Differences in EEG Event-Related Potentials during Dual Task in Parkinson's Disease Carriers and Non-Carriers of the G2019S-LRRK2 Mutation

BACKGROUND

The G2019S-LRRK2 gene mutation is a common cause of hereditary Parkinson's disease (PD), associated with a higher frequency of the postural instability gait difficulty (PIGD) motor phenotype yet with preserved cognition. This study investigated neurophysiological changes during motor and cognitive tasks in PD patients with and without the G2019S-LRRK2 mutation.

METHODS

33 iPD patients and 22 LRRK2-PD patients performed the visual Go/NoGo task (VGNG) during sitting (single-task) and walking (dual-task) while wearing a 64-channel EEG cap. Event-related potentials (ERP) from Fz and Pz, specifically N200 and P300, were extracted and analyzed to quantify brain activity patterns.

RESULTS

The LRRK2-PD group performed better in the VGNG than the iPD group (group*task; p = 0.05). During Go, the iPD group showed reduced N2 amplitude and prolonged N2 latency during walking, whereas the LRRK2-PD group showed only shorter latency (group*task p = 0.027). During NoGo, opposite patterns emerged; the iPD group showed reduced N2 and increased P3 amplitudes during walking while the LRRK2-PD group demonstrated increased N2 and reduced P3 (N2: group*task, p = 0.010, P3: group*task, p = 0.012).

CONCLUSIONS

The LRRK2-PD group showed efficient early cognitive processes, reflected by N2, resulting in greater neural synchronization and prominent ERPs. These processes are possibly the underlying mechanisms for the observed better cognitive performance as compared to the iPD group. As such, future applications of intelligent medical sensing should be capable of capturing these electrophysiological patterns in order to enhance motor-cognitive functions.

Randomized controlled trial of external cephalic version in term multiparae with or without spinal analgesia

BACKGROUND

Neuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia.

METHODS

Prospective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests.

RESULTS

Among 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia (P=0.009; 95% CI of difference: 0.075-0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (sd) 1.7 (2.4) vs 5.5 (2.9) without (P<0.0001). Maternal hypotension was seen after spinal analgesia in 10 of 31 (32%) (P=0.0003) and easily treated without adverse outcome. No complications were noted after the ECV.

CONCLUSIONS

Administration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort. The trial was registered at the National Institute of Health Trials Registry, NCT00119184, www.clinicaltrials.gov.

Ehlers-Danlos type IV in pregnancy. A case report and a literature review

BACKGROUND

Ehlers-Danlos syndrome is a heterogeneous group of connective tissue disorders, characterized by a defect in the synthesis of collagen. The syndrome is subdivided into different clinical subtypes, the most hazardous of which is type IV, the vascular type. It can manifest itself in various complications such as rupture of arteries and hollow organs. The obstetrical manifestations are the risk of uterine rupture during labor, damage to the vagina and perineum, bleeding and rupture of blood vessels and colon during the puerperium.

CASE REPORT

We describe a primigravida suffering from Ehlers-Danlos type IV who was followed and successfully delivered by a cesarean section at 36 weeks of gestation and made an uneventful recovery.

CONCLUSION

Following a thorough literature review, it seems wise to perform early delivery by cesarean section for pregnant women suffering from Ehlers-Danlos type IV.

Anaesthetic management of placenta accreta: use of a pre-operative high and low suspicion classification

Placenta accreta may be suspected prior to surgery, but the actual diagnosis is only confirmed at surgery. This prospective and observational study was performed to assess whether preparations should be made for potential massive blood loss prior to Caesarean surgery in all patients with suspected placenta accreta. Patients were classified as high or low suspicion for placenta accreta based on ultrasonography and clinical factors. Among 28 suspected cases of placenta accreta, diagnosis was confirmed at surgery in 50% (12/17 high and 2/11 low suspicion) cases. Hysterectomy was only performed in the 12 high suspicion patients with placenta accreta (p < 0.001). High suspicion patients required more blood transfusions: mean(SD) 6.5 (7.0) units vs 1.09 (1.1) units, p = 0.017. Anaesthetists should be prepared for major haemorrhage in all cases of suspected placenta accreta, although use of a system to grade level of suspicion may identify those at greater risk.

Monoamniotic twins: an update on antenatal diagnosis and treatment

OBJECTIVE

Monoamniotic twins are very uncommon and are characterized by a high perinatal mortality rate. Cord entanglement, prematurity, congenital anomalies and twin to twin transfusion are reportedly the main causes of death, which usually occurs before 24 weeks' gestation. The aim of this study was to review the newly developed methods for diagnosis and treatment and suggest a reasonable approach to the management of these rare cases.

METHOD

We reviewed the English-language literature in the past 15 years through Medline search and subsequent examination of individual publications.

RESULTS

In the past two decades, newer technologies such as advanced ultrasonography and color flow Doppler studies have enabled early diagnosis of this condition and its complications. Furthermore, new treatment modalities such as fetoscopy with laser coagulation of vascular anastomoses and treatment with non-steroidal anti-inflammatory drugs such as sulindac, to reduce amniotic fluid volume, may have contributed to a better outcome. Also, occlusion of one umbilical cord (fetal reduction) at an early stage has been suggested to prevent late complications.

CONCLUSION

Cumulative experience suggests that the majority of cases can be diagnosed reliably at an early gestational age. Treatment with medical amnioreduction, surgical amnioreduction or fetal reduction in selected cases may be offered before 24 weeks' gestation. Later, intensive antepartum fetal surveillance should probably be offered until 32 weeks, at which point elective preterm delivery may be considered to prevent possible fetal death.

