Clinical utility of esophagogastroduodenoscopy in the management of recurrent and intractable vomiting in pregnancy

OBJECTIVE

To determine the impact of esophagogastroduodenoscopy (EGD) on the clinical management of pregnancy women with recurrent vomiting and their pregnancy outcome.

STUDY DESIGN

Retrospective evaluation of 60 pregnant women who underwent diagnostic EGD in the first trimester of pregnancy.

RESULTS

Pregnant women were divided into 2 groups according to the indications for EGD: group 1, intractable vomiting with or without epigastric pain (n = 49) and group 2, vomiting and gastrointestinal bleeding (n = 11). The endoscopic findings found in both groups were esophagitis (43%), gastritis (17%), diaphragmatic hernia (17%) and normal EGD (28%). The diagnostic yield for EGD was 69% for group 1 and 82% for group 2. EGD was helpful for clinical management when performed for suspected gastrointestinal bleeding rather than for other indications. Mean gestational age at delivery, fetal weight and mean Apgar score did not differ by groups. No fetal malformations were observed.

CONCLUSION

Recurrent intractable vomiting in pregnancy may be accompanied by esophagitis or peptic disease in a significant proportion of patients. Based on the significant pathologies amenable to medical therapy, a therapeutic trial with a proton pump inhibitor during hyperemesis gravidarum seems warranted. EGD can be safely performed in pregnancy with no maternal or fetal complications.

Sonographic characteristics of the uterine cavity following first-trimester uterine evacuation

OBJECTIVE

To characterize the sonographic appearance of the uterine cavity after first-trimester uterine evacuation and to follow the evolution of these findings in an attempt to reduce the number of unnecessary surgical interventions following evacuation.

METHODS

We studied retrospectively the sonographic characteristics of the uterine cavity in 599 women, 5-8 days after first-trimester uterine evacuation. The patients were grouped according to the sonographic appearance of the uterine cavity. Patients with abnormal sonographic patterns were followed weekly until sonographic resolution.

RESULTS

Group 1 included 351 (58.6%) women with normal endometrium; Group 2 included 130 (21.7%) women with hypoechoic endometrial content only; Group 3 included 69 (11.5%) patients with mixed type (hypoechoic and hyperechoic) endometrial content; Group 4 included 49 (8.2%) patients with hyperechoic endometrial content only. The time needed until the uterine cavity was considered normal was significantly longer in Group 4 (median, 12 days) compared with Groups 3 and 2 (8 and 9 days, respectively, P < 0.0001). The duration of vaginal bleeding after the surgical procedure was longer in Group 4 (median, 10 days) compared with Groups 3, 2 and 1 (9, 7 and 5 days, respectively, P < 0.0001). Clinically, the patients were divided into two groups: asymptomatic (575 patients) and symptomatic (24 patients). The thickness of the abnormal endometrial content in the asymptomatic patients gradually decreased until normalization, around the time of menstruation. There was no such change in the symptomatic patients, who eventually needed surgical intervention.

CONCLUSIONS

An abnormal intrauterine sonographic pattern 5-8 days following first-trimester uterine evacuation is common and usually resolves spontaneously around menses. Therefore, in asymptomatic patients, we recommend a conservative approach.

Platin sensitivity and long-term survival in Stage III epithelial ovarian cancer patients

PURPOSE

The aim of the present study was to assess the effect of platin sensitivity on long-term survival of Stage III epithelial ovarian cancer (EOC) patients.

METHODS

The records of all histologically confirmed Stage III EOC and PPC patients diagnosed during 1995-2006 were reviewed. A comparison of selected characteristics was made between long-term (> 5 years) and short-term (< 3 years) survivors.

RESULTS

Among 58 Stage III patients, 20 had long-term and 18 short-term survival. The rate of platin sensitive patients in long-term survivors was significantly higher than in short-term survivors (95.0% vs 27.8%, p < 0.001). The sensitivity and specificity of platin sensitivity for long-term survival was 95% and 72.2%, respectively, and the positive and negative predictive value was 79.2% and 92.8%, respectively. No statistically significant difference between the groups was found with regard to other selected characteristics.

CONCLUSION

The rate of platin sensitive patients was significantly higher among long-term survivors than among short-term survivors but the specificity and positive predictive value of platin sensitivity for long-term survival prediction were relatively low precluding its practical clinical use.

