Double heterozygosity in the BRCA1 and BRCA2 genes in the Jewish population

BACKGROUND

The frequency and characteristics of disease in individuals who concomitantly harbor pathogenic mutations in both BRCA1 and BRCA2 genes are not established.

MATERIALS AND METHODS

Data were collected from the database of Clalit Health Services National Familial Cancer Consultation Service. Probands referred to this clinical service and their family members are routinely tested for the three Jewish founder mutations (BRCA1: 185delAG, 5382insC, BRCA2: 6174delT). In addition, carriers identified in a population-based cohort of all cases diagnosed with breast cancer in Israel in 1987-1988 allowed the estimation of the population frequency of this phenomenon.

RESULTS

In the clinic-based series of 1191 carriers of mutations in BRCA1 or BRCA2 belonging to 567 families, 22 males and females (1.85%) from 17 different families (3.0%) were found to harbor two different mutations. These included 18 individuals (1.51%) who concomitantly carried the 185delAG BRCA1 and the 6174delT BRCA2 mutations and four individuals (0.34%) who carried the 5382insC BRCA1 and the 6174delT mutations. All individuals were heterozygote carriers and none had a double mutation of both founder mutations in the BRCA1 gene itself. Seven of the 16 double carrier women (46.7%) had a personal history of breast carcinoma, diagnosed at a mean age of 44.6, compared with 372/926 (40.2%) carriers of a single mutation diagnosed with a mean age at diagnosis of 48.1 [odds ratio (OR)=1.3, 95% confidence interval (CI) 0.4-4.0]. One case (6.7%) had a personal history of ovarian carcinoma diagnosed at the age of 53 compared with 55/926 (5.9%) of the women with single mutation (OR=1.1, CI=0.2-7.6). The frequency of double mutations in the population-based national breast cancer cohort was 2.2% of all carriers, and 0.3% of all breast cancer cases in the Ashkenazi population in the cohort. The mean age at diagnosis of breast cancer was younger in the carriers of two mutations.

CONCLUSION

Double carriers of mutations in the BRCA genes are rare and seem to be carrying a similar probability of developing breast and ovarian cancers as carriers of single mutations.

The outcome of patients with stage I endometrial cancer involving the lower uterine segment

The objective of this study was to evaluate whether lower uterine segment involvement (LUSI) correlates with recurrence and survival in women with stage I endometrial adenocarcinoma and whether it is associated with poor prognostic histopathologic features. Three hundred seventy-five consecutive patients with endometrial carcinoma stage I compromised the study population. The patients were divided into two groups according to the presence of LUSI with endometrial carcinoma. The two groups were compared with regard to prognostic factors and outcome measures by using the Pearson χ2 test, log-rank test, and Cox proportional hazards model. LUSI was present in 89 (24%) patients with stage I endometrial carcinoma. LUSI was significantly associated with grade 3 tumor (P= 0.022), deep myometrial invasion (P< 0.0001), and the presence of capillary space-like involvement (CSLI) (P= 0.003). Kaplan–Meier survival curves demonstrated that patients with LUSI had a lower recurrence-free survival (log-rank test; P= 0.009) and a worse overall survival (log-rank test; P= 0.0008). In the Cox proportional hazards model, only a trend toward higher recurrence rate (HR = 2.4, 95% CI 0.7, 8.2; P= 0.16) and a trend toward poorer overall survival (HR = 1.54, 95% CI 0.82, 2.91; P= 0.18) were noted when LUSI was present. In patients with stage I endometrial cancer, the presence of LUSI is associated with grade 3 tumor, deep myometrial invasion, and the presence of CSLI. A larger group of patients is necessary to conclude whether higher recurrence rate and poorer overall survival are associated with the presence of LUSI.

Lymphvascular space involvement compromises the survival of patients with stage I endometrial cancer: Results of a multicenter study

AIMS

To quantify the relative risk associated with lymphvascular space involvement (LVSI) on outcome measures in patients with apparent stage I endometrial cancer.

METHODS

Six hundred and ninety nine consecutive patients with endometrial carcinoma apparent stage I, who underwent surgery in one of four gynecological oncology centers in Israel, comprised the study population. Forty cases with and 659 without LVSI were followed for a median time of 39 months. Recurrence free, disease specific and overall survival was compared between the two groups. The effect of LVSI, adjusted for other clinical and histo-pathological prognostic factors, was assessed by multivariate analysis.

