Thromboembolic events in pregnant and puerperal women after COVID-19 lockdowns: A retrospective cohort study

Objective

To explore the indirect impact of the COVID‐19 pandemic on patterns of pregnancy‐related venous thromboembolism (VTE) events, mediated by population mobility restrictions during lockdown periods.

Methods

Pregnancy‐related VTE hospitalizations were identified through a code‐targeted search of the Hadassah Medical Center's computerized database. A manual analysis of relevant medical records was performed, and cases diagnosed throughout the year 2020 were compared to those diagnosed during 2019 and 2018. Statistical analyses studied obstetrical outcomes, as well as the extent and treatment of VTE events during the COVID‐19 pandemic compared to those of preceding years, stratified by pre‐, intra‐, and post‐lockdown periods.

Results

The incidence of pregnancy‐related thromboembolic events during 2020 was 0.16% of all deliveries, significantly higher than in 2018 and 2019 (0.06% and 0.1%, respectively; P < 0.05). Higher rates of VTE events were found during post‐lockdown periods in 2020, compared with corresponding time periods in 2019 and 2018.

Conclusion

The present data suggest that lockdown periods impact pregnancy‐related VTE hospitalizations, possibly as a result of restricted population mobility. Increased awareness of this undesirable outcome may aid health policymakers in the continuing struggle with epidemics.

The present study suggests an association between national lockdowns resulting in relative immobilization and an increase in the incidence of pregnancy‐related venous thromboembolism events.

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

AIM

The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs).

METHOD

Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis.

RESULTS

In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005).

CONCLUSION

The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

INTRODUCTION AND HYPOTHESIS

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

METHODS

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

RESULTS

The patient's postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

CONCLUSIONS

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

Degree of bother from pelvic floor dysfunction in women one year after first delivery

OBJECTIVE

To investigate rates and range of pelvic floor dysfunction complaints, including anterior and posterior compartments and sexual function, in an unselected population of primiparous women one year from delivery, and examine the degree of bother they cause.

STUDY DESIGN

Cross sectional study. Primiparous women who delivered their first child in our delivery wards 10-14 months previously, were approached by phone and asked to complete the Pelvic Floor Symptom Bother Questionnaire (PFBQ) and provide general demographic information. Details regarding participants' labor and delivery were extracted from electronic medical records. PFBQ score was correlated to demographic and labor and delivery parameters.

RESULTS

198 women completed the questionnaire. Response rate was 94%. Scores ranged from 0 to 44.4 (out of a possible 100). At least one symptom of PFD was reported by 64% of respondents. Various degrees of urinary incontinence were reported by 9.1-12.1% of women. Some degree of fecal or flatus incontinence was reported by 10.1% of women; 11.1% reported some degree of obstructed defecation. Severe degree of bother from one or more PFD symptoms was reported by 40.1-90.9%. Some level of dyspareunia was reported by 37.3%. A "dose response" trend between mode of delivery and rate of dyspareunia was observed.

CONCLUSIONS

Two-thirds of primiparous women one year after delivery suffer PFD symptoms that cause some degree of bother. When asked, women are willing to discuss pelvic floor function; caregivers should initiate discussion and refer women promptly to interventions where necessary.

[Urogynecology: from past to future]

Over the last decade, the field of urogynecologic surgery has been subject to deep changes. A thorough understanding of the injury mechanisms responsible for pelvic organ prolapse (POP) and urinary incontinence in women, greatly contributed to the development of innovative surgical techniques and changing therapeutic approaches. The variety of treatment options to correct POP and incontinence has greatly expanded, partly thanks to the development of several advanced surgical kits by biotechnology companies. This review describes the evolution of surgical techniques in the field of pelvic floor reconstruction during the last century and raises questions regarding the safety and efficacy of the various techniques available in this field. This paper summarizes the "state of the art" for POP and the incontinence surgery approach in Western countries. It also provides a number of general recommendations based on the authors personal experience [expert opinion]. Such recommendations with slight variations appear in position statements of professional societies worldwide.

Human factors-focused reporting system for improving care quality and safety in hospital wards

OBJECTIVE

The aim was to develop a reporting system for collecting human factors problem reports to establish a database to guide activities for improving health care quality and patient safety.

BACKGROUND

The current error and incident report systems do not provide sufficient and adequate coverage of the factors contributing to impaired safety and care quality. They fail to examine the range of difficulties that clinical staff encounters in the conduct of daily work.

METHOD

A voluntary problem-reporting system was developed to be used by hospital wards' clinicians and was tested in four wards of two hospitals in Israel. The system is based on human factors--formatted problem reports submitted by physicians and nurses on difficulties and hazards they confront in their daily work. Reports are grouped and evaluated by a team of human factor professionals.

RESULTS

A total of 359 reports were collected in the wards during 12 weeks, as compared with a total of 200 incidents reports that were collected during a period of 5 years with the existing obligatory incident reporting system. In-depth observational studies conducted on the wards confirmed the ability of the new system to highlight major human factors problems, differentially identifying specific problems in each of the wards studied. Problems reported were directly related to general factors affecting care quality and patient safety.

CONCLUSION

Validation studies confirmed the reliability of the reporting system in pinpointing major problems per investigated unit according to its specific characteristics.

APPLICATION

This type of reporting system could fill an important information gap with the potential to be a cost-effective initial database source to guide human factors efforts to improve care quality, reduce errors, and increase patient safety.