Follicular growth and development under continuous gonadotropin-releasing hormone antagonist administration

OBJECTIVE

Ovarian follicle and cyst formation have been recognized as an advance phenomenon associated with GnRH agonist administration. With the use of GnRH antagonists, pituitary suppression is immediate and no flare effect and follicle growth are expected. We describe two patients who developed a dominant follicle and presumably ovulated in response to hCG triggering under continuous sole administration of a GnRH antagonist.

DESIGN

Case report.

SETTING

An IVF unit at a university hospital.

PATIENT(S)

Two young healthy female patients undergoing IVF because of male-factor infertility.

INTERVENTION(S)

Continuous daily administration of a GnRH antagonist from menstruation with the aim of achieving ovarian suppression.

MAIN OUTCOME MEASURE(S)

Endocrine and ultrasound characteristics of follicular growth.

RESULT(S)

Both patients developed a dominant follicle under sole administration of a GnRH antagonist, accompanied by a gradual rise in serum estradiol and endometrial thickness which culminated in a spontaneous LH surge. Ovulation was triggered by hCG and mid-luteal progesterone levels were suggestive of ovulation.

CONCLUSION(S)

We describe for the first time the development of a dominant follicle and presumable ovulation under continuous administration of a GnRH antagonist. Serum gonadotropin concentrations indicate that the pituitary failed to suppress in both patients. The exact mechanism of this phenomenon remains to be elucidated.

Re-laparotomy after cesarean section

OBJECTIVE

To assess the rate, indications, and outcome of re-laparotomy after cesarean section in the early postoperative period.

DESIGN

A retrospective observational study during a 121-month period.

SETTING

A tertiary care university center.

POPULATION

A cohort of 3380 women who underwent cesarean section out of 18,609 parturients.

MAIN OUTCOME MEASURES

Incidence of re-laparotomy after cesarean section in the early postoperative period.

RESULTS

The incidence of re-laparotomy after cesarean section was 0.53% (18/3380). Of these 18 women, 12 (66%) were operated for hemorrhage, 3 (17%) for eventration, and 3 (17%) for formation of intra-abdominal abscess. Hysterectomy was required in one case (5.5%). We had no maternal mortalities.

CONCLUSION

Although the incidence of re-laparotomy after cesarean in the early postoperative period is low and the outcome is favorable, several measures must be undertaken to reduce the need for re-laparotomy.

Reduced pseudocholinesterase activity in patients with HELLP syndrome

The authors previously reported a case of decreased pseudocholinesterase activity in a patient with HELLP syndrome. It was assumed that the reduced pseudocholinesterase activity in HELLP syndrome is associated with impaired liver function. The present study assesses the prevalence of low pseudocholinesterase in patients with HELLP syndrome. Serum pseudocholinesterase activity was determined with spectrophotometer in 15 patients with HELLP syndrome. Two control groups matched for gestational age were recruited: 15 healthy women with uncomplicated pregnancy and 15 women with severe preeclampsia without HELLP. The prevalence of reduced pseudocholinesterase activity lower than normal limit was 60.0% (9/15) in patients with HELLP syndrome, 33.3% (5/15) in patients with severe preeclampsia, and 6.6% (1/15) in women with normal pregnancy, respectively (P =.009). The pseudocholinesterase activity was found to correlate with serum alanine aminotransferase levels (r = 0.417, P = .006) and with serum aspartate aminotransferase levels (r = 0.462, P = .002). Considering the increased prevalence of reduced pseudocholinesterase activity in patients with HELLP syndrome, the authors suggest that whenever general anesthesia is applied in these patients, the anesthesiologist should be aware that the patient may show slow metabolic degradation of choline-ester drugs.

Once a cesarean always a cesarean? A computer-assisted decision analysis

OBJECTIVE

A previous decision analysis models for two strategic choices for trial of labor or repeated cesarean after prior cesarean concluded that the degree of wish for an additional future pregnancy appeared to be a major determinant for choice between the two strategic options. We had extended the analysis model to stillbirth and hypoxic-ischemic encephalopathy in addition to placental complications while updating most of the outcomes in the decision tree.

