Menachem Alcalay

Immunoreactive circulating endothelin-1 in normal andhypertensive pregnancies

Summary OBJECTIVE : The purpose of this study was to measure the circulatory levels of endothelin-1 inthe serum of pregnant women with hypertension. STUDY DESIGN : Endothelin-1 levels were measured by means of radioimmunoassay in the serum of 26 pregnant women with hypertension (14 with pregnancy-induced preeclamptic toxemia, 12 with chronic hypertension) and in the serum of 17 control pregnant women and 18 control nonpregnant women. The mean levels in the different groups were subject to statistical analysis with the analysis of variance RESULTS : The mean level among the women with preeclampsia (29.9 ± 13.2 fmol/ml) was significantlyhigher than those of the chronically hypertensive women (16.1 ± 7.3 fmol/ml, p = 0.002) and of the control pregnant women (19.7 ± 9.2 fmol/ml, p = 0.011). The mean level of the control nonpregnant women (26.9 ± 9.3) was significantly higher than that of the control pregnant women ( p = 0.029). Among the patients with preeclampsia there was no correlation between endothelin-1 levels and the mean arterial blood pressure. Six to 10 weeks after delivery the mean levels of 15 studied patients (7 with preeclampsia, 8 with chronic hypertension) were similar to the levels of the nonpregnant control women CONCLUSION : We conclude that increased endothelin-1 production may play a role in the pathogenesisof preeclampsia

The effect of fertility drugs and in vitro methods on the outcome of 106 triplet pregnancies

OBJECTIVEnTo compare the effect of fertility drugs and IVF on the outcome of triplet pregnancies.nnnDESIGNnProspective clinical study.nnnSETTINGnA single university medical center.nnnPATIENTSnOne hundred six consecutive triplet pregnancies treated from 1984 through 1992.nnnMAIN OUTCOME MEASURESnThe frequency of pregnancy loss, livebirths, and antenatal and neonatal complications was compared in spontaneous, clomiphene citrate (CC), menotropins, and IVF triplet pregnancies.nnnRESULTSnEighty-one of the 106 (76.4%) triplet pregnancies progressed beyond 25 weeks, comprising 6 of 7 (85.7%) spontaneous pregnancies, 13 of 16 (81.2%) CC induced, 44 of 56 (78.6%) menotropin induced, and 18 of 27 (66.6%) IVF gestations. There were no significant differences in the stillbirth and neonatal mortality rates according to the mode of conception. The mean gestational ages and the mean birth weights were similar in the four groups. The frequency of premature contractions, premature rupture of membranes, cesarean section, and neonatal complications were similar in the ovulation induction and IVF pregnancies.nnnCONCLUSIONnTriplet pregnancies after ovulation induction and IVF have a similar outcome.

Paradoxical pharmacodynamic effect of atropine on parasympathetic control: A study by spectral analysis of heart rate fluctuations

The power spectrum of instantaneous heart rate fluctuations was used to determine the optimal doses of atropine that induce a maximal vagolytic or vagomimetic effect. In a crossover placebo controlled study, eight volunteers received increasing bolus doses of intravenous atropine (0.1 to 2.3 mg per subject) or placebo, and frequency bands of the power spectrum were integrated. During atropine administration a significant bimodal dose dependence was observed for the respiratory peak (0.2 to 0.4 Hz, p; = 0.0006), the midfrequency band (0.09 to 0.15 Hz, p = 0.0035), and mean heart rate (p < 0.0001). Low doses (<0.4 mg per subject) increased the respiratory and midfrequency band power, with maximal response at 0.2 mg per subject. Larger doses of atropine, 0.5 to 2.3 mg per subject, markedly reduced the power in all frequency bands in a dose‐dependent way. The corresponding changes in mean heart rate were simultaneous, but in the opposite direction. We suggest that the respiratory peak of the power spectrum can be used to optimize drug effects on cardiac parasympathetic control.

Prelabour rupture of membranes at term: early induction of labour versus expectant management

OBJECTIVESnTo compare expectant management with early induction of labour in pregnant patients with prelabour rupture of membranes at term and unfavourable cervix.nnnSTUDY DESIGNnA prospective, randomised study of 154 women with prelabour rupture of membranes at term of whom 80 had been managed expectantly, and 74 had undergone oxytocin induction at a rate of 2.5 mU/min. Digital examination was not performed before oxytocin infusion, and the first was delayed until 4 h (nulliparae), or 2 h (multiparae) of regular uterine contractions.nnnRESULTSnThe mean period from rupture of membranes to delivery was significantly shorter in the induction group. The mean duration of labour was significantly shorter in the expectant group. Operative vaginal deliveries were more common in the induction group, and fetal distress was the most common cause of operative vaginal deliveries. The caesarean rates were low and similar in both groups. Maternal and neonatal infectious morbidity was similar and no difference was found in the length of hospitalisation.nnnCONCLUSIONSnExpectant management in patients with ruptured membranes at term is safe and reduces the frequency of operative vaginal deliveries.

Modulation of the dose-dependent effects of atropine by low-dose pyridostigmine: quantification by spectral analysis of heart rate fluctuations in healthy human beings.

