Michael Shenhav

Uterine rupture at 33 weeks' gestation subsequent to hysteroscopic uterine perforation****

A 40-year-old woman underwent operative hysteroscopy for suspected submucosal myoma, during which the uterine fundus was perforated. At laparotomy the perforation site was sutured. In a subsequent pregnancy she had a sudden onset of abdominal pain. Laparotomy revealed a uterine rupture with a partially protruding placenta. A healthy newborn was delivered by a low-segment cesarean section.

Ex vivo expansion of megakaryocyte progenitors from cryopreserved umbilical cord blood. A potential source of megakaryocytes for transplantation.

OBJECTIVE Umbilical cord blood (CB) provides an alternative source of hematopoietic progenitor cells for transplantation; however, prolonged thrombocytopenia remains a major obstacle due to the low numbers of megakaryocyte progenitor (Mk-prog) cells and their subsequent delayed engraftment. In this study, we improved techniques for enrichment, cryopreservation, and ex vivo expansion of Mk-prog cells from CB. MATERIALS AND METHODS CB mononuclear cells (MNC) were isolated and Mk-prog enriched by sedimentation on gelatin followed by centrifugation with Ficoll-Hypaque and cryopreserved. The capacity of MNC to produce Mk-prog cells, assessment of CD34(+) and Mk-prog expansion in liquid culture, and analysis of the cell populations by flow cytometry were studied in cryopreserved separated CB and compared to whole CB and freshly separated samples. RESULTS Excellent viability of greater than 85% was maintained after cryopreservation of separated CB. The number of colony-forming Mk-prog, myeloid, and erythroid progenitor cells did not decrease with cryopreservation. Flow cytometric analysis of cryopreserved cells revealed significant removal of the residual red blood cells while maintaining complete recovery of CD34(+), CD41(+) (Mk), myeloid, and T and B cells compared to noncryopreserved CB cells. There was no difference in the ability of separated cryopreserved MNC CB cells to be expanded in short-term liquid cultures. CONCLUSIONS The conditions defined here for cryopreservation of gelatin/Ficoll-Hypaque separated CB, followed by ex vivo expansion of MNC, allowed complete recovery of proliferating CD41(+), CD34(+), Mk-prog cells, and other hematopoietic progenitors. Mk-prog cell expansion just before the scheduled transplantation is easily applicable by this technically simple and economical procedure that requires only an aliquot of red cell cell-depleted MNC to be separated from the CB unit before cryopreservation.

Pregnancy associated with pemphigus.

Case report A 24 year old healthy, Ashkenazi Jewish woman complained of intermittent vulval and left axillary lesions for two years. The lesions included vegetation, erosion and pustules covered with crusts. Vulva1 biopsy demonstrated hyperkeratosis, parakeratosis, suprabasal cleft formation, acantholysis, papillomatosis, and eosinophilic infiltration of the dermis and epidermis. Immunofluorescence showed precipitation of immunoglobulin-G (IgG) and C, in the intercellular spaces of the epidermis. Electron microscopy demonstrated destruction of desmosomes. Based on these findings, pemphigus vegetans was diagnosed. Serum indirect immunofluorescence was negative. Histocompatibility antigens (HLA) typing demonstrated A-1 1, A-28, B-14, B-35, CW4, DR1, DRW1, and BW6 alleles. Steroid treatment with 80 mg fluorcortolone (Ultralan, Schering AG/Berlin) was started, and later azathioprine (100 mg/day) was added, in addition to local treatment with wet dressings and antibiotics. Gradual healing was accompanied by the development of hyperkeratosis and fissure formation in the vulval skin. Two years later, during one of her remissions, she conceived. The pregnancy was uneventful with a vaginal delivery at term of a healthy newborn. In subsequent years she suffered from intermittent flare-ups of the disease that were restricted to the vulva. She was treated with steroids during the flare-ups, but later tried homeopathy. During her second pregnancy there was a severe exacerbation of the disease, and at 26 weeks of pregnancy she was admitted to hospital. On admission, bullae and crustae covered an extensive part of her skin and mucous membranes. The labia majora were covered with erosions, with no vegetations or pustules. Skin biopsy showed typical pemphigus vulgaris changes with acantolysis, suprabasal cleft formation, and direct immunofluorescence demonstrated IgG autoantibodies within the intercellular spaces of the epidermis. There was no eosinophyllic infiltration in the dermis or epidermis. Indirect immunofluorescence demonstrated a titre of 1 : 80 serum IgG autoantibodies against the intercellular space of the epidermis. Based on these findings, pemphigus vulgaris was