STUDY DESIGN

A model was formulated using a decision tree based on reported probabilities for various outcomes and estimated utilities. The question asked was should trial of labor or repeated cesarean be performed after a prior cesarean, with a varying desire for an additional pregnancy. The highest expected outcome determines the preference of our model.

RESULTS

Our model favors repeated elective cesarean (0.9947) over trial of labor (0.9917) after a previous cesarean and is the preferred approach. This approach was preferable irrespective of the probability of additional pregnancy.

CONCLUSION

In contrary to previous models, when taking into account the occurrence of a live infant birth, birth of an infant with hypoxic-ischemic encephalopathy stillbirth, neonatal death, abnormal placental implantation, hysterectomy and maternal death the preferred approach for women with previous cesarean is an elective repeated cesarean rather than trial of vaginal delivery.

Efficacy and toxicity of weekly topotecan in recurrent epithelial ovarian and primary peritoneal cancer

OBJECTIVES

We assessed the efficacy and toxicity of once-weekly topotecan (Hycamtin; GlaxoSmithKline) for relapsed or persistent epithelial ovarian cancer (EOC) and primary peritoneal carcinoma (PPC).

METHODS

Patients with recurrent or persistent EOC and PPC previously treated with > or = 1 course of platinum-based chemotherapy were treated with weekly topotecan 4.0 mg/m2 on days 1, 8, and 15 of a 28-day cycle in this prospective open-label, single-arm, phase II study.

RESULTS

The median age of the 63 study patients was 63 years (range, 36-88); patients had been previously exposed to a median of 1 course (range, 1-4) of chemotherapy. A median of 5 courses (range, 1-16) were administered. Median follow-up time was 13. 2 month s (range, 1.5-39.0). The overall response rate (RR) was 23.8%, of which 17.5% (11 patients) represented a complete response and 6.3% (4 patients) a partial response. Patients with platinum-sensitive disease had a RR of 20%, whereas patients with platinum-resistant disease had a RR of 28.6%. Median time to progression was 6.2 months (95% confidence interval: 4.43, 7.97), and median survival from initiation of topotecan therapy was 22.3 months (95% confidence interval: 14.56, 30.04). Hematologic toxicities included grade 3 anemia in 3 (4.8%) patients, grade 3 thrombocytopenia in 3 (4.8%) patients, and grades 3-4 neutropenia in 5 (7.9%) patients. Dose reductions, granulocyte colony-stimulating factor, and erythropoietin support were required by 10 (15.9%), 6 (9.5%), and 16 (25.4%) patients, respectively. The most frequent nonhematologic toxicities were grades 2-3 fatigue in 10 (15.9%) patients and grades 2-3 nausea/vomiting in 3 (4.7%) patients.

CONCLUSION

Weekly administration of topotecan 4.0 mg/m2 is active and well tolerated by patients with recurrent or persistent EOC and PPC.

Assessment of Her-2/neu expression in hydatidiform moles for prediction of subsequent gestational trophoblastic neoplasia

OBJECTIVE

The aim of the present study was to asses the ability of Her-2/neu immunohistochemical staining of the molar tissue to predict the risk of developing gestational trophoblastic neoplasia (GTN).

METHODS

Sections prepared from 33 consecutive formalin-fixed paraffin-embedded archival reconfirmed hydatidiform mole tissue blocks were immunohistochemically stained for Her-2/neu. The staining was scored according to the subjectively evaluated intensity of staining and the proportion of stained villous cytotrophoblastic cells. Clinical data were abstracted from medical files.

RESULTS

23 patients had a complete and 10 a partial mole. Nine patients (27.3%) were diagnosed with GTN [7 of 23 patients with a complete mole (30.4%) and 2 of the 10 (20.0%) with a partial mole]. A positive immunohistochemical Her-2/neu stain was found in 6 (18.2%) of the patients with hydatidiform mole (3 with a complete mole). The rate of Her-2/neu expression was somewhat higher in moles with subsequent GTN than in moles with an uneventful course (22.2% vs. 16.6%, respectively). The difference did not reach significance (Fisher's Exact Test, P=0.55) possibly due to the small number of cases (power of <5%). The sensitivity and specificity of Her-2/neu expression for prediction of GTN was 22.2% and 83.3%, respectively, and the positive and negative predictive value 33.3% and 74.1%, respectively.

