Israel Meizner

Torsion of uterine adnexa in neonates and children: A report of 20 cases

Twenty children under the age of 14 years with torsion of the uterine adnexa are discussed. Of the 14 postnatal cases, 8 were associated with additional ovarian pathology whereas in 6 cases the torsion was of normal uterine adnexa. Six additional cases had antenatal torsion with pseudocyst formation. All 14 postnatal cases presented as acute abdominal emergency requiring immediate surgery. Only 6 of the 14 had been correctly diagnosed preoperatively, the rest being mostly diagnosed as acute appendicitis. Sonographic studies can improve the preoperative diagnosis. Hemorrhagic necrosis of the adnexa (secondary to the torsion) was found in all cases except one, and necessitated adnexal resection. In only one case preservation of the adnexa was possible. Fixation of the contralateral ovary is recommended in cases of torsion of normal uterine adnexa. All six cases of antenatal torsion were diagnosed by routine ultrasonography during pregnancy between the 29th and 40th week of gestation. The fluid-fluid level sign is characteristic of this lesion. These neonates were born in no acute distress and were found to be completely asymptomatic. Hence, they did not require urgent surgery and underwent operation electively at the age of 2 weeks. Resection of the pseudocyst with fixation of the contralateral ovary is the treatment of choice in these cases.

Fetal ovarian cysts : prenatal ultrasonographic detection and postnatal evaluation and treatment

Ovarian cysts were diagnosed by antenatal ultrasonographic examination in 15 fetuses between 19 and 37 weeks gestation. In six cases there was ultrasonographic evidence of torsion. Intracystic flocculation, which typically was deposited on the sloping part of the cyst, gave a characteristic liquid interface that was regarded as ultrasonographic evidence of torsion. All cases with evidence of torsion were managed surgically post partum, and in all patients this complication was confirmed. The remaining nine cases were followed up by repeated ultrasonograms, and in all patients disappearance of the cyst was documented within the first 6 months of life. The mean size of cysts with evidence of torsion was 5.41 +/- 0.25 cm, and the mean size of those without torsion was 4.33 +/- 0.3 cm (p less than 0.01). Histologic examination of the surgical specimen in the cases with evidence of torsion revealed follicular cysts in three cases and necrotic ovarian cysts with no specific epithelial findings in the remaining three. We recommend continuous ultrasonographic assessment of antenatally diagnosed cysts and believe that the choice of treatment depends on the appearance of the cyst and its evolution throughout pregnancy.

The effect of the duration of the second stage of labour on the acid‐base state of the fetus

A prospective study was made in 153 patients with a second stage of labour lasting 1 to 120 min. Maternal venous, umbilical artery and vein blood were analysed for acid‐base variables and lactate levels. Blood was obtained immediately at delivery. Fetal heart rate monitoring data and blood test results were related to the duration of the second stage of labour and clinical outcome. In primiparae and multiparae there was a steady rise in umbilical artery lactate levels, with duration of second stage of labour, P>0·025 and P= 0·023, respectively. The median umbilical artery pH decreased significantly from 7·31 in patients with a second stage of labour that lasted ≤15 min to a pH of 7·25 in patients with a second stage of labour that lasted more than 30 min. Changes in Po2 and Pco2 were not statistically significant.

Sonographic prediction of fetal macrosomia: the consequences of false diagnosis.

Objective. The purpose of this study was to determine the effect of false diagnosis of macrosomia (<4500 g) on maternal/perinatal outcomes. Methods. We conducted a case‐control study of women (n = 1938) in whom sonographically estimated fetal weight (EFW) was determined up to 3 days before delivery and actual birth weight (BW) was 3500 to 4499 g. Women with false‐positive and ‐negative findings for macrosomia were compared, respectively, with women with true‐negative and ‐positive findings for outcome variables. Results. The cesarean delivery (CD) rate was 2 to 2.5 times higher when EFW was 4000 to 4499 g, regardless of actual BW. Failure to detect macrosomia was associated with higher rates of perineal trauma, 5‐minute Apgar scores less than 7, and neonatal trauma, mostly related to the higher rate of surgical vaginal deliveries. The use of another sonographic model with a lower false‐positive rate could theoretically reduce the CD rate by approximately 5%. Conclusions. False diagnosis of macrosomia substantially increases the CD rate and leads to maternal/neonatal complications.

