Surgical Treatment of Bartholin's Gland Abscess: Is Word Catheter Superior to Marsupialization?

STUDY OBJECTIVE: Bartholin's gland abscess may occur in up to 2% of the women. Surgical drainage using the Word catheter application or marsupialization is the treatment of choice in the management of Bartholin's gland abscess. We aimed to compare the abscess recurrence rates between these 2 surgical methods. DESIGN: A retrospective cohort database study. SETTING: A university-affiliated, high-volume teaching hospital in southern Israel. PATIENTS: All women who were surgically treated for Bartholin's gland abscess. INTERVENTIONS: Different clinical and postoperative characteristics were retrieved from the patients' records. A univariate analysis was conducted, and p <.05 was considered significant. MEASUREMENTS AND MAIN RESULTS: During the study period, 321 women were admitted to our center with Bartholin's gland abscess and were managed surgically. Of these, 215 (67%) were treated using the Word catheter and 106 (33%) by drainage and marsupialization. No differences were found in clinical and microbiologic features between the study groups. In addition, recurrence rates as well as recurrent admissions did not differ significantly. Postoperative complications were similar between the groups. CONCLUSION: Our study reassures that both the Word catheter application and marsupialization are appropriate and safe when treating Bartholin's gland abscess.

Clinical and microbiological features of Bartholin's gland abscess in pregnant and non-pregnant women.

OBJECTIVE: The data regarding microbiological and clinical characteristics of Bartholin gland abscesses during pregnancy is limited. Given the hormonal and physiological changes during pregnancy we aimed to examine whether a difference exists in the clinical and microbiological features of Bartholin's gland abscess during pregnancy and the puerperium as compared with nonpregnant patients. In addition, we aim to evaluate whether a Bartholin's gland abscess during pregnancy is associated with adverse pregnancy outcomes. STUDY DESIGN: A retrospective cohort study was conducted, including all women with Bartholin's gland abscess who were treated surgically between the years 2009-2016 in the Soroka University Medical Center. Various demographic, clinical and microbiological characteristics were retrieved and a comparison was made between patients with a Bartholin's gland abscess during pregnancy and the puerperium (study group) as compared with nonpregnant patients (controls). In addition, obstetrical characteristics of patients in the study group were retrieved. RESULTS: Of the 363 women who were treated surgically, 38 (10.5%) were in the study group. Women in the study group were significantly younger (26.8 versus 32.8 p < .001). No differences were found between the groups with regard to the clinical presentation (affected side, fever, leukocytosis and need for antimicrobial treatment) or the selected mode of drainage. In addition, no difference was found in the percentage of positive culture results, nor in the distribution of the pathogens between the groups, in both groups the most common pathogen was Escherichia coli. Yet, among the study group, recurrence of the abscess was more common (13.5 versus 2.15% p = -.067) as evident by significantly higher recurrent referrals to the emergency department and recurrent hospitalizations (28.9 versus 14.8%, p < .05, and 26.3 versus 8.0% p < .001, respectively). Of note, fever after the procedures, pain, discharge and bleeding did not differ significantly between groups. No cases of premature rupture of membranes or chorioamnionitis were noted following treatment. CONCLUSIONS: In our cohort, no differences were found between the study groups in the clinical presentation and microbiological features. A significantly higher recurrence rate was noted in the study group. Among pregnant patients no adverse perinatal outcomes were noted.

Risk factors associated with recurrent referral to the emergency room following surgical treatment of Bartholin's gland abscess.

