Termination of pregnancy due to fetal central nervous system abnormalities performed after 24 weeks' gestation: survey of 57 fetuses from a single medical center.

PURPOSE: To assess fetal central nervous system (CNS) abnormalities presenting as major findings leading to late termination of pregnancy (late TOP) performed ≥ 24 weeks' gestation. METHOD: The study population included 2789 pregnant women that underwent late TOP in our institute between the years 1998 and 2015. RESULTS: Fifty-seven cases (2.0%) underwent late TOP because of fetal CNS indications and are the subjects of the current study. Those cases were subdivided into four categories (1) no routine prenatal screening with an incidental finding discovered ≥ 24 weeks' gestation (25 patients, 43.8%); (2) developmental or acquired findings detected during late second and third trimester (22 patients, 38.6%); (3) apparently normal routine screening with abnormal findings that could have been detected earlier (six patients, 10.6%); (4) routine prenatal care raised suspicion of abnormalities, and the final diagnosis was established only following additional tests (four patients, 7.0%). CONCLUSIONS: Combining the two categories of CNS abnormalities, i.e., pregnant women who did not undergo any fetal evaluation (group 1) and those that could have been detected earlier (group 3) consists 54% from our cohort in which late TOP could have been avoided. On contrary, 39% fetuses from our study population had CNS developmental findings which could be detected only at advanced stage of gestation.

Evaluation of Fetal Weight Estimation Formulas in Assessing Small-for-Gestational-Age Fetuses.

PURPOSE: The aim of this study was to compare the accuracy of multiple sonographic fetal weight estimation models in assessing small-for-gestational-age (SGA) fetuses. MATERIALS AND METHODS: The cohort included all singleton pregnancies recorded at a single medical center from January 2004 to September 2011, with a minimum of 24 weeks of gestation. SGA was defined as a fetal weight of less than the 10th percentile. We used birth weight (BW) distribution curves for our population, matched according to fetal gender and gestational age. Predicted birth weights were calculated using 26 sonographic fetal weight estimation models, including targeted formulas for SGA fetuses. RESULTS: 1218 cases of SGA fetuses that underwent sonographic fetal weight estimation within one week prior to delivery were found. Prediction of fetal weight was significantly less accurate in SGA fetuses than in the general population. The random error for SGA fetuses ranged from 7.2 % to 13.9 % in different models, while the systematic error ranged from -12.8 % to 26 %. Most non-targeted formulas showed a specificity of over 90 % but a sensitivity of only 20 - 35 % in the detection of SGA fetuses, while most targeted formulas had a low specificity but a high sensitivity. The model by Scott et al. was found to be the most accurate in assessing SGA fetuses in our population. CONCLUSION: Estimation of fetal weight in SGA fetuses is less accurate than in the general population. Some formulas which are designed for SGA are more accurate than others and their use might increase the sensitivity in identifying SGA fetuses, with only a small decline in specificity.

[Prenatal diagnosis of trisomy 13 and trisomy 18: the experience of Assaf-Harofe Medical Center].

INTRODUCTION: Trisomy 18 and 13 are the most common autosomal trisomies, after trisomy 21, and their frequency is rising due to the increased maternal age of pregnant women. The fetuses suffer from multi-organ damage that may lead to many gestational complications as well as short life expectancy. OBJECTIVE: To assess the indications for prenatal karyotyping of trisomy 13 (T-13, Patau syndrome) and trisomy 18 (T-18, Edwards syndrome) during pregnancy in our medical center. METHODS: This retrospective cohort study involved all singleton pregnancies locally diagnosed or referred to our Institute because of T-13 and T-18, during the years 1998-2011. RESULTS: There were 1879 cases of termination of pregnancies (TOPs) because of fetal indications, of them 53 cases of T-18 and 10 cases of T-13. The main indications for prenatal karyotyping in our study group were abnormal sonographic findings during anomaLy scans. In addition, 7 newborns with T-18 and 3 infants with T-13 were born in our hospital during the same period of time. We examined all cases that led to the Live birth of newborns with chromosomal anomalies, stemming from the Lack of extraction of the tests mentioned above and/or ignoring findings that raise suspicion that requires performing prenatal karyotyping during pregnancy. DISCUSSION: Our findings corresponded with other studies and showed that prenatal diagnosis of T-13/T-18 due to abnormal sonographic finding is rising. CONCLUSIONS: Our study shows that it was possible to identify the vast majority of T-13/T-18 among the pregnant women who had an increased risk based on a combination of the routine screening tests applied in Israel.

