Pregnancy outcome after laparoscopy or laparotomy in pregnancy.

STUDY OBJECTIVE: To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN: Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING: Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS: Three hundred eighty-nine pregnant women. INTERVENTION: Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS: Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION: Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Significance of sporadic deceleration during antepartum testing in term pregnancies.

We have investigated the significance of single sporadic deceleration during reactive nonstress testing in normal pregnancies at term. A prospective study was performed during a 1-year period including 4742 nonstress tests performed between the 38th and 42nd weeks of pregnancy in patients referred to our department for antepartum testing and without any complication or pathology. Nonstress test (NST) was carried out with the patient lying on her left side, and was defined as reactive if at least two accelerations of 15 beats/min (bpm) or more lasting 15 sec were observed in a 20-min period. Sporadic deceleration was defined as a decrease in the fetal heart rate to less than 90 bpm or a decrease of 40 bpm below the baseline, lasting at least 2 min. The sporadic deceleration was considered as single when only one appeared in the first 20 min of monitoring and repeated when observed again once in at least one subsequent monitoring. Thirty-four cases of single sporadic deceleration were observed among women with reactive NST. In 14 cases there were repeated sporadic decelerations. The patients were divided into two groups according to the presence or absence of repeated decelerations. Outcomes of patients with repeated sporadic decelerations were compared with a group of 34 patients where sporadic decelerations were not observed during the antepartum testing. A significantly higher percentage of pathological fetal heart rate traces during labor were observed in the group of repeated decelerations. In conclusion the presence of repeated sporadic decelerations during a reactive NST suggests that the cause of cord compromise is persistent and recurrent cord compression is possible. Therefore, in these cases an increased fetal risk could be expected.

The behavior of follicle cysts formed after long-acting gonadotropin-releasing hormone analog administration in patients with polycystic ovarian syndrome.

This study was conducted to examine the effect of ovarian cysts that develop after administration of a gonadotropin-releasing hormone (GnRH) analog during an ovulation induction program for patients with polycystic ovarian syndrome. Twenty-eight women received Decapeptyl Continuous Release for 70 cycles starting on day 3 of the menstrual cycle, after exclusion of any ovarian pathology by transvaginal ultrasonography. Fifteen days later ultrasonography was again performed and serum estradiol estimated. Cystic structures > or = 20 mm in the ovaries were defined as follicle cysts. In three cycles follicle cysts developed and low estradiol levels were measured (Group 1). In another six cycles cysts developed after GnRH analog, and elevated estradiol levels were found (Group 2). In the latter, estradiol decreased 3 to 7 days later, with cyst regression in three cases. Ovulation induction with human menopausal gonadotropin (hMG) was initiated only if the estradiol level was < or = 20 pg/ml, otherwise induction was postponed until estradiol decreased, disregarding the presence of cysts. When 2 to 3 follicles were > or = 18 mm, and generally when estradiol levels were < 1500 pg/ml, human chorionic gonadotropin was administered. All the cycles were ovulatory and two women from Group 2 conceived. The development of follicle cysts with low serum estradiol levels after GnRH analog administration represents a benign condition and is not a contraindication for hMG stimulation. In cases with elevated estradiol levels, ovulation induction can be postponed until the estradiol has decreased. Our study revealed good ovulatory and pregnancy rates as a result.

A follicular scoring system for monitoring ovulation induction in polycystic ovary syndrome patients based solely on ultrasonographic estimation of follicular development.

