Enthalpy of collagen interfibrillar bonds in fetal membranes

During pregnancy, the fetal membrane (FM) is subjected to mechanical stretching that may result in preterm labor. The structural integrity of the FM is maintained by its collagenous layer. The disconnection and reconnection of molecular bonds between collagen fibrils are the fundamental processes that govern the irreversible mechanical and supermolecular changes in the FM. Here, we study the activation enthalpy of interfibrillar bonds in ex-vivo human FM. We analyze the strain-rate and temperature dependence of the irreversible deformations in FM subjected to inflation tests, which apply mechanical conditions similar to those experienced by the FM prior to and during the initiation of labor contractions. The obtained activation enthalpy of interfibrillar bonds matches the typical enthalpy values of polyvalent ionic bonds, implying on another important role that ions like Ca and Mg may play in the gestation and labor.

Ectopic pregnancy risk factors for ART patients undergoing the GnRH antagonist protocol: a retrospective study

BACKGROUND

In-vitro fertilization is a known risk factor for ectopic pregnancies. We sought to establish the risk factors for ectopic pregnancy in GnRH antagonist cycles examining patient and stimulation parameters with an emphasis on ovulation trigger.

METHODS

We conducted a retrospective, cohort study of 343 patients undergoing 380 assisted reproductive technology (ART) cycles with the GnRH antagonist protocol and achieving a clinical pregnancy from November 2010 through December 2015.

RESULTS

Significant risk factors for ectopic pregnancy in the univariate analysis included prior Cesarean section (CS), endometriosis, mechanical factor infertility, longer stimulation, elevated estradiol and progesterone levels, GnRH agonist trigger, higher number of oocytes aspirated, and insemination technique. Independent risk factors for ectopic pregnancy in the multivariate analysis included GnRH agonist trigger, higher number of oocytes aspirated, insemination technique, and prior Cesarean section.

CONCLUSION

Excessive ovarian response, IVF (as opposed to ICSI), prior Cesarean section and GnRH agonist trigger were found to be independent risk factors for ectopic pregnancy. Caution should be exercised before incorporating the GnRH agonist trigger for indications other than preventing OHSS. When excessive ovarian response leads to utilization of GnRH agonist trigger, strategies for preventing ectopic pregnancy, such as a freeze all policy or blastocyst transfer, should be considered. Further studies should elucidate whether adjusting the luteal support can reduce the ectopic pregnancy risk.

Empty follicle syndrome: successful treatment in a recurrent case and review of the literature

Empty follicle syndrome is a condition in which no oocytes are retrieved after an apparently adequate ovarian response to stimulation and meticulous follicular aspiration. It is a rare condition of obscure etiology. A patient with primary infertility who underwent seven assisted reproductive technique cycles is described. In spite of a satisfactory ovarian response, aspiration yielded no oocytes in four cycles and 1-4 low quality oocytes in three cycles. In the index treatment cycle, ovulation was triggered using GnRH agonist 40 h prior to ovum pickup and hCG was added 6 h after the first trigger. Eighteen oocytes were recovered, of which 16 were mature and were inseminated by ICSI. Two embryos were transferred 48 h after aspiration and nine embryos were cryopreserved. The patient conceived and delivered a healthy boy at 38 weeks of gestation. The literature is reviewed and possible etiologies and treatment options of this enigmatic syndrome are suggested.

Effect of primary human endometrial stromal cells on epithelial cell receptivity and protein expression is dependent on menstrual cycle stage

BACKGROUND

Successful implantation requires a receptive endometrium. We hypothesized that effects of endometrial stromal cells (ESC) on epithelial cell receptivity and trophoblast-endometrium interaction are menstrual cycle dependent.

METHODS

An endometrial in vitro 3D co-culture model of primary human ESC with the endometrial epithelial cell line (RL95-2) was constructed. Co-cultures were prepared using primary ESC from biopsies taken before the window of implantation (ESCbw) and during the window of implantation (ESCw), on cycle days 10-17 and 19-23, respectively. RL95-2 served as a constant parameter upon which the influence of ESC from different phases of the cycle was investigated. proMMP-2 (MMP, matrix metalloproteinase) and proMMP-9 secretion was tested in response to progesterone. Progesterone receptor B (PR-B) and plexin B1 protein expression and mRNA levels were investigated using immunofluorescence and RT-PCR, respectively.

RESULTS

Progesterone increased proMMP-2 secretion in primary ESCbw (P = 0.0046) but decreased proMMP-2 and proMMP-9 secretion in ESCw (P < 0.0005). In the presence of ESCbw, JAR spheroid attachment rate to overlying RL95-2 cells was decreased (P < 0.0001), whereas in the presence of ESCw, attachment rate was unchanged. Progesterone treatment restored epithelial cell receptivity in co-culture with ESCbw (P = 0.00004). A correlation between spheroid attachment rate and plexin B1 mRNA level was observed (P = 0.01). PR-B protein and mRNA level were influenced by the interplay between RL95-2 and stromal cells.

CONCLUSION

The effects of human primary ESC on epithelial cell receptivity and trophoblast-endometrium interaction depended upon whether the ESC were taken before or during the window of implantation.

Evidence for blood chimerism in dizygotic spontaneous twin pregnancy discordant for Down syndrome

BACKGROUND

A monochorionic-diamniotic placenta (MCDAP) is rare in dizygotic (DZ) twinning. All reported cases have been documented in pregnancies achieved by the induction of ovulation alone or during the IVF cycle.