A search for the most accurate formula for sonographic weight estimation by fetal sex - a retrospective cohort study.

OBJECTIVE: The aim of this study was to assess the effect of fetal sex on the accuracy of multiple formulas for sonographic estimation fetal weight (SEFW). METHODS: The cohort included all singleton live births recorded at a single medical center from January 2004 to September 2011. The accuracy of SEFW was compared between male and female fetuses using 6575 SEFW performed within 3 days prior to delivery. Fetal weight was estimated using 27 models. RESULTS: The accuracy of different formulas in predicting birth weight of male and female fetuses was found to be significantly different in almost every accuracy index that was compared (P < 0.05). The model by Sabbagha et al. was found to be the most accurate in assessing female fetuses. The most accurate model for male fetuses was a sex-specific formula by Melamed et al. We also found that a combination of the most accurate formula for each sex to one combined sex-specific model increased SEFW accuracy significantly. CONCLUSION: The accuracy of SEFW is significantly related to fetal sex. The combination of the formulas by Melamed et al. and Sabbagha et al. for male and female fetuses accordingly allowed more accurate SEFW in our research population.

Do assisted conception twins have an increased risk for anencephaly?

BACKGROUND: The incidence rates of anterior neural tube defects, anencephaly and encephalocele appear increased among twins compared with singletons. The current study aimed to evaluate whether the etiology of this phenomenon is related to twinning, assisted reproductive technology (ART), or both. METHODS: The study cohort consisted of parturient women who were referred to our ultrasonography unit between January 1998 and December 2009 due to suspicion of severe fetal abnormality. The study cohort was divided into two subgroups based on mode of conception: spontaneous and ART (including IVF and ICSI). The subgroups were further subdivided into singleton and multiple pregnancies. We also compared pregnancies diagnosed with anencephaly in the study group to all live births in the Department of Obstetrics and Gynecology. RESULTS: Anencephaly was diagnosed in 43 fetuses out of 1154 (3.7%) pregnancies diagnosed with severe fetal anomaly. Anencephaly was diagnosed in 9 out of 78 twin pregnancies (11.5%); of these, 8 of 45 (17.8%) were ART conceived and 1 of 33 (3%) spontaneously conceived. A significant correlation was found between twinning and anencephaly, with an odds ratio (OR) of 3.4 [confidence interval (CI) = 1.3-8.9, P= 0.011], while no significant correlation was found between ART and anencephaly. A significant correlation was found between anencephaly and the combination of ART conception and twinning (OR of 6.6, CI = 2.8-15.3, P< 0.01). Analyzing the distribution of pregnancies diagnosed with anencephaly in the study group compared with the total number of live births in the department revealed a significant correlation between twinning and anencephaly, with an OR of 11.4 (CI = 4.9-26.5, P< 0.01), with no significant correlation between ART and anencephaly. Among all live births, a significant correlation was found between anencephaly and the combination of ART conception and twinning (OR of 24.6, CI = 11.4-53.2, P< 0.01). CONCLUSIONS: Our data suggest that twin pregnancies conceived by ART constitute a high-risk group for anencephaly, due to a possible synergistic effect of twinning and ART.

Pregnancy-related uterine arteriovenous malformations: experience from a single medical center.

PURPOSE: The purpose of this article was to investigate clinical ultrasonographic findings and the outcomes of post-pregnancy patients with acquired uterine vascular abnormalities including arteriovenous malformations (AVMs). MATERIALS AND METHODS: We performed a computerized database search for all patients with ultrasonographic findings of a vascular abnormality including AVM in our referral center between 2000-2008. An ultrasound finding of vascular abnormality was defined as an area of strong hypervascularity within the myometrium and the presence of marked turbulence. The inclusion criteria for angiography were abnormal vaginal bleeding in a hemodynamically stable patient, bhCG serum levels ≤ 30 mIU/ml, and ultrasound demonstration of large (≥ 15 mm on the larger side of the vessel) or multiple vascular lesions. RESULTS: 16 women were identified, of whom 10 (63 %) underwent uterine artery embolization. Angiography confirmed the pre-interventional ultrasound diagnosis of AVM in all cases. AVM feeding arteries were on the left side of the uterus in 80 % of the cases. Residual tissue was ultrasonographically detected in five patients: 2 underwent hysteroscopy and guided curettage following embolization and three received methotrexate. All tissue samples were benign. One small vascular abnormality resolved spontaneously. CONCLUSION: An acquired uterine vascular abnormality including AVM should be considered in the work-up of post-pregnancy vaginal bleeding.

Recurrent heterotopic pregnancy after bilateral salpingectomy in an IVF patient: case report.

