Preventing tuberculosis transmission at a maternity hospital by targeted screening radiography of migrants.

BACKGROUND: Israel has been the destination of large numbers of illegal migrants from East African countries in recent years. Despite efforts to detect and treat active tuberculosis (TB) at the border, 75% of all active TB cases diagnosed in our hospital were illegal migrants. In 2012, there was a large-scale TB exposure in our maternity ward, neonatal, and paediatric intensive care units following the admission of an infectious but apparently asymptomatic migrant who was in labour. A hospital-wide screening programme was subsequently implemented to prevent exposure of patients and staff to TB. AIM: To report the results of the first year of this intervention in the maternity hospital. METHODS: All illegal migrants from countries where TB is highly prevalent were screened by chest radiography (CR) upon admission to the maternity hospital. The results were immediately categorized by a radiologist as either 'suggestive of active pulmonary TB' or 'non-suggestive'. Patients with CR suggestive of TB were placed in airborne isolation and underwent further evaluation. FINDINGS: Four hundred and thirty-one apparently asymptomatic migrant women underwent CR screening. Most (363, 84%) presented in labour. Eleven women (2.6%) had a CR suggestive of active pulmonary TB which was confirmed in three (0.7% of screened women). No TB cases were missed by the CRs. Neither patients nor hospital staff were exposed to TB. CONCLUSION: Targeted CR screening for TB among high-risk women upon their admission to a maternity hospital had a high yield and was an effective strategy to prevent in-hospital transmission of TB.

Correlation of cancer risk evaluation and early detection (CADET) scores with abnormal ultrasonographic ovarian findings.

OBJECTIVE: To determine the utility of a modified version of ovarian cancer-focused cancer risk evaluation and early detection (CADET) scores as a screening tool for ultrasonographic ovarian findings. STUDY DESIGN: Prospective pilot study. MAIN OUTCOME MEASURES: CADET scores were compared with abnormal ultrasonographic ovarian findings of peri- and postmenopausal women who attended their gynecologist for a routine check-up. The women filled in the CADET questionnaire before seeing their gynecologists who were blinded to the CADET results. The women whom they referred for pelvic transvaginal ultrasonographic examination comprised the study group. The results of their scans were compared with their CADET scores. RESULTS: Of the 181 peri- and postmenopausal women who were candidates for this study, 154 were referred for ultrasonography, of whom 38 (24%, Group A) had abnormal ovarian scans (30 simple cysts and 8 complex findings). The other 116 (76%) women had normal sonograms (Group B). Demographic characteristics were similar for both groups. Thirteen Group A women (34%) and 52 Group B women (45%) had positive CADET scores (p = NS). The average group CADET scores were also not significantly different (0.8 +/- 1.7 for Group A and 1.7 +/- 2.5 for Group B). CONCLUSION: CADET scores did not correlate with abnormal ultrasonographic ovarian findings.

Risk factors for severe perineal injury during childbirth: a case-control study of 60 consecutive cases.

AIM: The study aimed to evaluate the current risk factors for severe perineal tears in a single university-affiliated maternity hospital. METHOD: An obstetric database of 31 784 consecutive women who delivered from January 2007 to December 2009 was screened for cases of third-degree or fourth-degree perineal tears. Four controls, matched by time of delivery, were selected for each case of third- or fourth-degree perineal tear. Maternal and obstetric parameters were analyzed and compared between the study and control groups. RESULTS: Sixty women (0.25% of all vaginal deliveries) had a third-degree (53 women) or a fourth-degree (seven women) perineal tear. The control group comprised 240 matched vaginal deliveries without severe tears. Primiparity, younger maternal age, Asian ethnicity, longer duration of second stage of labour, vacuum-assisted delivery and heavier newborn birth weight were significantly more common among women who had third- or fourth-degree perineal tears. Of the variables that were found to be statistically significant in the univariate analysis, only primiparity (OR = 2.809, 95% CI: 1.336-5.905), vacuum delivery (OR = 10.104, 95% CI: 3.542-28.827) and heavier newborn birth weight (OR = 1.002, 95% CI: 1.001-1.003) were found to be statistically significant independent risk factors for severe perineal trauma. CONCLUSION: Identification of women at risk may facilitate the use, or avoidance, of certain obstetric interventions to minimize the occurrence of childbirth-associated perineal trauma.

Improved quality of life with hyperbaric oxygen therapy in patients with persistent pelvic radiation-induced toxicity.