[Different interventions during birth and delivery and their connection to pelvic floor damage]

Pelvic floor may be affected by birth and delivery since these are risk factors for muscles, connective tissue and nerve damage. Women with pelvic floor injuries may suffer in the long term from pelvic floor organs prolapse as well as from functional impairment such as urinary and fecal incontinence or other disturbances such as pain and sexual dysfunction. Several interventions have been conducted through birth and delivery by the midwifery team, in order to alleviate discomfort from the mother and to promote mother and infant wellness. Interventions pertaining to the mother's posture, mode of pushing or warm compresses can have an immediate affect and create complications at a later stage. This review aims to examine these interventions and possible pelvic floor damage, based on clinical trials. The authors assume that relying on evidence based practice during labour may promote women's health in both the short and long term.

Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women

OBJECTIVE

We evaluated rate of levator ani muscle (LAM) avulsion among primiparae using 3-dimensional transperineal ultrasound to identify possible risk factors for such trauma.

STUDY DESIGN

We conducted a prospective observational study. Three-dimensional transperineal ultrasound was performed on all subjects. Primiparae were evaluated 24-72 hours after vaginal delivery. In all, 32 nulliparous gravidae (35-41 weeks) and 15 elective cesarean delivery primiparae were evaluated as methodological controls. We compared newborn head circumference (HC), birthweight, second stage duration, maternal age, baby sex, episiotomy, and instrumental delivery.

RESULTS

LAM trauma was observed in 39 of 210 (18.8%) patients and no controls. Odds ratio for LAM trauma when newborn HC >or= 35.5 cm was 3.343 (95% confidence interval, 1.33-8.42); when second stage duration >or= 110 minutes, odds ratio was 2.27 (95% confidence interval, 1.07-4.81). Logistic regression showed that HC >or= 35.5 and second stage duration >or= 110 minutes increased odds of LAM trauma by a factor of 5.32.

CONCLUSION

Large HC and prolonged second stage duration are risk factors in LAM trauma. Elective cesarean delivery may prevent LAM trauma.

Polymorphism in a gene coding for the inflammasome component NALP3 and recurrent vulvovaginal candidiasis in women with vulvar vestibulitis syndrome

OBJECTIVE

Patients with vulvar vestibulitis syndrome (VVS) and control subjects were tested for a polymorphism in the gene coding for the NALP3 component of inflammasomes, cytoplasmic structures regulating interleukin (IL)-1beta production.

STUDY DESIGN

DNA from 143 women with VVS and 182 control women were tested for a length polymorphism in intron 4 of the gene (CIAS1) that codes for NALP3. Vestibular tissue was examined for NALP3 expression. Whole blood cultures were tested for Candida albicans-induced IL-1beta production.

RESULTS

The allele 12 frequency was higher in control subjects than in the patients with VVS (P = .02). Among patients with VVS and a self-reported history of recurrent vulvovaginal candidiasis (RVVC), the allele 7 frequency was 43.9% as compared with 30.8% in patients with no history of RVVC and 26.9% in control women (P = .035 vs other patients and .001 vs control subjects). NALP3 was identified in vestibular tissue. C albicans-induced IL-1beta production was reduced in samples from women with the 7,7 genotype (P = .030).

CONCLUSION

Polymorphism in the CIAS1 gene may play a central role in the triggering of VVS in a subset of patients.

Posterior intra-vaginal slingplasty for the treatment of vaginal apex prolapse: Medium-term results of 140 operations with a novel procedure

OBJECTIVES

Urogynecologists are constantly looking for simple, safe and effective ways to cure vaginal apex prolapse. A novel surgical technique, posterior intra-vaginal slingplasty (PIVS), was reported recently to include both a high therapeutic rate and a low complication rate. The present study was aimed at evaluating the preliminary data of a series of PIVS-treated patients.

STUDY DESIGN

A total of 140 patients with vaginal apex prolapse underwent the PIVS operation in a daycare setting. Pre-operative demographics, operative details and post-operative follow-up data were prospectively collected for all patients.

RESULTS

The PIVS procedure dose requires neither laparotomy nor deep transvaginal dissection as previously required for operative intervention. No intra-operative complications were recorded. The hospitalization period was relatively short. Three patients (2.1%) presented with surgical failure, whereas 137 (97.8%) of the operated patients reported satisfaction with the therapeutic results. One patient had post-operative unilateral gluteal skin infection. She was treated by surgical removal of the infected hemi-tape. Twelve (8.6%) patients had vaginal tape protrusion, of which 11 underwent segmental tape resection at the outpatient clinic. Two patients had spontaneous rejection of the tape while the vaginal apex remained well suspended. One patient suffered from post-operative fever of unknown origin, which was effectively treated with oral antibiotics.

CONCLUSIONS

The novel PIVS operation reduces the complication rate and shortens the rehabilitation period previously reported for the types of operation designed in the past to cure vaginal apex prolapse. The current list of results supports the previously reported efficacy, safety and simplicity of this procedure. However, more long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operative technique.

[Posterior intra-vaginal sling (PIVS) for vaginal vault prolapse after hysterectomy: preliminary results of the first 80 operations with a novel procedure]

BACKGROUND

One of the most significant challenges in surgical gynecology during the last decade was the treatment of vaginal vault prolapse after hysterectomy. Difficult extensive procedures have been advocated for this purpose. The posterior intra-vaginal slingplasty (PIVS) has recently been introduced. This procedure is based on the integral theory of pelvic floor stability and the use of mesh implants to achieve more reliable tissue stability than attaching the prolapsed tissue to the pelvic bones and ligaments.

