Ran Svirsky

Can we rely on blind endometrial biopsy for detection of focal intrauterine pathology

OBJECTIVE To compare the diagnostic power of random endometrial biopsy with hysteroscopy for intrauterine lesions. STUDY DESIGN A retrospective cohort study of 639 women evaluated by diagnostic office hysteroscopy and endometrial biopsy (Novak curette) was carried out between 10/1997-6/2000. Reasons for evaluation were postmenopausal bleeding, abnormal uterine bleeding, ultrasound or hystero-salpingography findings, intrauterine device removal, suspected retained products of conception, infertility, late abortions and recurrent abortions. RESULTS The womens mean age was 43.4+/-13.3 years (range, 18-88). The most prevalent indication for investigation was abnormal uterine bleeding (n=218, 34.1%), followed by sonographic or hystero-salpingographic findings (n=167, 26.1%). Hysteroscopy revealed a normal uterine cavity in 367 (57.4%) women. Endometrial polyps and submucosal fibroids were the most common hysteroscopic findings (in 151 [23.6%] and 72 [11.3%], respectively). The hysteroscopic findings were compared with the pathology results in 558 cases. The sensitivity of the Novak curette for detection of endometrial polyps and submucosal fibroids was only 8.4% and 1.4%, respectively. The positive predictive value (30.9%) and the negative predictive value (57.9%) for both lesions were likewise low. On the other hand, hysteroscopy was not effective in diagnosing the 27 cases of hyperplasia (26 simple and one complex) all without atypia. CONCLUSION Random endometrial sampling alone is not effective for diagnosing focal lesions of the uterine cavity and should be combined with other modalities, preferably diagnostic hysteroscopy.

Fertility Performance and Obstetric Outcomes Among Women With Previous Cesarean Scar Pregnancy

The purpose of this study was to assess fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy.

The safety of conception occurring shortly after methotrexate treatment of an ectopic pregnancy.

The objective of this study was to determine whether a single or repeated injection of methotrexate (MTX) to treat ectopic pregnancy results in either teratogenicity or other bad obstetric outcome in the pregnancy that shortly follows treatment. Data were retrieved from the medical records of 314 women treated with MTX for ectopic pregnancy in our institute (2000-2006) included age, MTX dosage, interval between last MTX treatment to conception, results of ultrasonographic follow-up of the subsequent pregnancy, triple test, karyotype testing, pregnancy outcome, and newborn weight and Apgar score. A logistic regression model based on pregnancy outcome as the dependent variable and interval since last MTX treatment as the independent variable estimated the odds ratio for the safety of conception occurring shortly after the treatment. Complete information was obtained for 125 pregnancies. Forty-five pregnancies occurred within 6 months (mean 3.6+/-1.7) after the last MTX treatment. The outcome of these pregnancies was compared with that of 80 pregnancies which occurred > or =6 months (mean 23.6+/-14.7) after the last MTX treatment. The fetal malformation and adverse outcome rates for both groups were similar (odds ratio 1.003, 95% CI 0.98-1.02). According to a logistic regression analysis, the interval between the last MTX treatment for ectopic pregnancy had no effect on the outcome of the pregnancy that shortly followed it. The results of this study support the notion that conceiving within the first 6 months after treatment with MTX for ectopic pregnancy is safe and not associated with any increase in the examined adverse pregnancy outcome parameters.

Safety of late second-trimester pregnancy termination by laminaria dilatation and evacuation in patients with previous multiple cesarean sections

OBJECTIVE To assess whether there is an increased perioperative risk in termination of late second-trimester pregnancy after multiple cesarean sections by laminaria dilatation and evacuation. STUDY DESIGN During the period between January 2002 and June 2008, 636 consecutive patients underwent late second-trimester (17-24 weeks) pregnancy terminations by dilatation and evacuation. Patients were divided into 3 subgroups: those with no previous cesarean section (n = 545), those with 1 previous cesarean section (n = 59), and those with several previous cesarean sections (n = 32). RESULTS There were no significant differences in major perioperative complications, such as anesthetic complications, need for blood transfusion, and cervical lacerations comparing the 3 subgroups. Importantly, there were neither cases of uterine perforation nor retained products of conception in the 3 subgroups. CONCLUSION Late second-trimester pregnancy termination after multiple cesarean sections by laminaria dilatation and evacuation is probably not associated with an increased perioperative risk. Larger studies are needed to empower this study.