AIMS: We report the results of hyperbaric oxygen therapy (HBOT) used in the treatment of radiation-induced persistent side-effects after the irradiation of pelvic tumours. MATERIALS AND METHODS: Between January 2001 and December 2005, 13 women (median age 60.3 years) with radiation combined proctitis/cystitis (n=6), longstanding vaginal ulcers and fistulas (n=5) and longstanding skin injuries (n=2) underwent HBOT in a multiplace chamber for a median of 27 sessions (range 16-40). The treatment schedule was HBOT 100% oxygen, at 2 absolute atmospheres, for 90 min, once a day. For radiation-induced toxicity grading we used the National Cancer Institute Common Toxicity Criteria (CTC) grading system, before and after HBOT. RESULTS: Thirteen patients underwent an adequate number of HBOT sessions. The mean CTC grading score before HBOT was 3.3+/-0.75, whereas the mean CTC grading score after HBOT was 0.3+/-0.63. The scores showed a significant improvement after HBOT (P=0.001; exact Wilcoxon signed-rank test). Rectal bleeding ceased in five of six patients with proctitis and dysuria resolved in six of seven cystitis patients. Macroscopic haematuria stopped in seven of seven patients. Scar complications resolved in two of two patients. None reported HBOT-associated side-effects. CONCLUSION: HBOT is apparently safe and effective in managing radiation-induced late side-effects, such as soft tissue necrosis (skin and vagina), cystitis, proctitis and fistulas.

Post-hysterectomy pelvic fluid collection: is it associated with febrile morbidity?

We evaluated the clinical significance and possible association of febrile morbidity with sonographically detected post-hysterectomy fluid collections. Transvaginal ultrasound examinations were performed to assess the presence of fluid collections and correlated to clinical data. Fluid collection was detected in 27 (64%) women at postoperative day 2, in 15 (35%) at postoperative day 7 and in 5 (12%) at the fourth to fifth postoperative week. Febrile morbidity was not related to the presence, location or size of fluid collection. Postoperative pelvic fluid collections are common sonographic findings after hysterectomy and are not associated with postoperative febrile morbidity.

Integrated 18F-fluorodeoxyglucose positron emission tomography and computerized tomography in endodermal sinus tumor.

Application of an in-line positron emission tomography and computerized tomography (PET-CT) in endodermal sinus tumor (EST) is described in this study. CASE 1: A young female with massive ascites postovarian mass resection had elevated alpha-fetoprotein (AFP) serum levels. Following a positive PET-CT study with increased (18)F-fluorodeoxyglucose (FDG) uptake, a CT-guided core biopsy of a peritoneal mass was performed. EST was diagnosed histologically. The patient was disease free after chemotherapy. Follow-up PET-CT was negative in keeping with no viable tumor tissue. CASE 2: A large pelvic mass diagnosed histologically as primarily EST was removed in a teenage patient with elevated AFP levels. PET-CT showed diffuse abdominal spread of FDG uptake, suggesting extensive peritoneal seeding. The patient was disease free after chemotherapy. Follow-up PET-CT was negative. EST is an FDG-avid tumor. PET-CT delineated the prechemotherapy tumor extent adequately ruled out the presence of residual tumor after a successful treatment.

Apoptosis in cryopreserved human ovarian tissue obtained from cancer patients: a tool for evaluating cryopreservation utility.

Fertility preservation is of major importance for women with cancer in whom ovarian function may be disturbed by the use of potentially sterilizing chemotherapeutic drugs and/or pelvic irradiation. Cryopreservation of ovarian cortical tissue is one of the potential options for preserving fertility among these women. Cryopreserved thawed human ovarian tissue can be autografted either orthotopically or heterotopically, but may also be transplanted first into an animal host with subsequent maturation and collection of oocytes. The objective of this study was to investigate the prevalence of ovarian follicular apoptosis in fresh and frozen/ thawed human ovarian tissue as a measure of follicular viability. The study group included 6 women with cancer who underwent ovarian tissue cryopreservation (OTCP). Ovarian tissue samples (n = 2) were obtained from each woman with one sample undergoing evaluation for apoptosis immediately following removal (control, group A) and the other evaluated for apoptosis following freezing/thawing (group B). Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) and 4'6' diamido-2-phenylindole hydrochloride (DAPI) staining methods were used to investigate follicular apoptosis. Morphological changes in the same samples were evaluated in hematoxylin and eosin (H&E)-stained sections. In each slide, only primordial and primary follicles were evaluated for abnormal morphology and apoptosis. Abnormal morphology was demonstrated in 23.8+/-8.7% of group A follicles compared to 48.3+/-11.2% of group B follicles (p < 0.05). Apoptosis was demonstrated in 25.4+/-8.4% of group A follicles compared to 60.9+/-6.0% of group B follicles (p < 0.05). We have shown that the ovarian follicles in group B demonstrated a higher incidence of apoptosis compared to those of group A. Therefore, the data suggest that follicular apoptosis might be a consequence of the freezing and thawing procedure. This may be used as a method for evaluating and comparing the outcome of different freezing/thawing protocols.