Apolipoprotein e4 decreases whereas apolipoprotein e3 increases the level of secreted amyloid precursor protein after closed head injury

Apolipoprotein E (apoE4) and head trauma are important genetic and environmental risk factors for Alzheimer's disease. Furthermore, apoE4 increases both the acute and chronic consequences of head trauma. The latter are associated with the deposition of amyloid-beta, which is particularly elevated in apoE4 subjects. The short-term effects of head injury are associated with transiently increased metabolism of amyloid precursor protein (APP) and its secreted fragment, APPs. In the present study, we examined the possibility that the acute, short-term pathological effects of apoE4 following head trauma and the corresponding neuroprotective effects of apoE3 are related to isoform-specific effects of apoE on APP metabolism. Accordingly, male transgenic mice expressing human apoE3 or apoE4 on a null mouse apoE background and apoE-deficient and control mice were subjected to closed head injury (CHI). The resulting effects on brain APP, and on its secreted products, APPs and secreted product of the alpha-cleavage of APP (APPsalpha) were then determined 24 h following injury. Immunoblotting revealed no significant differences between the basal APP, APPs and APPsalpha levels of the hippocampus or the cortex of the control and the apoE3 and ApoE4 transgenic mice. The apoE-deficient mice also had similar cortical basal levels of APP and its metabolites, whereas their corresponding basal hippocampal APP and APPs levels were lower than those of the other groups. CHI lowered the hipppocampal APPs and APPsalpha levels of the apoE4 transgenic mice, whereas those of the apoE3 transgenic mice and of the control and apoE-deficient mice were not affected by this insult. In contrast, CHI raised the cortical APP and APPs levels of the apoE3 transgenic mice but had no significant effect on those of the other mice groups. These animal model findings suggest that the acute, short-term pathological effects of apoE4 following CHI and the corresponding neuroprotective effects of apoE3 may be mediated by their opposing effects on the expression and cleavage of cortical and hippocampal APP. Similar isoform-specific interactions between apoE and APP may play a role in the acute, short-term effects of head trauma in humans.

Treatment of obstetric hemorrhage with recombinant activated factor VII (rFVIIa)

Recombinant activated factor VII (rFVIIa, NovoSeven) was used in three patients with massive obstetric hemorrhage due to placenta previa accreta, rupture of the uterus and pre-eclampsia with HELLP. Administration of the drug markedly decreased the bleeding and enabled control of the hemorrhage. rFVIIa seems to be an adjunctive hemostatic measure for the treatment of severe obstetric hemorrhage.

Placenta accreta--summary of 10 years: a survey of 310 cases

The objective was to study the incidence, risk factors, and outcome of pregnancies complicated by placenta accreta in our population. Retrospective analysis of all deliveries between the years 1990-2000, and identification of all cases of placenta accreta, defined by clinical or histological criteria. For comparison purposes we defined two sub-groups: (i) all cases that ended with severe outcome and (ii) all patients who had a previous event of placenta accreta in one or more of their previous deliveries. We evaluated the potential risk factors leading to these conditions. The SPSS software package was used for statistical analysis. Univariate and multivariate analyses were performed by stepwise logistic regression. The study covered 34 450 deliveries from which 310 cases of placenta accreta were diagnosed (0.9 per cent). The risk factors associated with placenta accreta were previous cesarean delivery (12 per cent), advanced maternal age, high gravidity, multiparity, previous curettage and placenta previa (10 per cent). Hysterectomy was performed in 11 patients (3.5 per cent) with one case of maternal death, whereas 21 per cent of the patients required postpartum blood products transfusion. Antenatal diagnosis of placenta accreta or percreta by ultrasound or MRI, was achieved only in eight of the cases. In the sub-group of 15 patients (4.8 per cent) with severe outcome, the only significant risk factors were increased parity (O.R.=1.29, 95 per cent CI 1.056-1.585), anteriorly low placenta (O.R.=6.1, 95 per cent CI 1.4-25.3) and repeated cases of caesarean sections (O.R.=3.3, 95 per cent CI 0.9-12.5), whereas in the 49 (16 per cent) patients with repeated cases of placenta accreta the only significant risk factor was the number of deliveries (O.R.=1.5, 95 per cent CI 1.0-2.2). Repeated cesarean delivery, high parity, and anteriorly low placental location are associated with severe outcome in case of placenta accreta. Women with repeated events of placenta accreta may have better outcome and a genetic factor may serve as a cause for this condition.

Induction of labor in breech presentation

OBJECTIVE

Induction of labor in breech presentation, although not contraindicated, has rarely been reported. We have undertaken to evaluate the safety and outcome of this practice in two Israeli institutions along with a literature review of this controversial subject.

METHOD

The research design was a retrospective case control study covering the years: 1980-1999. We have studied 53 term (>37 weeks) breech deliveries induced for various medical and obstetrical reasons, in two major regional hospitals in Israel. Induction was performed with prostaglandin E(2) for the unripe cervix and with oxytocin for induction or augmentation when the cervix was ripe. Six women were induced by nipple stimulation. Controls were 53 women with spontaneous labor in breech presentation that had a trial of vaginal delivery, and 54 women with breech presentation who delivered by elective cesarean section.

RESULT

No significant difference in the various maternal and fetal outcomes was observed. CS rate was comparable in both study and control groups (34% vs. 32%) and two-thirds gave birth vaginally.

CONCLUSIONS

In properly selected and carefully managed cases of breech presentation, induction of labor seems a safe and reasonable option.

The outcome of grand-multiparous pregnancies of Arabic and Jewish populations in peripheral and central areas of Israel

OBJECTIVE

To compare the antepartum and intrapartum course of Jewish and Arab great-grandmultiparas from central and peripheral areas in Israel to age-matched control multiparous women.

METHODS

Medical records of four groups of parturients were compared: great-grandmultiparas (para > or = 9) and multiparae (para 2-5) delivering at Nazareth E.M.M.S. hospital (mostly Arabs) and Hadassah-Ein-Kerem hospital in Jerusalem (mostly Jews). The control groups consisted of demographically and geographically matched multiparas. Data was collected on prenatal care received, antepartum complications, as well as the intrapartum complications traditionally associated with high parity (e.g. malpresentation, placental abnormalities, peripartum hemorrhage, shoulder dystocia). Neonatal records were also examined to determine any neonatal morbidity or mortality.

