Ron Beloosesky

Adhesion prevention after cesarean delivery: evidence, and lack of it

In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery.

Computerized analysis of fetal heart rate after maternal glucose ingestion in normal pregnancy.

OBJECTIVEnTo examine the effect of maternal oral glucose ingestion on antepartum FHR indices in normal pregnancies at term.nnnSTUDY DESIGNnA prospective study was performed on 44 non-laboring healthy women with normal singleton pregnancy at 37-40 weeks gestation. All women had a normal oral glucose tolerance test at 24-28 weeks gestation. FHR was recorded with the Sonicaid Fetal Monitor System (Oxford 8000), for 30 min prior to and 60 min following oral ingestion of 50 g of glucose in the study group of 27 women, and following water ingestion in a control group of 17 women.nnnRESULTSnAll pregnancies had a normal outcome. The maternal blood glucose levels before and 30 and 60 min after glucose ingestion were 70+/-14, 107+/-121, and 106+/-22 mg/dl, respectively (P<0.001). A significant negative correlation was found between the changes in maternal blood glucose levels 30 min after glucose ingestion and the changes in the number of large FHR accelerations at 30 and 60 min after glucose ingestion (r=-0.44, P<0.01 and r=-0.42, P<0.01, respectively). A significant correlation was found between the changes in maternal blood glucose levels 30 min after glucose ingestion and changes in episodes of low FHR variation at this time period (r=0.45, P<0.01). No significant changes in any of the FHR variables were noted in the control group.nnnCONCLUSIONnIn normal pregnancies FHR indices of variation tend to decrease after maternal oral ingestion of glucose.

IUGR induced by maternal chronic inflammation: long-term effect on offspring’s ovaries in rat model—a preliminary report

PurposeExcess maternal inflammation and oxidative stress while in utero have been known to affect gross fetal development. However, an association between the inflammatory process in utero and the effects on ovarian development and future fertility has not yet been demonstrated. This study focused on LPS-induced chronic inflammation in early pregnancy and its effect on ovarian development and reserves of the offspring, using a rat model. Our aim was to determine whether maternal inflammation in utero disturbs reproductive system development in the offspring, given that maternal inflammation and oxidative stress has been shown to affect gross fetal development.MethodsProspective case control rat model. Sprague–Dawley pregnant rats (nxa0=xa011) received intraperitoneal lipopolysaccharide (LPS group) (50xa0µg/kg bodyweight) or saline solution (control group) on day 14, 16, and 18 of gestation. Pups were delivered spontaneously. At 3xa0months, female offspring were weighed and killed. Ovaries were harvested for (1) follicle count using hematoxylin and eosin staining, (2) apoptosis: ovaries were stained for caspase, and (3) serum CRP and AMH levels were determined.ResultsBirth weights of pups were significantly lower in the LPS group compared to the control group (6.0xa0±xa00.6 vs. 6.6xa0±xa00.4xa0gr; Pxa0=xa00.0003). The LPS group had fewer preantral follicles, and increased intensity of Caspase 3 staining (510 vs. 155.5xa0u; Pxa0=xa00.007). AMH levels were significantly lower in the LPS group (4.15xa0±xa00.46 vs 6.08xa0±xa01.88xa0ng/ml; Pxa0=xa00.016). There was no significant difference in the CRP and MCP-1 levels between the two groups.ConclusionsChronic maternal inflammation induced intrauterine growth restriction in offspring and a decrease in the proportion of follicles. This change might be due to premature apoptosis. These preliminary results suggest that maternal inflammation has a detrimental effect on the development of the female reproductive system of the offspring and thus, future fertility.

Early prenatal diagnosis of intraabdominal esophageal duplication cyst

Esophageal duplication cysts are uncommon, are usually diagnosed in infancy or childhood1 and are located in the posterior mediastinum in close contact with the esophageal wall2. Only intrathoracic and cervical esophageal duplication cysts have been detected prenatally1–5; in-utero diagnosis of abdominal cysts has not previously been reported. Here, we describe the prenatal sonographic features and pregnancy outcome of two cases of intraabdominal esophageal duplication cysts. In the first case, a 29-year-old primigravida with unremarkable medical history was referred at 15 weeks’ gestation following visualization of the ‘double bubble’ sign on transvaginal ultrasound. A fetal anatomic survey revealed appropriate biometry and the presence of a cystic mass located posterior and superior to the stomach and connected to the esophagus (Figure 1a,b)

Early prenatal diagnosis of intra-abdominal esophageal duplication cysts.

