George Daskalakis

Management of cervical insufficiency and bulging fetal membranes.

OBJECTIVE: To evaluate the efficacy of emergency cerclage in cases with dilated cervix and protruding fetal membranes in a group of women considered at low risk for preterm delivery by their obstetric histories. METHODS: All cases of cervical dilatation and bulging membranes were detected through a transvaginal ultrasonographic screening for preterm delivery between 18 and 26 weeks during a 6-year study period. Twenty-nine women underwent an emergency cervical cerclage and composed the cerclage group, whereas 17 others refused and formed the bed rest group. All patients were given antibiotics and prophylactic tocolysis. RESULTS: The mean prolongation of pregnancy (8.8 weeks) and the mean birth weight (2,101 g) after cerclage placement differed significantly from those of the bed rest group (3.1weeks and 739 g, respectively). Twenty-five of the 29 pregnancies in the cerclage group ended in live birth, compared with 7 of the 17 pregnancies in the bed rest group (P = .001) (relative risk [RR] 0.33, 95% confidence interval [CI] 0.11–0.98). Neonatal survival was 96% in the cerclage group and 57.1% in the bed rest group (P = .025) (RR 0.09, 95% CI 0.01–0.76). The preterm delivery rate less than 32 weeks was 31% and 94.1% in the cerclage and the bed rest groups, respectively (P < .001) (RR 0.33, 95% CI 0.19–0.57), whereas the admission to neonatal intensive care unit was 28% and 85.7% in the 2 groups, respectively, (P = .01) (RR 0.33, 95% CI 0.16–0.66). CONCLUSION: Emergency cervical cerclage can be accomplished safely in women with dilated cervix and bulging membranes. It can reduce preterm delivery before 32 weeks and improve neonatal survival compared with bed rest. LEVEL OF EVIDENCE: II-1

Emergency obstetric hysterectomy

Background. All cases of obstetric hysterectomies that were performed in our hospital during a seven‐year study period were reviewed in order to evaluate the incidence, indications, risk factors, and complications associated with emergency obstetric hysterectomy. Methods. Medical records of 45 patients who had undergone emergency hysterectomy were scrutinized and evaluated retrospectively. Maternal age, parity, gestational age, indication for hysterectomy, the type of operation performed, estimated blood loss, amount of blood transfused, complications, and hospitalization period were noted and evaluated. The main outcome measures were the factors associated with obstetric hysterectomy as well as the indications for the procedure. Results. During the study period there were 32,338 deliveries and 9,601 of them (29.7%) were by cesarean section. In this period, 45 emergency hysterectomies were performed, with an incidence of 1 in 2,526 vaginal deliveries and 1 in 267 cesarean sections. All of them were due to massive postpartum hemorrhage. The most common underlying pathologies was placenta accreta (51.1%) and placenta previa (26.7%). There was no maternal mortality. Conclusions. Obstetric hysterectomy is a necessary life‐saving procedure. Abnormal placentation is the leading cause of emergency hysterectomy when obstetric practice is characterized by a high cesarean section rate. Therefore, every attempt should be made to reduce the cesarean section rate by performing this procedure only for valid clinical indications.

Misoprostol for second trimester pregnancy termination in women with prior caesarean section

Objective  To examine whether a previous caesarean section increases the risk for complications in women undergoing a mid‐trimester pregnancy termination by labour induction.

Risk factors predisposing to fetal loss following a second trimester amniocentesis

Objective To examine the influence of possible risk factors on fetal loss rate following amniocentesis.

Gestational diabetes mellitus shares polymorphisms of genes associated with insulin resistance and type 2 diabetes in the Greek population

