Lancet M

The growth discordant twin.

The study of growth discordancy in twin gestation has gathered great momentum in recent years. Divergent intertwin growth is believed to be a direct result of the process of twinning and of the inability of the uterine environment to provide for the increased demand of multiple fetuses. The smaller twin faces increased risk of perinatal mortality and morbidity as well as reduced physical and mental development in later life. The advent of ultrasonography enabled a fairly accurate prediction of growth disparity. Although extensive investigative efforts have clarified many questions regarding divergent twin growth, the question how to manage such pregnancies remains to be answered. The present article is a review of the literature concerning the clinical aspects of growth discordant twins.

Prevention of premature labor by 17α-hydroxyprogesterone caproate

Abstract Eighty pregnant women at high risk of giving birth prematurely were divided randomly into two groups. Treatment with either 17α-hydroxyprogesterone caproate, 250 mg by intramuscular injection once a week, or a placebo was given in a double-blind fashion. Imminent premature labor occurred in 29.0% of the treated group and in 59.4% of the control group (p

Ovarian carcinoma during pregnancy: A study of 23 cases in Israel between the years 1960 and 1984

Data from a study on malignant ovarian tumors in pregnancy in Israel are presented. During the 25-year period of the survey, 23 new cases of malignant ovarian tumors during pregnancy were diagnosed, representing an incidence of 0.12/100,000 females over the age of 14; over half of the patients were in their third decade of life at the time of diagnosis of the tumor. Ovarian malignant tumors during pregnancy are more prevalent in Jewish women of European-American origin than in those of Asian-African descent. Borderline carcinomas were found in 35% of our patients; epithelial invasive tumors were found in 30%; the other tumors were dysgerminoma (17%), granulosa cell tumor (13%), and undifferentiated carcinoma (5%). Most of the patients (74%) were diagnosed in stage I. In three cases, ovarian cancer was diagnosed during surgery for tubal pregnancy, and in two during cesarean section at term. In early-stage disease and low-potential-malignancy tumors, surgery can be conservative; thus, 14 of 23 bore a live child. In advanced disease, aggressive surgery, chemotherapy, and/or radiotherapy should be instituted. Factors affecting prognosis were age of patient, histologic type of tumor, and clinical stage of disease. Overall, the survival is much better than that for ovarian tumors in general, because most of the tumors are of low potential malignancy and are diagnosed at an early stage.

Cystadenofibroma of the ovary: A clinicopathologic study of 34 cases and comparison with serous cystadenoma

The clinicopathologic features of 34 cystadenofibromas were analyzed and compared to those of 39 serous cystadenomas. The clinical features of the patients with cystadenofibromas were similar to those of the patients with cystadenoma. Pathologic features showed the following differences: Papillary projections of cystadenofibromas consisted of short, broad, firm structures which were frequently hyalinized. Those of cystadenomas were slender, delicate and friable showing less frequent hyalinization. Epithelial elements in both tumors were similar to those seen in a variety of neoplasms of müllerian derivation. However, while all the cystadenofibromas were histologically unequivocally benign, 6 cystadenomas showed epithelial tufting, 5 mitoses and atypia each, and 3 of these were diagnosed as borderline malignant. Characteristic histologic findings in the cystadenofibromas established beyond doubt their origin from germinal epithelium and underlying stroma, whereas in some of the other ovarian tumors of müllerian derivation, the cellular origin often remains conjectural at best. We concluded that ovarian cystadenofibroma is more common than generally believed and that is of an entirely benign nature, necessitating only conservative surgical therapy. The characteristic pathologic features of this neoplasm justify its separate listing in the group of müllerian ovarian tumors of surface epithelial and ovarian stromal origin.

Adult respiratory distress syndrome complicating ovarian hyperstimulation syndrome

A rare case of OHSS complicated by an ARDS from which the patient recovered after appropriate treatment is presented. Pulmonary capillary leakage induced by prostaglandin release, hypoalbuminemia, and shift of dextran 40 macromolecules to the intraalveolar space is considered the most probable reason for this complication.

Uterine sarcoma in Israel: A study of 104 cases

Data gathered during the first epidemiologic study of sarcoma of the uterus in Israel are presented. In the 7-year period of this survey, 104 new cases of sarcoma of the uterus were diagnosed, representing an incidence of 1.55/100,000 females over the age of 20. Half of the patients were in their fifth and sixth decades of life at the diagnosis of the tumor. Uterine sarcomas were more prevalent in women of European-American origin than in those of Asian-African descent. In 54.9% of the patients the diagnosis was made while the disease was in stage I. A definite correlation between sarcoma of the uterus, diabetes, hypertension, and obesity was not found. The 5-year survival rate in the present survey was 38%. Factors affecting prognosis were the clinical stage of the disease at diagnosis, histologic type, and the method of treatment.