There is no consensus regarding the best surgical modality for the treatment of Bartholin's gland abscess. The aim of the study was to evaluate the risk factors associated with the recurrent referral of the emergency room (ER) following surgical treatment for a Bartholin's gland abscess. A retrospective cohort study was done. Clinical and microbiological characteristics were retrieved from the patients' hospital records. A univariate analysis was followed using multiple logistic regression model. During the study period, 320 women were managed surgically, of those 54 (37.0%) had had a recurrent referral to the ER. The rate of positive previous cultured abscesses was significantly higher among patients with a recurrent referral to the ER (66.7% vs. 51.3%, p value < .05). The mode of a previous abscess drainage (Word catheterisation or marsupialisation) was not associated with recurrent referral to the ER or with recurrent hospitalisation. The possible association between positive cultures and recurrence warrants re-consideration of routine antimicrobial administration for Bartholin's gland abscess.IMPACT STATEMENTWhat is already known on this subject? A recurrence of a Bartholin's gland abscess following surgical treatment varies greatly and there is no consensus regarding the best surgical modality for treatment. None of the studies have examined a recurrent referral to the emergency room (ER) as a primary outcome.What do the results of this study add? Our study strengthens previous studies and reassures that recurrence is not associated with surgical modality. Specifically, a recurrent referral to the ER and hospitalisation were not found to be associated with surgical modality, both which may be attributed to various reasons other than the recurrence of the abscess. An association was found between positive culture results and a recurrent referral to the ER.What are the implications of these findings for clinical practice and/or further research? The association found that positive results warrant further larger studies in order to determine which of the patients may benefit from antibiotic treatment in addition to the surgical treatment.

Effectiveness and safety of late midtrimester cervical cerclage.

Objectives: To evaluate the safety and effectiveness of late cervical cerclage performed beyond 17 weeks of gestation. The outcomes of interest were effectiveness of late cerclage in prolongation of pregnancy and evaluation of pregnancy outcome including maternal and fetal complications. Study design: A total of 30 patients underwent late cervical cerclage during the study period. Of them, two were twin pregnancies. A late cerclage was performed after the diagnosis of cervical shortening or dilatation in 20 patients. We performed a retrospective case series review. One case was lost to follow up (delivery in another medical center). Medical information was retrieved from all cases of patients who underwent a late cervical cerclage between the years 2010 and 2016 at the Soroka University Medical Center, a tertiary medical center. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as proportions. Results: The average gestational age at birth was 35 ± 5.1 weeks of gestation. The mean interval between cerclage and delivery in the study population was 17 ± 5.62 weeks. Nine cases (32.1%) resulted in preterm deliveries, three of them below 34 weeks of gestation (one twin pregnancy and two pregnancies diagnosed with cervical dilation prior to cerclage). Among all the preterm deliveries, there were four cases of preterm prelabor rupture of membranes (13.3%). Of the 28 deliveries, 24 women (85.7%) had a vaginal delivery, while four women (14.3%) underwent a cesarean section. No cases of cervical tear were described. The cerclage was sent to bacteriology after removal, showing positive cultures for Candida species in nine cases (31%). Conclusions: In our study population, late cervical cerclage was found to be a safe procedure resulting in almost 90% of successful vaginal deliveries without maternal or fetal complications. This procedure might be effective in the prolongation of pregnancy in women with cervical dynamics in the late second trimester.

Clinical and microbiological characteristics of Bartholin gland abscesses.

OBJECTIVE: To examine the clinical course and causative microorganisms of Bartholin gland abscesses. METHODS: This was a retrospective study of all patients treated for Bartholin gland abscesses between the years 2006 and 2011 at the Soroka University Medical Center, a regional medical center in southern Israel. RESULTS: During the study period, 219 women were admitted as a result of an abscess of the Bartholin gland, 63% of which were primary abscesses and 37% recurrent abscesses (occurrence of a second clinical event). Pus cultures were positive in 126 (61.8%) of cases. Escherichia coli was the single most frequent pathogen found (43.7%) and 10 cases (7.9%) were polymicrobial. Culture-positive cases were significantly associated with fever (25% compared with 9.3%; P=.043), leukocytosis (50.4% compared with 33.8%; P=.027), and neutrophilia (17.9% compared with 5.9%; P=.021). The odds ratio of having any of these with a positive culture was 2.4 (95% confidence interval 1.3-4.3; P=.003). In the recurrent group, 81% recurred ipsilaterally and the mean time for recurrence was 32 ± 50 months. Infection with E coli was significantly more common in recurrent infection compared with primary infections (56.8% compared with 37%; P=.033). Three cases of resistance to most beta-lactam antimicrobials (extended-spectrum beta-lactamase-producing [E coli] strains) were identified. CONCLUSION: A substantial proportion of patients with Bartholin gland abscess are culture-positive with E coli being the single most common pathogen. Microbiological findings coupled with their clinical correlates are important parameters in the management of patients with a Bartholin gland abscess and in the selection of empirical antimicrobial treatment during the primary diagnosis. LEVEL OF EVIDENCE: : III.

