by Dr. Donald L. King The past decade has seen the ascent of ultrasonography to a preeminent position as a diagnostic imaging modality for obstetrics and gynecology. It can be stated without qualification that modern obstetrics and gynecology cannot be practiced without the use of diagnostic ultrasound, and in particular, the use of ultrasonogra phy. Ultrasonography quickly and safely provides detailed, high resolution images of the pelvic organs and gravid uterus. The quality and quantity of diagnostic information obtained by ultra sonography far exceeds anything previously available and has had a revolutionary impact on the management of patients. High resolution static images permit the intrauterine diagnosis of fetal growth retardation and fetal abnormalities. In addition to tradi tional images, newer dynamic imaging techniques allow observa tion of fetal motion, cardiac pulsation, and respiratory efforts. The use of ultrasonography for guidance has greatly augmented the safety and utility of amniocentesis. One of the great virtues of diagnostic ultrasound has been its apparent safety. At present energy levels, diagnostic ultrasound appears to be without any injurious effect. Although all the availa ble evidence suggests that it is a very safe modality and that the benefit to risk ratio is very high, the actual safety margin for its use Vll as yet remains unknown. As a consequence, practitioners are urged to limit its use only to those situations in which genuine clinical indica tions exist and real benefit to the patient is likely to result."

Extensive basic research and clinical trials have in some aspect of reproductive physiology, gyne been conducted on inert and medicated intrauterine cology, or family planning. There is in this volume devices. In the last decade, substantial progress has an attempt to provide a total coverage of current been made in understanding the modes of action progress in medicated intrauterine devices. The and the physiological mechanisms of IUDs - pro volume is intended for a broad readership, includ gress resulting from modern techniques and in ing physicians, medical workers, medical personnel, strumentation in microanatomy, immunology, pa and administrators in family planning. It is hoped thology, endocrinology, biochemistry and biophy that this volume will serve as a stimulus to basic sics. Such studies, however, are scattered in such a scientists and clinicians concerned with intrauterine wide spectrum of journals that the clinician and devices to intensify their research toward better family planner can hardly keep up to date with the contraceptive techniques. advances. An attempt is made in this volume to coordinate physiological and clinical parameters. Little is September 1980 known about the possible role of diet, diseases and environmental factors. E. S. E."

The motive to prepare this volume on antibiotics for the physician caring for women was based upon the editor's perception that the subject matter had never been fully developed for the obstetrician-gynecologist. Most textbooks of infectious disease have a small section devoted to antibiotics, which has little relevance for the physician caring for post-operative or post-partum infections. Basic antibiotic pharmacology is described and there is a reflex prohibition of antibiotics for the pregnant woman. Correctly, the reader assumes that the authors themselves do not care for women with bacterial infections of the pelvis. Recent texts in infectious disease in obstetrics gynecology have been little better. Although the focus has been more clini cally oriented, space requirements have too often kept the discussions at a superficial level. A total focus upon antibiotics in this volume eliminates the restraints of space in prior publications. The greatest reward in my task as editor of this volume is related to the quality of the individual authors. They range from former students, to con temporary colleagues, to respected peers in infectious disease. Since the quality of this volume is related to the sum total of the individual chapters, I wish to comment about each of the contributors. Philip Mead from the University of Vermont is an old friend, who brings to the question of prophylactic antibiotics, his wide clinical experience and encyclopedic knowledge."

The aim of this book is to transmit the message that asphyxia is the major cause of infant mortality in the ne asphyxia-if severe, caus onatal period. The sequelae of ing cerebral palsy; if mild, leading to MBD to seizures are all potential risks. It is important to make young physicians and nurses aware of this complication of the birth period, how to avoid it, and how to treat it. Facilitating such awareness is the chief purpose of this book. Alberto Lacoius-Petruccelli New York 7 Contents 1. Asphyxia: Definitions, History, and Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2. Occurrence in Utero, at Birth, and after Delivery ................................. 17 3. Physiopathology of Asphyxia and Its Staging .................................. 21 4. Work-up and Treatment in the Newborn: Delivery Room, Nursery, and Perinatal leU 25 5. Mechanical Ventilators .................... 31 6. Prognosis ................................ 37 7. Brain Asphyxia and Hemorrhage ., ........ 51 8. Types and Stages of Fetal Anoxia: Anoxic, Anemic, Stagnant, and Histotoxic ......... 57 9. Embryonic and Fetal Periods .............. 65 10. The Placenta: Origin and Functions ........ 77 9 CONTENTS 10 11. Fetal Circulation 87 12. Placental Insufficiency or Dysfunction ..... ."

