for in situ production of pregnenolone exists in these erythrocytes during human pregnancy. An additional source of pregnenolone supply for subsequent steroid biotransformation necessary for maintenance of pregnancy and development of the fetus is implicated. P3.15.04 COMPLETE MATURE TERATOMA FETIFORM N. Kuno, Dept. OB/GYN, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan. Objectives: A virginal 25 year-old Japanese woman was refereed to our institute with giant ovarian tumor. Tumor markers, X-ray, CT, MRI indicated the tumor is an ovarian mature cystic teratoma. The tumor was resected and pathologically diagnosed as benign dermoid cyst. A solid fetiform mass was discovered in it. This is to investigate the degree of differentiation of the fetiform mass and the limitation of development without paternal genome. Study Methods: The tumor was macro- and micro-scopically investigated. Results: The whole tumor was 110g with a smooth surface and in the tumor, buried deep in the fat and hair, was a small doll-like structure (10x7x7cm), weighing 150g, with distinguishable head, face upper and lower limbs and trunk. The whole structure was covered with thick white skin with coarse lanugo, but both cranial and caudal end were covered with thick, long and dark hair. Eye, teeth, brain-tissue, nails, rudimentary ear, phallus-like structure, and omphalocele were distinguishable in appearance. Intestinal tract, blood vessels, spinal cord, bone and bone marrow, peritoneal membrane, respiratory epithelium and dura mater were microscopially confirmed. Radiographic examination revealed the cranial bottom and occipital bone, spine like structure, upper and lower limb bones and lower metatarsal bones. Conclusion: This is an additional case of mature cystic teratoma fetiform and might be one of the biggest and most differentiated cases reported. The existence of cranio-caudal, antero-posterior and left-right axis indicate the primary developmental step of the axis formation might occur without the participation of paternal genes. The precise observation of this case may contribute to understand how much human

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parthenogenesis can be carried out only with maternal genetic information.

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P3.15.07 EFFECTS OF INFERTILITY TREATMENTS ON THE NEONATAL HEALTH F. Zarrinkoub, A. Beigi, Dept. OB/GYN/PED, Arash Maternity Hospital, Tehran University of Medical Sciences, Tehran, IRAN. Objectives: To evaluate health of newborns of women who conceived by infertility treatments. Study methods: In a prospective study on the 4,460 newborns that delivered at Arash hospital, Tehran university of medical sciences, from Feb 1996 to Jun 1999, the newborns of women who conceived spontaneously compare to those who used infertility treatments. Infertility treatment group divided into two group 1-stimulation group 2assisted reproductive technology (ART) group. Results: Infertility treatments were reported for 6.3% of pregnancies (283 women, 314 newborns) relative risk of low birth weight, prematurity, intrauterine growth retardation, morbidity, transfer to neonatal intensive care unit and birth defects were approximately 3 times higher for the stimulation group and 4-6 times higher for the ART group. Conclusions: We found an association between infertility treatments and neonatal morbidity, and most of this impact appeared to be mediated by multiplicity and prematurity, therefore reducing the number of medically induced multiple pregnancies is the most effective prevent ion of neonatal morbidity related to infertility treatments. P3.15.08 FETAL RENAL ANOMALIES AND FETAL ULTRASOUND G. Whincup, Dept. PED, The Conquest Hospital, The Ridge, St Leonards on Sea, East Sussex, UK. Objectives: To identify within the fetal population infants likely to have later true renal anomalies. Study Methods: A two year population sample (3,600 pregnancies) were included in a prospective study and had antenatal ultrasound scans on two or more occasions during pregnancy. Further scans were performed postnataly on infants where antenatal hydronephrosis was identified. Results: This study demonstrated an incidence of hydronephrosis of 10% with renal reflux of 1%. This is at odds with previously published figures. Within the study period infants who presented with a coincidental urinary tract infection but had normal scans antenatal were demonstrated reflux (20%). Conclusions: Antenatal ultrasound offers a safe and quick identification of the basic anatomy of the fetal kidney. It does not exclude reflux in this population. If neonatal scans at to and eight weeks with a full bladder are normal subsequent scans at nine months will also be normal. It is not possible to reassure the mother of a fetus that reflux does not exist hoewever antenataly. P3.15.09 FREQUENCY AND STRUCTURE OF CONGENITAL MAJORMALFORMATIONS OF 10,000 NEWBORN INFANTS M. Josimovska, V. Mitevska, M. Mihajlovska, Medical Centre, Kumanovo, Republic of Macedonia. The importance of congenital malformations in practical neonatal pediatrics illustrates the data that about 1% of newborn infants during delivery have clearly showed major-malformations, i.e.. those which have significant medical, surgical and estetic consequences and which disturb organism functions and development, or some parts of the organism. Here, congenital malformations which are diagnosed later in childhood (heart, kidney, lung malformations), are not included. Newborn infants were observed at Newborn Infants Division at the GYN/OB Dept. in Kumanovo Hospital from 119 to November 1996, or in total, 10,000 newborn infants. In 1992 there were 1.1% malformations, in 1993 2%; in 1994 0.8%; in 1995 0.7% and in 1996 until November 0.9%. This shows that the frequency of congenital malformations is almost the same, and at 10,000 newborn infants that is 0.98%. In 1999 were 1880 newborn infants with 19 with who had malformations. According frequency in the first place are extremity malformations 52% (pes equinovarus polidactilia, sundactilia); body malformations 20% (evisceracia, rashishizis with or without meningomielocele); multiple congenital anomalies 10% (syndrome Becwit, syndrome Down); then face malformations 8%

P3.15.05 DETERMINING OBSTETRIC RISK FACTORS AND PREGNANCY OUTCOME OF FETUSES WITH TRUE KNOTS OF THE UMBILICAL CORD E. Sheiner1, R. Hershkowitz1, T. Silberstein1, G. Holceberg1, I. ShohamVardi2, M. Katz1, M. Mazor1. Dept Ob/Gyn1 and Epidemiology2, Soroka University Medical Center, Ben-Gurion University of the Negev, BeerSheva, Israel. Objective: To determine the obstetric risk factors and pregnancy outcome of fetuses with true knot of the umbilical cord. Study design: We analyzed 69139 singleton birth files. Deliveries occurred in the between the years 1990-1997. Fetuses with malformations were excluded. Results: The incidence of true knots was 1.2% (841/69139). The following obstetric factors were found to be significantly correlated to true knots of the umbilical cord in a multiple logistic regression model: Chronic hypertension (OR=1.7; 95%CI 1.2-2.5), patients after amniocentesis (OR=1.2; 95%CI 1.1-1.5), male fetuses (OR=1.5; 95%CI 1.3-1.7), prolapse of cord (OR=3.4; 95%CI 1.8-6.2) and cord around the neck (OR=1.9; 95%CI 1.6-2.3). The incidence of fetal distress and meconium stained amniotic fluid was significantly higher among patients with true knots of cord [7.0% vs 3.6%; 22.4% vs. 16.2 respectively, p<0.0001]. Moreover, there was a fourfold higher rate of stillbirths among those fetuses [1.9% vs. 0.5% p<0.0001], and higher rates of cesarean sections [15.5% vs. 10.5%, p<0.0001]. Conclusion: True knots of the umbilical cord are associated with a higher rate of fetal distress and stillbirths than those without this condition. Thus, careful sonographic and Doppler examinations should be performed in high-risk patients for the detection of anomalies of the umbilical cord. P3.15.06 EARLY ADAPTATION AT NEWBORN HIGH INFECTIOUS RISK I. Antipova, A. Aksenov, L. Kuzmenko, T. Tareeva, N. Bashakin, Moscow Regional Scientific Research Institute OB/GYN, Moscow, Russia Objective: The aim of the study was to investigate the features of early adaptation newborn high infectious risk for optimization of tactics conducting. Study Methods: We surveyed 156 newborn from the mothers with chronic infectious diseases (ChID) in the early neonatal period. Clinical, ultrasound and immunologycal methods were used. Results: It was established, that ChID of the mother renders serious adverse influence on a condition of a fetus and current of early adaptation at newborn, resulting to development hypoxic, infectious and toxic defeat of brain (49.6%), intrauterine hypotrophy (29.4%), intrauterine and postnatal infection (30.4%). Was established 4 variants of current early neonatal of the period depending on a condition of the child at birth and dynamics of a condition at the first hours oclock. For newborn, high infectious risk (even clinically healthy) are characteristic to the infringements hemodynamics (later closing of fetal communications, decrease contractile activity of myocardium, high common peripheric vascular resistance, arterial hypertension), endocrine of adaptation (low level adrenocorticotrophin and cortisone), metabolism (decompensated metabolic and respiratory-metabolic acidosis, increase activity of blood enzyme), the change of the factors of specific and not specific protection (hypoimmunoglobulinaemia G is less 9.8 g/l, the decrease of a level scale gamma-interferon is less 8 ME, the increase of parameters activity peroxid oxidation of lipids MDA is more 6 ng/ml). Conclusion: Newborn from the mothers with ChID are the high risk children for disease in the early neonatal period. They need in the correction hemodynamics, metabolism and immunologycal disturbances.

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(cheliognatoplantoshizis); then head malformations 5% (microcephalia, hydrocephalia) and artrezio ani 5% from all major malformations. The basic criterion for practical importance for malformations is their pathological significance for the organism. Surgical therapy is almost the only possible way for malformations. Education and help are necessary in family planning always when there is a potential risk for posterity. P3.15.10 LEFT ATRIAL MYXOMA WITH ENDOCARDIAC FIBROELASTOSIS ON A NEWBORN (HISTOPATHOLOGICAL CONSIDERATIONS) F. Pricop (1), M. Pavaleanu (1), D. Gafitanu (1), C. Cotea (2), C. Asmarandei (2), C. Cotutiu (3), C. Amalinei (3); (1) Dept. OB/GYN, University Hospital Elena Doamna, Iasi, Romania. (2) Dept. Neonatology, University Hospital Elena Doamna, Iasi, Romania. (3) Dept. Morphopathology, University Hospital Elena Doamna, Iasi, Romania. Objectives: The aim of the study was to correlate the morphopathological findings with the outcome of a new born with atrial myxoma and endocardiac fibroelastosis. Cardiac tumors are extremely rare in childhood (150 published cases) and at the newborn age are exceptionally diagnosticated. Myxomas represent 10 15% from primary cardiac tumors. Frequently they are benign, but the benignity is histological, the evolution being usually grave. Study Methods: The lower case is the first in our 25 years of clinical existence. She is a girl, the seventh born naturally, breech presentation, Apgar 8, 3500 grams weight at 38 weeks of gestation. The family had another baby that died at 11 months with a cardiac malformation. The mother presented signs of premature labor, neglected urinary infection and anemia during the pregnancy evolution and only two prenatal consultations. The postpartum evolution of the child was favorable in the first two days. The third day, the general status was suddenly altered, with cyanosis, acute cardiobreathing distress, cardiogenesis shock, and the child died after seven hours by irreversible heart failure. The thoracic X-ray showed acute cardiomegaly. Results: Histopathological exam presented a left atrial myxoma, with the size of a cherry, gray white, with lean surface and thin tissue, placed next to the superior face of the mitrial valve. The parietal endocardium was thicker, and had a fibroelastosis aspect. Unfortunately the patient had been diagnosed after death. Conclusions: In the future, use of the antepartum and postpartum screening by echocardiography could improve the vital prognostic earlier diagnosis and effective surgical treatment.

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early stage of 12 to 24 hours after delivery, by determining CRP, Elastase a1 proteinase inhibitor and hemoculture. Conclusion: The infection participates with a high percentage in early preterm births. Persistence in detecting infections in the lower reproductive tract in this pregnancy or in earlier ones, as well as systematic treatment of bacterial vaginosis, reduced to a high degree the risk of preterm delivery and pPROM, and maternal-fetal morbidity, which is especially important for the prevention of high-risk premature infants. P3.15.12 MORBIDITY AND MORTALITY IN NEWBORDS OF ADOLESCENT MOTHERS WITH ECLAMPSIA C. Ferrada, M. Molina, R. Perex, L. Cid, V. Casanueva, C. Aedo, Y. Farlas, P. Pyarzun, P. Paredes. B. Rosal, Faculty of Medicine, Physical Science & Mathematics, University of Conception, Chile. Objectives: The aim of the study was to evaluate the perinatal morbidity and mortality in newborns of adolescent mothers with eclampsia. Study Methods: A retrospective study was conducted in 53 newborns of adolescent mothers with eclampsia at the Clinical Hospital of Conception, Chile, from 1988 to 1998. Results: These newborns were born by caesarean section (90.4%). The low weight at birth was 54.7% and the very low weight was 9.4%. The neonatal asphyxia was 29.4% and severe asphyxia (13.7%). 41.2% were premature and 32.1% small for gestational age. The mains neonatal morbidities were Respiratory Distress Syndrome (17.6%) and metabolic diseases (11.8%). There was 2 fetal deaths (3.8%) and 1 early neonatal death (1.9%). In this group Perinatal mortality was 5.7%. Conclusions: Eclampsia in adolescent mothers had a negative impact in perinatal morbidity and mortality.

P3.15.13 PERINATAL MORTALITY SURVEY IN A TEACHING INSTITUTION. N. Chavan, P.K. Shah, V.R. Badhwar, Dept. of Obgyn. & Lokmanya Tilak Medical College & Hospital, Mumbai, India. Objectives: The aim of the study was to calculate the Perinatal mortality rate (PNMR), to study associated maternal & foetal factors affecting it and to suggest control measures to reduce PNMR. Study Methods: Total number of patients delivered from February 1999 to July 1999 (Six Months) were 3490. The study was done according to following associated factors of reproductive age, gravidity, ANC status, socio economic and educational status, related maternal medical and Obstetric factors, condition of foetus and neonate at birth and presence of any congenital malformations. Results: Perinatal mortality rate (PNMR) was 52.7 / 1000 live births, corrected PNMR 44.69 per 1000 live births, and extended PNMR 61.03 per 1000 live births and early neonatal mortality rate 19.43 per 1000 live births. The study revealed that women less than 20 years and more than 30 years of age, primi and grand multipara, patient with poor socio economic and educational status where at greater risk of having perinatal mortality. In addition to these factors unregistered patients with poor antenatal attendance, transfer cases from peripheral hospitals had greater risk of perinatal mortality. PIH, anaemia, diabetis, APH, polyhydramnios, oligohydramnios and preterm labor were important maternal factors in increasing PNMR while immaturity, infection, asphyxia, RDS, congenital anomalies were major foetal factors Conclusions: Improvement in referral systems, awareness in society of antenatal registration and followup with better intrapartum foetal monitoring facilities and improvement in management of sepsis and preterm babies will reduce the PNMR in developing countries. P3.15.14 pH VALUES AND THE WAY OF ENDING THE DELIVERY IN PREVENTION ON INTRAPARTAL INJURIES OF NEWBORNS S. Aleksic, M. Bogavac, N. Curcic, Dept. OB/GYN, School of Medicine, University of Novi Sad, Novi Sad, Yugoslavia. Objectives: The aim of the study is to investigate the influence of pH values on intrapartal injuries of newborns. We have analyzed the glycosis of fetal erythrocytes that depend on pH values of blood.

P3.15.11 LOW BIRTH WEIGHT INFANTS: DETERMINING OF GENITAL TRACT INFECTION AS REASON FOR DELIVERY AND ESTIMATION OF MATERNAL-FETAL INFLAMMATORY RESPONSE K. Piperkova, Neonatology Dept., Clinic for Child Diseases, Skopje University, R. of Macedonia M. Trajanova, D. Buljukova, Spec. Hosp. OB/GYN "Cair", Skopje, R. of Macedonia Objective: In multifactorial etiology of preterm labor we determined the incidence of genital tract infections among mothers as reason for preterm labor and preterm rupture of membranes (pPROM), as well as for subsequent maternal-fetal inflammatory response. Study methods: We processed 164 preterm infants with birth weight between 500 and 1500 gm, and their respective mothers. The motherinfant pairs were grouped. Group 1 - includes preterm deliveries and pPROM caused by infection of the mother: vaginal, cervical, amniotic, and decidual. Group 2 - includes those who had a clear maternal or fetal indication for preterm delivery. Group 3 - included those with idiopathic preterm labor. Results: Of the total 164 preterm deliveries, in 66 cases (40.2%) the reason for preterm labor and pPROM was infection of the reproduction tract of the mother. Of these mothers, 24 (36.4%) had proven bacterial vaginosis where therapy had just started; 7 (10.6%) had chorioamnionitis; and 35 (53.0%) had asymptomatic untreated bacterial vaginosis. Maternal-fetal inflammatory response was detected in a very

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Study methods: The pH values of the blood taken intrapartally from the presenting part of fetus were analyzed in 300 deliveries. The analysis comprised pH values of newborns born by cesarean section in which pH values were determined from the blood of the umbilical cord, immediately after birth. The authors also analyzed pH values in newborns born by vacuum extraction as well as in normal vaginal deliveries, and pH values were determined from the blood of the umbilical cord, immediately after birth. A part of this paper deals with the influence of pH values on glycolysis of human fetal erthrocytes (in vitro). Results: Decease in pH values below 7.25 led to the slowing down of the glycolysis process which was two times of pH values on intrapartal injuries of newborn were investigated in the application of vacuum extraction. These injuries were more frequent in newborns which are acidosis, i.e. with lower values of pH blood. Conclusion :These authors concluded that vacuum extraction itself did not lead to injuries, but only augmented sensibility, i.e. there is a question of decreased. They believed that vacuum extraction was a good method when applied on time in indicated cases. Summarizing the obtained results we can say that we decide for cesarean section at rather early stage, which may be good, but we decide for vacuum extraction rather late, in cases when pH of blood is not taken intrapartally from the presenting part of the fetus. P3.15.15 PRESENCE OF PROLONGATED PREGNANCY AND PERINATAL MORBIDITY D. Bulukova, K. Piperkova, L. Kirovski, M. Trajanova, T. Bojadziev, A. Sopova, Special Gynecology & Obstetrics Hospital Cair, Skopje, Macedonia, Objectives: The aim of the study was to show the relationship between the prolonged pregnancy and perinatal morbidity. Study Methods: The total number of births in our Hospital during 1999 amounted 3352. Of these, 3319 (99,015 %) were live born, and 33 (0,98 %) were stillborn. Of the live born, term newborn were 3010 (89,80 %), preterm were 342 (10,2 %), and newborn from PP were 78 (2,3 %). We determined PP according to anamnestic (definition by FIGO), clinical and ultrasonographic characteristics of the fetus. Results: Perinatal morbidity was encountered in 1136 cases (34,33 %) of the total number of term newborn, and in 57 cases (73, 08 %) of the total number of newborn from PP. In regard to the encountered early morbidity, there is a high significance in the differences among the newborn from PP (p<0,001) in relation to the ill term newborn. The highest percentage of prolonged pregnancy we determined among mothers with first birth 52 (66,66%), with second birth 16 (20,05%), third birth 8 (10,25%), and multiple births 2 (2,56%). Of the women with PP, 8% had placental insufficiency, and the reasons in the other cases are unknown. Conclusion: Regular checkups during the pregnancy period and programmed delivery remain the most significant for reducing PP associated with the higher percentage of perinatal morbidity. P3.15.16 QUANTITATION AND CORRELATION BETWEEN DIFFERENT UMBILICAL CORD BLOOD CELL COUNTS ISOLATED FOR USE IN TRANSPLANTATION R. Czajka (1), P. Szolomicka-Kurzawa (1), W. Mikolajek (2) (1) Dept. Obstetrics and Perinatology, Pomeranian Medical University, Szczecin, Poland. (2) Dept. Biochemistry and Chemistry, Pomeranian Medical University, Szczecin, Poland. Objectives: The aim of the study was to investigate the percentage number of hematopoietic progenitor cells in different populations of umbilical cord blood white cells. Hematopoietic stem cells and progenitor cells were isolated from umbilical cord blood within the population of mononuclear cells (MNC). MNC can be found among small lymphocytes, these in turn belong to white blood cells. Study Methods: Ten samples of the umbilical blood collected after delivery of the placenta were assessed. The concentrations of leukocytes and lymphocytes were evaluated. Numbers of mononuclear cells and CD 34+ cells were analyzed after cell isolation. MNC were isolated in Ficoll-Hypaque gradient and CD 34+ cells were isolated with magnetic column use.

