Ella Ophir

Sonographic fetal sex determination.

Although sonographic fetal sex determination is feasible in most pregnancies, in some cases, it may pose difficulties. An attempt to determine the fetal sex should not be made before 12-weeks’ gestation because this early, it is relatively inaccurate. After 13 weeks, it is accurate in 99% to 100% of cases without malformed external genitalia. Sonographic fetal sex determination in the late second trimester is based on direct visualization of the external genitalia, whereas in the late first and early second trimester, it is based mainly on the direction of the genital tubercle (the “sagittal sign”): downward direction of the genital tubercle indicates a female fetus and upward direction a male fetus. Other sonographic landmarks, such as the fetal scrotum, the midline raphe of the penis, the labial lines, the uterus, the descended testis, and the direction and origin of the fetal micturition jet in males may contribute to the correct determination of fetal sex. Inaccurate fetal sex determination may occur when the external genitalia are malformed. Three-dimensional ultrasound, although of generally limited diagnostic value for fetal sex determination, may aid in better definition of congenital malformations of the external genitalia. Target Audience: Obstetricians & Gynecologists, Family Physicians Leaning Objectives: After completion of this article, the reader should be able to select the appropriate sonographic finding for determining fetal sex according to gestational age, list indications for sex determination in the fetus, and name abnormalities of genitalia that may alter sonographic findings.

Involvement of heparanase in the pathogenesis of localized vulvodynia.

Summary Recently, we have shown that vestibular hyperinnervation and the presence of 8 or more mast cells in a 10 × 10 microscopic field can be used as diagnostic criteria in localized vulvodynia (vulvar vestibulitis). We have also documented that degranulation of mast cells occurs in these cases. The present study further examines the characteristics of vestibular hyperinnervation and mast cell function in localized vulvodynia to elucidate if the 2 processes-hyperinnervation and mast cell increase and degranulation-are related. We examined vestibular tissue from 7 women aged 18 to 48 with severe localized vulvodynia and from 7 healthy control women. Parallel sections were stained by Giemsa and then immunostained for CD117 and heparanase. Nerve fibers that expressed protein gene product 9.5 were examined. Tissues from women with localized vulvodynia documented a significant increase in vestibular mast cells, subepithelial heparanase activity, and intraepithelial hyperinnervation compared with healthy women. This is the first documentation of heparanase activity in localized vulvodynia. Heparanase, which is degranulated from mast cells, is capable of degrading the vestibular stroma and epithelial basement membrane, thus permitting stromal proliferation and intraepithelial extension of nerve fibers, as seen in the present study. The hyperinnervation has been thought to cause the vestibular hyperesthesia distinctive of localized vulvodynia.

Intensive management and early delivery reduce antenatal mortality in monoamniotic twin pregnancies

Background.  Intensive management and elective delivery between 32 and 35 weeks of monoamniotic twin pregnancies were suggested as improving perinatal outcome. We sought to evaluate this management as viewed by the outcome of monoamniotic twin pregnancies in our population.

Is Cesarean Section Necessary for Delivery of a Breech First Twin

Eighty-two pregnancies involving a breech first twin were retrospectively analyzed over two study periods during which the cesarean section rates were 20.9 and 94.9%, respectively. The neonatal and maternal morbidity in both study periods was compared. There were no neonatal deaths during either study period and no cases of interlocking twins among patients delivered vaginally. Neonatal morbidity was unrelated to the mode of delivery. The incidence of maternal fever was, however, significantly higher in the cesarean section group compared with the vaginal delivery group (p < 0.001). Our study suggests that vaginal delivery of selected twin gestations with a breech first twin should be an alternative to cesarean delivery.

Water intoxication-a dangerous condition in labor and delivery rooms.

