Gonen Ohel

Activated Protein C Resistance and Factor V Leiden Mutation can be Associated with First‐ as well as Second‐Trimester Recurrent Pregnancy Loss

PROBLEM: To examine whether the occurrence of activated protein C resistance (APCR) and factor V Leiden mutation differs in women with first‐ compared to women with second‐trimester unexplained recurrent pregnancy loss. METHOD OF STUDY: Seventy eight consecutive women with two or more unexplained post‐embryonic recurrent pregnancy losses and 139 fertile women with at least one successful pregnancy and no abortions were prospectively investigated for APCR and the factor V Leiden mutation. No women were pregnant at the time of investigation. APCR was defined as APC–sensitivity ratio (APC–SR) of ≤2.0. All patients with an APC–SR ≤2.4 were investigated for the factor V Leiden mutation. Women in this study were divided into three groups. Group A included only women with a history of recurrent first‐trimester embryonic loss (37 women) and Group B included women with second‐trimester abortions with or without additional first‐trimester abortions (41 women). Group C included the controls (139 women). RESULTS: APCR and factor V Leiden mutations were significantly more prevalent in all recurrent pregnancy loss patients in this study as compared to controls, 38% (30/78) and 19% (15/78) in contrast to 8% (11/139) and 6% (8/139), respectively. All three groups in the study were comparable regarding age, parity, and number of living children, whereas Groups A and B were also comparable regarding gravidity. Mean APC–SRs were significantly higher in Group C as compared to Groups A and B. The incidence of APCR was significantly higher in Groups A and B, as compared to controls, 27 and 49% in contrast to 8%, respectively. Moreover, the incidence of the factor V Leiden mutation was significantly higher in Groups A and B as compared to Group C, 16 and 22% as distinct from 6%, respectively. The incidence of APCR was higher in Group B as compared to Group A, 49% in contrast to 27%, with borderline significance; however, the factor V Leiden mutation did not significantly differ between the two groups. CONCLUSIONS: APCR and factor V Leiden are associated with unexplained recurrent pregnancy loss. The occurrence of APCR and factor V Leiden seems to be linked to post‐embryonic first‐trimester as well as second‐trimester recurrent pregnancy loss. The significance of acquired, non‐heritable APCR in recurrent fetal loss patients, especially in the second‐trimester aborters, is still to be determined.

Maternal complications associated with multiple cesarean deliveries.

OBJECTIVE: The claim that a planned repeat cesarean delivery is safer than a trial of labor after cesarean may not be applicable to women who desire larger families. The aim of this study was to assess maternal complications after multiple cesarean deliveries. METHODS: The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group). RESULTS: Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004). CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number. LEVEL OF EVIDENCE: II-2

International Multicentre Term Prelabor Rupture of Membranes Study: Evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term

OBJECTIVES Our purpose was to determine significant predictors for the development of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. STUDY DESIGN Logistic regression analysis with odds ratios and 95% confidence intervals was used to determine the significant predictors of clinical chorioamnionitis and postpartum fever in women with prelabor rupture of membranes at term enrolled in this study. The study recently compared in a randomized controlled trial four strategies of management: induction with oxytocin, induction with prostaglandin, expectant management, and, if failed, induction with oxytocin or prostaglandin. RESULTS The following variables were significantly associated with clinical chorioamnionitis: (1) number of digital vaginal examinations: > 8, 7 to 8, 5 to 6, 3 to 4 (vs 0 to 2) (odds ratio 5.07, 3.80, 2.62, 2.06); (2) duration of active labor: > or = 12, 9 to < 12, 6 to < 9 hours (vs < 3 hours) (odds ratio 4.12, 2.94, 1.97); (3) meconium-stained amniotic fluid (odds ratio 2.28); (4) parity of 0 (odds ratio 1.80); (5) time from membrane rupture to active labor: > or = 48, 24 to < 48 hours (vs < 12 hours) (odds ratio 1.76, 1.77); and (6) group B streptococcal colonization (odds ratio 1.71). Variables significantly associated with postpartum fever were (1) clinical chorioamnionitis (odds ratio 5.37), (2) duration of active labor: > or = 12, 9 to < 12, 6 to < 9, 2 to < 6 hours (vs < 3 hours) (odds ratio 4.86, 3.53, 3.46, 3.04), (3) cesarean section, operative vaginal delivery (odds ratio 3.97, 1.86), (4) group B streptococcal colonization (odds ratio 1.88), and (5) maternal antibiotics before delivery (odds ratio 1.94). CONCLUSIONS Increasing numbers of digital vaginal examinations, longer duration of active labor, and meconium staining of the amniotic fluid were the most important risk factors for the development of clinical chorioamnionitis in women with prelabor rupture of membranes at term. The most important risk factors for the development of postpartum fever were clinical chorioamnionitis, increasing duration of active labor, and cesarean section delivery.

Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata

AbstractPurpose: Our purpose was to study the unusual and rare late manifestation of severe pelvic abscess, following oocyte pickup (OPU), for in vitro fertilization and embryo transfer (IVF-ET). Patients: The patients were three infertile women with stage IV endometriosis and ovarian endometriomata, as the sole reason for their infertility. Medical and surgical modalities to treat endometriosis and infertility proved to be unsuccessful. Interventions: All patients were prepared for IVF-ET employing a long GnRH-a and hMG protocol. Transvaginal OPU was performed under ultrasound guidance. Intravenous (iv) prophylactic antibiotic was routinely administered. Results: All women underwent ET, and one conceived. Forty, 24, and 22 days after OPU, respectively, these patients presented with acute symptoms of severe pelvic inflammatory disease (PID) and were found to have pelvic abscess. Broad-spectrum iv antibiotics were employed in all cases, however, two patients did not respond and bilateral adnexectomy was eventually performed. Conclusions: Severe endometriosis with ovarian endometriomata seems to be a significant risk factor for pelvic abscess development, following transvaginal OPU for IVF-ET. Prophylactic IV cefazolin does not seem to prevent this complication. Late manifestation of pelvic abscess supports the notion that the presence of old blood in an endometrioma provides a culture medium for bacteria to grow slowly after transvaginal inoculation.

