Gil A. Goldman

The grand multipara

Grandmultiparity (GMP) has long been considered an obstetric complication for both mother and fetus, although recent studies indicate that, with proper perinatal care, women with high-parity rates are no longer at high risk. The current study examines the outcome of delivery in 1700 women in their fifth or more delivery, as compared with two control groups: 622 primiparas and 735 multiparas (two to three previous deliveries). Excellent prenatal care was available free of charge to all parturients. Our objectives were to evaluate the management of GMP in contemporary obstetrics and to assess whether grand multiparas are still high-risk patients. The age of the grandmultiparas was significantly higher compared with with the control groups, which may explain the higher incidence among them of antenatal medical disorders, such as diabetes mellitus and hypertensive disease. No significant differences were found among the three groups for preterm or post-term births, small-for-gestational-age infants, polyhydramnios, oligohydramnios, perinatal death, fetal distress, multiple births, placenta previa, abruptio placentae or cord prolapse. Macrosomia was markedly higher in the grandmultiparas and multiparas than in nulliparas. Thus, our results indicate that good perinatal care can ensure better results in grandmultiparas, and that grandmultiparity no longer needs to be considered a high-risk obstetric category in our population.

Women's attitudes towards menopause and hormone replacement therapy

Objectives: To determine how women aged 50 years or more feel about menopause, and their knowledge, use of and attitude toward hormone replacement therapy (HRT). Methods: All study participants resided in a single urban community in central Israel and were selected at random from the computerized government registry. Responses were collected by either telephone interview (n = 171) or mailed questionnaire (n = 41) and were analyzed for the group as a whole and by different demographic and attitudinal factors. Results: Most (80%) of the women had a positive or neutral attitude to menopause. More than 80% had heard of HRT, 55% of whom from a physician. Of these, 12% were currently using HRT and 9.5% had done so in the past. Varied reasons were offered for starting or stopping treatment. Conclusions: Although the great majority of the participants had heard of HRT, and most of these had spoken about it with a doctor, only a small percentage were currently under therapy or had been in the past. We believe gynecologists should devote more effort to public education, in that those women who had discussed HRT with their physician were more likely to use it.

Great grand multiparity — beyond the 10th delivery

Objective: To investigate the perinatal outcome and obstetric complications of women delivering for the 10th time or more. Methods: Four hundred twenty women of great grand multiparity were analyzed in a modern health care setting and compared with our general population of obstetric patients, with regard to past history, maternal age, gestational age, mode of delivery, fetal outcome and intercurrent medical/obstetric problems. Results: The study group showed significantly lower rates of low birth weight infants and instrumental delivery. No significant difference was seen in the incidence of cesarean section, pathologic fetal presentation, maternal hypertension, gestational diabetes, hemorrhage, or perinatal morbidity or mortality. There was a slightly higher incidence of twin births compared with the general population. Conclusion: It is probable that women capable of reaching their 10th delivery are basically healthy. If offered adequate perinatal care, they are not a high‐risk group during subsequent deliveries.

Successful external version of B-twin after the birth of A-twin for vertex-non-vertex twins

OBJECTIVE To determine the optimal intrapartum management of twins, especially those in vertex--non-vertex presentation. STUDY DESIGN The study population consisted of 408 sets of twins delivered between 1988 and 1992, weighing at birth over 1500 g. According to our protocol, vaginal delivery was attempted in the vertex-vertex presentations. If non-vertex presentation was first, we performed cesarean section. In vertex--non-vertex cases, the first was delivered vaginally and external cephalic version or breech delivery was performed on the second. Apgar scores were compared according to presentation and delivery mode. RESULTS Vaginal delivery was accomplished in 122 (73%) of 169 vertex--vertex presentations, 96 (68%) of 142 vertex--non-vertex presentations, and 4 (5%) of 99 non-vertex--other presentations. External cephalic version (ECV) of the second twin and subsequent vaginal delivery in vertex--non-vertex was successful in 75% of cases, and internal podalic version and assisted breech delivery were performed in 20 cases, and the remaining two were delivered by cesarean section. Apgar scores were not significantly different among the various groups, and no complications arose from external cephalic version performed on second non-vertex twins. CONCLUSIONS External cephalic version was found safe for delivering second non-vertex twins in cases where the first twin is in vertex presentation. In our opinion routine cesarean section is thus no longer justified in such cases.

Treatment variables in relation to oocyte maturation: lessons from a clinical micromanipulation-assisted in vitro fertilization program.

Objective: In an effort to understand the mechanism underlying the improved pregnancy rate observed in IVF cycles when gonadotropin-releasing hormone analogues (GnRH-a) are applied, we investigated a possible relationship between treatment variables and oocyte-nuclear maturity.Design: Nuclear maturity was retrospectively assessed in cumulus-free, denuded oocytes, obtained from women undergoing micromanipulation-assisted IVF treatment following controlled ovarian hyperstimulation with GnRH-a and menotropins.Setting: The setting was the infertility and IVF unit of a tertiary academic medical center.Participants: Two hundred twenty-one patients underwent 435 treatment cycles.Main Outcome Measure: This was the proportion of germinal vesicle-intact immature (GVII) oocytes.Results: One hundred fifty-four of the 3520 oocytes studied (4.4%) were in the GVII stage. These oocytes were found in 66 of the treatment cycles (15.2%) and in 54 of the patients (24.4%). Cycles in which GVII oocytes were detected did not differ from those in which all the aspirated oocytes were mature in the following respects: patient age, type and duration of infertility, controlled ovarian hyperstimulation protocol and time of ovum pickup. However, the GVII group was characterized by a significantly higher peak estradiol level, as well as a higher number of mature follicles visualized sonographically (diameter, >14 mm) and oocytes retrieved.Conclusions: Comparing the present findings with previously published data, it appears that the inclusion of GnRH-a in the stimulation regimen is associated with a lower proportion of immature oocytes. A higher occurrence of oocyte-nuclear immaturity is apparently associated with a significantly better ovarian response to stimulation. The high incidence of immature oocytes observed in patients with normospermic partners and low fertilization rates in previous cycles may suggest that the fertilization failure in some of these cases is due to oocyte, rather than sperm, dysfunction.