Water intoxication, a form of acute hyponatremia, has been described in various clinical situations. Although hyponatremia is a common metabolic disorder in hospitalized patients, it is generally not well known as a hazard in the labor and delivery room. However, several factors predispose laboring women to develop hyponatremia. Moreover, because the fetus acquires water from the maternal circulation via the placenta, and there is a close correlation between maternal and cord blood serum sodium levels, the newborn infant of a hyponatremic mother is also at considerable risk of developing water intoxication. We review the epidemiology, pathophysiology, clinical features, and treatment of this hazardous disorder. We emphasize the need for awareness of this condition, and call attention to the risk of fluid overload during labor. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that clinical hyponatremia can occur during labor, which may be due to the treatments received during labor or to secondary causes, and to state that the fetus may also be adversely affected and the mother must be diagnosed and treated to prevent serious consequences.

Abnormal placental invasion--a novel approach to treatment case report and review.

The incidence of abnormal placental invasion has increased 10-fold in the past 50 years, reflecting the increased number of cesarean sections performed. Management relies on accurate early diagnosis with appropriate perioperative multidisciplinary planning to anticipate and avoid massive obstetric hemorrhage at delivery. Women at risk should plan to deliver at an institution with appropriate expertise and resources for managing this condition. We report a case of placenta increta management comprising preoperative placement of a pelvic artery balloon catheter, prophylactic balloon occlusion after delivery of the fetus, and embolization-assisted resection of the invaded uterine wall. We review incidence, methods of prenatal diagnosis, risk factors, and management of abnormally invasive placenta. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the participant should be better able to recall risk factors for abnormal placental invasion, explain the diagnostic choices for identifying abnormal placental invasion, and prepare a logical treatment plan for the woman with abnormal placental invasion.

Uterine rupture during trial of labor: controversy of induction's methods.

The rate of attempted vaginal birth after cesarean has decreased during the past 15 years. Most of the change since the mid 1990s is the result of increasing reports of uterine rupture during trial of labor, with the highest rates related to labor induction. Not all induction agents have the same magnitude of increased risk of uterine rupture, and there have been only a small number of randomized controlled trials of labor induction in women with previous cesarean delivery. Evaluation of the evidence on specific methods of induction reveals that the lowest rate of uterine rupture occurs with oxytocin at 1.1% (95% confidence interval [CI], 0.9%–1.5%) then dinoprostone at 2% (95% CI, 1.1%–3.5%), and the highest rate is with misoprostol, 6% (95% CI, 0.74%–51.4%). We review the incidence of uterine rupture during induction of labor after previous cesarean and examine the methods of induction and the safety of different techniques for cervical ripening, induction, and/or augmentation of labor in women with previous cesarean delivery. Target Audience: Obstetricians and Gynecologists, Family Physicians Learning Objectives: After completing this CME activity, physicians should be better able to assess the complications associated with different methods of induction of labor following previous cesarean delivery, identify the clinical situations associated with increased risk of uterine rupture, and evaluate the methods of induction of different techniques for cervical ripening, induction, and/or augmentation of labor in women with previous cesarean delivery.

β-HCG concentration in peritoneal fluid and serum in ectopic and intrauterine pregnancy

Objective. To evaluate the significance of P‐HCG levels in peritoneal fluid and serum in the diagnosis of ectopic pregnancy.

Prediction of abortion using three-dimensional ultrasound volumetry of the gestational sac and the amniotic sac in threatened abortion.

To determine whether gestational sac volume (GSV) or amniotic sac volume (ASV) and/or the difference between them can predict abortion in women with first‐trimester threatened abortion.

Congenital absence of salivary glands in Down syndrome

Background Children with Down syndrome have different saliva composition compared to normal children. The presence or absence of the salivary glands has not been previously reported. Objective To examine the presence or absence of the salivary glands in children with Down syndrome. Methods 15 children with Down syndrome underwent an ultrasound examination of the salivary glands. The control group consisted of 31 healthy children. The areas of the parotid and submandibular glands on both sides were scanned in an attempt to demonstrate all four glands. The result was reported as ‘present’ or ‘absent’. Results In four children out of 15 with Down syndrome, one or more salivary glands were absent (26.7%), while in the controls all salivary glands were present. The difference between the groups was statistically significant (p=0.008). There was no significant difference between the groups regarding age and sex. Conclusions At least one salivary gland is undetected by ultrasound in some children with Down syndrome.