Feto-feto-fetal transfusion syndrome in monozygotic monochorionic triamniotic triplets: vascular evaluation by a cast model.

A unique cast model of the placenta in a rare case of feto-feto-fetal triplet transfusion syndrome (FFFTTS) allowed the demonstration of why the transfusion syndrome developed in one fetus and not in the other two in that single placenta. The vasculature anatomy of a monochorionic triamniotic triplet placenta with FFFTTS of three healthy infants (one donor, two recipients) born in the 35th week of gestation was cast by means of dental casting materials. After the cast hardened, the tissue was corroded, revealing the cast blood vessels. The diameters and lengths of the chorionic blood and intraplacental vessels of the cast placenta were measured with a digital caliper. The cast revealed two artery-artery (A-A) anastomoses on the chorionic plate between the two recipients and the donor. Seven artery-vein (A-V) deep anastomoses connected only the arteries of the donor and the veins of the two recipients. The blood vessel connections among the fetuses allowed the evaluation of a pathologic case with its own control in a single placenta. From the vascular appearance, we speculate that the A-A anastomoses between the two fetuses protected them from developing blood transfusions, but that the A-V anastomoses contributed to their development.

Induction of polycystic ovary by testosterone in immature female rats: Modulation of apoptosis and attenuation of glucose/insulin ratio.

Polycystic ovarian syndrome is seen in 5% of fertile aged women. However, there is no satisfactory PCOS model in experimental animals. To induce polycystic ovary phenotype in immature female rats, Wistar rats 21 days of age were injected daily with testosterone propionate 1 mg/100 g body weight dissolved in propylene glycol or propylene glycol for up to 35 days. Seven days of injection with testosterone (T) resulted in the appearance of large cystic follicles and a dramatic accumulation of multi-layer preantral follicles. At 42 days of age puberty in control animals was evident by the appearance of corpora lutea. In contrast in T treated animals no corpora lutea formation was seen even at the age of 56 days. Progesterone in the control animals was elevated at the age of 42 days in contrast with the T treated animals in which progesterone remained low (20% of control). While during 14 days of T injection most of the follicles did not have progressive apoptosis, at 21-35 days of injection (42-56 days of age) the vast majority of follicles became apoptotic. Progressive degeneration of oocytes was evident in T treated animals reaching 70-85% of total oocytes at 21-35 days of T injection compared to 30-40% in control animals. Western blot analysis of ovarian homogenates revealed gradual decrease in Bcl-2 content, evident at 28 and 35 days of T injection compared to control animals. Interestingly, the fasting glucose/insulin ratio was dramatically reduced in T treated animals following 14 days of testosterone treatment compared to controls. Our data suggest that T injection to immature female rats can induce polycystic ovaries, block ovulation and attenuate progesterone production. Moreover, normal/low glucose and high insulin blood levels in the testosterone treated rats raises the possibility that elevated androgens can lead to insulin resistance in this experimental PCOS model.

Interleukin-18 is high in the serum of IVF pregnancies with ovarian hyperstimulation syndrome.