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Results: Only one statistically significant correlation was found, between MNC and CD34+ cell concentrations (p<0.05). The mean percentage of CD34+ cells within MNC ranged 0.8%. Conclusions: On the basis of results, it was established that MNC concentration indirectly allowed for estimation of hematopoietic stem cells concentration, which is not the case when leukocytosis and lymphocytosis are taken into consideration. P3.15.17 RATE OF NEWBORN ASPHYXIA AFTER SELECTIVE OPERATIVE DELIVERY V. Saprikin, I. Dragun, T. Gracheva, Dept. of Obstetrics, Research Center of OB/GYN, Moscow, Russia. Objective: To reveal the reason of asphyxia in term newborns after selected cesarean section. Material: Fulfilled examination included cardiotocographia, ultrasound and Doppler, biochemical blood analyses and O2 and CO2 levels and oxygen transport in fetus cord. First group consisted of 49 newborns delivered with asphyxia of different severity, the second one consisted of 84 newborns delivered with Apgar score 8-9. Results: Analysis of cardiotocogramm revealed deviation from normal values in 28.6% in the first group. Utero-placental and fetus-placental circulation was reduced in 24.5% by Doppler made 1-2 days before delivery and cord loop around fetus neck was found in 50% by ultrasound. Such changes in the second group were noted 3 times as rare. Time from the beginning of the operation to delivery was higher on 2.2 min in the I group than in the II group. 29% of newborns from the I group suffered from intrauterine infectious disease, that was 2.5 time higher than in the I group. Conclusions: Reasons for newborn asphyxia, firstly, were the result of intrauterine fetus condition before the delivery and it could be suggested that anesthesia and/or operative procedure by itself breaks uterineplacental-fetus circulation because changes of fetal heart rate was registered only in 30% of cases. P3.15.18 REPETITION OF OSTEOCHONDRODYSPLASIA A RARE HEREDITARY DISORDER OF BONES S.Sipos, T.Marton, A.Ujhzy, J.Rig Jr., I.Dept. OB/GYN Semmelweis University Medical School, Budapest, Hungary Background: Osteochondrodysplasia with defective bone mineralization is a rare hereditary disorder. It is characterized by bone structure defects and a deficiency of bone/liver/kidney alkaline phosphatase activity in serum and tissues. Case report: Type 2a osteochondrodysplasia was detected in the first and second pregnancies of a 28 year old woman. Fetal age was 20 and 17 gestational weeks, respectively. Ultrasonographical findings showed a soft, dilatated spine, narrow chest and short ribs as well as deformed bones and skull.An additional fetopathological finding ws hypomineralization of the skelet (diagnosed by hystopathology and XRay examination). The disorder proved to be Infantile Hypophosphatasia (congenital lethal type). Outcome: Both pregnancies were terminated after the diagnosis of the disorder. Conclusion: In order to detect this disorder, careful, repeated ultrasound exam should be performed in the first and second trimester. A Serum alkaline phosphatase level and elevated urinare phosphoethanolamine level of the family members may help to predict the disorder. P3.15.19 SUPPRESSION OF MEMBRANE PERMEABILITY TRANSITION IN FETAL RAT LIVER MITOCHONDRIA AND ITS ROLE IN OXIDATIVE STRESS T. Yoshioka (1), T. Yoshida (1), J. Akiyama (2) Div. OB/GYN, Kurashiki Medical Center, Kurashiki, Japan. Akiyama Memorial Hospital, Hakodate, Japan. Objectives: Because neonates are exposed to various hazards such as oxidative stress during and immediately after labor, protective mechanisms should exist, but few have been identified so far. The aim

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of this paper is to clarify the role of the mitochondrial membrane permeability transition (MPT) for protection of the fetus and neonates against the hazards arising during perinatal period. Study Methods: Mitochondria were isolated from livers of fetal (FM) and adult (AM) rats by the method of Hogeboom. Cytochrome content and rates of oxidative phosphorylation were measured by spectorphotometric and polarographic methods. MPT and cytochrome c (Cyt.c) release from mitochondria were measured by absorption at 540 nm and Western blot analysis, respectively. Caspase-3 activity was measured I a cell free system using a fluorgenic peptide substrate. Results: No typical absorption spectrum of reduced Cyt.c was observed in FM although Cyt.c was detected by Western blotting. The rates of oxidative phosphorylation and the respiratory control ratio were lower in FM compared to AM. Similarly, both mitochondrial MPT and Cyt.c release from FM induced by Ca2+ yielded lower values than those of AM. However, Triton treated FM supernatant activated caspase-3. Conclusions: The present results suggest that decreases in mitochondrial MPT and Cyt.c release and the consequent decrease in the activation of caspase-3 which induces chromosomal DNA fragmentation and apoptosis in liver cells might contribute to the protection of the tissues of both the fetus and the neonate against various hazards. P3.15.20 THE COMPARISON OF THE METABOLIC STAINS TOXICITY AGAINST HUMAN HAEMATOPOIETIC STEM CELLS ISOLATED FROM UMBILICAL CORD BLOOD. W. Mikolajek1, P. Szolomicka-Kurzawa2, R. Czajka2. 1Department of Biochemistry and Chemistry, 2Department of Obstetrics and Perinatology, Pomeranian Medical University, Szczecin, Poland Objectives: The aim of this study was to compare the potential toxicity of metabolic stains: Hoechst 342, Pyronin Y and Rhodamin 123, which were used for isolation of human haematopoietic progenitor cells from umbilical cord blood. Study methods: Twenty samples of the umbilical blood collected after delivery of placenta were assessed. The potential clonogenicity of the progenitor cells, isolated with the use of studied stains, measured as a number of BFU-E and CFU-GM colonies was evaluated to compare with clonogenicity of progenitors from control samples. Results: Less colonies of BFU-E and CFU-GM were found in all studied samples against to control. In the group where Pyronine Y was used, only number of CFU-GM colonies was statistically decreased. All studied metabolic stains had much stronger influence on CFU-GM colonies than on BFU-E. Conclusions: Based on the results, it was established that Rhodamin 123 and Pyronin Y were relatively safe metabolic stains for isolation of haematopoietic stem cells. Hoechst had higher toxicity. P3.15.22 THE INFLUENCE OF UMBILICAL CORD BLOOD STORAGE TEMPERATURE AND FREEZING METHOD OF ISOLATED MONONUCLEAR CELLS ON THEIR CLONOGENICITY. R. Czajka1, W. Mikolajek2, P. Szolomicka-Kurzawa1. 1Department of Obstetrics and Perinatology, 2Department of Biochemistry and Chemistry, Pomeranian Medical University, Szczecin, Poland

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Objectives: Temperature is the one of the most important parameter of storage of each biological material. The aim of the study was to find the optimal storage temperature for umbilical cord blood (UCB) just after collection and optimal method of isolated mononuclear cells (MNC) freezing. Study material: Forty nine samples of UCB were assessed in the first part of study. The viability and clonogenicity (as a number of risen BFU-E and CFU-GM) of UCB isolated MNC were evaluated after short-term storage (0-24h) in studied temperatures (+4C and room temp.). In the second part of experiment (20 samples of blood), the number, viability and clonogenicity of MNC retrieved after freezing in dry ice or in mechanical freezer with use of methanol bath were estimated. Results: It was established, that temperature of short-term storage of UCB had no influence on viability of MNC and clonogenicity measured for CFU-GM. But number of risen BFU-E colonies was higher after short-term storage in room temperature. Statistically significant decrease of number, viability and clonogenicity of MNC was found after freezing in dry ice. After freezing in methanol bath, the number of MNC decreased after two days and viability and clonogenicity after four days of experiment. Conclusions: Room temperature is a choice for short-term storage of UCB. The more effective method of isolated MNC freezing should be expected when the methanol bath is used for that purpose.

P3.15.23 ULTRA-VIOLET INTRAVASCULAR LASER IN COMPLEX TREATMENT OF LUNG PATHOLOGY IN NEWBORNS T. Shestakova, A. Zelynsky, M. Korsakova, V. Artyomenko, Dept. Perinatal Medicine, Child and Adolescent Gynecology, Odessa State Medical University, Odessa, Ukraine. Objectives: The aim of our research was to study the effectiveness of ultra-violet laser therapy in newborns suffering from lung pathology. During 1996 1998 intravascular laser therapy was performed in 122 newborns (81 with pneumopathy and 41 with congenital pneumonia). Study Methods: Clinical, paraclinical, biochemical, radioimmune, rentgenological and instrumental methods were used to determine the routine blood and urine data, partial O2 and CO2 blood pressure and its oxygenation, lungs R-graphy in 122 newborns of the main group (laser + traditional therapy) in comparison with 102 newborns of the control group (traditional therapy only). Laser irradiation was performed intravascularly daily (exposure 30 sec.) by means of ALOU-2 laser (wave length 0.63 mcm, continuous beam, up to 2 mVt capacity) during 7 days. Results: In newborns with pneumopathy the laser therapy leads to significant decrease of oxygen-dependent days quantity (4.50.34 days) in comparison with newborns of the control group (8.40.75 days) and significant increase of blood oxygen saturation (P<0.001 and P<0.005 respectively). After the intravascular laser application in newborns with congenital pneumonia the significant clinical condition improvement was observed along with blood and urine data normalization which was quicker in comparison with the same parameters in newborns of the control group. Conclusions: The ultra-violet intravascular laser therapy in newborns with pneumopathy and congenital pneumonia is very effective, leading to mortality and morbidity decrease and good far-reaching results.

P3.15.21 THE INFLUENCE OF CORTISOL AND MELATONIN ON THE EARLY ADAPTIVE CONDITIONS OF NEWBORNS FORM MOTHERS SUFFERING FROM GESTOSIS I. T. Govorukha, V. K. Chaika, Donetsk State Regional Center of Motherhood and Childhood Protection, Donetsk, Ukraine Objectives: The aim of the study was to estimate the level of cortisol and melatonin in blood serum in newborns from mothers suffering from gestosis. Study Methods: Forty-six newborns were divided into 3 groups. The fist group consisted of 13 babies born from ladies with normal pregnancy, 18 newborns were from mothers with preeclampsia, as a complication of pregnancy, 15 newborns from mothers with eclampsia consisted the third group. The level of cortisol and melatonin in serum were examined in all babies. Results: Newborns from 2 group had a raised level of cortisol and melatonin by 1.6 and 1.2 times compared to those of the control group. In the 3 group there was an increase in cortisol and melatonin by 2.1 and 0.85 times. Conclusions: There was a definite stressful adaptive capacity of newborns from mothers in preeclampsia as a complication of pregnancy and the loss of adaptive capacity in newborns from mothers with eclampsia.

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P3.16 OVARIAN CANCER P3.16.01 A NOVEL TUMOR-ASSOCIATED ANTIGEN "RCAS1" EXPRESSION IN THE OVARIAN CANCER T.Kaku, K.Sonoda, S.Ogawa, H.Nakano, Kyushu University School of Health Sciences, Maidashi 3-1-1, Fukuoka, Japan, 812-8582. Objectives: The aim of the study was to investigate the expression of a novel antigen "RCAS1" generated from a mouse immunized with a human uterine adenocarcinoma cell line, SiSo in the ovarian cancer. Study Methods: The expression of RCAS1 was immunohistochemically investigated in ovarian cancer (54 cases). Tissue specimens used in this study included 26 cases of ovarian mucinous adenocarcinoma, 11 of serous adenocarcinoma, 11 of clear cell carcinoma and 6 of endometrioid adenocarcinoma. Results: The RCAS1 was positive in all 26 cases (100%) of mucinous adenocarcinoma, and expressed diffusely and strongly in the cytoplasm and membrane, and often in supranuclei areas. The RCAS1 was also found weakly in 72.7% (8/11) of serous adenocarcinoma, 66.7% (4/6) of endometrioid adenocarcinoma, and 54.5% (6/11) of clear cell carcinoma. Conclusions: These data indicate that RCAS1 expression in ovarian epithelial tumor, especially in mucinous P3.16.02 A RETROSPECTIVE STUDY OF 102 BORDERLINE TUMORS OF THE OVARY: CLINICAL FEATURES AND PROGNOSTIC FACTOR J.W. Kim, M.H. Kim, J.W. Roh, N.H. Park, Y.S. Song, S.B. Kang, H.P. Lee, Seoul National University Hospital, 28 Yungun-Dong ChongnoKu, Seoul, Korea, Korea, South, 110-744. Objectives: To clarify the clinicopathologic features of borderline tumors of the ovary and analyze the treatment and survival characteristics through the study of our cases. Study Methods: One hundred two patients with borderline tumors of the ovary, aged from 14 to 79 years, treated between 1982 and 1999 at Seoul National University Hospital, were analyzed retrospectively for clinicopathologic features. Most informations about stage, treatment modality and prognosis were obtained by hospital record or contacting patient with telephone. Results: There were 77 patients (75.5%) with stage Ia, 5 stage Ib, 11 stage Ic, 4 with stage II and 5 with stage III by the classification of FIGO. Seventy three patients (71.6%) were mucinous type and the remainder (28.4%) were serous type. Thirty seven (44.0%) out of 84 patients showed morphologic malignancy by gray-scale sonography, and 19 (44.2%) out of 43 patients by CT or MRI scan. Tumor marker was abnormally increased in 27 (30.7%) out of 88 patients. Total abdominal hysterectomy, bilateral adnexectomy, and omentectomy were performed in 54 (52.9%) patients and fertility saving surgery in the others. Among them, enucleation of tumor and biopsy of contralateral ovary was performed in 11 (10.8%) patients. Twenty two patients (21.6%) were treated with postoperative adjuvant chemotherapy. The median duration of follow up was 52.0 months (5-204 months) and 6 patients developed recurrence several years after operation. The 10-year cumulative survival rate was 92.2% by Kaplan-Meier method and the only independent prognostic factors evaluated by Cox analysis in regards to corrected survival were the FIGO stage (p=0.0197). Conclusions: Most of the patients with borderline ovarian tumors were at the early stage of disease at initial diagnosis. The slow clinical course, low recurrence rate and good prognosis in our patients explained again the reason for therapeutic approach relying on surgery alone. P3.16.03 ACCURACY OF TISSUE POLYPEPTIDE SPECIFIC ANTIGEN (TPS) IN THE DIAGNOSIS OF OVARIAN MALIGNANCY P. Padungsutt, C. Thirapagawong, I. Suphanit, S. Neungton, S. Senapad, GYN/ONC Unit, Dept. OB/GYN, Faculty of Medicine, Siriraj Hospital, Mahiodol University, Bangkok, Thailand. Objectives: To evaluate the accuracy of serum tissue polypeptide specific antigen (TPS) by TPS ELISA in diagnosis of ovarian malignancies in comparison with histological results of ovaries.

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Study Methods: The study was performed in the gynecologic patients ward, operating room and pathological division, Dept. OB/GYN, Siriraj Hospital. 92 patients clinically diagnosed of ovarian tumors by history, physical examination, pelvic examination and/or pelvic ultrasonography were enrolled. All of them underwent surgical treatment by exploratory laparotomy in Siriraj Hospital. All patients had not been treated by chemotherapy, hormonal therapy and previously diagnosed any malignancies. Determination of serum TPS (TPS ELISA) level and comparison with the histopathological results. Statistical methods were used to analyze the accuracy of this tumor markers in ovarian malignancy diagnosis. Results: Tissue Polypeptide Specific Antigen was measured by ELISA in serum from 92 patients who were preoperatively diagnosed ovarian tumor: 52 benign pelvic mass patients and 40 malignant ovarian tumors patients. According to TPS positivity criteria by manufacturer (80 U/L), TPS level were evaluated in 28.8% benign pelvic mass patients and in 90% malignant ovarian tumor patients. However, in statistical analysis by two by two table at every cut off TPS level and receiver operating characteristic (ROC) curve, the optimal accuracy, sensitivity, specificity, positive predictive value, negative predictive value, false positive and false negative rate were 79.35, 90, 71.15, 70.59, 82.93, 28.85 and 10% respectively at positivity criteria 80 U/L by TPS ELISA in diagnosis of ovarian malignancies. Conclusions: The accuracy of serum TPS by TPS ELISA in diagnosis of ovarian malignancies is good and clinically acceptable. In a TPS level greater than 80 U/L is a useful positivity criteria for screening malignant ovarian tumor. And TPS level greater than 180 U/L is a positivity criteria for differentiating malignant ovarian tumor for benign pelvic mass. Because of its high false positive rate, any patients with TPS greater than 80U/L should be further evaluated or investigated for malignant ovarian tumor.

P3.16.04 ADULT GRANULOSA CELL TUMORS OF THE OVARY: HISTOPATHOLOGICAL PROGNOSTIC FACTORS AND OUTCOME T.Fujimoto, N.Sakuragi, S.Fujimoto, Hokkaido University School of Medicine, North 14 West 5, Sapporo, Hokkaido, Japan, 060-8638. The prognostic factos of adult granulosa cell tumor (AGCT) have not been well defined. The aim of this study was to determine histopathological prognostic factors of AGCT. In 27 AGCT patients, we examined clinical stage, microscopic patterns, mitotic index (MI), and lymph-vascular space invasion (LVSI) to determine whether these factors were related to patient outcome. We also performed immunohistochemical examination for p53. Seventeen cases represented stage I, 3 stageII, 6 stage III, and 1 stage IV. There was no statistical difference between the stage I/II diseases and stage III/IV diseases in terms of the disease-free survival (DFS) rate (p=0.0811). There was no relation between the microscopic pattern and the DFS rate (p=0.8251). The DFS time for patients with a MI>=4/10HPF was significantly shorter than that for patients with MI<=3/10HPF (p<0.0005). The DFS time for patients with moderate or prominent LVSI was significantly shorter than that for patients with no or minimum LVSI (p<0.0001). The survival of patients depended on blood vessel invasion although lymphatic space involvement had weaker impact on prognosis of patients with AGCT. As regards the immunohistcemical staning for p53 protein, no overexpression of the p53 protein was observed in the majority of cases (24/25). The results of this study suggest that prognosis for patients with AGCT depends on the MI and LVSI (especially blood vessel invasion). It was also suggested that p53 gene alterations

P3.16.05 ADVANCED OVARIAN CANCER WITH ASCITES AND PLEURAL EFFUSION H. Nakachi, and T. Kinjo*, Dept. of OB/GYN, *Dept. of Surgery, Okinawa Prefectural Nanbu Hospital, 870 Aza Maezato, Itoman-City, Okinawa, Prefecture, Japan, 901-0362 A 69 year-old female, gravida 6, para 3, presented with the chief complaints of cough and lower abdominal pain of several months

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duration. Computed tomography revealed a huge abdominal tumor with ascites and chest X-ray showed a pleural effusion on the right. Fine needle aspiration of the pleural effusion for cytology demonstrated cancer cells, suggestive of adenocarcinoma. Her preoperative serum CA 125 level was 6000 U/mL. She was diagnosed as having stage IV ovarian cancer with pleural metastasis. The following operative findings were found: Bloody ascites was present. Left ovary (primary tumor) was enlarged to 16 X 10 X 9 cm and the tumor capsule was ruptured. The uterus and right ovary were atrophic. She underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy. Pathological diagnosis in all operative specimens was serous papillary cystadenocarcinoma. Following surgery she was started on combination chemotherapy with carboplatin 500mg day 1, and etoposide 100mg days 1-3, repeated at 4 week intervals. After the first course of chemotherapy, ascites and pleural effusion disappeared and the serum CA 125 level normalized (<35U/mL). She is now free of disease after completion of three courses of this chemotherapy. She has tolerated the chemotherapy treatment well. Three more courses of chemotherapy are planned. We would like to present the therapy, clinical course, and laboratory data of this stage IV ovarian cancer. P3.16.06 CHARACTERIZATION OF HUMAN OVARIAN CANCER CELL LINES BY INFRARED SPECTROSCOPY I. Symonds (1), E. Dickerson (1), A. Wilson (2), M. Pearson (3) (1) School of Human Development, University of Nottingham, Derby City Hospital, Derby, UK. (2) Oncology Research Laboratory, Derby City Hospital, Derby, UK. (3) School of Chemistry, University of Nottingham, Nottingham, UK. Objectives: The aim of the study was to determine if infrared spectroscopy could detect differences between human epithelial ovarian cancer cell lines. Study Methods: 8 cell lines derived from 5 patients with epithelial ovarian cancer were analyzed by transmission Fourier-transform infrared spectroscopy and the resulting spectra compared to those obtained from 3 mesothelial cell lines. Cell lines were characterized by peak absorbances at 9 different frequencies in the mid-infrared, normalized to the 1540 cm-1 (amide II) band and by the ratio between the bands corresponding to cytoplasmic and nuclear proteins. Results: Cell lines derived from 4/5 patients studies showed significant differences in peak absorbance at one or more frequencies from the other cell lines tested. The greatest variation occurred in the C-O vibrational bands at 1050 cm-1 and 1152 cm-1 and the symmetric PO2- band at 1085 cm-1. Cell lines derived from solid tissue and those from ascites taken from the same patient showed no significant differences in IR spectra. All of the tumor cell lines demonstrated a significantly higher ratio of nuclear to cytoplasmic absorbance as measured by the ratio of the bands occurring at 1085 cm-1 and 1456 cm-1 than mesothelial cells. Conclusions: Infrared spectroscopy can be used to characterize ovarian cancer cell lines. Cell lines derived from different tumors show different patterns of IR absorbance.

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Results: In group A, 38 of 42 patients received 3.8 courses of NAC and 79% (30/38) were successfully debulked at IRS and 73% (22/30) of them achieved clinical remission. Among of several regimens of NAC, TAXOL and CPT-11 including regimens were effective. Patients who underwent NAC plus IRS showed better prognosis than those who did not under go IRS. Median survival interval of group A patients was 29 months. No statistical difference was observed in overall survival or surgical morbidity between group A and B. Conclusions: NAC plus IRS would offer unresectable ovarian cancer the same survival as the resectable tumor undergone primary debulking. This new strategy was beneficial for the patients with unresectable advanced ovarian cancer who were unable to receive standard treatment. P3.16.08 CLINICAL EVALUATION OF SQUAMOUS CELL CARCINOMA ARISING FROM MATURE CYSTIC TERATOMA OF THE OVARY K. Yoneyama, T. Takeshita, K. Okino, S. Suzuki, H. Kobayashi, M. Arai, D. Doi, Y. Ohta, T. Araki, Dept. OB/GYN, Nippon Medical School Main Hospital, Tokyo, Japan. Objectives: The aim of the study was to evaluate the value of tumor markers and clinical characteristics in making a differential diagnosis between mature cystic teratoma (MCT) and squamous cell carcinoma arising form MCT. Study Methods: Between September 1985 and January 2000, 19 patients with ovarian squamous cell carcinoma arising from MCT was treated by Nippon Medical School Gynecologic Oncology Group in Japan. We analyzed with respect to tumor markers, tumor size and patient age as parameters for differentiation between MCT and malignant transformation. Results: There were significant differences in age, tumor size (p<0.0001) and levels of SCC, CA125, CA19-9 and CEA (p<0.022) between MCT and squamous cell carcinoma arising from MCT. Diagnostic efficiency was highest for SCC (62.0%), followed by CA125 (50%). Receiver operating characteristic (ROC) curves demonstrated that tumor size (AUC; 0.91) was the best screening marker for squamous cell carcinoma arising form MCT, followed by SCC (AUC;0.82). The optimal cutoff values for age, tumor size, SCC, CA125, CA19-9 and CEA were 40 years, 9.1 cm, 2.8 ng/ml, 32.0 U/ml, 80.0 U/ml and 4.8 ng/ml respectively, according to ROC analysis. The combination assay, which combines SCC with CEA using the optimal cutoff values was the best screening marker for squamous cell carcinoma arising from MCT. Conclusions: These results demonstrated that the combination assay, which combines SCC with CEA using the optimal cutoff values was the best screening marker for squamous cell carcinoma arising form MCT. In addition, SCC and CEA levels should be measured in patients with age 40 years or older who have an MCT-like ovarian tumor larger than 9.1 cm in greatest dimension.

