Doron J.D. Rosen

Induction of labor versus expectant management in macrosomia: A randomized study

Objective Macrosomia at term is associated with increased maternal and neonatal morbidity, including a higher rate of cesarean delivery and shoulder dystocia. Induction of labor has been suggested as a means to prevent further weight gain and improve outcome. The aim of this study was to determine whether or not induction of labor in these cases improves maternal and neonatal outcome. Methods Patients at term with an ultrasonic fetal weight estimation of 4000-4500 g were prospectively randomized into two groups: induction of labor (group I) and expectant management (group II). Patients with diabetes, a previous cesarean delivery, or nonvertex presentation were excluded. Outcome variables included mode of delivery, arterial cord pH, presence of shoulder dystocia, brachial plexus injury, clavicular fracture, cephalophematoma, and intraventricular hemorrhage. Results Of 273 patients who were eligible for the study, 134 were randomized to group I and 139 to group II. Parity, gestational age, and fetal weight estimation were similar in the two groups. The neonates of group II patients were significantly heavier (4132.8 ± 347.4 versus 4062.8 ± 306.9 g; P = .024). The rate of cesarean delivery was 19.4% in group I and 21.6% in group II patients (not significant [NS]). Cord pH was similar in both groups. shoulder dystocia was diagnosed in five grup I and six group Ii patients (NS). None developed brachial plexus injury in group Ii patients without documented shoulder dystocia. Mild intraventricular bemorrhage was diagnosed in three of 44 group I and two of 31 group II neonates evaluated (NS). Conclusion In this prospective, randomized study, induction of labor for suspected macrosomia at term did not decrease the rate of cesarean delivery or reduce neonatal morbidity. Ultrasonic estimation of fetal weight between 4000 and 4500 g should not be considered an indication for induciton of labor.

Endometrial changes in postmenopausal women treated with tamoxifen for breast cancer

Objective To evaluate whether risk factors, other than tamoxifen, can be identified for the development of endometrial pathologies in postmenopausal breast cancer patients treated with tamoxifen.

Time-dependent effect of tamoxifen therapy on endometrial pathology in asymptomatic postmenopausal breast cancer patients.

Various endometrial lesions were more frequent among asymptomatic postmenopausal breast cancer patients who were treated with tamoxifen for > 48 consecutive months (30.8%) when compared with similar patients who were treated for 6-24 months or for 25-48 months (20.8% and 12.5%, respectively). However, this difference was not statistically significant. There were also no significant differences in the frequency of the various endometrial lesions between these three groups, although endometrial polyps were more frequently found among those treated for > 48 months. Overall, 20.7% of the 164 tamoxifen-treated patients in the study had an endometrial pathology. It can be concluded that there is a slight tendency among those postmenopausal patients who have been treated for > 48 consecutive months to have a higher frequency of endometrial lesions.

Endometrial decidual changes in a postmenopausal woman treated with tamoxifen and megestrol acetate

Sapir Medical Center Kfar-Saba 4428 1 Israel metrium is related to its capacity to occupy the oestradiol receptor in the endometrial cells. It has been suggested that tamoxifen exerts its effects on the endometrium via the oestrogen receptor, and that it has a long-term, low-grade oestrogenlike effect (Cross & Ismail 1990; Gusberg 1990). In postmenopausal women with breast cancer, an increase in the karyo-picnotic index indicates oestrogenic changes in the vaginal epithelium (Ferrazzi et al. 1977; Boccardo et al. 198 I), and this is supported by the observations of endometrial hyperplasia (Cross & Ismail 1990), or endometrial polyps (Nuovo et al. 1989). Stimulation of endometrial cancer cells in culture by tamoxifen has also been reported (Anzai et al. 1989). Moreover, several groups have observed an increased incidence of endometrial cancer in women with breast cancer and treated with tamoxifen (Killackey et al. 1985; Hardell 1988; Fomander et al. 1989). Hardell et al. (1988) found tamoxifen to be a risk factor for uterine carcinoma, as nearly half of the 23 women with breast cancer in their study who had endometrial

The effect of thigh-length support stockings on the hemodynamic response to ambulation in pregnancy.