AIM

To evaluate the therapeutic outcome, safety and complications of the PIVS procedure.

METHODS

A total of 80 post hysterectomy patients with vagina vault prolapse underwent PIVS operation within one year.

RESULTS

All patients but one expressed satisfaction with the 12 months therapeutic results. The PIVS procedure does not require either laparotomy or deep trans-vaginal dissection.

CONCLUSIONS

The PIVS was shown to be safe, effective and minimally invasive, and is therefore recommended as another treatment option for women with post hysterectomy vaginal vault prolapse.

Conservation of the prolapsed uterus is a valid option: medium term results of a prospective comparative study with the posterior intravaginal slingoplasty operation

It has been reported that, by the age of 80, the risk of women to undergo surgery for the treatment of pelvic organ prolapse (POP) exceeds 10%, a percentage expected to increase with the rise in life expectancy. The vaginal approach for POP reconstructive operations is associated with fewer complications and results in a shorter rehabilitation period than the abdominal route, whereas hysterectomy is widely performed concomitantly whenever the uterus is significantly prolapsed. However, there is no clear evidence supporting the role of hysterectomy in improving surgery outcome. We present our experience with a new minimally invasive procedure--the posterior intravaginal slingplasty (PIVS) for correction of advanced uterine prolapse--at the same time, comparing additive vaginal hysterectomy to uterine preservation, to evaluate the therapeutic significance of hysterectomy when vaginal apical prolapse is reconstructed with PIVS. Seventy-nine women presenting with moderate to severe uterine prolapse were enrolled into the current PIVS study. Vaginal hysterectomy was concomitantly performed upon patient's request (44 patients), whereas those wishing to preserve their uterus underwent reconstructive surgery only (35 patients). No intraoperative or postoperative major complications were recorded during an average follow-up of 29.8 months: One patient (1.3%) presented with surgical failure, whereas 71 (89.9%) of the operated patients reported satisfaction with the therapeutic results. Bladder overactivity symptoms declined from three thirds of the patients preoperatively to below 10% postoperatively. Ten (12.7%) patients had vaginal tape protrusion; all underwent segmental tape resection at the out-patient clinic. Because the PIVS procedure does not require either laparotomy or deep transvaginal dissection, as previously required for operative intervention, the hospitalization period was relatively short: 4.2 days for the hysterectomy group and 1.5 for the non-hysterectomy group. Other statistically significant differences between the hysterectomy and non-hysterectomy groups were the average ages (63.5 vs 51.0 years, respectively) and concomitant surgery (87% vs 69%, respectively, the higher percentage due to additive amputation of elongated uterine cervices). No other significant differences were recorded. The current results support the previously reported efficacy, safety, and simplicity of the PIVS procedure as well as the legitimacy of uterine preservation. Moreover, unstable bladder symptoms were found to be improved after this operation. However, long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operation.

[A new minimally invasive procedure for the conservative treatment of uterine prolapse--the posterior IVS]

BACKGROUND

The risk of women who undergo surgery for the treatment of pelvic organ prolapse (POP) by the age of 80 is reported to exceed 10%, and is expected to rise with the increase in life expectancy. Most women affected are in their 5th or 6th decade, and the majority will suffer other medical problems. The current medical literature asserts that the vaginal surgical approach for POP operations are followed by less complications and provide a shorter rehabilitation period than the abdominal route. Hysterectomy is widely accepted as part of POP reconstructive surgery whenever the uterus is significantly prolapsed, however, there is no clear evidence to support the role of hysterectomy in improving surgery outcome. We present our experience with a new minimally invasive procedure - the posterior intravaginal slingplasty (IVS) for utero-suspension in the presence of moderate and advanced uterine prolapse.

AIM

To evaluate the feasibility, intra- and post-operative complications and short term results of the posterior IVS procedure and uterosuspension for uterine prolapse.

METHODS

Reconstructive surgery using the posterior IVS was performed on 18 women with moderate to severe uterine prolapse who chose to preserve their uterus. Patients were then followed 1,6,12 months and 2 years post-operatively to assess any recurrence of pelvic organ prolapse.

RESULTS

No major intra- or post-operative complications were reported. Follow-up of one to 13 months showed good results.

CONCLUSIONS

Reconstructive POP surgery may not necessitate hysterectomy. The posterior IVS is a novel safe, minimally invasive, simple and effective surgical procedure for the treatment of POP, permitting uterine preservation. A larger number of patients and a longer follow-up period are required for proper evaluation of the actual safety and efficacy of this procedure.

Vaginal vault prolapse: Choice of operation

The surgeon who faces a patient with vaginal vault prolapse is dealing with a complex and intriguing challenge. Part of the complexity is due to the lack of standardization and routine application of tools to assess pre- and postoperative anatomical and functional outcomes. Patient satisfaction is a major endpoint for surgical success; thus all aspects of the prolapse pathology and the patient's lifestyle should be considered. The surgeon needs to be well versed and flexible in order to choose the most appropriate operative approach to achieve optimal results for an individual patient. In this chapter we present the vaginal and abdominal approaches for the correction of vaginal vault prolapse, with discussion of the surgical outcomes and complications for each technique. A comprehensive comparison of the various techniques is offered on the basis of current published literature. In addition, we focus on various controversies, including the prevention of vault prolapse at the time of hysterectomy, issues regarding uterine preservation, the management of overt or occult concomitant stress incontinence, and the place-if any-for combined anti-incontinence procedures at the time of prolapse surgery. New minimally invasive techniques for vault prolapse are also reviewed. We emphasize areas that call for further research and for standardized outcome criteria.

Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis

OBJECTIVE

To evaluate the success of a simple modified vestibulectomy in treating vulvar vestibulitis.

STUDY DESIGN

Fifty-nine patients with vulvar vestibulitis refractory to nonsurgical treatment underwent modified vestibulectomy. Response was defined as return to normal coitus and was graded as complete, partial or non-responsive.

RESULTS

The postoperative follow-up period was 6 months-10 years. Thirty-nine (73.6%) patients reported complete response, 7 (13.2%) had partial response, and 7 (13.2%) were non-responsive to surgery.

CONCLUSION

Surgery is an effective treatment for vulvar vestibulitis refractory to conservative treatment. Simple modified vestibulectomy is considerably less invasive, technically simpler and probably less time consuming. Postoperative results employing this surgical procedure are found to be in line with postoperative results reported by others who employ surgical methods that are more extensive.

[TVT-Obturator: preliminary results of the first 100 operations with a novel procedure for the treatment of female urinary stress incontinence]

BACKGROUND

Facing the fact that 20% of the parturient women suffer urinary stress incontinence, urogynecologists are constantly searching for simple, safe and effective ways to cure the underlying pelvic floor herniation. A novel surgical technique was reported lately to entail both high therapeutic rates and low complication rates.

AIM

To evaluate preliminary data from the first 100 TVT-Obturator patient series.

METHODS

A total of 100 patients with urodynamically proven USI underwent the TVT-Obturator operations.

RESULTS

The TVT-Obturator procedure did not require bladder catheterization or intra-operative diagnostic cystoscopy. Operative complications were not recorded. Ninety-three patients reported cure, six patients had minimal residual urinary leak and one patient reported therapeutic failure.

CONCLUSIONS

The TVT-Obturator is a novel mid urethral sling, designed to cure female urinary stress incoritinence and reduce peri-operative complications. These results agree with the previously reported efficacy, safety and simplicity of this procedure. However, long-term data is required prior to incorporating this operative technique within the armamentarium of anti-incontinence procedures.

The significance of intrauterine lesions detected by ultrasound in asymptomatic postmenopausal patients

A retrospective study on 82 women with an incidental sonographic finding suspected to be intrauterine polyps was undertaken to assess the histopathologic characteristics of such polyps utilising operative hysteroscopy. Endometrial polyps were found in 68 patients, submucousal myomas in 7, atrophic endometrium in 6 and thickened proliferative endometrium was found in 1 patient. Simple hyperplasia was found in one polyp but neither endometrial carcinoma nor complex hyperplasia was found. The total complication rate was 3.6%. It appears that the risk of endometrial carcinoma in postmenopausal women with asymptomatic endometrial polyps is low, although a larger series is required to confirm this finding.

Paula method of circular muscle exercises for urinary stress incontinence—a clinical trial

The aim of this study was to determine the efficacy of the Paula method of circular muscle training in the management of stress incontinence (SI). The theory behind this method states that activity of distant sphincters affects other muscles. In a pilot study, 59 women, mainly hospital employees, were randomly assigned to participate in exercises according to the Paula method or pelvic floor training. Efficacy was measured by reports of incontinence, quality of life (I-QOL), pad test, and pelvic floor muscle strength (assessed by perineometer and digital examination). Both the Paula exercises and pelvic floor training produced significant changes in urinary leakage compared to baseline as measured by the pad test [mean decrease of 5.4 g (p=0.002) and 9.5 g (p=0.003), respectively]. Women randomized to the Paula method reported improvement in I-QOL scores. The Paula method was found to be efficacious for SI in a population of Israeli women. Larger community-based studies will be required to confirm these results and enable evaluation of between-group differences.

Spontaneous ovarian hyperstimulation syndrome and hyperreactio luteinalis are entities in continuum

Hyperreactio luteinalis (HL) and spontaneous ovarian hyperstimulation syndrome (OHSS) are both rare conditions during pregnancy. The clinical presentation of HL and OHSS are comparable and both should be differentiated from ovarian carcinoma. We present a case of a 32-year-old woman who was initially seen with markedly enlarged multicystic ovaries and ascites in the 13th week of a spontaneously conceived pregnancy. Ultrasonographic follow-up and magnetic resonance imaging of the ovaries were employed in order to avoid exploratory laparotomy and rule out ovarian carcinoma. The patient received supportive therapy and delivered a healthy child at term. The increasing use of ultrasonography may lead to more frequent findings of multicystic ovaries in spontaneously conceived pregnancies. Making the distinction between HL and spontaneous OHSS in these cases may be difficult though clinically irrelevant as the approach to treatment is similar in both.

Should laparoscopy be a mandatory component of the infertility evaluation in infertile women with normal hysterosalpingogram or suspected unilateral distal tubal pathology?

OBJECTIVE

To assess the diagnostic benefit of laparoscopy in infertile women with normal hysterosalpingography (HSG) or suspected unilateral pathology on HSG.

STUDY DESIGN

Charts of infertile women that underwent complete infertility evaluation between 1996 and 1998 were retrospectively reviewed. Eighty-six patients in whom both HSG and laparoscopy were performed were included in the study. HSG results were compared with laparoscopic findings and the suggested treatment based on HSG results was compared with the treatment plan based on laparoscopic findings.

