Mordechai Goldenberg

The use of aspirin to prevent pregnancy-induced hypertension and lower the ratio of thromboxane A2 to prostacyclin in relatively high risk pregnancies

We carried out a prospective, randomized, double-blind, placebo-controlled study to investigate the capacity of aspirin to prevent pregnancy-induced hypertension and to alter prostaglandin metabolism. A total of 791 pregnant women with various risk factors for pre-eclamptic toxemia were screened with use of the rollover test (a comparison of blood pressure before and after the woman rolls from her left side to her back) during week 28 or 29 of gestation. Of 69 women with abnormal results (an increase in blood pressure during the rollover test), 65 entered the study and were treated with a daily dose of either aspirin (100 mg; 34 women) or placebo (31 women) during the third trimester of pregnancy. The number of women in whom pregnancy-induced hypertension developed was significantly lower among the aspirin-treated than among the placebo-treated women (4 [11.8 percent] vs. 11 [35.5 percent]; P = 0.024); the same was true for the incidence of preeclamptic toxemia (1 [2.9 percent] vs 7 [22.6 percent]; P = 0.019). The mean ratio of serum levels of thromboxane A2 to serum levels of prostacyclin metabolites after three weeks of treatment decreased by 34.7 percent in the aspirin-treated group but increased by 51.2 percent in the placebo-treated group. No serious maternal or neonatal side effects of treatment occurred in either group. We conclude that low daily doses of aspirin taken during the third trimester of pregnancy significantly reduce the incidence of pregnancy-induced hypertension and pre-eclamptic toxemia in women at high risk for these disorders, possibly through the correction of an imbalance between levels of thromboxane and prostacyclin.

Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy

A series of 201 cycles of ovarian hyperstimulation syndrome (OHSS) in 154 women were reviewed. Pregnancy occurred in 75 of 201 cycles. Twelve pregnant women (16%) presented with torsion of hyperstimulated ovary, but only 3 out of 126 patients (2.3%) who did not conceive had torsion. Because diagnosis of adnexal torsion is usually uncertain and surgical intervention is likely to be delayed, these infertile women risk losing their ovaries. The clinical picture of torsion of adnexa in patients with OHSS is presented here. The combination of ovarian enlargement, abdominal pain, nausea, progressive leukocytosis, and anemias might indicate torsion of adnexa. Although during operation the adnexa appears dark, hemorrhagic and ischemic, we suggest that it can be saved by simply unwinding it. In 11 such cases intraoperative unwinding of the adnexa was performed, and in 8 patients it was the only operative procedure. No postoperative complications were noted and in all the cases the ovaries were proven functional by ultrasonography. We concluded that torsion of hyperstimulated adnexa in patients who conceived after gonadotropin therapy, is a special entity that requires more attention to achieve early diagnosis. Nevertheless even with delayed diagnosis, the ovary can still be saved.

Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy

OBJECTIVE To compare the outcome of pregnancy after operative laparoscopy or laparotomy for the management of adnexal pathology during pregnancy. DESIGN Retrospective comparative study. SETTING University tertiary care referral center for endoscopic surgery. PATIENT(S) Eighty-eight pregnant women who underwent 93 operations for suspected adnexal pathology at our institute. Laparoscopy was performed during the first trimester in 39 patients. The remaining 54 patients underwent laparotomy, 25 during the first trimester and 29 during the second trimester. INTERVENTION(S) Laparoscopy or laparotomy for the management of adnexal masses during pregnancy. MAIN OUTCOME MEASURE(S) Operative and postoperative maternal complications, miscarriage, congenital malformations, and newborn long-term outcome. RESULT(S) No operative or postoperative maternal complications occurred in the pregnant women who underwent laparoscopic surgery. In this group of 39 women, 5 women had a first-trimester miscarriage and 2 newborns had congenital malformations (hypospadias and cleft lip and palate). Two miscarriages occurred in the first-trimester laparotomy group, and 1 congenital malformation (transposition of the great vessels) was diagnosed in the second-trimester laparotomy group. CONCLUSION(S) Laparoscopic gynecologic surgery appears to be safe during pregnancy, although prospective controlled studies and national registries encompassing larger numbers of cases are needed.