P3.16.07 CLINICAL ASSESSMENT OF NEOADJUVANT CHEMOTHERAPY AND INTERVAL CYTOREDUCTIVE SURGERY FOR UNRESECTABLE ADVANCED OVARIAN CANCER K. Ushijima, T. Nishida, T. Sugiyama, T. Kamura, Dept. OB/GYN, Kurume University Scholl of Medicine, Kurume, Japan Objectives: In spite of recent progress of medical technology, five years survival of unresectable advanced ovarian cancer still remains about 30%. The aim of the study was to investigate the clinical significance of neoadjuvant chemotherapy (NAC) followed by interval cytoreductive surgery (IRS) for unresectable advanced ovarian cancer. Study Methods: Between 1986 and 1998, one hundred and twenty patients with stage IIIc and IV epithelial ovarian cancer were treated in Kurume University Hospital. Forty-two patients who underwent exploratory laparotomy and NAC and IRS (group A), and 78 patients who had resectable tumor and underwent conventional primary debulking surgery with having more than 1cm residuals (group B) were compared with clinical courses after treatment, chemotherapeutic response, and surgical morbidity.

P3.16.09 CYCLIN-DEPENDENT KINASE INHIBITOR p27 IS UNDEREXPRESSED DURING OVARIAN CARCINOGENESIS PROCESS K. Shigemasa (1), Y. Shiroyama (1), T. Sawasaki (2), T. Fujii (2), N. Nagai (1), K. Ohama (1) (1) Dept. OB/GYN, Hiroshima University, Hiroshima, Japan. (2) Dept. OB/GYN, Kure National Hospital, Kure, Japan. Objectives: The aim of this study was to investigate the potential role of p27 in ovarian tumor development and progression. Study Methods: P27 protein expression was investigated by immunohistochemistry in 117 epithelial ovarian tumor tissues (15 adenomas, 23 borderline tumors, and 79 adenocarcinomas) and 8 normal ovaries. Immunohistochemical staining was performed by using the avidin-biotin peroxidase complex technique. p27 mRNA expression level was examined by semi-quantitative PCR technique. mRNA was isolated and cDNA was prepared from 32 ovarian tumor samples and 5 normal ovaries. p27 sequences were amplified in parallel with the btubulin gene as an internal control. p27 mRNA expression level relative to b-tubulin was determined by densitometry. All material was collected with informed consent. The c2 test of significance was used for statistical analysis.

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Results: Nuclear staining of p27 protein was observed in the normal ovarian surface epithelium. The epithelial cells of germinal inclusion cyst also showed positive p27 staining. The positive rates of p27 protein by immunohistochemistry in ovarian adenomas, borderline tumors, and adenocarcinomas were 60%, 35%, and 13% respectively. There were significant differences in the positive rates of p27 between benign and malignant tumors (p<0.01) and between borderline and malignant tumors (p=0.01). Semi-quantitative PCR analysis showed that p27 mRNA levels were under-expressed in 19 of 32 (81%) ovarian tumors compared to those in normal ovaries.

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Conclusions: The KY cell line was found to be a useful experimental model to investigate the characteristics of ovarian clear cell adenocarcinoma. P3.16.12 EVALUATION OF CARCINOEMBRYONIC ANTIGEN (CEA) LEVEL IN FEMALE GENITAL TRACT TUMORS M.H. Makarem, A.A. Youssef, M.M. Anwar and M.A. Bedaiwy, Dept of OB/GYN, Faculty of Medicine, Assiut University, Assiut, Egypt. Objectives: The aim of the study was to evaluate the level of CEA in serum in different genital tract neoplasm. Study Methods: Ninety-one patients with genital tract tumor and a control group of 30 healthy females were studied. Two samples of 10 cc blood were taken from patients; one in the immediate preoperative period and the second after 2 weeks postoperatively. One sample was taken from the controls. All samples taken were separated and stored at 20oC. The CEA level was measured by fluoroimmunoassay technique. Results: The preoperative serum level of CEA in the patients was statistically higher than in the controls. The level of CEA in ovarian and cervical malignancy was statistically higher than in the control, while the level of CEA in endometrial carcinoma, vulvovaginal malignancies and benign tumors was not different. Also it was observed that there was significant lowering of CEA in the patients postoperatively. Conclusions: CEA level is higher in special types of ovarian malignancies. Radical surgery; in the management of ovarian malignancy; resulted in much lowering in CEA in blood postoperatively. The CEA level can be used as a predictor for early recurrence of ovarian mucinous cystadenocarcinoma.

P3.16.10 EFFECT OF CARBOPLATIN BASED CHEMOTHERAPY ON PATIENTS WITH EPITHELIAL OVARIAN CANCER C. Xiaojun, F. Youji, Obstetrics and Gynecology Hospital, Shanghai Medical University, Shanghai, China. Objective: To investigate the effect of progestins in combination with carboplatin based cytotoxic chemotherapy on patients with epithelial ovarian carcinoma. Materials and methods: 82 patients with Stage I~IV Grade I~III epithelial ovarian carcinoma participated in this trial. All patients received cytoreductive surgery and standard carboplatin based chemotherapy. 45 patients received injections of progestin (Hydroxyprogesteroni Caproas 250 mg im Biw x 1 month; 500 mg im Q2w x 3 years). These patients were considered as the progestin group. The remaining 37 patients receiving standard chemotherapy were only in the control group. Life table was used to calculate the survival rate and recurrence rate. Results: The 3-year survival rate of the progestin group and the control group was: Stage I: 100%, 100%; Stage Ib~Ic: 92.0%, 87.5%; Stage III: 78.4%, 48.5%; Grade I: 100%, 100%; Grade II: 88.9%, 68.6%; Grade III: 92.9%, 83.0%. The 3-year recurrence rate of the progestin group and the control group was: Stage I: 0%, 0%; Stage Ib~Ic: 16.0%, 27.1%; Stage III: 39.7%, 73.0%; Grade I: 0%, 0%; Grade II: 52.0%, 65.7%; Grade III: 14.9%, 25.0%. Conclusions: Progestins in combination with carboplatin based chemotherapy may improve the long-term survival rate and reduce the recurrence rate in patients with epithelial ovarian carcinoma. P3.16.11 ESTABLISHMENT AND CHARACTERIZATION OF OVARIAN CLEAR CELL ADENOCARCINOMA LINE I. Fukasawa, T. Sakamoto, A. Yoshinaka, M. Tanaka, Y. Ota, N. Inaba, Dept. OB/GYN, S. Yasuda, Dept. Molecular Biology, Dokkyo University, Tochigi, Japan. Objectives: The aim of the study was to establish a new cell line derived from a clear cell carcinoma of the ovary, and to investigate the characterization of this cell line. Study Methods: Primary cells were obtained from the fresh ascitic fluid of a patient with a FIGO stage a ovarian clear cell adenocarcinoma. These cells, designated KY, were maintained in culture at 37 C within an atmosphere of 5% CO2/95% air. RPMI 1640 supplemented with 10% fetal bovine serum was used as the growth medium. Cultured cells were stained with periodic acid-Schiff(PAS) for glycogen and oil red O for lipid. The levels of vascular endothelial growth factor(VEGF), tumor necrosis factor- (TNF- ) and triglyceride in conditioned media were measured. Expression of VEGF mRNA was examined by reverse transcriptase-polymerase chain reaction. Results: The KY cell line has been successively subcultured more than 60 times over 25 months. The growth curve at the 20th generation indicated the population doubling time to be 33 hours. After subcutaneous heterotransplantation into nude mice, the KY cells were observed to produce tumors histologically similar to the original carcinoma. The volume doubling time of the tumor was estimated to be about 3.5 days. PAS positive and oil red O positive staining was found in the cytoplasm. VEGF and TNF- protein levels in the conditioned media were 34,500 and 0.5 pg/ml, respectively. Triglyceride was not detected. Expression of VEGF mRNA was observed in the cultured KY cells.

P3.16.13 EVALUATION OF TWO THERAPY MODALITIES OF OVARY CARCINOMA A. Drr, O. Blha, Z. Malo, Dept. OB/GYN, Masaryk University, OB/GYN University Hospital, Brno-Bohunice, Czech Republic, 639 00. Objectives: The goal of our study is to evaluate the results of ovary carcinoma treatment in group withouth and with using Platinum drugs as were carried out in a six years period Study Methods: Standard therapy method consisted in radical operation and subsequent chemotherapy. In group A (45 patients) followed chemotherapy withouth Platinum drugs and in group B (47 patients) followed chemotherapy with Platinum drugs, C A P combination ussually. We observed 5 years survival rates, disease free interval and side effects or complications. Results: 92 observed patients were stratified according to the stage of disease and by the size of residual tumour. Entire time of 5 years survived were found out for about 39% in group A and 43 % in group B(p<0,02). Prolongation of remision was observed in group B from 9,1 to 14,9 months (p< 0,05) Conclusions: Prolongation of 5 years survival rate and disease free interval was observed in patients with Platinum therapy and no more different side effects were observed. P3.16.14 EXPRESSION OF CARBONYL REDUCTASE IN EPITHELIAL OVARIAN CANCER AND ITS CLINICAL SIGNIFICANCE M. Umemoto, Y. Yokoyama, S. Sato, Y. Saito, Dept. OB/GYN, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan Objectives: The expression of carbonyl reductase (CR) in epithelial ovarian cancer and its clinical significance were examined. Study Methods: Using an anti-CR antibody, immunohistochemical staining (immunostaining) via the LSAB method was performed on 73 primary epithelial ovarian cancers, 24 intraabdominal disseminations (ID), 13 retroperitoneal lymph node (RLN) metastases, 12 recurrent tumors (RT), 13 borderline malignant tumors, and 25 benign ovarian tumors for a total of 160 specimens resected after patientss consent had been obtained. The degree of CR expression in the tissue of the tumor was divided into three grades of negative, weakly positive and strongly

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positive for evaluation based on the proportion of positive cells and the staining intensity. Results: The rate of specimens in which CR was positive was 30% for benign tumor, 38% for a borderline malignant tumor, and 62% for ovarian cancer, with a significant difference in CR expression between ovarian cancer and benign tumor (p<0.01). (1) The degree of CR expression was not significantly different between the primary cancer and ID, and between the primary cancer and RT. (2) Among primary cancers, the CR positive rate was 38% for those with RLN metastasis (n=13) and 67% for those without RLN metastasis (n=60), the former being significantly lower than the latter (p<0.05). (3) The 5-year survival rate was 62.7% for the ovarian cancer patients with negative CR (n=27) and 86.1% for the positive CR group (n=46) (p=0.078). Conclusions: The results suggest that decreased CR expression in ovarian cancer is involved in RLN metastasis and that CR is a useful negative marker in determining the prognosis of epithelial ovarian cancer. P3.16.15 FINAL STAGING OF OVARIAN CANCER CLASSIFIED AS STAGE I ( FIGO) DURING SURGERY Andrzej Bienkiewicz, Leszek Gottwald, Jacek Suzin, Dept. of Gynecological Oncology, Inst. of Obst. and Gynecol., Medical University, 37 Wilenska st., 94-029 Ldz, Poland Background.Ovarian cancer is one of the most common and difficult diagnostic and therapeutic problems in gynecological oncology. Surgical procedure together with chemotherapy is recommended even in late stages of disease. The precise evaluation of staging during surgery combined with frozen section is of critical importance in further management. Aim of study. We compared intraoperative clinical staging of ovarian cancer with the final histopathological examination in stages estimated as Ia-Ic during surgery. Material and methods. 50 women who underwent surgical procedure between 1994-1999 in our department due to the ovarian cancer involving one or both ovaries were included into the study. Results. In 34 cases the tumor was unilateral and in 16 cases both ovaries were involved. In 18 cases (36%) the ascites was observed. However the histopathological examination of removed tissues in 3 (6%) cases demonstrated the involvement of the uterus and the tubes, in 11 (22%) cases microimplants in the omentum were found. 2 out of those 11 patients were below 30. In 2 cases the microimplants were detected in the appendix. The cytologic examination of the peritoneal fluid was positive in 8 cases. The microimplants of neoplasmatic cells to the second ovary were detected in 2 cases. In 2 cases ovarian cancer coexisted with endometrial cancer of different histological type and with cervical preinvasive cancer. Among the clinical factors the adhesions of the tumor to the peritoneum and bowels correlated with higher stages of ovarian cancer estimated in histopathological examination. Conclusions. Due to the high rate of late stages of ovarian cancer among those which were classified initially as stage I, all those patients should be reffered to the Gynecological Oncology Departments, where the adequate procedures can be performed. In all cases of diagnosed ovarian cancer despite of clinically early stages in women below 30, the radical surgery should be recommended. P3.16.16 FOLLOW UP OF OVARIAN CANCER WHICH EXAMINATIONS ARE NECESSARY? F. Heller, T. Fehm, S. Ackermann, W. Jger, N. Lang Dept. OB/Gyn, University Erlangen-Nuremberg, Germany Objectives: The aim of the retrospective study was to investigate which examinations are necessary for detection of a relapse in ovarian cancer patients. Study Methods: Over the first two years after primary surgery follow up check ups were performed in 3 month intervals by interview, physical examination and CA 125 determination. During the following three years follow up checks were performed every 6 month and later only once a year. Dependent on a pathological finding further diagnostic methods were performed (e. g.: CT, sonography, local biopsy). Between

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1984 and 1999 62 patients with a completely documented follow-up, no secondary cancer and a complete remission for more than twelve months were included in the study. Results: In 25 (40%) patients all three methods resulted in a pathological finding. 11 (18%) patients reported well being, but a palpable abdominal mass was found and the CA 125 was elevated. Only an elevated tumormarker CA 125 could be measured in 9 (14%) cases. Elevated CA 125 value and patientsdiscomforts characterized 6 cases (10%) with ovarian cancer relapses. A normal CA 125 level was measured in 11 cases (18%), but with one exception, the women reported disorders or a tumor was palpable. After the suspected diagnosis without positive tumor evidence a CT was performed in 83% (n=52) and a sonography in 77% (n=48). Both imaging techniques showed false negative results in 10% (n=5) and 21% (n=10) respectively. Conclusions: Interview, physical examination and the determination of serum CA 125 level together detected 98% of ovarian cancer relapses. At that time the tumormarker CA 125 was normal in 18%. Imaging techniques (CT, Sonography) should only be used when a suspicion based on these parameters is raised. P3.16.17 GIANT PYOMYOMA AND ENDOCARDITIS MIMICKING OVARIAN CANCER J.P. Carvalho, M.L.N. Dias, P.R. Genta, T.A. Janiszewski, F.M. Carvalho, J.S. Souen, Dept. OB/GYN and International Medicine, Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil. Introduction: Diagnosis of ovarian cancer can be difficult because many diseases may mimic this neoplasm clinically, radiologically or by an increase in CA-125 levels. Case Report: A 60 year old female diabetic patient was admitted complaining of an abdominal mass, malaise and loss of 32kg in 3 months, and fever for the past two weeks. A systolic murmur could be heard along the left sternal border. A large pelvic mass extending to the epigastrium could be seen. Blood cultures grew Streptococcus agalactiae. Transesophageal echocardiogram showed a filamentary lesion at the tricuspid valve, suggestive of vegetation. Intravenous Penicillin was started and Amikacin was added later due to persistence of fever. Computed tomography showed a large mass with signs of necrosis extending from the pelvis to the hepatic hilum and deep venous thrombosis of the femoral and external iliac veins. CA-125 was 109.7U/mL. Ovarian cancer was suspected and the patient underwent surgery one month after admission when the infection and diabetes were controlled. A giant suppurated uterine mass was found and total abdominal hysterectomy with bilateral salpingooforectomy was performed. Culture of the uterine suppuration also grew S. agalactiae. Histopathological examination revealed an 18cm leiomyoma with cystic degeneration and abscess formation (pyomyoma). The patient recovered well and gained weight. She is doing well 6 months after surgery. Conclusion: Pyomyoma is a rare complication of uterine leiomyoma, only 12 cases being reported since 1945. Pyomyoma was never reported to be associated with endocarditis and with elevated CA 125, although elevated CA-125 had been related to uterine leiomyoma. P3.16.18 INSULIN-LIKE GROWTH FACTOR-i/GROWTH HORMONE AXIS, C-ERB B-2 ONCOPROTEIN LEVELS, CATHEPSIN-D AND PEROXIDASE IN OVARIAN CARCINOMA M. Zakhary (a), A. Sabra (b), T. El-Deep (a), A. Mustafa (c), H. Mahfouz (d), (a) Dept. OB/GYN, (b) Biochemistry, (c) Clinical Pathology, (d) Radiotherapy, Dept. Faculty of Medicine, Assiut University, Egypt. Objectives: To investigate the insulin like growth factor 1 (IGF1)/growth hormone axis, c-erb B-2 oncoprotein levels, activities of cathepsin-D and peroxidase in ovarian carcinoma. Study Methods: Serum and tissue samples of 48 patients with malignnat ovarian tumors, ovarian tissues of 10 patients with fibroids or DUB to obtain control and serum samples of 15 healthy females (control). Serum and tissue levels of IGF-1, c-erb B-2 oncoprotein, cathepsin-D, serum levels of growth hormone and tissue activity levels of peroxidase were studied.

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Results: Significant increase of IGF-1, c-erb B-2 oncoprotein, cathepsinD mean levels in patients compared with controls. Levels of serum growth hormone and tissue peroxidase increased significantly in patients with ovarian tumors compared with controls. Significant positive correlations existed between serum and tissue c-erb B-2 oncoprotein levels as well as serum growth hormone and serum IGF-1 levels. Levels of tissue IGF-1 correlated significantly with tissue activity. The changes in the bioindices studied reflected the biological behavior of the tumor being higher in advanced stage and high burden tumors. Conclusions: IGF-1/growth hormone axis seems to play an important role in the biological behavior of ovarian carcinoma, regulating their growth and spread. The use of IGF-1 antagonists would represent new therapeutic lines. Over-expression of c-erb B-2 oncogene is another important level in ovarian carcinoma. In addition cathepsin-D plays an important role in spread and advancement of ovarian tumors. The use of specific inhibitors to these enzymes would provide important adjuvant therapeutic lines. P3.16.19 INTERLEUKIN-8 SERUM LEVEL SHIFT IN PATIENTS WITH OVARIAN CANCER UNDER A PACLITAXEL CONTAINING CHEMOTHERAPY K. Mayerhofer (1), K. Bodner-Adler (1), M. Schindl (1), A. Kaider (2), L. Hefler (1), R. Zeillinger (1), S. Leodolter (1) and C. Kainz (1) (1) Dept. OB/GYN, University of Vienna Medical School, Vienna, Austria. (2) Dept. Medical Computer Sciences, University of Vienna Medical School, Vienna, Austria. Objectives: Paclitaxel was descried to induce interleukin-8 (IL-8) transcription and secretion in human ovarian cancer cells. Aim of this study was to investigate possible clinical implication of the effect of paclitaxel on Il-8 serum levels in patients suffering from ovarian cancer. Study Methods: Thirty-one patients with ovarian cancer, treated with a combination chemotherapy consisting of paclitaxel and carboplatin, entered the study. Il-8 serum levels and CA-125 serum levels were detected three times per patient, directly before, after 3 cycles and after 6 cycles of the chemotherapy. Additionally, serum samples of 59 health age-matched women were obtained. A quantitative human IL-8 immunoassay was used to determine the IL-8 serum levels. Results: 78% of patients responded to chemotherapy, with 62% of complete responses and 16% of partial responses. The median IL-8 serum level before chemotherapy was 75pg/mL (range: 2.7 903.3), during chemotherapy 23.75 pg/mL (range:0.5-248.2) and after chemotherapy 17.65 pg/ml (range: 0.6-377), The median IL-8 serum level in controls was 15.6 pg/mL (range: 1.4 106.3). We found a statistically significant decrease in both of IL-8 serum levels (p<0.05; p<0.05) and of CA-125 serum levels (p<0.05; p<0.05) from the first of the second measurement and from the first to the third measurement. We found no correlation between the shifts of IL-8 serum levels and CA-125 serum levels during chemotherapy. We observed no statistically significant correlation between IL-8 serum levels and any clinicopathological parameter. Conclusions: We found elevated IL-8 serum in patients with ovarian cancer and a decrease of IL-8 serum levels under a paclitaxel-containing chemotherapy. The results of this study may indicate that IL-8 probably acts as a useful monitoring marker in patients with ovarian cancer independent to CA-125. P3.16.20 INTRA-ARTERIAL INJECTION OF CARBOPLATIN AND INTRAVENOUS DRIP INFUSION OF PACLITAXEL IN PATIENTS WITH INOPERABLE ADVANCED OVARIAN CANCER T. Yamazaki (1), H. Hatano (1), N. Matsubara (1), Y. Yamaguchi (2), Y. Shigemori (2), I. Konishi (3) (1) Dept. OB/GYN, Iida Municipal Hospital, Iida, Nagano, Japan. (2) Dept. Radiology, Iida Municipal Hospital, Iida, Nagano, Japan. (3) Dept. OB/GYN, Shinshu University School of Medicine, Nagano, Japan. Objectives: Preoperative chemotherapy by intra-arterial injection has been reported in only a few patients with ovarian cancer. Therefore, we concurrently conducted intra-arterial injection of carboplatin (CBDCA)

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and intravenous drip infusion of paclitaxel (TXL) in patients with inoperable advanced ovarian cancer and evaluated their clinical efficacy. Study Methods: 2 patients (Case No.1:46 years old, No.2: 69 years old) had an inoperable giant ovarian cancer and showed dyspnea due to accumulation of a large amount of pleural effusion and ascites. Intraarterial injection of CBDCA (AUC=5) was conducted through a 4 Fr pigtail catheter inserted into the abdominal aorta directly beneath the renal artery. Concurrently, TXL was administered at 175mg/m2 by intravenous drip infusion. This treatment was repeated every 4 weeks before surgery. Case No. 1 and No. 2 received 2 and 3 cycles, respectively. Results: In both patients, pleural effusion and ascites disappeared. Image diagnosis also showed almost complete disappearance of the giant tumors. High blood tumor marker values rapidly returned to normal. Complete operation could be conducted after completion of the chemotherapy. Pathological diagnosis of resected tumor samples showed slight serous papillary adenocarcinoma in both left and right ovaries in both patients, but most tumor tissues showed necrosis. The clinical course of both patients has been monitored following surgery. The clinical course of both patients has been monitored following surgery. The clinical course of both patients has been monitored following surgery. No evidence of recurrence has been observed. Conclusions: Combination of intra-arterial injection of CBDCA and intravenous drip infusion of TXL was thought to be very effective before surgery in patients with inoperable advanced ovarian cancer. P3.16.21 INVOLVEMENT OF VASCULAR ENDOTHELIAL GROWTH FACTOR IN ASCITES FORMATION OF OVARIAN CANCER CELLS AND ITS REGULATION BY GnRH AGONIST N. Akutagawa, A. Nishikawa, M. Iwasaki, T. Fujimoto, Y. Kitajima, K. Manase, H. Henmi, T. Endo, R. Kudo, Dept. OB/GYN, Sapporo Medical University, School of Medicine, S1-W16, Chuo-ku, Sapporo, JAPAN, 060-8543 Objectives: The aim of the experiment is to elucidate the molecular mechanism of ascites formation in ovarian cancer cells and to assess whether GnRH agonist (GnRHa) can regulate the ascites in GnRH receptor (GnRH-R)-positive cells. Study Methods: We used two human ovarian cancer cell lines (HTBOA and AMOC-2). Expression of VEGF and GnRH-R was analyzed by Northern blot or the RT-PCR method. We utilized human a ovarian cancer ascites model by using nude mice. We administered GnRHa (leuprorelin acetate, 60mg/mouse) daily from 14 days after inoculation of cancer cells. Mice were sacrificed 3 weeks after GnRHa administration and the formation of tumor, ascites and peritoneal dissemination were evaluated. Results: HTBOA (poorly differentiated carcinoma) expressed both VEGF and GnRH-R mRNA, and presented peritoneal dissemination and ascites formation. AMOC-2 (serous cyst adenocarcinoma) did not express VEGF mRNA but presented solid tumors without ascites formation. The frequency of ascites formation was significantly decreased in the group of mice treated with GnRHa compared with the control group. Conclusions: VEGF plays an important role in ascites formation. It is suggested that GnRHa might regulate the ascites formation in ovarian cancer cells.

