Alon Shrim

Diagnosis and treatment of heterotopic pregnancy compared with ectopic pregnancy.

STUDY OBJECTIVEnTo compare the diagnosis and management of ectopic (EP) and heterotopic pregnancies (HP).nnnDESIGNnRetrospective comparative study (Canadian Task Force classification II-2).nnnSETTINGnUniversity tertiary referral center for endoscopic surgery.nnnPATIENTSnTwelve women with HP and 210 women with laparoscopically confirmed EP.nnnINTERVENTIONnLaparoscopic treatment.nnnMEASUREMENTS AND MAIN RESULTSnAmong the 12 women with HP, all but 1 had received ovulation induction, 10 underwent in vitro fertilization-embryo transfer, and 1 conceived with clomiphen citrate. In the EP group 33 patients (15.7%) conceived spontaneously (p <0.05). Six women (50%) with HP had had previous pelvic surgery and three had a history of EP and salpingectomy. Four patients (33.4%) with HP and 29 (13.8%) with EP suffered from hypovolemic shock and required blood transfusion (p <0.05). Three of these four women with HP experienced physician and patient delays before admission. The sonographic diagnosis was correct in all women with HP and in 94.3% of women with EP. The median gestational age at diagnosis was 7.5 and 7.2 weeks for HP and EP, respectively. Six (50%) women with HP had evidence of fetal pulse in the ectopic gestation compared with 17 (8.1%) with EP (p <0.05). In addition, 66.7% and 24.7%, respectively, had ruptured tube (p <0.05). Mean +/- SD hemoperitoneum was 833.4 +/- 777 and 305 +/- 121 ml, respectively (p <0.05). Conversion to laparotomy was required in one (8.3%) and eight (3.8%) women, respectively (p <0.05). No major operative or postoperative maternal complications occurred in either group. Two women with HP had miscarriages, two have a continuing pregnancy, and eight delivered healthy newborns.nnnCONCLUSIONnWomen with HP are at significantly greater risk for hypovolemic shock and requiring blood transfusion than those with EP. The diagnosis of EP in cases of HP is difficult due to the presence of an intrauterine gestational sac and hyperstimulated ovaries. A greater level of suspicion may allow early laparoscopic intervention before life-threatening intraabdominal bleeding has occurred.

One Hour versus Two Hours Postprandial Glucose Measurement in Gestational Diabetes: A Prospective Study

OBJECTIVE:To compare the rate of adverse perinatal outcomes among women with gestational diabetes mellitus (GDM), monitored by 1 versus 2 hour-postprandial glucose (PPG) measurements.METHODS:A total of 112 women diagnosed with GDM, by the criteria of Carpenter–Coustan, were included in the study population. Women were recruited from two different treatment settings, but were managed by the same team of health-care professionals using a standardized protocol. Allocation to treatment group was based on treatment setting. Glucose levels were measured fasting, and either 1 hour (1-hour monitoring group-target values <140u2009mg/dl) or 2 hours (2-hour monitoring group-target values <120u2009mg/dl) postprandially. Demographic data and perinatal outcomes were collected from their medical records.RESULTS:In all, 66 women were assigned to 1-hour monitoring group (1u2009h-PPG) and 46 women to 2-hour monitoring group (2u2009h-PPG). There were no differences in parity, family history of diabetes, rate of GDM in previous pregnancies, weight gain, pregestational BMI and 50-g-glucose challenge test (GCT) and 100-g oral glucose challenge test (OGTT) results. As expected, there was a significant difference in mean blood glucose levels between the two groups (108.1±19.2 and 94.9±21.2u2009mg/dl, 1- and 2 hours, respectively, p<0.0001); however, HbA1C levels were similar in the two groups. Perinatal outcomes were defined as gestational week at delivery; fetal weight (3325±471 vs 3309±608u2009g, respectively) and percentile (47.2±27 vs 49.6±30, respectively), and were similar for both groups. Insulin therapy was initiated more frequently in 2-hour monitoring group (28 and 40% of women in groups 1 and 2, respectively; p<0.05). Rates of macrosomia (7.5 versus 10.6%), large for gestational age (7.4 versus 15.2%), and delivery by cesarean section (24 versus 30%) were increased in group 2 (2u2009h-PPG) but these differences did not reach statistical significance.CONCLUSION:These data suggest that diet control in women with GDM managed by 1-hour PPG measurements is associated with a decreased rate of insulin therapy. However, neonatal and obstetrical outcomes are not determined by the timing of their glucose determinations.

Early detection by diffusion‐weighted sequence magnetic resonance imaging of severe brain lesions after fetoscopic laser coagulation for twin–twin transfusion syndrome

Monochorionic twins treated by fetoscopic laser coagulation (FLC) for twin–twin transfusion syndrome (TTTS) are at increased risk of neurodevelopmental impairment. Our aim was to evaluate the additional value of diffusion‐weighted imaging (DWI) over fetal sonography and T2 magnetic resonance imaging (MRI) in the detection of acute ischemic cerebral lesions shortly following FLC.