RESULTS

The univariate Kaplan-Meier procedure for survival analysis showed that patients with LVSI had lower recurrence free survival (p=0.0003), worse disease specific (p=0.0007) and overall survival (p<0.0001). Cox proportional hazards model demonstrated a trend toward shorter recurrence free survival (HR=2.0, 95% CI 0.9, 4.5; p=0.08), a worse disease specific survival (HR=2.8, 95% CI 1.1, 7.4; p=0.04) and decreased overall survival (HR=2.0, 95% CI 1.1, 3.8; p=0.03) in cases with LVSI.

CONCLUSIONS

In patients with apparent stage I endometrial cancer the presence of LVSI, an independent poor prognostic factor, is associated with a two fold increased risk of death. The presence of LVSI warrants consideration when deciding upon post operative management.

A multicenter study of CA 125 level as a predictor of non-optimal primary cytoreduction of advanced epithelial ovarian cancer

AIMS

To provide a large database of pre-operative CA 125 levels which may predict inappropriate cytoreductive surgery in patients with advanced epithelial ovarian cancer.

METHODS

A multicenter review of the records of 424 patients with FIGO stage III and IV epithelial ovarian cancer of patients who underwent primary cytoreductive surgery was performed. The validity of pre-operative CA 125 level measurement as a single predictor of the possibility to achieve only suboptimal cytoreduction was evaluated by calculating the sensitivity and the specificity of various cut-off values. The relative importance of different cut-off values in achieving the best predictive validity was assessed by a receiver operating characteristics (ROC) curve.

RESULTS

Optimal cytoreduction (largest diameter of residual tumour < or =1 cm) was achieved in 242 patients. The median CA 125 level in optimally cytoreduced patients was lower than in those patients suboptimally debulked (304 vs 863 U/mL; p<0.001). The area under the ROC curve was 0.65 (95% confidence interval, 0.60-0.71) and the CA 125 threshold derived from the ROC was 400 U/mL. The accuracy of the test at this level was 62%.

CONCLUSIONS

The clinical applicability of the ROC derived CA 125 threshold is limited. The data accrued in the study provides a basis for decision-making regarding the place of primary surgery various CA 125 levels.

[Role of intercellular adhesion molecule-1 and E-selectin in the pathogenesis of ovarian hyperstimulation syndrome]

OBJECTIVE

To explore the ICAM-1 and E-selectin in patients with OHSS and clarifying its role in pathogenesis of the syndrome.

MATERIALS AND METHODS

20 patients were included in the research and 20 control patients with stimulating ovarian cycle for the purposes of ART, during the period from 01.01.2004 till 01.01.2005 years in the center of ART-MU-Varna and Department of Obstetrics and Gynecology-IVF-ward-MU-Ben-Gurion, Israel. The patients were divided into 3 subgroups according to the degree of OHSS by the classification of Golan- mild, moderate, severe. The method of ELISA was used to record the values of the factors under research.

RESULTS

Six patients with severe OHSS, showed increase in the value of the ICAM-1 and somebody of them, showed low level of E-selectin testing in serum and ascitic fluid in comparison with the control group and the rest of the patient with OHSS.

CONCLUSION

OHSS is a life-threatening complication in which the main pathophysiology factor is the increased of capillary permeability. ICAM-1 are expressed on human granulosa cells and by the vascular endothelium after the stimulation by inflammatory cytokines and acts as a mediator of the cohesion with the lymphoid cells. E-selectin is produced by the endothelium after cytokine activation. The soluble forms of these molecules are found in serum, follicular fluid during the COH, as well as in ascitic fluid in severe OHSS. In our research adhesion molecules- ICAM-1 are correlated to the OHSS, especially in the severe forms of the syndrome.

The significance of the degree of myometrial invasion in patients with stage IB endometrial cancer

OBJECTIVE

To study the validity of the FIGO staging classification of endometrial cancer Stage IB by correlating degree of myometrial invasion depth with outcome measures.

STUDY DESIGN

Fifty patients with endometrial adenocarcinoma FIGO Stage IB who underwent hysterectomy between 1989 and 2001 were divided into two groups according to depth of myometrial invasion. The first group comprised of 31 patients with myometrial invasion of less than or equal to one-third. The second group included 19 patients with invasion greater than one-third but less than one-half. The two groups were compared with regard to prognostic factors and outcome measures.