The birth of a baby is the culmination of months of anticipation and plan ning. Most often, mother and infant are healthy and readily able to estab lish close contact-a bond. However, in some situations either mother or baby or both present complications. The more prompt and rational the treatment, the sooner the normal parent-infant relationship will commence. This book is devoted exclusively to the first days following birth. In its 15 chapters, postpartum and postnatal physiology and pathophy i: .;logy are reviewed by 18 specialists. Normal and abnormal development of mother and child is correlated with proven means of clinical management. Chapters 1 through 3 cover maternal postpartum developments and complications. Chapter 4 stresses the importance of a normal parent newborn relationship, a concept of increasing concern in modern society. The following ten chapters discuss neonatal physiology and pathophysi ology; the effects of obstetric anesthesia on infant behavior, pulmonary function measurements in the postnatal period and treatment of the sick newborn are discussed in detail. The final chapter reviews maternal and perinatal mortality; the data, based on extensive surveys in New York City, indicate that current management is effecting an overall decline in mortality."

This is a unique book in that it brings together the two key investigative techniques in Gynaecology and Obstetrics, namely ultrasound and endoscopy. So often in the past they were regarded by their exponents as rival techniques but it is now recognised that they are complementary to each other. Consequently future trainees in endoscopy should become efficient in transvaginal sonography and vice versa. Ultrasound can be used to study the morphology of the pelvic organs such as the endometrium, myometrium and ovaries, and being non-invasive, safe and convenient can be repeated as often as is deemed necessary to monitor changes over time; for example in the investigation of the infertile woman the development of the dominant follicle, the maturation of the endometrium and the formation of the corpus luteum can be documented throughout the menstrual cycle while growth of ovarian cysts can be precisely measured to determine the need for surgery. A seldom-mentioned strength of the ultrasound examination is its interactive quality, for example by performing abdominal palpation during the scan, the mobility of the uterus and ovaries can be assessed. Also the images as they appear can be shown to the patient to aid understanding. Ultrasound can also determine function and the use of Doppler has been used for example to access endometrial receptivity, follicular maturity and the likelihood of malignancy in the endometrium or ovary.

This volume represents the Proceedings of the World Conference on Embryo Transfer, In Vitro Fertilization and Instrumental Insemination held on September 24-27, 1980 in Kiel, West Germany. Professor Dr. L. Mettler and Dr. H. H. Riedel of Frauenklinik der UniversiUit in Kiel were the local co chairpersons, who contributed very richly to the program. Basic research, clinical trials, preparation of manuscripts, editorial assistance and presentation of results were generously supported by the following institutions and organizations: Kulturministerium des Landes Schleswig-Holstein Medizinische FakuItat der Christian-Albrechts-UniversiUit, Kiel Wayne State University School of Medicine; Detroit, Michigan, USA C. S. Mott Center for Human Growth and Development; Detroit, Michigan, USA Universitats-Frauenklinik und Hebammenlehranstalt; Kiel, West Germany Serono GmbH; Freiburg, West Germany Hutzel Hospital; Detroit Medical Center; Detroit, Michigan, USA Deutsche Gesellschaft fUr Gynaekologie und Geburtshilfe; West Germany Deutsche Gessellschaft zum Studium der Fertilitat und Sterilitat; Sektion Andrologie Thanks are also due to Aponti GmbH (5000 Koln 21), Bayropharm GmbH (5000 Koln 80), Deutsche Lufthansa (5000 Koln), Organon GmbH (8024 Oberschleissheim), Winthrop GmbH (6080 New Isenburg), and Wisap GmbH (8029 Sauerlach), for financial assistance. Sincere appreciation and gratitude are due to the contributors who meticulously prepared their chapters; to Ms Jackie Mucci for editorial skills and assistance, and Ms. Jackie Smieska for editorial help. Thanks are also due to Dr. H. D. Brackebusch for his assistance during the conference; to Ms. E. Seiss for her secretarial assistance; and to Mr."

The Fourth International Congress on the Menopause was held in Lake Buena Vista, Florida, USA in October - November 1984. It was different from the previous meetings held under the auspices of the International Menopause Society in three respects: the duration of the Congress was extended to five days, plenary sessions were held on each day, and the scope of the subject matter was expanded to provide a total or holistic overview of the subject - hence the theme for the Congress 'Climacteric Medicine and Science: A Societal need. ' In recent years there has been an increased interest in the menopause and middle year aging by scientists and clinicians in fields as diverse as anthropology, urodynamics, nutrition and exercise physiology, while 'newer' issues in clinical medicine, such as osteoporosis prevention and management, attracted specialists in nuclear immaging techniques and internal medicine. Over 120 invited speakers plus numerous contributors to the free communication, special lectures and the poster sessions provided a virtual cornucopia of information on the menopause, that has indeed brought a newer perspective to a subject previously the domain of a single specialty, the gynecologist, and dominated by a single therapy, estrogen replacement.