Pregnancy Outcome after Laparoscopy or Laparotomy in Pregnancy

STUDY OBJECTIVE To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS Three hundred eighty-nine pregnant women. INTERVENTION Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Outcome of hysteroscopic resection of submucous myomas for infertility

OBJECTIVE To examine the reproductive outcome after operative hysteroscopic resection of submucous myomas in women for whom no other infertility factor was identified. DESIGN Fifteen infertile women with submucous myomas underwent an intensive workup to exclude other causes of infertility. Operative hysteroscopy for resection of the submucous myomas was performed using a rigid 26 French resectoscope (Karl Storz GmbH & Co., Tuttlingen, Germany). SETTING Academic tertiary referral center. RESULTS The mean +/- SD duration of the procedure was 25.5 +/- 5.6 minutes. No operative or postoperative complications occurred and all patients were discharged within 6 hours. The follow-up period was 12.0 +/- 4.2 months (mean +/- SD). Seven women conceived (pregnancy rate of 47%) and six of them subsequently delivered at term. CONCLUSION The results of this study indicate that operative hysteroscopy achieved a pregnancy rate comparable to myomectomy via laparotomy. These results suggest that operative hysteroscopy is the procedure of choice for the resection of submucous myomas in infertile women.

Laparoscopic detorsion allows sparing of the twisted ischemic adnexa.

STUDY OBJECTIVE To determine the safety and outcome of laparoscopic detorsion in the management of the twisted ischemic, hemorrhagic adnexa. DESIGN Retrospective chart review and prospective follow-up (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Fifty-eight women with twisted black-bluish ischemic adnexa encountered at laparoscopy. INTERVENTION Laparoscopic detorsion with adnexal sparing. MEASUREMENTS AND MAIN RESULTS All patients had a benign immediate postoperative course. Transient temperature elevation occurred in seven women (12.1%). No signs of pelvic or systemic thromboembolism were detected in any patient. Long-term follow-up included transvaginal ultrasound, which revealed follicular development in the previously twisted adnexa in 54 women; normal macroscopic appearance at incidental subsequent surgery in 9; and in vitro fertilization with retrieval of oocytes from the previously twisted side in 4. CONCLUSION Laparoscopic detorsion of the twisted ischemic, hemorrhagic adnexa is a safe procedure with minimal postoperative morbidity and a potential for the ovary to recuperate fully with preservation of normal function. Laparoscopic adnexa-sparing procedures should be performed in place of traditional salpingo-oophorectomy in women with this disorder who desire future fertility. (J Am Assoc Gynecol Laparosc 6(2):139-143, 1999)

Sonographic and clinical characteristics of struma ovarii.

Our objective was to evaluate the preoperative clinical, laboratory, and sonographic characteristics of struma ovarii in comparison to ovarian dermoid cysts. A retrospective review of gynecologic patients operated on for mature cystic teratoma over a 10 year period identified 12 cases of struma ovarii. These cases, combined with 4 additional cases from an earlier report, were the subject of this study. Results were compared to 32 cases of ovarian dermoid cysts. Ovarian struma ovarii occurred in 12 (4.8%) of 251 cases of ovarian dermoid cysts. Most patients were premenopausal, and the mean lesion diameter was 57.3 mm (range, 30‐95 mm). Struma ovarii occurred more frequently (68.8%) in the right adnexa and was seen with a normal CA‐125 level. Blood flow, assessed by Doppler ultrasonography, was located in the center of the lesion in all cases of struma ovarii. Rare cases were seen with elevated tumor markers and low resistance blood flow. With regard to dermoid cysts, blood flow had a higher resistive index. In addition, no blood flow could be detected from the center of the echoic lesion in dermoid cysts (P < 0.0001). In summary, it is difficult to distinguish between struma ovarii and dermoid cysts on the basis of their sonographic appearance. Nevertheless, Doppler flow may aid in the preoperative diagnosis of struma ovarii. Blood flow signals, detected from the center of the echoic lesion, and low resistance to flow may be more common in struma ovarii.

