Ron Auslender

First-Trimester Fasting Hyperglycemia and Adverse Pregnancy Outcomes

OBJECTIVE The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study found strong associations between higher levels of maternal glucose at 24–32 weeks, within what is currently considered normoglycemia and adverse pregnancy outcomes. Our aim was to evaluate the associations between first-trimester fasting plasma glucose level and adverse pregnancy outcomes. RESEARCH DESIGN AND METHODS Charts of all patients who delivered at our hospital between June 2001 and June 2006 were reviewed. Only subjects with singleton pregnancy and a recorded first-trimester fasting glucose level were included. Women with pregestational diabetes, fasting glucose level >105 mg/dl, or delivery <24 weeks were excluded. Fasting glucose levels were analyzed in seven categories, similar to the HAPO study. The main outcomes were development of gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates and/or macrosomia, and primary cesarean section. Multivariate logistic regression analysis was used; significance was <0.05. RESULTS A total of 6,129 women had a fasting glucose test at median of 9.5 weeks. There were strong, graded associations between fasting glucose level and primary outcomes. The frequency of GDM development increased from 1.0% in the lowest glucose category to 11.7% in the highest (adjusted odds ratio 11.92 [95% CI 5.39–26.37]). The frequency of LGA neonates and/or macrosomia increased from 7.9 to 19.4% (2.82 [1.67–4.76]). Primary cesarean section rate increased from 12.7 to 20.0% (1.94 [1.11–3.41]). CONCLUSIONS Higher first-trimester fasting glucose levels, within what is currently considered a nondiabetic range, increase the risk of adverse pregnancy outcomes. Early detection and treatment of women at high risk for these complications might improve pregnancy outcome.

First trimester fasting hyperglycemia as a predictor for the development of gestational diabetes mellitus.

OBJECTIVE Screening for gestational diabetes mellitus (GDM) is usually done at 24-28 weeks of gestation. Our goal was to study the association between first trimester fasting plasma glucose level and GDM risk and to evaluate its efficacy as a screening test for GDM in comparison to a traditional risk factor, pregestational body mass index (BMI). STUDY DESIGN The charts of all patients who delivered in our hospital between June 2001 and June 2006 were reviewed. Only subjects with a singleton pregnancy and a recorded first trimester fasting glucose level and BMI were studied. Women with pregestational diabetes mellitus, fasting glucose level >105mg/dl or delivery at <24 weeks were excluded. Screening properties of both fasting glucose level and BMI were calculated and compared using receiver operator characteristic curves. RESULTS GDM was diagnosed in 135 of the 4876 women included in this study. Fasting glucose cut-off levels of 80-85mg/dl yielded sensitivities of 75-55% and specificities of 52-75% for GDM prediction. BMI cut-off values of 25-28 had sensitivities of 60-40% and specificities of 72-86% for GDM prediction. Receiver operator curves for fasting glucose levels and BMI showed similar performance in predicting GDM (area under curve 0.72±0.023 vs. 0.74±0.021 (P=0.44)). There was approximately a 1.5-fold increase in the risk of developing GDM with each 5mg/dl increase in fasting glucose or 3.5kg/m² increase in BMI. CONCLUSION Higher first trimester fasting glucose levels, within the normoglycemic range, constitute an independent risk factor for the development of GDM among young pregnant women.

Low-grade serous ovarian cancer: A review

Epithelial ovarian cancers can be divided into the more common, aggressive type II cancers and the less common, slow-growing type I cancers. Under this model, serous ovarian carcinomas can be subdivided into high-grade (type II) and low-grade (type I) tumours. The two-tier system for grading serous ovarian carcinomas is superior to more detailed grading systems in terms of predicting survival. Low-grade serous carcinomas typically present in young women and have a relatively good prognosis, despite being resistant to chemotherapy. Low-grade serous cancers have a high prevalence of KRAS and BRAF mutations, but a low prevalence of TP53 mutations (which are characteristic of high-grade serous cancers). Among women with low-grade serous ovarian cancer, the presence of a KRAS/BRAF mutation is a favorable prognostic factor. Studies of the mitogen-activated protein kinase (MAPK) inhibitor in low-grade serous ovarian cancer suggest that identifying MAPK mutations might eventually be useful in guiding treatment.

Doppler and gray‐scale sonographic classification of adnexal torsion

To propose, in cases with coiling of the ovarian vessels, a classification of severity of torsion based on Doppler and gray‐scale ultrasound findings and to suggest a treatment strategy for each situation.

Removal of an Eroded Transobturator Tape from the Bladder Using Laser Cystolithotripsy and Cystoscopic Resection

This case presentation describes a unique minimally invasive technique of treating transobturator tape erosion into the urinary bladder with calculus growth. A 42-year-old woman was admitted for recurrent urinary tract infections, 9 months after a transobturator tape procedure. Pelvic sonography, followed by cystourethroscopy, demonstrated an eroded tape in the bladder with heavy calculus growth and diffuse mucosal inflammation. The calculus was fragmented by using laser cystolithotripsy, and the tape was excised and removed by using cystoscopic resection. Intravesical tape erosion with calculus growth can complicate transobturator tape procedures, and is amenable to transurethral laser cystolithotripsy and cystoscopic resection.

