Oded Raban

A comparison between electrical uterine monitor, tocodynamometer and intra uterine pressure catheter for uterine activity in labor

Abstract Objective: We aimed to evaluate the performance of a non-invasive EMG electrical uterine monitor (EUM) versus tocodynamometry (TOCO) by comparing both to internal uterine pressure catheter (IUPC). Study design: Prospective observational trial. Uterine activity was recorded continuously and simultaneously, in women during active term labor, with TOCO, EUM and IUPC. Uterine activity tracings were analyzed by three blinded physicians. Results: Overall, 385 tracings from 43 women were analyzed. A similar rate of interpretable tracings between physicians was demonstrated for EUM (87%; 95% CI 80.9–92.7%) and IUPC (94.8%; 95% CI 83.4–96.3%), with a significantly lower rate for TOCO (67.5%; 95% CI 59.4–76.8%, p < 0.001). There is a significant difference in the contraction frequency for EUM versus IUPC (0.77 ± 2.3) compared to TOCO versus IUPC (−3.34 ± 4.97). There is a high variability between the timing of TOCO contractions as compared to IUPC (4.74 ± 10.03 seconds), while a gap of 8.46 ± 4.24 seconds was detected for EUM. The sensitivity, positive predictive value and false positive rate for individual contraction identification by TOCO and EUM are 54.0%, 84.4%, 15.6% and 94.2%, 87.6%, 12.4%, respectively. Conclusion: EUM is efficient as IUPC for uterine activity assessment and both techniques are superior in comparison to external tocodynamometry. Our results support the use of non-invasive EMG technology to monitor uterine activity.

Obstetrical outcome in women with self-prepared birth plan

Objective: To determine whether introducing a pre-prepared birth plan upon labor admission has an impact on obstetrical outcome.Methods: A retrospective study of all women who prepared an ante-partum birth plan, from 2007–2010. Outcome was compared with a control group consisting of women without a birth plan matched by age, parity and gestational week in a 3:1 ratio. Results: 154 women were compared to a matched control group of 462 women. Women preparing a birth plan, were less likely to undergo an intra partum cesarean section (11.7% vs. 20.3%, p = 0.016). First and second degree perineal tears occurred more frequently in women preparing a birth plan (72.1% vs. 25.5%, p < 0.001). The utilization of birth plan was also associated with a higher rate of epidural administration (81.2% vs. 68.8%, p = 0.004) and a lower rate of intravenous analgesics use (1.3% vs. 10.2%, p < 0.001). Conclusion:Women presenting with a birth plan, compared to an age-, parity- and gestational week- matched control group are less likely to undergo a cesarean section, more likely to have first and second degree perineal tears and more likely to use an epidural. The paucity of data and the mis-concepts of medical staff suggest that larger prospective studies are needed.

Precision and accuracy of noninvasive hemoglobin measurements during pregnancy

Introduction: The NBM-200 is a novel device allowing noninvasive hemoglobin measurement. The system is based on occlusion spectroscopy technology in the red/near-infrared range. At the core of this technology is the production of a new bio-physical signal, resulting from temporarily occluding the blood flow in the measurement site. The measurement is performed using an annular, multi-wavelength probe with pneumatically operated cuffs, with which an over-systolic pressure is produced at the finger base. Methods: OrSense NBM200 was tested during the years 2011–2012 in a population of pregnant women. Upon receipt of informed consent, two noninvasive Hemoglobin measurements were performed on the right and left thumbs of each subject. Reference hemoglobin values were obtained from venous blood samples drawn at the same time of the noninvasive measurement. Blood Hemoglobin was evaluated on an LH-750 Beckman Coulter counter, acting as the reference “gold standard.” Results: A total of 126 data pairs were obtained in the trial from 63 women. The mean error (bias) of the NBM200 readings compared to the reference was 0.1 g/dL and the accuracy, defined as the standard deviation of error, was 0.86 g/dL. A Bland–Altman comparison of the NBM200 versus the Coulter device shows that the 95% limits of agreement is −1.59 to 1.79 g/dL. Conclusion: Our study demonstrates a good correlation between reference blood hemoglobin and noninvasive hemoglobin measurements. The NBM-200 can accurately assess hemoglobin levels, in a noninvasive fashion, during pregnancy.

The significance of paracardiac lymph-node enlargement in patients with newly diagnosed stage IIIC ovarian cancer.

