Eran Ashwal

Gestational diabetes mellitus: Where are we now?

Gestational diabetes mellitus (GDM) is defined as any carbohydrate intolerance first diagnosed during pregnancy. The prevalence of GDM is about 2-5% of normal pregnancies and depends of the prevalence of same population to type 2 diabetes mellitus. It is associated with adverse outcome for the mother, the fetus, neonate, child and adult offspring of the diabetic mother. Detection of GDM lies on screening, followed as necessary by diagnostic measures. Screening can either be selective, based upon risk stratification or universal. Timely testing enables the obstetrician to assess glucose tolerance in the presence of the insulin-resistant state of pregnancy and permits treatment to begin before excessive fetal growth has occurred. Once a diagnosis of GDM was made close perinatal surveillance is warranted. The goal of treatment is reducing fetal-maternal morbidity and mortality related with GDM. The exact glucose values needed are still not absolutely proved. The decision whether and when to induce delivery depends on gestational age, estimated fetal weight, maternal glycemic control and bishop score. Future research is needed regarding prevention of GDM, treatment goals and effectiveness of interventions, guidelines for pregnancy care and prevention of long term metabolic sequel for both the infant and the mother.

Presentation, Diagnosis, and Treatment of Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE To describe the clinical characteristics and treatment of ovarian torsion in premenarchal girls with surgically verified ovarian torsion. DESIGN AND PARTICIPANTS A retrospective cohort study design was used. The medical charts of all premenarchal girls with surgically verified ovarian torsion treated in a university-affiliated tertiary medical center from 1997 to 2012 were reviewed for clinical, treatment, and outcome data. RESULTS Thirty-two premenarchal girls were identified. Their median age was 9 years. There were 7 recurrences during the study period (17.9%), for a total of 39 cases. The main presenting symptoms were abdominal pain (92.3%) and nausea and vomiting (84.6%). Physical examination revealed abdominal tenderness in 25 cases (64.1%). Abdominal ultrasound, performed in 31 patients (38 cases), yielded pathologic findings in 28 (73.7%), mainly an enlarged ovary (11 cases, 28.9%). Doppler flow studies were abnormal in 15 cases. In 26 cases (68.4%), the tentative preoperative working diagnosis was ovarian torsion. Laparoscopy was performed in 26 cases, laparotomy in 10, and laparoscopy converted to laparotomy in 3 cases. Conservative management, mainly with additional cyst drainage or cystectomy, was used in 37 cases (95.2%) with oophoropexy in 5 cases. Two patients required oophorectomy because of a suspected neoplasm and severe ovarian necrosis. Pathologic examination demonstrated 5 simple cysts, 1 necrotic ovary, and 1 mature cystic teratoma. CONCLUSIONS Ovarian torsion in premenarchal girls is associated with nonspecific signs and symptoms. Abdominal ultrasound and Doppler imaging may assist in the diagnosis. Laparoscopy with conservative management is preferred. Owing to the high recurrence rate, oophoropexy may be considered.

The association between Mullerian anomalies and short-term pregnancy outcome.

Abstract Objective: To determine the association between Mullerian anomalies (MuAs) and short-term perinatal outcome. Study design: A retrospective cohort study, comparing pregnancy outcome in women with and without MuAs matched by age, number of fetuses and parity in a 1:2 ratio. Results: Among 243 women with MuAs, 156 (64.2%) had bicornuate uterus, 38 (15.6%) had septate uterus, 27 (11.1%) had unicornuate uterus and 22 (9.1%) had didelphic uterus. Compared to controls (n = 486), women with MuAs had higher rates of previous preterm deliveries (PTDs) (20.2 versus 5.9%, p < 0.001) and previous cesarean section (CS) (50.6% versus 12.5%, p < 0.001). Women with MuAs had higher rates of PTDs <37 weeks (25.1% versus 6.1%, p < 0.001) and <32 weeks (4.1% versus 0.6%, p = 0.001), preterm premature rupture of membranes (PPROM) (12.8% versus 2.7%, p < 0.001) and small for gestational age (SGA) infants (12.3 versus 6.8%, p = 0.01). There was higher rate of CS in the MuA group (82.3 versus 22.1%, p < 0.001), mainly due to higher rates of malpresentation and previous CS. In multivariate analysis, MuA was associated with SGA (2.04, 1.15–3.63), PTDs <37 weeks (3.72, 1.79–7.73), PTDs <32 weeks (7.40, 1.54–35.56), PPROM (6.31, 3.04–13.12), malpresentation (21.62, 12.49–37.45) and retained placenta (4.13, 1.73–9.86). No increased risk was observed in the rate of in-labor CS (0.52, 0.21–1.30, p = 0.16). When the rate of adverse outcomes was stratified according to MuAs subtypes, women with unicornuate uterus had the highest rate of breech presentation at delivery (55.6%) and women with didelphy uterine had the highest proportion of PTDs <37 weeks (40.9%). Conclusion: Women with MuAs are at increased risk for adverse pregnancy outcome, mainly PTDs + and PPROM, SGA infants and CS due to malpresentation. However, the risk of in-labor CS is not increased compared to the general population.

