Moshe Fejgin

Induction of labor versus expectant management in macrosomia: A randomized study

Objective Macrosomia at term is associated with increased maternal and neonatal morbidity, including a higher rate of cesarean delivery and shoulder dystocia. Induction of labor has been suggested as a means to prevent further weight gain and improve outcome. The aim of this study was to determine whether or not induction of labor in these cases improves maternal and neonatal outcome. Methods Patients at term with an ultrasonic fetal weight estimation of 4000-4500 g were prospectively randomized into two groups: induction of labor (group I) and expectant management (group II). Patients with diabetes, a previous cesarean delivery, or nonvertex presentation were excluded. Outcome variables included mode of delivery, arterial cord pH, presence of shoulder dystocia, brachial plexus injury, clavicular fracture, cephalophematoma, and intraventricular hemorrhage. Results Of 273 patients who were eligible for the study, 134 were randomized to group I and 139 to group II. Parity, gestational age, and fetal weight estimation were similar in the two groups. The neonates of group II patients were significantly heavier (4132.8 ± 347.4 versus 4062.8 ± 306.9 g; P = .024). The rate of cesarean delivery was 19.4% in group I and 21.6% in group II patients (not significant [NS]). Cord pH was similar in both groups. shoulder dystocia was diagnosed in five grup I and six group Ii patients (NS). None developed brachial plexus injury in group Ii patients without documented shoulder dystocia. Mild intraventricular bemorrhage was diagnosed in three of 44 group I and two of 31 group II neonates evaluated (NS). Conclusion In this prospective, randomized study, induction of labor for suspected macrosomia at term did not decrease the rate of cesarean delivery or reduce neonatal morbidity. Ultrasonic estimation of fetal weight between 4000 and 4500 g should not be considered an indication for induciton of labor.

Short telomeres may play a role in placental dysfunction in preeclampsia and intrauterine growth restriction

OBJECTIVE Telomeres shorten and aggregate with cellular senescence and oxidative stress. Telomerase and its catalytic component human telomerase reverse-transcriptase regulate telomere length. The pathogenesis of preeclampsia and intrauterine growth restriction involves hypoxic stress. We aimed to assess telomere length in trophoblasts from pregnancies with those complications. STUDY DESIGN Placental specimens from 4 groups of patients were studied: severe preeclampsia, intrauterine growth restriction, preeclampsia combined with intrauterine growth restriction, and uncomplicated (control). Telomere length and human telomerase reverse-transcriptase expression were assessed by using quantitative fluorescence-in-situ protocol and immunohistochemistry. RESULTS Telomere length was significantly lower in preeclampsia, intrauterine growth restriction, and preeclampsia plus intrauterine growth restriction placentas. More aggregates were found in preeclampsia, but not in intrauterine growth restriction placentas. Human telomerase reverse-transcriptase was significantly higher in the controls compared with the other groups. CONCLUSION Telomeres are shorter in placentas from preeclampsia and intrauterine growth restriction pregnancies. Increased telomere aggregate formation in preeclampsia but not in intrauterine growth restriction pregnancies, implies different placental stress-related mechanisms in preeclampsia with or without intrauterine growth restriction.

Therapeutic maturation of endometrium in in vitro fertilization and embryo transfer

OBJECTIVE To provide an up-to-date review of studies that have examined the relative role of endometrial development in in vitro fertilization (IVF) and embryo transfer (ET) treatment in relation to the treatment outcome. DATA IDENTIFICATION The most important published studies and personal communications related to this topic have been identified through a computerized bibliographical search (MEDLINE). STUDY SELECTION Studies that have evaluated the endometrial maturation in IVF and ET treatment with respect to different treatment protocols of ovarian stimulation. Clinical trials exploring the efficacy of various combinations of hormonal supplementation that aim to improve the endometrial environment and treatment outcome. Publications and personal communications reporting a variety of treatment protocols and drugs utilized for the creation of artificial endometrial cycles in IVF treatment employing donated eggs. RESULTS Ovarian stimulation frequently adversely affects the process of endometrial maturation. Various kinds of hormonal supplementation, used in clomiphene citrate- and/or human menopausal gonadotropin (hMG)-stimulated cycles have not improved treatment outcome. Human chorionic gonadotropin or natural progesterone (P) supplementation administered after controlled ovarian stimulation with gonadotropin-releasing hormone and hMG effectively corrected the luteal phase defect and resulted in an improved conception rate. The endometrium of agonadal women is highly conducive to hormonal manipulation. All estrogen preparations used effectively promoted endometrial growth and proliferation. Natural P is superior to synthetic progestins for induction of receptive secretory endometrium. CONCLUSION The development of adequately receptive endometrium is a major factor determining the outcome of IVF and ET treatment.

Telomeres are shorter in placental trophoblasts of pregnancies complicated with intrauterine growth restriction (IUGR)

OBJECTIVE Telomeres are nucleoprotein structures located at the termini of chromosomes, and protect them from fusion and degradation. Telomeres are progressively shortened with each mitotic cycle and by environmental factors. We hypothesized that antepartum stress can lead to accelerated telomere shortening in placental trophoblasts, and plays a role in intrauterine growth restriction (IUGR). METHODS Placental biopsies were derived from 16 pregnancies complicated with IUGR and from 13 uncomplicated pregnancies. Fluorescence-in-situ protocol was used to determine telomere length. Immunohistochemistry for hTERT was performed to assess telomerase activity. Clinical and histopathological characteristics were collected to ensure that IUGR was secondary to placental insufficiency. Fluorescence-in-situ-hybridization was used to rule out aneuploidy as a reason for shortened telomeres. RESULTS The number and intensity of telomeres staining and telomerase activity were significantly lower in the IUGR placentas. No aneuploidy was detected for the chromosomes checked in the placental biopsies. CONCLUSIONS Telomeres are shorter in trophoblasts of IUGR placentas.