RESULTS

There were 139 and 141 great-grandmultiparas in the Nazareth and the Jerusalem study groups, respectively (mean parity was 10.1 and 10.9, respectively), and 142 and 139 multiparas in the Nazareth and the Jerusalem control groups, respectively (mean parity was 2.9 and 2.5, respectively). The rate of physician visits during the prenatal period in the Nazareth and the Jerusalem study groups was 2.3 +/- 2.4 and 3.2 +/- 2.7, respectively (p=0.0041). This rate was significantly higher in the controls of both areas (4.0 +/- 3.0 and 4.9 +/- 2.9, respectively). There was no difference in the rate of nurse visits in all groups in all areas. Maternal and neonatal outcomes were similar in both study groups, and were also similar in the control groups, but perinatal mortality was higher in both great-grandmultiparous groups compared to the controls (11/280 and 2/281, respectively; p<0.05).

CONCLUSIONS

The differences in the intensity of prenatal care between these rural and urban areas did not affect the maternal outcomes of great-grandmultiparous pregnancies. In addition, there were no significant differences in maternal outcomes between great-grandmultiparas and multiparas in rural and urban areas although prenatal care was less intense in the former. However, increased incidence of perinatal mortality in the great-grandmultiparas may be due to factors unrelated to prenatal care intensity or quality.

Breaking bad news and personality assessment

Breaking bad news to seriously ill patients is an especially difficult and important part of patient education and counseling. Guidelines for breaking bad news have been previously presented, but this is the first report to address the personality of the patient in deciding how to break had news. A case study of a patient diagnosed with amyotrophic lateral sclerosis is presented. A psychiatric consultation assisted in assessing the patient's personality and thus preparing the medical staff for breaking the bad news to him. The patient was assessed as having an obsessive-compulsive personality, and consequently the staff was instructed to concentrate on facts and not on feelings when breaking the bad news to him. The patient coped adaptively with this procedure, as did the staff. This case report illustrates that personality assessment may be of benefit in breaking bad news to seriously ill patients. It remains to be seen whether this procedure can be successfully generalized to other patients and settings as well as to other domains of patient education and counseling, and if so--whether this will also prove to be cost-effective.

Significance of success rate of external cephalic versions and vaginal breech deliveries in counseling women with breech presentation at term

OBJECTIVE

To appreciate the role of success rates of external cephalic versions and breech deliveries, in order to assess the risk reduction in women with breech presentation at term.

STUDY DESIGN

We reviewed the patient files of all women with breech presentation whom had an attempt of external cephalic version (ECV) at term. Most of the ECVs were performed under intravenous ritodrine infusion. All women had a trial of labor (TOL) as long as they did not meet one or more of the exclusion criteria of vaginal delivery. Success rates of ECV and TOL were assessed, and statistical analysis was performed by using the student t-test for continuous data, and the Chi-square and Fisher's exact tests for categorical data. Statistically significant differences required a P value of <0.05.

RESULTS

Of all women with breech presentation at term and not in labor, who had no contraindication for an ECV, 164 consented and were included in the study. The success rate of ECV was 30% (22/74) and 67% (60/90) for nulliparae and multiparae, respectively. Multiparity was the only significant positive predicting variable for ECV success (OR=4.73, 95% CI 4.19-5.27, P=0.00001). Of all the women that underwent a successful ECV, 18/22 primiparae (82%), and 52/60 multiparae (87%) had a vaginal delivery, compared to only 52% of the primiparae and 63% of the multiparae that reached labor with a breech presentation. There were no significant perinatal complications except for one case of mild placental abruption. In the primiparous women, ECV decreased the chance of cesarean delivery by only 9% (P=0.2), compared to a 16% decrease in the multiparae (P=0.019).

CONCLUSIONS

When counseling women with breech presentation at term, complete information is needed for consent, and should take into account the success rate of ECVs and of vaginal breech deliveries in the specific center.

Indomethacin for preterm labor: a randomized comparison of vaginal and rectal-oral routes

OBJECTIVE

To compare the efficacy of intravaginal and intrarectal plus oral indomethacin for the treatment of preterm labor.

METHODS

Between December 1996 and November 1998, 46 eligible gravidas admitted with singleton pregnancies and idiopathic preterm labor before 33 gestational weeks were randomized to receive 200 mg of intravaginal or intrarectal plus oral indomethacin.

RESULTS

Twenty-three subjects were allocated to each study group. The interval from initiation of treatment to delivery was significantly longer in the intravaginal indomethacin group (26.5 +/- 5.7 versus 12.6 +/- 3.7 days; P =.007). Delivery was delayed by more than 7 days in 18 of 23 subjects (78%) in the intravaginal indomethacin group compared with ten (43%) in the intrarectal plus oral indomethacin group (P =.03). Birth weights were significantly higher (2306 +/- 436 versus 1862 +/- 232 g; P =.002) and hospitalization in a neonatal intensive care unit (NICU) (3.1 +/- 0.8 versus 9.3 +/- 3. 7 days; P =.001) and mechanical ventilation (1.4 +/- 0.2 versus 5.3 +/- 1.6 days; P =.001) were significantly shorter in the intravaginal indomethacin group.

CONCLUSION

Intravaginal indomethacin is more effective than intrarectal plus oral application in delaying preterm labor and is associated with higher birth weights, shorter NICU stays, and shorter intervals of mechanical ventilation.