Association of isolated polyhydramnios at or beyond 34 weeks of gestation and pregnancy outcome.

OBJECTIVE: To evaluate pregnancy outcome among women with isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation. METHODS: Retrospective cohort study at a tertiary medical center between 2007 and 2012. Isolated polyhydramnios was defined as amniotic fluid index (AFI) greater than 25 cm at admission in the absence of gestational or pregestational diabetes mellitus or fetal structural or chromosomal anomalies. Women with isolated polyhydramnios were compared with women with a normal AFI (5–25 cm). RESULTS: Overall, 31,376 women were eligible for analysis, of whom 215 (0.7%) had isolated polyhydramnios and 31,161 normal AFI. Women with isolated polyhydramnios had higher rates of labor induction (7.9% compared with 4.8%, P=.04) and cesarean delivery (12.1% compared with 5.1%, P<.001). They also had higher rates of placental abruption (0.9% compared with 0.2%, P=.02), abnormal or intermediate fetal heart rate (FHR) tracings (7.0% compared with 3.2%, P=.002), and prolonged first stage of delivery (6.0% compared with 1.4%, P<.001). Isolated polyhydramnios was also associated with higher rates of shoulder dystocia (1.9% compared with 0.3%, P<.001) and respiratory distress syndrome (0.5% compared with 0.03%, P=.001). On a multiple logistic regression model, isolated polyhydramnios was an independent risk factor for labor induction (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.01–2.8), cesarean delivery (adjusted OR 2.6, 95% CI 1.7–4.0), prolonged first stage of delivery (adjusted OR 3.6, 95% CI 1.97–6.7), abnormal or intermediate FHR tracings (adjusted OR 2.6, 95% CI 1.6–4.5), placental abruption (adjusted OR 8.4, 95% CI 2.00–35.4), shoulder dystocia (adjusted OR 3.4, 95% CI 1.2–9.7), and respiratory distress syndrome (adjusted OR 38.9, 95% CI 4.6–332.6). Mild isolated polyhydramnios (AFI 25.1–30.0) was independently associated with cesarean delivery, prolonged first stage of delivery, placental abruption, abnormal or intermediate FHR tracings, and shoulder dystocia. CONCLUSION: Isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation is associated with adverse obstetric and neonatal outcomes. LEVEL OF EVIDENCE: II

Characteristics and Management of Ovarian Torsion in Premenarchal Compared With Postmenarchal Patients.

OBJECTIVE: To compare the clinical, ultrasonographic, and operative characteristics of premenarchal and postmenarchal patients with surgically verified ovarian torsion. METHODS: A retrospective cohort study of all patients with surgically verified ovarian torsion operated on at a single university-affiliated tertiary medical center during 1997–2013. Age at presentation, presenting symptoms, diagnostic studies, surgical procedure, and pathologic findings were analyzed. RESULTS: A total of 41 premenarchal and 208 postmenarchal patients were diagnosed with ovarian torsion during the study period. Median ages were 9 and 27 years, respectively. Median duration of symptoms before first presentation was longer among the premenarchal patients (24.0 compared with 8.0 hours, P<.001) as was the median interval from hospital admission to surgery (9.5 compared with 4.6 hours, P<.001). Premenarchal girls had a higher rate of restlessness, fever, and evidence of pelvic mass at presentation and a similar rate of ultrasonographic signs for torsion (78.5% compared with 73.1% P=.53). During surgery, a finding of a black–bluish ovary was more common in premenarchal girls (61.0% compared with 41.3%, P=.02). CONCLUSION: Ovarian torsion in premenarchal girls is associated with a longer interval from onset of symptoms and an increased rate of fever and pelvic mass at presentation compared with postmenarchal patients. These data may aid the physician in the evaluation of abdominal pain in premenarchal girls. LEVEL OF EVIDENCE: II

