Gabriel Levin

Predicting success of methotrexate treatment by pretreatment HCG level and 24‐hour HCG increment

To evaluate β‐human chorionic gonadotropin (β‐HCG) level and its 24‐hour increment as predictors of successful methotrexate treatment for ectopic pregnancy.

Re: Risk of hypertension after hysterectomy: a population‐based study

against follow up. In the cohort study, women with asymptomatic recurrence had a significantly better 3-year survival rate compared with women with symptomatic recurrence (80.3 versus 54.3%). Any survival benefitobtained fromfollow up would have to be the result of earlier detectionofrecurrence.Nodifferencewas found in time to recurrence between women with and without symptoms (12.1 versus 12.6 months, P = 0.81). Hence, the difference in survival is more likely explained by length-time bias, which occurs as the proportion of aggressive fast-growing tumours is likely to be higher in the symptomatic group. No evidence suggests that earlier detection of asymptomatic disease improves a woman’s survival. Tegnerowicz questions the assumption that 2/1000 women with stage I low-intermediate risk disease would potentially benefit from follow up. This estimate was derived from 16 retrospective studies and relied on the assumption that only 50% of vaginal recurrences are salvageable, which indeed can be questioned. In our population-based study, 14/1000 women would have an asymptomatic vaginal recurrence, and could potentially benefit from follow up. However, not all vaginal recurrences are salvageable and there has been no evidence that a woman’s survival is improved by early diagnosis at the asymptomatic stage. Tegnerowicz emphasizes that the survival rate of 17.5% in distant recurrences is crucially important for the patients. We acknowledge the importance of any survival benefit in women with metastatic disease, but question whether the reported survival rate is a result of follow up or merely represents the effect of palliative treatment in women with symptomatic distant disease. Tegnerowicz further questions whether patient-initiated followup could givepatients a false senseof security, delay self-referral and give patients the impression that extra-vaginal recurrences are salvageable. Patient-initiated follow up is expected toreducediagnosticdelay, as the women have open access to specialised care and react to symptoms promptly rather than awaiting the next scheduled visit. The women were thoroughly instructed in a wide range of alarm symptoms and were also encouraged to contact the department in case of any symptoms or worry. With this patient involvement combined with an open access approach, the intention was to improve the patient empowerment. The information did not include any promise of salvage therapy. In conclusion, we have no evidence to support a survival benefit of hospitalbased followup.Hence, it is reasonable to consider alternative options and benefits of follow up. These efforts are not merely focused on reducing costs but even more on providing patient-centred follow-up, in which the individual woman is empowered to react promptly to symptoms and decide the form and content of her individual follow-up care.&

Inositol for women with polycystic ovary syndrome—possibly just better than placebo

We read the review by Tanbo etxa0al. with great interest (1). The authors propose their management approach for unovulatory women diagnosed with polycystic ovary syndrome (PCOS) for whom a variety of treatment options exist. Although the authors performed a comprehensive review of published data, we believe that their main conclusion regarding the preferred therapeutic approach requires further consideration. This article is protected by copyright. All rights reserved.

The role of procalcitonin in the diagnosis and management of infections in the field of obstetrics and gynecology

We read the editorial by Tujula etxa0al. with great interest (1). They described the role of procalcitonin as biomarker for the diagnosis of infection and monitoring of antibiotic treatment. Despite their meticulous citation data collection, several important issues need further consideration.In their report, the authors have claimed that proclacitonin seems to be a useful biomarker for severe bacterial infections and this is likely to be the case also in Obstetrics and Gynecology. This article is protected by copyright. All rights reserved.

Social egg freezing—Better early than never

We read the commentary by Jones etxa0al. with great interest (1). The authors describe the utilization of an elective oocyte cryopreservation as an opportunity to postpone motherhood. Although the authors delineate a comprehensive overview of the subject, several important issues need further consideration regarding the aforementioned commentary. This article is protected by copyright. All rights reserved.