OBJECTIVE Extra-abdominal metastases in epithelial ovarian cancer (EOC) are relatively rare. Interpreting computed tomography (CT) scans, during initial work-up, little attention is focused on enlargement of paracardiac lymph nodes (PCLN) and their significance is not clear. We aimed to examine whether the presence of PCLN during initial diagnosis of EOC influences prognosis. METHODS A retrospective study comparing patients with stage 3 EOC who were diagnosed with PCLN on CT scan during initial evaluation to stage 3C patients without PCLN. Scans were reviewed by a single radiologist for peritoneal involvement, distal metastases and presence of PCLN. Disease status at diagnosis, results of surgery, chemotherapy and response, disease-free interval (DFI) and overall survival (OS) were recorded. RESULTS Thirty one patients with stage 3C EOC with PCLN on initial CT scan were included and compared with 41 controls. There was no significant difference between groups in abdominal optimal cytoreduction rate. Lower rates of complete response (CR) to initial treatment were detected in the study group (45.2% vs. 78.0%, p=.004). In survival analysis, the DFI for patients with PCLN was shorter (median 9.0 vs. 24.0 months, p=.0097) and overall survival was shorter (median 31.7 vs. 61.3 months, p=.001). Multivariate analysis showed that PCLN was significantly associated with a lower rate of CR, a shorter DFI and a shorter OS. CONCLUSION The presence of enlarged PCLN at presentation appears to be associated with poor prognosis in stage 3C EOC. Further attention should be given to detection and follow-up of such findings when considering treatment.

Effect of Prostaglandin E2 on Myometrial Electrical Activity in Women Undergoing Induction of Labor

OBJECTIVE To investigate the effect of prostaglandin E2 (PGE2) on electrical uterine activity using a novel uterine muscle electromyography device in patients undergoing induction of labor. STUDY DESIGN Electrical uterine myography (EUM) was prospectively measured using a noninvasive nine channels recorder in 31 women undergoing induction of labor with vaginal PGE2 tablets. Women were monitored before and up to 12 hours after vaginal PGE2 application. EUM index was defined as mean electrical activity of the uterine muscle over a period of 10 minutes measured in units of microjoule (µJ, µWs). RESULTS The EUM index was not increased significantly during the first 2 hours following PGE2 application (overall increase of 5.3 ± 60.1%, p = 0.7). Peak EUM activity was observed during 2 to 8 hours following PGE2 application, which represented a statistically significant increase compared with the EUM index before PGE2 application (3.3 ± 0.5 µJ vs. 2.5 ± 0.95 µJ, p = 0.01), and with the EUM index 0 to 2 hours following PGE2 application (3.3 ± 0.5 µJ vs. 2.3 ± 0.9 µJ, p = 0.004). CONCLUSION The data suggests that in women undergoing labor induction with PGE2, uterine activity peaks 2 to 8 hours following PGE2 application. This information may provide more insight into the mechanism of PGE2 action.

Robotic blue-dye sentinel lymph node detection for endometrial cancer – Factors predicting successful mapping

OBJECTIVE Sentinel lymph node (SLN) mapping has emerged as a viable option for the treatment of patients with endometrial cancer. We report our initial experience with SLN mapping algorithm, and examine the factors predicting successful SLN mapping. METHODS We analyzed all data recorded in our institute on robotic blue-dye SLN detection mapping from the time it was first introduced to our department in January 2012-December 2014. Data included patient demographics, SLN allocation, operating room times, and pathology results. RESULTS During the study period, 74 patients had robotic assisted surgery for endometrial cancer with attempted SLN mapping. SLN was found overall in 46 patients (62.1%). At first, SLN was detected in only 50% of cases, but after performing 30 cases, detection rates rose to 84.6% (OR = 3.34, CI 1.28-8.71; p = 0.003). Univariate analysis showed a higher detection rate with methylene blue than patent blue dye, 74.3% vs. 52.3% (OR = 2.744, 95% CI 1.026-7.344; p = 0.042). In multivariate analysis, high body mass index (BMI) was associated with failed mapping (OR = 0.899; 95% CI 0.808-1.00), as was the presence of lymph-vascular space invasion (LVSI) (OR = 0.126; 95% CI 0.24-0.658) and few cases per surgeon (OR = 1.083, 95% CI 1.032-1.118). Factors related to uterine pathology itself, including tumor histology, grade, method of diagnosis, the presence of an endometrial polyp, and lower uterine segment involvement were not found to be associated with successful mapping. CONCLUSIONS Surgeon experience, BMI and LVSI may affect the success rate of SLN mapping for endometrial cancer. These factors should be investigated further in future studies.