PROBLEM: The presence of interleukin-18 (IL-18) in serum and pre-ovulatory follicular fluid (FF) and its possible correlation to in-vitro fertilization/embryo transfer (IVF/ET) outcome and ovarian hyperstimulation syndrome (OHSS) development. METHOD OF STUDY: A prospective study was carried out. Assays for serum and pooled pre-ovulatory FF levels of IL-18 were performed on 30 patients who underwent oocyte retrieval for IVF/ET. RESULTS: Mean serum and FF levels of IL-18 were 370.4 +/- 224 and 228.9 +/- 208 pg/mL, respectively (r = 0.77, P < 0.0001). Levels of FF IL-18 were comparable between the two ovaries (right = 221 +/- 166.8 pg/mL, left = 237 +/- 171.9 pg/mL; r = 0.7550, P = 0.49). A positive correlation was found between IL-18 FF levels and number of retrieved oocytes (r = 0.45; P = 0.019). In three patients (10%) who developed OHSS, the mean serum level of IL-18 at day of ovum pickup was significantly higher compared with patients without OHSS (620 +/- 196 pg/mL versus 345 +/- 251 pg/mL, respectively, P = 0.04). CONCLUSIONS: Both pre-ovulatory FF and serum levels of IL-18 correlate with the number of retrieved oocytes. The serum IL-18 level at day of ovum pickup may predict consequent development of OHSS. Further investigations are warranted to determine the role of IL-18 in the folliculogenesis and OHSS pathogenesis.

Clinical evaluation of atypical glandular cells of undetermined significance upon cervical cytologic examination in Israeli Jewish women.

The adjusted incidence of cervical carcinoma among Israeli Jewish women is approximately 5 out of 100 000. This retrospective study sought to determine the clinical implications of finding atypical glandular cells of undetermined significance (AGUS) in cervical cytologic specimens in this population. Cervical cytologic examinations during January 2001-June 2003 diagnosed as AGUS were identified by a computerised database. Medical records were reviewed to determine the presence or absence of associated significant pathologic conditions of the cervix and identified 45 out of 11 800 patients (0.38%) with AGUS. AGUS was the only cytologic diagnosis in 14 patients, while 31 patients had both AGUS and an additional atypical squamous cell of undetermined significance (ASCUS). All subjects underwent colposcopy, endocervical curettage, and cervical biopsy. A clinically significant diagnosis (cervical intraepithelial neoplasia (CIN) II, CIN III, or carcinoma) was made in 24 patients (53.3%), including cancer in three (6.7%): one had microinvasive adenocarcinoma and two had microinvasive squamous cell carcinoma. Squamous carcinoma coexisting with a clinically significant lesion carried a risk of 61.3%, compared with a risk of 35.7% for AGUS alone (P=0.20). Detection of AGUS during cervical cytologic screening, especially with a coexisting ASCUS, indicates the existence of serious pathologic processes; management by cervical colposcopy, endocervical curettage, and cervical biopsy is recommended.

Increased erythrocyte aggregation in ovarian hyperstimulation syndrome: a possible contributing factor in the pathophysiology of this disease.

BACKGROUND: Many theories regarding the pathophysiology leading to ovarian hyperstimulation syndrome (OHSS) have been proposed and tested. Increased erythrocyte aggregation is associated with capillary slow flow and tissue hypoxaemia. We performed this study in order to assess the degree of erythrocyte aggregation in the peripheral blood of individuals with OHSS and undergoing controlled ovarian stimulation (COH). METHODS: Twenty women with severe OHSS, 20 women undergoing COH under IVF protocol, and 20 healthy matched controls were recruited for this prospective study. Blood samples were drawn for determination of erythrocyte aggregation as well as haematological indices. The percentage of slide covered by the cells ('erythrocyte percentage': EP) was determined using a simple slide test and image analysis. Lower EP values correspond to higher degrees of aggregation. RESULTS: The respective measures of EP were 59.2 +/- 3.0, 42.0 +/- 3.0 and 35.0 +/- 2.4% micro m for the controls, women with COH and OHSS (P < 0.01 between controls and the two stimulation groups). CONCLUSIONS: The degree of erythrocyte aggregation is enhanced in the peripheral venous blood of patients with both COH and OHSS. This finding, known to cause capillary leak, may contribute to the pathophysiology of the OHSS.

Spindle imaging: a new marker for optimal timing of ICSI?

BACKGROUND: The LC Polscope facilitates visualization of the meiotic spindle in human oocyte. This study aimed to investigate meiotic spindle assembly in correlation to time elapsed after HCG administration, and to determine whether spindle imaging may serve to indicate the likelihood of fertilization and embryo cleavage. METHODS: Metaphase II (MII) oocytes from 103 couples who were being treated for male infertility were imaged with the Polscope prior to sperm injection. Spindle imaging was correlated to time elapsed from HCG administration, fertilization rate and embryo cleavage. The main outcome measures were spindle visualization, fertilization and embryo cleavage on day 3. RESULTS: A total of 770 MII oocytes were imaged. A spindle was imaged in a significantly higher number of oocytes from >or=38 h after HCG administration compared with those in the <38 h group (78.1-81.5% versus 61.6%; P < 0.001). The fertilization rate in oocytes with a visible spindle was statistically higher compared with oocytes in which spindle could not be detected (70.4% versus 62.2%; P = 0.035). We found no relationship between spindle imaging and embryo cleavage on day 3. CONCLUSIONS: Spindle imaging, in addition to first polar body appearance, is an accurate indicator for oocyte maturity. We suggest that spindle imaging be performed prior to sperm injection.