In vitro fertilization has resulted in an estimated 4000-5000 births in the world. The procedure has been accepted in Europe, America and Australia and several hundred IVF clinics are operating successfully. The newer procedures of GIFf, embryo freezing and donor oocyte IVF have become established and are dealt with in several chapters. GIFf has become the procedure of choice for patients with infertility of unknown origin. Oocyte freezing represents an important new technology which is being developed. The routine IVF procedure has improved slightly; variation in results can be reduced by quality control of laboratory and clinical techniques. Male factor infertility has been dealt with by IVF in mild and moderate cases, but newer techniques will be required to deal with severe problems in the male. Most countries have accepted that the straightforward IVF pro cedure is ethical. Limitations concerning the use of donor oocytes and embryo experimentation exist in some religions and countries; legal control of the new reproductive technologies ranges from the passage of statutes to no control at all. Many countries are still considering the need for legislative control. The text endeavours to indicate new areas of importance and to guide those organizing services as to how to introduce newer technolo gies.

Infertility, as with many aspects of medicine, is at the mercy of rapid technological advance. Many of these developments initially seem attractive to both clinicians and patients, but need to be rigorously assessed if their real value is to be understood and clinical practice is to develop. In this book issues of importance to the management of infertile patients are discussed. The gaps in our knowledge which prevent a better understanding of the condition are identified, and recent developments, both clinical and scientific, are subjected to peer review and discussion. An important feature of the book is an acceptance that training in infertility practice is a real problem. This is perceived not only by the practising clinicians, both doctors and nurses, but particularly by the clinical scientists, including embryologists, who now provide such an essential part of the service. Similarly the provision of the clinical service has been examined in detail from a variety of standpoints, in an attempt to make sensible recommendations which balance real need with limited resource. The book is based on the papers presented and discussed at the 25th RCOG Study Group held in April 1992. The discussion after each paper was civilised but uncompromising and forms an important part of this publication. The rapid processing of the written and recorded material by the staff at the RCOG, and particularly Miss Sally Barber, has ensured that the book has been produced while the issues are live, the reviews contemporary and the discussion relevant.

This volume contains all the invited papers, symposium contributions and workshop reports of the 7th International Congress of Human Genetics, held in West Berlin from September 22 to 26, 1986. The organizers of this congress made sure to gain the cooperation of the leading scientists in the field from all over the world. These contributions therefore document the enormous progress made in human genetics research in recent years. The volume covers a wide range of topics, from analysis of the human genome to basic mechanisms, diagnosis and therapy of hereditary diseases, and to distribution of normal and pathological genes and DNA variation in human populations. Ethical issues raised by modern developments are discussed thoroughly. The volume is a must for all scientists and medical doctors working in human genetics research, its teaching and practical applications.

Conceptual advances in the biological sciences are marked by the applica tion of new techniques and experimental strategies. Nowhere has this ge neric principle been more apparent than in the study of testicular cells, as judged by the evolution of themes presented at the Testis Workshop over the past 23 years. Like its predecessors, the 1995 Testis Workshop was structured to offer fresh insights and approaches for understanding the mechanisms of spermatogenesis and steroidogenesis. The chapters pre sented in this book emphasize three aspects of testicular cell function: first, the molecular analysis of the cell cycle; second, examination of the cell cycle, including the function and identification of specific macromolecules that direct the proliferation and differentiation of germ cells; and third, the development of Leydig cells and the role of specific macromolecules in the formation of testicular steroids. Each chapter is based on a lecture presented at the XIIIth Testis Work shop held on March 30 to April 1, 1995, at the Radisson Plaza Hotel in Raleigh, North Carolina. The selection of topics reflects the recommenda tions of the workshop'S organizing committee. Sincere thanks are due to the speakers who agreed to lecture and prepare chapters."