The outcome of post-term pregnancy. A comparative study.

The aim of this study was to evaluate whether prolonged pregnancy was associated with dangers to the fetus, and to assess the incidence of cesarean section as well as fetal distress. The outcome for mother and baby in both groups of patients with post-term pregnancies was generally good. Furthermore, the improvement of prognosis for postdate pregnancy is due to the availability of electronic fetal monitoring and ultrasound, making possible the identification of fetal distress, as well as the use of prostaglandin to ripen a stubborn cervix, and induce labor successfully in most cases. Consequently, we feel that fetal jeopardy with continued intrauterine existence, as well as the excellent results of induction of labor, justify the active approach. The routine induction of labor in postdate pregnancy may reduce perinatal morbidity, as indicated in previous reports [2], and confirmed in this study.

Primary abdominal pregnancy: can artificial abortion, endometriosis and IUD be etiological factors?

Primary abdominal pregnancy is a very rare condition, accompanied by high rates of perinatal and maternal mortality. The etiology of this condition is not clear; nevertheless several theories have been proposed. We have reported three cases in whom the etiological factors may have been the presence of an IUD, and patches of endometriosis adjacent to the site of the pregnancy in two cases. It is suggested that in cases suspected of ectopic pregnancy, in the presence of IUD or other pelvic pathology, it should first be determined whether it is the dangerous condition of abdominal pregnancy, in view of the high mortality rates.

The value of GnRH agonists in the treatment of failed cycles in an IVF-ET program: a comparative study

Occasionally, menotropins fail to induce ovulation for IVF-ET, due to early luteinization resulting in high cancellation rates of 15-40% of cycles. The efficacy of GnRH agonists in reducing these problems was prospectively studied in 91 women undergoing repeated IVF-ET, after desensitization with GnRH agonists. In all patients, the cycles that had been induced by menotropins alone failed due to early luteinization. By comparing these patients to a control group with significantly lower cancellation rates as well as significantly higher fertilization, the cleavage and pregnancy rates were achieved for the former group (p less than 0.001 in all parameters). Pituitary down-regulation by means of GnRH agonists prior to the induction of ovulation seems to be an effective and rewarding method for minimizing cancellation rates, and for achieving improved results in IVF-ET therapy.

The impact ofd-Trp6 luteinizing hormone-releasing hormone (LH-RH) on carbohydrate metabolism

BackgroundThe population exposed to repeated cycles of gonadotropin-releasing hormone analogue treatment before in vitro fertilization is growing rapidly. Sex steroids have been shown to induce changes in carbohydrate metabolism. In view of the effect of gonadotropinreleasing hormone analogues on sex steroid levels, it seems of interest to investigate carbohydrate metabolism following treatment with these compounds.PurposeOur purpose was to assess possible changes in glucose tolerance following administration of the longacting gonadotropin-releasing hormone and analogue,d-Trp6 LH-RH.DesignA 3-hr oral glucose tolerance test with 100 g glucose was performed on all patients, before and after 6 weeks of treatment.ResultsNo significant changes in either glucose tolerance or insulin levels following treatment withD-Trp6 LH-RH were demonstrated in the group of 25 women investigated.ConclusionWith respect to carbohydrate metabolism,d-Trp6 LH-RH may safely be administered to healthy women. Further studies are still required to assess the safety of this GnRH analogue when treating potentially diabetic and diabetic patients.

The impact ofd-Trp6 LH-RH on plasma lipid levels

AbstractBackground: There is increasing evidence regarding the correlation between the risk of death from cardiovascular disease and low levels of HDL-cholesterol or high plasma concentrations of LDL-cholesterol, total cholesterol, and triglycerides. Gonadotropin releasing hormone (GhRH) analogues are widely used in assisted reproduction programs. Therefore, it seems important to evaluate possible changes in serum lipoprotein levels following treatment with these compounds. Purpose: Our purpose was to assess possible lipoprotein changes following administration of the long-acting GnRH analogue,d-Trp6 luteinizing hormone-releasing hormone (LH-RH). Design: Serum levels of cholesterol, HDL-cholesterol, LDL-cholesterol, and triglicerydes were determined before and after 6 weeks of treatment. Results: No significant changes in either cholesterol or HDL-cholesterol, LDL-cholesterol, or triglicerydes following treatment withd-Trp6 LH-RH were demonstrated in the group of 25 patients investigated. Conclusions: Short-term use ofd-Trp6 LH-RH is not associated with any significant change in plasma lipid levels. Further studies are still required with patients undergoing repeated treatment cycles, especially those who exhibit elevated pretreatment plasma lipid levels, to confirm the long-term safety of GnRH analogues with respect to lipid metabolism.