METHODS AND RESULTS

We report a spontaneous pregnancy in a 39-year-old patient with evidence of MCDAP in DZ twins, discordant for trisomy 21. The first and second-trimester sonographic scans indicated male twins with MCDAP. Amniocentesis, performed because of advanced maternal age, revealed a normal karyotype in one fetus, and trisomy 21 in the other. Molecular studies, performed in order to confirm the zygosity and chorionicity, demonstrated that the fetuses were DZ. In order to identity the affected twin, a detailed sonographic examination was repeated, but no abnormal findings associated with Down syndrome were demonstrated in any of the fetuses. Therefore, umbilical cord blood samples were obtained from both fetuses. Chromosomal analysis revealed in both fetuses two cell lines: a normal cell line of 46,XY and a 47,XY,+ 21 cell line, in 65 and 80% of the cells, respectively. This result was independently confirmed by both FISH and G-banding. DNA extracted from both cord blood samples demonstrated an admixture of two distinct genotypes in each sample.

CONCLUSIONS

We propose that this case represents a monochorionic-dizygotic twin pregnancy with blood chimerism. The most plausible mechanism underlying this phenomenon is placental fusion early in pregnancy, resulting in an architecturally single placenta originating from two distinct zygotes. The newly formed blood vessels created anastomoses between the DZ twins and allowed reciprocal blood chimerism between the normal and the trisomic twin.

Hysteroscopy may be justified after two miscarriages

BACKGROUND

Recurrent pregnancy loss is traditionally investigated after three or more consecutive pregnancy losses. Although there is a trend to start investigation after two miscarriages, data are not available to date to justify this approach. We sought to compare the frequency of uterine anomalies between women referred to hysteroscopy for repeated miscarriages after two, and three or more, miscarriages respectively.

METHODS

A retrospective analysis of acquired and congenital uterine anomalies in all patients undergoing hysteroscopy for repeated pregnancy loss at an academic and referral medical centre.

RESULTS

Hysteroscopy was performed on 165 women referred for recurrent pregnancy loss: 67 after two and 98 after three or more consecutive miscarriages. The rate of uterine anomalies did not differ significantly and was 32 versus 28% respectively.

CONCLUSIONS

Hysteroscopy may be justified following two spontaneous pregnancy losses.

Differential activity of the gelatinases (matrix metalloproteinases 2 and 9) in the fetal membranes and decidua, associated with labour

Degradation of the extracellular matrix in fetal membranes has been implicated in the rupture of fetal membranes, the process of parturition and placental detachment from the decidua after parturition. In this study we assessed labour-associated changes in gelatinase activity in cultured human amnion, chorion and decidua, as well as in amniotic fluid. We found that in media conditioned by decidua, following the establishment of uterine contractions, matrix metalloproteinase-2 (MMP-2) activity is increased while the protein tissue inhibitors of matrix metalloproteinase-1 (TIMP-1) level is decreased. The formation of a 130 kDa gelatinase band was also significantly increased after contractions began. In media conditioned by chorion, the initiation of uterine contractions did not change MMP activity or TIMP-1 levels. However, an increase in MMP-9 activity and a decrease in TIMP-1 protein levels were observed following the establishment of uterine contractions in media conditioned by amnion. We suggest that this differential spatial regulation provides a form for modulatory hieratical activity of the MMPs in the onset of labour allowing rupture of the membranes while avoiding premature placental separation.

Pregnancy outcome after laparoscopy or laparotomy in pregnancy

STUDY OBJECTIVE

To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy.

DESIGN

Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2).

SETTING

Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals.

PATIENTS

Three hundred eighty-nine pregnant women.

INTERVENTION

Laparoscopy or laparotomy for various indications.

MEASUREMENTS AND MAIN RESULTS

Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies.

CONCLUSION

Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Ultrasound-guided umbilical cord occlusion using bipolar diathermy for Stage III/IV twin-twin transfusion syndrome

OBJECTIVES

To evaluate bipolar diathermy as a technique for selective fetocide in the treatment of advanced (Stage III/IV) twin-twin transfusion syndrome (TTTS).

METHODS

A prospective observational study in two tertiary referral fetal medicine centres: Queen Charlotte's Hospital, London, UK and Haemek Hospital, Afula, Israel. Fifteen cases of TTTS (14 twins and one triplet pregnancy) were treated by selective occlusion of either the donor (n=8) or recipient's (n=7) umbilical cord using ultrasound-guided bipolar diathermy. Following each procedure, patients were scanned serially for fetal growth, liquor volume and umbilical Doppler measurements. Procedural complications and obstetric outcome were recorded. Postnatal placental injection studies were performed.

RESULTS

Overall co-twin survival in Stage III/IV TTTS was 13/14 (93%). There were no treatment failures. The incidence of preterm prelabour rupture of membranes (PPROM) within 3 weeks of the procedure was 3/15 (20%). In those cases where pre-procedure umbilical artery Dopplers were abnormal, the Doppler findings normalised post-procedure in all non-cord-occluded fetuses. Growth velocities of surviving donors were similar to those of surviving recipients.

CONCLUSIONS

Bipolar diathermy appears an effective technique for the selective reduction of monochorionic twins complicated by severe as well as preterminal TTTS, with recipient and donor fetuses being equally appropriate choices for fetocide. We suggest that for advanced-stage disease where the parents can contemplate this option, cord occlusion as a single preemptive procedure maximises the opportunity for intact survival of a single survivor.