Gestational diabetes mellitus (GDM) and type 2 diabetes (T2D) share common pathophysiological features, including β-cell dysfunction and insulin resistance. In this study, we investigated the association between GDM and five recently identified T2D susceptibility loci, in a Greek population. We studied 148 women with GDM and 107 non-diabetic unrelated pregnant Greek women, for polymorphisms in the TCF7L2 gene (rs7903146 C/T), the PPARG gene (Pro12Ala), the KCNJ11 gene (E23K), the IRS1 gene (G972R) and in the FOXC2 gene (-512C>T). The T-allele of the TCF7L2 rs7903146 (C/T) polymorphism was found to be significantly associated with an increased risk of GDM [p = 0.0003; odds ratio (OR) 2.04 (95%CI 1.38–3.00)]. Additionally, CT and TT genotypes were significantly overrepresented in women with GDM compared to controls (p = 0.0003 and p = 0.0148, respectively). Analysis of the IRS1 G972R polymorphism showed that the R-allele frequency was increased in women with GDM [(p = 0.009; OR 1.67 (95%CI 1.14–2.47)]. The genotypes and allele frequencies of the other polymorphisms studied did not statistically differ between the GDM and the control women. Thus, our data suggest that the common T2D susceptibility polymorphism of TCF7L2 (rs7903146 C/T) gene, and the G972R polymorphism of the IRS1 gene, seem to predispose to GDM in Greek women.

Sonographic Cervical Length Measurement before Labor Induction in Term Nulliparous Women

Objective: The purpose of the study was to determine if transvaginal sonographic measurement of the cervical length is a useful method to predict successful labor induction in nulliparas. Methods: 137 women who were scheduled for medically indicated induction of labor had a transvaginal sonographic measurement of the cervical length before labor induction. Inclusion criteria were: (1) singleton pregnancy; (2) gestational age between 37–42 weeks; (3) live fetus in cephalic presentation; (4) intact membranes; (5) no vaginal bleeding; (6) no previous history of uterine surgery; (7) nulliparous women, and (8) no allergy or asthma in response to prostaglandins. Induction of labor was performed within 6 h of the ultrasonographic examination, by inserting 2 mg of dinoprostone in the posterior vaginal fornix, repeated if needed every 6 h for up to three doses. When the cervix became favorable and no regular contractions were observed, amniotomy and oxytocin augmentation, starting at 1 mIU/min and increasing 1 mIU every 30 min as necessary, was performed. Results: All women were Caucasians and the mean age was 24.3 years (range 19–37 years). The mean cervical length was 28 mm (range 11–39 mm). The Bishop score was ≤5 in 101 women and >5 in the 36 others. Vaginal delivery occurred in 92 women (67.1%), and the vast majority of them (89 women; 96.7%) gave birth within 24 h of induction. Forty-five women (32.8%) had a cesarean section. The Bishop score was not predictive of the mode of delivery. Thirty-six of 101 women (35.6%) with a Bishop score ≤5 delivered by cesarean section, compared to 9 of 36 women with a Bishop score >5 (25%) (p = NS). Women with a cervical length <27 mm were more likely to deliver vaginally. Using this cutoff value the sensitivity of a successful labor induction was 76% and the specificity was 75.5%. Conclusions: Transvaginal sonographic measurement of cervical length is a good predictor of a successful labor induction at term in nulliparas.

Combined ultrasonographically guided drainage and methotrexate administration for treatment of endometriotic cysts

We report an effective alternative for the management of endometriotic cysts with transabdominal drainage under ultrasonographic control, followed by injection of 30 mg of methotrexate.

Uterine prolapse complicating pregnancy.

BackgroundUterine prolapse is extremely rare during pregnancy. However in some cases significant complications may develop. We report a case of uterine prolapse which developed during pregnancy. Our case was managed conservatively and there were no fetal or maternal complications. Postnatally the uterine prolapse recovered spontaneously. Early recognition and close follow-up during pregnancy is essential. Successful pregnancy outcome requires individualized treatment but bed rest should always be considered.

Myasthenia gravis and pregnancy

Three pregnancies in two women with myasthenia gravis (MG), are presented. The first woman expressed no antenatal complications and delivered a full-term 3350 g baby by caesarean section, because of a previous caesarean. The second woman had two preterm births in subsequent pregnancies, which were complicated by hydramnios. Her first pregnancy ended in neonatal death of a 860 g female with multiple congenital anomalies. In her second pregnancy there was an exacerbation of MG and the baby, an 880 g male died soon after birth, due to respiratory failure.

First trimester diagnosis of dicephalus conjoined twins.

Dicephalus twinning is an extremely rare type of conjoined twins. Early prenatal diagnosis of this condition is important to provide an opportunity for pregnancy termination. We present such a case, which was diagnosed by ultrasound examination at 12 weeks of gestation. The ultrasonographic criteria are discussed together with implications for management.