Does the level of amniotic fluid have an effect on the accuracy of sonographic estimated fetal weight at term

Abstract Objective: Controversy exists concerning the impact of amniotic fluid index (AFI) on the accuracy of sonographic estimation of fetal weight (EFW). Thus, we aimed to evaluate whether differences in AFI has an influence on the accuracy of sonographic EFW. Methods: All term, singleton pregnancies which underwent a sonographic EFW and measurement of AFI within a week from delivery were included. Cases were stratified into three categories according to AFI: (1) Normal AFI (51–249 mm), (2) Oligohydramnios (AFI ≤ 50 mm) and (3) Polyhydramnios (AFI ≥ 250 mm). Inaccurate EFW was defined if there was more than 15% difference between sonographic EFW and actual birthweight. Results: Overall, 1746 pregnancies were identified (1096 with normal AFI, 455 with oligohydramnios and 195 with polyhydramnios). Mean AFI was 115.8 ± 60 mm, 28.1 ± 13 mm and 293 ± 35 mm, p < 0.001, and mean sonographic EFW was 3182.5 ± 573 g, 3118.8 ± 517 g and 3713.2 ± 461 g, p < 0.001, respectively. Demographic data and gestational age at delivery were similar. Mean birthweight was 3221.7 ± 535 g, 3132.5 ± 505 g and 3654.1 ± 480 g, p < 0.001, respectively. The rate of inaccurate EFW was similar between the groups (8.4%, 8.7% and 9.7%, p = 0.19, respectively). On multivariate analysis, AFI was not associated with EFW inaccuracy (OR 1.01, 95% C.I 0.67–1.54, p = 0.93). Conclusion: AFI has limited impact on the percentage of errors in sonographic fetal weight estimation a week prior delivery.

Effect of Meconium-Stained Amniotic Fluid on Perinatal Complications in Low-Risk Pregnancies at Term.

OBJECTIVE This study aims to determine the impact of meconium-stained amniotic fluid (MSAF) in low-risk pregnancies at term on pregnancy outcome. STUDY DESIGN A retrospective cohort study of women with MSAF during labor who delivered in a tertiary hospital at 37 to 41(+6) weeks of gestation (2007-2013). Exclusion criteria included: multiple gestations, noncephalic presentation, fetal structural/chromosomal anomalies, hypertensive disorders, diabetes, oligohydramnios, or small for gestational age. Pregnancy outcome of women with MSAF (N = 4,893) was compared with a control group of women without MSAF (N = 39,651). Neonatal respiratory morbidity was defined as the presence of any of the following: respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, or need for ventilatory support. RESULTS Overall, 10.9% of low-risk pregnancies at term were diagnosed with MSAF. Compared with the controls, women with MSAF had higher rates of nulliparity, gestational age at delivery ≥ 41 weeks, induction of labor, nonreassuring fetal heart rate, and operative deliveries. In multivariate analysis MSAF was associated with operative delivery (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.63-2.09; p < 0.001), cesarean section (OR, 1.48; 95% CI, 1.31-1.69; p < 0.001), respiratory morbidity (OR, 4.74; 95% CI, 3.87-5.82; p < 0.001), and increased risk for short-term neonatal morbidity. CONCLUSIONS MSAF is associated with a higher rate of adverse perinatal outcome even in low-risk pregnancies at term.