Sonographically thick placenta: a marker for increased perinatal risk--a prospective cross-sectional study

The aim of this study was to determine placental thickness by ultrasound examination throughout pregnancy and establish the correlation of sonographically thick placenta with perinatal mortality and morbidity. Placental thickness was determined by routine sonographic examination throughout pregnancy in 561 normal singleton pregnancies. Thick placenta was determined as placenta that was above the 90th percentile. Gravidae between 20-22 weeks' gestation (n=193) and 32-34 weeks (n=73) were then divided into two groups according to placental thickness. The study group consisted of 44 gravidae with thick placenta. The control group included 151 gravidae with placental thickness between the 10th and 90th percentile. A comparison of perinatal mortality and morbidity rates as well as the incidence of small and large for gestational age neonates was conducted.A linear increase of placental thickness was found to correlate with gestational age throughout pregnancy. No statistical differences were observed between the two groups with regard to obstetrical variables such as maternal age, parity and gestational age at delivery. No correlation was found between placental thickness and maternal age or parity. The incidence of perinatal mortality was significantly higher among gravidae with thick placentae (6.82% versus 0.66 per cent, P=0.037, 95 per cent confidence interval 1.71-70.29). Birthweight at term was found to be above 4000 g in 20.45 per cent of the thick-placenta group as compared to 5.3 per cent in the control group (P=0.001, 95 per cent CI 2.08-13.85), and birthweight of less than 2500 g was found in 15. 9 per cent of the thick-placenta group as compared to 7.3 per cent in the control group (P=0.03, 95 per cent CI 1.11-8.14). The incidence of fetal anomalies was 9.1 per cent in the thick-placenta group and 3.97 per cent in the control group (not significant). Sonographically thick placenta is associated with increased perinatal risk with increased mortality related to fetal anomalies and higher rates of both small for gestational age and large for gestational age infants at term.

Umbilical artery waveforms in triplet and quadruplet pregnancies

The incidence of abnormal umbilical waveforms in triplet and quadruplet pregnancies and its correlation with adverse pregnancy outcome was studied by a retrospective review of all our triplet and quadruplet pregnancies (1986-1993) with documented Doppler flow assessment. Obstetrical outcomes were analyzed in relation to abnormal umbilical artery waveforms. Nineteen triplet and 4 quadruplet pregnancies were studied. Of 73 fetuses, 6 had abnormal umbilical artery waveforms (8.2%). All abnormal waveforms were characterized by persistent absence of the end-diastolic velocities (AEDV). In comparing the abnormal and normal groups, significant differences were found in birth weights (910+/-433 vs. 1,724+/-434 g; p = 0.0004), small for gestational age rate [5/6 (83%) vs. 5/67 (7.5%); p = 0.0003], and perinatal mortality rate [3/6 (50%) vs. 2/67(3%); p = 0.001]. There were no differences in congenital anomalies, gestational age at birth, and neonatal intensive care admission. In conclusion, it seems that Doppler umbilical artery waveforms in multiple pregnancies were either normal or extremely abnormal (e.g. AEDV). AEDV was associated with adverse perinatal outcomes such as low birth weight, growth restriction and perinatal mortality.

Pharyngeal flap for velopharyngeal incompetence in patients with myotonic dystrophy

Velopharyngeal incompetence (VPI) has been associated with neuromuscular disorders. Only 4 patients with myotonic dystrophy (MD) who underwent pharyngeal flap elevation for VPI have been reported in the literature. In 3 patients, surgery preceded the diagnosis of MD. Cardiorespiratory complications characterized the postoperative period of 3 patients. The authors present 3 patients with VPI and an established diagnosis of MD (by molecular genetics) who underwent pharyngeal flap elevation. The operation resulted in a major improvement in speech in all patients, although some relapse was noted later in 1 patient. Contrary to previous reports, none had peri- or postoperative cardiorespiratory complications. MD, although an uncommon etiology, should be considered in cases of late-onset VPI. Owing to differences between the authors' findings and previous reports, additional studies are needed before final conclusions can be reached regarding the benefit and safety of pharyngeal flap surgery in MD patients. At present, MD should not be considered a contraindication for this procedure, although close perioperative monitoring is indicated.

Gaucher's disease and pregnancy

Gaucher's disease is an autosomal recessive lysosomal storage disease, resulting from a deficiency of the enzyme glucocerebrosidase, which is required for the lysosomal degradation of glycolipids. The clinical manifestations of the disease show a large heterogeneity, including hepatosplenomegaly, "bone crisis" and fracture, anemia, thrombocytopenia and, in the rarest types II and III, neurological decompensation. Type I, the most common form, usually presents with less severe symptoms and at a more advanced age. More than 30 mutations within the glucocerebrosidase gene have been recognized, and certain mutations seem to be related with a particular phenotype expression of the disease. Modern diagnosis of Gaucher's disease is performed by either determining the enzyme activity in peripheral blood leukocytes or through DNA-based analysis. Pregnancy concurrent with Gaucher's disease has several risks, including an increased severity of anemia and thrombocytopenia that can potentiate postpartum bleeding, and increased risk of infection and possibly an increased spontaneous abortion rate. Nevertheless, the majority of these pregnancies seem to proceed to term without significant complications. The effects that pregnancy might have on the course of the disease are still unresolved. Enzyme replacement therapy with alglucerase is the treatment of choice for patients with Gaucher's disease, but it is yet to be shown whether alglucerase reduces the risk of these complications during pregnancy and whether its use has any adverse effect on fetal development. We present an extensive review of the current literature regarding Gaucher's disease with special emphasis on pregnancies coexistent with this disease and, an analysis of the genetics, relevant prenatal diagnostic issues, and current treatment modalities.

Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata

PURPOSE

Our purpose was to study the unusual and rare late manifestation of severe pelvic abscess, following oocyte pickup (OPU), for in vitro fertilization and embryo transfer (IVF-ET).

PATIENTS

The patients were three infertile women with stage IV endometriosis and ovarian endometriomata, as the sole reason for their infertility. Medical and surgical modalities to treat endometriosis and infertility proved to be unsuccessful.

INTERVENTIONS

All patients were prepared for IVF-ET employing a long GnRH-a and hMG protocol. Transvaginal OPU was performed under ultrasound guidance. Intravenous (i.v.) prophylactic antibiotic was routinely administered.

