Ian Bukovsky

Congenital anomalies of the müllerian system

Congenital anomalies of the müllerian system, the most common of which are uterine malformations, are associated with fertility problems. Multifactorial polygenic and familial factors are involved in their formation. The result may be deficient development (agenesis, rudimentary horn, unicornuate uterus), nonfusion (didelphys or bicornuate uterus), or defective canalization of the müllerian ducts (septate uterus). The principal diagnostic procedures include HSG, laparoscopy, hysteroscopy, and US. The clinical presentation varies from symptoms of obstruction of the menstrual flow in adolescence to hypomenorrhea and fertility problems in adult life. Repeated fetal loss, after excluding other reasons, is usually the indication for surgical intervention. Uterine septa should be resected hysteroscopically. A prophylactic cerclage has been suggested by various authors, including those of this work, in cases of symmetric uterine anomalies, especially bicornuate uteri, as a simple and effective treatment to be tried before embarking on major surgery such as metroplasty.

A Comparison of Clinical and Ultrasonic Estimation of Fetal Weight

Objective To compare the accuracy of routine ultrasonic and clinical birth weight estimation. Methods The study sample included 1717 women with singleton pregnancies, admitted in early labor with an ultrasonic estimated fetal weight (EFW) performed during the preceding week. Clinical EFW was obtained before rupture of the membranes by the attending senior resident, who was unaware of the ultrasonic EFW. Accuracy was determined by the percentage error, the absolute percentage error, and the proportion of estimates within 10% of the actual birth weight (birth weight ± 10%). Statistical analysis was done by the paired t test, the comparison of correlated variances, the Wilcoxon sign test, and the χ2 test. Actual birth weight in the study sample averaged 3334 ± 607 g (± standard deviation, [SD]) and ranged between 690 and 5320 g. Results The means of all error terms of the clinical EFW were significantly smaller than those of the ultrasonic EFW. However, the rates of estimates within 10% of birth weight were not significantly different (72 and 69%, respectively). In birth weights less than 2500 g, both methods overestimated the birth weight, but the mean errors of the ultrasonic EFW were significantly smaller than those of the clinical EFW. The ultrasonic EFW had significantly higher rates of birth weight ± 10% than the clinical EFW (63 compared to 49%, respectively). In the 2500–4000 g birth weight, only the clinical EFW had no systematic error, whereas the ultrasonic EFW underestimated the birth weight. The mean errors of the clinical EFW were significantly smaller and the rate of birth weight ± 10% significantly higher than those of the ultrasonic EFW. In the birth weight greater than 4000 g, both methods underestimated the birth weight, and the mean errors and the rate of estimates within 10% of birth weight were similar for both methods. Conclusion Clinical estimation of birth weight in early labor is as accurate as routine ultrasonic estimation obtained in the preceding week. In the lower range of birth weight (less than 2500 g), ultrasonic estimation is more accurate; in the 2500–4000 g range, clinical estimation is more accurate. In the higher range of birth weight (greater than 4000 g), both methods have similar accuracy.

Ripening of the unfavorable cervix with extraamniotic catheter balloon : Clinical experience and review

The use of an extraamniotic catheter balloon, inflated above the internal cervical os, has been advocated as a nonpharmacological, mechanical method of cervical ripening before induction of labor. Additional measures may include applying traction on the catheter, or the infusion of normal saline (1 ml/min) via the catheters port into the extraamniotic space. The results of catheter balloon cervical ripening are reviewed from 13 published reports and a departmental series of 190 pregnancies with unfavorable cervix, encompassing nearly 1000 patients. A mean change in cervical score of at least 3 points, was noted in most studies after balloon expulsion or removal. The present series and other studies suggest that oxytocin use for induction and/or augmentation of labor is increased after balloon ripening, compared with its use in spontaneous labor or after cervical ripening by prostaglandins. In 11 studies, catheter balloon ripening was compared with cervical ripening by other mechanical, or pharmacological (i.e., oxytocin or prostaglandins) methods. Of these, eight were prospective and randomized-controlled and three were case-controlled studies. It is suggested that ripening efficacy by catheter balloon is similar, or better, than other methods; but there is no significant difference in the mode of delivery or perinatal outcome. This review also suggests that cervical ripening with extraamniotic catheter balloon has the advantages of simplicity, low cost, reversibility, and lack of systemic or serious side effects.

Investigation of the uterine cavity in recurrent aborters

To prospectively compare the diagnostic ability of both HSG and diagnostic hysteroscopy in recurrent aborters, an HSG followed by a diagnostic hysteroscopy was performed in 106 patients during an investigation into recurrent abortions. The uterine cavity findings on HSG and at hysteroscopy were compared. Among the 60 abnormal HSG patients, intrauterine pathology was demonstrated in 37 (34.9%). Among the 46 normal HSG patients, a normal uterine cavity was found in 33 (31.3%). The sensitivity of the HSG in revealing intrauterine abnormalities was therefore 79% and its specificity 60%. In 23 pathologic HSG, no abnormalities were seen by hysteroscopy. In 13 cases, hysteroscopy demonstrated mild intrauterine findings overlooked by HSG. The false-positive rate was 38% and the false-negative rate was 28%. Hysterosalpingography showed a high false-positive rate, especially in the intrauterine adhesions group. In view of the low specificity and high false-positive and false-negative rates, we believe that hysteroscopic evaluation of the uterine cavity is superior to HSG in recurrent abortions.