P3.16.22 MALIGNANT OVARIAN GERM CELL TUMOR; 208 CASES: OUTCOMES AND PROGNOSTIC STUDY P. Padungsutt, C. Thirapakawong, S. Therasakvichaya, P. Inthasorn, P. Tanmahasamut, I. Suphanit, S. Neungton, S. Senapad, GYN/ONC Unit, Dept. OB/GYN, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Objectives: To study outcomes of malignant ovarian germ cell tumor (MOGCT). Study Methods: The authors performed a retrospective analysis of women with MOGCT managed in gynecologic oncology unit, Dept. OB/GYN, during the period 1975-1997. We analyzed patients & tumor data by using Kaplan-Meier survival analysis and Cox regression analysis.

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Results: 208 patients were included. The mean age was 24 years (range 7-64), median age was 23 years, median follow up time was 39 months (range 1-288). Histology were confirmed MOGCT included dysgerminoma for 62 patients, non-dysgerminoma for 146 patients. All patients underwent operation: radical surgery for 118 patients (56.73%) and fertility sparing surgery for 90 patients (43.27%). According to FIGO 1987 staging system; 89, 25, 67 and 27 patients were classified in stage I, II, III and IV respectively. 195 patients were treated by chemotherapy but evaluable patients were achieved in 167 patients. Outcomes of these patients were complete response 133 patients (79.6%). Failure to fist line chemotherapy occurred in 44 patients (29.3%) mostly in non-dysgerminoma but only 10 of 44 (22.7%) were completely responded to second line chemotherapy and still free of disease. Recurrence occurred in 11 patients (6.4%) but 7 out of 11 patients (63.6%) who relapsed were successful salvaged. Overall 5-year survival rate was 80.77%. The 5-year survival rate for dysgerminoma and non-dysgerminoma were 93.8 and 72.9% respectively. The 5-year survival rate for radical and conservative surgery were 77 and 81% (P>0.05). In analysis of prognostic factors for survival showed that advanced stage and non-dysgerminoma were independent prognostic factors (P<0.05). Conclusions: This retrospective review is one of a large series to understand natural history, outcomes and prognostic factors. Advanced stage and non-dysgerminoma remained the most significantly adverse prognostic factors. Conservative surgery or fertility sparing surgery must be considered and did not affect overall survival outcome in malignant ovarian germ cell tumors. P3.16.23 MALIGNANT TRANSFORMATION OF MATURE TERATOMAS REPORT OF TWO CASES A. Pregal, D. Costa, N. Afonso, J.M. Furtado, P. Vieira de Castro, D. Pereira, J. Pinto de Oliveira, M. Osrio, (1) Dept OB\GYN; Sra Oliveira Hospital, Guimares, Portugal, (2) Dept of Medical Oncology, Instituto Portugues Oncologia, Oporto, Portugal Malignant transformation of mature teratomas is rare (1,8%) with squamous cell carcinoma being the most frequent histological type (80%).These tumors carry a worse prognosis than all other types of epithelial ovarian cancer and grade of differentiation and vascular invasion represent the most important prognostic factors. Surgical extirpation seems to be the procedure of choice but radiotherapy and combined multi-agent chemotherapy are being further evaluated especially in those cases with pelvic and peritoneal metastasis, associated with poor prognosis. The authors describe the cases of two patients aged 70 and 49 years diagnosed with mature teratoma with squamous cell malignization. Both patients first complaint was abdominal enlargement and diagnosis was made at laparotomy. The older of the patients (staged Ic GII) has a very short follow up time. The other patient was staged IIIc GII, received adjuvant chemotherapy and is alive and disease free nine months after diagnosis. Review of the literature concerning this pathology was made and discussion about diagnosis, treatment and prognosis is presented. P3.16.24 MANAGEMENT OF ENDODERMAL SINUS TUMORS OF OVARY WITH ALPHAFETOPROTEIN T. Hoshino, Y. Taguchi, T. Okamoto, S. Hamada, H. Kuroda, K. Nakamura, T. Komatsu, M. Shiotani, H. Shimada, Y. Ihara, Dept. OB.GYN, Kobe City General Hospital, Kobe, Hyogo, Japan. Objectives: The aim of the study is to improve the management of patients with endodermal sinus tumors (EST) of the ovary, monitoring serum alphafetoprotein (AFP) level. Study Methods: Preoperative and postoperative AFP were examined serially. Four patients now have no evidence of disease (NED), but 3 died from the disease. The half time of AFP was calculated in the postoperative course. In NED cases (long survivors), mean and standard deviation (M and SD) of SFP were calculated. Results: The half time of AFP was relevant to the prognosis. In NED cases, AFP values were changing within the very small range and M were different to each other in statistically significant level.

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Conclusions: AFP was found to be a useful tumor marker for the management of patients with EST. The individual normal range of AFP was very small and different to each other. P3.16.25 PACLITAXEL INDUCES MDR1-GENE EXPRESSION IN OVARIAN CARCINOMAS T. Schndorfa, C. Benzb, R. Neumannb, H. Kolhagena, C. M. Kurbachera, P. Mallmanna, U.-J. Ghringa a Dept. Gynecol / Obstet, University of Cologne, D-50924 Cologne, Germany b Bayer AG, ZF-BTD, D-47812 Krefeld, Germany Objectives Resistance to antineoplastics (multidrug resistance, MDR) is a major concern in ovarian cancer therapy. Clinical MDR is often associated with overexpression of the mdr1-gene. Our aim was to investigate the involvement of anticancer drugs in mdr1-gene induction. Study Methods We cultivated tumor cells of 7 different ovarian cancer cell lines for three days. Addition of either no supplement (control) or the commonly applied therapeutics adriamycin, paclitaxel or cisplatin, respectively, simulated the clinical situation. Total RNA was extracted using the Rneasy kit (Qiagen). RNA yields were adjusted to 75 ng/PCR. The mdr1 transcripts were amplified in a 25ml quantitative RT-PCR using TaqMan technology. Levels of the target sequence and the internal GAPDH reference were determined simultaneously. Results In 6/7 ovarian carcinoma cell lines, drug application induced increasing transcription of the mdr1-gene to varying extent ranging from 1.3 to 2-fold. Particularly, in all six cell lines, the most striking augmentation was induced by paclitaxel treatment. Conclusions In summary, the quRT-PCR enables detection of mdr1expression even at low transcript levels. In future, detection of mdr1expression could be incorporated into ovarian cancer staging and may serve as a helpful marker in decision of an individual therapy.

P3.16.26 PELVIC ADNEXAL MASS MANAGEMENT AND OPERATIVE FINDINGS E. Bajalaski, B. Boskovski, N. Bakalova, Ginekoloska Bolnica Cair, Skopje, Republic of Macedonia. Objectives: The aim of this article is to make analyses between the clinical and operative findings including the final histological diagnosis. Study Methods: In this study object of observation are patients that have been operated between 1995-1999 because of adnexal mass as a leading indication or as additional diagnosis for other benign disorder of the uterus. There were 132 such an operated cases, among 1320 gynecological operation or 10%. Results: The patohistological results shows that 93% of the operated cases were benign ovarian tumors and 9 cases or 7% were malignant. The leading three diagnosis of the benign ovarian tumors were cysta endometroides 20 cases, cystadenoma serosum 17, teratoma srosum benignum 16, and cysta symplex ovarii 15. The other type of benign tumors presented in very small number of cases. There were very rare ovarian tumors like Brener tumor ovarii, thecoma, leomioma ovarii as a single case in this study group. The malignant tumors presented in 9 cases or 7%. The major number (4) were cystadenocarcinoma serosum ovarii. The age of the patients was between 45-60 years. Conclusions: The conclusion from the presented facts is that the pelvic adnexal masses must be treated very seriously, especially those in the middle age (45-60) because of the high percentage of malignancy.

P3.16.27 PHENOTYPE OF TUMOR INFILTRATING LYMPHOCYTES (TIL) IN PATIENTS WITH MALIGNANT ASCITES J. Tosner, M. Touskova, B. Melichar, I. Ditetova, J. Krejsek, O. Kopecky, Charles University Medical School, Hradec Kralove, Czech Republic Objectives: To compare the phenotype of TIL in ascites of patients (pts) with ovarian carcinoma (OC) and different primary tumors. Study methods: The phenotype of TIL was examined by two-color flow cytometry in ascites of 51 patients [OC:21pts; pancreatic cancer (PC):9pts; gastrointestinal cancers (GIC)-colorectal cancer 8pts, gastric

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cancer 4pts; malignant melanoma (MM) 4pts; other primary 5pts]. Interleukin-10 (IL-10) and neopterin (NEO) were determined in ascitic fluid by enzyme-linked immunosorbent assay. Results: Most of the TIL (OC 74+12%; PC 69+8 %; GIC 70+14 %; MM 89+5 %; other 78+12%) had CD3+ phenotype. The majority of CD3+ cells expressed CD4 antigen. Compared to OC, pts with PC had higher NK cells (22+9 vs 12+8%, p0.01), and lower CD3+CD45RO (38+11vs 54+12%, p0.01), CD8+CD28+ (9+2% vs 14+6%, p0.01), CD19+CD86+ (0.3+0.3 vs 0.8+0.7%, p0.05), and CD3+CD152+ cells (0.4+0.3 vs 1.2+1.1%, p0.025). Patients with GIC had lower CD19+ (4+3 vs 7+4%, p0.025) and CD19+CD86+ (0.4+0.3 vs 0.8+0.7%, p0.05) cells. Percentages of other TIL subsets as well as concentrations of IL-10 and NEO were similar among patients with different primaries, and were for the whole cohort CD3+CD4+: 40+14%, CD3+CD8+: 32+13 %, CD3+CD25+: 5+6%, CD3+HLA-DR+: 7+11%, CD3+RA: 13+9%, CD3+CD80+: 2+2%, CD+CD57+: 3+4%, CD3+CD95+ 32+14%, IL10: 114+ 86 pg/ml, NEO: 14.6+13.1 nM. A substantial number of all cells in the ascites exhibited dendritic cell (DC) phenotype (1.2+1.6%). A significant correlation was observed between the concentrations of IL10 in ascitic fluid and percentages of CD3+CD25+ cells (Spearman rank correl. coeff., rs=0.29, p0.05), DC (0.36, p 0.05), and NEO and CD8+CD28+ cells (rs = - 0.32, p 0.05). Conclusions: Most of the TIL are CD3+ with memory cell phenotype. A substantial minority of cells express activation markers, costimulatory molecules, or naive cell phenotype. Differences were observed in TIL phenotype of pts with different primaries with lower NK cells and higher CD8+CD28+ in OC. Increased ascitic IL-10 is associated with higher DC numbers. (Supported by IGA grants 5196-3 and 4676-3).

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P3.16.29 POTENTIAL ANGIOGENESIS BIOMARKERS IN OVARIAN CARCINOMA A.Sabra (1), M. Zakhary (2), A. Kamel (3), Faculty of Medicine, Assiut University, Assiut, Egypt. (1) Dept. OB/GYN (2) Dept. of Biochemistry (3) Dept. of Clinical Pathology Objectives: To investigate the role of antiangiogenic drugs in treating ovarian carcinoma. Study Methods: Serum and tissue levels of angiogenic stimulators, vascular endothelial cell growth factor (VEGF), basic fibroblast growth factor (b-FGF), nitric oxide (NO), gangliosides and hyaluronan were determined in 48 patients with ovarian carcinoma together with 11 samples obtained from patients undergoing hysterectomy for fibroid or dysfunctional uterine bleeding. Results: The study revealed significant increase in the levels of angiogenic stimulators in either sera or tissue homogenates of patients with ovarian carcinoma compared with controls (P<0.001). The levels of these angiogenic stimulators reflected tumor stage as well as tumor burden. Patients with serous cystadenocarcinomas showed higher levels of serum and tissue angiogenic stimulators, compared with mucinous cystadenocarcinoma and undifferentiated tumors. No relationship could be detected between any of these angiogenic stimulators and patients age or menopausal status. The source(s) of these angiogenic stimulators are multifactorial, originating from the tumor cells themselves, connective tissue cells and the recruited inflammatory cells invading the tumor mass. Conclusion: From these data, it could be concluded that antiangiogenic drugs could be valuable in treating ovarian carcinoma. P3.16.30 PREDICTIVE VALUE OF RISK OF MALIGNANCY INDEX IN THE EVALUATION OF PELVIC MASSES A.P. Manjunath, Pratapkumar, K. Sujatha, R.Vani, Kasturba Medical College & Hospital, Manipal, Karnataka State, India, 380016. Objectives: To evaluate the ability of Risk of malignancy index (RMI) incorporating menopausal status, serum CA 125 levels and ultrasound features to discriminate benign from malignant pelvic masses. Study methods: A retrospective study of one hundred and fifty two women admitted between January 1997 and August 1999 for surgical exploration of pelvic masses was conducted at Kasturba Hospital, Manipal. Risk of malignancy index is the product of menopausal score, ultrasound score and serum CA 125 levels, was calculated for all patients. The sensitivity specificity and positive predictive value of serum CA 125 levels, ultrasound findings and menopausal status were taken separately and combined in to the RMI to diagnose ovarian cancer. Results: The Risk of malignancy index is more accurate than the menopausal status, serum CA 125 levels and ultrasound features separately in diagnosing malignancy. The Risk of malignancy index at a cut off level of 200 gave a sensitivity of 74%, specificity of 91% and positive predictive value of 93%. Conclusions: The risk of malignancy index identified women with malignant pelvic masses efficiently. The risk of malignancy index is a simple scoring system, which can be used in less specialized gynecology centers. We recommend the risk of malignancy index to facilitate the selection of patients for referral to an oncological unit for adequate staging and optimal debulking. P3.16.31 PREGNANCY FOLLOWING CONSERVATIVE SURGICAL TREATMENT OF THE MALIGNANT GERM-CELL TUMOR L. Tasic, N. Prokic, S. Runic, N. Antic, V. Rajkovic, M. Dzinic, M. Pantic, R. Lukic, M. Zamurovic, OB/GYN Clinic, Narodni Front, School of Medicine, University of Belgrade, Yugoslavia. Objectives: The aim of this study is to demonstrate that by the application of the conservative surgical treatment, the complete healing of the malignant germ-cell tumor stage I-a according to the FIGO classification is possible, as well as the conservation of the reproductive function of the young women.

P3.16.28 PLASMA UROKINASE PLASMINOGEN ACTIVATOR AND ITS RECEPTOR IN OVARIAN AND CERVICAL NEOPLASIA D. Contreras, C. Lox and S. Chavez, Dept. OB/GYN, Texas Tech School of Medicine, Lubbock, Texas, USA. Objectives: Advanced ovarian and cervical cancer has a poor prognosis. Therefore, we examined components of the fibrinolytic mechanism to see if any of these might serve as a tumor marker. Study Methods: Menopausal controls and patients with either benign ovarian cyst or cervical dysplasia or ovarian cystadenocarcinoma or squamous cell cervical carcinoma were included in this study. Plasma was collected prior to surgery and during the course of chemotherapy. Surgery was either oopherectomy and/or hysterectomy. Therapy was taxol and cisplastin for ovarian and cisplastin plus radiation for cervical. The therapy was continued for up to a year as required for the ovarian. Plasma samples were evaluated by enzyme-linked immunoabsorbant assays (ELISA) for circulating levels of urokinase plasminogen activator (uPA), and urokinase plasminogen activator receptor (uPAR). Results: The levels of uPA were elevated during chemotherapy, while the receptor for uPA was markedly elevated in both types of cancer and during chemotherapy, while the ratio of uPA/uPAR was significantly depressed in both cancer groups. A major evaluation in both uPA and uPAR occurred prior to metastatic recurrence in 2 patients with ovarian carcinoma. The ratio of uPA/uPAR markedly increased in 2 patients with cervical carcinoma following chemotherapy, a positive indicator of response. Conclusions: It appears that uPA, uPAR and their ratio are indicative of tumor mediated induction of alterations of fibrinolysis in both benign and malignant tumors of the ovary and cervix, and may be a viable tumor marker. It has been suggested that these factors may directly aid in tumor cell migration and metastasis. The activation of these factors may help explain the poor survival of patients with advanced ovarian and cervical cancer.

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Study Methods: In one patient, nulligravid, the color-doppler revealed the presence of a solid-cystic tumor sized 15 cm. With adequate vascularization and lower Resistance index (Ri 0.4-0.44). The tumor markers HCG and AFP were increased. This was the case of the malignant germ-cell tumor, histopathalogically of the mixed type (75% embrional carcinoma and 25% dysgerminoma) which belonged to the eIa stage according to the FIGO classification. The treatment consisted of the unilateral ovariectomy and biopsy of another ovary, with the lymphadenectomy along the external illiac artery, interilliacally and from the paraaortal space. Results: Following the conservative operative treatment, completed by the hemotherapy scheduled for the malignant germ-cell tumors (BEP: Bleomycin, Etoposid, Cysplatine, three to four treatments in 21 day intervals), the patients had the control check up monthly in the beginning and afterwards every 3 or 6 months by the method of colordoppler ultrasound and the control of the tumor makers (HCG, AFP). Our patient conceived spontaneously two years following the operation and brought the pregnancy to the term without major complications. Even five years following the operation all the laboratory analyses are within the normal range. Conclusion: The malignant germ-cell tumors belonging to the I-a stage according to the FIGO classification can be treated successfully by the conservative surgical method which does not interfere upon the reproductive function of these women.

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Study Methods: Uncontrolled, observational study. This study discusses the presentation and management of twenty cases from 1985 through 1997. The clinical background, ultrasonographic finding, and hormonal analysis of contents in the cyst were evaluated. Results: Diagnoses at the time of hysterectomy are uterine myoma, endometriosis, carcinoma in situ, colon tumor. Symptoms occurred within 1 year to over 8 years. Each pelvic mass ranged from 5cm to 14cm in size. Ultrasonographic finding is manifested by characteristic echo-free mass with irregular margin, in which ovarian follicles can be detected. Hormonal analysis of the content was performed in 6 cases. The concentration of estradiol is between 22.6 and 4210 pg/ml, the concentration of progesterone is between 1.6 to 16 ng/ml. Treatments carried out with GnRHa in 5 cases, oral contraceptives in 4 cases, puncture of the cysts in 6 cases, laparatomy in 2 cases, and observation in 5 cases. Conclusions: The diagnosis of ROS can be identified by characteristic ultrasonographic findings and hormonal analysis of content in the cyst. Conservative treatment should be chosen.