RESULTS

All women underwent ET, and one conceived. Forty, 24, and 22 days after OPU, respectively, these patients presented with acute symptoms of severe pelvic inflammatory disease (PID) and were found to have pelvic abscess. Broad-spectrum i.v. antibiotics were employed in all cases, however, two patients did not respond and bilateral adnexectomy was eventually performed.

CONCLUSIONS

Severe endometriosis with ovarian endometriomata seems to be a significant risk factor for pelvic abscess development, following transvaginal OPU for IVF-ET. Prophylactic IV cefazolin does not seem to prevent this complication. Late manifestation of pelvic abscess supports the notion that the presence of old blood in an endometrioma provides a culture medium for bacteria to grow slowly after transvaginal inoculation.

Early treatment of gestational diabetes reduces the rate of fetal macrosomia

This study tested the hypothesis that to reduce the rate of macrosomic infants in gestational diabetes cases, good glycemic control should be initiated before 34 completed gestational weeks. The study population included 84 women with gestational diabetes, ascertained by universal screening of all women attending the antenatal clinic of the Hadassah Medical Center, over a 2-year period. The 60 women (71%), who initiated treatment before 34 completed weeks, composed the "early" group. The 24 women (29%), who initiated treatment after the 34th week, composed the "late" group. All patients were managed by an intensified protocol, including stringent glycemic control. In the "early" and "late" groups, mean gestational age at the beginning of treatment was 30.0 +/- 3.8 and 36.2 +/- 1.2 weeks, and duration of treatment was 9.6 +/- 4.1 and 3.7 +/- 1.8 weeks, respectively. Maternal characteristics were similar in the two groups. The rate of macrosomic and large-for-gestational-age infants were 5 and 11%, respectively, in the early group as compared to 25 and 29% in the "late" group (p < 0.05). No significant differences were found between the two groups in the mode of delivery or Apgar scores. We conclude that to reduce the rate of macrosomic infants in gestational diabetes cases, good glycemic control should be initiated before 34 completed gestational weeks.

Legionnaire's disease during pregnancy: a case presentation and review of the literature

Acute pneumonia complicating pregnancy can have serious consequences for both the mother and the fetus. Streptococcus pneumoniae remains the most common bacterial pathogen, but Legionella pneumophila must be considered as well, especially in severe multisystem disease. With severe disease, premature delivery may occur as has been described in the only previous report of Legionnaire's disease during pregnancy. We present here the first report of Legionnaire's disease in pregnancy, resulting in the term delivery of a healthy infant. Also presented is an extensive review of the literature.

Failed trial of vacuum or forceps--maternal and fetal outcome

OBJECTIVE

Our purpose was to compare the maternal and neonatal morbidity associated with a failed trial of instrumental delivery with that of proceeding directly to cesarean section during the second stage of labor.

STUDY DESIGN

All second-stage cesarean deliveries between January 1986 and December 1992 in a tertiary care teaching hospital were retrospectively reviewed. Specific maternal and neonatal outcome parameters were studied to compare the failed instrumental group with the direct-to-cesarean section group.

RESULTS

Of 29,457 live births at > 37 weeks' gestation, 401 women had a cesarean section performed in the second stage of labor. There were 326 cases in which cesarean section was performed directly during the second stage of labor and 75 women who had a failed attempt of instrumental delivery (forceps 33, vacuum 25, both 17) before cesarean delivery was done. The three instrumental groups and the direct-to-cesarean section group did not differ in any of the outcome variables for either mother or newborn.

CONCLUSIONS

Failed instrumental delivery performed as a trial of forceps and/or vacuum in a setting where a cesarean section can follow promptly is not associated with increased morbidity of either mother or baby.

Expectant management of post-term patients: observations and outcome

Post-term pregnancy is associated with increased perinatal mortality. In a retrospective study based on our post-term protocol from 1990 until May 1995 1,798 post-term pregnant women with reliable dating were evaluated for expectant management. A group of 2,633 pregnant women who delivered between 37 and 41 weeks during 1994 served as a control group. The perinatal mortality (0.56 per 1,000 vs. 0.75 per 1,000 in the control group) was similar in both groups. The incidence of induction of labor (7.45% vs. 7% in the control group), meconium of more than +1 (5.2% vs. 4% in the control group), shoulder dystocia (0.33% vs. 0.19%), high birthweight (> 4,500 g) (1% vs. 1%), and cesarean section rates (7.5% vs. 7% in the control group) were similar. However the fetal distress rates (11.6% vs 16%; P = .004), instrumental deliveries (10.1% vs. 13%, P = .002), and the rate of 5-minute Apgar score of less then 7 (1.1% vs. 5%, P = .000001) were found to be significantly lower in the post-date group than in the control group. We conclude that the expectant management and our intensive observation and follow-up in post-term is indicated for both mother and fetus.

Vaginal birth after cesarean section: current opinion

Although the current literature attests to the merits of a trial of labor in the patient with a prior cesarean section, some controversies remain. For example, can women with two or more sections be allowed a trial of labor and can patients who undergo a trial of labor receive oxytocin or prostaglandins for induction? Also, do certain indications for previous cesarean section such as relative cephalopelvic disproportion/failure to progress or the diagnosis of breech or twins in the present pregnancy constitute an indication for elective repeat cesarean delivery? These questions along with some other controversies are discussed in the light of newly accumulated data in the English literature and our own experience over the last decade in a major university-based tertiary medical center.

Therapy and prevention of thrombotic thrombocytopenic purpura during pregnancy: a clinical study of 16 pregnancies

Thrombotic thrombocytopenic purpura (TTP) is a severe multisystem disorder of unknown pathogenesis, with preference to women. The mortality rate of patients with TTP was 90% until the introduction of plasma therapy that increased the survival rate to 70-80%, with minimal or no sequelae. Of the survivors, 30-60% suffer from relapses, often in association with precipitating factors such as infections, surgery, and pregnancy. Women who are either pregnant or in the postpartum period make up 10-25% of TTP patients, and once the disease occurs during a pregnancy, it tends to recur in subsequent ones. We treated five women who suffered at least one TTP episode during pregnancy. They had a total of 16 pregnancies, eight of which were complicated by TTP. They suffered seven additional TTP episodes that were not associated with pregnancy. We assessed the severity of each TTP episode with a scoring system used in our previous studies. Presented is the course of their disease and their pregnancies, and guidelines for the management and prevention of TTP during pregnancy are provided.