Oxidative parameters of embryo culture media may predict treatment outcome in in vitro fertilization: a novel applicable tool for improving embryo selection

OBJECTIVE To examine whether the oxidative status of an individual embryo before transfer may predict chances of implantation. DESIGN A prospective laboratory study. SETTING An IVF unit in a university-affiliated hospital. PATIENT(S) One hundred thirty-three women undergoing IVF-ET treatment cycles. INTERVENTION(S) Before ET, 10 μL of embryo culture medium was retrieved individually from each embryo and the oxidative status assessed by the thermochemiluminescence (TCL) analyzer. MAIN OUTCOME MEASURE(S) The occurrence of pregnancy. Two parameters were recorded: the TCL amplitude after 50 seconds (H1) and the TCL ratio. These were compared with demographic, clinical, and laboratory parameters and treatment outcome. All data underwent statistical analysis. RESULT(S) Altogether 284 embryos were transferred in 133 ET cycles. Forty-one pregnancies occurred (31%). For embryos transferred after 72 hours (77 transfers), the highest H1 levels in each group of transferred embryos correlated with the occurrence of pregnancy. The combination of maximal intracohort H1 level <210 counts per second with a TCL ratio of ≤ 80% had a positive predictive value of 70.6% for the occurrence of pregnancy. CONCLUSION(S) The oxidative status of the early embryo in IVF is associated with the chances of implantation. Assessment of the oxidative status of embryos in culture media before transfer may serve as an applicable tool for improving embryo selection in light of the legal limitations of the number of transferred embryos allowed.

Symptomatic pelvic hematoma following transvaginal reconstructive pelvic surgery: incidence, clinical presentation, risk factors, and outcome

OBJECTIVE To assess the incidence, clinical presentation, risk factors and outcome of symptomatic pelvic hematomas following transvaginal pelvic reconstructive surgery. MATERIALS AND METHODS We reviewed the medical records of all women undergoing transvaginal reconstructive pelvic surgery in our institution between January 2006 and July 2009. RESULTS 462 patients underwent pelvic reconstructive surgery, of whom 28 (6%) presented with symptomatic pelvic hematomas. All cases occurred after transvaginal hysterectomy, 25 (90%) presented with fever, 20 (71%) with pelvic pain and 5 (20%) with urinary retention. All hematomas were diagnosed by ultrasound. They were located at the vaginal cuff in 18 (64%), anterior vaginal wall in six (21%) and posterior vaginal wall in four patients (14%), and had a mean volume of 590 ± 140 cm(3). Laboratory data included leukocytosis (71%), thrombocytosis (57%) and elevated liver enzymes (18%). Nine patients (33%) required ultrasound-guided drainage of the hematoma, which resulted in marked clinical improvement. Surgical outcome was not affected by the presence of pelvic hematoma. CONCLUSIONS A postoperative symptomatic pelvic hematoma is not rare and is closely related to transvaginal hysterectomy. Its clinical presentation includes fever, pelvic pain, leukocytosis, thrombocytosis and occasionally liver dysfunction. Surgical outcome is generally unaffected.

Starry sky pattern of fetal liver sonogram as first sign of twin–twin transfusion syndrome

‘Starry sky’ liver is one of the most common sonographic patterns in diffuse liver disease. It is characterized by clearly identified portal venules due to diminished parenchymal echogenicity. In advanced cases of twin‐to‐twin transfusion syndrome (TTTS), volume overload is considered the key factor in the pathogenesis of cardiac dysfunction of the recipient twin. When right‐sided failure occurs, the liver might show signs of edema and, as in acute hepatitis, the appearance of starry sky might develop. We present a case in which the sonographic appearance of starry sky liver, along with right‐sided cardiac failure (tricuspid regurgitation), were the first signs of TTTS in monochorionic twins at 20 weeks. A short time later, at 21 weeks, other signs of overload and signs of worsening heart failure were noted, as the typical triphasic waves in the inferior vena cava were replaced by a biphasic flow profile. Twin 2 at that time had relative oligohydramnios. A few days later, relative polyhydramnios and edema of the placental domain of the recipient twin were also noted. To the best of our knowledge, this is the first case report describing this hepatic sonographic pattern as an early sonographic sign of TTTS. Copyright

The effect of bladder fullness on evaluation of pelvic organ prolapse

To investigate the effect of bladder fullness on pelvic organ prolapse (POP) staging via the Pelvic Organ Prolapse Quantification System (POP‐Q).

p27 and its ubiquitin ligase Skp2 expression in endometrium of IVF patients with repeated hormonal stimulation

This preliminary study examined a possible effect of long duration repeated hormonal stimulation on the endometrium using a molecular tool. The expression of the hormone stimulated, cell cycle regulators, p27 and its ligase S-phase kinase-interacting protein2 (Skp2), were assessed in 46 endometrial samples of patients who underwent repeated IVF cycles (3-21). Skp2 protein is usually undetectable in normal tissue and can be demonstrated only in rapidly dividing cells. Samples from non-stimulated, normal cycling women served as control group A. Samples of endometrial carcinoma served as control group B. In secretory endometrium, the expression of p27 was found to be lower and Skp2 higher in the study group compared with control group A. Moreover, in 25% of patients of the study group, Skp2 expression was significantly higher (P < 0.05) compared with control group A, reaching concentrations demonstrated in endometrial carcinoma. The findings of this study suggest that repeated hormone stimulation cycles may disrupt endometrial physiology, potentially towards abnormal proliferation. These changes in protein expression are described for the first time in IVF patients and should be further investigated.