Ron Auslander

Normal fasting plasma glucose levels during pregnancy: a hospital-based study

Abstract Objective: Recently, the International Association of Diabetes and Pregnancy Study Groups have suggested new criteria for the diagnosis of gestational diabetes including a fasting glucose level of ≥92 mg/dL. We determined reference levels for normal fasting plasma glucose levels throughout pregnancy and evaluated the new normal cut-off for fasting glucose level. Methods: Charts of patients who delivered in our hospital between June 2001 and June 2006 were reviewed. Women with pregestational diabetes, fasting glucose level >105mg/dL or delivery at <24 weeks were excluded. Fasting glucose levels were assessed in 11 time categories between three months prior and four months postpartum in 7946 women. Results: Compared to preconception levels, fasting glucose levels decreased by a median of 3 mg/dL in the first trimester (81–78 mg/dL). During the third trimester a slight further glucose reduction was observed (median 76 mg/dL). After delivery fasting glucose levels increased sharply (84 mg/dL in the puerperium and 81 mg/dL by three months postpartum). Throughout pregnancy 5.2–9.0% of pregnant women had a fasting glucose level of ≥92 mg/dL ;ibcompared to 8.2% in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study]. Conclusion: Fasting glucose levels decrease early in pregnancy with only slight further decrease later on. It seems that the same fasting glucose cut-off can be used throughout pregnancy for the diagnosis of gestational diabetes mellitus.

Cystoscopy after total or subtotal laparoscopic hysterectomy: the value of a routine procedure

Ureteral injury during hysterectomy is one of the most troubling complications gynecologists need to be aware of. In various studies, such injury occurred in laparotomy, laparoscopy, and vaginal hysterectomy. The objective of our study was to assess the necessity, efficiency, and cost-effectiveness of cystoscopy at the end of total or subtotal laparoscopic hysterectomy (TLH/STLH). This is a retrospective analysis of 7 years’ experience in a university-affiliated hospital. All hysterectomies were performed on an overnight basis by experienced surgeons. Out of 338 patients, 106 patients underwent TLH, and 232 underwent STLH. Four cases (1.18%) of ureter injury were noted (one after TLH and three after STLH). Diagnosis was clinically made by postoperative vaginal sonography and was confirmed by intravenous pyelography. A cystoscopy was performed after intravenous indigo carmine injection. The study period consisted of two phases. In the first phase, we used bipolar cautery to occlude the uterine artery; consequently, a nearby thermal injury could be misdiagnosed. In the second phase we clipped the uterine artery with a new hemoclip called Hem-o-lok (Weck Closure Systems, USA), which forced an exact uterine artery closure. As a result, in the second phase no cases of ureteral injury were noted. In view of the fact that the equipment for cystoscopy is used during surgery for TLH/STLH and is sterile and available, the only additional cost of the cystoscopy is an ampule of indigo carmine. Therefore, we conclude that cystoscopy at the end of surgery for TLH/STLH is an important evaluation and provides the following significant advantages: In patients presenting with postoperative flank pain, cystoscopy may prevent the need for further evaluation and expensive testing, and cystoscopy increases the surgeon’s and the patient’s confidence in the integrity of the urinary tract during the recovery period.

The three-dimensional “insect eye” laparoscopic imaging system-a prospective randomized study

The VS-1 “insect eye” technology is a new three-dimensional (3D) imaging system used for laparoscopic surgery. It is based on a microscopic array of hundreds of thousands of lenses that form a single apparatus, providing streaming 3D imaging without the side effects of previous 3D systems. This study analyzed the VS-1 system in terms of operative results and surgeon satisfaction compared with the standard two-dimensional (2D) imaging system. Eighty-eight patients undergoing laparoscopic surgery of different difficulty levels, performed by three different surgeons, graded as novice or experienced, were randomly assigned for the VS-1 3D or the standard 2D imaging systems, 44 patients in each group. Results showed that, when using the 3D VS-1 system, surgery duration was reduced for both novice and experienced surgeons. Surgeons reported having good depth perception, anatomic understanding and procedure efficiency, as well as physician confidence and efficiency during complicated maneuvers. No user side effects were reported. The VS-1 “insect eye” 3D imaging system provided improved operative results when compared with the 2D imaging system, with a decrease in surgery duration, along with good surgeon confidence and satisfaction, and without user side effects.

