Ehud Weiner

Clinical and echographic features of in utero cardiac dysfunction in the recipient twin in twin-twin transfusion syndrome.

OBJECTIVE--Fetal twin-twin transfusion syndrome (TTTS) presenting in the second trimester has been associated with almost no perinatal survival until recently, when serial drainage of amniotic fluid has improved the prognosis to 70%-80%. Most recipient twins now survive but develop cardiac dysfunction. The study was undertaken to evaluate the abnormal echocardiographic features and clinical complications of cardiac disease in the recipient twin of TTTS. DESIGN--Antenatal and postnatal echocardiographic and clinical observational study. SETTING--Antenatal studies in a tertiary referral centre. Postnatal management and follow up were performed by the same paediatric cardiologist, either at the obstetric hospital or at the regional referral centre. PATIENTS--Twin pregnancies complicated by TTTS with severe polyhydramnios diagnosed earlier than 25 weeks that proceeded until viability (n = 5). INTERVENTION--Serial fetal echocardiography with colour Doppler. Postnatal echocardiography in the first week and between two and seven months. Serial amnioreduction was performed in all pregnancies. Digoxin treatment, pericardiocentesis, paracentesis, or laser ablation of placental anastomoses was undertaken when there was hydrops. RESULTS--Increased cardiothoracic ratio and tricuspid regurgitation were seen in all recipient twins. High pulmonary artery velocities developed in three. One recipient twin died a week after delivery of endocardial fibroelastosis and infundibular pulmonary stenosis. Two other had balloon dilatation for pulmonary stenosis, one shortly after birth and one at four months. A further twin has apical thickening of the right ventricle at six months. The remaining recipient twin had normal echocardiographic findings at follow up. CONCLUSION--This report characterises for the first time a cardiac disease acquired in utero in the recipient twin in pregnancies complicated by TTTS. Clinical manifestations in utero range from mild to critical pulmonary stenosis or lethal cardiomyopathy. Although perinatal prognosis seems to be related to the severity of dysfunction when first diagnosed in utero, follow up in infancy is recommended in view of the possibility of progressive pulmonary stenosis.

Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial

Abstract Objective: To compare perinatal outcome and glycaemic control in two groups of pregnant diabetic patients receiving two insulin regimens. Design: Randomised controlled open label study. Setting: University affiliated hospital, Israel. Participants: 138 patients with gestational diabetes mellitus and 58 patients with pregestational diabetes mellitus received insulin four times daily, and 136 patients with gestational diabetes and 60 patients with pregestational diabetes received insulin twice daily. Intervention: Three doses of regular insulin before meals and an intermediate insulin dose before bedtime (four times daily regimen), and a combination of regular and intermediate insulin in the morning and evening (twice daily regimen). Main outcome measures: Maternal glycaemic control and perinatal outcome. Results: Mean daily insulin concentration before birth was higher in the women receiving insulin four times daily compared with twice daily: by 22 units (95% confidence interval 12 to 32) in patients with gestational diabetes and by 28 units (15 to 41) in patients with pregestational diabetes. Glycaemic control was better with the four times daily regimen than with the twice daily regimen: in patients with gestational diabetes mean blood glucose concentrations decreased by 0.19 mmol/l (0.13 to 0.25), HbA1c by 0.3% (0.2% to 0.4%), and fructosamine by 41 μmol/l (37 to 45), and adequate glycaemic control (mean blood glucose concentration <5.8 mmol/l) was achieved in 17% (8% to 26%) more women; in patients with pregestational diabetes mean blood glucose concentration decreased by 0.44 mmol/l (0.28 to 0.60), HbA1c by 0.5% (0.2% to 0.8%), and fructosamine by 51 μmol/l (45 to 57), and adequate glycaemic control was achieved in 31% (15% to 47%) more women. Maternal severe hypoglycaemic events, caesarean section, preterm birth, macrosomia, and low Apgar scores were similar in both dose groups. In women with gestational diabetes the four times daily regimen resulted in a lower rate of overall neonatal morbidity than the twice daily regimen (relative risk 0.59, 0.38 to 0.92), and the relative risk for hyperbilirubinaemia and hypoglycaemia was lower (0.51, 0.29 to 0.91 and 0.12, 0.02 to 0.97 respectively). The relative risk of hypoglycaemia in newborn infants to mothers with pregestational diabetes was 0.17 (0.04 to 0.74). Conclusions: Giving insulin four times rather than twice daily in pregnancy improved glycaemic control and perinatal outcome without further risking the mother. Key messages Improving maternal glycaemic control during pregnancy is the key to better perinatal outcome In pregnant diabetic women insulin four times daily achieved better glycaemic control and lower rate of perinatal complications (hypoglycaemia, hyperbilirubinaemia) than insulin twice daily Better glycaemic control resulted from a larger total daily insulin dose The intensified regimen did not lead to higher rate of severe maternal hypoglycaemia

Transvaginal sonography as the ultimate diagnostic tool for the management of ectopic pregnancy: experience with 840 cases