Management of labor and labor complications

Obstetricians assume a dual role in the provision of health care for both mother and fetus during labor. Not only do they function as consultants for medical and surgical problems peculiar to labor, but they also assume a more broad-based role in the prevention of labor complications to achieve the best possible health maintenance for both patients. This includes the provision of continuous health care throughout pregnancy, delivery, and postpartum management. A summary of the common problems of management of labor and labor complications is provided, including fetal monitoring during labor, augmentation of labor, vaginal delivery after cesarean section, epidural analgesia and its effects on delivery, and fecal incontinence after delivery.

High delivery intervention rates in nulliparous women over age 35

OBJECTIVE

To assess the effect of maternal age and parity on obstetric interventions and pregnancy outcome.

STUDY DESIGN

A retrospective review of 35,140 deliveries including 4268 parturients aged 35 years or more (1985-1992). Obstetrical interventions and outcome were analyzed in relation to age and parity.

RESULTS

Nulliparous women aged 35 years or more had a 2-fold increase in cesarean delivery rate over younger nulliparae, and 50% more cesarean deliveries than the multiparae aged 35 years or more. Similar trends were observed in preterm labor, labor induction, breech presentation, and instrumental delivery. Higher risk was encountered in neonatal 1 min Apgar scores < 3, and in admissions to the neonatal intensive care unit. There were no differences in all parameters between women over age 40 and women aged 35-40 years. The perinatal mortality was not increased and was similar in all groups.

CONCLUSIONS

Nulliparae aged more than 35 years are at increased risk for interventions and cesarean sections. However, women aged 35-40 have a similar risk as women aged over 40 years.

Abortion rate in assisted reproduction--true increase?

Pregnancies achieved by assisted reproduction were considered to carry an increased risk for spontaneous abortion, and ectopic and heterotopic pregnancies. In order to examine the validity of this hypothesis we compared the outcomes of spontaneous pregnancies and assisted reproduction pregnancies using the published reports in the world literature during the last decade. We also studied the outcome of 53,928 in vitro fertilization (IVF) pregnancies reported during the years 1985-91. The reported loss rates in spontaneous pregnancies (abortions and ectopic pregnancies) compared to pregnancies achieved by assisted reproduction were 19% and 30%, respectively. The differences in loss rates between spontaneous and assisted reproduction pregnancies are not completely understood and may originate from predisposing factors such as tubal disease, uterine disorders, corpus luteum dysfunction, and endometriosis that are more frequent in patients suffering from infertility. Increasing maternal age correlates with a higher risk of fetal chromosomal anomalies which results in an increased rate of abortions.

Acute postpartum inflammatory sacroiliitis. A report of four cases

We report four patients with unilateral postpartum sacroiliitis presenting with agonising unilateral pain, an elevated ESR, elevated alkaline phosphatase levels, leucocytosis and positive bone scans. The diagnosis of a non-infectious inflammatory cause was supported by the postpartum onset, the response to non-steroidal anti-inflammatory drugs, negative aspiration cultures in two cases and the lack of changes in the sacroiliac joints on long-term follow-up radiographs.

Acute postpartum inflammatory sacroiliitis. A report of four cases

We report four patients with unilateral postpartum sacroiliitis presenting with agonising unilateral pain, an elevated ESR, elevated alkaline phosphatase levels, leucocytosis and positive bone scans. The diagnosis of a non-infectious inflammatory cause was supported by the postpartum onset, the response to non-steroidal anti-inflammatory drugs, negative aspiration cultures in two cases and the lack of changes in the sacroiliac joints on long-term follow-up radiographs.

The effect of estradiol depletion during the luteal phase on endometrial development

OBJECTIVE

To examine whether luteal E2 is obligatory for obtaining an adequately developed endometrium.

DESIGN

Survey of women with premature ovarian failure (POF) in a prospective, controlled, randomized study.

SETTING

In vitro fertilization unit in a tertiary care university medical center.

PATIENTS

Fourteen amenorrheic women with POF, candidates for oocyte donation, were divided into two distinct groups with seven women in each subgroup.

INTERVENTIONS

Endometrial priming with a fixed dose of oral micronized E2, 4 mg/d for 14 days, was similarly performed in the study and the control groups. Progesterone replacement during the luteal phase was also identical in the two groups and was accomplished by IM P in oil, 50 mg/d for another 14 days. Only the control group continued to have the same E2 regimen during the luteal phase.

MAIN OUTCOME MEASURES AND RESULTS

Follicular phase mean E2 levels as well as luteal phase mean P levels were similar in both groups. However, luteal E2 levels differed significantly between the study and the control groups (21 +/- 5 and 692 +/- 199 pg/mL, respectively; conversion factor to SI units, 3.671). Nevertheless, histologic evaluation of endometrial biopsies on days 21 and 26 were similar for both groups. Endometrial gland dating, using light microscopy in the study and the control groups, on day 21, was 19.1 +/- 0.8 and 18.4 +/- 0.5, respectively, and on day 26, 25.4 +/- 0.8 and 25.9 +/- 0.5, respectively. Dating of the stroma in the two biopsies was also similar in both groups. Moreover, transmission electron microscopy performed in two patients of the study group showed typical characteristics of a secretory endometrium.

CONCLUSIONS

Luteal E2 depletion in the human does not seem to adversely affect the morphological developmental capacity of the endometrium. Our results suggest that E2 secretion by the corpus luteum in the human does not appear to be obligatory for the development of a normal secretory endometrium. The actual receptivity of the endometrium after such preparation needs to be evaluated.