OBJECTIVE: To assess the predictive value of a follicular scoring system for monitoring ovulation induction in polycystic ovary syndrome (PCOS) patients, solely with ultrasound (US). DESIGN: Ultrasound measurements were performed on alternate days to define a serial follicular score for monitoring ovulation induction with hMG alone, as well as GnRH analogue and hMG, in comparison with E2 concentration obtained on the same day. SETTING: Outpatient Infertility Clinic, Department of Obstetrics and Gynecology. PATIENTS: Thirty-four consecutive PCOS patients treated for 63 cycles. MAIN OUTCOME MEASURE: The follicular score was established considering the summation of points obtained after measuring the mean diameter of each follicle > 5 mm, as follows: 5 to 8 mm = 1 point, 9 to 12 mm = 1.5 points, 13 to 16 mm = 2 points, > or = 17 mm = 3 points. RESULTS: Follicular score correlated positively with E2 concentrations. A score of > or = 30 points was associated with E2 levels of concentration that reached > 1,500 pg/mL (conversion factor to SI unit, 3.671) and could predict ovarian hyperstimulation. A lower follicular score allowed hCG administration. CONCLUSIONS: A follicular scoring system may be a safe, simple, and highly efficient method to replace serial E2 measurements in monitoring ovulation induction. Moreover, ovarian hyperstimulation may be predicted.

Comparative study of extra-amniotic prostaglandin F2 alpha infusion and increasing intravenous oxytocin for termination of second trimester missed abortion.

Extra-amniotic infusion of prostaglandin F2 alpha (PGF2 alpha) and intravenous (IV) oxytocin in increasing doses were compared in a retrospective study to establish the efficacy of the two methods for termination of pregnancies with second trimester missed abortion. Sixty women with this complication underwent pregnancy termination, 28 by extra-amniotic infusion of PGF2 alpha and oxytocin augmentation, if necessary, and 32 by IV oxytocin in increasing doses. All patients in the PGF2 alpha group aborted within 24 hours from onset of infusion and seven of them needed oxytocin augmentation. There were nine failures in the oxytocin group and the other 23 aborted within 17 hours. The mean (plus or minus standard error of the mean) induction-abortion interval was significantly less in the oxytocin group (6.9 +/- 3.4 hours) than in the PGF2 alpha group (12.6 +/- 5.7 hours) p < 0.001. Eight patients in the group had mild side effects, such as nausea, flushes or transient hypotension. Uterine hypertonus was observed in two women receiving PGF2 alpha and treated by temporary interruption of the infusion. In the oxytocin group, one patient had coagulation disturbances and one, hemorrhage. We conclude that extra-amniotic PGF2 alpha infusion is more effective than IV oxytocin in increasing doses, for termination of second trimester missed abortion, but takes effect more slowly. We can assume that further use of IV oxytocin immediately after termination of the PGF2 alpha administration can shorten the induction-abortion interval.

Intrauterine PGF2 alpha infusion for termination of pregnancies with second-trimester rupture of membranes.

Intrauterine prostaglandin (PG) F2 alpha infusion and intravenous (IV) oxytocin infusion were compared to evaluate the effectiveness of the two methods for termination of pregnancies with second-trimester rupture of membranes. Twenty-two women with this complication were randomly allocated to receive either 20 mg PGF2 alpha, diluted in 500 mL of NaCl 0.9% and administered through a Foley catheter inserted through the cervix, or IV oxytocin infusion in increasing doses. All subjects in the PGF2 alpha group aborted after the first administration. Repeat infusion was necessary in three oxytocin-treated subjects. The mean (+/- SD) induction-abortion interval was significantly shorter in those receiving PGF2 alpha (6.7 +/- 1.2 hours) than in those receiving oxytocin (8.8 +/- 2.7 hours). Minor side effects, such as nausea and vomiting, were observed in three women during PGF2 alpha infusion and were treated symptomatically and by temporary interruption of the infusion. Uterine hypertonus, observed in one subject in each group, was treated by temporary cessation of the infusion. We conclude that intrauterine PGF2 alpha infusion seems more effective than IV oxytocin for termination of pregnancies with second-trimester rupture of membranes.

The predictive value of fetal breathing movements in the outcome of premature labour.