Improved fertility following ectopic pregnancy.

The reproductive performance subsequent to operative removal of ectopic pregnancy was examined in 154 women. They represent 64% of 242 women admitted for ectopic pregnancy between 1969 and 1979. The follow-up period averaged 42 years. The patients at risk had a conception rate of 81%, with a repeat ectopic pregnancy incidence of 7.8%, and 65% had at least one live birth. Postoperative infertility was significantly associated with (1) previous sterility, (2) coexistent periadnexal adhesions and/or tubal disease, (3) rupture of the ectopic pregnancy, and (4) older age. A statistically significant advantage of conservative over radical treatment, as regards future fertility, was demonstrated only in 53 patients with either history or findings suggestive of previously impaired fertility. Early, prerupture diagnosis and treatment, coupled with conservative and restorative measures, might account for the improved reproductive performance.

Ovarian pregnancy: A report of twenty cases in one institution

A series of 20 cases of primary ovarian pregnancy that were diagnosed and treated in one institution is reported. The prevalence rate of 1:3600 deliveries seems to be increasing in past years and comprises 3.3% of all extrauterine pregnancies. Clinical presentation, possible pathogenesis, diagnostic steps, preferred management, and future fertility are detailed. Inasmuch as all our 18 fertile patients used an intrauterine contraceptive device before the operation, special emphasis is made on the controversial relationship between use of intrauterine contraceptive devices and ovarian pregnancy.

Hysteroscopy is superior to hysterosalpingography in infertility investigation

Background. The development of advanced endoscopic instrumentation in recent years has demonstrated the superiority of direct visual examination over radiographic demonstration of various body cavities. Just as laparoscopy has gradually taken a primary role in the surgical investigation of the ovulatory infertile patient, the role of intrauterine endoscopy in comparison to hysterosalpingography (HSG) needs to be reevaluated.

Mifepristone (RU486) alone or in combination with a prostaglandin analogue for termination of early pregnancy: a review

The availability of a medical mode of termination of early pregnancy by the administration of RU486, an antiprogesterone alone, or in combination with one of the PG analogues significantly reduces the maternal morbidity and mortality associated with the classical surgical abortion. RU486 given alone in early pregnancy induces complete abortion in 60% to 85% of cases, and when combined with prostaglandin analogues, gemeprost or sulprostone, reaches a success rate of 95% to 99%. RU486 may also be of potential value in the medical treatment of ectopic pregnancy. Its use as a postcoital contraception is suggested, but further research is required to determine whether RU486 can be used on a once-a-month basis for contraception.

Local methotrexate injection: A nonsurgical treatment of ectopic pregnancy

Twenty seven patients with unruptured tubal pregnancy were selected for nonsurgical treatment with the use of one injection of 12.5 mg of methotrexate into the ectopic site at laparoscopy. No adverse reactions were observed. In three patients (11%), a laparotomy was performed because of rising beta-human chorionic gonadotropin titers. In the other patients, serum beta-human chorionic gonadotropin levels decreased to the nonpregnant range with no further intervention, and the patients recovered uneventfully. This method is suggested as an alternative to surgery in selected cases of early unruptured tubal pregnancy.

Dynamic ultrasonographic imaging of the third stage of labor: New perspectives into third-stage mechanisms

OBJECTIVE Dynamic ultrasonographic imaging of the third stage of labor was performed to document ultrasonographic findings and to present new perspectives into third-stage mechanisms. STUDY DESIGN Twenty-five normal deliveries and five with prolonged third-stage labor were studied. RESULTS Normal third-stage labor could be divided into four phases: (1) latent phase, characterized by thick, placenta-free wall and thin, placenta-site wall; (2) contraction phase, with thickening of placenta-site wall (from < 1 cm to > 2 cm); (3) detachment phase, in which the placenta completes its separation and detaches; and (4) expulsion phase, with a sliding movement of the placenta. Although oxytocic agents were routinely used, they do not seem to influence the findings. In five cases with retained placenta the placenta-site wall was initially thin. In four of them it became thick, and the placenta was removed by traction of the cord, whereas in the fifth case the placenta-site wall remained thin and the placenta had to be removed manually. CONCLUSION Shearing forces seem to tear the decidual septae and thereby separate the placenta. This process is completed only when the placenta-site wall attains full thickness. In cases of prolonged third-stage labor, traction of the cord should be applied only when this phase is completed and the actual sliding movement of the placenta is observed.