Ofer Markovitch

Extrauterine mislocated IUD: is surgical removal mandatory?

The incidence of intrauterine device perforation is 0.87 per 1000 insertions. An intrauterine device (IUD) may perforate through the uterine wall into the pelvic or abdominal cavity or into adjacent organs. The accepted treatment for displaced IUDs is surgical removal because of the putative risk of adhesion formation or of damage to the intestine or urinary bladder. The purpose of this article is to present three cases of IUD perforation where surgical removal may not have been necessary. In all three cases, the IUD was removed by laparoscopy. No adhesions were found in any of the patients. Criteria for the surgical removal of a displaced IUD, as a result of uterine perforation, should be re-evaluated. Whilst surgical procedures to remove a misplaced IUD must be performed on symptomatic patients, asymptomatic patients, under certain circumstances, may benefit from conservative management.

Severe juvenile vaginal bleeding due to Glanzmann's thrombasthenia : Case report and review of the literature

Glanzmanns thrombasthenia is a rare inherited hematological disorder defined by deficiency or abnormality of the glycoprotein (GP) IIb‐IIIa complex. Presenting symptoms are hemorrhagic events, mainly epistaxis, purpura, or menorrhagia. We describe the clinical course and management of a 14‐year‐old girl with Glanzmanns thrombasthenia and severe menorrhagia. Following treatment with 20 U of packed red blood cells, 37 U of platelets, 7 U of fresh frozen plasma, cryoprecipitate, intravenous estrogens, and methylergotrine maleate with no improvement, the uterine cavity was packed for 48 hr. This unusual procedure halted the bleeding and avoided the necessity for a hysterectomy. When treating acute menorrhagia in patients with Glanzmanns thrombasthenia, the physician should be familiar with the characteristics and all treatment modalities for this disorder. Am. J. Hematol. 57:225–227, 1998.

Skin closure at cesarean delivery, glue vs subcuticular sutures: a randomized controlled trial

BACKGROUND: The optimal choice of skin closure at cesarean delivery has not yet been determined. OBJECTIVE: This study compared wound complications and scar healing following cesarean delivery between 2 methods of skin closure: glue (Dermabond; Ethicon, Somerville, NJ) and monofilament (Monocryl; Ethicon) epidermal sutures. STUDY DESIGN: We conducted a randomized controlled trial in which pregnant women undergoing a scheduled cesarean delivery were randomly assigned to skin (epidermis) closure with glue or with a monofilament synthetic suture. The subcutaneous tissue was sutured for all patients. Outcome assessors were blinded to group allocation. Scars were evaluated >8 weeks. Primary outcome measures were Patient and Observer Scar Assessment Scale scores. Secondary outcome measures were surgeon satisfaction, duration of surgery, duration of hospitalization after the cesarean delivery, and complications of surgical site infection or wound disruption (hematoma or seroma). A sample of 104 women was needed to achieve a clinically significant effect with a power of 80%. RESULTS: Demographic characteristics, patients’ clinical background, prepregnancy body mass index, and subcutaneous thickness were similar in both groups. Length of surgery between the groups (37 ± 10 minutes for glue vs 39 ± 13 minutes for sutures, P = .515) was similar. Scores immediately after the wound closure were similar for both groups regarding surgeons’ time estimate of closure (P = .181) and closure appearance (P = .082). Surgeons’ satisfaction with the technique was significantly higher in the suture group (P = .003). No significant differences were found between the groups in blood loss, surgical site infection, length of postpartum hospitalization, or wound disruption. Glue and suture skin closure scores using Patient and Observer Scar Assessment Scale were similar 8 weeks after surgery, at P = .710 for patients and P = .568 for a physician observer. CONCLUSION: Skin closure using glue or a monofilament synthetic suture had similar results. Both methods were shown to be safe and successful for skin closure after a scheduled cesarean delivery and, therefore, can be used based on surgeon and patient preferences.