CONCLUSION

While the specificity of Her-2/neu immunohistochemical staining for prediction of GTN is relatively high, the low sensitivity and low positive and negative predictive value precludes its practical clinical use for prediction of post-molar GTN. The quest for a precise predictor of post-molar GTN should continue.

Total and differential leukocyte counts percentiles in normal pregnancy

OBJECTIVE

To establish leukocyte count and leukocyte differential percentiles in normal uncomplicated pregnancy.

STUDY DESIGN

This retrospective longitudinal study was performed in an outpatient facility for routine antenatal care. The study population comprised of 726 healthy women from the 5th to the 41st week of pregnancy. Altogether, there were 1749 complete blood count evaluations, of which 481 were in the 1st trimester, 687 in the 2nd trimester and 581 in the 3rd trimester. The total and differential leukocyte counts were determined by an automated cell counter.

RESULTS

The leukocyte and neutrophil counts gradually and significantly increased form the 1st to the 3rd trimester. The monocyte count increase became significant only during the 3rd trimester. The eosinophil count did not significantly change throughout pregnancy. The basophil count significantly decreased during the 2nd trimester and returned to 1st trimester values during the 3rd trimester.

CONCLUSION

In this study, we provide total and differential leukocyte counts' mean+/-S.D., minimal and maximal values, and the 3rd, 5th, 10th, 50th, 90th, 95th, and 99th percentiles for entire pregnancy and for each trimester separately. These reference values should prove useful for diagnostic and research purposes.

Distribution of cervical intraepithelial neoplasia across the cervix is random

OBJECTIVE

This study was undertaken to assess the validity of an assumption that histologically confirmed cervical intraepithelial neoplasia (CIN) lesions are not randomly distributed across the cervix.

STUDY DESIGN

This retrospective study included 359 women ranging in age from 17-81 years (mean +/- SD, 34.4 +/- 12.1 years) who underwent colposcopically directed cervical biopsy. Data were examined to determine the distribution of histologic diagnosis across the cervix. The study had 80% power to detect a true, relative by-location difference.

RESULTS

Two hundred ninety (80.8%) women were classified as nondysplastic, whereas 69 (19.2%) were classified as dysplastic (CIN1, or CIN2, or CIN3). The most common location for biopsy was the 11 o'clock position (22%), whereas the least common location was the 10 o'clock position (0.8%). The most common location for dysplastic as well as nondysplastic lesion was the 11 o'clock position. No association was found between types of histologic lesion on colposcopically directed biopsy and location of lesion.

CONCLUSION

Contrary to previous assumptions, histologically confirmed CIN lesions are randomly distributed across the cervix site.

Timing intra-Fallopian transfer procedures

With the gradual decline in the use of zygote intra-Fallopian transfer (ZIFT), current practice is to offer ZIFT almost exclusively to patients with repeated implantation failure (RIF). For practical reasons, the procedure is sometimes deferred by 1 day and embryo intra-Fallopian transfer (EIFT) is performed. The aim of the present study was to compare the reproductive outcome of ZIFT versus EIFT. In a retrospective analysis, 176 patients who failed in 7.65 +/- 3.7 previous IVF cycles underwent 200 ZIFT and 73 EIFT procedures. Implantation and live birth rates were compared for both groups. Patients in both groups were found comparable for demographic and clinical parameters. Similar numbers of oocytes were retrieved and fertilized in both groups, and 5.2 +/- 1.2 zygotes/embryos were transferred. Implantation and live birth rates (10.5 and 26.5% versus 10.9 and 24.7% for ZIFT and EIFT respectively) were comparable. It is concluded that tubal transfer of zygotes and day-2 cleavage stage embryos are equally effective.

Different degrees of fetal oxidative stress in elective and emergent cesarean section

BACKGROUND

Several studies have addressed the influence of labor and mode of delivery on oxidative stress. Still it is unclear whether oxidative stress is related to delivery itself or whether it reflects a pre-existing fetal oxidative status.

OBJECTIVE

To investigate whether the degree of fetal oxidative stress is different between distressed fetuses that were delivered by emergent cesarean section and non-distressed fetuses that were delivered by elective cesarean section.