RESULTS

Among 63 patients with a normal HSG or suspected unilateral tubal pathology, who were assigned to ovulation induction and intrauterine insemination (IUI), 60 patients were found to have laparoscopic findings that did not necessitate any change in the original treatment plan. In three patients (4.8%), abnormalities discovered at laparoscopy were of such an extent that a change in the original treatment regimen and referral to in vitro fertilization (IVF) was needed. Among 23 patients with suspected bilateral tubal occlusion on HSG, 16 patients (69.6%) were found to have an abnormal laparoscopy with bilateral tubal adhesions, 6 patients (26%) had unilateral tubal adhesions, and 1 patient (4.3%) had pelvic adhesions with no obstruction. These latter findings led to changes in the original treatment plan of these seven patients from IVF to ovulation induction and IUI.

CONCLUSIONS

Laparoscopy may be omitted in women with normal HSG or suspected unilateral distal tubal pathology on HSG, since it was not shown to change the original treatment plan indicated by HSG in 95% of the patients. However, laparoscopy should be recommended in cases with suspected bilateral tubal occlusion on HSG, since it altered the original treatment plan in 30% of the patients from IVF to induction of ovulation with IUI. The reassuring results found in the present study may be related to the low prevalence of pelvic inflammatory diseases and endometriosis in our population.

Management of a perforated levonorgestrel-medicated intrauterine device--a pharmacokinetic study: case report

Intrauterine contraception is a widely used, highly effective method of birth control. Uterine perforation is a serious albeit rare complication with the use of an intrauterine device (IUD). Although uterine perforation by the levonorgestrel-releasing intrauterine system (LNG-IUS) has already been described, no plasma LNG concentrations in this setting were reported. Neither has the management of LNG-IUS been commented on to date. Two months after insertion of an LNG-IUS into a 33-year-old woman, it was noted to be in the peritoneal cavity. Laparoscopy for IUD removal was conducted 5 months after insertion. LNG and sex hormone-binding globulin plasma concentrations were measured prior to and following the laparoscopic removal of the IUD. Intra-peritoneal dislocated LNG-IUS resulted in plasma LNG levels 10 times higher (4.7 nmol/l) than the plasma level of LNG observed with LNG-IUS placed in utero. This high plasma LNG level suppresses ovulation. Therefore a misplaced LNG-IUS should be removed when pregnancy is desired.

Intraperitoneal levonorgestrel-releasing intrauterine device following uterine perforation: the role of progestins in adhesion formation

BACKGROUND

Intrauterine contraception is a widely used, highly effective means of birth control. Uterine perforation is a serious, albeit rare, complication of intrauterine device (IUD) use. Although uterine perforation by levonorgestrel-releasing (20 micro g/day) intrauterine system (LNG-IUS) has already been reported, the peritoneal adhesion potential of this IUD is unknown.

METHODS

The medical files of all patients diagnosed with an intra-peritoneal IUD between the years 1990-2002 at Hadassah Medical Center were reviewed. Histopathological study of peritoneal adhesion tissue adjacent to levonorgestrel medicated IUD was conducted in one case.

RESULTS

Eight cases of dislocated IUDs were found. Four cases used LNG-IUS and four other cases used copper-IUD. Laparoscopy for IUD removal disclosed mild local peritoneal adhesions between omentum and pelvic organs in all cases. No difference was noted in the appearance of the peritoneum in the presence of either a copper-IUD or LNG-IUS. Histological examination of peritoneal tissue encasing the levonorgestrel-intrauterine system revealed loose connective tissue with aggregates of submesothelial cells with a pseudo-decidual change. Immunohistochemical staining for progesterone receptor was negative.

CONCLUSIONS

The peritoneal adhesions potential of LNG-IUS is low, similar to that of the copper-bearing IUD.

[Prenatal diagnosis of developmental congenital malformations--the limitations of ultrasound scanning]

Prenatal diagnosis of congenital malformations is a major goal of obstetric sonography. Although significant progress has been made in the ability to detect fetal anomalies by ultrasound, some fetal anomalies cannot be detected during second trimester routine ultrasound scanning. Among the "undiagnosed anomalies" are many fetal anomalies that follow a developmental course in-utero and have a late-onset sonographic appearance, and hence cannot be diagnosed early in pregnancy or during the traditional mid-second trimester scan. Several mechanisms cause in-utero development of fetal malformations, and the developmental course of each fetal anomaly depends on the cause, mechanism, extent and timing of the insult. In some cases the destructive or disruptive event might occur at a relatively advanced gestational age and thus go undiagnosed. Some malformations are the result of an early insult but are manifested and detected late, while others have a "late onset". This concept of the developmental natural course of fetal anomalies in-utero, must be recognized and lead to a new nomenclature for fetal malformations. In this review we describe some developmental fetal malformations and discuss the clinical, diagnostic and medicolegal implications.