Senescence and Telomere Homeostasis Might Be Involved in Placenta Percreta—Preliminary Investigation:

Objective: Placenta percreta (PP) is an abnormal condition of trophoblast maturation and terminal differentiation through the uterine wall. We opted to study telomere homeostasis and senescence expression in trophoblasts from PP, the most severe subgroup of placenta accreta. Study Design: Paraffin-embedded placental biopsies from pregnancies with percreta and normal placentation, matched by gestational age at delivery, were assessed for telomere length, aggregates, and senescence-associated heterochromatin foci using quantitative fluorescence in situ hybridization. Cyclin-dependent kinase inhibitors p21, p15, p16, and the tumor suppressor protein p53, known senescence-related markers, were assessed using immunohistochemical staining. Results: Short telomeres were found more often in trophoblasts from the samples of PP (n = 9) compared to controls (n = 8; 54% ± 20% vs 2.3% ± 1.16%, respectively; P < .05). More cells with telomere aggregates (18.3% ± 6.9%) were observed in the PP than in the control group (4.8% ± 5.4%; P = .0005). The percentage of nucleic senescence-associated heterochromatin foci in the PP and control samples was similar (10.9% ± 10.4% vs 10.7% ± 15%, respectively; P = .97). Immunohistochemistry of senescence markers was expressed differently in PP compared to the controls: higher p15 expression (46.42% ± 15.2% vs 36.63% ± 12.2%, P = .004), higher p21 expression (59.8% ± 22.1% vs 47.5% ± 21.9%, P = .011), lower p16 expression (54.8% ± 26.3% vs 73.4% ± 18.9%, P = .000), and lower p53 expression (24.4% ± 33.8% vs 34% ± 14.4%, P = .000). Conclusion: Placenta percreta exhibits telomere alterations and changes in expression of several senescence markers. These might be related to altered trophoblast invasion maturation and placental detachment postpartum.

OC138: Suggested pathophysiology for the high incidence of cord entanglement during early pregnancy detected by three-dimensional sonography

Objectives: 1) To determine the incidence of cord entanglement during early gestation using three dimensional (3D US) sonography. 2) To establish relationship between fetal and umbilical cord lengths, as a suggested pathophysiology for the cord entanglement incidence throughout pregnancy. Material and Methods: A prospective consecutive study was designed and 3D US was performed. Two hundred and thirty seven singleton pregnancies between 13–16 weeks were included. Cord entanglement was defined when one or more of the following was detected: cord around neck, hand, leg, thorax, abdomen shoulder, pelvis. Floating free cord through all its length in the amniotic fluid was defined as normal position cord. Results: Abnormal cord position was observed in 149 (62.9%) patients. Of those: 42.9.0% around neck, 15.4% legs, 12.7% hands, 4.8% -abdomen, 24.2% -other body parts (thorax, shoulder and pelvis). Incidence of total cord entanglement was similar between 13–16 weeks gestation. A decreasing ratio between cord length and CRL (according to literature) was calculated throughout pregnancy. Conclusions: A high incidence of early second trimester cord entanglement was found. This may be explained by the high calculated ratio between cord and fetal lengths during early pregnancy. Cord entanglement should be considered a part of normal early fetal movements and development.

Trial of vaginal delivery for twins – is it safe? a single center experience

Abstract Purpose: This study assessed our hospital protocol of vaginal delivery for twins and evaluated whether trial of vaginal delivery (unless contraindicated) was as safe as elective cesarean. Risk factors leading to failed trial of labor (TOL) were characterized to improve our ability to advise patients and select cases for TOL. Methods: This retrospective, cohort study included women >32 weeks gestation, with twin A in cephalic presentation and no contraindications for vaginal delivery. Controls were women with twin pregnancy and planned cesarean delivery (PCD). Maternal and neonatal morbidity between TOL and PCD were compared. TOL group was subcategorized by vaginal or cesarean delivery to characterize pre-labor risk factors for failed TOL. Results: Of the 411 twins, 215 had TOL and 196 had PCD. Among TOL, 196/215 (91%) delivered vaginally. TOL was more likely to have spontaneous pregnancy, pregnancy complications and tended to deliver earlier. More TOL had postpartum hemorrhage (p < .05), although transfusion rates in each group were similar. Neonatal outcomes between groups did not differ. Induction and gestational age at delivery were risk factors for failed TOL. Conclusions: The results support the contemporary practice of TOL for twins at term when the first is in cephalic presentation with no other contraindications.

Can sonographic measurements and changes in cervical length during pregnancy predict preterm labour in an asymptomatic low-risk population?