Sonographic Diagnosis of Ovarian Torsion Accuracy and Predictive Factors

The purpose of this study was to determine the accuracy of sonographic diagnosis of ovarian torsion and the predictive value of typical sonographic signs.

Late selective termination of fetal abnormalities in twin pregnancies: a multicentre report.

Objective To evaluate the outcome of late selective fetal termination based on combined data from eight tertiary perinatal centres.

Expectant management of twin pregnancies discordant for anencephaly

Objective To study the clinical course and perinatal outcome of twin pregnancies discordant for anencephaly, with-out selective termination. Methods We conducted a descriptive retrospective study of 14 cases of dichorionic twin pregnancies discordant for anencephaly, which were managed expectantly in five Israeli perinatal centers. Results None of the patients miscarried. The mean gestational age at delivery was 35.9 ± 2.8 weeks (range 29–39). Only three patients (21%) delivered before 35 weeks gestation. Polyhydramnios occurred in six of the anencephalic amniotic sacs. Nevertheless, most occurrences were mild and none necessitated therapeutic amniocentesis. The mean birth weight of the normal fetus was 2610 ± 690 g (range 1100–3200). One apparently normal twin had a cardiac anomaly and died shortly after birth, and one was electively delivered at 33 weeks because of severe intrauterine growth retardation and subsequently developed cerebral palsy. The rest had normal short- and long-term outcomes. Conclusions Expectant management of a twin gestation discordant for anencephaly diagnosed at the second trimester is associated with a favorable outcome for the unaffected fetus.

Accuracy of ultrasonographic fetal weight estimation in twin pregnancies.

OBJECTIVE: To compare the accuracy of fetal weight estimations between normal and growth-restricted twin and singleton pregnancies in a single tertiary center. METHODS: The computerized ultrasound database of a tertiary center was searched for all fetal weight estimations made in twin pregnancies from 2001 to 2006, which were performed up to 3 days before delivery. Accuracy was compared with a control group of singleton pregnancies at a 3:1 ratio. Estimated fetal weight was calculated by the Hadlock formula. Analyses were performed for the whole group and for pregnancies associated with fetal growth restriction and discordancy. RESULTS: The study groups included 278 twins and 834 singleton pregnancies. The twins group was characterized by a higher mean absolute percentage error compared with the singleton group (8.9% compared with 6.8%). Accuracy was lower for the second twins than for the first twins. When comparing the subgroup of fetal growth restriction, differences in sensitivity and specificity were small for singleton compared with overall twins (47.5% compared with 48.9% and 97.7% compared with 95.7%, respectively). Overall accuracy was better in the singleton group (95% compared with 88%), mainly due to relatively low accuracy in the second twin (86%). For detection of discordancy, estimated fetal weight had a sensitivity of 52%, specificity of 88%, and overall accuracy of 81%. CONCLUSION: The accuracy of the ultrasonographic estimated fetal weight seems to be lower for twin gestations than for singleton gestations, especially for second twins. These data should be considered by clinicians when making decisions based on ultrasonographic characteristics. LEVEL OF EVIDENCE: II

Niemann-Pick disease associated with nonimmune hydrops fetalis

The number of metabolic disorders associated with nonimmune hydrops fetalis is very small and includes only Gaucher disease, GM1 gangliosidosis type 1, Hurler syndrome, and mucolipidosis type I. We report another association of a nonimmune hydrops fetalis with Niemann-Pick disease as evident by electron microscopy, and wish to add this disorder to the list of conditions associated with nonimmune hydrops fetalis.

Fetal Sex and Intrauterine Growth Patterns

To analyze the effect of fetal sex on intrauterine growth patterns during the second and third trimesters.