Fetal breathing movements (FBM) were assessed in 28 pregnant women, presenting with uterine contractions before 34 weeks gestation. External tocometry was used to determine uterine contractions objectively. The first group consisted of 17 patients, treated by tocolytics after the ultrasound scanning showed absence of FBM. The second group comprised 11 patients with FBM present, who were observed only. In the first group nine women were delivered within 1 week, whereas in the second group no patient was delivered in that period, all of them being discharged. In patients with premature contractions the presence of FBM seems to indicate that the pregnancy will continue while absence of FBM foreshadows early delivery.

Management of pregnancy-induced hypertension with pindolol--comparative study with methyldopa.

Thirty-two consecutive women with pregnancy-induced hypertension of early onset were randomly allocated to treatment with pindolol or methyldopa. There was no difference between the groups in regard to the average time of delivery (36.33 vs. 36.6 weeks) and weight of the newborn (2850 vs. 2870 g). A significant drop in systolic (P less than 0.005) and diastolic (P less than 0.05) blood pressure was observed in the group of patients treated with pindolol as compared with the methyldopa group. In the pindolol group an improvement in renal function was observed as determined by CCT and serum creatinine. There were no side effects from the drugs in the mother or in the newborn.

Prostaglandin F2 alpha for prevention of urinary retention after vaginal hysterectomy.

The delay in spontaneous micturition after pelvic surgical procedures is a significant complication. This study was performed to establish the validity of intravesical instillation of prostaglandin F2 alpha in the prevention of urinary retention after vaginal surgery. For this purpose 102 patients were randomly and alternatively allocated to receive either 16 mg of prostaglandin F2 alpha diluted in 40 mL of saline or saline only given intravesically. Similar numbers of patients with vaginal hysterectomy (27 versus 31), vaginal repair (12 versus 11), and repair with Kelly urethral plication (12 versus 9) were included in the study and control group, respectively. The frequency of urinary retention in the women treated with prostaglandin F2 alpha was decreased significantly as compared with those treated with saline alone (P less than .02). But this was true for women undergoing vaginal hysterectomy only. There was also a significantly shorter hospitalization of women receiving prostaglandin F2 alpha (P less than .05) and there were no side effects.

Is term breech presentation in primigravida an absolute indication for cesarean section?

Excessive perinatal loss is associated with breech presentation, this loss being accounted for by prematurity, congenital anomalies and birth trauma. In the endeavor to exert an effect on two of these problems, cesarean section has been resorted to increasingly. We have compared two management regimes of primigravida term breech presentation corresponding to two 4-yr periods. During the first period every case was evaluated carefully and, if no other pathology was found, a trial vaginal delivery was allowed. During the second period all the cases were delivered by elective cesarean section. Of the 108 cases of the first period, 46 delivered vaginally and 62 underwent cesarean section. 119 cases were scheduled for abdominal delivery during the second period. Immediate infant outcome for each group was determined by the 1 and 5 min Apgar scores. Analysis of 5 min Apgar scores demonstrated no significant differences in immediate outcome between infants delivered vaginally and by cesarean section. Fetal morbidity related to birth trauma was higher in the vaginal delivery group but there were no perinatal deaths. Maternal morbidity was observed only in the cesarean section groups. This study suggests that properly selected primigravid term breech infants could be delivered vaginally without increased perinatal mortality and with immediate outcomes comparable to those found with cesarean section.

Surgical treatment of varicocelle in oligospermic patients: a re-evaluation.

Left varicocele ligation was performed in 64 infertile men seen at our clinic during 1974-1978. High ligation of the left internal spermatic vein was done in all cases. The ages of patients were 23--46 yr. The criteria for operation were: palpatory findings of varicocele, primary or secondary infertility, and abnormal sperm analysis. Statistical analysis of the 3 main sperm parameters before and after surgery shows a significant increase in sperm count (P < 0.005) and motility index (P < 0.005), while the sperm morphology was not improved (P = 0.2). The pregnancy rate was 43.8%.

Epidural analgesia in labour performed by obstetricians.