Cannabidiol changes P-gp and BCRP expression in trophoblast cell lines.

Objectives. Marijuana is the most commonly used illicit drug during pregnancy. Due to high lipophilicity, cannabinoids can easily penetrate physiological barriers like the human placenta and jeopardize the developing fetus. We evaluated the impact of cannabidiol (CBD), a major non-psychoactive cannabinoid, on P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP) expression, and P-gp function in a placental model, BeWo and Jar choriocarcinoma cell lines (using P-gp induced MCF7 cells (MCF7/P-gp) for comparison). Study design. Following the establishment of the basal expression of these transporters in the membrane fraction of all three cell lines, P-gp and BCRP protein and mRNA levels were determined following chronic (24-72 h) exposure to CBD, by Western Blot and qPCR. CBD impact on P-gp efflux function was examined by uptake of specific P-gp fluorescent substrates (calcein-AM, DiOC2(3) and rhodamine123(rh123)). Cyclosporine A (CsA) served as a positive control. Results. Chronic exposure to CBD resulted in significant changes in the protein and mRNA levels of both transporters. While P-gp was down-regulated, BCRP levels were up-regulated in the choriocarcinoma cell lines. CBD had a remarkably different influence on P-gp and BCRP expression in MCF7/P-gp cells, demonstrating that these are cell type specific effects. P-gp dependent efflux (of calcein, DiOC2(3) and rh123) was inhibited upon short-term exposure to CBD. Conclusions. Our study shows that CBD might alter P-gp and BCRP expression in the human placenta, and inhibit P-gp efflux function. We conclude that marijuana use during pregnancy may reduce placental protective functions and change its morphological and physiological characteristics.

Cannabidiol enhances xenobiotic permeability through the human placental barrier by direct inhibition of breast cancer resistance protein: an ex vivo study.

OBJECTIVE: Drugs of abuse affect pregnancy outcomes, however, the mechanisms in which cannabis exerts its effects are not well understood. The aim of this study was to examine the influence of short-term (1-2 hours) exposure to cannabidiol, a major phytocannabinoid, on human placental breast cancer resistance protein function. STUDY DESIGN: The in vitro effect of short-term exposure to cannabidoil on breast cancer resistance protein in BeWo and Jar cells (MCF7/P-gp cells were used for comparison) was tested with mitoxantrone uptake, and nicardipine was used as positive control. The ex vivo perfused cotyledon system was used for testing the effect of cannabidoil on glyburide transport across the placenta. Glyburide (200 ng/mL) was introduced to maternal and fetal compartments through a recirculating 2 hour perfusion, and its transplacental transport was tested with (n = 8) or without (n = 8) cannabidoil. RESULTS: (1) Cannabidoil inhibition of breast cancer resistance protein-dependent mitoxantrone efflux was concentration dependent and of a noncell type specific nature (P < .0001); (2) In the cotyledon perfusion assay, the administration of cannabidoil to the maternal perfusion media increased the female/male ratio of glyburide concentrations (1.3 ± 0.1 vs 0.8 ± 0.1 at 120 minutes of perfusion, P < .001). CONCLUSION: (1) Placental breast cancer resistance protein function is inhibited following even a short-term exposure to cannabidoil; (2) the ex vivo perfusion assay emphasize this effect by increased placental penetration of glyburide to the fetal compartment; and (3) these findings suggest that marijuana consumption enhances placental barrier permeability to xenobiotics and could endanger the developing fetus. Thus, the safety of drugs that are breast cancer resistance protein substrates is questionable during cannabis consumption by pregnant women.