Perinatal outcome of monochorionic twins with selective IUGR compared with uncomplicated monochorionic twins

OBJECTIVEnTo evaluate the perinatal outcome of MC twins with selective IUGR (sIUGR).nnnSTUDY DESIGNnA prospective study, which included three groups of MC twins: Group A, uncomplicated MC twin pregnancies (n = 91); group B, sIUGR with normal umbilical artery Doppler (n = 19); and group C, sIUGR with abnormal (absence or reversed EDV) umbilical artery Doppler (n = 18). The latter were routinely hospitalized in the high-risk ward under strict surveillance.nnnRESULTSnNeonatal outcome of fetuses complicated with sIUGR and normal Doppler was similar to controls. Neonates born to pregnancies complicated by sIUGR and abnormal Doppler had significantly increased incidence of CNS findings, RDS, NEC, sepsis, and neonatal death compared to controls. Adverse outcome in this group was independently associated only with gestational age at birth.nnnCONCLUSIONnThe perinatal outcomes of MC twins complicated with sIUGR and normal Doppler are similar to uncomplicated MC pregnancies. MC twins with sIUGR and abnormal Doppler have reasonable outcomes, yet significantly more neonatal complications compared to non-complicated MC twins.

Three‐dimensional ultrasound demonstration of the fetal palate in high‐risk patients: the accuracy of prenatal visualization

The aim of this research was to evaluate the ability of three‐dimensional (3D) ultrasound for demonstrating the palate of fetuses at high risk for cleft palate.

Sonographic assessment of fetal secondary palate between 12 and 16 weeks of gestation using three‐dimensional ultrasound

To evaluate fetal secondary palate in fetuses at 12 to 16u2009weeks gestation by three‐dimensional ultrasound.

P17.03: Ultrasound demonstration of the fetal palate—the accuracy of prenatal diagnosis and fetal outcome

chromosomal alterations and female sex. In these cases, new amniocentesis is indicated with localization of the SRY gene because this part of the chromosome is the determinant of the fetal sex. In our case, the SRY was missing and this was the reason for the discrepancy. In our case, ultrasound was definitive for a correct diagnosis. Conclusion: If we find fetal gender discrepancy we must: exclude sample error and placental mosaicism; perform a detailed ultrasound examination; and if repeat karyotyping is indicated, localize the SRY chromosome gene.

OP34.01: Monochorionic twins: mode of delivery in a tertiary center with a strict policy of induced delivery prior to 37 weeks of gestation

Objective: To evaluate the mode of delivery of monochorionic twins (MC) in a tertiary center with a strict policy of late preterm delivery. Methods: Retrospective evaluation of all MC twin pregnancies delivered at Sheba medical center between 08/2005 and 08/2008. Complicated MC pregnancies were defined as patients with TTTS or sIUGR. Uncomplicated MC pregnancies were delivered between 35 to 37 weeks of gestation. The control group consisted of 1234 twin dichorionic (DC) pregnancies delivered between 2005–2007. Results: The study group included 140 pregnancies. 81 (58%) were uncomplicated and 59 (42%) were complicated. Gestational age at delivery of all MC twins was similar to controls. Complicated MC pregnancies were delivered significantly earlier than uncomplicated MC pregnancies. The rate of CS of MC twins was slightly higher compared with DC pregnancies, mainly due to the group of complicated MC pregnancies. Patients with uncomplicated MC pregnancies were more likely to attempt vaginal delivery compared to complicated pregnancies (OR = 2.23, p = 0.03) but the rate of successful vaginal delivery was similar in both groups. Complicated MC twins had a significantly higher rate of CS due to non reassuring fetal condition (7/81 vs. 15/59, p = 0.007). Newborns delivered to the complicated pregnancies had significantly lower mean 1and 5-minutes Apgar scores compared with the uncomplicated group (7.3 vs. 8.7, 8.7 vs. 9.8, both p < 0.01). Conclusions: With the above policy, gestational age at delivery of uncomplicated MC pregnancies was not lower than, nor CS section rate higher than for DC pregnancies.

OP29.08: Short term outcome of MC twins with selective IUGR managed in a tertiary center

LCN between twins, first trimester discrepancy identified 3 cases and only one of them was discordant at delivery. So, LCN discrepancy was not a predictor of birthweight discordance by any of these methods (p = 0.72 and p = 0.63 for chi-squared tests respectively). ROC curve using FHTV discrepancy (in %) suggested a significant prediction on birthweight discrepancy. The area under curve was 0.76 and the analysis suggested that the best cut-off was between 15 and 20% of discrepancy reaching sensitivity and specificity around 80%. With a cut-off of 15% 13 cases of first trimester discrepancy were identified. From them, 8 were discordant at delivery (61.5%). So, the identification of 88.9% of cases of birthweight discrepancy (8/9). Conclusions: Measurements of first trimester FHTV can be useful for predicting birthweight discordance.

OC039: Three dimensional (3D) ultrasound imaging of fetal palate between twelve and sixteen weeks' gestation

24 pregnancies that evaluated by both U/S and MRI, 5 underwent TOP: in 1 both U/S and MRI were normal, in 2 pregnancies the U/S was normal and MR abnormal, and in 2 both U/S and MR considered abnormal. 19 women delivered at term. Normal U/S and MRI findings diagnosed during pregnancy in 14 pregnancies: 13 of them are developing normal and deafness was diagnosed in one. Normal U/S and abnormal MRI found in 4 pregnancies: 3 of them are developing normal and 1 with pathologic Bera test. In one pregnancy abnormal findings diagnosed in both U/S (echogenic bowel and IUGR) and MRI (hyperintense signals in the white matter in the temporal and parietal areas). The child is developing normal at 2 years of age. The time of maternal infection in the 19 women that delivered was: 5 cases in the first trimester, 9 cases in the second, and 5 cases in the third trimester of pregnancy. Conclusions: Primary CMV infection with normal U/S and MRI follow-up have favorable outcome for the infant. If the U/S followup alone is considered normal the risk for severe neurologic sequlae is minimal.