Eli Rimon

Low molecular weight heparin versus no treatment in women with previous severe pregnancy complications and placental findings without thrombophilia.

Low molecular weight heparin (LMWH) treatment has been recommended for pregnant women with previous adverse pregnancy and who were diagnosed as having a thrombophilia. We now examined the effect of LMWH on pregnant women without thrombophilias who had severe pregnancy complications and placental vasculopathy in an earlier pregnancy. Seventy-two women with a history of severe preeclampsia, fetal growth restriction (FGR) less than fifth percentile, severe placental abruption and/or stillbirth after 20 weeks, whose thrombophilia workup was negative, were enrolled. Placental vasculopathy was defined as villous infarcts, fibrinoid necrosis of decidual vessels, fetal vessel thrombosis, evidence of placental abruption and perivillous fibrin deposition. The study group consisted of 32 pregnant women who were treated with LMWH and 40 pregnant women who were not treated with LMWH (control group) in their ensuing pregnancy in our institution between 2003 and 2007. The incidences of severe preeclampsia, FGR, placental abruption and stillbirth in the previous pregnancies were similar for both groups. The incidences of severe preeclampsia and placental abruption in the study group in the index pregnancy were significantly lower than the control group (3.13 versus 20%, P = 0.03; and 0 versus 15%, P = 0.03, respectively). The respective incidence of FGR was 6.25 versus 22.5%, and of overall adverse outcome was 9.4 versus 60% (P = 0.001). Treatment with LMWH may reduce the rate of the recurrence of severe pregnancy complications and significant placental vasculopathy in women without thrombophilias.

Low molecular weight heparin treatment during subsequent pregnancies of women with inherited thrombophilia and previous severe pregnancy complications

Objectives. The aim of this study was to investigate the effect of low molecular weight heparin (LMWH) on incidence of adverse outcome in women with thrombophilias and previous severe pregnancy complications. Materials and methods. The study included 116 women with history of severe preeclampsia, fetal growth restriction (FGR) ≤5th percentile, severe placental abruption and stillbirth >20 weeks carrying factor V Leiden or prothrombin mutations, or protein S or C deficiency. Eighty-seven women referred to us for follow-up were treated with LMWH starting from weeks 5–15 (study group, A). Twenty-nine non-treated women referred only for delivery in our institution constituted the control group (B). Results. The incidence of severe pregnancy complications in previous pregnancies was similar in both groups. Following treatment with LMWH, the incidence of severe preeclampsia was 4.6% in group A compared to 21% in group B, p = 0.007. The incidence of FGR was 2.3% in group A compared to 21% in group B, p = 0.03. The incidence of stillbirth or placental abruption was 0% in group A compared to 7% in group B, p = 0.06. The total incidence of adverse outcome was 7% in group A compared to 55% in group B, p = 0.0001. Conclusion. LMWH treatment of women with previous severe pregnancy complications and thrombophilias significantly reduces the rate of recurrence.

Vertebral osteomyelitis : a rare complication of transvaginal ultrasound-guided oocyte retrieval

OBJECTIVE To present a case of vertebral osteomyelitis as a complication of transvaginal oocyte retrieval. DESIGN Case report. SETTING The IVF unit of a university-affiliated hospital. PATIENT(S) A 41-year-old woman who underwent IVF-ET treatment. INTERVENTION(S) Standard IVF-ET treatment cycles with the use of transvaginal ultrasound for oocyte retrieval and computed tomography-guided needle aspiration. MAIN OUTCOME MEASURE(S) Recovery of the patient, sequelae, and recurrence. RESULT(S) Vertebral osteomyelitis was diagnosed and treated with antibiotics. CONCLUSION(S) When severe low back pain occurs after ovum retrieval, vertebral osteomyelitis should be considered. Early diagnosis requires a high index of suspicion.

The influence of prolonged preterm premature rupture of the membranes on neonatal outcome of the presenting and non-presenting twin.