P3.16.34 RETROSPECTIVE STUDY OF 215 CASES OF OVARIAN CANCER E.C. Neagu, B. Marinescu, M. Neagu, L. Tasca, Dept. OB/GYN, University Hospital P. Sarbu, Bucharest, Romania. Objectives: The aim of the study is to investigate retrospectively 215 cases of ovarian cancer, concerning diagnosis, therapy and follow up. Study Methods: Two hundred and fifteen cases of ovarian cancer were operated from 1986 to 1999 (14 years), representing 17% of all cases of genital cancer operated. The middle age was 49.6 years, with limits of 13 and 78 years. The greatest frequency was in the 5th and 6th decades (24.7% and 20.3%). The diagnosis was performed by clinical signs, echography, CT, laparotomy. Results: The distribution after the stage was: stage I 49.9%; stage II 15.7%; stage III 14% and stage IV 20.2%. Ascitis was present in 54 cases (25.3%). The lesion was bilateral in 52 cases (24.1%). From 163 one side cancer cases, 48 (29%) presented borderline tumor in the other side ovary. The histology showed: differentiated adenocarcinoma in 80% of cases (papillary in 66% and mucinous in 13.8%), nondifferentiated carcinoma in 9.2% of cases, sarcoma in 6.1%, malignant disgerminoma in 3% of cases. Six cases were operated in emergency (3.6%). A radical resection, consisting in total hysterectomy with bilateral anexectomy and omenectomy was possible in 68% of cases. In 23% of cases only partial resection was possible (debalking surgery) and in 9% of cases only the biopsy was performed. Intraperitoneal chemotherapy was performed in all the cases. The postoperative polychemotherapy was performed: 3 cycles for stages I and II and 6 12 cycles for stages III and IV. The operative mortality was null. For 96 cases operated before 1994 the survival at 5 years was 32% (31 cases). For the same period, 37% of the stage I cases and 28% of the stage II cases developed mestastasis. Conclusion: In spite of an aggressive complex therapy, in absence of a screening program, ovarian cancer continues to have a severe prognosis. P3.16.35 STUDY OF THROMBOPHILIAS MARKERS IN PATIENTS WITH BENIGN AND MALIGNANT OVARIAN MASSES AFTER SURGICAL TREATMENT A.M. Chabrov, A.G. Solopova, U.U. Tabakman, E. Luginina, A.D. Makatsaria, Dept. OB/GYN, Laboratory of Hemostasis Pathology, Sechenov Moscow Medical Academy, Moscow, Russia. Objective: Thrombotic complications remain the leading cause of lethal outcomes in patients with ovarian carcinoma. Appropriate anticoagulant therapy pre- and post- surgical treatment can reduce thrombotic risk. Study Methods: We performed pilot study of 14 patients with benign ovarian masses and 26 patients with ovarian carcinoma. Detection of thrombin-antithrombin 111 complexes (TAT) and F1+2 was performed by ELISA (Behring, Germany), FDP by staphyl clamping test. For statistical analysis criteria of Willcoxon-Mann-Whitney was used. Results: Patients with ovarian carcinoma demonstrated initial high mean concentration of TAT and F1+2 40.6mg/l and 3.02nmol/l respectively. In postoperative period significant decrease of TAT to 3.9mg/l (p<0.01) and F1+2 to 0.96nmol/l (p<0.05) was detected. The same tendency was

P3.16.32 PRIMARY ADENOCARCINOMA OF A FALLOPIAN TUBE OF 3 CASES T. Saito, T. Yano, K. Otaka, T. Kinoshita, and M. Ito. Dept. OB/GYN, And Group of K. Hiruta, and N. Kameda, Dept. (Cytopathology), Sakura Hospital, Toho University, Sakura, Chiba, Japan Objective: The primary fallopian tube carcinoma is one of the least frequent tumors of the female genital tract. Our research has been completed including reviewing of the worldwide and national literature. Methods: Three patients with primary cancer of the fallopian tube treated at the Sakura Hospital of Toho University, between 1993 and 1999 was retrospectively evaluated for stage, histopathology, treatment and results. Results: Median age was 61 (range 55-69 years old). Two (2) patients had vaginal bleeding and One (1) patient had sense of abdominal fullness. All patients had 104-1600U/ml of Serum levels of CA125. All cases were diagnosed after surgery. There was a doubt of ovary cancer before surgery for vaginal bleeding in case of two patients. In case of patient with abdominal fullness, accumulation of abdominal dropsy with malignant cell was only found. Therefore, diagnostic surgery has been taken. All cases were adenocarcinoma according with cytological diagnosis. All patients had surgery, both total abdominal hysterectomy and bilateral salpingo-oophorectomy. In addition rertroperitoneal lymphadenectomy had done for 2 cases. According to FIGO staging, 2 cases were evaluated as stage I, 1 case as stage III. Relapse was found 1 year after this surgery, however both removal and CAP6 Treatment was applied. At result relapse was not found anymore. CBDCA was dosed before surgery. As result accumulation of abdominal dropsy has decreased. Conclusions: 1. Preoperative diagnosis is very much difficult in fallopian tube carcinoma. 2. With tumor marker, high level of CA125 was observed. 3. As a part of treatment, there is a possibility of platinum and it may be effective. P3.16.33 RESIDUAL OVARY SYNDROME - CLINICAL MANAGEMENT OF POST-OPERATIVE ADHESIVE RETENTION CYST OF ADNEXA Y. Tamaki, K. Kotake, Y. Izawa, S. Kaneko, Dept. OB/GYN, Matsudo Municipal Hospital, Matsudo Chiba, Japan. Objectives: Residual ovary syndrome (ROS) has become recognized as a cause of lower abdominal pain, dyspareunia and pelvic mass. The purpose of this study is to investigate clinical management of postoperative adhesive retention cyst originating from preserved ovary at the time of hysterectomy.

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mentioned in patients with benign processes with a lesser degree of decrease. Activation of intravascular coagulation was detected in 65% of patients with ovarian carcinoma (FDP low concentration in 46%, moderate in 15% and high concentration in 4%) with significant increase of FDP in postoperative period (low 27%, moderate 62% and high in 8%). Conclusion: Close hemostasis monitoring pre- and post-operatively is mandatory for timely and appropriate anticoagulant management of patients with benign and malignant ovarian masses. P3.16.36 THE RESULTS OF THE TREATMENT OF OVARIAN CANCER ESTONIAN EXPERIENCE Inga Vaasna, University of Tartu, Clinic of Hematology and Oncology, 7 Vallikraavi Str., Tartu 51003, Estonia. Objectives: The aim of the study is to report our results and to make some conclusions of our experience of treatment of ovarian cancer. Study Methods: This retrospective study analysed 290 patients with ovarian cancer treated in our clinic between 1990- 1998. Results: As ovarian cancer is often asymptomatic in its early stage, &#61566;70 % of patients have already reached stage III-IV at the time of diagnosis.The main treatment regimen of ovarian cancer is surgical treatment combined with chemotherapy.The aim of the surgery is to operate as radicaly as possible- the less the residual disease , the better the reaction on chemotherapy and the better are the results.The most common chemotherapy for advanced disease is Taxol- Cisplatin or Cisplatin- Cyclophosphamid. 17% of patients with ovarian cancer had stage I, 6 % stage II, 54 % stage III, 23 % stage IV at the time of diagnosis. The most common histological type was serous adenocarcinoma - 74 %. 80 % of the patients with ovarian cancer were in menopause at the time of diagnosis.18 % of ovarian cancer patients had had sterilitas primaria.The 5- year survival rate of ovarian cancer patients is 27 %. Conclusions: The survival rate depends on the stage, histological type, differentiation,the residual disease, the age.The smaller the residual disease the better the survival both for stage III alone and for all stages.The data suggest that further improvement in survival may be achived by aggressive debulking of stage III patients and confirm the survival benefit of Taxol and platinum based chemotherapy. P3.16.37 TRANSVAGINAL COLOR DOPPLER SONOGRAPHY IN OVARIAN TUMORS WITH USE OF LEVOVIST FOR IMPROVED VISUALIZATION OF THE BLOOD FLOW E. Blanco, J. Carvalho, A. Fonseca, J. Pinotti, R. Pastore, Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil. Objective: The purpose of this study was to evaluate the potential contribution of color Doppler sonography to ultrasound diagnosis by increasing Doppler signal intensities in small vessels of ovarian tumors with injection of Levovist. Study Methods: Thirty women were studied at the Department of Obstetrics and Gynecology, University of Sao Paulo (Brazil). Medical history, physical examination and laboratory examination showed that all of the patients were suitable for inclusion in this study, and none had a history of galactose intolerance. Levovist is a specially manufactured suspension containing 99.9% galactose microparticles and 0.1% palmitic acid. Each vial contained 4 g of microparticles and after its suspension in water it was administered intravenously via a peripheral vein. Doppler sonographic findings were compared before and after injection of 10 ml of Levovist at a concentration of 400/ml. Results: The general tolerance of Levovist was excellent. The baseline B mode scan revealed anechoic unilocular cysts in 6 cases, 9 were unilocular of multilocular cysts with septa or papilas and 15, complex lesions with cystic and solid parts. In all patients we found an increase in Doppler signal intensity with a slight increase in 7 patients and a considerable to optimal increase in 17 cases. In 22 cases sonography findings were changed after injection of Levovist, as color flow mapping showed increased vascularity either in the cystic wall or in solid structures within the tumor. Conclusions: Our results show that the injection of Levovist facilitates imaging of very small vessels with poor velocity patterns in ovarian tumors. In 22 cases color flow mapping showed increased vascularity. In

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addition, we found an enhancement of Doppler signal intensity in all lesions.

P3.16.38 TROUSSEAUS SYNDROME: A CASE OF SYSTEMIC THROMBOEMBOLIC EVENTS IN OVARIAN CARCINOSARCOMA M. Nakayama, T. Iha, M. Tokashiki, K. Kanazawa, Dept. OB/GYN, University of the Ryukyus, Okinawa, Japan. Objectives: Trousseaus syndrome, thromboembolic disorders associated with neoplastic disease, was first recognized by Trousseau in 1865. The aim of this report was to describe a case of the syndrome presented with systemic manifestations of coagulopathic events in ovarian malignancy. Case Report: A 56-year old Japanese woman presented with the benumbed arm and leg and visual disturbance. Examinations confirmed a huge irregular mass raising the possibility of underlying ovarian malignancy. CT scan imaged low-density areas of the left occipital lobe, spleen and kidney, indicating thromboembolic lesions. Visual disturbance was diagnosed to be a right homonymous hemianopsia due to ischemic damage of the right optic area. Numbness of the arm and leg was suspected to be also due to transient ischemic brain damage because of no signs for venous thrombosis of the involved extremities. Furthermore, blood flow scintigraphy indicated multiple pulmonary emboli. Inverted T-wave in ECG strongly suggested mild myocardial infarction. No abnormalities were observed in blood coagulation/fibrinolysis analyses. Anti-coagulation therapy was initiated with intravenous injection of heparin. Two weeks later, the symptoms were almost improved with the exception of visual disturbance. Thereafter, she underwent radical surgery that explored Stage Ic ovarian carcinosarcoma, followed by cisplatin-based chemotherapy of 6-cycles. She has been free of disease with no relapse, but with visual disturbance, more than 5 years. Conclusions: To our knowledge, this is the first case of Trousseaus syndrome with intracranial thromboembolic event.

P3.16.39 UTILITY OF MUCIN HISTOCHEMISTRY AND MORPHOMETRY IN THE EVALUATION OF SEROUS AND MUCINOUS EPITHELIAL TUMOURS OF THE OVARY. Karuna Rameshkumar, Department of Pathology, St.Johns Medical College, Bangalore, India. Background: Ovarian epithelial tumours form a morphologic continum from benign, borderline to malignant tumours. Mucin histochemistry and morphometry applied to such tumours may provide additional information to light microscopy and clinical features. Objectives: To assess the incidence of serous and mucinous ovarian tumours from 1988 to 1998 and to evaluate the utility of mucin histochemistry and morphometry. Material and Methods: The clinical data was accrued from archives. In addition to routine stains for basic morphology, mucin histochemistry was done using 12 stains. Morphometry to measure height of the epithelium was done by visopan and eyepiece micrometry. Results: An incidence of 67.87% of epithelial tumours was observed, which on further categorisation showed 283 serous(s) and mucinous(m) tumours ( benign- 151s and 92m; Borderline- 8s and 14m; Malignant -6s and 14m). Mucin histochemistry showed a significant decrease of acid mucins from benign to borderline to malignant mucinous tumours. Nacetyl sialomucin which showed a decrease in malignant tumour paralleled with an increase in malignant potential of the tumour. Serous tumours showed predominantly neutral mucins which also showed a similar trend. The height of the epithelium showed a similar decrease from benign to malignant mucinous tumours while such a distinction was not marked in serous tumours. Conclusions: The morphometry and mucin histochemistry showed a definite change in relation to degree of malignancy and differentiation in mucinous tumours and hence may be of value in addition to cellular features to assess the malignant potential .In serous tumours utility value of such procedure is low.

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P3.17 PHYSIOLOGY OF REPRODUCTION P3.17.01 EFFECTS OF OXYTOCIN AND STAUROSPORINE ON THE CELL CYCLE IN MOUSE EARLY EMBRYO N. Makimura, U. Fukui, T. Shibazaki, T. Tanaka, K. Kuroda, I. Nagata, Dept. OB/GYN, National Defense Medical College, Tokorozawa, Japan. Objectives: We reported previously that protein kinase C (PKC) was activated by oxytocin (OT) in mouse early embryo, suggesting a close relationship between PKC and embryo development. The purpose of this study was to examine the influence of OT and an inhibitor of PKC, staurosporine (ST), on the embryo development and to clarify the mechanism of cell cycle in early embryo. Study Methods: (1) One-cell stage embryos were incubated in mBWW medium containing ST for 1h, transferred to the fresh medium containing OT, and incubated for 4 days to the blastocyst stage. (2) One-cell stage embryos (n=200) were incubated in mBWW alone, with ST or with OT. They were further divided into the following subgroups. They were incubated from G1 phase to S phase (1-S), S/G2 phase (1-S/G2) in 1-cell stage embryos, and to S stage (2-S) in 2-cell stage embryo. The expression of cyclin D1, cyclin A2, cylcin-dependent kinase (cdk) 2 and p27 mRNA in embryos were analyzed by RT-PCR method. Results: (1) The embryo stopped developing at the 2-cell stage in the presence of ST. However, the stopped 2-cell embryo restarted developing by OT. (2) The low level of cyclin D1mRNA was detected in all groups. The high level of cyclin A2 mRNA was observed at the OT group in 1-S/G2 and 2-S phase. The level of cdk2 mRNA increased with embryo development in all groups. The high level of p27 mRNA was detected in the OT group in 1-S/G2 phase. Conclusions: OT may restore the embryo development impaired by some environmental factors. OT may promote the cell cycle of mouse embryo from G1 phase to S phase, since the appearance of cyclin A2 mRNA expression was quickened by OT. Thus, OT may exert a favorable influence on the mechanism of cell cycle, and consequently activate the viability of the embryo. P3.17.03 ESTIMATION OF THE BIOLOGIC VARIATION OF PRE AND POSTOVULATORY PARTS OF GESTATIONAL LENGTH AND THE VARIATION OF THE ERROR OF SECOND TRIMESTER ULTRASOUND ASSESSMENT OF GESTATIONAL LENGTH B. Backe (1), H. Buhaug (2), J. Nakling (3) (1) Dept. OB/GYN, University Hospital of Trondheim, Norway. Norwegian Institute for Hospital Research, SINTEF-UNIMED, Trondheim, Norway. (2) Dept. OB/GYN, Central Hospital, Lillehammer, Norway.

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Objectives: To estimate the random error of ultrasound gestational age assessment, the biologic variation in gestational length from conception to delivery, and the biologic variation of the interval from last menstrual period to conception. Study Methods: A cohort study of 9620 singleton pregnancies with spontaneous onset of labor was done. Routine ultrasound assessment of gestational age was performed in second trimester, and all women had a reliable last menstrual period. Combining the two estimated dates with the observed day of delivery, the variance of the different proportions of the gestational time can be assessed. Results: The standard deviation of the period from conception to spontaneous delivery was 13.2 days and the time between first day of last menstrual period and conception 7.1 days. The standard deviation of the difference between real and ultrasound estimated fetal age at the time of second trimester routine ultrasound examination was 3.9 days. Conclusion: The naturally occurring or biologic variation of the preovulatory part of gestation is substantially larger than the random error associated with the ultrasound method. Second trimester ultrasound assessment of gestational age is more reliable than calculation based on last menstrual period. P3.17.04 FRACTION OF CD4+ T CELLS CONTAINING IFN-g, BUT NOT IL-4 IS EXPANDED IN WOMEN WITH PRE-ECLAMPSIA COMPARED WITH NON-PREGNANT WOMEN T. Aoya, A. Ohkuchi, H. Minakami, A. Izumi, R. Usui, I. Sato, Dept. OB/GYN, Jichi Medical School, Tochigi, Japan. Objectives: Change in Th1/Th2 cells ratio may be involved in the development of pre-eclampsia. It is suggested that a fraction of Th1 cells is expended in women with pre-eclampsia. However, it is not known whether the number of Th1 cells is actually increased in women with pre-eclampsia. Study Methods: 12 healthy non-pregnant women, 10 women with uncomplicated pregnancies in the third trimester, and 10 women with pre-eclampsia were examined. PBMCs were collected using Histopaque1077. Three-color flow cytometric technique was used to analyze intracellular cytokines. After treatment of the PBMCs with phorbol ester, ionomycin and brefeldin A for 4 hours, individual cell was classified into CD4+ T cells or CD8+ T cells. These cells were treated with saponin and intracellular cytokines, IFN-g and IL-4, were stained by specific antibodies. Results: Mean percentage ( SD) of cells that had intracellular substances reacted with anti-IFN-g antibody, but not with anti-IL-4 antibody among CD4+ T cells was 135.8%, 105.8%, and 195.2% in non-pregnant, healthy pregnant, and pre-eclamptic women, respectively. Percentage of the cells that had intracellular substances reacted with anti-IFN-g antibody, but not with anti-IL-4 antibody among C8+ T cells was 4120%, 3516%, and 4818% in the 3 corresponding groups, respectively. Conclusions: These results suggested that a fraction of Th1 cells appeared to be expanded in women with pre-eclampsia compared with non-pregnant women and healthy pregnant women.

P3.17.02 EFFECTS OF OXYTOCIN AND STAUROSPORINE ON THE CELL CYCLE IN MOUSE CUMULUS CELL U. Fukui, N. Makimura, T. Shibazaki, M. Murakami, K. Furuya, I. Nagata, Dept. OB/GYN, National Defense Medical College, Tokorozawa, Japan. Objectives: We reported previously that protein kinase C (PKC) was activated by oxytocin (OT) in mouse embryo and OT was secreted from mouse cumulus cells surrounding ovum just after ovulation. The purpose of this study was to investigate the effects of OT and staurosporine (ST, PKC of inhibitor) on the progress of cell cycle in the cumulus cells. Study Methods: Mouse cumulus cells were removed from oocytes and separated by hyaluronidase. Synchronized cumulus cells (1x105cells/ml) were incubated for 1, 3, 6 and 12h in the RPMI 1640 medium alone (control group), and with OT (OT group) or ST (ST group). The expressions of mRNAs of cyclin D1, cyclin A2 and cyclin-dependent kinase (cdk) 2 in culture cells were analyzed by RT-PCR method. Results: During culture, expression of cyclin D1 mRNA was detected markedly in the ST group. The expression of cyclin A2 mRNA was observed earlier and higher in the OT group than in the other groups. Cdk2 mRNA was expressed constantly in all groups during the incubation. Conclusions: OT and ST act on the cumulus cells around the postovulated ooctye in the following ways. (1) ST may induce G1 cell cycle arrest since it expressed high levels of cyclin D1 mRNA, continuously. (2) OT may promote the step of cell cycle from G1 to S phase since it quickens the expression of cyclin A2 mRNA.

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P3.17.05 HORMONAL CHANGES AND THEIR INFLUENCE ON LIPIDS METABOLISM IN PHYSIOLOGICAL PREGNANCY E. Romejko, R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski, K. Czajkowski, J. Teliga, A. Malinowska, 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objective: The aim of the study was to investigate the influence of total estrogens, human placental lactogen, estradiol and prolactine on lipids metabolism in physiological pregnancy. Methods: One hundred thirty-six women in the third trimester (36.13.4 weeks) of the physiological pregnancy entered the study. The following serum parameters were measured: total lipids, total LDL fraction, total cholesterol, free cholesterol, phospholipids, triglicerides, HDLcholesterol, LDL-cholesterol, total estrogens, human placental lactogen, estradiol, prolactine. Methods generally accepted in clinical biochemistry were used. The statistical analysis and correlation were performed. Results: The following results were obtained: total estrogens and human placental lactogen create an increased of serum concentrations of: total lipids (p<0.001), total LDL fraction (p<0.001), phospholipids (p<0.001) and triglicerides (p<0.001) while total cholesterol, free cholesterol, HDL-cholesterol and LDL-cholesterol remain unchanged. Prolactine lowers the serum concentration of LDL-cholesterol (p<0.01) and does not alter any other of the lipids. Estradiol does not influence lipids metabolism. Conclusions: The elevated concentrations of lipids in women with physiological pregnancy are related to an increase of total estrogens and human placental lactogen. Prolactin has little effect on lipids also does not alter estradiol levels. This may suggest that the increase of the lipids concentration in physiological pregnancy might be related mainly to estradiol activity.

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P3.17.07 LIPIDS METABOLISM IN PREGNANCY COMPLICATED WITH PRIMARY HYPERTENSION E. Romejko, R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski, K. Czajkowski, J. Teliga, A. Malinowska, 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objective: The aim of the study was to evaluate eight parameters of lipids metabolism in pregnant women with primary hypertension. Methods: Twenty-eight women with primary hypertension (the studied group) and 136 healthy women (the control group) entered the study. All women were in the third trimester of pregnancy and there was no significant difference in mean gestational age 35.03.8 vs. 36.13.4 wks. Patients in the studied group presented blood pressure 16311/1005.9 mmHg. The following parameters in blood serum were measured: total lipids, total LDL, total cholesterol, free cholesterol, phospholipids, triglicerides, HDL-cholesterol, LDL-cholesterol. Generally accepted clinical biochemistry methods were used. Results: Women in the studied group versus control group showed following results: total lipids 777195 vs. 692122 mg%; p<0.03, total LDL 562207 vs. 465100 mg%; p<0.01, total cholesterol 28984 vs. 26440 mg%; NS, free cholesterol 8327vs. 7714 mg%; NS, phospholipids 34068 vs. 29847 mg%; p<0.002, triglicerides 363161 vs. 23273 mg%; p<0.0001, HDL-cholesterol 6915 vs.6920 mg%; NS, LDL-cholesterol 16071 vs. 15038. Conclusions: Women in the third trimester of pregnancy complicated with primary hypertension present significant alteration in lipids metabolism manifesting in elevated serum concentrations of total lipids, triglicerides, phospholipids and total LDL. Primary hypertension does not change serum concentrations of total cholesterol, free cholesterol, HDL-cholesterol and LDL-cholesterol. P3.17.08 PHYSIOLOGICAL SIGNIFICANCE OF HYPERPOLARIZATIONACTIVATED INWARD CURRENTS IN SMOOTH MUSCLE CELLS FROM THE CIRCULAR LAYERS OF PREGNANT RAT MYOMETRIUM Y. Inoue (1), K. Okabe (2), H. Soeda (2), T. Kawarabayashi (1) (1) Dept. OB/GYN, Fukuoka University, Fukuoka, Japan. (2) Dept. Physiol., Fukuoka Dental College, Fukuoka, Japan. Objectives: The aim of this study was to clarify the properties of hyperpolarization-activated current were investigated in pregnant rat uterus (17~ 19 days gestation). Study Methods: The microelectrode and patch-clamp techniques were applied to enzymatically-isolated rat myometrial cell and isometric tension recording was performed using myometrial strips. Results: The resting membrane potentials were 58.4 mV and 48.5 mV in longitudinal and circular muscle cells, respectively. Application of hyperpolarizing current pulses produced a time-dependent anomalous inward rectification of membrane potential only in circular muscle cells. Under voltage-clamp conditions, inward currents (I h) were activated by long hyperpolarizing pulses below 60 mV in circular but not in longitudinal muscle cells. Application of Cs+o but not Cs+I reduced the amplitude of I h in a concentration-dependent manner (an IC50 of 0.15 nM). The reversal potential for Ih was 26.2 mV and the slope conductance was 5 nS/pF. Changes in the [K+]o and [Na+]o shifted the reversal potential, and Ih amplitude increased with excess [K+]o and decreased with low [Na+]o. The steady-state activation of Ih was well fitted by a Boltzmann equation with a half-activation potential of 84.3 mV and a slope factor of 9.6 mV. Time courses of activation and deactivation of the current strongly depended on membrane potential, and were well fitted by a single exponential function. In isometric tension recording, application of Cs+o to the circular muscles reduced the frequency, but not the amplitude of spontaneous contractions in a concentration-dependent manner. Conclusions: It is concluded that in pregnant rat uterus Ih channels are predominantly distributed in smooth muscle cells from the circular layer. Since Ih is activated at the resting membrane potential, it is likely that this current contributes to the maintenance of resting membrane potential and spontaneous activity in circular smooth muscle cells of late pregnant rats.

