The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel.

AIM: The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs). METHOD: Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis. RESULTS: In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005). CONCLUSION: The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

A prospective, randomized, controlled study comparing Gynemesh, a synthetic mesh, and Pelvicol, a biologic graft, in the surgical treatment of recurrent cystocele.

We compared safety and efficacy of Gynemesh PS and Pelvicol for recurrent cystocele repair. One hundred ninety patients were randomly divided into Gynemesh PS and Pelvicol groups and underwent tension-free cystocele repair. The Chi-square test was used to compare categorical variables, the paired t test for continuous parametric variables, and the Mann-Whitney test for continuous nonparametric variables. Ninety-six Gynemesh PS patients and 94 Pelvicol patients were studied. Mesh erosions occurred in 6.3% of Gynemesh PS patients. No erosions were observed in Pelvicol patients (p = 0.02). Objective cure was 71.9% for Gynemesh PS and 56.4% for Pelvicol (p = 0.06). Subjective cure was the same in both groups except for better sexuality in the Pelvicol group. At 24 months follow-up, only Gynemesh PS patients had mesh erosions. Anatomical outcome was similar in the two groups. Pelvicol gave a better impact on voiding and sexuality.

A combined intravesical therapy with hyaluronic acid and chondroitin for refractory painful bladder syndrome/interstitial cystitis.

The aims of this study were to evaluate the efficacy and tolerability of intravesical instillations of high-molecular-weight hyaluronic acid (HA) 1.6% and chondroitin sulfate (CS) 2.0% in patients with refractory painful bladder syndrome/interstitial cystitis (PBS/IC) and to observe their impact on Quality of Life. Twenty-three women were enrolled. They received bladder instillations with HA and CS weekly for 20 weeks and then monthly for 3 months. Mean follow-up after completion of therapy was 5 months. We observed a significant improvement in urinary symptoms on voiding diaries and Visual Analogue Scale for frequency (p = 0.045), urgency (p = 0.005), and pain (p = 0.001). The O'Leary-Sant Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index resulted in a significant improvement in both scores (p = 0.004 and 0.01, respectively). The Pelvic Pain and Urgency/Frequency Symptom Scale only showed significant improvement in the symptom score (p = 0.001). This promising experience seems to offer an additional therapeutic option in patients with refractory PBS/IC.

Effect of sex hormone administration on circulating ghrelin levels in peripubertal children.

BACKGROUND: Ghrelin levels gradually decrease throughout childhood and with advancing pubertal stage. The change during puberty is more pronounced in boys than girls. OBJECTIVE: The objective of the study was to investigate whether the pubertal drop in ghrelin secretion is modified by the increase in sex hormones. PATIENTS AND METHODS: Ghrelin levels were measured in 34 short peripubertal children (17 boys and 17 girls) aged 8-12.5 yr before and after sex hormone priming for GH stimulation testing. RESULTS: In boys, priming with testosterone increased testosterone to pubertal levels (23.7 +/- 7.1 nmol/liter), which in turn induced a marked decrease in ghrelin (from 1615.8 +/- 418.6 to 1390.0 +/- 352.0 pg/ml) and leptin (from 8.0 +/- 4.5 to 5.8 +/- 3.2 ng/ml) and an increase in IGF-I (from 162.7 +/- 52.8 to 291.1 +/- 101.6 ng/ml) (P < 0.001 for all parameters). In girls, priming with estrogen led to a supraphysiological increase in estradiol levels (1313.8 +/- 438.0 pmol/liter), which had no effect on ghrelin, leptin, or IGF-I. There was no correlation between ghrelin levels and levels of sex hormones, leptin, or body mass index in either boys or girls. CONCLUSIONS: A pharmacological increase in sex hormones is associated with a marked decline in circulating levels of ghrelin in boys but not girls. Additional longitudinal studies through puberty are needed to elucidate the physiological interaction between sex hormones and ghrelin.