Esophageal duplication cysts are uncommon, are usually diagnosed in infancy or childhood1 and are located in the posterior mediastinum in close contact with the esophageal wall2. Only intrathoracic and cervical esophageal duplication cysts have been detected prenatally1–5; in-utero diagnosis of abdominal cysts has not previously been reported. Here, we describe the prenatal sonographic features and pregnancy outcome of two cases of intraabdominal esophageal duplication cysts. In the first case, a 29-year-old primigravida with unremarkable medical history was referred at 15 weeks’ gestation following visualization of the ‘double bubble’ sign on transvaginal ultrasound. A fetal anatomic survey revealed appropriate biometry and the presence of a cystic mass located posterior and superior to the stomach and connected to the esophagus (Figure 1a,b)

Ovarian stimulation in in vitro fertilization with or without the “long” gonadotropin-releasing hormone agonist protocol: effect on cycle duration and outcome

OBJECTIVEnTo study the correlation between stimulation duration of IVF cycles, with and without GnRH agonist (GnRH-a), and cycle outcome.nnnDESIGNnRetrospective analysis of data.nnnSETTINGnUniversity-affiliated IVF clinic.nnnPATIENT(S)n998 IVF cycles in which long GnRH-a protocol was used, and 155 cycles with hMG only.nnnINTERVENTION(S)nIVF cycles.nnnMAIN OUTCOME MEASURE(S)nCycle outcome in number of oocytes and embryos, and pregnancy rate.nnnRESULT(S)nThe mean stimulation duration (+/-SD) was 9.6+/-1.7 and 6.7+/-1.0 for the GnRH-a and the hMG-only cycles, respectively (P<0.01). In the GnRH-a group, no statistically significant correlation between cycle duration and pregnancy rate was found. Interestingly, the patients treated for 9 days had the highest number of oocytes retrieved and the highest pregnancy rate. Stimulation duration was not affected by age in either protocol. GnRH-a cycles yielded a significantly higher number of oocytes and embryos compared to cycles without GnRH-a. The pregnancy rate was similar in both groups.nnnCONCLUSION(S)nStimulation duration in the long GnRH-a protocol group was significantly longer than in the hMG-only group. Stimulation duration was not affected by age. No statistically significant correlation was found between stimulation duration and cycle outcome in the long protocol group.

The impact of extending the second stage of labor to prevent primary cesarean section on maternal and neonatal outcomes

Background: A low rate of primary cesarean delivery is expected to reduce some of the major complications that are associated with a repeat cesarean delivery, such as uterine rupture, adhesive placental disorders, hysterectomy, and even maternal death. Since 2014, and in alignment with the American College of Obstetricians and Gynecologists and the Society for Maternal−Fetal Medicine, we changed our approach to labor dystocia, defined as abnormal progression of labor, by allowing a longer duration of the second stage of labor. Objective: To examine the effect of prolonging the second stage of labor on the rate of cesarean delivery, and maternal and neonatal outcomes. Materials and Methods: In a historical control group, we compared maternal and neonatal outcomes over 2 periods. Period I (9300 patients): from May 2011 until April 2014, when a prolonged second stage in nulliparous women was considered after 3 hours with regional anesthesia or 2 hours if no such anesthesia was provided. Second‐stage arrest was defined in multiparous women after 2 hours with regional anesthesia or 1 hour without it. Period II (10,531 patients): from May 2014 until April 2017, allowed nulliparous and multiparous women continuing the second stage of labor an additional 1 hour before diagnosing second‐stage arrest. Singleton deliveries at or beyond 37 weeks’ gestation were initially considered for eligibility. We excluded women with high‐risk pregnancies and known fetal anomalies. For comparing means, we used the t test. If variables were not normally distributed, we used the Mann−Whitney test instead. For comparing proportions, we used the χ2 test with continuity correction. Results: The primary cesarean delivery was decreased in nulliparous women from 23.3% (819 of 3515) in period I to 15.7% (596 of 3796) in period II (relative risk [RR], 0.67; 95% CI, 0.61−0.74), a trend that was also significant in multiparous women (10.9%, 623 of 5785, in period I vs 8.1%, 544 of 6735, in period II; RR, 0.75; 95% CI, 0.67−0.84). The rate of operative vaginal deliveries in nulliparous women was higher in period II than in period I (19.2%, 732 of 3515, vs 17.7%, 622 of 3796, P < .0001). Rates of third‐ and fourth‐degree laceration and of shoulder dystocia were also higher in period II. The rate of arterial cord pH < 7.0 and the rate of admission to the neonatal intensive care unit were higher in period II, but the early neurological outcome was not different when comparing the 2 periods. Conclusion: The new policy of labor management successfully decreased primary cesarean deliveries, with a small rise in instrumental deliveries. However, it also increased the other immediate maternal and neonatal complications. A higher rate of lower umbilical artery cord pH was the most significant finding; however, the early neurological outcome did not change. It is possible that the ongoing adjustment to the new labor protocol will avoid, in the future, maternal and neonatal complications. The long‐term maternal and neonatal consequences of our new approach will be evaluated in future studies.