The effect of progesterone administration in the follicular phase of an artificial cycle on endometrial morphology: a model of premature luteinization

OBJECTIVE

To evaluate the effect of premature P administration on artificially prepared endometrium in women with ovarian failure.

DESIGN

To mimic premature luteinization, patients with ovarian failure were treated with continuous estrogen and episodic P during the follicular phase of artificial cycles.

SETTING

In vitro fertilization unit at a university hospital.

PATIENTS

The study group included 16 patients with ovarian failure who were randomly divided into two groups. Group A (8 patients) was treated by episodic P administration during the artificial follicular phase on days 2 and 7 (12.5 mg of P in oil IM), and in group B (8 patients), P (6.25 mg) was added on days 3, 4, and 5. Another 16 patients (group C), age matched to the study group, were arbitrarily allocated to serve as controls and had standard preparatory cycles without P supplementation in the follicular phase. Serum E2 and P levels and endometrial biopsies were taken on days 14 and 26.

RESULTS

Serum E2 levels were comparable between the study group (group A+B) and controls on both days 14 and 26. Although serum P levels did not differ between the groups on day 26, it was higher in the follicular phase of the study group than in the controls (1.9 +/- 4.0 and 0.2 +/- 0.1 ng/mL, respectively). In the study group, 8 of 16 patients demonstrated early secretory changes in the late follicular phase biopsies, and 9 of 16 women developed stromal-glandular discrepancy in the late luteal phase. This differed significantly from the controls in which only one late luteal biopsy was out of phase.

CONCLUSIONS

Episodic surges of P during the follicular phase may result in impaired endometrial development that cannot be corrected by P supplementation during the luteal phase. This unique model provides evidence for the potential detrimental effect of premature P secretion in the follicular phase on endometrial function.

Complications of assisted reproductive techniques

OBJECTIVE

To review and appreciate the relevant data on assisted reproduction techniques and their potential complications.

DATA RESOURCES

Major publications on assisted reproduction that include the information concerning complications associated with this practice.

RESULTS

Assisted reproduction is a common practice in modern reproductive medicine. Complications are associated with ovulation induction and the extracorporeal methods that are used for IVF-ET, GIFT, and zygote intrafallopian transfer (ZIFT). These complications are associated with laparoscopy, anesthesia, oocyte retrieval, and laboratory facilities. Pregnancies resulting from assisted reproduction are more complicated than spontaneous pregnancies. There are higher rates of ectopic, heterotopic, and multifetal pregnancies; abortions; and premature deliveries. Increased rates of perinatal mortality and morbidity result from prematurity, and higher rates of maternal diseases in pregnancy (preeclampsia, diabetes mellitus, bleeding, anemia) contribute to fetal intra-uterine growth restriction and maternal morbidity.

CONCLUSIONS

Assisted reproduction practice should be well controlled in view of the potential for complications before and during pregnancies.

The effect of growth hormone on granulosa cell function during in-vitro fertilization

The effect of growth hormone addition to human menopausal gonadotrophin (HMG), after pituitary down-regulation, on granulosa cell function, in in-vitro fertilization (IVF) was evaluated. Growth hormone or placebo were added in a prospective, randomized and double-blind manner to an existing IVF stimulation protocol. Forty-two normal ovulatory women (< or = 38 years old) with mechanical factor infertility and normal male factor were included in the study. Gonadotrophin-releasing hormone agonist (GnRHa) was given from day 21 of the previous cycle until human chorionic gonadotrophin (HCG) administration. Follicular stimulation with HMG was started after pituitary down-regulation. Growth hormone 12 IU/day or placebo were administered on alternate days, beginning day 1 until day 7 of HMG treatment. Granulosa cell function was evaluated, in all patients, by follicular fluid levels of ovarian steroids and insulin-like growth factor-I (IGF-I). In 14 patients, chosen arbitrarily granulosa lutein cells were cultured in the presence and absence of additional HCG. Follicular fluid levels of oestradiol, progesterone, testosterone and IGF-I were similar in both growth hormone and placebo groups. Basal and post-HCG levels of oestradiol and progesterone did not differ significantly between the two groups of granulosa lutein cell cultures. We conclude that after pituitary down-regulation, in-vivo administration of growth hormone with HMG in young ovulatory women does not seem to affect granulosa cell function when compared to the administration of HMG alone.

Transverse versus longitudinal uterine incision in cesarean delivery of triplets

It is commonly accepted that cesarean section is the preferred mode of delivery of triplets. The present study was performed to evaluate maternal complications and neonatal outcome in 21 women operated on by a transverse lower segment incision as compared to 8 parturients who underwent surgery by a longitudinal uterine incision. There was no significant difference in mean gestational age at delivery, mean weight of the newborns, Apgar scores, perinatal mortality rates, or intraoperative or postpartum hemorrhage incidence between the two groups. Thus, a transverse lower segment uterine incision should be used in triplet deliveries to increase the chances of a normal vaginal delivery in the future.

The effect of gonadotropin-releasing hormone agonist on embryo quality and pregnancy rate following cryopreservation

OBJECTIVE

To examine the effect of GnRH analogue (GnRH-a) on the quality of frozen-thawed embryos and the pregnancy rate (PR) resulting from transfer.

DESIGN

A retrospective study of two groups of women undergoing transfers of frozen-thawed embryos. In group 1 ovulation induction with hMG was begun after hypophyseal desensitization with GnRH-a for 2 weeks. In group 2 ovulation was induced with hMG only. The freezing and thawing techniques were identical for both groups.

SETTING

In vitro fertilization unit at a university hospital.

PATIENTS

The study group (group 1) included 108 women who underwent 137 transfer cycles of frozen-thawed embryos, and the control group (group 2) included 44 women in 51 cycles of thawed ETs.

INTERVENTIONS

Ovum pick-up and ET techniques were the same for both groups. Methods of embryo freezing and thawing were identical, as were the morphological criteria for grading the embryos.