RESULTS

The overall 5-year recurrence-free survival, disease specific survival and overall survival rates were 87%, 94% and 77%, respectively. These outcome measures did not vary significantly between the two groups. There were no statistically significant differences between the two groups with regard to the following parameters: duration of follow-up, age, proportion of patients who underwent complete surgical staging and postoperative adjuvant radiotherapy. Histologic parameters of the two groups, such as histological type, grade and proportion of patients with capillary space-like involvement and lower uterine segment involvement were not significantly different.

CONCLUSIONS

In patients with Stage IB endometrial cancer the amount of myometrial invasion defined as less than one third compared with invasion greater than one third does not appear to correlate with their outcome, thus validating the FIGO staging system.

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.

Primary breast carcinoma of the vulva: case report and review of literature

The occurrence of ectopic breast tissue within the vulva is uncommon and the development of breast carcinoma within vulvar ectopic breast tissue is very rare. To date, only 12 cases of primary vulvar breast carcinoma have previously been reported in the English literature. This paper presents the 13th reported case of primary breast carcinoma of the vulva. The patient presented with a vulvar ulcerated lump and the diagnosis was based on a morphologic pattern consistent with breast carcinoma and the presence of estrogen and progesterone receptors. Primary surgery consisted of radical vulvectomy and bilateral groin dissection. The groin lymph nodes were involved bilaterally. Adjuvant therapy consisted of systemic chemotherapy (4 cycles of adriamycin and cyclophosphamide followed by 4 cycles of paclitaxel) and pelvic radiotherapy. Oral tamoxifen 20 mg/day was started for the next five years. It is concluded that the management of primary breast carcinoma of the vulva should be modeled after that for primary carcinoma of the orthotopic breast with primary surgery followed by systemic chemotherapy and pelvic radiotherapy. Chemotherapy should be similar to that employed for breast carcinoma. Tamoxifen should be prescribed for patients whose tumors contain estrogen receptors.

Adrenocortical oncocytoma in pregnancy

BACKGROUND

Adrenal oncocytomas are uncommon, nonfunctioning tumors occurring most often in endocrine organs.

CASE

A 32-year-old woman presented at 25 weeks' gestation complaining of right flank pain. Abdominal ultrasonography and computed tomography revealed a 9 x 10-cm solid right-sided adrenal mass. Endocrine evaluation was normal. At 36 weeks' gestation, she underwent cesarean followed by resection of the adrenal mass. Histopathologic and ultrastructural studies revealed a benign adrenocortical oncocytoma.

CONCLUSION

Although rare, adrenocortical oncocytomas should be included in the differential diagnosis of solid, nonfunctioning, adrenal tumors in pregnancy.

Sweeping of membranes vs. intracervical prostaglandin E2 gel for cervical ripening. Randomized trial

OBJECTIVE

To compare intracervical prostaglandin E2 gel and membrane sweeping for cervical ripening.

STUDY DESIGN

Fifty patients were randomized to either intracervical prostaglandin E2 or membrane sweeping. A Bishop score was assigned by a blinded examiner prior to and 24 hours following the procedure.

RESULTS

The Bishop scores assigned 24 hours after prostaglandin instillation and membrane sweeping were not significantly different (3.4, SE 0.42, vs. 3.3, SE 0.37, respectively; P > .05). The proportions of women entering active labor or delivering within 24 hours were similar in the prostaglandin and membrane groups (21% and 19%, respectively; P > .05).

CONCLUSION

When both intracervical prostaglandin insertion and membrane sweeping are feasible, their salutary effects are comparable.

Preoperative CA-125 level as a predictor of non optimal cytoreduction of advanced epithelial ovarian cancer

BACKGROUND

Suboptimal cytoreduction of advanced ovarian cancer is related to initial tumor bulk which correlates with CA125 level.

METHODS

Retrospective record study of 40 patients with stage III ovarian cancer. The ability of a CA125 threshold level of 500 U/mL to predict suboptimal cytoreduction was determined.

RESULTS

Twenty-four (60%) of the patients were optimally cytoreduced. At the CA125 cut off level of 500 U/mL the sensitivity for predicting suboptimal debulking was 62% and specificity was 83%. Above a CA 125 level of 1500 U/mL none of the patients were optimally cytoreduced.

CONCLUSIONS

More data are needed to determine the CA125 cut off level at which the standard approach of initial laparotomy and cytoreduction may be modified.