Pivotal role of CEACAM1 protein in the inhibition of activated decidual lymphocyte functions

Lymphocytes in direct contact with embryonic extravillous trophoblasts constitute more than 40% of decidual cells and appear to play major roles in implantation and early gestation. A unique subset of NK cells, making up 70-80% of decidual lymphocytes, express high levels of CD56 but lack CD16. We have recently demonstrated a novel class I MHC-independent inhibitory mechanism of NK cell cytotoxicity that is mediated by CEACAM1 homotypic interactions. This mechanism is used by some melanoma cells to avoid attack, mainly by CD16(-) NK cells. We now demonstrate that CEACAM1 is expressed on primary extravillous trophoblasts and is upregulated on the vast majority of IL-2-activated decidual lymphocytes, including NK, T, and NKT cells. Importantly, we present evidence that CEACAM1 interactions inhibit the lysis, proliferation, and cytokine secretion of activated decidual NK, T, and NKT cells, respectively. In vivo analysis of decidual lymphocytes isolated from cytomegalovirus-infected (CMV-infected) pregnant women revealed a dramatic increase in the expression of CEACAM1. Finally, we suggest that a novel ligand for this adhesion molecule is present on the surface of CMV-infected fibroblasts. These combined results demonstrate a major role for the CEACAM1 protein in controlling local decidual immune responses.

[Review of risk factors for breast cancer--what's new?]

Breast cancer is the most common malignancy in women and constitutes 18% of all cancers in women. Female gender, age and country of birth are the strongest determinants of disease risk. Family history and mutations in tumor suppressor genes BRCA1 and BRCA2 are important correlates of lifetime risk. Genetic polymorphisms associated with estrogen synthesis and metabolism are viewed as major factors in breast cancer prevalence in specific populations. Atypical hyperplasia and ductal/lobular carcinoma in situ although uncommon, are considered as pre-malignant conditions as well as markers for invasive breast cancer. Lately, increased bone density and high breast tissue density on mammogram in postmenopausal women have been reported in association with increased risk of breast carcinoma, probably attributable to increased levels of endogenous estrogen. Serum estrogen levels are higher in breast cancer cases as compared with controls. Current use of oral contraceptives and prolonged, current or recent use of postmenopausal hormonal replacement therapy are also considered as risk factors for breast cancer. Tamoxifen and raloxifene, selective estrogen receptor modulators, were shown to reduce breast cancer risk among high-risk women. Various nutrients were evaluated for their possible effect on breast cancer risk but further studies are needed. High socioeconomic status is found to be associated with increased risk of breast malignancy for as yet unestablished reasons. Studying breast cancer risk factors and further research into the molecular etiology of the disease will enable early diagnosis and detection of high-risk women and ultimately improve prognosis.

[Fallopian tube prolapse after hysterectomy]

Fallopian tube prolapse is a rare complication of hysterectomy, characterized by vaginal discharge, abdominal pain, pelvic inflammatory disease and vaginal bleeding. The diagnosis is often delayed, and is usually done after an histopathological examination identifies fallopian tube on biopsy. The advised treatment is surgical resection, which can be done through vaginal incision, abdominally or by laparoscopy. We report a case of fallopian tube prolapse after vaginal hysterectomy in 47-year-old patient in whom the prolapsed-tube was successfully resected vaginally, and review the presentation and surgical methods to correct this rare complication.

Risk of fetal loss in twin pregnancies undergoing second trimester amniocentesis(1)

OBJECTIVE

To assess the rate of fetal loss among bichorionic twin gestations undergoing genetic amniocentesis compared with singletons undergoing the procedure and untested twins.

METHODS

In a retrospective cohort study, three groups were compared: 476 women with twins undergoing amniocentesis, 489 women with singleton gestations undergoing amniocentesis, and 477 women with twins presenting at a similar gestational age for ultrasound studies only. All subjects were scanned at 17-18 weeks' gestation and again approximately 4 weeks after the procedure or first ultrasound scan. Excluded were twin pregnancies after fetal reduction or chorionic villus sampling, fetuses with structural anomalies, and cases in which one fetus had died at the time of examination or after fetal reduction.

RESULTS

Thirteen twin gestations in the tested group (2.73%) aborted spontaneously up to 4 weeks after the procedure compared with three twin controls (0.63%, P =.01) and three post-procedure singleton controls (0.6%, P =.01). An abnormal karyotype was discovered in 15 tested twin pregnancies (3%) and in six tested singletons (1.23%). All affected twin pairs were discordant for the chromosomal anomaly.

CONCLUSION

The risk of early fetal loss in twins undergoing amniocentesis appears to be higher than that of exposed singletons or unexposed twins.

A study of human leukocyte antigen G expression in hydatidiform moles

OBJECTIVE

Human leukocyte antigen G (HLA-G) is a nonclassic major histocompatibility gene normally expressed only in extravillous trophoblasts throughout pregnancy. It may be responsible in part for the successful evasion of the hemiallogenic trophoblasts from maternal immune surveillance. We investigated whether HLA-G is expressed in molar pregnancies.

STUDY DESIGN

We examined 5 complete hydatidiform mole specimens and 5 partial hydatidiform mole specimens to determine whether HLA-G is expressed by immunohistochemistry and by RNA in situ hybridization analysis.

RESULTS

We found that both the protein and RNA of HLA-G is expressed in complete and partial hydatidiform moles.

CONCLUSION

HLA-G RNA and protein are expressed in molar pregnancies. HLA-G expression is independent of embryonic development and may therefore be an integral part of placental development. Furthermore, expression of HLA-G in the complete hydatidiform mole, a naturally occurring androgenote, confirms expression of the paternal allele of HLA-G. Imprinting of HLA-G is therefore unlikely to play a role in protecting fetal trophoblasts from maternal immune rejection.