Transvaginal ultrasound and diagnostic hysteroscopy as a predictor of endometrial polyps: risk factors for premalignancy and malignancy.

The aim of this study is to assess accuracy of transvaginal ultrasound (TVUS) and diagnostic hysteroscopy in diagnosing endometrial polyps and to determine premalignancy and malignancy rates in asymptomatic women. The study was designed to retrospectively analyze 438 women who underwent operative hysteroscopy in a day-care unit when endometrial polyp was suspected after TVUS and diagnostic hysteroscopy. Multivariate logistic regression modeling showed effects of age, previous breast cancer with tamoxifen treatment, and menopause with or without bleeding on pathologic results. The results indicate that positive predictive value of TVUS with diagnostic hysteroscopy was 79.9%. Premalignancy or malignancy occurred in 3.2% and was significantly related to menopause with abnormal bleeding (P < 0.001), which carried a 20-fold higher risk of pathology than any other group. Age was also a risk factor. It was concluded that TVUS with diagnostic hysteroscopy reliably evaluates endometrial polyps. The low incidence of endometrial tumors in asymptomatic (especially premenopausal) women suggests that their operative evaluation may not be cost effective. Larger studies are needed to support this tentative conclusion.

A model for disclosing the first trimester part of an integrated Down's syndrome screening test.

This study was designed to evaluate a model for disclosing the first part of an integrated Down's syndrome (DS) test without affecting its low false-positive results. Parturient women underwent sequential DS-screening tests. They included nuchal translucency (NT) and biochemistry assessments in the first trimester and a mid-gestation triple test. Although screening tests results were given following each test, fetal karyotyping was performed by means of mid-gestation amniocentesis. The proposed approach for disclosure refers to either (a) cases picked by a statistical model (this is based on a logistic regression analysis and a receiver-operated curve that was set to a specificity of 100% of first-trimester markers pointing on at very high probability of aneuploidy) or (b) cases demonstrating a first trimester DS risk > or = 1 : 40 (a threshold level at which the integrated test results will always be screen positive). The results of the sequential screening and pregnancy outcome were available for 372 normal and 22 chromosomal affected singletons. NT and pregnancy-associated placental protein A emerged as the most sensitive marker combination. The statistical model picked up seven of 22 abnormal cases (32%), and a first-trimester DS risk > or = 1 : 40 was detected in 11 (50%) (there was an overlap of five cases). The combined strategy yields a 60% detection rate (13/22) of the affected pregnancies and without any increase in the false-positive results. This can be achieved immediately following the first part of the integrated DS test. This model obviates the ethical, clinical, and financial implications of further assessing about 60% of the affected pregnancies.

Nuchal translucency measurements in consecutive normal pregnancies. Is there a predisposition to increased levels?

OBJECTIVE: The current study aims to assess the relative risk of isolated increased nuchal translucency (NT) in consecutive normal pregnancies. METHODS: A retrospective search of the fetal medicine unit database in which NT assessment was conducted. Only singleton fetuses with an unremarkable pregnancy outcome were included in this study. The repeated NT either at a threshold of >2.5 mm or > or =95th centile of the normal range for various CRLs (2 mm at a CRL < or =44 mm to 2.85 mm at CRLs 83-84 mm) was assessed. Pearson's correlation was applied to investigate any correlation between a log(10) NT obtained in two consecutive pregnancies. The chance of an increased NT in the first pregnancy followed by similar results in the subsequent one was assessed using Fisher's exact test. RESULTS: Ninety-two pregnant women with two consecutive normal pregnancies were identified. There was a highly significant correlation between the log(10) NT values measured in the consecutive pregnancies (r = 0.38; p < 0.001). The relative risk of an isolated NT > or =2.5 mm in the first pregnancy to be followed by a similar finding in the subsequent one was 18.21 (95% confidence interval [CI]: 3.62-91.55). The relative risk of an isolated NT > or =95th centile in the first pregnancy to be followed by a similar result in the subsequent one was 21 (95% CI: 4.53-97.44). CONCLUSION: The current results indicate a significant correlation of NT values in consecutive unaffected pregnancies. There also was a predisposition for a repeated isolated increased NT in subsequent pregnancies. Additional series and more information are needed before firm conclusions can be made.