Matrix metalloproteinase (MMP)-2 and MMP-9 and their inhibitor, TIMP-1, in human term decidua and fetal membranes: the effect of prostaglandin F(2alpha) and indomethacin

Degradation and breakdown of gestational membranes and the adjacent decidua are essential processes for the advancement of labour. We have assessed the effect of prostaglandin (PG) synthesis on the expression and activity of matrix metalloproteinase (MMP)-2 and MMP-9 and tissue inhibitor of metalloproteinases (TIMP-1) in fetal membranes at the edge of the placenta and decidua, by using ex-vivo organ culture of the tissues in the absence or presence of PGF(2alpha) (0.1, 1.0 and 10 microg/ml) or a PG synthesis inhibitor, indomethacin (10(-4)-10(-6) mol/l). Conditioned media were assessed for MMP by zymography on gelatin containing sodium dodecyl sulphate-polyacrylamide gels and for TIMP-1 by Western blot analysis. Compared to the membranes, decidua produced significantly more MMP-2 and MMP-9 as well as TIMP-1. PGF(2alpha) caused a 2.4- and 1.9-fold increase in the production of MMP-2 and MMP-9 in the decidua, respectively (P < 0.05), and an 11.3-fold increase of the active form of MMP-2 (62 kDa) which could hardly be detected in basal culture conditions (P < 0.01). PGF(2alpha) decreased TIMP-1 production by 70% in the decidua. The production of MMP-2 and MMP-9 and TIMP-1 by the amniotic and chorionic membranes was not affected by PGF(2alpha). Indomethacin decreased the production of MMP-2 and MMP-9 by 78 and 35% in chorion, and by 70 and 58% in amnion, respectively (P < 0.05), but did not affect production in decidual tissue. Indomethacin increased the production of TIMP-1 in chorion and amnion [by 4.1- and 4.5-fold respectively (P < 0.01)], but had no effect on decidua. Cumulatively, PGF(2alpha) increases decidual gelatinolytic activity. Meanwhile the inhibition of PG production by indomethacin reduces total gelatinolytic activity in fetal membranes, possibly accounting for some of its labour-arresting property.

Laparoscopic subtotal hysterectomy and bilateral adnexectomy in a child with congenital adrenal hyperplasia

OBJECTIVE

To report the results of a subtotal hysterectomy and bilateral adnexectomy in a child with congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

DESIGN

Case report.

SETTING

Gynecology department, Afula, Israel.

PATIENT(S)

An 11-year-old child with a female genotype and saltwasting type congenital adrenal hyperplasia who was being raised as a boy.

INTERVENTION(S)

Laparoscopic subtotal hysterectomy and bilateral salpingo-oophorectomy were performed.

MAIN OUTCOME MEASURE(S)

Surgical efficiency, operating time, recovery, and aesthetic result.

RESULT(S)

The procedure was performed without complications in 26 minutes, and the child was dismissed the following day. Three 5-mL abdominal incisions were required.

CONCLUSION(S)

Laparoscopic subtotal hysterectomy and bilateral adnexectomy can be safely performed in children and is the procedure of choice in the rare cases in which it is indicated.

Diabetes in pregnancy: efficacy and cost of hospitalization as compared with ambulatory management--a prospective controlled study

BACKGROUND

Pregnant diabetic women are often subjected to frequent and prolonged hospitalizations to assure tight glycemic control, but in recent years attempts have been made at ambulatory control. The financial and social advantages of ambulatory management are obvious, but no report to date has prospectively compared its efficacy with that of hospitalization.

OBJECTIVES

To evaluate the efficacy and cost of ambulatory care as compared to repeated hospitalizations for management of diabetes in pregnancy.

METHODS

We conducted an 8 year prospective controlled study that included 681 diabetic women, experiencing 801 singleton pregnancies, with commencement of therapy prior to 34 gestational weeks. During 1986-1989, 394 pregnancies (60 pregestational diabetes mellitus and 334 gestational diabetes mellitus) were managed by hospitalization, and for the period 1990-1993, 407 pregnancies (61 PGDM and 346 GDM) were managed ambulatorily. Glycemic control, maternal complications, perinatal mortality, neonatal morbidity and hospital cost were analyzed.

RESULTS

There was no difference in metabolic control and pregnancy outcome in women with PGDM between the hospitalized and the ambulatory groups. Patients with GDM who were managed ambulatorily had significantly lower mean capillary glucose levels, later delivery and higher gestational age at induction of labor as compared to their hospitalized counterparts. In this group there were also lower rates of neonatal hyperbilirubinemia, phototherapy and intensive care unit admissions and stay. The saved hospital cost (in Israeli prices) in the ambulatory group was $6,000 and $15,000 per GDM and PGDM pregnancy, respectively.

CONCLUSIONS

Ambulatory care is as effective as hospitalization among PGDM patients and more effective among GDM patients with regard to glycemic control and neonatal morbidity. This is not only more convenient for the pregnant diabetic patient, but significantly reduces treatment costs.

Doppler fetal echocardiography in endocardial fibroelastosis

BACKGROUND

Endocardial fibroelastosis is a congenital heart disease known to cause congestive heart failure in early infancy. We report a case using new modalities for early prenatal diagnosis of endocardial fibroelastosis causing fetal heart failure.

CASE

A multipara with two children, who died of endocardial fibroelastosis, was referred for fetal echocardiography at 20 weeks' gestation. A mildly asymmetric four-chamber view with slightly enlarged atria and no other fetal heart abnormalities suggested endocardial fibroelastosis. Doppler studies demonstrated abnormal cardiac function with extremely low atrioventricular E/A ratio, defined as the ratio between the rapid ventricular filling (E wave) and the atrial systole (A wave), and abnormal venous flow velocity waveforms establishing the diagnosis. On a repeat scan 2 weeks later, the abnormal morphologic signs suggesting endocardial fibroelastosis were more prominent, and pregnancy was terminated.

CONCLUSION

When morphologic signs are not definitive, Doppler studies of the fetal heart may be useful in making the diagnosis of endocardial fibroelastosis.

Can we abandon routine evaluation of serum estradiol levels during controlled ovarian hyperstimulation for assisted reproduction?

OBJECTIVE

To assess whether abandoning measurement of serum estradiol (E2) and spacing ultrasound evaluations at greater intervals had an effect on the results of assisted reproduction technology (ART).

DESIGN

A retrospective comparison of two consecutive periods.

SETTING

Division of Assisted Reproduction Technology, Department of Obstetrics and Gynecology, Ha'Emek Medical Center, Afula, Israel.