Tie-2 and angiopoietin-2 expression at the fetal-maternal interface: a receptor ligand model for vascular remodelling

The blood vessels at the fetal-maternal interface widen dramatically during pregnancy in order to increase blood flow to nourish the developing fetus. This vessel remodelling destroys normal vessel integrity and encompasses the dissolution of vessel muscle and elastic tissue. It also includes the displacement of endothelial cells by fetal trophoblasts that invade the maternal arteries of the uterus. Interaction between the endothelial cell receptor, Tie-2, and its recently discovered antagonist ligand, angiopoietin-2 (Ang-2), has been implicated in the loosening of vessel structure. Using Northern blot hybridization and RNA in-situ hybridization analysis the expression pattern of Tie-2, and Ang-2 in the placenta throughout pregnancy, was investigated. We found Ang-2 expressed in the syncytiotrophoblast during the first trimester. In addition to the expected expression of the Tie-2 receptor in both fetal and maternal endothelial cells, we observed Tie-2 expression in endovascular invasive trophoblasts. These cells of epithelial origin invade the uterine spiral arteries and acquire endothelial cell properties. The temporal- and lineage-specific pattern of expression of Tie-2 and Ang-2 suggests that this receptor-ligand pair functions during the critical phase of development of the fetal vasculature and reworking of the maternal vessels during normal placentation.

Young low responders protected from untoward effects of reduced ovarian response

OBJECTIVE(S)

To correlate fertilization and clinical pregnancy rates (PRs) in low responders with their E2 levels (<500, 500-800, >800-1,000 pg/mL), age (20-30, 31-40, >40 years), number of follicles, and number of oocytes retrieved.

DESIGN

A retrospective study.

SETTING

The IVF unit of an academic hospital.

PATIENT(S)

One hundred forty-three women who failed to attain E2 levels of 1,000 pg/mL on the day of hCG administration.

INTERVENTION(S)

Controlled ovarian hyperstimulation, blood E2 and progesterone measurements, ultrasonographic scanning of ovarian follicles, oocyte retrieval after hCG administration, and ET.

MAIN OUTCOME MEASURE

Clinical PR.

RESULT(S)

Although E2 levels, fertilization rates, age, and number of oocytes did not differ significantly between the three age groups, the PR achieved in the youngest group was approximately three times as high (19.3%) as that achieved in the two older groups.

CONCLUSION

Young low responders represent a unique subset in that their age protects them from the deleterious effects of poor ovarian response.

Observer variability in the diagnosis and management of the hysterosalpingogram

OBJECTIVE

To determine the reproducibility of hysterosalpingogram (HSG) interpretation and clinical management recommendations among trained observers.

DESIGN

Fifty HSG films were distributed to five fertility practitioners with a mean of 20 years clinical experience. Each observer evaluated components of uterine and tubal status and provided clinical recommendations for hysteroscopy and laparoscopy.

SETTING

University hospital-affiliated reproductive endocrine practice.

INTERVENTION(S)

None MAIN OUTCOME MEASURE(s): The level of agreement among observers for each uterine and tubal category as determined by the kappa(kappa) statistic. Determinants of clinical recommendation for further diagnostic studies were assessed.

RESULT(S)

The level of agreement between observers as determined by kappa ranged from 0.645 in the hydrosalpinx category, indicating fair reliability, to 0.111 for pelvic adhesions, indicating poor reliability. The composite kappa for uterine status was 0.345 whereas the composite kappa for tubal status was 0.430. Agreement among observers concerning management showed marginal reproducibility with a kappa of 0.261. Overall, more than one abnormality of either the cavity or the fallopian tubes led to a diagnostic recommendation for further workup in > or = 90% of cases.

CONCLUSION(S)

In a group of five experienced clinicians, there was considerable variability in the interpretation as well as the clinical management of the HSG. Physicians caring for infertile couples should be aware of this discrepancy and should, if possible, review carefully both the original films as well as the report of the attending radiologist in formulating their diagnostic evaluation and management plan.

Characterization of intraperitoneal cytokines and nitrites in women with severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the potential involvement of cytokines and nitrites in the hyperpermeability characterizing the ovarian hyperstimulation syndrome (OHSS).

DESIGN

A controlled clinical study comparing peritoneal fluid (PF) from patients with severe OHSS and from non-OHSS controls.

SETTING

Women hospitalized with severe OHSS in three tertiary medical centers.

PATIENTS

Twelve patients with severe OHSS necessitating paracentesis and 20 non-OHSS controls.

INTERVENTIONS

The criteria for ultrasound-guided paracentesis were tense ascites, hydrothorax, hemoconcentration, or oliguria.

MAIN OUTCOME MEASURES

Interleukin (IL) 1 beta IL-1 receptor agonist, IL-2, IL-6, IL-8, and tumor necrosis factor alpha (TNF alpha) levels in PF were assayed by ELISA; nitrites were measured by the "Griess" reaction. Estradiol and P were determined by RIA.

RESULTS

Ovarian hyperstimulation syndrome patients had significantly higher PF IL-6 (3,523 versus 30 pg/mL), TNF alpha (14 versus 4.2 pg/mL), and IL-8 (1,695 versus 900 pg/mL). In the serum, only IL-6 levels were significantly higher (375 versus 11 pg/mL). Conversely, nitrite levels were significantly lower in PF of OHSS patients (0.5 versus 34 nmol/mL). Interleukin 1 levels were higher and IL-1 receptor antagonist levels were lower in OHSS patients, suggesting potentially increased biologic potency of IL-1.