Each new volume of this publication brings the privilege of expressing some of my thoughts on subjects of interest to its readers. In the past year or so public concern about environmental and societal dangers has largely turned to those of cosmic proportion-Chernobyl, the thinning ozone layer, AIDS, and the like-and thankfully our subject matter has been allowed a respite. Even the miniepidemic of craniofacial and other malformations caused by the retinoid antiacne drug Accutane made no headlines. Incidentally, this might have been a tragedy of far greater proportions had it not been nipped in the bud by the historical ground work that quickly permitted it to be recognized as due to an environ mental teratogen-the sort of fact the public and authorities inadequately appreciate. But there is a warning connected with this abeyance of media focus on teratological matters. Disquiet over cosmic imbalances will sub side as they are corrected or horrendous projections fail to materialize, and even cures for dread infectious diseases, or Puritan revolution in terdicting such plagues, will be forthcoming, and these things will occur long before congenital malformations are no more. And as the year-in and year-out recurrence of over 100,000 an nual births of seriously malformed infants in the United States alone continues to force itself on the public consciousness, we can expect a heightened demand that "a cure" be found, because "if we can land a man on the moon, if we can prevent polio, why can't we . . ."

In recent years, papillomaviruses in general and human papillo maviruses in particular have been recognized as possible agents of important diseases, including some forms of human cancer. The purpose of this book is to present a concise panorama of the pre sent status of knowledge of this topic. This knowledge is as impor tant to molecular biologists and virologists as it is to clinicians and pathologists. To bridge the gap among these diverse groups of investigators, we conceived of a book covering a broad spectrum of the basic scientific, clinical, and pathological aspects of diseases associated with papillomaviruses. Although the principal thrust of this book is directed at human papillomaviruses, fundamental knowledge of animal viruses is essential to the current understand ing of the molecular mechanisms of cell transformation. For this reason, a chapter on animal viruses has also been included. Some of the experimental work having to do with the elucidation of transformation and other aspects of interaction between the virus and the cell cannot be based on human papillomaviruses because of a lack of suitable experimental models. Hence, some of the chapters dealing with fundamental aspects of viral molecular biol ogy are based on animal models. We were very fortunate in having persuaded a number of distin guished colleagues to contribute to this work."

Breast Care: A Clinical Guidebook for Women's Primary Health Care Providers presents the expertise and protocols of the renowned Breast Diagnostic Center at USC School of Medicine's Department of Obstetrics and Gynecology. A user-friendly reference for the primary care physician, this book details the management of both benign and malignant breast diseases. Topics include: * the clinical examination and instruction for self-exam * mammography for both screening and diagnosis, management of the abnormal mammogram * lactation and breast feeding * diagnosis and treatment of lumps, cysts, fibroadenomas * fine-needle aspiration and ultrasound guided tissue core needle biopsy * evaluation and management of mastalgia * menstrual and hormonal therapy effects on the breast * the cosmetically treated breast * guidelines for follow-up and surveillance An important section on consultation and referrals reviews the roles of the radiologist, oncologist, and surgeon and provides the primary care physician with the information necessary to counsel the patient on the myriad aspects of multidisciplinary treatment planning. The text includes more than 100 illustrations and algorithms -- with 16 in color -- as well as "Practice Guides" which organize the key practice points, signs, and symptoms. This is a must-have handbook for all providers of health care to women.

These four volumes comprlslng "GnRH Analogues in Cancer and Human Reproduction" are a distillation of the presentations of the invited speakers at a landmark International Symposium bearing the same name, organized by one of us (B. L. ) and held in Geneva, SwitLerland in February 1988. The Symposium was truly interdisciplinary spanning gonadal hormone dependent disease including various forms of cancer and ranging to control of fertility, both pro- and conception. The international flavor can be caught from the 480 participants and 259 contributors drawn from 14 countries. The Symposium, and therefore this book, would not have been possible without the backing of The International Commitlee for Research in Reproduction and the sponsorship of the International Society of Gynecologic Endocrinology, The Swiss Society of fertility and Sterility, The University of Geneva School of Medicine, The Swiss Society of Endocrinology and The US foundation for Studies in Reproduction Inc. , and help from the World Health Organization. B. H. Vickery B. Lunenfeld June 1989 xiii LIST OF CONTRIBUTORS TO THE SERIES A. Abbondante H. Bartermann First Institute of Obstetrics and Urologische Universitatsklinik Kiel Gynecology Arnold-Heller Strasse 7 University "La Sapienza" D-2300 Kiel 1, FRG Rome, Italy M. Bartholomew P. Abel Department of Medicine/Endocrinology Department of Urology Milton S. Hershey Medical Center Hammersmith Hospital Pennsylvania State University DuCaneRoad PO Box 850, Hershey, PA 17033, USA London W12 OHS, UK D. Beck H.

