Jacob Bar

Endometrial polyps during menopause, characterization and significance

BACKGROUND To characterize postmenopausal women with endometrial polyps and to evaluate their significance. METHODS The study population included all consecutive postmenopausal patients with a diagnosis of endometrial polyp, treated at our center over a two-year period. Demographic, medical and gynecological data were assessed with regard to the endometrial histologic findings. RESULTS Of the 146 eligible patients, 15 had endometrial hyperplasia (four with atypia); there were no cases of endometrial carcinoma. The 20 patients (13.7%) using hormone replacement therapy had a significantly higher rate of endometrial hyperplasia than non-hormone users (p<0.006). No differences were observed among the endometrial histological categories for any of the presenting symptoms and signs, ultrasonographic findings, or medical histories. CONCLUSIONS Postmenopausal endometrial polyp is a common, mostly benign entity. However, the relatively high rate of concomitant endometrial hyperplasia, especially in patients receiving hormone replacement therapy, dictates a thorough histological evaluation in all cases.

Pregnancy in Renal Transplant Recipients: Long-term Effect on Patient and Graft Survival. A Single-center Experience

Background. There are limited data on the effect of pregnancy on long-term renal allograft function. The aim of the study was to compare long-term graft and patient outcome between pregnant and nonpregnant women after renal transplantation. Methods. The study group consisted of 39 women attending the Perinatal Division of the Rabin Medical Center who conceived after undergoing renal transplantation (total number of live births: 55). All had a functioning allograft at the time of conception. Each patient was matched with 3 controls for 12 factors known to affect graft survival. The controls were derived from a cohort of 250,000 transplant patients registered in the Collaborative Transplantation Study (CTS) database. The groups were compared for graft survival, long-term patient survival, and kidney function (CTS clinical grading scale). Results. Graft (61.6%) and patient (84.8 %) survival from transplantation to the end of follow-up (15 years) in the women who conceived after transplantation did not differ from the rates observed in the 177 women in the matched control group (68.7% and 78.8 %, respectively). There were no between-group differences in long-term graft function. Conclusion. Pregnancy does not appear to have adverse effects on long-term graft or patient survival or kidney function in women after renal transplantation.

Course and outcome of obstetric patients in a general intensive care unit

Background. To characterize the course, interventions required to achieve predetermined end‐points and outcome of obstetric patients admitted to a general intensive care unit.

Indicated labor induction with vaginal prostaglandin E2 increases the risk of cesarean section even in multiparous women with no previous cesarean section

Abstract Aims: To evaluate the impact of induction of labor with vaginal tablets of prostaglandin E2 on the rate of cesarean section (CS), and to identify possible predictors of successful vaginal delivery. Methods: 1541 consecutive women admitted for induction of labor with vaginal tablets of PGE2 were retrospectively compared with 574 consecutive women with spontaneous onset of labor. Results: Maternal age, nulliparity, previous CS, gestational age, and birth weight were similar in the study and control groups. The CS rate was twofold higher in the study group (20.7% vs 10.6%). CS rates in the study and control groups were 26.9% and 12.8% for the nulliparous women, and 11.2% and 5.1% for the multiparous women with no previous CS. Neither group had major maternal or fetal complications. A logistic regression model and stepwise analysis showed that nulliparity, previous CS, maternal age, number of PGE2 applications, birth weight, and the induction of labor by itself were independent significant risk factors for increased CS rate. Conclusions: Induction of labor with vaginal PGE2 tablets results in a vaginal delivery rate of 79.3%, with apparently no serious maternal or fetal complications. Nulliparity, and previous CS are the most significant risk factors for increased CS rate. However, even after these risk factors are excluded and controlling for possible predictors for CS, PGE2 induction is independently associated with a twofold increase in CS rate, most often because of labor dystocia.

Transcutaneous electrical nerve stimulation (TENS) for adjuvant pain-relief during labor and delivery

Objective: We examined the efficacy of transcutaneous electrical nerve stimulation (TENS) in general and the new Freemom TENS device (LifeCare, Israel) in particular, for pain relief during labor and delivery. Methods: The study group consisted of 104 women. Forty‐six nulliparas (44.2%) and 58 multiparas (55.8%), all of whom used the TENS device for pain relief during labor. All participants completed a questionnaire on the degree of pain relief afforded them by TENS during the delivery and related questions. The objective evaluation was based on the documented labor and delivery parameters including medical interventions during delivery. Results: The majority of subjects (72% of the nulliparas and 69% of the multiparas) considered TENS effective for the relief of pain during labor. Most of them (67% of the nulliparas and 60% of the multiparas) responded positively to the use of TENS in future deliveries. Sixty‐five percent of the multiparas considered TENS at least as effective as the other pain relief methods they had used before. TENS significantly reduced the duration of the first stage of labor P<0.001 for nulliparas, P<0.005 for multiparas and it significantly decreased the amount of analgesics administered to individual patients. No significant difference was found in fetal heart rate tracings, Apgar scores and cord blood pH between the study group and an equal number of matched controls who used other forms of pain management. Conclusions: TENS is an effective non‐pharmacological, non‐invasive adjuvant pain relief modality for use in labor and delivery. TENS application reduced the duration of the first stage of labor and the amount of analgesic drug administered. There were no adverse effects on mothers or newborns.