OBJECTIVE To compare the neonatal outcome in twin gestations complicated by prolonged preterm premature rupture of membranes (PPROM). STUDY DESIGN Between the years 2000 and 2010 we identified 48 women with twin pregnancies who were diagnosed as having PPROM and a latency period to delivery >24h. We compared the neonatal morbidity and mortality between the presenting and non-presenting twins, assuming that the rupture occurred in the lower sac. Importantly, in 30 women we were able to identify the location of the ruptured sac by ultrasound examination demonstrating oligohydramnion. In these 30 cases, neonatal outcome of fetuses in the ruptured sac and those in the intact sac were compared. RESULTS The median gestational age was 31 weeks (range 28-33) with a median latency period between PPROM and delivery of 9 days (range 1-18). Of the identified ruptures 90% (27/30) occurred in the lower sac (presenting twin). There was no significant difference between the presenting and non-presenting twin in terms of neonatal morbidity and mortality. Moreover, no difference was found when fetuses with ruptured sac were compared to those with intact membrane sac. Importantly, the outcomes were not affected by the length of the latency period. CONCLUSION The current study results demonstrated that the outcome of fetuses exposed to prolonged preterm rupture of membranes is similar to that of fetuses with intact membranes. Our data suggest that rupture of membranes per se did not cause any deleterious clinical manifestations or lead to clinical discordant inflammation and poor neonatal outcome, supporting a conservative management of twin pregnancies with PPROM.

Placental abruption remote from term associated with Q Fever infection.

BACKGROUND: It has been suggested that Q fever infection in pregnancy is associated with various maternal and neonatal adverse outcomes, including intrauterine growth restriction, stillbirth, preterm delivery, intrauterine fetal death, and oligohydramnios. CASE: We describe the cases of two pregnant women remote from term who presented with premature contractions and fever of unknown origin. During their hospitalizations, they had development of near-complete placental abruption. In both cases, immediate delivery ensued. Fever of unknown origin work-up revealed chronic Q fever infection, and polymerase chain reaction investigation of the placenta demonstrated chronic Q fever placentitis. CONCLUSION: Q fever placentitis may result in placental abruption remote from term. Therefore, in endemic areas, the diagnosis of Q fever requires appropriate surveillance and prenatal care.

Severe pregnancy complications are associated with elevated factor VIII plasma activity.

The objective of this study is to investigate the prevalence of elevated factor VIII activity among women with severe complications of pregnancy. The study group included 49 patients with a previous history of pregnancy complications: severe preeclampsia (n = 9); intrauterine fetal death (IUFD) (n = 9); severe intrauterine fetal growth restriction (IUGR) (n = 12); IUGR and preeclampsia (n = 7); preeclampsia and placental abruption (n = 2); IUFD and IUGR (n = 5); and abruptio placenta (n = 5). The control group included 49 healthy women who had had at least one normal pregnancy. Seventeen women of the study group (34.6%) had elevated factor VIII activity compared to one woman (2.1%) in the control group (P < 0.05). The mean level of factor VIII was 159 ± 52% and 88 ± 17.4% of normal activity (mean ± SD, t-test, P < 0.05). Importantly, 10 women of the study group (20.4%) had only elevated factor VIII activity with no other known thrombophilia compared to one woman (2.1%) in the control group (P < 0.05). Elevated plasma activity of factor VIII might be a risk factor for severe pregnancy complications.

Visual deterioration during pregnancy due to skull base tumors compressing the optic apparatus.

Intracranial tumors may rapidly enlarge during pregnancy. When the tumor abuts the optic apparatus, tumor growth may cause visual deterioration. The decisions regarding the management of these tumors should take into consideration visual function, fetal and maternal safety, and the ability for total resection of the tumor. The objective of the study was to describe our experience and to establish principles for management of intracranial tumors compressing the optic apparatus that present during pregnancy or in the early post partum period. A retrospective case-series review was conducted. Women who presented with visual deterioration either during pregnancy or in the early post partum period due to an intracranial tumor were included. Neurosurgical and obstetrical data were collected from the patients’ hospital files and outpatient clinic records. Between 2005 and 2011, nine pregnant women with visual deterioration were diagnosed and treated. Of them, four underwent a neurosurgical procedure during pregnancy. Of the five patients who underwent surgery for tumor resection after delivery, three required urgent cesarean section either due to acute visual deterioration or obstetrical reasons. There was no maternal or fetal mortality and a good overall neonatal outcome was achieved. Improvement in visual acuity and visual fields was achieved in all patients. Postoperative complications included two cases of CSF leak, which resolved after treatment. Visual deterioration during pregnancy due to tumors that compress the optic apparatus requires treatment by a multi-disciplinary team. Surgery is well tolerated by mother and fetus during early and midpregnancy; thus, in cases where visual deterioration is detected, delay of surgery is not justified.