OBJECTIVE Our purpose was to determine the effect of thigh-length support stockings on hemodynamic response when pregnant subjects change from the sitting to the lateral recumbent position and then after standing with ambulation. STUDY DESIGN Eighteen subjects in the late second and early third trimester of pregnancy acted as their own controls. The cardiovascular status of the subjects was assessed by a noninvasive technique--thoracic electrical bioimpedance before and after wearing support stockings for 1 week. Urine catecholamines were measured in 13 patients before and after wearing support stocking to assess the release of catecholamines. Samples were collected after the subjects had been in the lateral recumbent position 40 minutes and again 40 minutes later after standing with ambulation. RESULTS Heart rate and mean arterial blood pressure decreased significantly when subjects changed from the sitting to the lateral recumbent position and then increased with ambulation. Wearing compression stockings significantly increased mean arterial pressure and afterload in all three positions. Position change from lateral recumbent to standing and ambulation marginally increased urinary dopamine levels (p = 0.097) and significantly increased norepinephrine levels (p = 0.006). CONCLUSIONS There are significant hemodynamic changes in pregnant subjects when they change from the sitting position to the lateral recumbent position and then change to standing with ambulation. Support stocking have a significant mechanical effect: they significantly increase afterload and systemic vascular resistance by preventing pooling of blood in the lower extremities. There may also be a biochemical effect that results in less catecholamine release. These results suggest that compression stockings could play an important role in supporting the circulation during ambulation.

The use of PGE2 for induction of labor in parturients with a previous cesarean section scar

Controversy still dominates the discussion of the correct method for delivering patients with a previous cesarean section (C/S) scar. Although many have abandoned the slogan of “once a cesarean, always a cesarean”, repeat cesareans are still the rule in many institutions. We have abandoned this dogma, and are now advancing to new ideas and are promoting a new protocol. Nineteen post‐one cesarean section patients were induced on various indications by means of PGE2 pessaries. Close surveillance revealed no complications and 16 were delivered vaginally. All neonates had good Apgar scores, and all scars were found to be intact upon examination. We recommend cautious use of prostaglandins for selected post‐cesarean patients.

Transvaginal ultrasonographic quantitative assessment ofaccumulated cut-de-sac fluid

Preoperative quantitative assessment of pelvic fluid is an important diagnostic tool in clinical decision making. In this study, we used high-frequency transvaginal ultrasonography in 10 healthy women to assess both the correlation between various amounts of fluid installed in the cul-de-sac and ultrasonic imaging and to determine whether correct estimation of fluid volume can be reached. No fluid could be ultrasonically detected when the volume was less than 35 to 40 ml. Between 35 and 100 ml there was a clear image of accumulated fluid in the cul-de-sac with good correlation between volume and image, whereas with larger amounts no clear correlation between the amount of fluid introduced and size of fluid area visualized by ultrasonography was possible. Transvaginal ultrasonography may enable quantitative evaluation of certain volumes of pelvic fluid, although amounts less than 35 ml cannot be visualized.

Repeated external cephalic version at term

External version was performed three times in a patient at term because of spontaneous reversion to breech presentation. She was then delivered vaginally. Spontaneous reversion to breech presentation can be managed with additional external cephalic version procedures.

Advanced primary ovarian carcinoma in pregnancy

A case of advanced ovarian carcinoma in pregnancy is described. The entity is usually difficult to diagnose; when it does occur, the objective should be to optimize both fetal and maternal outcome.

Toxic shock syndrome after loop electrosurgical excision procedure

Toxic shock syndrome can occur after any surgical procedure. We report the first case of toxic shock syndrome that has occurred after a loop electrosurgical excision procedure. The patient recovered with supportive care and antibiotics.