Comparative pharmacokinetics of once daily intravenous and intramuscular gentamicin in patients with post partum endometritis

In patients with post partum endometritis once daily intramuscular administration of gentamicin may be convenient in certain clinical settings. However pharmacokinetic data on once daily intramuscular gentamicin are not reported. In this study 10 women with post partum endometritis were given once daily intravenous gentamicin (4 mg/kg ideal body weight) followed at a later day by a similar intramuscular dose. Gentamicin levels coincided at 30 min. Levels at 60 and 90 min were lower with the intravenous route. Further clinical studies are needed to confirm reduced nephrotoxicity and ototxicity with the intramuscular route.

Thyroid hormone levels in cord blood of infants with acidemia at birth

OBJECTIVE

To study the funic thyroid hormone levels in cases were fetal distress during labor resulted in acidemia at birth.

MATERIAL AND METHODS

Arterial and venous levels of TSH, total T4, free T4 and total T3 obtained from cord blood at birth of twelve acidemic fetuses were compared with normal controls.

RESULTS

Acidemic fetuses had a significanly higher TSH levels than controls (16.5+/-2. 1 microI/dl vs. 9.6+/-1.4 microI/dl, P=0.01). Total T3 levels were significantly lower in acidemic fetuses (49.2+/-2.9 ng/dl vs. 63+/-5. 5 ng/dl, P=0.04). Total and free T4 levels were similar and there was no difference between arterial and venous levels of the hormones.

CONCLUSIONS

Birth acidemia from fetal distress during labor is associated with higher TSH levels and lower T3 levels.

The current clinical presentation of complete molar pregnancy

OBJECTIVE

To study the current clinical presentation of complete molar pregnancy.

METHOD

Retrospective study of the clinical and ultrasonographic records of 41 patients with complete hydatidiform mole.

RESULTS

17 (41%) patients were asymptomatic. 24 patients (58%) presented with vaginal bleeding, 6 (15%) had excessive uterine size, 1 (2%) had anemia and 1 (2%) had hyperemesis. Non of the patients had any other systemic manifestation. Pre-evacuation ultrasound was performed in all cases and molar pregnancy was diagnosed in 36 (88%).

CONCLUSIONS

Currently with routine first trimester ultrasonography a significant proportion of patients with molar pregnancy are asymptomatic at the time of diagnosis.

Preoperative diagnosis of intestinal intussusception in pregnancy. A case report

BACKGROUND

Intestinal intussusception is a rare event during pregnancy. The diagnosis of intestinal obstruction from any cause in pregnancy is made more difficult by the common overlapping complaints of nausea, vomiting and abdominal pain, which may persist during the second trimester.

CASE

Intestinal obstruction occurred at 17 weeks' gestation. A preoperative diagnosis of intussusception was made by ultrasound by demonstrating multiple ecodense and ecolucent rings in the right lower quadrant of the abdomen.

CONCLUSION

Ultrasonography may support the diagnosis of intussusception in pregnant women with intestinal obstruction.

Prevalence of hydronephrosis in patients with genital prolapse

OBJECTIVE

To determine the prevalence of hydronephrosis in patients with genital prolapse and evaluate contributing factors.

METHODS

Retrospective study of the records of 189 patients with pelvic organ prolapse who underwent preoperative renal imaging studies.

RESULTS

Of the 189 patients 31 (17.4%) had hydronephrosis; in 20 (10.6%) patients the hydronephrosis was mild, in 7 (3.7%) it was moderate and in 4 (2.7%) it was severe. The patients with hydronephrosis were older (mean age 68+/-9.5 SD vs. 60.5+/-10.8 SD, P<0.001) had a higher creatinine levels (0.84+/-0.4 SD vs. 0.78+/-0.3 SD P<0.005) and had a higher degree of uterine prolapse (mean 2.6+/-0.9 SD vs. 1.1+/-1.2 SD, P<0.005). After adjusting for age and type of prolapse, only patients with uterine prolapse remained significantly more likely to suffer from hydronephrosis (adjusted odds ratio 1.9, 95% CI 1.1, 3.2).

CONCLUSION

The prevalence of hydronephrosis in patients with genital prolapse is appreciable and is related primarily to degree of uterine prolapse.