Direct lower abdominal ureteral jet as sonographic sign of bladder exstrophy

Bladder exstrophy is a rare malformation characterized by an infra-umbilical abdominal wall defect, incomplete closure of the bladder with mucosa continuous with the abdominal wall, epispadias and alterations in the pelvic bones. Its incidence is low at 1 in 20 000–50 000 live births. It is diagnosed easily at birth but rarely in utero. Previous reports have identified four prenatal sonographic findings associated with bladder exstrophy: (1) the bladder is not visualized on ultrasound; (2) presence of a lower abdominal bulge representing the exstrophied bladder; (3) a small penis with anteriorly displaced scrotum; and (4) short umbilical cord insertion-to-genital tubercle length1–4. In this report, we suggest a novel auxiliary sign for the diagnosis of bladder exstrophy using power Doppler ultrasound. In the normal fetus, the ureters arise from the pelvis of each kidney and enter the bladder posteriorly on the left and right sides. A urine jet from the ureters into the bladder can often be seen by ultrasound. In cases of bladder exstrophy, the posterior urinary bladder wall is continuous with the abdominal wall and urine from the ureters passes directly into the amniotic sac. We hypothesized that, since the urine production and ureteral function in cases of bladder exstrophy are normal, visualization of urine jets directly into the amniotic cavity would be diagnostic. Using power Doppler ultrasound (Philips iU 22; 3–9-MHz transvaginal probe; CPA, 77%; MED, 1500 Hz; WF, 90 Hz; 3–6-MHz transabdominal probe; CPA, 77%; MED, 1500 Hz, WF, 90 Hz), we were indeed able to observe a urine jet coursing from the abdominal wall into the amniotic cavity, confirming the presence of bladder exstrophy. During a 5-year study period, we diagnosed bladder exstrophy in four fetuses (three at 15 weeks and one at 23 weeks). In these cases, the bladder was not visualized in the presence of normal kidneys, there was no lower abdominal bulge and cord insertion was slightly lower in the abdomen. In all four cases, the urine jet was seen flowing from the ureters directly into the amniotic cavity using color Doppler ultrasound (Figures 1a and 2, Videoclips S1–S3). In all cases the pregnancy was terminated on parental request and the autopsies confirmed the diagnosis of bladder exstrophy (Figure 1b).

P01.01: Transabdominal cervical length measurements above 35mm exclude short cervix in both twin and singleton pregnancies

A. Shrim5, R. Beloosesky6, M. Steinberg6,5, K. Nizar3, Y. Ginsberg1, Z. Weiner2, D.M. Schwake4 1Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; 2Rambam Medical Centre, Haifa, Israel; 3Obstetrics and Gynecology, Rambam Medical Centre, Acre, Israel; 4Obstetrics and Gynecology Ultrasound Unit, Rambam Medical Centre, Haifa, Israel; 5Technion Israel, Neve Yarak, Israel; 6Obstetrics and Gynecology, Rambam Medical Centre, Haifa, Israel

Direct lower abdominal ureteral jet: an auxiliary sonographic sign for diagnosing bladder extrophy.

Bladder exstrophy is a rare malformation characterized by an infra-umbilical abdominal wall defect, incomplete closure of the bladder with mucosa continuous with the abdominal wall, epispadias and alterations in the pelvic bones. Its incidence is low at 1 in 20 000–50 000 live births. It is diagnosed easily at birth but rarely in utero. Previous reports have identified four prenatal sonographic findings associated with bladder exstrophy: (1) the bladder is not visualized on ultrasound; (2) presence of a lower abdominal bulge representing the exstrophied bladder; (3) a small penis with anteriorly displaced scrotum; and (4) short umbilical cord insertion-to-genital tubercle length1–4. In this report, we suggest a novel auxiliary sign for the diagnosis of bladder exstrophy using power Doppler ultrasound. In the normal fetus, the ureters arise from the pelvis of each kidney and enter the bladder posteriorly on the left and right sides. A urine jet from the ureters into the bladder can often be seen by ultrasound. In cases of bladder exstrophy, the posterior urinary bladder wall is continuous with the abdominal wall and urine from the ureters passes directly into the amniotic sac. We hypothesized that, since the urine production and ureteral function in cases of bladder exstrophy are normal, visualization of urine jets directly into the amniotic cavity would be diagnostic. Using power Doppler ultrasound (Philips iU 22; 3–9-MHz transvaginal probe; CPA, 77%; MED, 1500 Hz; WF, 90 Hz; 3–6-MHz transabdominal probe; CPA, 77%; MED, 1500 Hz, WF, 90 Hz), we were indeed able to observe a urine jet coursing from the abdominal wall into the amniotic cavity, confirming the presence of bladder exstrophy. During a 5-year study period, we diagnosed bladder exstrophy in four fetuses (three at 15 weeks and one at 23 weeks). In these cases, the bladder was not visualized in the presence of normal kidneys, there was no lower abdominal bulge and cord insertion was slightly lower in the abdomen. In all four cases, the urine jet was seen flowing from the ureters directly into the amniotic cavity using color Doppler ultrasound (Figures 1a and 2, Videoclips S1–S3). In all cases the pregnancy was terminated on parental request and the autopsies confirmed the diagnosis of bladder exstrophy (Figure 1b).