Complete failure of fertilization in couples with mechanical infertility: implications for subsequent in vitro fertilization cycles

OBJECTIVE To determine whether complete failure of fertilization of oocytes in couples with mechanical infertility during the first IVF cycle indicates a poor prognosis for subsequent IVF cycles. DESIGN A retrospective study of 172 cycles of IVF in 50 couples with mechanical infertility and complete failure of fertilization during their first IVF trial. SETTING In vitro fertilization unit of the Sheba Medical Center. PATIENTS Fifty couples undergoing one to eight cycles of IVF for mechanical infertility. MAIN OUTCOME MEASURE(S) Fertilization rate of retrieved oocytes and pregnancy rate. RESULTS Of the initial 50 couples, 44 underwent additional IVF cycles, and 43 (97.7%) achieved fertilization during the second or third cycle. Twenty-four patients conceived during the study period as a result of IVF. CONCLUSIONS Complete failure of fertilization in couples with mechanical infertility does not necessarily persist during subsequent IVF cycles. Therefore, at least two more IVF cycles should be attempted before reverting to other therapeutic options. Complete failure of fertilization during the first cycle of IVF in couples with mechanical infertility is accompanied by a good prognosis for subsequent cycles.

Accuracy of the Preoperative Diagnosis in 100 Emergency Laparoscopies Performed Due to Acute Abdomen in Nonpregnant Women

STUDY OBJECTIVE To assess the validity of preoperative diagnosis in the emergency room in relation to the surgical diagnosis at laparoscopy. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS One hundred consecutive nonpregnant women who underwent emergency laparoscopy for acute abdomen between 1997 and 1999. Intervention. Emergency diagnostic laparoscopy. MEASUREMENTS AND MAIN RESULTS The preoperative diagnosis was confirmed by laparoscopy in 29 (44%) of 66 cases of ovarian torsion, 9 (82%) of 11 cases of ovarian cyst, and 12 (80%) of 15 cases of bleeding corpus luteum. Unsuspected diagnoses among nonconfirmed cases were ovarian cysts (24), adhesions (5), bleeding corpus luteum (3), degenerative myomas (3), pelvic inflammatory disease (2), and appendicitis (1). The preoperative diagnosis was confirmed by emergency laparoscopy in 56% of all patients. Diagnoses most likely to be predicted accurately were ovarian cysts and bleeding corpora lutea. Ovarian torsion was most difficult to diagnose preoperatively, as it was not confirmed during laparoscopy in over half patients. Ovarian cysts and adhesions were the most common unsuspected findings. CONCLUSION Patients and surgeons alike should be aware of difficulty making accurate preoperative diagnoses of acute gynecologic pathologies in the emergency room. (J Am Assoc Gynecol Laparosc 8(1):92-94, 2001)

Rescue of menotrophin cycles prone to develop ovarian hyperstimulation

Summary. In an attempt to prevent the loss of‘overstimulated cycles’ associated with human menopausal gonadotrophin (hMG)‐induced ovulation, oestradiol levels and ovarian follicular state were monitored in 12 women with‘overstimulated cycles’ after withholding hMG for several days. Human chorionic gonadotrophin (hCG) was administered when oestradiol levels were 1700 pg/ml and the leading follicles between 17 and 22 mm in diameter. During the withholding period follicular growth continued in all patients, while oestradiol levels declined in all but three. These three patients conceived. Ovulation was observed in six additional women. Ovarian hyperstimulation did not occur in any of the 12 patients. We conclude that a rescue of‘overstimulated cycles’ is sometimes possible. Conception seems to depend on a continuing rise of E2 levels and early detection of‘overstimulation’.