The association between young maternal age and pregnancy outcome

Abstract Objective: We aimed to determine the association between young maternal age at delivery with adverse pregnancy outcome in a single, tertiary, university-affiliated medical center. Methods: A retrospective, cohort, matched control study using the first percentile distribution of maternal age at delivery (21 years old, n = 461) as the study group, and four control groups by maternal age matched by parity in a 2:1 ratio (22–25, 26–30, 31–35 and 36–40 years; n = 922 each). Results: Women aged ≤21 years were found to have lower rates of chronic hypertension [compared with women aged 36–40 years old (0.0% versus 1.3%, p < 0.05)], lower rates of gestational diabetes mellitus (GDM) (1.3% versus 3.7%, p = 0.007), higher rates of perineal lacerations [compared with women aged 31–35 and 36–40 years old, 41% versus 31.8% and 31.1%, respectively, p < 0.01)], higher rates of postpartum hemorrhage (4.6% versus 1.5%, p < 0.0001) and higher rates of low 5-min Apgar score (2.2% versus 0.8%, p = 0.004). No significant differences were found in terms gestational age at delivery, birth weight, fetal sex, intrapartum or antepartum mortality. Conclusion: Young maternal age at delivery is associated with increased risk of short-term complications after delivery.

Is there an association between subclinical hypothyroidism and preterm uterine contractions? A prospective observational study*

Abstract Objective: To investigate the association between subclinical hypothyroidism and preterm contractions. Methods: Prospective observational study among women at 23 + 0/7 and 34 + 6/7 weeks of gestation, with no known thyroid function abnormality, and preterm uterine contractions (PTC). All patients underwent laboratory evaluation of Thyroid Stimulating Hormone (TSH) and Free Thyroxin (FT4). Patients with and without PTC were compared. Results: No association was found between PTC and subclinical hypothyroidism. Rate of spontaneous preterm delivery (PTD) was comparable between women with abnormal and normal thyroid function tests. Excluding indicated PTD, patients in the study group had a higher rate of spontaneous PTD (24.7% versus 9.6%, p = 0.03). Patients with past PTD and preterm contractions had higher rates of hypothyroxinemia compared with patients without past PTD (54.6% versus 19.0% and 31.2%, p = 0.001), and patients with past PTD (regardless of the presence or absence of PTC) had higher rate of subclinical hypothyroidism compared with patients with PTC and without PTD (59.1% and 66.7% versus 31.6%, p = 0.017). Conclusions: No association was found between PTC and subclinical hypothyroidism in the entire cohort, except for patients with preterm contractions and a history of past PTD. This specific group of patients might benefit from thyroid function evaluation.

Isolated Fallopian Tube Torsion: A Unique Ultrasound Identity or a Serial Copycat?: Ultrasound Diagnosis of Fallopian Tube Torsion

To report the preoperative ultrasound (US) signs of isolated fallopian tube torsion in surgically verified cases and to estimate whether preoperative US detection of this condition can be improved.

Postoperative radiation rates in stage IIA1 cervical cancer: Is surgical treatment justified? An Israeli Gynecologic Oncology Group Study

OBJECTIVES Data on the outcome of stage IIA1 cervical cancer is limited, as these tumors comprise a small percentage of early tumors. NCCN guidelines suggest consideration of surgical management for small tumors with vaginal involvement. Our objective was to evaluate the risk of adjuvant radiotherapy in stage IIA1 cervical cancer and its associated features, in order to improve selection of patients for surgical management. METHODS A retrospective cohort study comparing surgically treated cervical cancer patients with stage IB1 and stage IIA1 disease. Women treated between 2000 and 2015 in ten Israeli medical centers were included. Patient and disease features were compared between stages. The relative risk (Fishers exact test) of receiving post-operative radiation was calculated and compared for each risk factor. A general linear model (GLM) was used for multivariable analysis. RESULTS 199 patients were included, of whom 21 had stage IIA1 disease. Most features were comparable for stage IB1 and stage IIA1 disease, although patients with vaginal involvement were more likely to have close surgical margins (23.8% vs 8.5%, p = 0.03). Patients with stage IIA1 disease were more likely to receive radiation after surgery (76% vs. 46%, RR = 1.65 (1.24-2.2), p = 0.011). Vaginal involvement as well as depth of stromal invasion, LVSI and lymph node metastases were independent predictors of radiation on multivariable general linear modeling. CONCLUSIONS Cervical cancer patients with vaginal involvement are highly more likely to require postoperative radiation. We recommend careful evaluation of these patients before surgical management is offered.