Saturated fatty acid composition of human milk in Israel: a comparison between Jewish and Bedouin women.

BACKGROUND: Breast milk is well established as the ideal source of nutrition for infants. Mature human breast milk generally contains 3.5-4.5% lipids comprising mostly triacylglycerols. In general, the fat composition of maternal human milk in developing countries shows higher levels of saturated fats, reflecting diets rich in carbohydrates. OBJECTIVES: To determine the profile of unsaturated fatty acids in the breast milk of two populations in southern Israel--urban Jewish and rural tent-dwelling Bedouin women. METHODS: This study involved 48 lactating Israeli mothers, 29 Jewish and 19 Bedouin (16-20 weeks postpartum), whose full-term infants were fed exclusively with breast milk. Total milk lipid extracts were transmethylated and analyzed by using an improved gas chromatographic method. RESULTS: The breast milk of the Bedouin women contained significantly higher levels of total major saturated fatty acids, lauric acid and palmitic acid (45.2 +/- 4.7% vs. 41.0 +/- 5.6%, P = 0.005; 5.2 +/- 2.1 vs. 6.8 +/- 2.0%, P = 0.03; and 22.7 +/- 2.4 vs. 20.6 +/- 3.8%, P = 0.02) respectively. No difference was found in the myristic acid level between the groups. The level of stearic acid was significantly higher in the Jewish group compared to the Bedouin group (5.7 +/- 1.1 vs. 5.1 +/- 1.1%, P = 0.04). There was a linear correlation between the levels of C14:0 and C12:0 in the Bedouin and lewish groups respectively (R = 0.87, R = 0.82, P < 0.001). CONCLUSIONS: Higher levels of saturated fatty acids were measured in the breast milk of Bedouin women, an economically weaker population. The results emphasize the importance of diet among lactating women and its influence on milk quality.

Defensive medicine among obstetricians and gynecologists in tertiary hospitals.

OBJECTIVE: To describe the daily work practice under the threat of defensive medicine among obstetricians and gynecologists. STUDY DESIGN: A prospective cross-sectional survey of obstetricians and gynecologists working at tertiary medical centers in Israel. RESULTS: Among the 117 obstetricians and gynecologists who participated in the survey, representing 10% of the obstetricians and gynecologists registered by the Israel Medical Association, 113 (97%) felt that their daily work practice is influenced by concern about being sued for medical negligence and not only by genuine medical considerations. As a result, 102 (87%) physicians are more likely to offer the cesarean section option, even in the absence of a clear medical indication, 70 (60%) follow court rulings concerning medical practices, and 85 (73%) physicians mentioned that discussions about medical negligence court rulings are included in their departments' meetings. CONCLUSIONS: Defensive medicine is a well-embedded phenomenon affecting the medical decision process of obstetricians and gynecologists.

"Habitual adnexal torsions"--recurrence after two oophoropexies in a prepubertal girl: a case report and review of the literature.

BACKGROUND: Recurrent adnexal torsion rarely affects girls. Various surgical techniques for its prevention are available. We describe a case of recurrent asynchronous bilateral torsions in a prepubertal patient. CASE: An 8-year-old girl first presented with a right adnexal torsion and underwent a laparoscopic untwisting. During the following 3 years, 4 additional laparoscopies were required for treatment of left adnexal torsions. Although undergoing bilateral utero-ovarian ligament plication twice, torsion recurred. After examining the various options, we fixated the left ovary to the sidewall just below the pelvic brim. SUMMARY AND CONCLUSION: In the absence of clear evidence, treatment should be flexible and dependent on the individual case. Thorough patient education is imperative in order to prevent a delay in diagnosis and treatment of recurrent adnexal torsion.