Sonographically diagnosed pelvic hematomas and postcesarean febrile morbidity

OBJECTIVE

To evaluate the incidence of ultrasonographically-diagnosed postcesarean hematomas and correlate their presence with febrile morbidity.

METHODS

Prospective study of 111 consecutive patients who had a pelvic ultrasound 4-6 days post-operatively. Ultrasonographic findings were correlated with clinical data.

RESULTS

Postoperative fever was diagnosed in 28 (25%) patients. Fifteen (13.5%) women had hematomas; 10 (9%) had bladder-flap and five (4.5%) had subfascial hematomas. Only subfascial hematomas were significantly associated with post-operative fever (P = 0.01).

CONCLUSIONS

Postcesarean bladder-flap hematomas are not predictive of post-operative fever. The presence of subfascial hematomas should be specifically sought in the evaluation of a febrile postcesarean patient.

Endometrial cancer in patients undergoing diagnostic curettage

We made a retrospective review of in 2769 patients in whom curettage was performed. Of 1468 women under 50 years of age, only one (0.08%) had endometrial cancer. Of 834 patients presenting with postmenopausal bleeding 31, (3.7%) had endometrial cancer.

Thrombocytopenia with the HELLP syndrome. Report of two cases with reversal in normotensive and nonproteinuric gravidas

BACKGROUND

In the absence of hypertension and proteinuria, pregnant women with hemolysis, elevated liver enzymes and low platelet count (HELLP syndrome) present a diagnostic and therapeutic problem.

CASES

Two atypical cases occurred of HELLP syndrome diagnosed by hemolysis, elevated liver enzymes and low platelet count. The patients presented early in the third trimester with epigastric pain and lacked the usual signs of preeclampsia, such as hypertension and proteinuria. The patients were managed expectantly; during this time they became hypertensive, but the thrombocytopenia resolved.

CONCLUSION

Pregnant women with hemolysis, elevated liver enzymes and thrombocytopenia who do not have hypertension or proteinuria should undergo complete diagnostic evaluation. If other etiologies are ruled out, the patient should be managed as appropriate for severe preeclampsia complicated by the HELLP syndrome.

Umbilical cord androgens in infants of diabetic mothers

The aim was to measure umbilical cord testosterone and androstenedione and to explore possible relationships with fetal weight and insulin levels. Testosterone, androstenedione and insulin were measured at birth in venous umbilical blood in 12 infants of gestational diabetic mothers and in 12 control subjects. The mean concentrations of umbilical testosterone and androstenedione were not significantly different between the infants of the diabetic and control mothers. No significant correlation was found between maternal weight, fetal weight or insulin concentrations and androgen levels.

Budd-Chiari syndrome complicating severe preeclampsia in a parturient with primary antiphospholipid syndrome

A 27-year-old primipara with severe preeclampsia and primary antiphospholipid syndrome developed right upper quadrant pain, massive ascites, HELLP syndrome, and disseminated intravascular coagulation shortly following vaginal delivery. Computed tomography and color Doppler studies were compatible with complete thrombosis of the right hepatic veins, the Budd-Chiari syndrome. Anticoagulation was initiated, along with supportive measures, and the patient recovered completely. Imaging studies 6 months later were normal. This case demonstrates that nearly fatal forms of venous thrombosis may complicate preeclampsia in women with antiphospholipid syndrome; Doppler studies of the hepatic vein are of value in establishing the diagnosis.

Reproductive outcome after expectant management of ectopic pregnancy

OBJECTIVE

To study fertility rates following expectant management of clinically stable ectopic pregnancies.

STUDY DESIGN

Twenty of 33 patients with laparoscopically confirmed aborting tubal pregnancies managed expectantly were followed for a period of 1-5 years (mean 2.7 years). Excluded were the patients not desiring pregnancy, and patients with known impediments to fertility, such as age > 40 years and previous infertility, as well as patients lost to follow-up.

RESULTS

Successful pregnancies occurred in 16 patients (80%); one patient (5%) had a repeat ectopic pregnancy.

CONCLUSIONS

Expectant management is associated with a favorable reproduction outcome.

Retroperitoneal abscess after normal delivery. A report of two cases

BACKGROUND

Retroperitoneal abscess is a rare complication of normal labor and delivery, and no apparent etiology is evident.

CASES

We report on two patient who presented with back and leg pain soon after normal deliveries. While the condition was initially clinically misdiagnosed, ultrasonography and computed tomography demonstrated retroperitoneal collections and aided in guided percutaneous drainage. After a protracted course of antibiotic treatment and daily irrigation, the collections resolved.