Abstract Objective: This study measured cervical length (CL) at 14–16 and 21–24 weeks of gestation and assessed whether the difference between the measurements is predictive of preterm delivery (PTD). Methods: This retrospective, cohort study included patients with two consecutive CL measured with transvaginal sonography at 14–16 weeks of gestation (CL1) and 21–24 weeks (CL2). Electronic medical records were reviewed for demographic, medical and obstetric history; complications during the current pregnancy and delivery data. CL1, CL2 and the change between scans were evaluated and correlated to PTD prediction. Results: Among the 216 patients, 196 (90.7%) delivered at term (≥37 weeks) and 20 (9.3%) preterm (<37 weeks). CL1 was not a good predictor of PTD (p = .70). CL2 was significantly shorter in the PTD group (p < .05). The correlation between CL change and PTD was not significant (p = .55). Perinatal outcomes between term and preterm deliveries were similar. Conclusions: Sonographic measurement of CL at 14- to 16-week gestation and the difference between CL in the first and second scans are not reliable predictors of PTD. However, cervical length at 21–24 weeks in low-risk women is predictive of this complication.

Diagnostic accuracy, work‐up, and outcomes of pregnancies with clubfoot detected by prenatal sonography

To assess diagnostic accuracy, related findings, and outcomes of fetuses with clubfoot.

Sonographic assessment of post-cesarean section uterine scar in pregnant women

Purpose: To detect location of uterine cesarean scar in relation to cervix in pregnancies with previous cesarean section (CS) and to compare location between elective and emergent previous CS. Study design: Prospective study, 91 pregnant women with previous low transverse CS. Two groups: previous elective [36 (39.6%)] and emergent CS [55 (60.4%)]. Transvaginal ultrasound was performed between 14 and 16 weeks. Cervical length (CL) and distance between external oss to hypoechogenic line (EO-HL distance), which describes location of cesarean scar, were measured. Surgical incision was considered cervical when EO-HL distance was smaller than CL. Results: Mean CL and EO-HL distance: 45.4 + 7. 0 and 39.0 + 9.4 mm, respectively for all patients. No significant differences were observed in CL (45.9 + 6.2 vs. 45.1 + 8.5 mm; p = not significant [NS]) and EO-HL distance (40.7 + 9.7 vs. 37.9 + 9.1 mm; p = NS) between both groups. Sixty-four cases (70.3%) had cervical scar, eight (8.8%) at the level of the internal oss and 19 (20.9) in the lower uterine segment. No significant difference was observed between both groups regarding location of scar (cervix −72 vs. 67% emergent vs. elective, respectively; p = NS). Conclusion: CS incisions are mostly performed in cervix, in elective as well as in emergent operations.

OP30.08: Sonographic detection of uterine scar location following Cesarean section among pregnant women

Objectives: To measure the volume of the uterus and the uterine cavity after uncomplicated deliveries using three-dimensional (3D) ultrasound throughout the puerperium Methods: 3D ultrasound was used to measure the volume of the uterus and uterine cavity of 50 women after normal vaginal delivery. It was a prospective longitudinal study with measurements made on day one, one week, two weeks, four weeks and eight weeks postpartum. The uterus and the cavity were measured using Virtual Organ Computer-aided AnaLysis (VOCAL). Six adjacent planes and a 30-degree rotation were used. Intrauterine content was described for every woman, and the cavity volume was measured only if intrauterine content was observed. Results: The mean volume of the uterus was reduced from 805 cm3 on day one postpartum to 451 cm3 after one week, 266 cm3 after two weeks, 134 cm3 after four weeks and 72 cm3 after eight weeks postpartum. The mean volume of the cavity was 30 cm3 on day one postpartum, 19 cm3 after one week, 9 cm3 after two weeks, 1 cm3 after four weeks and not measurable eight weeks postpartum. At this time the cavity was empty in all 50 cases. Intrauterine content was found in 36% of the cases on day one, 95% after one week, 87% after two weeks, 28% after four weeks. The variation of the uterine volume between cases was larger on the first day postpartum compared to eight weeks later when the variation was smaller. Conclusions: 3D ultrasound is a non-invasive tool to measure the volume of the uterus and the uterine cavity during the puerperium. Although there are individual variations the reduction of the volume follows a similar pattern in all cases and can be used as reference data. This can be valuable for diagnosis in cases of secondary postpartum haemorrhage.