Intrauterine irrigation with prostaglandin F2‐α for management of severe postpartum hemorrhage

BACKGROUND Severe postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. The use of prostaglandin F2-alpha to control severe postpartum hemorrhage may avert surgery for the control of bleeding. METHODS After ruling out the possibility of genital tract injuries, 18 patients with severe postpartum hemorrhage caused by uterine atony were enrolled in the study. None of the patients responded to treatment with oxytocin, methylergonovine, or uterine massage. A Foley catheter was introduced into the uterine cavity and the balloon was inflated with 5 ml sterile saline solution. The catheter was connected to an infusion line of 500 ml saline solution containing 20 mg prostaglandin F2-alpha. The solution was infused at a rate of 3-4 ml/minute for the first 10 min, and then reduced to 1 ml/minute for a period of 12 24 hours. RESULTS In 17 patients (94.4%) bleeding ceased within several minutes of initiation of intrauterine prostaglandin F2-alpha infusion, the uterus was firmly contracted and uterine bleeding did not recur. In one patient with placenta increta bleeding continued and hysterectomy was performed. None of the patients had any side effects. CONCLUSIONS Intrauterine irrigation with low concentrations of prostaglandin F2-alpha is a simple, rapid and effective treatment for severe postpartum hemorrhage and facilitates constant and continuous hemostasis. Moreover, the minute dosage used eludes potentially complicating side effects.

Can Labor with Breech Presentation Be Induced

Our objective was to evaluate the efficacy and safety of labor induction in women with a breech presentation, and an unripe cervix. We conducted a retrospective, matched-paired study on patients with breech presentation and an unripe cervix (n = 23), who underwent induction of labor using extra-amniotic saline instillation. The women were compared to three matched control groups: 46 women with vertex presentation and an unripe cervix, whose labor was induced by the same method, 23 with breech presentation who underwent a vaginal trial of labor, and 23 women with breech presentation who underwent a cesarean section without a trial of labor. In the study group, 12 women (52.2%) delivered vaginally. Rates of Apgar score, birth trauma, and maternal morbidity were similar in all groups. Induction of labor in patients with a breech presentation and an unripe cervix may be attempted in selected cases as it seems to be efficacious (vaginal delivery rate of 52.2%) and safe for both fetus and mother.

The need for a new outlook on labor monitoring

Fetal heart rate monitors, including the newer pulse-oximetry and STAN monitors, are designed to detect fetal distress that affects less than 1% of women in labor. Non-progressive labor is a much more common disorder than fetal distress, with approximately 50% of women in labor requiring oxytocin. Current technology assessing labor progress is subjective and inaccurate. There is a need for objective and accurate technology to measure labor progress and the effect it may have on managing labor and, specifically, non-progressive labor.

Distribution of Third-Stage Length and Risk Factors for Its Prolongation.

Introduction The aim of our study was to demonstrate the distribution of an uncomplicated third stage and to determine the optimal time for manual intervention. Risk factors for a prolonged third stage were studied. Materials and Methods Computerized data of all vaginal deliveries at our L&D unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation were extracted for further analysis. Cases necessitating manual removal of the placenta due to immediate postpartum hemorrhage (PPH) were also excluded. Patient demographics, obstetrical history, course of delivery, and delivery outcome were assessed, and risk factors for a prolonged third stage were analyzed. Results There were 31,226 vaginal deliveries during the study period. Of these, 25,160 deliveries met inclusion criteria. The median third-stage length was 12 minutes. Within 30 minutes 97% of the placentas separated spontaneously. Independent risk factors for a third stage > 30 minutes included older maternal age, primiparity, history of abortions, twin gestation, and intrapartum fever. Conclusion The average time for third stage is < 15 minutes with 97% occurring by 30 minutes and 100% by 60 minutes. In the absence of PPH, it is clinically prudent to perform manual removal after 30 minutes.