David Peleg

Spontaneous resolution of ectopic tubal pregnancy: natural history

OBJECTIVE To determine the characteristics and long-term outcome of women succeeding or failing expectant management of ectopic pregnancy (EP). DESIGN Prospective, defined protocol. SETTING University-affiliated gynecology department. PATIENTS We used a protocol that selected women with laparoscopic confirmed ectopic tubal pregnancy and declining plasma hCG values. Over a 5-year period, 60 women representing 20.1% of EPs fulfilled the inclusion criteria. Women were followed with serial hCG testing and transvaginal ultrasound. MAIN OUTCOME MEASURE Success or failure of expectant management. RESULTS Expectant management was successful in 28 (47.7%) of the patients. Thirty-two (53.3%) failed expectant management, and a treatment procedure was required. There was no difference in the resultant ipsilateral tubal patency or 1-year fertility rates of those women succeeding or failing expectant management. Analysis showed that in the face of declining values and with a starting hCG > 2,000 mIU/mL (conversion to SI unit, 1.00), 93.3% failed expectant management, whereas < 2,000 mIU/mL, 60.0% succeeded. CONCLUSION We conclude that expectant management should be offered as a treatment option only in those women fulfilling the criteria for a good prognosis.

LYMPHOMA AND LEUKEMIA COMPLICATING PREGNANCY

The hematologic malignancies rarely complicate pregnancy. Pregnancy is not thought to affect the course of either Hodgkins lymphoma, non-Hodgkins lymphoma, or the leukemias. The prognosis worsens only if there is a delay in diagnosis or treatment. Both chemotherapy and radiotherapy have been administered during pregnancy with favorable results.

Laparoscopic management of adnexal cystic masses in postmenopausal women.

Objective: To evaluate laparoscopic treatment of postmenopausal women with an adnexal cystic mass predicted to be benign. Methods: Selection criteria were transvaginal sonographic appearance other than a complex cyst and a normal serum CA 125 level. During the period May 1988 to June 1993, 55 women fulfilled the criteria and underwent operative laparoscopy. During the same period, 75 postmenopausal women underwent exploratory laparotomy for an adnexal cystic mass that was complex in appearance or associated with elevated serum CA 125. Results: Laparoscopic bilateral oophorectomy was performed in all 55 women. All had benign masses (positive predictive value 100%). Malignant tumors were found in 23 of the 75 women undergoing laparotomy (negative predictive value 30.7%). There was no significant difference in size of the tumors between women undergoing laparoscopy or laparotomy. Conclusion: Because of its safety and efficacy, laparoscopic management is the preferred procedure in postmenopausal women with a non‐complex adnexal mass and a normal CA 125 level. (Obstet Gynecol 1994;83:594‐6)

Limited role for intratubal methotrexate treatment of ectopic pregnancy

OBJECTIVE To test the effectiveness of laparoscopic intratubal methotrexate (MTX) injection or salpingostomy in the treatment of ectopic pregnancy (EP). DESIGN Prospective predefined protocol. SETTING Department of Obstetrics and Gynecology of a university-affiliated hospital. PATIENTS AND INTERVENTIONS Between January 1988 and December 1993, we treated 342 women with EP, of which 99 were treated by either laparoscopic salpingostomy (n = 55) or intratubal MTX injection (n = 44). MAIN OUTCOME MEASURES The success and failure rates were calculated for each treatment protocol. Also analyzed were subsequent tubal patency and fertility rates. RESULTS Salpingostomy was successful in 51 of 55 patients (92.7%), whereas intratubal MTX injection was successful in only 27 of 44 women (61.4%). Methotrexate injection particularly was unsuccessful if the initial hCG was > 2,000 mIU/mL (conversion factor to SI unit, 1.00) or the size of the tubal mass was > 2.0 cm as measured during laparoscopy. There was no difference in the subsequent tubal patency rates of fertility rates between women undergoing MTX injection or salpingostomy. CONCLUSIONS These results suggest that salpingostomy is effective in the treatment of EP. Methotrexate injection failed in more patients despite preferential selection criteria, suggesting that its use should be limited to the subgroup of women with initial hCG < 2,000 mIU/mL and size at laparoscopy < 2.0 cm.

Comparison of 12- and 72-Hour expectant management of premature rupture of membranes in term pregnancies

Objective To compare 12-hour and 72-hour expectant management of premature rupture of membranes (PROM) in singleton term pregnancies. Methods In a prospective, nonrandomized study, 566 low-risk women with singleton term pregnancies presenting with PROM were assigned to either 12-hour or 72-hour expectant management. Patients who had not entered labor at the end of the assigned period were induced with oxytocin. The pregnancy outcome of both methods was compared with regard to infectious complications and method of delivery. Results There was no statistical difference in the rate of chorioamnionitis between the 12-hour and 72-hour expectant management groups (11.7 versus 12.7%; relative risk [RR] 0.9, 95% confidence interval [CI] 0.6-1.5; P = .83). Cesareans were performed to a similar degree in both groups (4.7 versus 6.7%; RR 0.7, 95% CI 0.3-1.4; P = .39). Fifty-five percent of the 12-hour group underwent oxytocin induction, compared with 17.5% of those in the 72-hour group (RR 5.8, 95% CI 3.9-8.5; P < .001). Women undergoing induction after 72-hour expectant management had an increased risk of cesarean delivery compared with those after a 12-hour wait (RR 5.9, 95% CI 2.3-15.1; P < .001). Overall, women in the 12-hour group had shorter admission-to-discharge times than the 72-hour group (5 versus 6 days, 95% CI of the difference 0.6-1.3; P < .01). Conclusion Regimens of 12-hour and 72-hour expectant management of PROM are comparable regarding infectious complications and pregnancy outcome. However, the longer wait prolongs the interval to delivery and increases hospitalization costs.