PATIENT(S)

One thousand nine hundred and eighty-five controlled ovarian hyperstimulation (COH) cycles for ART were initiated during the years 1996 to 1999.

INTERVENTION(S)

During the first 2 years an intensive follow-up protocol was used that included E2 blood levels measurements. In the next 2 years a less intensive protocol was adopted that did not use E2 measurements.

MAIN OUTCOME MEASURE(S)

ART results and the rate of ovarian hyperstimulation syndrome (OHSS).

RESULT(S)

The patients' background characteristics did not differ between the two periods. The cancellation rate was not different (9.8% vs. 7.2%). There was no difference in the duration of stimulation or the amount of gonadotropins used. The number of oocytes retrieved (12.1 +/- 9.3 vs. 9.6 +/- 6.3), fertilization rates (74% vs. 75%), and clinical pregnancy rates (26.2% vs. 27.9%) did not differ. The incidence of severe ovarian hyperstimulation syndrome was not significantly different between the two periods.

CONCLUSION(S)

Controlled ovarian hyperstimulation for ART can be done reliably without routine, serial serum E2 measurements without compromising the treatment results.

A randomized, double-blind clinical trial using fixed daily doses of 100 or 200 IU of recombinant FSH in ICSI cycles

The effect of 100 and 200 IU per day recombinant FSH (rFSH) on numbers of oocytes retrieved and the total dose used in ovarian stimulation before intracytoplasmic sperm injection was investigated in a double-blind, randomized multicentre trial. A total of 91 women was treated with a low-dose protocol and 88 with a high-dose regimen at five centres. For each started cycle, significantly more oocytes were retrieved in the 200 IU group than in 100 IU group (12.0 versus 5.7, P < 0.001); total rFSH consumption was 1121 and 1875 IU in the low- and high-dose groups respectively. Significant variations were noted between centres with regard to numbers of oocytes collected per started cycle, ranging from 2.8 to 7.2 in the 100 IU group and from 9.0 to 19.1 in the high-dose group. Exploratory analyses of secondary outcomes suggested there were no differences in vital pregnancy rates per started cycle (19.2 versus 16.9%) and per embryo transfer (26.2 versus 19.3%) in the low- and high dose groups respectively. There were four hospitalizations due to ovarian hyperstimulation syndrome, all in the 200 IU group.

[Laparoscopy as part of the evaluation and management of ovarian and cervix neoplasms]

INTRODUCTION

Surgery is the treatment of choice in most early stages of cervical cancer and advanced stages of ovarian cancer. Failing to preoperatively diagnose para-aortic and parametrial metastases in cervical cancer or a non-resectable, ovarian cancer, may results in a superfluous laparotomy.

AIM

To evaluate the advantage of using laparoscopy in cervical and ovarian cancer.

PATIENTS AND METHODS

Study population includes patients with ovarian or cervical cancer referred between 1997-1999. A CT scan and a trans-vaginal sonography were used to detect involvement of pelvic and para-aortic lymph nodes, parametrium and other metastases. In patients with cervical cancer, para-aortic lymph node dissection was laparoscopically performed. When para-aortic nodes were negative and parametrium was clear, radical hysterectomy and pelvic lymph nodes dissection was conducted through laparotomy. When para-aortic lymph nodes or parametrium were positive, patients were referred for radiation therapy. In ovarian cancer patients, the upper abdomen and the pelvis were examined laparoscopically to evaluate the possibility of optimal debulking surgery. Staging was done for patients who were not candidates for optimal debulking surgery and second debulking surgery was considered.

RESULTS

Nine patients with stage 1b-11a cervical cancer were included. Preoperatively, 2 of them were suspected for lymph node involvement. Following laparoscopy one was confirmed to have para-aortic lymph node involvement and the other did not. In the remaining 8 patients, one was found to have parametrial involvement and laparotomy was avoided, while the rest were treated surgically. Eighteen ovarian cancer patients were included in this study. Laparoscopy revealed an extensive disease in 7 patients and therefore staging laparoscopy was completed. In the remaining 11 patients, laparotomy was performed, operable disease was found and complete debulking surgery was conducted. In only one patient of the 11 complete debulking surgeries was not possible.

CONCLUSIONS

In accordance with the experience and skills of the surgical team, we propose utilizing laparoscopy in cases where laparotomy may be avoided.

The dilemma of prenatal diagnosis of bladder exstrophy: a case report and a review of the literature

Bladder exstrophy is a very rare congenital anomaly characterized by the exteriorization of the viscera on the abdominal surface, low insertion of the umbilical cord, divergent pubic rami and abnormal exterior genitalia. We report a case of prenatal diagnosis of fetal bladder exstrophy in which the urachus resembled the normal bladder. Considering that non-visualization of the bladder is one of the main findings in cases of bladder exstrophy, special attention should be given to fetal lower abdominal cystic images in order to differentiate them from a normally positioned fetal bladder. A review of the literature together with a sonographic study of the urachus is provided.

The balance between MMP-9 and MMP-2 and their tissue inhibitor (TIMP)-1 in luteinized granulosa cells: comparison between women with PCOS and normal ovulatory women

Polycystic ovarian syndrome (PCOS) involves follicular atresia, formation of multiple ovarian cysts and is frequently associated with a higher abortion rate. Follicular development, ovulation, formation of corpus luteum and its regression involve extensive tissue remodelling. Mammalian ovaries express a number of matrix metalloproteinases (MMP) and their tissue inhibitors (TIMP). We assessed the differences in production of MMP-2, MMP-9 and TIMP-1 by cultured luteinized granulosa cells from women with PCOS and normal ovulatory women after ovarian stimulation for IVF treatment. In follicular fluid from women with PCOS, levels of MMP-9 and MMP-2 were higher than the normal group, as was the basal production of these proteins by cultured cells. Basal production of TIMP-1 by cultured cells was not different between PCOS and normal groups. A time-dependent increase in the production of MMP-9 was observed in cells from both normal and PCOS women, although the increase was more pronounced in the latter. Thus the MMP-TIMP balance is shifted toward greater MMP activity in luteinized granulosa cells from women with PCOS.