International Multicenter Term PROM Study: Evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term

OBJECTIVE Our objective was to determine significant predictors for the development of neonatal infection in infants born to patients with premature rupture of membranes at term. STUDY DESIGN Multivariate analysis was used to determine the significant predictors of neonatal infection in infants born to women with premature rupture of the membranes who were enrolled in the Term PROM Study. In a randomized, controlled trial, the Term PROM Study recently compared induction of labor with expectant management for premature rupture of membranes at term. RESULTS The following variables were identified as independent predictors of neonatal infection: clinical chorioamnionitis (odds ratio 5.89, P < .0001), positive maternal group B streptococcal status (vs negative or unknown, odds ratio 3.08, P < .0001), 7 to 8 vaginal digital examinations (vs 0 to 2, odds ratio 2.37, P = .04), 24 to < 48 hours from membrane rupture to active labor (vs < 12 hours, odds ratio 1.97, P = .02), > or = 48 hours from membrane rupture to active labor (vs < 12 hours, odds ratio 2.25, P = .01), and maternal antibiotics before delivery (odds ratio 1.63, P = .05). CONCLUSIONS Among infants born to patients with premature rupture of membranes at term, clinical chorioamnionitis and maternal colonization with group B streptococci are the most important predictors of subsequent neonatal infection.

High Progesterone Levels and Ciliary Dysfunction—A Possible Cause of Ectopic Pregnancy

AbstractObjectives: To investigate the effects of different levels ofhormones on the ciliary activity of human oviducts and,consequently, to assess their possible role in tubalimplantation of the fertilized egg. Design: Fallopian tube epithelial samples were incubatedin media with the addition of Estradiol (E2), progesterone(P), human menopausal gonadotropin (hMG), LH, or pureFSH (Metrodin) in different concentrations. The ciliary beatfrequency (CBF) was measured after 24 h of incubation.Then the media were exchanged to media without theaddition of hormones and the CBF was measured again 24 hlater by using the photoelectric technique. Setting: University teaching hospital, IVF unit. Results: Twenty-four hr after the addition of P to the culturemedium in concentrations of 0.5 or 1 ng/ml a significantdecline of the CBF down to 63% of the control level wasobserved (P < 0.001) and with P in concentration of 2 ng/ml or greater, 50–70% of the cilia were paralyzed. Theseeffects of P were found to be reversible. Incubation with E2induced a slight increase of 4% in the mean CBF (P =0.002). Twenty-four hr incubation with Metrodin, Pergonal,or LH did not affect ciliary motility. Conclusions: Higher levels of progesterone cause ciliarydysfunction and subsequently may be a possible cause ofectopic pregnancy.

Common oral manifestations during pregnancy: a review.

Pregnancy has far-reaching systemic effects extending beyond the reproductive system. Oral and masticatory changes during pregnancy have been documented for many years; however, their magnitude and frequency have not been stressed. This review highlights the major oral complications during pregnancy. Pregnancy gingivitis and pregnancy tumor are described and presented, and possible preventive strategies are suggested. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to summarize the major oral complications during pregnancy, to outline the etiologic factors associated with each of these conditions, and to explain the role of dental treatment during pregnancy.

Multiple primary malignant neoplasms in breast cancer patients in Israel

The data of an epidemiologic study of multiple primary malignant neoplasms in breast cancer patients in Israel are presented. During the 18‐year period of the study 12,302 cases of breast carcinoma were diagnosed, and, of these, 984 patients (8%) had multiple primary malignant tumors. Forty‐seven of these patients developed two multiple primary cancers. A significantly higher than expected incidence of second primary cancers occurred at the following five sites: the opposite breast, salivary glands, uterine corpus, ovary, and thyroid. Cancers of the stomach and gallbladder were fewer than expected. Treatment of the breast cancer by irradiation was associated with an increased risk of subsequent cancers of lung and hematopoietic system. The prognosis was mainly influenced by the site and malignancy of the second primary cancer. The incidence of multiple primary malignancies justifies a high level of alertness to this possibility in the follow‐up of breast cancer patients.

Decidualization of Ovarian Endometriosis During Pregnancy Mimicking Malignancy

The purpose of this series is to present deciduosis (the formation of extrauterine decidua) as one of the differential diagnoses of a malignant tumor during pregnancy.

Ehlers-Danlos syndrome: insights on obstetric aspects.

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders characterized by joint hypermobility, skin hyperelasticity, tissue fragility, easy bruising, and poor healing of wounds. The clinical manifestations vary depending on the type of disease. The syndrome may be associated with a number of pregnancy and peripartum complications. Because of the multi-organ involvement and varied presentation of this disease, no uniform or routine obstetric and anesthetic recommendations can be made for the perinatal care of these patients. We present a review of the literature on EDS with emphasis on the obstetric, anesthetic, and perinatal consequences. We also report our experience with this syndrome: an uneventful term vaginal delivery in a 32-year-old woman diagnosed with hypermobility type of EDS. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall the potentially severe nature of Ehlers-Danlos Syndrome (EDS) in both pregnant and nonpregnant patients, summarize the wide range of signs and symptoms and its genetic inheritance, and explain the difficulty in recommending obstetric and anesthesia procedures to avoid complications.