Etty Daniel-Spiegel

For how long should oxytocin be continued during induction of labour

Objective  To answer the question of whether oxytocin induction of labour should be discontinued when active labour begins.

Wide clinical spectrum in a family with hereditary lymphedema type I due to a novel missense mutation in VEGFR3.

AbstractHereditary lymphedema type I (HL-I), also known as Milroy disease, is an autosomal dominant disorder characterized by typical phenotype of infantile onset lower-limb lymphedema accompanied by variable expression of recurrent episodes of cellulites, toenail changes, and papillomatosis. Mutations in the vascular endothelial growth factor receptor 3 (VEGFR3), also known as FLT4 gene, which encodes a lymphatic endothelial-specific tyrosine kinase receptor, have been identified as a genetic cause of HL-I. We report a large Muslim Arab family residing in northern Israel with 14 individuals presenting clinical features of HL-I. Genetic analysis revealed novel missense mutation E1106K in the tyrosine kinase domain II of VEGFR3 that cosegregates with the disorder in the family. Most affected individuals presented with bilateral congenital lower-limb lymphedema. Wide intrafamilial phenotypic variability included two asymptomatic individuals, a case of prenatal hydrothorax evolving to hydrops fetalis, and a late-onset complication, yet unreported, of chronic degenerative joint disease of the knees. This report broadens the known “classic” phenotype of HL-I.

Matrix metalloproteinase-2 is elevated in midtrimester amniotic fluid prior to the development of preeclampsia

ObjectiveTo evaluate levels of matrix metalloproteinases (MMP) and their inhibitors (TIMP) in second trimester amniotic fluid of women with hypertensive disorders compared to normotensive women.Study DesignAmniotic fluid was obtained from 133 women undergoing genetic second trimester amniocentesis. Zymography was performed for MMP characterization and an MMP-2 ELISA kit was used to determine MMP-2 levels. TIMP-2 expression was evaluated using western blot.ResultsMean amniotic fluid MMP-2 and TIMP-2 levels were significantly higher in women who developed a hypertensive disorder compared to normotensive women (P < 0.0004 and P < 0.01, respectively). When subdivided into subgroups, amniotic fluid from women who eventually developed preeclampsia or superimposed preeclampsia showed significantly higher MMP-2 levels than normotensive women (P < 0.05). However, no statistical difference in MMP-2 levels was found between patients with gestational hypertension and normotensive patients.ConclusionHigher amniotic fluid MMP-2 and TIMP-2 levels are found in women who eventually develop preeclampsia.

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.

Outcomes From Polyhydramnios With Normal Ultrasound.

OBJECTIVE: To investigate the short- and long-term outcomes of children from pregnancies complicated with polyhydramnios, defined as amniotic fluid index (AFI) >24 cm, and with a normal detailed ultrasound examination. METHODS: This retrospective cohort study examined 134 children aged 4 to 9 years with polyhydramnios and normal detailed ultrasound examination during pregnancy compared with 268 controls with normal AFI and normal detailed ultrasound examination matched for maternal age, year of delivery, gestational week at delivery, and presence or absence of diabetes. The primary outcome was the rate of malformations diagnosed postnatally. Additional outcomes were obstetrics outcomes, genetic syndromes, and neurodevelopment. RESULTS: Polyhydramnios was associated with increased risk for cesarean delivery (CD) and birth weight >90th percentile. This elevation in CD was attributed to increased rate of elective CD due to suspected macrosomia. Polyhydramnios was associated with increased risk for congenital malformations (n = 25 [19%] compared with 27 [10%], respectively; P = .016) without a statistically significant increase in the rate of major malformations (11 [8%] vs. 10 [4%]; P = .057). Genetic syndromes were more prevalent in the polyhydramnios group (5 [3.7%] vs. 2 [0.75%]; P = .043), as were neurologic disorders and developmental delay (9.7% vs. 3%; P = .004). CONCLUSIONS: Despite a normal detailed ultrasound examination, polyhydramnios is associated with increased rate of fetal malformations, genetic syndromes, neurologic disorders, and developmental delay, which may be diagnosed only after birth.