[Burch laparoscopic procedure for repairing proven stress incontinence--report of 32 cases]

There are more than 200 procedures for repairing stress urinary incontinence. We evaluated the safety and efficiency of the Burch laparoscopic procedure in 32 women with urodynamically proven genuine stress incontinence. Mean operating time was 40 minutes and mean hospitalization time after the procedure was 30 hours. The cure rate was 97%, similar to that reported in other studies (80-95%). The major complications were 2 cases (6.2%) of unintended bladder injury, diagnosed and repaired laparoscopically. Although follow-up has only been for 3-42 months, the high cure rate and safety and advantages of laparoscopy over laparotomy, make laparoscopic Burch colposuspension the procedure of choice for repairing stress incontinence.

Immunodetection of living trophoblast

BACKGROUND

Human chorionic gonadotropin, the pregnancy hormone, is synthesized by trophoblast cells which make up the placenta.

OBJECTIVE

To determine whether antibody to hCG can be used to specifically detect living trophoblast in vitro by binding to the external membrane.

METHODS

Trophoblast was isolated from fresh placentas of women undergoing termination of pregnancy in the first trimester and incubated with monoclonal antibody to hCG. Anti-mouse immunoglobulin G with a fluorescent marker was then added.

RESULTS

Syncytiotrophoblast stained positive on the external surface of the cell, while controls of leukocytes, endometrial cells and hepatocytes were negative.

CONCLUSION

The hCG monoclonal antibody may be used to specifically detect hCG on the surface of living trophoblast in vitro.

The effect of propofol anaesthesia on oocyte fertilization and early embryo quality

Propofol, frequently used for i.v. induction of anaesthesia in assisted reproduction procedures, has been suspected of damaging oocytes. Concentrations of propofol have recently been shown to increase in follicular fluid during oocyte retrieval. Our study was designed to assess whether exposure to increasing concentrations of propofol has a measurable effect on in-vitro fertilization, cleavage and embryo development. A cohort of 130 women underwent i.v. anaesthesia using propofol and fentanyl. Time of anaesthesia from i. v. injection of propofol was measured, as were the doses of the two drugs. In 32 women expected to have more than 15 oocytes retrieved, first, middle and last oocytes were cultured separately. The mean time from i.v. injection to first follicle aspiration was 200 s. The mean time for the aspiration of each additional oocyte was 17.6 s. In 10 out of 11 cases where follicular fluid concentrations of propofol were measured, there was an increase from the first to the last follicle, but no difference was found in the ratio of mature to immature oocytes. Nor were any differences found in fertilization, cleavage and embryo cell number. In so far as in-vitro development reflects embryo quality, we conclude that the time elapsed between retrieval of the first and last oocyte does not affect oocyte quality.

Internal jugular vein blood flow in normal and growth-restricted fetuses

OBJECTIVE

To assess internal jugular vein blood flow patterns during the second half of pregnancy in normal and growth-restricted fetuses.

METHODS

We did Doppler ultrasound studies of internal jugular veins and the inferior vena cavas longitudinally on 21 normal singleton fetuses from 20 weeks to term, and on eight growth-restricted fetuses with absent end-diastolic flow at the umbilical artery (UA). The three components of the venous flow velocity waveforms were used to calculate peak velocity ratio: Peak systolic velocity (S wave) minus reverse peak velocity (R wave) divided by peak velocity during early diastole (D wave) and velocity time integral ratio: systolic velocity time integral minus reverse velocity time integral divided by velocity time integral during early diastole. Statistical analysis of longitudinal measurements used K-related samples Friedman test; groups were compared with Mann-Whitney U test and chi(2) test.

RESULTS

In normal fetuses we found significant increases in peak velocity ratio and velocity time integral ratio of internal jugular veins and the inferior vena cavas throughout gestation. The mean +/- standard deviation (SD) of the internal jugular veins peak velocity ratio (1.12 +/- 0.4 versus 1.46 +/- 0.15, P <.05) and velocity time integral ratio (1.1 +/- 0.2 versus 1.55 +/- 0.17, P <.05) were significantly lower in growth-restricted fetuses compared with normal fetuses at 28-32 weeks' gestation but inferior vena cava indices were not. None of the eight growth-restricted fetuses had umbilical venous pulsations or changes in inferior vena cava or ductus venosus blood flow patterns. All had arterial pH above 7.15 at birth.

CONCLUSION

Growth-restricted fetuses with absent end-diastolic velocity in the UA have changes in internal jugular vein blood flow patterns that probably indicate increased cerebral blood flow, more evidence of redistribution of blood flow in growth-restricted fetuses that can be used to maintain them.

Case report: a novel surgical approach to obstructed hemiuterus: sonographically guided hysteroscopic correction

Unilateral obstruction of a duplicate uterus is very rare. The current recommendation for its correction involves transmural incision of the uterine muscle. A method is presented here that was successfully applied in one patient suffering from this anomaly, using sonographically guided hysteroscopy. This method obviated the need for an extensive operation.

First trimester diagnosis of conjoined twins in a triplet pregnancy after IVF and ICSI: case report

A case of conjoined twins in a triplet pregnancy after in-vitro fertilization and intracytoplasmic sperm injection is described. The diagnosis was made by high-resolution vaginal sonography, as early as the eighth week of gestation. The third fetus, of different chorionicity, was normal. Selective termination was successfully done at 12 weeks. The possible association between assisted reproduction and conjoined twinning is discussed. The importance of expert early vaginal sonography of pregnancy resulting from assisted reproduction technology is emphasized.