P3.17.06 HORMONAL CHANGES AND THEIR INFLUENCE ON LIPIDS METABOLISM IN THE PREGNANCY COMPLICATED WITH PRIMARY HYPERTENSION E. Romejko, R. Smolarczyk, J. Wojcicka-Jagodzinska, P. Piekarski, K. Czajkowski, J. Teliga, A. Malinowska, 2nd Dept. OB/GYN, Warsaw Medical School, Warsaw, Poland. Objectives: The aim of the study was to investigate the influence of total estrogens, human placental lactogen, estradiol and prolactine on lipids metabolism in the third trimester of the pregnancy complicated with primary hypertension. Methods: Twenty-eight pregnant women with primary hypertension (35.03.8 weeks, blood pressure 16311/1005.9 mmHg) entered the study. The following serum parameters were measured: total lipids, total LDL fraction, total cholesterol, free cholesterol, phospholipids, triglicerides, HDL-cholesterol, LDL-cholesterol, total estrogens, human placental lactogen, estradiol, prolactine. Methods generally accepted in clinical biochemistry were used. The statistical analysis and correlation were performed. Results: The following results were obtained: total estrogens (1753774 mmol/l, human placental lactogen 78411919 ng/ml, estradiol 23,88410,022 pg/ml, prolactine 20051 ng/ml). The levels of total estrogens, human placental lactogen and estradiol did not significantly differ form those in normal pregnancies while prolactine was decreased (p<0.001). Positive correlation occurred between total lipids and total estrogens (p<0.01). Human placental lactogen and prolactine did not correlate with any of the lipids parameters whilst estradiol elevated concentration of triglicerides (p<0.03). Conclusions: The elevated concentrations of lipids in women with pregnancy complicated with primary hypertension are not related to the hormonal changes. The only positive correlation is between estradiol and triglycerides. These observations are different form physiological pregnancy in which an increase in serum lipids concentration is strongly related to total estrogen and human placental lactogen. The elevated serum lipids concentration in pregnancy complicated with primary hypertension may be related to the other yet unknown mechanism.

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P3.17.09 PROTEIN EXPRESSION OF PLATELET-ACTIVATING FACTOR ACETYLHYDROLASE ISOFORMS I AND II IN HUMAN UTERINE MYOMETRIUM AND MYOMA K. Yasuda, H. Okada, T. Nakajima, H. Kanzaki Dept OB/GYN, Kansai Medical University, Osaka, Japan Objectives: Platelet-activating factor(PAF), which induces myometrial contraction, is inactivated by plasma and/or intracellular types of platelet-activating factor acetylhydrolase (PAF-AH). Intracellular PAFAH isoform I is composed of a1, a2, and b sub-units, and isoform II is monometric enzyme. The aim of the study is to investigate the protein expression of intracellular PAF-AH in human uterus during pregnancy. Study Methods: The protein expression of intracellular PAF-AH isoforms I and II in human uterine myometrium and myoma was investigated by western blot analysis, and PAF-AH activities in these tissues were assayed by radioactive tracer experiment. Results: PAF-AH isoform I and II were found in uterine myometrium and myoma. The a2 and b subunits of PAF-AH isoform I were markedly detected, but, the a1 subunit of PAF-AH isoform I and PAFAH isoform II is negligible in these tissues. The levels of the a2 and b subunit in pregnant uterus were significantly lower than those in nonpregnant uterus and myoma. Further, PAF-AH activity in pregnant uterus was significantly lower than that in non pregnant uterus and myoma. In contrast, the level of b sub-unit in myoma was significantly higher than that in non-pregnant uterus, although no significant difference in the level of a2 sub-unit was found between these tissues. PAF-AH activity in myoma was also significantly higher than that in non-pregnant uterus. Conclusions: These results indicate that the decrease of PAF-AH activities in human pregnant uterine myometrium is due to relatively low protein expression of the a2 and b sub-units of PAF_AH isoform I, suggesting that the action of PAF increases in human uterus. The increase of PAF-AH activities in myoma may be due to relatively high protein expression of b sub-unit, resulting in reduction of the PAF ACTION.

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Study Methods: We enrolled 32 mother-and-infant pairs delivered after 36 weeks of normal pregnancy and 13 pairs in whom the neonates showed IUGR of below -1.5 SD. Immediately after delivery, samples of umbilical arterial and venous blood, maternal venous blood and placenta were collected. A panel of trace elements was determined precisely using inductively coupled plasma mass spectrometry or particle induced X-ray emission method. Results: Fifteen trace elements: Na, Mg, K, Ca, Mn, Fe, Co, Cu, Zn, Se, Rb, Sr, Cd, Cs, and Ba were determined. K, Ca, Mn, Fe, Zn, Rb and Cs levels were higher, and Cu and Se levels were lower in umbilical serum than in maternal serum. Zn, Sr and Cs levels in umbilical serum correlated positively with the maternal serum levels. In contrast, umbilical blood levels of Mg, Ca, Cu, and Se remained constant irrespective of the maternal levels. Within the [Mg, Ca, Fe, Cu, Se and Sr] and [K and Rb] groups, correlations with respect to the ratios of umbilical to maternal levels were found between elements. In concentrations expressed in dry weight, 3 patterns were observed: maternal blood < umbilical blood << placenta (Mn, Zn, Rb and Cs), maternal blood < umbilical blood < placenta (Mg, Sr and Ba), and maternal blood > umbilical blood > placenta (Cu). Mg, Rb and Cs levels were significantly higher in the placenta of IUGR neonates. Conclusion: The relation of trace element concentration between umbilical and maternal blood differs depending on element, suggesting the presence of different trace element-specific regulatory mechanisms in the placenta. P3.17.12 VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) AND ITS RECEPTORS IN THE PLACENTAL BED OF HEALTHY AND PREECLAMPTIC PREGNANCIES, AND THOSE COMPLICATED BY FETAL GROWTH RESTRICTION P. Vuorela1, O. Carpen2, E. Halmesmki1 - 1Department of Obstetrics and Gynecology, Helsinki University Central Hospital, 1Department of Pathology, Helsinki University, Finland. Objectives: In pre-eclamptic pregnancies (PE), as well as in pregnancies complicated with fetal growth restriction (FGR) with no hypertension or other symptoms, the physiological adaptation of the blood vessels in the placental bed is inadequate. Vascular endothelial growth factor (VEGF) and its receptors play a crucial role in embryonic vascular development, and are expressed in the placenta. Therefore, we wanted to study whether VEGF and its receptors VEGF receptor-1 (VEGFR-1) and VEGFR-2 are expressed in the placental bed, and whether PE or FGR are associated with changes in their expression. Study Methods: Placental bed samples from 5 women with PE, 5 women with FGR, and 5 healthy controls were collected following elective Cesarean delivery, and snap-frozen immediately. 5 mm tissue sections were analyzed by immunohistochemistry using polyclonal antibodies against VEGF, VEGFR-1 and VEGFR-2 (Santa Cruz Biotechnology). Localization and intensity of staining were compared between the groups. Results: VEGF, VEGFR-1 and VEGFR-2 were expressed in the vascular endothelium of the placental bed and, surprisingly, in the myometrial cells, but not in the decidualized stromal cells (Figure 1). No differences between the different study groups were observed. Conclusion: VEGF, VEGFR-1 and VEGFR-2 may play a role in the uterine myometrium in term pregnancy. The localization or strength of their immunoreactivity in these cells is not affected by PE or FGR. P3.18 PRE-CANCER, HPV P3.18.01 ANALYSIS OF WOMEN WHO FAIL TO ATTEND FOR COLPOSCOPY APPOINTMENTS S. McNeill, A. Hamilton, Craigavon Area Hospital, Portadown, Co. Armagh, N. Ireland, United Kingdom Aim: We felt that our did not attend (DNA) rate was excessively high for the colposcopy clinics and we wished to identify why women failed to attend for these appointments. The concern was that these women are failing to attend for what is a potentially serious but treatable condition. Methods: Over a 7 month period in 1998, 121 patients failed to attend without informing the clinic (DNA rate =13%). Charts were reviewed and a questionnaire was then sent out to each of these patients. Hospital

P3.17.10 TISSUE FACTOR PATHWAY INHIBITOR (TFPI) IN AMNIOTIC FLUID M. Uszynski, E. Zekanowska, J. Kuczynski, The Rydygier Medical University, Bydgoszcz, Poland. Objectives: The question of the study was whether there is TFPI in amniotic fluid an inhibitor of extrinsic pathway coagulation which may modulate biological activity of major procoagulant of the amniotic fluid, i.e. tissue factor (TF). Study Methods: The study group consisted of 26 women with physiological pregnancy who were giving birth at term. 10 non-pregnant women were the control group. The amniotic fluids were obtained first in the 1st stage of labor by puncturing the lower pole of the amniotic sac, and then after the childbirth. The venous blood was also sampled. An ELISA method was used. A t-Student test was used in the statistical analysis. Results: A detectable amount of TFPI was found in the amniotic fluid it appeared in the concentration 40.7 20.4 ng/ml, while the concentration in blood plasma was 71.4 20.4 ng/ml (p<0.001). The concentration of TFPI in the blood plasma of non-pregnant women was not statistically significantly different from the concentration in pregnant women, and was 82.3 12.3 ng/ml. Conclusion: Tissue factor pathway inhibitor (TFPI) appears in amniotic fluid in the concentration about 50% of that in blood plasma of parturient women.

P3.17.11 TRANSPLACENTAL PASSAGE OF TRACE ELEMENTS AND ITS REGULATORY MECHANISM H. Osada (1), K. Seki (1), Y. Watanabe (2), Y. Nishimura (2), M. Yukawa (2), S. Sekiya (1) - (1) Dept. OB/GYN, Chiba University School of Medicine, Chiba, Japan. (2) Division of Human Radiation Environment, National Institute of Radiological Sciences, Chiba, Japan. Objectives: To examine the passage of trace elements from mother to fetus, and the role of the placenta that regulates both.

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records were reveiwed 6 months after completion of the study to ascertain if these patients had subsequently attended. Results: 51% of all patients who DNA once fail to do so again. 35% had or had been treated for a diagnosis of moderate to severe dyskaryosis. The response to the questionnaire was poor (no=31). Commonest reasons for non-attendance were no appointment received, menstruation, pregnancy, and civil unrest. 42% said they had contacted the hospital to cancel their appointment. 80% said they would subsequently attend, and 74% did. Of the group who did not reply, 43% did not subsequently attend. 25% of non-attendees were new patients. The estimated cost to the trust was 3537. Conclusions: Patients with a history of non-attendance are likely to do so again. A third of these patients had or had been treated for a potentially serious lesion. Anxiety regarding visits does not appear to be a major contributing factor. P3.18.02 ASSOCIATION BETWEEN NUMBER OF RECENT SEXUAL PARTNERS AND THE RISK OF ACQUIRING CERVICAL HPV IS INFLUENCED BY YEARS SINCE FIRST INTERCOURSE. E.I.Svare1, S. Krger Kjaer2, J.E.Bock3 C.J.L.M.Meijer4,, J.M.M. Walboomers3,, A.J.C. van den Brule3,. 1 Dept. OB/GYN, Gentofte University Hospital, Denmark 2Institut of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark.3Dept. OB/GYN, University Hospital Rigshospitalet, Copenhagen, Denmark. 4Dept.of Pathology, University Hospital, Vrije Universiteit, Amsterdam, The Netherlands. Objectives: Genital infection with high-risk Human Papillomaviruses (HPV) is the most important risk factor for cervical cancer. Several data indicate, however, that most women infected with HPV gain some degree of immunity towards the infection. This implicates, that a repeated exposure should strengthen the immunity and, consequently, decrease the susceptibility to the virus. Study methods: Three hundred and sixty-one women attending STD clinics and 303 pregnant women (first trimester) were included. Presence of a wide range of genital HPV types was tested in cervical swabs using PCR. Personal data were obtained in an interview using a standardized questionnaire. Adjusted prevalence odds ratios (PORs) were computed including adjustment for possible confounders. Results: In both study groups, the women who had been sexually active for a relatively short time were significantly more likely to be HPV positive, given the same number of recent sex partners than women who had been sexually active for a longer time with adjusted POR of, respectively 4.9 (95% CI:1.8-13.3) and 2.5 (95% CI:1.0-6.3). Conclusions: Our data could support the hypothesis that some immunity to HPV is acquired over time and contributes to the opinion that vaccination is a possibility in reducing risk of HPV infection. P3.18.03 ATYPICAL AND LOW GRADE SQUAMOUS INTRAEPITHELIAL (ASCUS/LSIL) LESIONS ON PAP: ASSOCIATION OF HUMAN PAPILLOMA VIRUS (HPV), HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND AGE WITH CERVICAL DYSPLASIA (CIN 1-3). S.E. Brooks, N. Khanna, G. Taylor; N. J. Gordon, A. Simsir, T. T.Chen, University of Maryland Medical Systems, 405 W. Redwood Street, Baltimore, MD, United States, 21201. Objective: To evaluate the association of ASCUS, LSIL, HPV, HIV and age with cervical dysplasia. Method: Prospective study of 179 women attending urban University colposcopy clinics. All underwent: questionnaire, colposcopy, HPV subtyping (Hybrid Capture II) and biopsy, if indicated. HIV(+) status was by laboratory report. HIV(-) status was self reported. HPV high-risk and mixed-risk (HPV-HR) included oncogenic HPV subtypes. HPV low-risk (HPV-LR) did not. Chi Square and multivariate analysis was utilized. Results: The mean age of HIV(+) women was 41 and 26 in HIV(-) women (p=0.0001). Ninety- three per cent (38/41) of HIV(+) and 69%(90/138) of HIV(-) patients were HPV(+). HIV(+) status (p=0.01)and HPV-HR(+) (p=0.0003)were associated with dysplasia. Fewer than 10% were HPV-LR(+). Overall, dysplasia was detected in 18% (33/179), but was 23% (30/128) in HPV(+) women and 2% (1/51) in HPV(-) women. The rate of dysplasia in HIV(+) women was

WEDNESDAY, SEPTEMBER 6
34%(14/41) and 14%(19/138) in HIV(-) women. The negative predictive value of HPV typing was 97.8% (95% CI 88%-100%). The predictive positive value was 24% (95% CI 16.6%-31.4%). The risk of dysplasia was <1% in: HIV(-), HPV(-), or HPV-LR(+) <21 with an ASCUS Pap; and was 809 fold higher in: HIV(+), HPV-HR(+), >21 and LSIL. Conclusion: In a population with a high rate of HPV, cervical dysplasia was uncommon (2%) in women with ASCUS/LSIL who were HPV(-) or HPV-LR(+). Colposcopy is of higher yield in older patients with LSIL and HPV-HR, especially if HIV(+). P3.18.04 CERVICAL HUMAN PAPILLOMAVIRUS INFECTION IN PERIMENOPAUSAL WOMEN WITH ABNORMAL COLPOSCOPIC FINDINGS D. Jeremic, B. Stanimirovic, Gyn/Ob University Clinic Narodni front, Belgrade, Yugoslavia Objectives: The aim of this study was to compare the prevalence of HPV infection in cervical pathologic changes of perimenopausal women to women of general reproductive age. Study methods: Twenty-nine women over 45 years of age with abnormal colposcopic findings were undergone cervical biopsy for hystopathologic examination. HPV detection and typisation was done from cervical smears, using commercial kits based on RNA-DNA hybridization with probes against the six most common anogenital HPV types. The control was 60 women at any of reproductive age with same abnormal colposcopic findings who underwent the same procedure. Results: The mean age of the studied patients was a little over 50 years (from 45 to 62). There was no difference between two groups in numbers of deliveries or abortion, numbers of sexual partners and age at first intercourse. Most common colposcopic findings (mosaic and acetowhite) were similarly found in both groups. Same was with benign, inflamatory hystopathology or LSIL. The only significance was shown with HSIL (31% in studied group, 15.3% in control, p<0.05). When detected (65.5% in studied group and 71.7% in contro), HPV types 6/11 alone, or in combination with other types were the most often in both groups (41% and 44.1%), followed by high-risk types 16/18 (38% and 37%), while types 31/33 were detected at 21% of studied patients and 22.7% of control. No significance was shown. Conclusion: Similar HPV presence in pathological cervical changes of women of any age suggest that HPV detecting and typing should be a part of regular checking not only for young, but also for women in peri and even postmenopausis

P3.18.05 CLINICAL EVALUATION OF LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION (LSIL) CYTOLOGY E. A. G. Pereyra, C. I. Parellada, A. C. S. Chuery, E. Narimatsu, L. Assoni, P. L. Schivartche, Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil. Objectives: The aim of this study was the analysis of low grade squamous intraepithelial lesion (LSIL) cytology correlating with colposcopic findings and the histology of punch biopsy. Study Methods: In the period between January 1996 and July 1999, 5779 women were referred to the Gynecology Ambulatory of cancer prevention of FMUSP and they all had Pap smear and colposcopy done. Patients presenting LSIL on Pap smear were selected which meant 333 of them (5.7%). In the presence of abnormal colposcopic findings, the biopsy was performed. Results: The colposcopic findings were normal in 150 patients (45%), abnormal in 149 (44.7%), miscellaneous in 11 (3.3%) and unsatisfactory in 23 (6.9%). The histology of all abnormal findings and 2 cases of ulcers were negative in 68 cases (45%), low grade neoplasia in 55 (36.4%), high grade neoplasia in 27 (17.8%) and vaginal intraephithelial neoplasia grade III in 1 (0.7%). The exact agreement between cytology and punch biopsy was 36.4%. Conclusions: In LSIL approximately half of the cases had normal colposcopy. In the presence of abnormal colposcopic findings almost 50% did not confirm the cytology, 36.4% were agreed and 17.8% had a major lesion.

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P3.18.06 CYTOLOGIC FINDINGS IN LOW GRADE NEOPLASIA E. A. G. Pereyra, C. I. Parellada, A. C. S. Chuery, L. S. N. Pinto, P. L. Schivartche, F. Carvalho. Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil. Objectives: The purpose of this study was to evaluate the cytologic results in cases of low grade neoplasia histologically confirmed. Study Methods: In the period between July 1996 and July 1999, 4957 women were submitted to Pap smear and colposcopy. In the presence of abnormal findings, the biopsy was performed. Low grade squamous neoplasia was confirmed in 178 cases (3.6%). Results: In these 178 cases of low grade neoplasia, the Pap smear showed normal results in 105 cases (59%), atypical squamous cells of undetermined significance in 2 (1.1%), low grade squamous intraepithelial lesion in 43 (24.1%) and high grade squamous intraephithelial lesion in 28 (15.7%). Conclusions: The majority of the cases of low grade neoplasia had normal cytology. Pap smear is efficient as a screening method, but when it is associated to colposcopic evaluation the sensibility to detect precursor lesions is much improved. P3.18.07 CYTOLOGIC FINDINGS IN HIGH GRADE NEOPLASIA E.A.G. Pereyra, CI. Parellada, ACS Chuery, M. Tacla, P.L. Schivartche, J.A. Pinotti, Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil. Objectives: The goal of this paper was to determine the cytologic findings in high grade neoplasia confirmed by histology. Study Methods A total of 4957 women were examined with Pap smear and colposcopy between July 1996 and July 1999. 117 (2.4%) women with histologic diagnosis of high grade squamous neoplasia on colposcopically directed punch biopsy were evaluated, correlating with cytology. Results: In these 117 cases of high grade neoplasia, the Pap smear showed normal results in 19 cases (16.2%), atypical squamous cells of undetermined significance in 4 (3.4%), low grade squamous intraepithelial lesion in 20 (17.1%), high grade squamous intraephithelial lesion in 66 (56.47%) and suggestive of invasive cancer in 8 (6.8%). Conclusions: The agreement between cytology and histology is greater in the high grade neoplasia in comparison with low grade. However, the false negative of cytology is worrying. The colposcopy is a good alternative to detect these missed cases.

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and invasive cancer groups. Also no difference in the frequency of Arg/Arg genotype was detected even between control and HSIL groups or control and invasive cancer infected with high risk HPVs groups. Conclusions:There was no obvious relationship between Arg genotype at codon 72 of p53 and predisposition to HPV associated cervical neoplasia.