Fetal Urine Production in Normal Twins and in Twins with Acute Polyhydramnios

In twelve twin pregnancies with normal amniotic fluid volume, the urine output of each twin was lower than in fetuses from singleton pregnancies, and the combined urine output of both twins was between the 50th and 95th centile for singletons. In three twin pregnancies at 21–24 weeks of gestation with acute polyhydramnios, presumed to be due to the twin-twin transfusion syndrome, the urine output of the smaller fetus was zero and that of the larger was above the 95th centile for normal singleton pregnancies. These three pregnancies were managed by repeated amniocenteses and rapid drainage of large volumes of amniotic fluid. With advancing gestation, there was a tendency for normalization of urine output in the twins.

Scleroderma in pregnancy.

We conducted a detailed literature search for the rare combination of scleroderma and pregnancy. Ninety-four patients were reported, 14 of whom died during the course of the pregnancy, mainly due to secondary renal and cardiopulmonary involvement. Out of the 95 fetuses, 19 were lost. Thus, when complications arise, the option of prompt termination of the pregnancy should be considered.

Pregnancy with an artificial pacemaker.

Complete heart block in pregnancy is not a common encounter. The first case was reported in 1914 by Nanta and today some 100 cases are documented. Heart block may be congenital or acquired secondary to cardiac surgery, rheumatic heart disease, or infective disorders. Heart block, whether congenital or acquired, rarely creates any special obstetric problems. Today there is an increasing use of cardiac pacemakers in younger people and the first reported obstetric experience with a cardiac pacemaker implanted before pregnancy was by Shouse and Acker. This review will document the course and outcome of all reported pregnancies in women conceiving with an artificial pacemaker, and discuss complications and principles of management. We will also report our experience with a woman suffering from a complete heart block in whom an internal cardiac pacemaker was inserted before pregnancy.

Management of immune thrombocytopenic purpura in pregnancy.

Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and mucocutaneous bleeding. Pregnancy does not increase the incidence of ITP nor does it exacerbate a preexisting disease. Although pregnant women with ITP may experience several maternal and fetal complications, in most cases even with a very low platelet count, there is neither maternal nor fetal morbidity or mortality. Corticosteroids are the first line of therapy in pregnant women; intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D (Rhogam®) and splenectomy during pregnancy have been reported. Antiplatelet IgG antibodies can cross the placenta and can induce fetal thrombocytopenia. In most women there is no indication to assess fetal platelet counts during the pregnancy. The mode of delivery is determined by obstetrical considerations. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that chronic immune thrombocytopenic purpura (ITP) has very little direct effects on mother and fetus, relate that most patients respond to first-line therapy, and explain that it is rare that there is fetal thrombocytopenia even though the IgG antibodies cross the placenta.

Egg donation in an in vitro fertilization program: an alternative approach to cycle synchronization and timing of embryo transfer

A new flexible protocol for the induction of recipient endometrial cycles is presented. For stimulation of endometrial growth, a fixed dose of conjugated estrogens, 3.75 mg/d was employed. The duration of the proliferative phase varied from 9 to 14 days, thus being adjusted to match the length of the follicular phase of the donor. Embryo transfer was performed on the fifth day of progesterone administration. Four term pregnancies resulted from 12 treatment cycles. In the conception cycles, the hormonal support was continued until the luteal placental shift occurred, regardless of gestational age.

Telomere length in Hepatitis C.

Telomeres are nucleoprotein structures located at the termini of chromosomes that protect the chromosomes from fusion and degradation. Hepatocyte cell-cycle turnover may be a primary mechanism of telomere shortening in hepatitis C virus (HCV) infection, inducing fibrosis and cellular senescence. HCV infection has been recognized as potential cause of B-cell lymphoma and hepatocellular carcinoma. The present study sought to assess relative telomere length in leukocytes from patients with chronic HCV infection, patients after eradication of HCV infection (in remission), and healthy controls. A novel method of manual evaluation was applied. Leukocytes derived from 22 patients with chronic HCV infection and age- and sex-matched patients in remission and healthy control subjects were subjected to a fluorescence-in-situ protocol (DAKO) to determine telomere fluorescence intensity and number. The relative, manual, analysis of telomere length was validated against findings on applied spectral imaging (ASI) in a random sample of study and control subjects. Leukocytes from patients with chronic HCV infection had shorter telomeres than leukocytes from patients in remission and healthy controls. On statistical analysis, more cells with low signal intensity on telomere FISH had shorter telomeres whereas more cells with high signal intensity had longer telomeres. The findings were corroborated by the ASI telomere software. Telomere shortening in leukocytes from patients with active HCV infection is probably due to the lower overall telomere level rather than higher cell cycle turnover. Manual evaluation is an accurate and valid method of assessing relative telomere length between patients with chronic HCV infection and healthy subjects.