Double-blind, randomized, controlled trial of atosiban and ritodrine in the treatment of preterm labor: a multicenter effectiveness and safety study

OBJECTIVE

This study was undertaken to compare the efficacy and safety of intravenous administration of atosiban versus ritodrine for the treatment of preterm labor.

STUDY DESIGN

Women with preterm labor and intact membranes diagnosed at 23 to 33 gestational weeks (n = 247) were randomly assigned to treatment arms and received atosiban (6.75 mg intravenous bolus, 300 microg/min for 3 hours, then 100 microg/min intravenously) or ritodrine (0.10-0.35 mg/min intravenously) for as long as 18 hours. Tocolytic effectiveness was assessed in terms of the numbers of women who had not been delivered after 48 hours and after 7 days. Safety was assessed in terms of maternal side effects and neonatal morbidity. Secondary outcomes included mean gestational age at delivery and mean birth weight. An intent-to-treat analysis was performed with the Cochran-Mantel-Haenszel test.

RESULTS

The proportion of women who had not been delivered at 48 hours was 84.9% (n = 107) in the atosiban group and 86.8% (n = 105) in the ritodrine group. At 7 days 92 women had still not been delivered in both the atosiban (73.0%) and ritodrine (76.0%) groups. Neither of these differences was statistically significant. The incidence of maternal cardiovascular side effects was substantially lower in the atosiban group (4.0% vs 84.3%, P <.001). In addition, intravenous therapy was terminated more frequently as a result of maternal adverse events in the ritodrine group (29.8%) than in the atosiban group (0.8%). The overall occurrences of fetal adverse events in the two treatment groups were comparable. Neonatal morbidity was similar between the treatment groups after adjustment for unbalanced enrollment of women with multiple pregnancies and for gestational ages within treatment groups.

CONCLUSION

Atosiban was comparable in clinical effectiveness to conventional ritodrine therapy but was better tolerated than ritodrine, with no evidence of significant maternal or fetal adverse events. Neonatal morbidity, which was similar between the two treatment arms, was apparently related to the gestational age of the infant rather than to the exposure to either tocolytic agent.

Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial

OBJECTIVE

To compare perinatal outcome and glycaemic control in two groups of pregnant diabetic patients receiving two insulin regimens.

DESIGN

Randomised controlled open label study.

SETTING

University affiliated hospital, Israel.

PARTICIPANTS

138 patients with gestational diabetes mellitus and 58 patients with pregestational diabetes mellitus received insulin four times daily, and 136 patients with gestational diabetes and 60 patients with pregestational diabetes received insulin twice daily.

INTERVENTION

Three doses of regular insulin before meals and an intermediate insulin dose before bedtime (four times daily regimen), and a combination of regular and intermediate insulin in the morning and evening (twice daily regimen).

MAIN OUTCOME MEASURES

Maternal glycaemic control and perinatal outcome.

RESULTS

Mean daily insulin concentration before birth was higher in the women receiving insulin four times daily compared with twice daily: by 22 units (95% confidence interval 12 to 32) in patients with gestational diabetes and by 28 units (15 to 41) in patients with pregestational diabetes. Glycaemic control was better with the four times daily regimen than with the twice daily regimen: in patients with gestational diabetes mean blood glucose concentrations decreased by 0.19 mmol/l (0.13 to 0.25), HbA(1c) by 0.3% (0.2% to 0.4%), and fructosamine by 41 micromol/l (37 to 45), and adequate glycaemic control (mean blood glucose concentration <5.8 mmol/l) was achieved in 17% (8% to 26%) more women; in patients with pregestational diabetes mean blood glucose concentration decreased by 0.44 mmol/l (0.28 to 0.60), HbA(1c) by 0.5% (0.2% to 0.8%), and fructosamine by 51 micromol/l (45 to 57), and adequate glycaemic control was achieved in 31% (15% to 47%) more women. Maternal severe hypoglycaemic events, caesarean section, preterm birth, macrosomia, and low Apgar scores were similar in both dose groups. In women with gestational diabetes the four times daily regimen resulted in a lower rate of overall neonatal morbidity than the twice daily regimen (relative risk 0.59, 0.38 to 0.92), and the relative risk for hyperbilirubinaemia and hypoglycaemia was lower (0.51, 0.29 to 0.91 and 0.12, 0.02 to 0.97 respectively). The relative risk of hypoglycaemia in newborn infants to mothers with pregestational diabetes was 0.17 (0.04 to 0.74).

CONCLUSIONS

Giving insulin four times rather than twice daily in pregnancy improved glycaemic control and perinatal outcome without further risking the mother.

Osteosclerosis, hypoplastic nose, and proptosis (Raine syndrome): further delineation

We describe a newborn girl with a lethal sclerosing bone dysplasia leading to prenatal skeletal alterations and microcephaly, proptosis, hypoplastic nose and midface, small jaw, cleft palate, hypertrophied gums, intracranial calcifications, and generalized osteosclerosis. There is a remarkable similarity between our patient and six previously reported infants subsequently categorized as having a distinct entity: Raine syndrome. Autosomal recessive inheritance is postulated based on parental consanguinity in several of the previous cases and in our patient.

Midazolam/ketamine sedative combination compared with fentanyl/propofol/isoflurane anaesthesia for oocyte retrieval

Assisted reproduction may be associated with repeated occasions of surgical intervention. Propofol, which is frequently used for induction of anaesthesia in such procedures, has been suspected of damaging oocytes. We compared in a randomized prospective design the use of general anaesthesia with fentanyl 0.017 mg/kg, propofol 2.5 mg/kg and isoflurane to that of sedation with midazolam 0.06 mg/kg and ketamine 0.75 mg/kg for transvaginal oocyte retrieval in 50 patients with no premedication. Overall, patient satisfaction was not different between the groups. Sedated patients were more arousable than anaesthetized patients during the procedure and experienced less postoperative abdominal pain at 30 min. Despite some movement in response to pain, oocyte retrieval was conveniently feasible in all sedated patients, of which none required a switch to general anaesthesia. A comparable number of oocytes was retrieved per cycle, 10.8 (+/-7.8) versus 9.6 (+/-10.9) with sedation and anaesthesia respectively. No patient recalled any pain sensation during the procedure. The rate of embryo transfers and pregnancies were not different between the two groups. We conclude that the sedative combination of midazolam and ketamine for oocyte retrieval may serve as an alternative for general anaesthesia.