P3.18.09 GLANDULAR ATYPIA IN CERVICAL SMEAR: CYTOHISTOLOGIC AND CLINICAL CORRELATION S. Swain, K. Elsapagh, S. Ghosh, H. Dunsmore, K. W McMullen, J. D Steven, K. D Morton* Dept. OB/GYN and Pathology*, Stirling Royal Infirmary, Scotland, UK. Objectives: To audit all the cases of cervical glandular atypia detected by cervical cytology and to correlate with colposcopic and histologic diagnosis and subsequent follow up these patients Study Methods: A retrospective case note based study over previous three year period at a district general hospital in central Scotland. Results: Of the 38 women with cervical glandular atypia reported in cervical smear; the mean age was 38 years, and 9 (24%) were nulliparous. Histopathologic examination showed 6(15.7%) cases to have malignant lesions (3 cervical squamous cell carcinoma, 2 endocervical adenocarcinoma, lendometrial adenocarcinoma). The precancerous lesions included 4(10.5%) cervical glandular intraepithelial neoplasia (GIN), 14(37%) cervical squamous intraepithelial neoplacia (CIN), 2 had both CIN and GIN. The benign pathology included 9 (24%) chronic cervicitis, 2 cervical endometriosis and 2 cases of human papilloma virus infection. No pathology was identified in 1 case. The median follow up of these women was 20 months. Conclusions: The retrospective study suggests that a diagnosis of cervical glandular atypia correlated with a clinically significant lesion in the majority of cases. In addition to malignant lesions, cervical squamous intraepithelial neoplasia and cervical glandular intraepithelial neoplasia were the most common lesion identified. Cytological and colposcopic follow up, including cytobrush endocervical cytological sampling and long term follow up, is recommended in these women.

P3.18.10 HIGH PREVALENCE OF HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESIONS (HSIL) AND MICROINVASIVE CARCINOMA IN WOMEN WITH CYOLOGIC DIAGNOSIS OF LSIL K.S. Law, T.C. Chang, C.H. Lai, F.P. Chen, Dept. OB/GYN, Chang Gung Memorial Hospital, Keelung, Taiwan. Objectives: To evaluate the histological nature of LSIL in a region with high prevalence of invasive cervical carcinoma and propose a management protocol. Study Methods: Eight hundred and seventy seven women with LSIL were compare with histological diagnosis through colposcopic biopsy, endocervical curettage, conization or hysterectomy during a study periosd from July 1994 to February 1998. Results: Among a total of 128, 925 Pap smear taken, there was 877 (0.68%) diagnosed as LSIL. Among theses, 722 women with CIN-SIL and 32 with HPV-SIL were enrolled in the final analysis. Of the 543 women with CIN-SIL, there were 145 (27%) cases of HSIL, as disclosed histologically with 16 (3%) cases of microinvasion. 32 women with HPV-SIL revealed 18% of CIN 2/3 without microinvasion noted. Among those followed up at an interval of 3 months with Pap alone, the persistence rate was 46.8% with regression rate of 40%. Conclusions: A high percentage of cervical intraepithelial neoplasia 2/3 as well as microinvasive lesions will go unnoticed if it were not evaluated with a colposcopic examination.

P3.18.08 CODON 72 POLYMORPHISM OF p53 AS A RISK FACTOR FOR PATIENTS WITH HUMAN PAPILLOMAVIRUS ASSOCIATED SQUAMOUS INTRAEPITHELIAL LESION AND INVASIVE CANCER OF UTERINE CERVIX Y.Tsuyoshi, W. Yukio, I. Hidetoshi, I. Mutsuo., Dept. OB/GYN, Asahikawa Medical College, Midorigaoka Higashi 2-1-1-1, Hokkaido, Asahikawa, Japan Objectives: It has recently been reported that a patient homozygous for arginine (Arg) allele has about a seven times higher risk of developing cervical cancer than a patient homozygous for proline (Pro). To confirm this result and elucidate whether this allelic deviation of Arg genotype seen in invasive cervical cancer occurs in the premalignant lesion, SIL, we analyzed 219 SIL and 101 invasive cancer samples from Japanese patients and 252 cytological samples as controls. Study Methods: Genomic DNA from cytological samples was extracted with Isogen/Isogen-LS or DNA extractor WB kit. For paraffinembedded tissues, DNA was extracted with DEXPAT. To detect HPVs DNA, two different consensus primer sets and type specific primers were used for PCR amplification. For analysis of alleles with Arg or Pro at codon 72 region, modified PCR-RFLP was applied. Results:Samples from 88 SIL and 76 invasive cancer were identified as HPV infected samples and used for further analyses; in these, the frequency of Arg homozygotes was 31.8%, 33.0% and 36.8% in controls, SIL and invasive cancer, respectively. The distributions of allelic status of codon 72 (Pro/Pro, Pro/Arg and Arg/Arg) did not show significant differences between either control and SIL groups or control

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P3.18.11 HISTOLOGIC EVALUATION OF HUMAN PAPPILOMAVIRUS (HPV) INFECTION IN WOMEN WITH LOW AND HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION Massabki, JOP; Fonseca, AM; Assis, JS; Bagnoli, VR; Chnee, LH; Junqueira, PAA & Halbe, HW. Dept. OB/GYN, So Paulo University Medical School, So Paulo, Brazil. Objectives: To evaluate the HPV infection on cervical histology in women with low and high grade squamous intraepithelial lesion. Methods: Thirty women with low grade intraepithelial lesion (Group A) and 30 women with high grade squamous intraepithelial lesion (Group B) were included in this study. Pap smear, colposcopy and biopsy were performed to identify the presence of HPV infection on histology. Results: The comparison between the 2 groups are shown in the table below. Groups A B With HPV 26 (86,7%) 11 (36,7%) Without HPV 4 (13,3%) 19 (63,3%) Total 30 30 Conclusions: The presence of cytopathic changes of HPV infection can be seen mainly in low grade intraephitelial lesions (86,7%) when compared with high grade lesions (36,7%). This could be explained because the HPV-DNA is on the epissomal form causing cytopathic changes on histology in low grade lesions, as long as in high grade lesions the HPV-DNA is on the integrated form, making the diagnoses difficult.

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Study methods: This study was undertaken among 80 patients of cervical cytoabnormality attending in the outpatient department of Gynaecological Oncology of NIRCH Dhaka, Bangladesh over a period of one year and six months(between July 98' to Dec 99'). The study population were divided into two groups. One groups(40patients) were treated by cryotherapy and the other group by large loop excisional procedure. Datas were wel matched in both groups. In both group 10 patients with severe inflamation with atypia, 9 patients of chronic cervicitis with CIN I , 9 patients with CIN II, 12 patients of CIN I with concomitant squamous metaplasia were treated by Cryotherapy and large loop excissional procedure. All the cases were reviewed after 3 months with cervical smear. Results: On followup study at 3 months the group of patients were treated with Cryo therapy shown to have persistence of the previous pathology in severe inflamation with atypia 3(7.5%)in CIN I 4(10%), in CIN I with squamous metaplasia 3(7.5%)and in CIN II 5 (12%)cases. On the other hand at 3 months review the group of patients treated with large loop excissional procedure had shown CIN II 2 (5%)and in CIN I 1 (2.5%) cases. Conclusions: By large loop electrosurgical exicissional procedure gave a much better results in cases of cervical cytoabnormalities over cryotherapy.

P3.18.12 LEEP VERSUS COLD KNIFE CONIZATION IN THE THERAPY OF CERVICAL INTRAEPITHELIAL NEOPLASIA C. Dannecker, R. Kimmig, C. J. Thaler, H. Hepp, P. Hillemanns Dept. of OB/GYN, Klinikum Grosshadern, University Munich, Germany Objectives: This study was performed to evaluate the effectiveness and side effects of loop electrosurgical excision procedure (LEEP) in comparison to cold knife conization for the treatment of cervical intraepithelial neoplasia (CIN). Study Methods: Between January 1996 and July 1998, 177 patients underwent conization. In a matched-pair setting, 50 cases with LEEP were compared with 100 classical conization cases. LEEP was performed with ectocervical and endocervical excision. Results: Perioperative complications were less in the LEEP group (6% vs. 11%). The mean volume of the LEEP specimens (1,6 cm3) were significantly smaller than the volume of the cone specimens (2,6 cm3). Thermal artifacts were negligible. There were no significant differences in the proportion of margin involvement (20% vs. 19%) and residual/recurrent CIN. The endocervical excision contained dysplastic tissue in 38% of the cases; more important, a positive endocervical excision was found in 11/12 CIN 3 cases (92%). The success rate was similar in both groups (96% vs. 97%). Hospitalization time was less for the LEEP group. Conclusions: LEEP conization is a safe and cost effective procedure with a lower complication rate providing a significantly smaller specimen compared to cold knife conization. Therefore, LEEP conization may substitute cold knife conization. However, we do recommend to perform LEEP conization with an endocervical excision to reduce residual CIN. P3.18.13 OUTCOME OF TREATMENT RESULT OF CERVICAL ATYPIA BY LARGE LOOP EXCISION OF TRANSFORMATION ZONE OVER CRYOTHERAPY. K.J. Maula , Dept. of Gynaecological Oncology, National Institute of Cancer Research and Hospital, Dhaka 1212, Bangladesh M.S. Flora, Dept of Epidemology, NIPSOM, Dhaka, Bangladesh B. Islam, Dep of Cytopathology, NIRCH, Dhaka, Bangladesh Objectives: The objective of the study was to compare the treatment out come of cervical atypia between large loop excision of the transformation zone of cervix and cryotherapy as an outpatient procedure

P3.18.14 PREVALENCE OF CERVICAL INTRA-EPITHELIAL NEOPLASIA ACCORDING TO THE CHRONOLOGICAL AGE AND THE INTERVAL SINCE FIRST SEXUAL INTERCOURSE L.C. Zeferino; M.G.L. D'Ottaviano-Morelli; J.G.Cecatti; E.Z.Martinez, School of Medicine, Universidade Estadual de Campinas, Cidade Universitaria, Rua Alexandre Fleming, 101, Campinas, Brazil, cep: 13083-970. Objectives: To analyze the association between cervical intra-epithelial neoplasia (CIN), chronological age and interval since first sexual intercourse (IFSI). Study Methods: The results of 120635 routine Pap tests, collected in the Public Health System in the area of Campinas, Brazil, form September 1998 through April 1999, performed at the Cytopathology Laboratory of the University. The prevalence , the prevalence ratio by chronological age and IFSI, with a 99% confidence interval, were estimated. A test for trend and a logistic regression model were used. Results: Based on cytological diagnosis, 427 cases of CIN1,308 of CIN2 and 170 of CIN3 were found. The prevalences of CIN1 and CIN2 tended to decrease as the chronological age and IFSI increased. On the other hand, the prevalence of CIN3 tended to increase. Using the logistic regression model, the odds ratio was 0.901 for age and 1.046 for IFSI, for CIN1; 0.886 for age and 1.083 for IFSI, for CIN2; 0.956 for age and 1.176 for IFSI, for CIN3. Conclusion: The CIN1 and the CIN2 prevalences are more associated with the chronological age, than with the IFSI. The prevalence of CIN3 is more associated with IFSI than with the chronological age.

P3.18.15 SCREENING FOR CERVICAL CARCINOMA IN A HIGH RISK POPULATION GROUP IN POKHARA VALLEY, NEPAL S. Bajpai, Dept. OB/GYN, Manipal College of Medical Sciences, Pokhara, Nepal. Objectives: To evaluate the results of cervical cytology screening using Bethseda system. Study Methods: Cytological evaluation of cervical smears was carried out in 460 multiparous women (Parity 2 and above), over a period of one year, at their first visit to Manipal Teaching Hospital, Pokhara. Results: Cystopathology showed 36 (7.8%) Normal, 370 (80%) Inflammatory, of which 16 (4%) showed Trichomonas vaginalis; 4 (0.8%) Reparative, 28 (6%) Squamous metaplasia, 8 (1.7%) Atypical Squamous Cells of Undetermined Significance, 14 (3%) Low Grade Squamous Intraepithelial Lesion, 2 (0.4%) High Grade Squamous Itraepitelial Lesion. LSIL and HSIL were present in women all of whom were smokers, married at 17 years or below, of the low socio-economic strata. In 60% cases, husbands were away from home for long periods and multiple sexual contacts cannot be ruled out. Serology in the inflammatory group was positive for Chlamydia trachomatis in 38.5%.

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Conclusion: This study emphasizes the need for cytological screening in high risk women, in view of the prevailing custom of early marriage and young age at first coitus, smoking and a significant incidence of Pelvic Inflammatory Disease. P3.19.02 A CASE OF EVENTRATION OF THE DIAPHRAGM S. Watababe, T. Maemura, C. Aoki, M. Shiokawa, K. Itou, Y, Yao, K. Masaki, M. Tanaka, H. Kubo, S, Hirakawa Dept OB/GYN, Toho School of Medicine, Tokyo, Japan

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P3.18.16 STUDY ON THE MANAGEMENT OF SIL OF THE UTERINE CERVIX M.Oda (1), M. Ohmura (1), Y. Ishii (2), N. Ishida (2), (1) Tokyo Metropolitan Cancer Detection Center, 2-5 Kandasurugadai, Chiyodaku, Tokyo, Japan, 101-0062, (2) Tokyo Kenbikyou-In Foundation, Chiyoda-ku, Tokyo, Japan. Objective: Establishment of a following-up system for squamous intraepithelial lesion (SIL) of the uterine cervix by retrospective study. Method: Between 1984 and 1994, we have been mass-screened 177,340 subjects for uterine cervical cancer, and detected 798 cases of low SIL and high SIL (excluding cases of CIS) of the uterine cervix at the Tokyo Metropolitan Cancer Detection Center (detection rate 0.45%). We followed 860 cases, including cases that were referred to us. The following criteria were used in evaluating the outcome of SIL. Cases in which both cytological and colposcopical results were negative at least 3 times and continuously for at least 2 years were evaluated as regressing. Cases in which intraepithelial carcinoma or worse was confirmed histologically were evaluated as progressing. Cases which did not progress nor regress during at least 2 years of follow-up were evaluated as persisting. The average follow-up period for SIL was 49.8 months. Results: 1) Out of 383 cases of low SIL, 12 cases (3.1%) progressed, 97 cases (25.3%) persisted and 274 cases (71.4%) regressed. 2) Out of 194 cases of high SIL, 39 cases (20.1%) progressed, 68 cases (35.1%) persisted and 87 cases (44.8%) regressed. 3) Of the 361 cases that regressed, 301 did so within 2 years of followup. 4) Of the 51 cases that progressed, the operative histologic diagnosis was established in 44 cases. The breakdown was; CIS, 31 cases; MIC, 5 cases; SCC 1b, 4cases. Conclusion: High SIL is a lesion that progresses at a rate of approximately six times that of low SIL. Closely controlled follow-up of high SIL is possible, but medical treatment is indicated if there is no regression within 2 years. P3.19 ULTRASOUND P3.19.01 COMPARISON OF MATERNAL MIDDLE CEREBRAL ARTERY BLOOD FLOW VELOCITY AS MEASURED IN PREECLAMPTIC, HEALTHY PREGNANT AND NON-PREGNANT WOMEN BY TRANSCRANIAL DOPPLER SONOGRAPHY. J. Zatik (1), J. Aranyosi(1), T. Major (1), L. Ovari(2), D. Pall (3), B. Fulesdi (1), (1) Dept. OB/GYN, (2) Dept. Int. Med. (3) Dept. Anesth. and Intensive Care, University Medical School of Debrecen, Hungary. Objectives: The aim of the study was to test the hypothesis that cerebral blood flow velocity is altered in preeclamptic pregnant women as compared to healthy pregnant and non-pregnant women. Study Methods: Preeclamptic (n=21) and healthy pregnant (n=17), as well as non-pregnant (n=29) women had undergone transcranial Doppler blood flow velocity measurements of the middle cerebral artery. Mean blood flow velocities of the middle cerebral artery (MCAV) were compared between the different groups. Results: MCAV values was significantly higher in non-pregnant women as compared to healthy pregnant women. Preeclamptic women showed significantly higher MCAV values compared to non-pregnant females. Same to the non-pregnant women, healthy pregnant patients showed lower MCAV values compared with preeclamptic women. Conclusions: We detected increased resting cerebral flow velocities in the middle cerebral arteries of pregnant patients with preeclampsia. In our opinion this finding refers to arteriolar dilation of the resistance vessels of the brain.

Eventration of the diaphragm is relatively rare to diaphragmatic hernia. The prenatal diagnosis is very difficult, because of the similarity of diaphragmatic hernia. We present a case that diagnosed diaphragmatic hernia at preterm but was eventration eventually. A 39-year-old female, GOPO, performed amniocentesis for high age pregnancy and family history of Down syndrome of her husbands sister. But no chromosomal abnormalities revealed. Ultrasonography that performed at 28 weeks revealed the fetal stomach to be at the level of the back of the heart and colon gas of the left side of the heart. Diagnosis considered were diaphragmatic hernia at that time. Emergency Cesarean section was done for premature rupture of membrane at 37 weeks, and 2017 g, male infant that was slept by the anesthesia delivered and respiration was controlled by the ventilation at once. He had no malformation. On day 6, open surgery was done and excess diaphragm visualized under the operation. This was considered eventration. Post operative day 4, respiratory function improved and the tube was removed.

P3.19.03 AN ASSESSMENT OF GESTATION SPECIFIC AMNIOTIC FLUID INDEX AMONGST INDIAN WOMEN S. Khadilkar, S. Desai, C. Purandare, S. Tayade, M. Patel, Cama and Albless Hospital [University teaching Hospital], A2 Aparna Vaibhav, B.W. Pathare Road, Mumbai, Maharashtra, India, 400028. Objectives: To obtain a gestational reference range for the amniotic fluid index amongst the Indian women and to compare the study with those from other countries. Study Methods: An analysis of AFI estimations was undertaken in 1000 Indian patients with normal pregnancy between 16 to 40 weeks of gestation.Patients with fetal anomalies, PIH, diabetes mellitus and other maternal complications were excluded from the study.The median ,the 5th and the 95th percentile values were calculated for each gestational week and these values were compared with other studies. Results: The median value of AFI reached its peak at 28 weeks and all gestation specific medians were significantly lower in studied population of Indian women as compared to other studies. Conclusion: We standardized the reference value for normal AFI in Indian women and AFI values differ with different population and geographical distribution.

P3.19.04 CLINICAL VALUE OF PLACENTAL LOCALISATION AT THE 18-20 WEEKS SCAN S G Toh, B Ahmed, A Hildreth, K Hinshaw, Department of Obstetrics & Gynaecology, Sunderland Royal Hospital, Sunderland, United Kingdom. Objective: To determine the significance of ultrasound location of placental site at the 18-20 weeks anomaly scan. Study design: A retrospective analysis of 517 consecutive anomaly scans performed between 18 20 weeks gestation at Sunderland Royal Hospital, between January to March 1998. A low implantation of the placenta at anomaly scan was arbitrarily defined as lower placental edge situated within 20mm from the internal cervical os. Subsequent antenatal courses and outcomes of these pregnancies were ascertained from the case notes. The Minitab statistic programme was used to assist data analysis. Results: At 20 weeks scans, 96 (18.6%) were reported to have low-lying placenta. Among these, 14 (14.6%) were reported to cover the internal os and within this group, 5 (35.7%) were posteriorly sited. There was no significant difference in the incidence of bleeding (8%) whether the placenta was low-lying or normally sited at 20 weeks scan (p=1.00). At delivery, there were 3 cases of major placenta praevia giving a frequency of 0.6%. Two of these cases were reported to have low-lying and posteriorly sited placenta at 20 weeks. In the remaining case, the placenta was actually normally sited at 20 weeks scan. Therefore, the PPV of low-lying placenta was only 2.1% (95% CI 0.2-7.3) but the PPV of placenta covering os was 14.3% (95% CI 1.8-42.8). However, the PPV of posterior placenta covering os for major praevia was 40% (95%

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CI 13.6-77.2). In addition, the NPV of normally sited placenta was 99.8% (95% CI 98.7-99.9). Conclusions: The placental site does not seem to have any influence on the subsequent admission rates for antepartum haemorrahge. A lowlying placenta at 20 weeks scan does not warrant a routine repeat scan in third trimester, but rescanning those with placenta covering os, particularly if posteriorly sited, appears to be more cost effective. Furthermore, an apparently normal placentation at 20 weeks scan is very reassuring indeed, but it still does not absolutely exclude major placenta praevia in later pregnancy.

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Conclusion: In normal pregnancy, it was found that vascular resistance toward fetal adrenal gland gradually decreases with advancing gestational age, reflecting developing vascular network, and that it changes in lower values in fetuses with hypoxia, anemia and insufficient feto-placental circulation, indicating dominant blood flow in the adrenal gland under hypoxic and/or anemic condition.

P3.19.05 COMPARING THE VAGINAL AND RECTAL APPROACH FOR MEASURING THE FEMALE URETHRA WITH THREEDIMENSIONAL ULTRASOUND D. Stutterecker, W. Umek, O. Preyer, E. Hanzal, Urogynecology Unit, Department of Gynecology and Obstetrics, University Hospital, Vienna, Austria Objectives: The aim of this study was to assess differences in urethral measurements by comparing transvaginally and transrectally acquired images of urethral and periurethral tissues. Study methods: We examined 68 women (mean age 51,318,4 years) using a mechanical sector probe (7,5 MHz) with real-time and threedimensional (3D) facilities on a Combison 530D (Kretztechnik, Austria). The probe was applied both vaginally and transrectally. The stored images allowed detailed morphologic assessment of the urethra including the measurement of volumes in three perpendicular planes. Length of the urethra, length, maximum thickness and volume of the rhabdosphincter, maximum thickness of the inner part of the urethra (consisting of smooth muscle, submucous vascular plexus and urothelium) were measured. SPSS statistical software system was used for calculation. Results: Both vaginal and rectal scans were tolerated well. Values for length of the urethra (27,83,6 mm vaginally vs. 27,75,0 rectally), length (16,54,3 vs. 15,73,3), thickness (6,11,4 vs. 6,31,8) and volume (0,70,3 ml vs. 0,80,4) of the rhabdosphincter did not differ between the two methods. The inner layer of the urethra was significantly thicker when examined vaginally (11,52,3 vs. 8,81,5; p<0,001). Conclusion: Vaginal and rectal approaches of 3D-ultrasound provide equal values for most female urethral structures. However, the part of the urethra consisting of smooth muscle and vascular plexus appears to be compressed on vaginal scans. P3.19.06 DOPPLER VELOCIMETRY IN THE ADRENAL ARTERY IN THE HUMAN FETUS FOR THE DETECTION OF FETAL STRESS Y. Fujita, S. Satoh, S. Yanai, K. Tsukimori, H. Nakano, Dept. OB/GYB, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan Objectives: The aim of the study is to clarify the age-related chronological changes and hemodynamic aberrations in complicated pregnancies in the velocity of waveforms of the fetal adrenal artery. Study Methods: A total of 125 cases between 24 and 41 weeks gestation are included in this study. In these , 108 cases had normal pregnant course with reactive NST, no structural or growth abnormality, and no neonatal asphyxia. Other 17 cases had fetal complications; 4 cases with suspected IUGR, 10 with structural abnormality, 2 with nonreactive NST and 1 with oligoamnios. After detecting the middle adrenal artery by color Doppler flow imaging, velocity waveforms are recorded in condition without fetal movements. The RI value was calculated as the average from 2 consecutive cardiac cycles in each case. Using the data obtained in normal cases, the regression analysis was made for every 2-week interval from 24 to 41 weeks gestation. The deviation of RI values was investigated as for cases with fetal complications. Results: In normal cases, RI values in fetal adrenal artery decreased gradually with advancing gestational age. The means values ad 24 and 41 weeks are 0.74 and 0.66 respectively (RI=-0.0006wk2+0.034wk0.0259, R2=0.964). In cases with fetal complication, 7 cases had RI values below the mean-2SD. Out of 7, 3 cases (3/7;42.9%) had fetal hypoxia, fetal anemia and insufficient feto-placental circulation.