OBJECTIVE To evaluate the efficacy of transvaginal sonography and serum beta-hCG levels as diagnostic tools for deciding whether to perform operative laparoscopy in the treatment of presumed ectopic pregnancy (EP). DESIGN A prospective protocol for the evaluation and treatment of women with presumed EP. SETTING Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel. PATIENT(S) Eight hundred forty women with presumed EP who were seen in our emergency department from January 1988 through December 1995. INTERVENTION(S) On the basis of specific sonographic signs and beta-hCG levels, we performed immediate operative laparoscopy in patients with demonstrable extrauterine fetal heart activity or >100 mL of fluid in the pelvic cavity. We followed up all other patients, using defined criteria for laparoscopic intervention. MAIN OUTCOME MEASURE(S) The accuracy of transvaginal sonography in predicting EP was evaluated as part of the described protocol. RESULT(S) Overall, 380 patients were found to have EP. Of these, 331 were identified positively by transvaginal sonography and 49 were not. In 27 of 358 laparoscopies, no EP was found. The sensitivity of transvaginal sonography for the prediction of EP was 87% and the specificity was 94%. The positive and negative predictive values were 92.5% and 90%, respectively. CONCLUSION(S) In this protocol, which invariably captured the true location of the products of conception, using transvaginal sonography as the primary modality in the evaluation of patients with presumed EP resulted in the use of laparoscopy mainly as a treatment tool. This approach is both safe and economical.

Pharmacokinetics of methotrexate after local tubal injection for conservative treatment of ectopic pregnancy

Methotrexate peak level after intratubal injection was found to be significantly lower than the accepted toxic level. After IM injection, MTX peak level and the AUC were found to be similar to the levels observed after intratubal injection. The advantage of tubal injection over IM injection is challenged.

PRENATAL DIAGNOSIS OF DIASTEMATOMYELIA: CASE REPORTS AND REVIEW OF THE LITERATURE

Diastematomyelia is a rare malformation characterized by complete or incomplete division of the spinal cord by osseous or fibrocartilaginous septum. Most cases are seen in association with other anomalies of the vertebral column such as spina bifida, kyphoscoliosis, butterfly vertebra, and hemivertebra. In this report we describe two cases of isolated diastematomyelia detected at routine second‐trimester detailed ultrasound scan, the most striking feature being the detection of an echogenic focus in the posterior aspect of the spine in association with widening of the interpedicular vertebral space. The prenatal literature is reviewed to assess the clinical significance of this finding.

Endothelin-1,2 levels in umbilical vein serum of intra-uterine growth retarded fetuses as detected by cordocentesis

Introduction: The objective of this study was to determine whether the circulatory levels of endothelins, potent vasoconstrictor polypeptides produced mainly by endothelial cells, are increased in growth‐retarded fetuses.

Exogenous Estrogen Therapy Concurrent with Clomiphene Citrate – Lack of Effect on Serum Sex Hormone Levels and Endometrial Thickness

The antiestrogenic action of clomiphene citrate (CC) is claimed to have an adverse effect on the development of the secretory endometrium. This effect can be assessed: (1) sonographically by measuring endometrial thickness, and (2) by serum hormone levels. The aim of this study was to evaluate whether administering ethinyl estradiol (EE) during CC treatment has any effect on endometrial thickness and/or hormone levels. Seventeen patients were treated with CC for one cycle and with CC plus EE in an adjacent cycle either before or after. The patients were followed by daily assessment of endometrial thickness, follicular growth and serum estradiol levels as well as midluteal prolactin and progesterone levels. We did not find any significant difference in either endometrial thickness, estradiol level, midluteal prolactin or progesterone levels between the two treatment protocols. We conclude that exogenous EE, in the dosage used in this study, does not overcome CC-induced alterations in endometrial thickness.

Clinical variation of Aarskog syndrome in a large family with 2189delA in the FGD1 gene.

The clinical diagnosis of ASS (Aarskog–Scott syndrome or Faciogenital Dysplasia) was made in seven individuals belonging to a large Arabic family, which was supported by molecular studies revealing a 2189delA mutation in exon 15 of the FDG1 gene. The affected individuals in this family demonstrated clinical variability particularly in their cognitive skills, raising the question whether other genetic factors might be involved in the phenotypic evolution of ASS.

Fetal Habituation to Sound Stimulus in Various Behavioral States

The correlation between arousal state and fetal habituation was tested. Four behavioral states were determined according to fetal heart activity and movement pattern in 52 fetuses. Repeated wide low-frequency sound was used as external stimulus. Ceasing of response to 5 consecutive stimuli indicated habituation. The time from response to habituation was defined as habituation time. Although fetuses in a lower arousal state habituate more rapidly, the difference is not statistically significant.

Establishment of Fetal Biometric Charts Using Quantile Regression Analysis

Fetal growth evaluation is an essential component of pregnancy surveillance. There have been several methods used to construct growth charts. The conventional charts used in current daily practice are based on small numbers and traditional statistical methods. The purpose of this study was to improve fetal biometric charts based on a much larger number of observations with an alternative statistical method: quantile regression analysis. A comparison between the charts is presented.