Fetal pituitary negative feedback at early gestational age

We describe an early prenatal diagnosis and the successful treatment of fetal Graves' disease from transplacental transfer of maternal thyroid stimulating autoantibodies (TSAb). The diagnosis of fetal thyrotoxicosis was made by umbilical cord sampling (UBS) at 20 weeks gestation, based on suppressed TSH with elevated FT4 levels. Therapy with propylthiouracil (PTU) improved fetal thyroid function tests as well as the clinical signs of fetal Graves' disease. Three more UBS were conducted before delivery indicating persisting mild fetal hyperthyroidism. Undetectable concentrations of thyrotrophin in fetal serum in the presence of markedly elevated FT4, suggests pituitary negative feedback at as early as 20 weeks gestation. Amniotic fluid thyrotrophin levels were measured at 20,24 and 26 weeks and were shown to correlate better with (elevated) maternal rather than (suppressed) fetal TSH values; therefore, we believe that amniotic fluid thyrotrophin measurement is unreliable for prediction of fetal thyroid status. Our observation is the first documentation of an intact feedback mechanism so early in fetal development and it suggests that pituitary maturation occurs earlier than previously believed.

Resistance to activated protein C and the leiden mutation: high prevalence in patients with abruptio placentae

OBJECTIVE

The Leiden mutation, a point mutation in the gene encoding coagulation factor V, is associated with a high frequency of thromboembolic phenomena. It has recently been connected with adverse outcomes of pregnancy. We carried out this study to define its connection with abruptio placentae.

STUDY DESIGN

Twenty-seven women who had abruptio placentae and 29 control subjects matched for age, parity, and ethnic origin were studied. We studied all women for possible hypercoagulation defects. All women demonstrating resistance to activated protein C were studied for the presence of the factor V Leiden mutation.

RESULTS

Seventeen of 27 case patients had an activated protein C ratio </=2.5, compared with 5 of 29 control subjects (odds ratio 8.16, 95% confidence interval 3.6-12.75, P =.00125). Participants with activated protein C ratios </=2.5 underwent deoxyribonucleic acid analysis. Eight case patients were found to have the factor V Leiden mutation (5 heterozygous and 3 homozygous, 29.6%), compared with 1 heterozygote among the control subjects who were tested (3.4%).

CONCLUSION

Factor V Leiden mutation was found quite frequently in patients with abruptio placentae.

Ultrasound evaluation of the width of the fetal nose

The aim of the study was to construct a normal range for the width of the fetal nose during gestation. The study group included 229 healthy pregnant women with normal singleton pregnancies at 15-42 weeks of gestation. The ultrasound measurements were taken at the level of the lower border of the ala nasi, using the modified coronal view. Routine biometric measurements were obtained from the participants, including biparietal diameter, head and abdominal circumferences, cerebellum and femur lengths. Our results were used to construct objective measurements of the fetal nasal width across all gestational ages. We conclude that the nasal width can be easily measured from 15 weeks of gestation using the modified coronal view. A linear growth relationship was found between nasal width and gestational age, biparietal diameter, head and abdominal circumferences, and transcerebellar and femoral lengths. We feel that such measurements may prove useful in the diagnosis of cases at high risk for fetal facial abnormalities.

Two-day IUI treatment cycles are more successful than one-day IUI cycles when using frozen-thawed donor sperm

The difference in pregnancy rates following intrauterine insemination (IUI) for 1 vs. 2 days in the periovulatory period has been reported as either inconsequential or favoring the use of two consecutive inseminations, 24 hours apart. Our study compared the monthly fecundity and cumulative probability of pregnancy in a large group of women (n = 123) undergoing controlled ovarian hyperstimulation and 1- or 2-day inseminations with donor sperm prepared from frozen-thawed samples. All patients underwent controlled ovarian hyperstimulation employing either clomiphene citrate in 217 cycles or human menopausal gonadotropin in 185 cycles. The choice of single or double insemination was decided by the day of the week each patient received human chorionic gonadotropin for ovulation induction. Approximately 80% of all the patients underwent both single and double insemination treatments during the 2.5-year study period. Ninety-three patients received single inseminations in 180 cycles, whereas 103 patients received double inseminations in 222 cycles. Nine clinical pregnancies were achieved in the 1-day group (5% per cycle, 9.7% per patient), while 39 pregnancies occurred in the 2-day group (17.9% per cycle, 37.9% per patient). Two and five spontaneous abortions occurred in the 1- and 2-day groups, yielding take-home baby rates of 3.9% per cycle (7.5% per patient) and 15.3% per cycle (33.0% per patient), respectively. The cumulative probability of conception over 15 cycles of treatment was consistently twice as high or higher for the 2-day group. The results of this study support the use of 2-day IUI treatment cycles when using frozen-thawed donor sperm.