PREDISPOSING FACTORS IN THE FORMATION OF TRUE KNOTS OF THE UMBILICAL CORD-ANALYSIS OF MORPHOMETRIC AND PERINATAL DATA

Fifty‐four umbilical cords with a true knot were analysed and compared to 108 normal cords. True knots were found in 1.22% of births. They occurred at a significantly higher rate in longer cords (P < 0.00001), in male fetuses (P < 0.05) and in multiparous women (P < 0.003). Signs of fetal distress were observed more frequently in female fetuses, especially in those with longer cords. A true knot seems to disrupt the significant correlation (P < 0.007) between cord length and birth weight that we observed in controls. The present study reviews the literature on the subject and suggests a possible mechanism for true knot formation.

Treatment of premature labor contractions with combined ritodrine and indomethacine

The results of combined ritodrine and indomethacine treatment (RI) in premature labor contractions were compared with ritodrine alone (R). One hundred and twenty patients with threatened premature labor in weeks 26–34 were studied. Sixty RI women received 100 mg ritodrine in infusion followed by 60 mg daily orally until 35 weeks and indomethacine 200 mg on the first day of treatment only. The R group included 60 women with identical tocolysis indices, age of pregnancy and anamnestic parameters who received ritodrine only. The mean prolongation index (PI) was 18.2 in the RI group, against 11.5 in the R patients (P < 0.05). The mean prolongation of pregnancy was 5.6 weeks in the first and 3.6 in the control group (P < 0.05). Birthweight and Apgar scores were similar in the two groups. In order to examine the possible early closure of the ductus arteriosus due to the indomethacin therapy, echocardiograms were done on all newborn in the RI group: the pre‐ejection period and right ventricular ejection time ratio was 0.19–0.26 after delivery and 0.17–0.22 1 month later, which excludes pulmonary diastolic hypertension due to premature closure of the duct. The combined RI treatment is more effective that R alone and does not give rise to any complications in the mother or the fetus.

MANAGEMENT OF PUERPERAL SEPARATION OF THE SYMPHYSIS PUBIS

Thirteen post‐partum patients with symphysiolysis were treated by intra‐symphysial injection of a combination of hydrocortisone, chymotrypsin and lidocain. The injection was given once a day and the full treatment consisted of between three to seven injections according to the severity of the symptoms. No other medication was given. Immediate relief was obtained in all cases after the first injection and all symptoms disappeared after the completion of treatment. The average time of hospitalization was 9.8 days. No complications were seen as a result of the treatment and the patients resumed their normal activities after being discharged from hospital. In comparison with other modes of treatment, the intra‐symphysial injection of the above drug combination shortened the time of morbidity and effected complete recovery.

Non-aggressive management of post-date pregnancies

A non-aggressive approach to the management of post-date pregnancies was tested in a clinical trial involving 156 patients who had reached 294 days of amenorrhea and had a pelvic score of 4 or less. Dates had been established with certainty in each case. In half of the patients (the study group) no time limit was imposed on the pregnancy, but the women were checked at frequent intervals for any increase in pelvic score and for changes in any of the following: fetal movement count recorded daily by the mother, an oxytocin challenge test, and amnioscopy. The pregnancy ended either through spontaneous contractions or through surgical induction carried out because of a change in any one of the parameters or an increase above 4 in the pelvic score. In the 78 control patients labor was induced surgically on day 294, even if the pelvic score was low. In the study group, labor started spontaneously in 52 patients; labor was induced in 17 women after they showed an elevated pelvic score, in 7 because of a pathologic parameter and in one because a mild pre-eclampsia developed. There were 7 cesarean sections in the study group compared with 16 in the control group (P less than 0.05). The average duration of labor was 6.7 h in the study group, compared with 9.4 h in the control (P less than 0.01). There was no significant difference between the two groups with regard to meconium staining during labor, pathologic fetal heart rate, or the 5 min Apgar score. In the study group there was one neonatal death as a result of severe congenital heart disease, and in the control group one infant died due to asphyxia. It is concluded that conservative management of prolonged pregnancies, with close supervision, gives better results than routine induction of labor at 42 wk. The importance of the pelvic score as an indication for induction is stressed. A protocol has been developed which can be used in cases of uncertain dates as well.