The use of epidural analgesia by obstetricians in 2,645 women in labour is reported. The use of this technique as one of the routine methods is proposed even in those centres where no anaesthetist for pain relief is available for the 24-hour period. This is possible by the previous training of obstetricians. Advantages, side-effects and complications of epidural analgesia are discussed.

A technique for management of obstructed labour with antenatal fetal death.

A technique for management of obstructed labour associated with fetal death is presented. The new method makes it possible to decrease fetal head size by evacuation of brain tissue by suction using thoracic-type trocar. Three patients with obstructed labour and fetal death were managed successfully using this technique. The method permits a decrease of fetal head size easily and rapidly, avoiding the risks of other techniques. Moreover, its use makes it possible to eliminate craniotomy from obstetric practice. The method should be equally suitable for cases of major hydrocephaly.

The treatment of postmenopausal syndrome by monthly oral doses of quinestrol.

Seventy patients between the ages of 37 and 59 suffering from the menopausal syndrome were included in a clinical trial and treated for a period of 6 to 18 months. Out of the seventy, 43 were suffering from spontaneous and 27 from surgical menopause. Forty of them were given 1 mg of quinestrol and 30 received placebo. The drug was administered orally in a one-tablet dose once a month. An improvement took place in 35 (87.5%) of the women receiving quinestrol but in only 15 (50%) of those receiving placebo. Among the patients with spontaneous menopause an improvement was seen in 22 out of 25 (88%) receiving quinestrol, compared with 9 out of 18 (50%) receiving placebo. Tolerance of the drug was good and most of the laboratory tests as well as blood pressure and body weight showed statistically non-significant changes. This kind of treatment is expecially suitable when daily intake is undesirable.

PIP: Use of small daily doses of quinestrol, a synthetic estrogen consisting of 3 cyclopenthyl-ether of ethinyl estradiol, has been reported to result in remission of postmenopausal symptoms in many patients. This study used quinestrol in 1 mg monthly oral doses in a group of women (N=70) suffering from the menopausal syndrome (43 from spontaneous and 27 from surgical menopause). 40 women received quinestrol 1 mg and 30 were given placebo. Of the 40 who were given quinestrol, 25 had spontaneous menopause and 15 were surgically induced. In the placebo group, 18 had spontaneous menopause and 12 were surgically induced. Treatment lasted from 6-18 months; none of the patients knew whether they had quinestrol or placebo. Blood samples were taken in 10 patients before treatment and 6 months later. As a whole, improvement was observed in 87.5% of the quinestrol-treated group, in contrast to 50% of the placebo-treated group. For women with spontaneous menopause, an improvement was observed in 88% of the quinestrol group and 50% of the placebo group. With respect to the effectiveness of quinestrol, no significant difference in the relief of symptoms was observed between the 2 groups (spontaneous and surgical menopause). Observed side effects were skin rash in 2 patients, thrombophlebitis in 1 patient, vaginal bleeding in 3 patients and nausea in 4 patients. It was concluded that quinestrol therapy is especially suitable in surgical menopause where substitutive therapy is indicated, as well as in cases where daily intake is not favored.

Perceptions of the role of the physician assistant: degree of agreement between physician and physician assistant concerning activities, settings, and responsibility in primary care settings.

An investigation of the differences in the perceptions of the role of physician assistant between physicians and physician assistants in the same primary care practice was conducted. A sample of six practices (one physician and one physician assistant from each practice), obtained from six Appalachian counties in New York State, was examined. Data was collected through the administration of a questionnaire, personal interviews, and on-site activity observations. Comparisons were made for two items: Number of errors between physicians' or physician assistants' perceptions and actual observations for a specified group of 23 activities, and the number of discrepancies between physicians' and physician assistants' perceptions for the same 23 activities. Study results produced significant numbers of errors and discrepancies suggesting that certain barriers to communication exist between the physicians and physician assistants and that a substantial amount of physician-physician assistant activity interaction is necessary to ensure positive conformance of standard duties and functions to practice goals and objectives.