METHODS

The protocol of this prospective study was approved by the Institutional Review Board Committee. Amniotic fluid and umbilical artery blood were prospectively collected from 21 parturients who were delivered by an emergent cesarean section for non-reassuring fetal heart rate pattern and from 21 parturients who were delivered by an elective cesarean section in a tertiary care center. Oxidative stress was evaluated in amniotic fluid, umbilical cord plasma and erythrocytes by determining malondialdehyde concentration and glutathione peroxidase (GPX) activity.

RESULTS

Malondialdehyde concentration was higher in amniotic fluid (mean +/- SEM) (2.2 +/- 0.7 nmol/l vs. 0.6 +/- 0.02 nmol/l, p < 0.05), in umbilical cord plasma (1.2 +/- 0.2 nmol/l vs. 0.7 +/- 0.3 nmol/l, p < 0.05) and in umbilical cord erythrocytes (159.6 +/- 48.6 nmol/g Hb vs. 85.8 +/- 5.2 nmol/g Hb, p < 0.05) in women delivering by emergent cesarean compared to those delivering by elective cesarean. GPX activity was enhanced in amniotic fluid (12.4 +/- 2.2 U/l vs. 5.1 +/- 0.6 U/l, p < 0.05) and GPX activity/hemoglobin ratio was higher in cord blood (22.0 +/- 0.8 U/g Hb vs. 18.7 +/- 0.9 U/g Hb, p < 0.05) in women delivering by emergent cesarean compared to those delivering by elective cesarean.

CONCLUSION

Distressed fetuses delivered by emergency cesarean exhibited increased malondialdehyde concentrations, an indicative parameter for oxidative damage, and enhanced GPX activity an antioxidant enzyme, in amniotic fluid and umbilical cord blood compared to non-distressed fetuses delivered by elective cesarean section. This is probably an indication of higher fetal oxidative stress.

Cord around the neck: should it be severed at delivery? A randomized controlled study

Umbilical cords often become encircled around portions of the fetus, usually the neck. The incidence ranges from 21% in one loop to 0.2% in three loops. In the present study, we assessed the practice of severing the cord, which was encircled once around the neck of the fetus, after delivery of the anterior shoulder and prior to extraction of the body. This was a prospective, randomized, controlled study. The study and the control groups included 30 women each. Cord around the neck was diagnosed during labor by ultrasound. It was cut intentionally in the study group and left intact in the control group. Demographic data were obtained. The course of labor was assessed. Neonatal outcomes measured were cord pH, Apgar scores at 5 minutes, and need for resuscitation. Length of maternal and neonatal hospitalization was determined. No differences were found between the study and the control group before, during, and after labor regarding perinatal variables such as meconium-stained amniotic fluid, fetal heart rate patterns, Apgar scores at 5 minutes, and umbilical cord pH after delivery (7.29 +/- 0.07 [SD] in the study group and 7.32 +/- 0.06 [SD] in the controls; p=0.1). Single nuchal encirclement by the umbilical cord during labor, after delivery of the anterior shoulder, can be severed or left intact. We could not detect any adverse perinatal outcome in such deliveries.

Is Her-2/neu expressed in nonepithelial ovarian malignancies?

OBJECTIVE

The objective of this study was to assess the expression of Her-2/neu in nonepithelial ovarian malignancies.

STUDY DESIGN

Formalin-fixed paraffin-embedded archival tissue blocks of 20 unselected nonepithelial ovarian malignancies (12 granulosa cell tumors and 8 germ cell tumors) diagnosed between 1993 and 2005 were immunohistochemically stained for Her-2/neu.

RESULTS

Immunohistochemical staining for Her-2/neu was not present in any of these nonepithelial malignancies examined.

CONCLUSION

Our limited sample size does not allow a generalized conclusion concerning the lack of Her-2/neu expression in nonepithelial ovarian malignancies, but it adds information with regard to the expression of this oncogene in these rare neoplasms and seems to indicate that it is not a frequent occurrence.

Favorable outcome following emergency second trimester cerclage

BACKGROUND

To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes.

METHODS

A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16-27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients.

RESULTS

Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3+/-6.5 vs 9.3+/-4.8 weeks, p=0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6+/-4.6 vs 29.5+/-3.2 weeks, p=0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p=0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p=0.2).

CONCLUSIONS

Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.