Nasojejunal feeding in hyperemesis gravidarum--a preliminary study.

Hyperemesis gravidarum is a severe form of nausea and vomiting during the first trimester of pregnancy. Our objective was to assess the feasibility of nasojejunal feeding in our patients. Eleven pregnant women aged 23-46 years with hyperemesis gravidarum, persisting in spite of an in-hospital treatment of 2-15 days by intravenous fluids and antiemetic drugs and accompanied by weight loss, consented to have a nasojejunal feeding tube inserted endoscopically. Mean in-hospital weight loss prior to tube insertion was 2.2+/-1.1 kg (range 0.9-5.1 kg). A clear reduction in the extent of vomiting was already apparent within the first 48 h after tube insertion, but vomiting ceased completely after a mean of 5+/-4 days (range 1-13 days). Weight gain was recorded in six patients who stayed on tube feeding for more than 4 days. Patients were encouraged to start drinking and eating along tube feeding after 3-4 days. Ceasing vomiting and a concomitant sufficient oral intake of at least 1000 kcal/day resulted in the decision to remove the tube after 4-21 days. In three cases, however, the tube was expelled by recurrent vomiting after 1-4 days, or was blocked as in one case. The tube was not reintroduced and patients did not resume vomiting. There were no complications associated with this feeding approach in this population. Only one patient was readmitted. None of the rest resumed vomiting after tube withdrawal.The above suggests that nasojejunal enteral feeding can be an effective option in hyperemesis gravidarum persisting despite intravenous fluids and antiemetic drugs.

Clinical and economic benefit of HPV-load testing in follow-up and management of women postcone biopsy for CIN2-3.

This study aimed to evaluate the clinical and economic implications of integrating human papilloma virus (HPV) load testing into the follow-up and management protocol of women postconisation for high-grade cervical intraepithelial neoplasia (CIN2-3). We evaluated 130 suitable women: 63 were screened biannually by Pap smears ('conventional approach') and 67 also had HPV-load testing ('HPV approach'). More stringent criteria for undergoing colposcopy or reconisation were observed by the former group compared to the latter. Both approaches were analysed for cost effectiveness. There were 33 out of 67 (49.2%) colposcopic referrals and 24 out of 67 (35.8%) reconisation/hysterectomies with the 'conventional approach' compared to 9 out of 63 (14.2%) and 7 out of 63 (11.1%) with the 'HPV approach'. Cervical intraepithelial neoplasia 2-3 residual disease was detected in 7 out of 67 (10.5%) and 7 out of 63 (11.1%) women. The 'conventional approach' had more negative colposcopic biopsies and more negative reconisation/hysterectomy histologies than the 'HPV approach'. The respective cost per detection of one case of residual disease was US$3573 and US$3485. The 'HPV approach' required fewer colposcopic and reconisation procedures to detect one case of residual CIN2-3. Its higher positive predictive value than that of cytology provided a significant decrease in false positive rates and a reduction of US$88 per detected case.

The possible association between in vitro fertilization treatments and cancer development.

The objective of this paper is to assess whether ovarian hyperstimulation and in vitro fertilization (IVF) are associated with increased risk of cancer development, using an historical cohort analysis of infertile women who attended the IVF unit, Lis Maternity Hospital Tel Aviv Medical Center, Tel Aviv, Israel. One thousand and 82 women participated in the IVF treatment program between 1984 and 1992. Cancer incidence rates were determined through the National Cancer Registry and were compared to the expected rates with respect to appropriate age and continent of birth. Twenty-one cases of cancer were observed as compared to 11 that were expected (SIR 1.91; 95% CI 1.18-2.91). When cancer cases that were diagnosed within one year of the IVF treatment were excluded from the analysis (SIR = 1.46; 95% CI 0.83-2.36), no significant excess risk of cancer was noted. We conclude that in this cohort of infertile women, the higher than expected cancer rate could not be attributed to IVF treatments. Special attention should be made to women who may be diagnosed with cancer during or shortly after IVF treatment.