The perimenopause is an extremely important time in a woman's life. In a similar but reverse sequence to puberty, it signals a change in ovarian status. Although some women pass through this transition without symptoms or concern, for many women, the perimenopause, which can last several years, is of great concern. Symptoms of estrogen deficiency, menstrual irregular ity, concerns over changes in mood, as well as reproductive concerns lead to anxiety and frustration. Because it is poorly understood, many clinicians are equally frustrated in finding ways to help their patients and question the appropriateness and/or need for treatment. This Serono Symposia USA, Inc., meeting was designed to help address some of these issues from both a basic science and a clinical perspective, and to provide a forum for discussion. The waning of ovarian function can be divided into two events that are dissociated: gametogenic and endocrine failure. Thus, the symposium was divided into three parts to address these two phenomena and to discuss treatment options. An outstanding international group of clinicians and investigators assembled to first address oocyte depletion and possible markers. Next the complex endocrine changes were discussed as well as the physiologic consequences of these changes. This included a discussion of hot flushes, bone and cardiovascular changes, menstrual irregularity, mood disturbances and depression, and anatomical changes in the ovary and breast. The third part of the symposium addressed treatment options, both in terms of symptoms as well as reproductive and fertility concerns."

Ultrasonic surgical techniques were first used by Dr. Kelman in the 1960s to fragment cataracts through a 2-mm incision allowing for minimally invasive surgery. The results from this procedure stimulated the development of a larger, move powerful ultrasonic unit that was used in neurosurgery. This instrument allowed the neurosurgeon to selectively remove tumor tissue with decreased blood loss and tissue trauma. The ability now of ultrasonic equipment to selectively fragment, irrigate, and aspirate tissue with minimal coagulation effect spurred its rapid use in surgery on the liver, spleen, kidney, and other intra-abdominal organs. This instrument has been invaluable in ovarian cancer cytoreduction and intricate segmental organ resection. The newest technical developments include electro cautery capability built into the hand piece and extended hand pieces for laparoscopic surgery. The impetus for assembling this volume has been to provide an extensive review of the field of ultrasonic surgery as it has currently developed including principles, equipment features, and surgical tech niques. It is hoped that the information will be of use to physicians in training and surgeons in practice. The book takes a multidisciplinary approach with chapters authored by a diversity of subspecialists in gen eral surgery, urology, surgical oncology, and gynecologic oncology. Each chapter contains basic information on surgical techniques. Together, these chapters cover surgery of the GI tract, kidney, liver, and lower genital tract, and present a number of personal approaches."

Since the awarding of the Nobel Prize to Drs. Guillemin and Schally iJ) 1971 for isolation and chemical characterization of gonadotropin releasing hormone, we have experienced a remarkable period of growth of interest in this hormone. The last 20 years have been characterized by a swift translation of basic science discovery into clinical utility. Approval of GnRH and its analogs for treatment of prostate cancer, endometriosis, of ovulation indicate the range and precocious puberty and for induction of these agents. of usefulness In order to bring together the leaders in the basic and clinical science of GnRH, a conference was organized on "Modes of Action of GnRH and GnRH Analogs" and held in Scottsdale, Arizona, February 26 to March 2, 1991. The presentations, given as chapters in this volume, show both the advances in the body of information in this discipline and the efforts underway to reduce basic science to clinical practice. The audience was a combination of representatives from universities, government, industry, and physicians in practice. The lively discussions and insightful questions indicated the interest in the topics discussed and frequently served to catalyze planned interactions of the meeting participants. The organizers are grateful to the speakers and poster presenters for their contributions and for the timely preparations of the manuscripts included in the present volume. We are also thankful to the staff of Serono Symposia, USA, for the organizational skills and support that allowed the meeting organizers to focus on the science and medicine presented.

Why Efforts to Expand the Meaning of "Teratogen" Are Unacceptable Disagreement about nomenclature in teratology is not new. Dissent even about the very fabric of the discipline-what congenital malformations consist of-has often been voiced. Time, instead of resolving such diffi culties, has sometimes worsened them. For example, in the past it was agreed that congenital malforma tions are abnormalities of structure present at birth, but differences of opinion concerning where the line between normal and abnormal was to be drawn prevailed. It was obvious that, in order to discover the causes of congenital malformations and cast strategies for their prevention, it would be necessary to have knowledge of the baseline of their frequency, and that this required uniformity of definition of terms. Since malfor mations of primary social concern are those having grave outcomes (and are, paradoxically, also the commonest ones), it is logical that such condi tions were the first consideration of investigators and were the defects whose frequency was considered to comprise the required baseline.

Proceedings of the NATO Advanced Study Institute, San Miniato, Italy, September 2-13, 1985