Monochorionic diamniotic in vitro fertilization twins have a decreased incidence of twin-to-twin transfusion syndrome

OBJECTIVE To compare the incidence of twin-to-twin transfusion syndrome (TTTS) in spontaneous versus IVF-conceived twin pregnancies. DESIGN Retrospective multicenter study. SETTING University-affiliated tertiary medical centers. PATIENT(S) Women admitted for 11-14 weeks scan between January 1997 and July 2013 who were diagnosed with monochorionic (MC) diamniotic twin pregnancies. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Mode of conception, TTTS. RESULT(S) The study cohort included 327 pregnant women with live MC diamniotic twins. Of them, 284 (86.9%) and 43 (13.1%) were spontaneous and IVF conceived, respectively. The mean maternal age was significantly higher in IVF compared with in spontaneously conceived pregnancies (33.8 ± 5.5 vs. 31.6 ± 5.4, respectively). Thirty-seven twins (11.3%) had TTTS, of whom 36/284 (12.7%) versus 1/43 (2.3%) were spontaneously and IVF conceived, respectively. The mean week of delivery was significantly lower in MC twins diagnosed with TTTS compared with those without TTTS (32.7 ± 3.3 vs. 35.5 ± 2.5, respectively). Furthermore, there was a significantly higher birthweight discordancy in twins diagnosed with TTTS compared with those without (20.6% vs. 11%, respectively). CONCLUSION(S) The significantly lower proportion of TTTS found in IVF-conceived twins may suggest a different embryological process that lies at the core of IVF conception of monozygotic twinning.

Bifid Tongue, a Rare Congenital Malformation, Is a Prenatal Clue for Secondary Cleft Palate

Prenatal diagnosis of a secondary cleft palate without a cleft of the primary palate and lip is very rare and is a challenge for the sonographer. However, in utero detection of this malformation is highly important for prenatal counseling. The organogenesis of the palate and tongue takes place within the same embryonal period; therefore, the association between tongue malformations and a cleft palate is clear. We report the prenatal sonographic and postnatal findings of a case with micrognathia, a secondary cleft palate, and a bifid tongue. By introducing this case, we wish to alert the physician to look for palatal defects when tongue abnormalities are found. A 32-year-old pregnant woman with multiple sclerosis, gravida 2, para 1, was referred at 25 weeks’ gestation for evaluation of sonographically detected fetal anomalies. Her first pregnancy resulted in a healthy female infant who is currently 4 years old. The obstetric history of the nonconsanguineous couple was unremarkable. Prenatal scans at the 21st and 25th weeks of this pregnancy revealed micrognathia. A targeted sonographic examination with emphasis on an active fetal swallowing mechanism and nasopharyngeal structures revealed, in addition to previously identified micrognathia, a cleft palate, an abnormal pharynx, glossoptosis, and a bifid tongue (Figure 1, A and B). After genetic counseling, the pregnancy was terminated by request of the couple. Unfortunately, the couple declined a full autopsy but gave consent for a

Dilated cerebral venous system observed in growth-restricted fetuses

Abstract Purpose: The dilation of the fetal cerebral veins is a rare phenomenon that may be associated to a bad obstetric outcome, and is usually connected to antenatal thrombosis of the posterior dural venous sinuses. There are several descriptions of cerebral vein distension on magnetic resonance imaging (MRI), but all of them are detected postnatally. We present herein two cases of fetal antenatal cerebral dilation of the venous system, without any association to any sign of vein thrombosis, and a systematic review of literature regarding pathogenesis, diagnosis and outcomes associated to the antenatal detection of this condition with the use of MRI. Materials and methods: To identify potentially eligible studies, we searched PubMed, Scopus, Cochrane Library (all from inception to October 20th, 2016) and applied no language restrictions. Results: The electronic database search provided a total of 22,843 results. After the exclusion of duplicates, manuscripts that resulted not relevant to the review based on title and abstract screening, and analysis of manuscripts eligible for full-text assessment, no papers were found related to the subject reported in the present manuscript. Conclusions: Our report adds importance to MRI as a tool in cases of complex ultrasound finding with the presence of fetal heart failure and deterioration of fetal growth, in order to improve the prognostic evaluation and patient?s counseling.

Immunosuppressive properties of follicular fluid and media conditioned by zygotes correlate with subsequent conception in in vitro fertilization

Dirnfeld M, Lahat N, Daniel‐Spiegel E, Wiener‐Megnazi Z, Goldman S, Abramovici H, Shalev E. Immunosuppressive properties of follicular fluid and media conditioned by zygotes correlate with subsequent conception in in vitro fertilization. AJRI 2002; 48:329–333