The interaction between a low-dose cholinesterase inhibitor, pyridostigmine (PYR), and atropine was investigated by spectral analysis of heart rate fluctuations in eight healthy humans. Each subject was given increasing boluses of IV atropine during treatment with PYR (30 mg.3/day) or placebo. PYR attenuated the bimodal dose-dependent changes in the respiratory peak (which respresents the parasympathetic control) in response to atropine. We suggest that spectral analysis can be used for quantifying the complex dose-dependent cholinergic agonist-antagonist interactions, and may help to disclose an asymptomatic low-dose intoxication with acetylcholinesterase inhibitors.

Pharmacological modulation of vagal cardiac control measured by heart rate power spectrum: A possible bioequivalent probe

The autonomic cardiac control was studied as a sensitive parameter of anticholinergic treatment in humans, using heart-rate (HR) power spectrum. A cross-over placebo controlled study was performed in 8 young volunteers who received increasing bolusdoses of IV atropine (from 1.3 micrograms/kg to 29.9 micrograms/kg) or placebo. Computing the HR power spectrum and integrating over specific frequency bands, we focused in particular on the respiratory frequency band (usually between 0.2-0.4 Hz) which is purely of vagal mediation. At small atropine doses (less than 5.2 micrograms/kg), the respiratory peak increased, relative to baseline, with maximal response at 2.6 micrograms/kg (from 1.0 to 1.9 +/- 0.9). Larger doses of atropine (greater than or equal to 6.5 micrograms/kg) reduced the power of the respiratory peak, by a few orders of magnitude, in a dose-dependent way. Corresponding changes were observed in mean HR but in the opposite direction i.e., a maximal bradycardia at 2.6 micrograms/kg and a nearly two fold increase in mean HR at 29.9 micrograms/kg. We conclude that atropine has a bimodal dose-dependent effect on parasympathetic cardiac control. Since the use of HR spectral analysis has been demonstrated in various animal species, we suggest that it can be used as a sensitive noninvasive probe for animal to man transformation studies.

Immunoreactive Endothelins in Human Follicular Fluid

Endothelin levels were measured by means of [125I]endothelin-1,2,3 radioimmunoassay in the follicular fluids of 22 mature ovarian follicles of 11 patients, obtained during ovum pickup. In all but 1 of the follicles, endothelin levels were detectable and ranged between 0.2 and 3.6 pg/ml (mean 1.47 +/- 0.99). In this preliminary study, no correlation was found between follicular endothelin levels and oocyte fertilization or the hormonal ovarian response during the follicular phase.

OC20.04: The effect of a repeat delivery on long‐term outcome in women with obstetric anal sphincter injury (OASIS): a prospective longitudinal ultrasound study

Results: Overall, 248 women were included in the study. Among these, 141 (56.9%) had spontaneous vaginal birth, while 43 (17.3 %) had instrumental delivery and 64 (25.8%) underwent CS. In comparison with the Caesarean section group, women with vaginal delivery had comparable values of APD at rest (5.13 ± 0.74 cm vs. 5.11 ± 0.63 cm, P = 0.818), under pelvic floor muscle contraction (4.18 ± 0.60 cm vs. 4.11 ± 0.56 cm, P = 0.384), and under Valsalva’s manoeuvre before and after visual feedback (5.54 ± 1.10 cm vs. 5.50 ± 0.87 cm, P = 0.814 and 5.74 ± 1.21 cm vs. 5.74 ± 1.02 cm, P = 0.946, respectively). Similar results were obtained when comparing women with operative delivery (Vacuum or Caesarean) with women with spontaneous vaginal delivery. Conclusions: In nulliparous women at term, dynamic pelvic floor dimensions before the onset of labour do not seem to correlate with the mode of delivery.

Mesh erosion into bladder after transobturator prolapse repair

We present three cases of mesh erosion into the bladder revealed from 5 to 36xa0months after cystocele repairs with Perigee® and Prolift®, respectively. The initial procedures were in two of the cases complicated by perforation of the bladder during the dissection. We describe different ways of treating this serious complication. Although these cases are anecdotal, it might be prudent not to proceed with the mesh procedure in cases of accidental opening of the bladder during the dissection.

OP24.01: A prolonged second stage of labor may be a predisposing factor for levator ani injury in women with 3rd and 4th degree perineal tears

transvaginal sonography. Evacuation of uterus was performed based on vaginal bleeding, lower abdominal pain and/or sonographic findings of hyperechoic material or endometrial thickness more than 8 mm. Maternal age, gestational age, clinical signs and symptoms, sonographic findings were recorded. Correlation of clinical and sonographic findings with histopathologic reports was made and the sensitivity and specificity of vaginal bleeding, abdominal pain and sonographic appearance of endometrium for detecting products of conception were assessed. Results: Histopathologic analysis confirmed the presence of chorionic villi in 55 cases (60%) and decidua in 36 women. Vaginal bleeding was more frequent in women with RPOC (P < 0.001), whilst lower abdominal pain was more frequent symptom in those with decidua (P = 0.019). The ultrasound finding of hyperechoic material had sensitivity of 78%, specificity of 100% and positive and negative predictive value of 100%. Vaginal bleeding as predictor of RPOC had sensitivity of 93%, specificity, positive and negative predictive value of 50%, 74% and 82%. Combination of hyperechoic material and vaginal bleeding increased sensitivity to 98% and negative predictive value to 95%. There was no significant difference in endometrial thickness between two groups. Conclusions: Ultrasound finding of hyperechoic material is the best predictor for the diagnosing RPOC. In the absence of hyperechoic material and vaginal bleeding, RPOC are extremely unlikely.