The expression of mannose-ligand receptor is correlated with sperm morphology.

The objective of the present study was to evaluate the association between the expression of sperm mannose-ligand receptors and sperm morphology. Sperm samples were obtained from 45 men, 30 fertile sperm donors and 15 infertile men. Sperm concentration, motility and morphology were evaluated and then incubated with control medium (Ham's F-10 + 1% HSA) for 4 h. Expression of mannose-ligand receptors was evaluated by mannosylated-BSA-FITC (subdivided into 3 patterns: I, for uncapacitated sperm; II, for capacitated; and III, for acrosome-reacted sperm). The mean (+/- SE) frequencies of sperm cells of the total sperm population that expressed patterns I, II, and III were 88 +/- 2.1%, 7 +/- 1.6%, and 5 +/- 0.8%, respectively, for fertile men, and 90 +/- 2.1%, 7 +/- 1.3%, and 3 +/- 0.5%, respectively, for infertile men. The rate of pattern III expression of mannose-ligand receptors was significantly higher in the fertile group compared to the infertile patients (p <.01). A poor but significant correlation was observed between the rate of pattern III and the percentage of normal-forms sperm cell in the ejaculate (r =.35, p =.018). Fertile sperm samples express more advanced patterns of mannose-ligand receptors compared to infertile men. This phenomenon is related to the morphology of human sperm cell in the ejaculate more than to any other basic sperm characteristics.

Probability of sperm detection in nonobstructive azoospermic men undergoing testicular sperm extraction procedures unrelated to clinical parameters.

The study was conducted to evaluate the significance of preoperative clinical parameters for detection of mature testicular sperm cells in nonobstructive azoospermic men. Sixty-five consecutive men with nonobstructive azoospermia underwent testicular sperm extraction procedures. Testicular samples were analyzed histologically with patterns classified as mature spermatogenesis (normal or partial), arrest of spermatogenesis, and Sertoli cell only. Testicular sperm cells were isolated for use in an IVF/ICSI program. Histologic patterns and detection rate of sperm cells were correlated to clinical characteristics. Mature sperm cells were found in all levels of serum FSH. The men were divided into 3 groups based on their clinical characteristics (serum FSH level and testicular size). The distribution of the different testicular histologic patterns, as well as detection rate of sperm cells, was similar in all groups. No correlation was found between serum levels of FSH, LH, prolactin, or testosterone and sperm presence. None of these parameters, nor the testicular size and consistency, can serve as predictive variables of the histological pattern or the presence of mature sperm cells in the testicular biopsies in cases of nonobstructive azoospermia. Until an effective predictive tool is available, a trial of sperm retrieval is recommended for all azoospermic men independent of their clinical characteristics.

Prediction of fetal weight by ultrasound: the contribution of additional examiners.

OBJECTIVES: To assess the contribution of additional examiners to: the average discrepancy between estimated and actual fetal weights; the correlation between estimated and actual fetal weights; the reduction in major (> 10%) discrepancies between estimated and actual fetal weights. DESIGN: Three experienced sonographers independently measured fetal biparietal diameter, head circumference, abdominal circumference and femur length in 39 fetuses at term. The estimated fetal weights were calculated for each examiner. Fetal biometric measurements were analyzed to obtain the source of differences in estimations among the examiners. Discrepancy, correlation and number of major (> 10%) discrepancies between the estimated and actual fetal weights were calculated for each examiner, and the contribution of additional examiners was analyzed. RESULTS: The differences in measurements of the biparietal diameter and femur length were lower than those of the head and abdominal circumferences. For each of the three examiners, the average discrepancy between the estimated and actual fetal weights was 6.1%, 5.9% and 6.3%. When the estimation was based on two examiners, the discrepancy decreased to 4.8-5.6%. The contribution of a third examiner was nil. Major (> 10%) discrepancies between estimated fetal weight and actual birth weight were found in seven, eight and nine estimations of the examiners. Estimation by two examiners decreased the number of major discrepancies, and estimation by all three examiners further decreased by approximately 50% the number of major discrepancies between the estimated and actual fetal weights. CONCLUSION: Measurements by multiple examiners changes only slightly the average number of discrepancies between estimated and actual fetal weights. However, the reduction in major (> 10%) discrepancies is statistically and clinically significant.