CONCLUSION

These findings suggest that these substances could be involved in mediating the capillary hyperpermeability characterizing this syndrome.

Interleukin-1-mediated stimulation of prostaglandin E production is without effect on plasminogen activator activity in human granulosa lutein cell cultures

In continuation of earlier observations on the involvement of interleukin-1 (IL-1) in ovarian function, we examined the ability of IL-1 to modulate plasminogen activator (PA) activity and prostaglandin (PG) synthesis in human granulosa lutein cells (GLCs). Toward this goal, GLCs were obtained from women undergoing in vitro fertilization, preincubated with 10% fetal calf serum for 48 h, and subsequently cultured for 48 h in serum-free media in the absence or presence of IL-1 beta (10 ng/mL). Cellular PA activity was measured by plasminogen-dependent cleavage of the chromogenic substrate H-D-valyl-L-leucyl-L-lysine-p-nitroanilide (S-2251). Prostaglandin E (PGE) levels were assayed by conventional RIA. Exposure of GLCs to IL-1 resulted in a 50% increase in PGE production, a 33% suppression of PA activity, and a 75% increase in the ability of the corresponding conditioned media to inhibit exogenous urokinase activity. The inhibitory capacity was attributable to an IL-1-mediated increase in PA inhibitor type-1 (PAI-1) production, inasmuch as urokinase inhibition could be abolished by the administration of a polyclonal antihuman PAI-1 immunoglobulin G. IL-1 treatment had no effect on plasmin or trypsin inhibition. Exposure of GLCs to IL-1 receptor antagonist abolished the ability of IL-1 to enhance PA inhibitory activity and PGE production, thereby establishing specific IL-1 receptor-mediated effects. The ability of IL-1 to suppress PA activity and to produce PAI-1 persisted in the presence of indomethacin, a potent inhibitor of PG synthesis. Likewise, transforming growth factor-beta 1 suppressed the ability of IL-1 to stimulate PGE production without affecting the IL-1-induced effects on the PA system. The present findings suggest a pluripotent response of GLCs to IL-1, characterized by the induction of PAI-1 and the suppression of PA occurring concurrent with, but independent of, PG production. These observations support the potential involvement of IL-1 in the regulation of human ovulatory processes.

Fetal middle cerebral artery blood flow during normal active labour and in labour with variable decelerations

OBJECTIVE

To assess the distribution of fetal blood flow impedance of the umbilical and middle cerebral artery in active uncomplicated labour and in labour complicated by variable decelerations.

INTERVENTIONS

Blood flow impedance of the umbilical and fetal middle cerebral arteries was assessed by means of pulsed Doppler ultrasonography and measured by the resistance index (RI) and the systolic/diastolic ratio.

SUBJECTS

35 women at 38-40 weeks gestation admitted to, or monitored in the intrapartum unit. One group of 25 women had a normal active labour, the second group of 10 women were in active labour with moderate variable decelerations. A control group of 25 women--healthy pregnant women at term but not in active labour. All three groups were comparable for maternal age and parity.

SETTING

Hospital department of obstetrics and gynaecology, Israel.

DESIGN

A prospective descriptive study.

RESULTS

There was a 40% reduction in middle cerebral artery blood flow impedance in the two groups of women in active labour compared with the control group. Umbilical blood flow did not differ significantly between the three groups. Fetal middle cerebral blood flow impedance in labour was not significantly different in uncomplicated labours and those complicated by fetal heart rate decelerations.

CONCLUSIONS

During active labour, mechanisms that may be unrelated to low fetal blood oxygen content reduce fetal brain blood vessel impedance.

Third trimester torsion of persistent ovarian cyst following ovarian hyperstimulation--an unusual cause of preterm labor

Herein, a patient being operated for cesarean section due to preterm labor in the 31st week of a triplet pregnancy induced by gonadotropins is being described. On celiotomy, peritoneal effusion was present secondary to torsion of a 10 x 6 cm right ovarian cyst. This uncommon finding contradicts the common belief that the chances for an ovarian cyst in the overcrowded peritoneal space due to a 40-week-size uterus to twist around its pedicle are remote. The possibility that preterm labor was initiated by the torsion is discussed.

Extraluminal hyperechogenic echo detected by transvaginal ultrasonography as a prognostic factor in recurrent hydatidiform mole

Measuring beta hCG titers by either bioassay or radioimmunoassay has become the cornerstone in the management and treatment of hydatidiform mole. It is this very determination which will indicate either spontaneous remission or the need for chemotherapy treatment due to rising or plateauing titers. Herein, we report on the potential assistance of a unique ultrasonographic appearance of a hyperechogenic shadow located in the uterine wall, before and after an attempt for full evacuation of hydatidiform mole. The behavior of this echogenic area was more sensitive in predicting the course of the disease than did the beta hCG titers. Thus, using transvaginal sonography may serve as another predictor and indicator in evaluating the treatment of hydatidiform mole.

Increased middle cerebral artery blood flow impedance in fetal subdural hematoma

This case describes the prenatal diagnosis at 30 weeks' gestation of a posterior fossa subdural hematoma. Doppler velocimetry studies of the middle cerebral artery at that time showed an abnormally high resistance pattern with reverse end-diastolic flow. Ultrasonic assessment of the fetus indicated that there was associated quadriplegia. No cause for the lesion was demonstrated. A fetal blood sample, obtained by cordocentesis, revealed a normal karyotype. Fetal blood gas analysis was also normal. The pregnancy was terminated at the parents' request.