Quality of Medical Care in Diabetic Women Undergoing Fertility Treatment We should do better

OBJECTIVE Diabetic women are at increased risk for adverse pregnancy outcomes that can be improved by preconception care. Our goal was to evaluate the quality of medical care in diabetic women who undergo fertility treatment and compare it with the quality of medical care in diabetic women with spontaneous pregnancies. RESEARCH DESIGN AND METHODS This retrospective study on reproductive-age women undergoing fertility treatment in Clalit Health Services (CHS) used data on fertility treatments, prescription fillings, HbA1c levels, and demographics extracted from CHS computerized systems. The control group comprised women with spontaneous pregnancy. Three quality measures in the periconception period were evaluated: folic acid prescription fillings, evaluation and level of HbA1c, and use of potentially hazardous drugs. RESULTS There were 230 fertility treatment cycles in 83 diabetic women, and 30 diabetic women had spontaneous pregnancy. Women in the fertility group were older and had fewer children. There were no significant differences in marital status or ethnicity. Regular folic acid use, HbA1c recording, and the percentage of women with HbA1c <7% was similar between women in fertility treatment and those with spontaneous pregnancy (23.9, 57.8, and 31.3% vs. 20.0, 73.3, and 40.0%, respectively). Several women in both groups continued the use of potentially hazardous medication. CONCLUSIONS The periconception medical care of diabetic women who undergo fertility treatment is suboptimal and no better than that of diabetic women with spontaneous pregnancies. More intensive and targeted counseling regarding the importance of folic acid and glycemic control is needed to optimize periconception care of these diabetic patients.

CA 19-9 in evaluation of adnexal mass: retrospective cohort analysis and review of the literature

Objective The aim of this study was to estimate the diagnostic accuracy of serum marker CA 19-9 levels in the triage of adnexal masses. Methods This retrospective cohort study was carried out in patients referred to the Gynecology Department at Carmel Medical Center due to adnexal masses. All patients underwent preoperative measurements of serum CA 125 and CA 19-9 and surgery with histopathologically confirmed diagnosis. Results Between January 2005 and December 2012, 503 patients with adnexal masses were evaluated with serum tumor markers. Combination of CA 19-9 with CA 125, compared with CA 125 levels alone, suggested a nonsignificant effect on sensitivity (86.9% vs. 88.9%, respectively, p = 0.54) or specificity (79.5% vs. 73.5%, p = 0.1) in differentiating malignant from benign adnexal masses. CA 19-9 was not helpful in detecting mucinous histological types or borderline tumors. Mean CA 19-9 levels were higher in metastatic cases compared with primary ovarian malignancy (488.7 ± 1,457 vs. 46.3 ± 149.8 U/mL, respectively, p = 0.001). In mature cystic teratomas, mean CA 19-9 levels were higher and CA 125 levels were lower than in ovarian carcinoma (p = 0.049 and p = 0.0012, respectively). Conclusions The combination of the tumor markers CA 19-9 and CA 125 did not contribute significantly to the detection of malignant adnexal masses compared with CA 125 alone. As our results suggest that higher CA 19-9 levels could be helpful in differentiating metastatic tumors from primary ovarian malignancy; this issue should be investigated in large well-designed prospective cohort trials.

Does the Experience of the Provider Affect Pregnancy Rates After Embryo Transfer

Embryo transfer is one of the most critical procedures in assisted reproduction. The influence of the individual physician performing the embryo transfer on pregnancy outcome is unclear, and published reports on this issue have shown conflicting results. While some research found that the pregnancy rate varied greatly among individual physicians within the same IVF, others have not found such a difference. A difference in implantation and pregnancy rates between clinicians, if found, could be related to the experience of the provider and the technical method of embryo transfer. It seems that this difference between physicians could be overcome with a learning curve and practice, and by standardizing the method of transfer.