Perinatal complications following gestational diabetes mellitus how 'sweet' is ill?

Objective. We tested the effect of patient compliance, fasting plasma glucose on oral glucose tolerance test, maternal body constitution, and the method of treatment (diet versus insulin) on the perinatal outcome of patients with gestational diabetes mellitus.

The placental factor in early- and late-onset normotensive fetal growth restriction

OBJECTIVE Our objective was to investigate the placental component in early- and late-onset fetal growth restriction (FGR) compared to placentas from neonates appropriate for gestational age (AGA). STUDY DESIGN Placentas from normotensive women who gave birth at 24-42 weeks to neonates with a birth-weight below the 10th percentile (FGR group), or to healthy AGA neonates (AGA group), were analyzed. Placental lesions were classified to lesions related to maternal underperfusion, lesions consistent with fetal thrombo-occlusive disease and inflammatory lesions. Findings were compared between patients who delivered ≤ 34 weeks (early-onset FGR) or >34 weeks (late-onset FGR) and controls with AGA neonates. RESULTS The early-onset FGR group (n = 24) had a higher rate of placental vascular lesions related to maternal underperfusion than the late-FGR group (n = 334) (41.7% vs. 8.7%, P < 0.001) and more villous lesions related to maternal underperfusion than the preterm AGA group (n = 68) (70.8% vs. 5.9%, P < 0.001). The late-onset FGR group had more placental villous lesions related to maternal underperfusion (57% vs. 19% P < 0.001) and more lesions consistent with fetal thrombo-occlusive disease (26.3% vs. 8.5%, P < 0.001) than the term AGA group (n = 153). CONCLUSION Early- and late-onset FGR have different placental pathology compared with AGA controls, suggesting that a combination of fetal and maternal vascular compromise is more dominant in the late-onset FGR, rather than more severe maternal vascular compromise in early-onset FGR.

Is immunosuppression therapy in renal allograft recipients teratogenic? A single‐center experience

The aim of the study was to determine whether immunosuppressive agents used in renal allograft recipients are teratogenic or otherwise associated with pregnancy outcome. The study population consisted of 38 renal allograft recipients treated with combinations of prednisone, azathioprine, cyclosporin A, and tacrolimus attending our Hypertension in Pregnancy Clinic. The 48 live offspring of 73 pregnancies in this group were evaluated for major congenital malformations and mild errors of morphogenesis. Findings were compared with those in 48 offspring of 41 women with primary renal disease not treated with immunosuppressive drugs. Pregnancy outcome parameters were also compared between the study and control groups in the perinatal period and on a long‐term basis (2–7 years after birth). Two major anomalies (4.2%), subcoronal hypospadias and rudimentary thumb, and 10 mild errors of morphogenesis (20.8%) were detected in the study group. These rates did not differ significantly from those in the control group (4.2% and 16.6%, respectively). Pregnancy outcome was worse in the renal transplant patients than in the women with primary renal disease in terms of prematurity (60% vs. 21%, P = 0.001), growth restriction (52% vs. 17%, P = 0.001), and hospitalization in a neonatal intensive care unit (35% vs. 6%, P = 0.01). In conclusion, the similar prevalence of major anomalies and mild errors of morphogenesis in offspring of the renal transplant patients and the women with primary renal disease suggests that immunosuppressive therapy is not a teratogenic factor. It may, however, be associated with worse pregnancy outcome.

Pregnancy outcome in patients with insulin dependent diabetes mellitus and diabetic nephropathy treated with ACE inhibitors before pregnancy.

The preconception and intrapregnancy parameters that are relevant to outcome in women with insulin dependent diabetes mellitus (IDDM) and diabetic nephropathy remain controversial. We analyzed the types and frequencies of maternal and neonatal complications in 24 IDDM patients with diabetic nephropathy (24 pregnancies), all with preserved to mildly impaired renal function. All patients received treatment with captopril for at least six months prior to planned pregnancy and were maintained under strict glycemic control from at least three months before pregnancy to delivery. A successful pregnancy outcome (live, healthy infant without severe handicaps two years after delivery) was observed in 87.5% of the patients. Preexisting hypertension was the only parameter found to be significantly predictive of an unsuccessful outcome (p = 0.0004). We conclude that in patients with IDDM complicated by diabetic nephropathy, pre-pregnancy captopril treatment combined with strict glycemic control offers a prolonged protective effect against possible renal deterioration and probably improves pregnancy outcome.

Brachial plexus injury and obstetrical risk factors

Objective: To determine whether known historical risk factors of brachial plexus injury differ between affected neonates and healthy controls. Methods: The files of all 62 children with Erbs palsy who were diagnosed after birth were reviewed. The control group consisted of 124 randomly selected uninjured infants born within the same period. Results: Compared with the control group, the mothers of the neonates with brachial plexus injury were found to be significantly older (32.1±5.2 years vs. 28.9±5.8 years, P=0.01), and had a significantly higher incidence of diabetic pregnancy (69% vs. 14.5%, P=0.001); the infants had a significantly higher mean birth weight (3846±576 g vs. 3220±582 g, P=0.0001) and higher incidence of birth weight ≥4000 g (27% vs. 4.8%, P=0.0001). Two of the infants in the study group (3.2%) were born by elective cesarean section. Conclusions: Brachial plexus injury is associated with several non‐predictable or preventable risk factors.