The impact of pregnancy on the accuracy and delay in diagnosis of acute appendicitis

Abstract Objective: To determine the accuracy and the delay in diagnosis of presumed acute appendicitis in pregnancy. Methods: Pregnant women undergoing appendectomy for presumed acute appendicitis were compared to non-pregnant age-matched women in a 3:1 ratio undergoing appendectomy in a tertiary medical center from 2001 to 2012. Results: Out of 1618 women who underwent appendectomy during the study period, 81 (4.2%) were pregnant who were compared to 243 age-matched non-pregnant women. There was a significantly shorter interval between admission to the hospital and surgery and shorter surgery length (10.2 versuss 15.7 h, 1.2 ± 0.4 versus 1.4 ± 0.5 h, respectively, p < 0.001) in the pregnant group with similar rates of negative appendectomy (19.8% versus 21.8%, respectively, p = 0.86). The positive and negative predictive values of ultrasonography (US) for the diagnosis of acute appendicitis were 88.2% and 100%, and 92.9% and 57.1%, among the pregnant and the non-pregnant group, respectively. In multivariate analysis, early gestational age was found to be independently associated with higher rate of accurate US results (OR = 0.92, 95% CI 0.85–0.99, p = 0.39). Conclusion: Pregnant women undergoing appendectomy have shorter admission to surgery interval and surgical length with similar negative appendectomy rates compared to non-pregnant women. Ultrasound is an accurate tool for the diagnosis of acute appendicitis during pregnancy, especially during early gestation.

Nonvisualization of the Fetal Gallbladder: Can Levels of γ-Glutamyl Transpeptidase in Amniotic Fluid Predict Fetal Prognosisγ

Objective: In cases of nonvisualization of the fetal gallbladder (NVFGB), we investigated whether amniotic fluid levels of γ-glutamyl transpeptidase (GGTP) can distinguish normal development or benign gallbladder agenesis from severe anomaly such as biliary atresia. Methods: This is a retrospective cohort study of pregnancies in which the gallbladder was not visualized in the second-trimester fetal anatomy scan. Levels of GGTP in amniotic fluid were analyzed prior to 22 weeks of gestation by amniocentesis. Data were collected regarding other fetal malformations, fetal karyotype, and screening results for cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations. Results: Of 32 cases of NVFGB, 27 (84%) had normal GGTP levels and a normal CFTR gene screening, and 1 of them had an abnormal karyotype. Three of the 5 cases with low GGTP were diagnosed with extrahepatic biliary atresia, proven by histopathological examination following termination of pregnancy. The fourth case had hepatic vasculature abnormality and the fifth isolated gallbladder agenesis. In 22 of 32 cases (68.7%), the gallbladder was detected either later in pregnancy or after delivery. Conclusion: The findings support low levels of GGTP in amniotic fluid, combined with NVFGB, as a sign of severe disease, mainly biliary atresia. Normal GGTP levels, concomitant with isolated NVFGB, carry a good prognosis.

Pre-induction cervical ripening: comparing between two vaginal preparations of dinoprostone in women with an unfavorable cervix

Abstract Objective: Prostaglandin E2 (PGE2-Dinoprostone) is accepted for both ripening of the cervix and induction of labor. As conflicting data exist concerning the efficiency and safety of different treatment modalities, we aimed to compare slow-release vaginal insert PGE2 with serial vaginal tablets of PGE2 for cervical ripening and induction of labor. Methods: A retrospective cohort study comparing all pregnancies who underwent induction of labor by either a single slow-release vaginal insert of 10 mg PGE2 (study group) to a historical control group of women who were treated with serial administration of 3 mg vaginal PGE2 tablets in a 2:1 ratio, matched by parity. Results: Overall, 639 women were enrolled (213 treated with PGE2 tablets and 426 with slow-release vaginal inserts). Vaginal insert was associated with shorter initiation-to-ripening interval (12.4 ± 7.7 versus 18.6 ± 15.2 h, p < 0.001) and a higher rate of delivery within 24 h (61.5 versus 51.6%, p = 0.018). Vaginal insert was associated with an increased rate of tachysystole (8.0 versus 3.1%, p < 0.01); however, the rates of cesarean section or operative delivery due to non-reassuring fetal heart rate (NRFHR) were similar. On multivariable analysis, slow-release vaginal insert was independently associated with a higher rate of delivery within 24 h (OR 1.50, 95% CI 1.04–2.18). Conclusion: Slow-release PGE2 vaginal insert achieves cervical ripening and subsequently delivery over a shorter time period than PGE2 tablets, without increasing uterine hyperstimulation rate.