PURPOSE: To report a rare clinical case of recurrent heterotopic pregnancy in the same patient following bilateral salpingectomy and in-vitro fertilization (IVF) treatments. METHODS: A 35 year-old woman, suffering from mechanical infertility, was treated by IVF, resulting in two episodes of heterotopic pregnancies within 2 years. The first episode ended in bilateral salpingectomy due to unilateral tubal pregnancy and contralateral severely damaged tube. The intrauterine pregnancy ended in early missed abortion. The second heterotopic pregnancy presented as bleeding cornual pregnancy, managed by laparoscopic resection of the tubal stump, and ended in a term singleton delivery. CONCLUSION: The possibility of cornual heterotopic pregnancy following bilateral salpingectomy, though very rare, should be considered by every gynecologist treating IVF patient.

Perioperative morbidity and mortality of gynecological oncologic surgery in elderly women.

The study compares the perioperative morbidity and mortality rates of elderly (> or =70 years) and younger (< 70 years) patients. The study cohort consisted of 171 women undergoing explorative laparotomy due to uterine or ovarian cancer. Clinical data included patients' age, comorbidities, chronic use of medications, body mass index (kg/m(2)), past and current surgical procedures, surgical FIGO stage, histologic type and number of dissected lymph nodes, optimal versus nonoptimal debulking, occurrence of perioperative complications, and postoperative hospital stay (days). Participants were divided to 108 (63.2%) patients with uterine cancer and 63 (36.8%) patients with ovarian cancer. Women having uterine cancer were further subdivided to those <70 years of age (72 women, 66.7%) and those > or =70 years of age (36 women, 33.3%). Women with ovarian cancer were subdivided to those <70 years of age (48 women, 76.2%) and those > or =70 years of age (15 women, 23.8%). Excluding the occurrence of postoperative ileus and poorly controlled hypertension in the elderly subgroup of women with uterine cancer, the rate of early postoperative complications was similar between the two subgroups. Chronological age by itself should not be a contraindication for the treatment of elderly women with gynecological malignancy since it is a poor predicting factor for perioperative morbidity.

Ectopic pregnancies in Caesarean section scars: the 8 year experience of one medical centre.

BACKGROUND: Our aim was to supplement the mostly individual case reports on the rarely occurring and life-threatening condition of ectopic pregnancy developing in a Caesarean section scar. METHODS AND RESULTS: Eight of all the patients treated in our department between 1995 and 2002 had been diagnosed for ectopic pregnancy that developed in a Caesarean section scar. They comprised this case series group. Four of them underwent methotrexate treatment; one had expectant management, one transcervical aspiration of the gestational sac and two by open surgery. All the non-surgically treated women had an uneventful outcome. One underwent a term Caesarean hysterectomy and the other first trimester hysterotomy and excision of the pregnancy located in the scarred uterus. Analysis of all these women's obstetric history revealed that five of them (63%) had been previously operated because of breech presentation, one had a cervical pregnancy and one had placenta previa. Four of them (50%) had multiple (> or = 2) Caesarean sections. CONCLUSIONS: The women at risk for pregnancy in a Caesarean section scar appear to be those with a history of placental pathology, ectopic pregnancy, multiple Caesarean sections and Caesarean breech delivery. Heightened awareness of this possibility and early diagnosis by means of transvaginal sonography can improve outcome and minimize the need for emergency extended surgery.

Luteinizing hormone in peritoneal and ovarian cyst fluids: a predictor of ovarian carcinoma.

OBJECTIVE: The aim of this study was to define the role of luteinizing hormone (LH) as a tumor marker, specific for ovarian cancer. METHODS: The study included 34 women with functional and benign ovarian cysts, 11 women with borderline ovarian tumors, 22 patients with advanced ovarian cancer and 15 patients with non-ovarian intraperitoneal malignancies. Serum, peritoneal fluid and ovarian cyst aspirates were obtained intraoperatively (laparoscopy or laparotomy) and were subjected to the LH analysis. RESULTS: Peritoneal fluid LH levels were significantly increased in patients with ovarian cancer and those with borderline ovarian tumors as compared to patients with functional and benign ovarian cysts (P=0.005 and P=0.007, respectively). The patients with non-ovarian malignancies demonstrated the same peritoneal fluid LH levels as patients with benign ovarian tumors. There was no significant difference in the level of peritoneal fluid LH between ovarian cancer patients with and without ascites. The patients with functional and benign ovarian cysts demonstrated also significantly lower cyst fluid LH levels as compared to patients with malignant and borderline ovarian cysts (P=0.01 and P=0.03, respectively). Peritoneal and ovarian cyst fluid levels of LH were significantly increased in patients with fibrothecomas as compared to patients with other benign ovarian cysts. There were no significant differences in the serum LH levels comparing patients from all study groups. CONCLUSION: LH, detectable in peritoneal and ovarian cyst fluids, can be used as a tumor marker for identification of patients with borderline and malignant ovarian tumors.