The effect on thrombin generation and anti-Xa levels of thromboprophylaxis dose adjustment in post-cesarean obese patients - A prospective cohort study

OBJECTIVEnTo examine the laboratory anticoagulant effect of two thromboprophylactic low-molecular weight heparin (LMWH) regimens in post-cesarean obese patients.nnnMETHODSnA prospective cohort study, performed during 2017-2018 at a university hospital, of post-cesarean obese (>90u202fkg) patients receiving 40u202fmg/day (nu202f=u202f30) or 60u202fmg/day (nu202f=u202f30) enoxaparin, and a control group of non-obese (nu202f=u202f30) post-cesarean patients receiving 40u202fmg/day enoxaparin. Thrombin generation and anti-Xa were measured twice on the third postoperative day: prior to and 3.5-4u202fh following the third LMWH dose.nnnRESULTSnAge, parity, weight and body mass index were comparable between the obese study groups. Compared to the control non-obese group, the 40u202fmg obese and 60u202fmg obese groups showed increased baseline thrombin generation: medians 491, 581, 571u202fnM, respectively (Pu202f=u202f0.001 and Pu202f=u202f0.04, respectively). At peak LMWH activity, thrombin generation was higher in the 40u202fmg than in the 60u202fmg obese and control groups: medians 2599, 2391, 2229u202fnM, respectively (Pu202f=u202f0.01 and Pu202f<u202f0.0001, respectively); and thrombin generation was comparable between the 60u202fmg obese and the control groups (Pu202f=u202f0.58). Similarly, a significantly lower proportion of patients in the 40u202fmg obese group (10%) had anti-Xa levels within the recommended prophylactic range (0.2-0.5u202fIU/mL) than in the other groups (Pu202f<u202f0.0001 for both comparisons).nnnCONCLUSIONnAs determined by thrombin generation and anti-Xa testing, post-cesarean obese patients have an increased procoagulant potential, which was diminished only in those receiving higher dosages of LMWH. These findings support the need for clinical evaluation of LMWH dose adjustment in this setting.

The effect of surgery-to-conception interval on pregnancy outcomes after sleeve gastrectomy

BACKGROUNDnThe optimal timing of pregnancy after bariatric surgery has not been established, with data limited regarding laparoscopic sleeve gastrectomy (LSG), currently the most common bariatric operation performed.nnnOBJECTIVESnWe explored associations of the surgery-to-conception interval with pregnancy outcomes after LSG.nnnSETTINGnA university hospital.nnnMETHODSnWe assessed pregnancy outcomes in relation to the surgery-to-conception interval for all women who underwent LSG and delivered during 2006 to 2018.nnnRESULTSnOf 154 patients, 67 (43.5%) conceived within the first 18 months postoperatively (early-pregnancy group), whereas 87 (56.5%) conceived later (late-pregnancy group). The median surgery-to-conception interval was 390 (interquartile range 247-459) days in the early-pregnancy group and 1104 (8527-1548) days in the late-pregnancy group. Compared with the early-pregnancy group, the late-pregnancy group had higher gestational weight gain (median 11 versus 8 kg, P < .001) and lower hemoglobin levels in early pregnancy (12.3 versus 12.6 g/dL, Pu202f=u202f.03) and after delivery (10.0 versus 10.4 g/dL, Pu202f=u202f.02). Other maternal and perinatal outcomes were similar between the groups, including the proportion of small-for-gestational-age infants (11.9% versus 14.9%, Pu202f=u202f.64) for those who conceived within or later than 18 months after surgery. Similar rates of small-for-gestational-age infants were found between those who conceived within or ≥12 months after surgery (Pu202f=u202f1.0).nnnCONCLUSIONSnTiming of pregnancy after LSG was found not to be associated with pregnancy outcomes. Together with documentations of a similar safety profile of pregnancy occurring earlier or later in the postoperative course, these data should reassure women who do not wish to delay conception after surgery.