Laparoscopic resection of ovarian benign cystic teratomas: experience with 84 cases

Laparoscopic treatment of benign cystic teratoma of the ovary has been recommended following the study of relatively small numbers of patients. We reviewed our experience with a prospective ongoing protocol for the treatment of benign ovarian teratomas, between January 1990 and December 1996. Sonography established the diagnosis, and biochemical markers were used to screen for possible malignancy. Surgery consisted of resecting the cyst and conserving the ovary if appropriate. The resected cyst was aspirated of its contents following insertion into an EndoCatch bag. Removal was accomplished via the narrowest incision possible by pulling the bag's margins through the incision and grasping the solid parts with conventional surgical instruments. The diameter of the cysts ranged from 2 to 15 cm. Cystectomy was performed in 47, and oophorectomy in 37, patients. Spillage occurred in 11 cases, but none developed peritonitis or fever. The mean duration of post-operative stay was 0.9 days (range 0.5-2). We conclude that laparoscopic resection of benign teratomas of the ovary is safe, well tolerated, and shortens hospital stay.

Hyperandrogenic anovulation (the polycystic ovary syndrome)--back to the ovary?

Hyperandrogenic anovulation is characterized by polycystic appearance of the ovaries, elevated free serum testosterone with decreased concentrations of serum sex hormone binding globulin, an increased ratio of luteinizing hormone to follicle stimulating hormone and varying degrees of insulin resistance. We hypothesize that this is the result of variably increased 'ovarian androgenic insulin responsiveness' acting in combination with body mass. Women who develop hyperandrogenism and anovulation when lean (having normal serum insulin concentrations) represent the more severely affected individuals, whereas those who can resume ovulation by losing weight (and lowering their elevated serum insulin) represent a milder form. The tendency of these women to develop ovarian hyperstimulation syndrome despite hypophyseal desensitization suggests a primary ovarian defect which is apparently more pronounced in lean subjects. The unique ability of surgical damage to the ovary to induce ovulation, raises the possibility that inflammatory-like tissue remodelling has a major role in rescuing follicles from androgen-induced atresia. Approaches that may facilitate the study of this possible mechanism may include examination of in-vitro perfused, post-surgery mammalian ovaries and the elucidation of signal transduction mechanism(s) of insulin in the ovary, with special reference to cells emanating from affected women.

Transvaginal sonography as the ultimate diagnostic tool for the management of ectopic pregnancy: experience with 840 cases

OBJECTIVE

To evaluate the efficacy of transvaginal sonography and serum beta-hCG levels as diagnostic tools for deciding whether to perform operative laparoscopy in the treatment of presumed ectopic pregnancy (EP).

DESIGN

A prospective protocol for the evaluation and treatment of women with presumed EP.

SETTING

Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel.

PATIENT(S)

Eight hundred forty women with presumed EP who were seen in our emergency department from January 1988 through December 1995.

INTERVENTION(S)

On the basis of specific sonographic signs and beta-hCG levels, we performed immediate operative laparoscopy in patients with demonstrable extrauterine fetal heart activity or >100 mL of fluid in the pelvic cavity. We followed up all other patients, using defined criteria for laparoscopic intervention.

MAIN OUTCOME MEASURE(S)

The accuracy of transvaginal sonography in predicting EP was evaluated as part of the described protocol.

RESULT(S)

Overall, 380 patients were found to have EP. Of these, 331 were identified positively by transvaginal sonography and 49 were not. In 27 of 358 laparoscopies, no EP was found. The sensitivity of transvaginal sonography for the prediction of EP was 87% and the specificity was 94%. The positive and negative predictive values were 92.5% and 90%, respectively.

CONCLUSION(S)

In this protocol, which invariably captured the true location of the products of conception, using transvaginal sonography as the primary modality in the evaluation of patients with presumed EP resulted in the use of laparoscopy mainly as a treatment tool. This approach is both safe and economical.

Individual implantation rate: proposal for a new index for evaluation of assisted reproduction results

OBJECTIVE

To assess whether implantation in assisted reproductive technology (ART) cycles is a random event.

DESIGN

Retrospective analysis of results.

SETTING

Division for Reproductive Endocrinology and ART, Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel.

PATIENT(S)

A cohort of all cycles reaching ET from July 1, 1995, through June 30, 1996, and a cohort of all pregnancies recorded from January 1, 1995, through October 31, 1996.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rate of multifetal pregnancy in relation to overall pregnancy rate. The number of gestational sacs observed by sonography, out of transferred embryos in conception cycles, was defined as the individual implantation rate.

RESULT(S)

Of 367 ETs, 75 (20.4%) yielded pregnancies, of which 31 (41%) were multifetal. Considering the mean number of embryos transferred (3.67), if implantation would have been random, multifetal gestation rate should have been only 14.8%, significantly less than the observed rate. In 110 pregnancies recorded between January 1995 and October 1996, individual implantation rate was 49.4% +/- 27.1% in intracytoplasmic sperm injection cycles compared with 40.5% +/- 20.4% in IVF cycles.

CONCLUSION(S)

Embryo implantation is not a random event. The index of individual implantation rate may help shed light on mechanisms underlying implantation.

Fractured clavicle and Erb's palsy unrelated to birth trauma

OBJECTIVES

Our purpose was to determine the perinatal factors associated with clavicular fracture or Erb's palsy in neonates and to document the percentage of cases where no risk factors were involved.

STUDY DESIGN

We reviewed the medical records of all live-born singleton infants admitted to the newborn nurseries between 1992 and 1995. Mothers and infants with clavicular fracture or Erb's palsy were compared with those without these birth injuries.

RESULTS

Of 11,636 neonates, there were 236 (2.03%) with clavicular fracture and 51 (0.44%) with Erb's palsy. Clavicular fracture was significantly associated with shoulder dystocia and high birth weight. Significant factors associated with Erb's palsy were shoulder dystocia, high birth weight, prolonged second stage, instrumental delivery, fetal distress, use of oxytocin, and epidural anesthesia. A total of 51.7% of the neonates with clavicular fracture and 29.4% of those with Erb's palsy had none of the risk factors examined.

CONCLUSIONS

Although macrosomic fetuses and instrumental or difficult deliveries are risk factors for clavicular fracture and Erb's palsy, > 50% and 25%, respectively, occur without the risk factors examined.