A. Herman

Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar

Case report A 28 year old woman was referred at seven weeks of gestation because of vaginal bleeding. Three years before she had undergone caesarean section because of breech presentation of a baby who weighed 3.8 kg at birth. The puerperium was complicated by febrile morbidity. Other than slight vaginal bleeding, there were no clinical findings. Ultrasound examination showed a pregnancy located in the i s t h c a l region (Fig. 1). Since the gestational sac was displaced anteriorly, the possibility of ectopic implantation in the previous caesarean section scar was considered. After discussion with the couple, a mutual decision. was reached to avoid any intervention at that point. It was judged that the sac, located in the isthmical region, would eventually coalesce with the uterine cavity and continue as a normal pregnancy. Repeated ultrasound examinations at 13 and 14 weeks’ gestation (Fig. 2A, B) showed a tip of the sac bulging towards the uterine cavity. However, several weeks later, the sac remained outside the uterine cavity (Fig. 2C, D). The findings and the potential dangers were discussed again, but because of the increased risk of hysterectomy associated with termination at that stage, management was unchanged. Besides diet-controlled gestational diabetes, the course of the pregnancy was uneventful. Vaginal examinations disclosed a normal cervix displaced up and laterally by the sac that was bulging into the right fornix. Caesarean delivery was planned for the 36th week of gestation, and she was admitted to the hospital two weeks before this. At 35 weeks an urgent caesarean section was performed because of acute abdominal pain. A longitudinal incision was made into the coverings of the amniotic sac and a healthy male infant weighmg 3.6 kg was born. The membranes were covered with thin fibromuscular tissue and peritoneum. The uterus was displaced to the left by the pregnancy sac and both cavities communicated at the isthmical level. There was no chorion free in the peritoneal cavity, and the placenta and its vessels were visible through transparent thin uterine wall and peritoneum. The placenta was of normal size, attached firmly to the low anterior aspect of the sac, and was

Hysteroscopy is superior to hysterosalpingography in infertility investigation

Background. The development of advanced endoscopic instrumentation in recent years has demonstrated the superiority of direct visual examination over radiographic demonstration of various body cavities. Just as laparoscopy has gradually taken a primary role in the surgical investigation of the ovulatory infertile patient, the role of intrauterine endoscopy in comparison to hysterosalpingography (HSG) needs to be reevaluated.

Detrusor instability following colposuspension for urinary stress incontinence.

Summary. Sixty‐two patients with genuine stress incontinence (group A) and 30 women with combined detrusor instability and genuine stress incontinence (group B) had a colposuspension operation. The proportion with symptoms of detrusor instability was significantly reduced from 24% before operation to 9% after operation in group A and from 73% to 33% in group B. Urodynamically, detrusor instability developed after surgery in 17 of the 62 patients (27%) in group A whereas only 12 of the 30 women (40%) in group B had detrusor instability after surgery. No urodynamic explanation was found to explain the effect of colposuspension in relieving the symptoms of detrusor instability in some and causing them in others. Nevertheless, it is suggested that colposuspension is helpful for most patients with combined detrusor instability and genuine stress incontinence.

Comparison of nuchal translucency measurement and second-trimester triple serum screening in twin versus singleton pregnancies

Maternal serum screening for Down syndrome (DS) in twin pregnancies poses difficulties due to a lack of precise biochemical information about each co‐twin. The current study attempts, for the first time, to compare two screening methods: nuchal translucency (NT) measurement and serum screening for DS, in twin pregnancies. 60 women with twin pregnancies (study group) underwent both first‐trimester NT scanning and mid‐trimester triple‐marker serum screening, and were followed throughout their gestation. Nuchal translucency measurements were compared with a matched control of 120 singleton pregnancies with a similar (±2 years) maternal age and fetal crown–rump length (CRL) (±3 mm). In both analyses, a risk of 1:380, or higher, of having a DS newborn was considered screen positive. Both mean maternal age (31±3 years) and CRL (62±11 mm) were similar in the study and control groups. The median NT measurement expressed as multiples of the median (MOM) for CRL was similar in the study and control groups (0.85 and 0.88, respectively). Based on NT measurements, 5 per cent of the pregnancies in the study group and 2.5 per cent in the control group were defined as screen positive (p =N · S). Mid‐gestation serum screening was associated with 15 per cent and 6 per cent screen‐positive rate in study and control groups, respectively (p<0.05). There was a ratio of 1:3 screen‐positive rate between first and second‐trimester screening tests within the study group. This high false‐positive rate results led to 18.3 per cent amniocentesis rate in the study group compared with 7.5 per cent of the control group (p<0.03). Only one co‐twin which was picked up by the NT screen was further diagnosed as trisomy 21, and one co‐twin with cardiac and neural tube defect was missed by the two screening tests and was later picked up in an anomaly scan. Although the current series is too small to provoke any changes in screening practice, when twin pregnancies are diagnosed, it seems very reasonable to offer them NT measurement. A larger group may be needed to clarify which approach is the most beneficial screening policy for this highly selected group of pregnant women. Copyright

Correlation between nuchal translucency and nuchal skin‐fold measurements in Down syndrome and unaffected fetuses

To assess whether there is a correlation between nuchal translucency (NT) and nuchal skin‐fold (NF) measurements, in Down syndrome and in normal pregnancies.

Extremely large number of twists of the umbilical cord causing torsion and intrauterine fetal death

Extremely large number of twists of the umbilical cord causing torsion of the entire length of the umbilical cord was found in two cases of intrauterine fetal death. It was twistd in one case 35 times and in the other 20 times. No additional pathology, such as stricture or abnormality of the Whartons jelly, was found. The two mothers complained of decreased fetal movements and both newborns were found later to be growth retarded. A long cord of 120 cm was present in one case and normal length of 70 cm in the other. Close antenatal care in cases with growth retarded fetuses or decreased fetal movements may help in avoiding fetal demise in such rare cases.

High-output left ventricular failure after dextran use in an operative hysteroscopy

High-output left ventricular failure occurred in a patient after a difficult case of hysteroscopic lysis of adhesions using dextran as a distension medium. The excessive dissection in the uterine wall, the long duration of the operation, and the large volumes of dextran probably caused intravasation of dextran into the systemic circulation inducing a significant shift of fluids from the third space. This was possibly assisted by the large volume of fluids given intravenously in a 45-kg patient initiating the reported sequence of events.

A model for second-trimester Down syndrome sonographic screening based on facial landmarks and digit length measurement.

To determine whether Down syndrome can be detected by combining measurements of fetal nasal bone (NB) length, prenasal thickness (PT) and digits 2 and 3 of the hand.

Bedside estimation of Down syndrome risk from second‐trimester ultrasound prenasal thickness

To construct tables for ‘bedside’ estimation of Down syndrome risk based on maternal age and ultrasound prenasal thickness (PT) measurements.

On-to-on versus on-to-out nuchal translucency measurements

Objective To analyze variables affecting the differences between on‐to‐on and on‐to‐out methods of nuchal translucency measurement.