P3.19.07 DOWNS SYNDROME RISK ASSESSMENT COMBINED SECOND TRIMESTER SERUM SCREENING AND ULTRASONOGRAPHY V. Dimitrova, T. Chernev, V. Mazneikova, I.Kremensky, State University Hospital Maichin Dom, Sofia, Bulgaria Objectives: To assess sensitivity and necessity for invasive testing in second trimester Downs syndrome [DS] screening based on serum tests alone and on serum tests combined with genetic sonogram [GS]. Study Methods: Two methods for second trimester DS risk assessment were compared in a group of 1150 patients, 227 (19,7%) of them above the age of 37. Serum screening [SS] with two markers - AFP and free hCG - was going on prospectively. The cut-off risk value for invasive testing was 1:250 at birth. Parallel with that DS risk obtained from the SS was recalculated depending on the results from the GS. In the absence of fetal anomalies or sonographic markers for chromosomal defects risk was reduced by 40%. In the presence of specific ultrasound markers (increased nuchal fold thickness, short femur, echogenic bowel, pyelectasis) risk was corrected by specific factors proposed in literature. Fetal anomalies were considered an indication for amniocentesis despite the results from the SS. Results: There were 183 abnormal SS test results in the group studied (15,9%) and 11 (0,95%) chromosomally abnormal fetuses (8-DS, 3 other aneuploidies). Nine of them were in patients older than 37 and 2 in younger ones. SS alone detected 8 out of the 11 chromosomally abnormal fetuses (sensitivity 72,7%) and 7 of the 8 DS ones (sensitivity 87,5%). If only the results from the SS were considered 3 cases with chromosomal defects would have been missed one DS fetus, one with trisomy 18 and one with unbalanced translocation. Abnormal sonograms were found in 34 out of 1150 fetuses (2,9%). 19 of them were in the low-risk SS group (1,97%) and 15 were in the high-risk SS group (8,2%). Five of the DS fetuses had one or more sonographic markers but 3 of them had none. The three fetuses with other but DS chromosomal defects had easily detectable sonographic markers. Risk recalculation based on data from the SS and the GS resulted in overall reduction of the number of high-risk results and amniocenteses required by 37 (20%). Detection rate was 100% for both DS fetuses and the ones with other chromosomal defects with 12,7% invasive testing. In the 3 cases of DS fetuses without sonographic markers SS risk was so high that it warranted amniocentesis even after risk recalculation. Conclusions: Combined second trimester SS and GS can reduce the number of amniocenteses required because of positive SS results in a predominantly high-risk population. Detection rate for DS is not affected and the detection rate for other chromosomal defects is increased. P3.19.08 HYDATIC CYST OF THE BREAST D. Zeghal, A. Souki, M.B. Chennouffi, M.S. Hendaoui, E. Sfar, H. Chelli, Centre de Maternit et de Nonatologie de Tunis, Tunis, Tunisia Objectives: In Tunisia, the hydatic cyst is an endemic disease but the breast localisation is exceptionally reported. In this poster, a new case is described. Study Methods: Case report and review of the litterature. Results: We colleged one case of hydatic cyst of the breast. The woman was 52 years old and lived in a rural area. The systematic examination of the breast founded a 3 cm nodule. The mammography practiced showed a calcified image of 30 mm. The breast ultrasound showed a well-haited formation of 30 mm, having an heterogeneous echostructure with some membranes that evoked a breast hydatic cyst. In this case, we found another hydatic localisation in the VII th segment of the liver. The X-ray investigation of the thorax was normal. The treatment was surgical; it consisted in a simple resection of the cyst allowing a recovery without complications. The histological study gave a confirmation of the diagnostic.

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Conclusion: Mammary hydatic disease is a benign and harmless affection caused by ecchinococcus granulosus. In a country where this disease in endemic breast localisation should be considered.. P3.19.09 MORPHOLOGIC OBSTETRIC ULTRASOUND INDICATIONS AND DIAGNOSTIC FINDINGS OF EXAMINATIONS PERFORMED IN A REFERENCE HOSPITAL. F.Dib, A.Berezowski, G.Duarte, R.Yano, F.Costa, S.Cunha. University of So Paulo, Ribeiro Preto City, So Paulo State, Brazil, 14049-900. Objectives: To establish the profile of fetal abnormalities that exists in the population assisted at an Universitary Hospital. Study Methods: From January to December, 1998, 176 pregnants were referred to an Universitary Hospital to be submitted to a morphological obstetric ultrasound examination. Results: Most of fetuses were anatomically normal. The most common abnormalities were from central nervous system, followed by genitourinary tract abnormalities and multiple malformations. A complete table listing all diagnostics is available for presentations. Conclusions: Most of fetuses were anatomically normal. The most common abnormalities were from central nervous system, followed by genito-urinary tract abnormalities and multiple malformations a complete table listing all diagnostics is available for presentations. Under any suspected abnormality detected by a routine ultrasound examinations the patient must be referred to a specialized center to confirm the diagnostic. Most of indications for morphological ultrasound had revealed normal fetuses, so this exam must be performed by well trained professionals only. According to many reports the central nervous system and the genito-urinary tract abnormalities were the most frequent.

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Study Methods: One hundred and fifty seven consecutive patients who attended the Outpatient One-Stop clinic for trasvaginal scanning were included I the study. Following the procedure, each patient was asked to complete an anonymous questionnaire relating to their views on the information leaflet sent prior to the appointment, the procedure itself in relation to pain, anxiety (using 10-point visual analogue scale) and the clinical environment. Results: One hundred and forty patients completed the questionnaires (89% response). Of those patients, 128 (91.4%) found the written information regarding the procedure, which were sent prior to their appointment, clear to understand and helped in reducing their anxieties. All patients described the procedure as acceptable with preserved dignity, 139 (99%) experienced slight to mild pain/discomfort only with one reported no pain at all. One hundred and sixteen (82.8%) watched the monitor during scanning; 100 patients (86.2%) found this helpful in reducing their anxieties. Conclusions: All patients in this sample found TVS acceptable, with bearable mild to moderate pain experience. The study highlighted several areas for improvement. P3.19.12 SPECIAL CHARACTERISTICS OF ULTRASOUND DETECTION OF LEVONORGESTREL IUS (MIRENA) IN THE UTERUS A. Soder, Zehntwiesenstrae 5, D-76275 Ettlingen, Germany Objectives: Ultrasound control of intrauterine devices is a common procedure in gynaecological practice. The hormonal LNG IUS is not as easily detectable as a Copper IUD because it does not contain echogenic copper wire. The aim of this case study was to define typical features of the LNG IUS in longitudinal and transverse view. Study Methods: In this case study 420 women using LNG-IUS were examined by transvaginal sonography (Sonoscope 3, Kranzbhler device). Results: In all cases LNG IUS could be detected in the uterus.The hormone cylinder shows a typical trapezoid dorsal shadow in the longitudinal sonografic view. The caudal and cranial ends of the hormone cylinder body are clearly identified by echo-rich spots. The distance between the uterine fundus and the cranial end of the LNG IUS corresponds to half the uterus diameter, and thus shows optimal position of LNG IUS in the uterus. In transverse view the expanded arms show strong echogenicity while the tips of the arms and the hormone cylinder are identified by shadows. Conclusions: The LNG IUS shows typical features in ultrasound, different from those of the Copper IUDs. Transvaginal ultrasound is a suitable method to control the position of the LNG IUS in utero.

P3.19.10 NECESSITY OF BREAST ULTRASOUND IN ROUTINE GYNECOLOGICAL EXAMINATIONS M. Gojnic, M. Pervulov, S. Petkovic, T. Mostic, University of Belgrade, Clinical Centre of Serbia, Institute for Gynecology and Obstetrics, Belgrade, Yugoslavia. Objectives: The aim of this study was to present the necessity of making ultrasound examinations in routine gynecological screening and introducing that diagnosis in gynecology, not only in oncology. Study Methods Last year, we started to make routine ultrasonography in examined group of gynecological patients, with no significant breast problems. Making ultrasound examinations of breast in 570 women, aged 20 to 40 years, without problems, we wanted to point out necessity of examinations. Results: During routine control of women with no significant problems, we have found that: - 62% have microcystic diplasia, needed frequent controls 21% have cystic tumors for further necessary punctions 14% of fibroadenom tumors 2.6% exactly 15 women with first signs of ductal carcinomas Conclusions: We wanted to suggest that routine ultrasonography of the breast must be in the first step of diagnosis together with palpatory examinations and ultrasonography of genital organs, Papanicolau, vaginal secretion, colposcopy. Giving women the first chance of having examinations in oncology department makes our first health step more distant and much scaring to ordinary people.

P3.19.13 THE USE OF ENDOLUMINAL SONOGRAPHY AT DELIVERY IN PRIMIPAROUS WOMEN. A. Baxter, K. Phillips, G. Duthie, A. Gardiner, Castle Hill Hospital, Hull, United Kingdom Objectives: To establish the accuracy, practicality, reliability and reproducibility of endoluminal ultrasonography (ELUS) immediately after delivery in nulliparous women. The incidence of anal sphincter tears after vaginal delivery is 0.5-2%. ELUS has been shown to be more sensitive at identifying women with subclinical injuries than digital examination. Using ELUS it has been shown that anal sphincter injury can occur in up to 35% of women delivering for the first time. We have used ELUS to detect tears immediately after delivery with a view to immediate repair. Method: All primiparous women were offered an EAS immediately after delivery. Using a B&K 360 degree scanner with 10Mz probe the images were recorded at 1cm and 2cm from the anal margin and just below pubo-rectalis. These were scored independently as intact, thinned or disrupted by four assessors. The assessment of the senior team member was taken as the gold standard against which the other assessments would be compared. Results: 62 primigravidae were scanned. External anal sphincter defects were identified in 31% and internal sphincter defects in 6%. Agreement in the assessments was reached in 80% of cases with defects and 97% with none. The quality of the hard copy image was deemed adequate for analysis in 100% of cases.

P3.19.11 PATIENTS PERCEPTION OF TRANSVAGINAL ULTRASOUND SCANNING (TVS) C. Absi, K. Reddy, N. Amso, Dept. OB/GYN, University Hospital of Wales, Cardiff, UK Objectives: Trasvaginal Ultrasound Scanning is a routine investigation for women presenting with gynecological complications. However, very little research has been undertaken into the womens perception to this very intimate and embarrassing procedure. The aims of this study were to seek the patients view to the service provided and womens experiences before and after the vaginal scan.

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Conclusion: Satisfactory images were obtained in all cases, indicating that EAS is a practical tool for use in the immediate postpartum period. Images were acquired in 3-4 minutes causing only minimal discomfort. The technique is reproducible and importantly, interpretation of the images is highly consistent. The high anal sphincter damage incidence in the group reflects higher scan acceptance rates when there was concern of sphincter damage. P3.19.14 TRANSVAGINAL ULTRASONOGRAPHY IN EARLY DIAGNOSTIC OF ENDOMETRIAL HYPERPLASIA T.F. Tatarchuk, T.D. Zadorognaya, E.V. Burlaka, J.P. Solsky Institute of Pediatrics, Obstetrics and Gyneacology, Ukraine Objectives: We aimed to detect the early ultrasonic signs of endometrial hyperplasia. Study Methods: The study included 84 peri- and postmenopausal women at the age of 45-55 in period, which had the indication for dialation and curettage of uterine cavity. In order to receive more objective results of investigation the endometrium/myometrium coefficient was estimated, that is the ratio of the endometrium thickness to anteroposterior diameter of uterus. The control group consisted of 75 peri- and postmenopausal women who underwent transvaginal sonography and had none pathological changes in the endometrium and the values of the TE (the thickness of the endometrium) and EUC (Enometrium - Uterus coefficient) were within normal range of the age. Results: During the first year of Menopause we revealed only in 6 of 52 women hyperplasia with atypia has been revealed and was accompanied by abnormal bleeding. In postmenopausal women during the second year of Menopause the hyperplasia with atypia has been found in 8 cases of 32 women (25%). It should be stressed that 4 of these women had nome of the clinical symptoms. This proves the importance of subclinical diagnostic criteria for hyperplasia with atypia and the estimation of the EUC may be one of these criteria. The results of ET in women during the second year of postmenopause have demonstrated that values in women with atipical hyperplasia (6,3+2,13) were not significantly different compared to control group (5,9+1,76) and were significantly lower than in women with hyperplasia (12,8+2,57) and polyposis (14,1+1,93). Concerning the results of EUC it was revealed that in women with atipical hyperlasia the values (0,29+0,07) were significantly higher than in control group (0,11+0,02) and did not reliably differ from the complex hyperplasia (0,31+0,04) and polyposis of endometrium (0,31+0,08). The increase of echogenecity and the increase of conduction of the sound in the hyperplastic endometrium testify the hyperplasia with atypia. Conclusions: The results indicate the expediency of measuring EUC and ET in postmenopausal women.

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was found in 91% under ultrasound investigation. In single cases, ascitis was in quantity 200-300 ml. In 77% of cases, our investigation proved the damage of the omentum. In other cases, the tumor changes in omentum did not find. Key difficulties in determination of localization of the tumor, sizes and nature of process, condition of the other ovary were depended on marked adhesive process in pelvis and abdomen cavity. The main cause of hypodiagnosis of damage of omentum was the absence ascitis in abdomen cavity that made special acoustic medium. Receiving additional data in the conditions of gynecological department contributed to more rapid moving of patients in oncological hospital with the following composite treatment, that undoubtedly was affected to the final result of therapy.

P3.19.16 ULTRASOUND EVALUATION OF THE UTERINE CAVITY IN THE EARLY PUERPERIUM B. Ahmed, A. Fayyad, N. Christoforidis, T. Hildreth, K. Hinshaw, Dept. OB/GYN, Sunderland Royal Hospital, Newcastle-Upon-Tyne, UK. Objective: To evaluate the size and contents of the uterine cavity with 24 48 hours following normal vaginal delivery using transabdominal ultrasound. Aims: 1. To describe the size and contents of the uterine cavity in the early puerperium. 2. To compare findings in primiparous and multiparous women. 3. To define the clinical significance of heterogenous echoes in the uterine cavity. Study Methods: 100 women following normal singleton vaginal delivery at term were evaluated sonographically within 48 hours of delivery, using transabdominal real-time ultrasound. The amount of lochia in all women was normal. The uterine cavity was measured in two planes. The maximum length and anteroposterior diameter were measured in the mid-sagittal plane. The maximum transverse diameter was measured in the true axial plane of the uterus. The internal appearance of the endometrial cavity and any echoes within it were evaluated. All women were followed up to eight weeks post-partum for any significant vaginal bleeding or infection. Results: 37% had mixed heterogenous echoes with the uterine cavity. None of these women had abnormal symptoms. The only scan parameter that was significantly different between the groups with heterogenous or homogenous echoes was the antero-posterior diameter of the cavity: 9.2(3.2-30.7) mm vs. 5/8(3.2-15.1) mm [median range] p=0.0003 (Mann-Whitney). There were no significant differences between the AP, length or transverse cavity measurements related to parity. Only one woman presented with secondary PPH; she had originally been in the group with a homgenous (empty) cavity in the early puerperium. Conclusions: In the early puerperium, the ultrasound finding of mixed echogenic shadowing in the uterine cavity is common (37%). In the presence of normal lochia, it does not seem to imply pathology (i.e. retained products of conception). We suggest that the ultrasound appearances we have described should be regarded as normal at that stage. In future studies, women with heterogenous echoes in the uterine cavity in the early puerperium will be evaluated longitudinally in order to define how quickly they resolve.

P3.19.15 ULTRASOUND DIAGNOSIS OF MALIGNANT TUMORS OF OVARY N.V. Vedernicova, M.N. Zholobova, L.S. Aleksandrov, N.V. Vinogradskya, E.V. Nachodkina, G.B. Saakyan, E.B. Savinova, Moscow Medical Academy, Urgent Medical Aid Hospital, Moscow, Russia. The problem of the diagnosis of the tumors in the genital tract is far from decision in gynecology. Among all neoplasia of the genital tract, 25% are malignant tumors. The ultrasound diagnosis allows us to determine tumors in pelvis in 95-98% and establish its topical location in 85-98% of cases. Any solid mass, thickening of the capsule or septum supposes malignancy. Diagnostic accuracy of ultrasound picture was determined in comparison with the results of morphological investigations. Under the comparison the indicator of sensitivity was 93% and the indicator of specificity was 47%. We considered the tumor to be benign if the pulsative index was more than 1.00 and malignant when it was less or equal to 1.00. Velocities curves, taken from different areas of tumor have wide spectrum results from low to high. In 61.6% of investigated patients with the tumors of ovary, we did not receive date for the existence malignant processes. Among earlier operated patients, in 16 we diagnosed the relapse of tumor. The ultrasound investigation improved the diagnosis of malignant tumors of ovary on 17.7% in comparison with clinical data. Among patients with ascites, ascitic fluid

P3.19.17 ULTRASOUND GUIDED PUNCTURES OF PELVIC CYSTIC MASSES: 8 YEARS EXPERIENCE Z. Puzigaca, T. Starovic-Medan, Z. Sretenovic, V. Ivanovski, M. Savic, R. Nikolic, G. Bunjevacki, Center for Family Planning and Human Reproduction, Mother and Child Heath Care Institute of Serbia, Belgrade, Yugoslavia. Objectives: The objective was to evaluate the role of ultrasound guided punctures in the management of pelvic cystic masses. Study Methods: Thirty patients, aged 5-68, with pelvic cystic masses ultrasonographically determined as unilocular, anechoic, without papillary projections, and with a diameter over 5 cm, were subjected to puncture. Results: Recidives appeared in six patients (20%) within an interval ranging from two months to five years. Conclusions: Ultrasonography is an efficient method for diagnosing pelvic cystic masses, and can assist us in deciding on the accurate

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treatment. Further studies are required to re-evaluate our criteria indicating cysts puncture, since the rate of recidives is high.

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P3.20 VAGINAL CANCER P3.20.01 MANAGEMENT OF MALIGNANT MELANOMA OF THE VAGINA: A REPORT OF 15 CASES Razvi K, Selo-Ojeme D, Lowe D, Nasir N, Blake PM, Gore ME, Barton DPJ, Shepherd JH. St Bartholomews Hospital and the Royal Marsden Hospital, London, UK. Objective: To review the management and results of treatment of malignant melanoma of the vagina in 2 gynaecological cancer centres in London. Methodology: A retrospective review of a computerised database records as well as case-notes over a 25-year period ending December 1999. Results: Completed data for 15 patients were available for review. Abnormal vaginal bleeding was the principal complaint in most cases with the lower third of the vagina being the most common site of occurrence. Of the 10 patients who had initial surgery, 7 had a wide local excision and 3 had radical surgery. The other 5 patients had pelvic radiotherapy as primary treatment. Five surgical patients had post-op adjuvant radiotherapy and a further 2 had radiotherapy within a year of surgery for recurrent disease. Of the 5 patients given systemic therapy or chemotherapy, 3 had it for recurrent disease and 2 as adjuvant treatment. The survival period ranged from 2 to 78 months (mean 20.9 months) with only 2 patients surviving at least 5 years. Discussion: This study confirms the extremely poor prognosis of vaginal melanomas regardless of the type of primary or adjuvant treatment. Thus, conservative procedures should be recommended as the primary treatment. There is an urgent need to identify novel therapeutic strategies in order to improve survival of this condition. P3.20.02 VAGINAL SARCOMA: UNUSUAL PRESENTATION AND DILEMMA OF MANAGEMENT K. Gupta, N.R. Mondol, S.K.Banerjee, Dept. GYN, Cancer Center Welfare Home & Research Institute and Child Care Center, Thakurpukur, Calcutta, India. Objectives: To share an unusual presentation of vaginal sarcoma in a primipara within seven months of a normal vaginal delivery and the ensuing dilemma of its management. Study Methods: In addition to the routine hematological and radiological screening, special investigations like CT scan of the whole abdomen was performed. Examination under anesthesia followed by excision biopsy of the vaginal nodule and subsequent panhysterectomy was performed. Histopathological examination (HPE) of the excised vaginal nodule revealed low grade endometrial stromal sarcoma, while HPE of the uterus, cervix, fallopian tubes and ovaries were free from any malignancy. Results: Following surgery, she was followed up monthly. In the fourth post-operative month, she suddenly presented with unilateral inguinal lymph node enlargement. Fine needle aspiration cytology (FNAC) of the swelling was negative for malignancy. On the sixth postoperative month, she presented with bilateral inguinal lymph node enlargement. Since bilateral inguinal lympgh node dissection was not feasible, external radiation (5500 cGY in 25 fractions over six weeks) was administered. Despite such aggressive treatment, in the fifteenth post-operative month, she was found to have extensive unilateral pleural effusion and lung metastasis. Pleural tapping was done and intrapleural chemotherapy advised. She is still under follow-up as of December 23, 1999. Conclusions: Unusual presentations of rare malignancies make it extremely difficult to plan a definitive protocol for effective and predictable treatment.