RESULTS

The morphology of embryos was similar in both groups, as was the number of embryos that had at least 50% intact blastomeres (83% +/- 23% and 78% +/- 30% for group 1 and group 2, respectively). The PR (16 of 137 [11.7%] and 6 of 51 [11.8%], respectively) as well as the abortion rate (30%) were similar for both groups.

CONCLUSIONS

The use of GnRH-a does not affect the quality of embryos nor the pregnancy outcome. Because the yield of frozen embryos per ovum pick-up is higher in cycles stimulated by GnRH-a/hMG, the PR per pick-up cycle is thus anticipated to be higher.

Appraisal of in vitro fertilization

In-vitro fertilization and embryo transfer techniques are now used all over the world (53 countries). The results of 492 of all world units were collected from national surveys and registries of different countries. Since 1985, more than 53,635 women were treated and 34,316 babies were born by 224,473 treatment cycles, followed by more than 160,518 transfer cycles. Only about 65%-75% of all resulting pregnancies attained live births. The remainder ended with spontaneous abortions (26%), or ectopic pregnancies (5.54%). The multiple pregnancy rate (22%) was higher than the normal population and contributed to higher rates of preterm deliveries and perinatal mortality. No increased incidence of chromosomal aberrations and malformations were noted during the years (2.25%). Success rates did not improve significantly within the 5-year period surveyed, in most parts of the world. The indications for treatment were broadened during the years and the procedure became a final step for diagnosis and treatment of unexplained infertility. We conclude that IVF/ET is not an empirical treatment anymore and is a relatively safe procedure, although it should be used only when properly indicated. Male infertility and infertility of unexplained origin may be accepted indications for IVF/ET. More research and centralization of treatment in fewer but large units should be established in order to improve success rates and lower the cost per live birth child. Quality control by professional or public associations should be regulated.

Defective oocytes: a new subgroup of unexplained infertility

OBJECTIVE

To define a new category of unexplained infertility and its potential treatment.

DESIGN

Normal infertile couples underwent prospectively, cross-fertilization attempts in which the wife's oocytes were inseminated by the husband and donor semen. After recurrent failure of fertilization, cross insemination of donor oocytes was attempted with the husband sperm.

SETTING

In vitro fertilization unit at a teaching hospital.

PATIENTS

Three couples who were diagnosed as suffering of unexplained infertility and treated by in vitro fertilization (IVF).

RESULTS

The female partner of these couples produced morphologically normal oocytes that were demonstrated to be functionally defective and failed to fertilize in vitro with both husband and donor sperm. Donated oocytes inseminated by the husband's sperm were fertilized in all patients, demonstrating the normal fertilizing ability of the husbands' semen. One patient conceived and delivered after an oocyte donation.

CONCLUSIONS

Conclusive diagnosis of defective oocytes as a cause of infertility may be made only after IVF and oocyte donation.

Angiotensin-I-converting enzyme and its correlation with human follicular fluid steroids

Angiotensin-I-converting enzyme (ACE) is a peptidyl-dipeptide hydrolase which splits off the dipeptide His-Leu from the decapeptide angiotensin I and thus converts it to angiotensin II. We determined ACE activity in human preovulatory follicular fluid to further establish the intraovarian activity of the renin angiotensin system. Follicular fluids (n = 18) were obtained from eight patients undergoing in vitro fertilization (IVF) and embryo transfer (ET). ACE activity in follicular fluid and serum was determined by fluorescent spectrophotometry. The median follicular fluid ACE activity was 1.12 (range: 0.19-1.56) nmol/min/ml. This value was significantly lower than ACE activity in serum, 1.50 (range: 1.22-1.57) nmol/min/ml (P less than 0.001). In contrast to this 3:4 ratio between follicular fluid and serum ACE when expressed per ml fluid, the values were very similar when expressed per mg of protein: 0.025 vs. 0.023 nmol/min/mg in follicular fluid and serum, respectively. Correlations were sought between follicular fluid ACE activity and both serum and follicular fluid E2 and P4. A highly significant correlation (P less than 0.0005, r = 0.73) was found between ACE activity in follicular fluid and follicular fluid P4. The presence of significant ACE activity in human follicular fluid further supports the local-ovarian activity of the renin angiotensin cascade.

Triplets are not so rare any more

Triplet gestations present a considerable management challenge due to a high rate of antenatal, intrapartum and neonatal complications. The introduction of ovulation inducing agents resulted in a marked increase of these pregnancies. Consequently, triplet conceptions are not considered a rare phenomenon and have become almost routine high risk pregnancies. In our department the triplet gestation frequency increased 2-4 times in a 10 year period from a rate of 0.07-0.14% during 1978-84 to 0.28% of all deliveries in 1987. This high incidence of triplet deliveries results in a threefold increase in the frequency of triplet neonates and their associated complications. It is reasonable to assume that the wide application of various assisted reproductive techniques will result in continuous increase in the incidence of triplets which will in turn require coordinated management of a high risk pregnancy unit, delivery room and neonatal intensive care unit.

Successful pregnancy and normal delivery with Marlex mesh replacement of the abdominal wall

A case of a woman who underwent a wide excision of an abdominal wall desmoid tumor is reported. The lesion was covered with Marlex mesh, and she went through an uncomplicated pregnancy and successful delivery. Management is described and discussed.

Sinusoidal fetal heart rate pattern associated with the twin to twin transfusion syndrome

Sinusoidal fetal heart rate pattern (FHR) is regarded by most authors as signifying a compromised fetus. In most cases, this is secondary to fetal anemia of different causes, usually Rh isoimmunization, more rarely to fetomaternal transfusion, bleeding vasa previa, placental chorioangioma, or traumatic amniocentesis. A case is described which to our knowledge is the first reported of a sinusoidal FHR pattern occurring in the relatively anemic donor twin in a case of the twin to twin transfusion syndrome. The importance of separate antepartum biophysical evaluation of each member of a twin pregnancy is emphasized.