Down Syndrome Screening in Assisted Conception Twins: An Iatrogenic Medical Challenge

BACKGROUND Hypertensive disorders of pregnant women are one of the important causes of maternal and perinatal morbidity and mortality. Evidence showed mental stress might be a risk factor of gestational hypertensive disorders. OBJECTIVE The objective of this study was to evaluate the relationships between mental stress and gestational hypertension/preeclampsia in pregnant women. METHODS Relevant studies were identified by PubMed, Cochrane, Chinese medical datasets (Wanfang, CNKI, and VIP Database). Only case-control or cohort studies evaluating an association of preeclampsia or gestational hypertension with mental stress were included in the present meta-analysis. Essential information was extracted from the qualified studies. Odds ratio (OR) was used as a pooled effect size. Potential heterogeneity and publication bias were detected as well. RESULTS Thirteen studies were included in the final analyses, which totally recruited 668,005 pregnant women. The results indicated that mental stress was associated with an increased risk of gestational hypertension (OR, 1.26; 95% confidence interval [CI], 1.00-1.59; P = 0.047) and preeclampsia (OR, 1.49; 95%CI, 1.27-1.74; P < 0.001). Meanwhile, work stress (OR, 1.50; 95% CI, 1.15-1.97; P = 0.003) and anxiety or depression (OR, 1.88; 95%CI, 1.08-3.25; P = 0.02)were positively associated with risk of preeclampsia. CONCLUSIONS Mental stress during life or pregnancy may be a risk factor for gestational hypertension and preeclampsia among pregnant women.Objective The objective of this study was to provide a critical analysis of the impact of assisted conception on prenatal screening for Down syndrome (DS) in twin pregnancies and the value of various screening modalities for early detection of anomalies. Methods The literature was searched using PubMed and the Cochrane Library focusing on prenatal screening and antenatal care of assisted-conception twin pregnancies. Results Serum screening alone is of limited value in detecting aneuploid twins, because the unaffected cotwin can “mask” the abnormal serum results of an affected one. In addition, this test can designate the pregnancy as at high risk but not identify the affected fetus. Nuchal translucency (NT) screening is the best available modality and a highly effective screening method for twin pregnancies. Among twins, NT alone has a 69% DS detection rate, first-trimester combined NT and serum biochemistry has a 72% DS detection rate, and an integrated screen will have an 80% DS detection rate at a 5% FPR. The data in the literature concerning the effect of assisted conception on maternal serum screening markers in twin pregnancies are scarce. Conclusions Down syndrome screening in assisted-conception twins presents clinical and technical challenges. Therefore, assisted-conception twins need close monitoring from conception to delivery, by a practitioner familiar with the available screening modalities and their relative accuracy. Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to identify the problems associated with prenatal diagnosis of Down syndrome in twins in general, and in assisted reproduction technology–conceived twins in particular, and perform the screening tests for spontaneous and assisted reproduction technology–conceived twin pregnancies, including identifying their diagnostic accuracy and pitfalls.

First trimester maternal serum placental protein 13 levels in singleton vs. twin pregnancies with and without severe pre-eclampsia.

Abstract Aims: To determine first trimester maternal serum placental protein 13 (PP13) in singletons vs. twins with and without severe preeclampsia (PE). Methods: Serum samples were prospectively collected at 8–14 weeks of gestation. PP13 was determined by solid-phase immunoassay. Patients were recruited in community clinics throughout the country, and from the twin antenatal assessment clinic in Assaf Harofeh Medical Center, Zerifin, Israel. Demographics, medical, and pregnancy history were obtained at enrollment. Pregnancy outcome was collected after delivery. PP13 was compared by the Wilcoxon rank sum test. Results: In singletons, PP13 declined with maternal weight and was lower in in vitro fertilization. Levels were converted into multiples of the median (MoMs) accordingly. In twins, the median was 1.74 MoM (n=76) vs. 1.00 in singletons (n=676, P<0.0001). Among twins with severe PE (n=10), the median was 1.53 MoM vs. 1.74 in unaffected twins (P=0.10), and 2.26 (n=6) for mild PE (P=0.30). Among singletons with severe PE, the median was 0.44 MoM (n=26, P<0.0001), and for mild PE 0.62 (n=17, P<0.001). Conclusion: PP13 is higher in twins than singletons, corresponding to the larger placental mass. Among singletons with severe PE, levels were significantly reduced, however, among twins, only a non-significant tendency for a reduction was recorded, and warrants further investigation in a larger series.

Prediction of morbidly adherent placenta using a scoring system

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

First trimester markers of preeclampsia in twins: maternal mean arterial pressure and uterine artery Doppler pulsatility index

This study aims to evaluate the distribution of mean arterial pressure (MAP) and uterine artery Doppler pulsatility index (PI) in first trimester twins with and without preeclampsia.

Predicting of morbidly adherent placenta using a scoring system: A prospective study

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

First‐ and second‐trimester maternal serum markers of pre‐eclampsia in twin pregnancy

To evaluate the distribution of first‐ and second‐trimester maternal serum markers in twin pregnancy with and without pre‐eclampsia.