CONCLUSION

Ultrasonography and computed tomography were invaluable in the diagnosis and guided drainage of rare psoas abscesses complicating delivery.

The outcome of pregnancy in an immigrant Ethiopian population in Israel

To study the assumption that obstetric risk factors would change over time in an immigrant Ethiopian population, a retrospective study of the records of singleton births among the Ethiopian immigrants between 1981-88 was undertaken and compared to a similar study of the general population. The Ethiopian immigrants were characterized by pregnancies at age extremes, a greater incidence of preeclampsia and premature deliveries, and a lower incidence of premature rupture of membranes. There was over time an increase in maternal weight gain among the Ethiopians as well as an increase in the incidence of preeclampsia and perinatal mortality.

Evaluation of breast stimulation for induction of labor in women with a prior cesarean section and in grandmultiparas

BACKGROUND

Information on the efficacy of breast stimulation for inducing labor in grandmultiparas and in women with a previous cesarean section with or without premature rupture of membranes is limited.

METHODS

Retrospective study of labor data from 135 women of grand multiparity or those with a previous section with or without premature rupture of the membranes in whom labor was induced by breast stimulation.

RESULTS

The success rate in achieving vaginal delivery was 84%. The duration of breast stimulation, length of labor, vaginal delivery rate, and Apgar score did not differ significantly among the four groups studied.

CONCLUSION

Breast stimulation in grandmultiparas and in women with a previous cesarean section is efficacious and safe.

Uterine adenofibroma presenting as a cystic adnexal mass

Uterine adenofibroma is a form of mixed mesodermal tumor in which both the epithelial and stromal components are benign. Almost all previously reported cases have been confined to the endometrium or endocervical mucosa. Our patient presented with a cystic adnexal mass and had a hysterectomy.

Transverse lower segment uterine incision in cesarean sections for transverse lie. A retrospective survey

A transverse lower uterine incision was made at cesarean section in 79 term patients with a singleton fetus in a transverse lie. The mean Apgar score was 9.5 (SD 0.8). One infant sustained a fractured femur, and another had a torticollis. In no case did the incision extend into the uterine vessels.

Pregnancy in a patient with fibrolamellar hepatocellular carcinoma

Pregnancy in a patient with hepatocellular carcinoma is rare. Fibrolamellar hepatocellular carcinoma is a distinct clinicopathologic variant with a better prognosis. We report such a case in which pregnancy was apparently not deleterious.

Oral sustained-release ritodrine as a substitute for prolonged intravenous tocolysis

Prolonged administration of intravenous ritodrine is necessary in some pregnant women with recurrent preterm labor as serum levels achieved by oral administration of ritodrine are insufficient to prevent recurrent contractions. New oral sustained-release ritodrine at 320 mg/day was given to 38 women with recurrent preterm labor. Serum levels of the drug at this dosage are considered comparable with levels achieved by i.v. treatment. The average duration of treatment was 8 days (range, 1-22). Patient tolerance was acceptable, and major maternal complications did not occur. We conclude that in selected cases, it may be possible to substitute oral sustained-release ritodrine at 320 mg/day for prolonged i.v. treatment.

Incidence and contribution of predisposing factors to transverse lie presentation

OBJECTIVES

Reassessment of predisposing factors to transverse lie presentation.

METHODS

Retrospective analysis of delivery data on 92 women with transverse lie presentation, using ultrasonography, and 92 randomly chosen control vertex deliveries.

RESULTS

The association between transverse lie and multiparity, prematurity, placenta previa, polyhydramnios and uterine anomalies is reaffirmed. Predisposing factors were found in 66% of primiparas but in only 33% of multiparas.

CONCLUSIONS

Known predisposing factors to transverse lie presentation withstood a closer and more accurate assessment of their incidence.

Pneumomediastinum in labor

We describe pneumomediastinum in a primigravida with delay in the second stage of labor. The pathophysiology, clinical presentation, and management are reviewed.

Synchronous intrauterine and tubal pregnancies with subchorionic hematoma

A case of a heterotopic pregnancy is presented. Clinical manifestations included vaginal bleeding, and on ultrasonography a subchorionic hematoma was demonstrated. The subchorionic hematoma may be regarded as blood draining from the tubal pregnancy through the uterus.