Morbidity with total laparoscopic and laparoscopically assisted vaginal hysterectomy.

We evaluated the operative and postoperative morbidity among 103 women who underwent total laparoscopic hysterectomy and 107 others who underwent laparoscopically assisted vaginal hysterectomy. Blood loss was significantly greater in the assisted vaginal hysterectomy group (178.0 ± 12.1 ml) than in the total hysterectomy group (130.2 ± 10.7 ml) (p < 0.001). Despite higher uterine weight in the total hysterectomy group, the operative time of both techniques was similar. The complications of both hysterectomies were also comparable. The results from our study suggest that the complication rates of laparoscopically assisted vaginal hysterectomy and total hysterectomy are similar. However, laparoscopically assisted vaginal hysterectomy is associated with increased blood loss.

Difference between serum beta-human chorionic gonadotropin levels in pregnancies after in vitro maturation and in vitro fertilization treatments.

OBJECTIVE: To compare ß-hCG levels measured as the first pregnancy test in women who conceived after in vitro maturation (IVM) or IVF. DESIGN: Retrospective matched cohort analysis. SETTING: University-based medical center. PATIENT(S): Women treated with IVM or IVF. INTERVENTION(S): We studied the first serum ß-hCG levels in 104 pregnant women who were successfully treated with IVM and in another 104 women with IVF treatment. Blood samplings for ß-hCG were drawn on day 12-15 after ET. The two groups were matched by age, order of pregnancy, and day of blood sampling. MAIN OUTCOME MEASURE(S): First ß-hCG levels. RESULT(S): Serum ß-hCG levels on days 12 to 13 after ET of IVM viable singleton pregnancies were significantly higher than those of IVF pregnancies (343.2±48.4 vs. 264.0±29.2 IU/L, 95% confidence interval [CI] 22-229). Similarly, ß-hCG levels on days 14 to 15 after ET of IVM viable singleton pregnancies were higher than those of IVF pregnancies (350.1±126.4 vs. 284.4±30.2 IU/L). Similar trends were found in ß-hCG levels on days 12 to 13 after ET of twin viable pregnancies (IVM, 682.1±97.7 vs. IVF, 434.5±41.8 IU/L; 95% CI 44-662). Grouped linear regression with covariance analysis showed a significant difference between IVM and IVF regression lines. CONCLUSION(S): The first serum ß-hCG levels in pregnancies after IVM are consistently higher than those after IVF treatment. More studies are needed to elucidate these findings.

Effects of ovarian endometrioma on the number of oocytes retrieved for in vitro fertilization.

OBJECTIVE: To evaluate the effects of ovarian endometrioma on the number of oocytes retrieved for IVF. DESIGN: Retrospective case control study. SETTING: University-based tertiary medical center. PATIENT(S): We studied 81 women with unilateral endometrioma who underwent their first IVF cycle. INTERVENTION(S): Oocyte collection. MAIN OUTCOME MEASURE(S): The numbers of antral follicles and the retrieved oocytes in the ovary that contained endometrioma were compared with those from the contralateral ovary. Antral follicle count and the total number of oocytes retrieved from these women then were compared with those in 162 age-matched women with no endometrioma or endometriosis, who also underwent the first IVF treatment cycle. RESULT(S): There was no significant difference in the number of antral follicles and oocytes retrieved in the endometrioma-containing ovary (6.0 ± 0.4 and 7.7 ± 1.0, respectively) and in the opposite ovary (6.1 ± 0.5 and 8.5 ± 0.9, respectively). There was no correlation between the size and the number of endometriomas with the number of retrieved oocytes. Antral follicle count and the number of retrieved oocytes in these women (15.0 ± 1.6 and 11.9 ± 0.8) were similar to those in women with no endometrioma (14.2 ± 1.4 and 11.4 ± 0.5, respectively). CONCLUSION(S): The presence of ovarian endometrioma in a controlled ovarian hyperstimulation cycle for IVF treatment is not associated with a reduced number of oocytes retrieved from the affected ovary.