Letter to ‘Effectiveness of antenatal perineal massage in reducing perineal trauma and post‐partum morbidities: A randomized controlled trial’

We have read with interest the article by Ugwu et al. The authors evaluated the effectiveness of antenatal perineal massage (APM) in reducing perineal trauma. There are some questions regarding the study that need to be further clarified. First, participants were contacted at an interval of 1 week to reinforce compliance. Yet, neither the compliance rate nor whether the compliance itself was examined in the study group is described. Moreover, sample size calculation does not mention for which outcome it was performed. As some of the measured outcomes may not be frequently encountered, the study may have been underpowered to assess their occurrence. Second, patients were followed-up at 3 months using a questionnaire. The anal incontinence (AI) was evaluated using a questionnaire which has not been previously validated. Moreover, the proposed definition of AI used was relatively broad and not objectively measured – thus exposing the measured outcome to a substantial bias. Furthermore, the follow-up period up to 3 months might be too short to assess patient outcomes, since it was previously shown that physiological changes occur following delivery and thus evaluation for urinary and AI should be performed remotely from delivery. Third, the main outcome measured – episiotomy has an inherent bias since it is performed at the discretion of the treating obstetrician. An additional potential bias is the lack of evaluation of the indication for episiotomy as it may performed for indications which may not affect perineal function (e.g. expedite delivery in the setting of fetal heart rate abnormalities or for relief of shoulder dystocia). Moreover, it is surprising that the occurrence third degree or forth degree perineal tear was not reported, as these subset of perineal tears are the ones mostly associated with maternal morbidity. Moreover, as the rate of first and second degree perineal tears was comparable in both study groups, it may seem that episiotomy is the only factor affecting the rate of intact perineum, which as mentioned is a major limitation as its indication was not investigated. Finally, the author state that APM performed in the last weeks of gestation reduced the likelihood of episiotomy and the risk of flatus incontinence. This is in strike contrast to a previously published Cochrane review. Due to the various limitations stated above, we believe the authors should be more cautious in their conclusions, and claim for association rather than causation.

The predictive role of serum hCG 0–4 days after methotrexate treatment for ectopic pregnancy is yet to be determined

We read the article of Wong et al.1 with great interest. They studied the predictive role of serum human chorionic gonadotropin (hCG) levels 0–4 days after singledose methotrexate administration for ectopic pregnancy. Despite their meticulous study methods, several important issues need further consideration. Regarding the utilization of a drop in day 0–4 serum hCG levels to predict treatment success, one can deduce from study’s results that 29.5% (13/44) of patients had a decrease in serum hCG prior to the administration of treatment. This represents a substantial portion of patients in which viable ectopic pregnancy was probably spontaneously resolving before the initiation of treatment. Hence, this subset of patients should have been excluded in the arithmetic calculation of treatment success as the administration of methotrexate treatment is usually indicated in situations where serum hCG level is increasing or at least stable. Moreover, it can be inferred from the manuscript that in the 20.0% (11/55) of patients who experienced a drop in day 0–4 hCG levels pretreatment serum hCG level data were not available; one can postulate that serum hCG level could have been diminishing in these patients as well. Therefore, the eligibility for methotrexate treatment was unclear and questionable for 43.6% (24/55) of patients overall. Another important limitation of the study stems from the fact that a drop in day 0–4 serum hCG levels occurred in only 52.4% (55/105) of patients. Therefore, its potential clinical utilization was hampered owing to it being irrelevant for almost half of the treated patients. The authors have nicely stated that that an earlier indicator of treatment efficacy would reduce patient anxiety. Early diagnosis and treatment decisions are of paramount importance, and every effort should be made to comply with this statement, and studies have been performed in light of this concept.2,3 Therefore, it should be also emphasized that 35.9% (28/78) of all successfully treated patients did not experience an early drop of serum hCG levels, and would have received a false early prediction of treatment failure—with associated anxiety and reduced hope. Moreover, 20.8% (5/24) of patients who experienced a n early drop of serum HCG went on to encounter treatment failure; these patient would have received early notification predicted success and had to eventually confront the fact that treatment had failed. We suggest a more subtle approach regarding the high predictive role of the authors’ findings.

Case report of Staphylococcus epidermidis maternal sepsis and chorioamnionitis following fetoscopy

A patient aged 28 years (gravida 5 para 3) who was at 21 weeks of a monochorionic diamniotic pregnancy, underwent fetoscopic laser ablation of placental blood vessels owing to stage-3 twin-to-twin transfusion syndrome (Figure 1). Ultrasonography on post-operative day 1 demonstrated marked improvement of both embryo urinary bladder filling and Doppler blood flow measurements. n nThis article is protected by copyright. All rights reserved.