Is endotracheal adrenaline deleterious because of the beta adrenergic effect?

IV adrenaline increases coronary and cerebral perfusion pressures during cardiopulmonary resuscitation. We recently showed that endotracheal adrenaline can decrease blood pressure (BP), a detrimental effect presumably mediated by the beta 2-adrenergic receptor unopposed by alpha-adrenergic vasoconstriction. This prospective, randomized, laboratory comparison of endotracheal adrenaline (0.05 mg/kg diluted with normal saline to 10 mL total volume) with or without nonselective beta-blocker (propranolol) pretreatment was conducted in an attempt to clarify the mechanism of this BP decrease. Five mongrel dogs were given 0.05 mg/kg endotracheal adrenaline (diluted) or 0.05 mg/kg endotracheal adrenaline followed by an IV propranolol (0.1 mg/kg) pretreatment. Each dog served as its own control (10 mL of normal saline administered endotracheally) and received each regimen at least one week apart. Endotracheal adrenaline given after the propranolol pretreatment produced an increase in systolic, diastolic, and mean arterial BPs, from 165/110 mm Hg (mean 128 mm Hg) to 177.5/125 mm Hg (mean 142.5 mm Hg), respectively, as opposed to the hypotensive effect of isolated endotracheal adrenaline (P < 0.03). Thus, endotracheal adrenaline was associated with predominantly beta-adrenergic-mediated effects, causing hypotension via peripheral vasodilatation unopposed by alpha-adrenergic vasoconstriction. The search for the optimal dose of endotracheal adrenaline should be aimed at achieving the higher alpha-adrenergic vasoconstrictive threshold.

Hereditary insensitivity to pain with anhidrosis.

Hereditary sensory neuropathy type IV is an autosomal-recessive disorder characterized by congenital insensitivity to pain and anhidrosis and resulting in recurrent hyperpyrexia, self-mutilation, recurrent infections, chronic osteomyelitis, bone and joint deformities, and limb amputations. Described is a child with signs as well as skin and nerve biopsy results compatible with this disease, emphasizing the importance of early diagnosis and appropriate medical and educational care to prevent complications.

Epinephrine pharmacokinetics and pharmacodynamics following endotracheal administration in dogs: the role of volume of diluent.

OBJECTIVE: to define the optimal volume of dilution for endotracheal(ET) administration of epinephrine (EPI). DESIGN: prospective, randomized, laboratory comparison of four different volumes of dilution of endotracheal epinephrine (1, 2, 5, and 10 ml of normal saline). SETTING: large animal research facility of a university medical center. SUBJECTS AND INTERVENTIONS: epinephrine (0.02 mg/kg) diluted with four different volumes (1, 2, 5, and 10 ml) of normal saline was injected into the ET tube of five anesthetized dogs. Each dog served as its own control and received all four volumes in different sequences at least 1 week apart. Arterial blood samples for plasma epinephrine concentration and blood gases were collected before and 0.25, 0.5, 0.75, 1, 2, 3, 4, 5, 10, 15, 20, 25, 30 and 60 min after drug administration. Heart rate and arterial blood pressure were continuously monitored with a polygraph recorder. MEASUREMENTS AND MAIN RESULTS: higher volumes of diluent (5 and 10 ml) caused a significant decrease of PaO2, from 147 +/- 8 to 106 +/- 10 torr, compared with the lower volumes of diluent (1 and 2 ml), from 136 +/- 10 to 135 +/- 7 torr (P < 0.05). These effects persisted for over 30 min. Mean plasma epinephrine concentrations significantly increased within 15 s following administration for all the volumes of diluent. Mean plasma epinephrine concentrations, maximal epinephrine concentration (Cmax) and the coefficient of absorption (Ka) were higher in the 5 and 10 ml groups. The time interval to reach maximal concentration (Tmax) was shorter in the 5 and 10 ml groups. Yet these results were not significantly different. Heart rate, systolic and diastolic blood pressures did not differ significantly between the groups throughout the study. CONCLUSIONS: Dilution of endotracheal epinephrine into a 5 ml volume with saline optimizes drug uptake and delivery without adversely affecting oxygenation and ventilation.