Effect of different types of ovarian cyst on antral follicle count.

We compared antral follicle count in ovaries harboring different types of cysts to the contralateral normal ovaries. Besides endometrioma, the presence of other types of ovarian cysts does not influence the antral follicle count.

Effects of excision of ovarian endometrioma on the antral follicle count and collected oocytes for in vitro fertilization.

We compared the response of operated and nonoperated ovaries to gonadotropin stimulation in 38 women who had had excision of ovarian endometrioma. The antral follicle count, numbers of dominant follicles, and number of oocytes collected in the operated ovaries were significantly lower than in the nonoperated ovaries suggesting reduced ovarian reserve after excision of ovarian endometrioma.

Progesterone levels in cesarean and normal delivered term placentas.

BACKGROUND: One of the most important hormones synthesized by the placenta during pregnancy is progesterone. The regulating mechanisms of progesterone synthesis and the mechanism responsible for the spontaneous onset of labor in women are still not fully understood. Progesterone is thought to have been involved in human parturition. The objective of this study was to compare the levels of progesterone in the human placentas, at the end of the gestation (37-41 weeks) in vaginal versus cesarean deliveries, and to evaluate the pattern of progesterone accumulation, instantly following its synthesis by the human placenta at the end of the pregnancy. METHODS: Progesterone levels in human placental tissue were determined by immunochemiluminescent analysis, following tissue homogenization. Progesterone secretion and accumulation pattern in the placental tissue was demonstrated using the ex vivo, closed, dual perfusion system of isolated human placental cotyledon. RESULTS: Immunochemiluminescent analysis of progesterone levels in human normal and cesarean-delivered placentas showed that placentas following normal vaginal delivery store higher concentrations of progesterone, and produce progesterone more intensively. Results obtained from 120-min perfusions (of vaginal and cesarean-delivered placentas) showed that progesterone tended to accumulate in the maternal rather than the fetal compartment. CONCLUSIONS: These data indicate that progesterone levels continuously rise till the end of pregnancy, with no apparent drop in progesterone levels during the labor process. In addition, progesterone is released from the syncytiotrophoblast preferably into the maternal component of the placental tissue.

A significant linear association exists between nuchal translucency thickness and adverse perinatal outcome in euploid fetuses.

OBJECTIVE: Evaluating the correlation between the nuchal translucency (NT) measurement throughout its range of values independent of gestational age, and adverse pregnancy outcome: in euploid structurally normal fetuses. METHODS: A prospective observational study was conducted in which NT measurements were made in consecutive singleton euploid fetuses derived from an unselected pregnant population. Pregnancies terminated before the 22nd gestational week, and those with major malformations (diagnosed before or after delivery) were excluded from the analysis. We evaluated the linear association between NT thickness and selected obstetric outcomes. RESULTS: A total of 2205 euploid singleton fetuses were evaluated during the study period. Significant linear-by-linear association was documented between the NT measurement and perinatal mortality (p < 0.001). Thicker NT was significantly associated with diabetes (either gestational or pre-gestational) (p = 0.013). CONCLUSIONS: A linear association exists between NT thickness in chromosomally and structurally normal fetuses, and the risk for gestational diabetes and perinatal mortality.

Three dimensional ultrasound diagnosis of caudal regression syndrome at 14 gestational weeks.

Caudal regression syndrome (CRS) is a rare complex abnormality, characterized by agenesis of the sacrum and lumbar spine, with lower limb neurological deficit and accompanying deformities of the pelvis, lower extremities, genitourinary, gastrointestinal and cardiac systems. Pregnancies complicated by insulin treated diabetes carry higher risk of fetal CRS than non-diabetic pregnancies. Three dimensional (3D) and four dimensional (4D) ultrasound may assist in early detection of CRS. We report a case of CRS diagnosed by 3D and 4D ultrasound examination at 14 weeks of gestation in a diabetic patient.