Prediction of pregnancy outcome in subgroups of women with renal disease.

BACKGROUND: The preconception and intraconception parameters that are relevant to outcome in women with underlying renal disease remain controversial. SUBJECTS, MATERIALS AND METHODS: We analyzed the types and frequencies of short- and long-term (2 years after delivery) maternal and neonatal complications in 38 patients with primary renal disease (46 pregnancies), 24 IDDM patients with diabetic nephropathy (24 pregnancies), and 27 patients with a functioning renal allograft (42 pregnancies), most of them with mild renal insufficiency. Logistic regression models were formulated to predict successful outcome. RESULTS: Successful pregnancy outcome (live, healthy infant without severe handicap 2 years after delivery) was observed in 98% of the patients with primary renal disease, 96% of the IDDM patients with diabetic nephropathy, and 89% of the patients with a functioning renal allograft. Factors found to be significantly predictive of successful outcome were absence of preexisting hypertension in all groups, in addition to low preconception serum uric acid level in the primary renal disease patients, and long interval from transplantation to conception and use of a low dose ofprednisone in the renal transplant patients. CONCLUSION: Most women with different subtypes of renal disease have a successful pregnancy outcome with proper prenatal care. Worse pregnancy outcome was observed in women with moderate or severe renal failure. Fitted logistic models may provide useful guidelines for counseling women with preexisting renal disease about their prospects for a successful pregnancy in terms of immediate and long-term maternal and neonatal outcome.

White coat hypertension and pregnancy outcome.

The presence and outcome effect of white coat hypertension in pregnancy was determined with 24-h ambulatory blood pressure (BP) monitoring. Sixty women presenting with high clinic BP (>/=140/90 mm Hg) in the second trimester were included. Patients were divided into two groups based on daytime ambulatory BP findings: <135/85 mm Hg, white coat hypertension (n = 37); >/=135/85 mm Hg, 'true' hypertension (n = 23). Complicated pregnancy outcome was defined as the presence of pre-eclampsia and/or intrauterine growth restriction. Groups were compared for pregnancy outcome and for background and delivery factors. The predictive value of ambulatory BP measurements for pregnancy outcome was determined. Pregnancy outcome was better in the white coat hypertension group than in the true hypertension group: pre-eclampsia-3 (8.1%) vs 13 (56.5%) (P = 0.0046); intrauterine growth restriction-5 (13.5%) vs 10 (43.4%) (P = 0. 0139); and preterm delivery-11 (29.7%) vs 15 (65.2%) (P = 0.015). Night-time ambulatory BP measurements were the best predictor of complicated pregnancy, followed by daytime and 24-h measurements. We conclude that second trimester ambulatory BP monitoring can be used to differentiate patients who have white coat hypertension, which is associated with a better pregnancy outcome than true hypertension.

The effect of low-dose aspirin treatment on biochemical markers in pregnant hypertensive patients.

We evaluated the known metabolic effects of aspirin in pregnant hypertensive patients. Eighty-seven pregnant women (12th-24th gestational week) were randomly allocated to low-dose aspirin or placebo treatment. Between the 24th-28th gestational week the following tests were performed: oral glucose tolerance test, venous blood pH and base excess, coagulation profile, platelet count, morning (8 a.m.) cortisol, creatinine clearance and serum uric acid. A significantly higher serum uric acid level was detected in the low-dose aspirin group (5.6±2.2 mg/dl) compared with the placebo group (4.7±1.2 mg/dl, p=0.048). No other significant difference was found for any of the other parameters tested. We conclude that low-dose aspirin treatment during the second half of pregnancy in hypertensive patients seems safe in terms of its effect on various maternal metabolic effects.