Perinatal management of women with immune thrombocytopenic purpura: survey of United States perinatologists.

OBJECTIVE The aim of the study was to determine how perinatologists in the United States manage the care of women with immune thrombocytopenic purpura with respect to mode of delivery. STUDY DESIGN US members of the Society of Perinatal Obstetricians were surveyed with a 4-question questionnaire. Two mailings were sent. Questions 1 and 2 asked for a response regarding the perinatal management of delivery for women with chronic immune thrombocytopenic purpura and new-onset disease. The options were cordocentesis or fetal scalp blood sampling and cesarean delivery if the platelet count was <50,000 cells/microL, cesarean delivery if the maternal platelet count was <50,000 cells/microL, cesarean delivery of all women with immune thrombocytopenic purpura, and trial of labor without determining fetal platelet count. The third question asked for an opinion on whether cesarean delivery was protective against intracranial hemorrhage in cases of immune thrombocytopenic purpura. The fourth question asked whether the practitioner was in academic or private practice or both. RESULTS Among the 1596 perinatologists surveyed, there were 940 informative responses (58.9%). Most would allow a trial of labor for women with chronic (59.0%) or new-onset (66.6%) immune thrombocytopenic purpura. In cases of chronic immune thrombocytopenic purpura, 31.0% of those responding would perform an invasive procedure to determine fetal platelet count, followed by cesarean delivery if this count was <50, 000 cells/microL. In cases of new-onset immune thrombocytopenic purpura, 25.4% would do so. Of the respondents, 11.8% reportedly considered cesarean delivery protective against intracranial hemorrhage, whereas 56.6% did not and 31.6% were unsure. CONCLUSIONS The management of women with immune thrombocytopenic purpura remains controversial in the United States. Approximately two thirds of perinatologists would allow a trial of labor without a procedure to determine fetal platelet count. Most physicians surveyed did not consider cesarean delivery to be protective against intracranial hemorrhage.

Expanded Möbius syndrome.

A woman presented at 33 weeks gestation with reduced fetal movements and a nonreactive nonstress test. Fetal ultrasound examination revealed a peculiar unilateral arm tremor. At emergency cesarean section, performed for fetal indications, a 1,672-gm male infant was delivered requiring intubation for feeble respiratory effort. After delivery the neonate was transiently hypertonic and later hypotonic. Continuing ventilatory support at minimal settings was necessary. The work-up for aneuploidy, metabolic disorders, and infection was negative. The infant died after being removed from ventilatory support on day 22. Postmortem examination revealed extensive bilateral brain gliosis and mineralization without evidence of inflammation, partial absence of cranial nerve nuclei III-XI, and a total absence of cranial nerve roots VI-XI. Together these finding are compatible with a diagnosis of expanded Möbius syndrome.

Predictors of cesarean delivery after prelabor rupture of membranes at term

OBJECTIVE To identify the significant predictors of cesarean delivery after prelabor rupture of membranes (PROM) at term. METHODS In a multicenter study involving 72 institutions in six countries, 5041 women were randomized to induction of labor with oxytocin or prostaglandins or to expectant management. We did univariate and multivariate logistic regression analyses to determine the statistically significant independent predictors of cesarean delivery (P < .05). RESULTS The following variables were found to be significantly associated with cesarean delivery: delivery in Israel, versus Canada (odds ratio [OR] 0.34); delivery in Australia, versus Canada (OR 1.93); nulliparity (OR 2.81); labor lasting more than 12 hours, versus less than 6 hours (OR 2.78); labor lasting 6-12 hours, versus less than 6 hours (OR 1.66); previous cesarean delivery (OR 2.75); epidural anesthesia (OR 2.66); clinical chorioamnionitis (OR 2.42); internal fetal heart rate monitoring (OR 2.19); birth weight of at least 4000 g (OR 2.07); use of oxytocin (OR 1.97); maternal age of at least 35 years (OR 1.44); latent period of at least 12 hours (OR 1.41); and meconium staining (OR 1.41). CONCLUSION Strong predictors of cesarean delivery after PROM at term were country of birth, nulliparity, long labor, previous cesarean delivery, and epidural anesthesia.

Laparoscopic treatment of adnexal torsion

Adnexal torsion remains an infrequent and difficult to diagnose gynecologic emergency. Until recently, laparoscopic diagnosis was followed by laparotomy. Now, with proper laparoscopic technique, it is possible to untwist the adnexa or to remove it with excellent results. We report herein our cumulative four year experience with laparoscopic detorsion or removal of the adnexa in 41 patients. Ten patients were simultaneously pregnant, seven having the ovarian hyperstimulation syndrome, six with paraovarian cysts and 18 with idiopathic torsion. All of the women had an uneventful recovery, with 14 of 19 patients who claimed desire for pregnancy becoming pregnant within one year after the procedure, emphasizing its advantages and safety.

Relapsing thymic carcinoma during pregnancy

A 23 year old woman, who was known to be in remission from thymic carcinoma, presented in her first trimester. She had previously been treated with radiation and chemotherapy. Her pregnancy was complicated by fevcr and contractions at 30 weeks and ended with the birth of a live preterm male infant. Subsequent investigation revealed a massive relapse of her mediastinal tumor. This case reinforces the devastating consequences that pregnancy has on thymic hyperplasia. Of nine previously reported cases, five of the women died either during pregnancy or within six months and only one was alive longer than five years. Therapeutic abortion should be considered in the pregnant woman with known thymic neoplasia.