Roy Mashiach

Comparison of adnexal torsion between pregnant and nonpregnant women

OBJECTIVEnThe purpose of this study was to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women.nnnSTUDY DESIGNnWe conducted a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed.nnnRESULTSnRecurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women; 83.3% of pregnant women delivered at term. Laparoscopic detorsion was the main surgical procedure.nnnCONCLUSIONnPresentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.

Long-term Outcome After Laparoscopic Treatment of Heterotopic Pregnancy: 19 Cases

STUDY OBJECTIVEnTo determine the long-term outcome of intrauterine pregnancies after treatment of heterotopic pregnancies.nnnDESIGNnRetrospective cohort study (Canadian Task Force classification II-3).nnnSETTINGnTertiary center university hospital.nnnPATIENTSnAll women who underwent surgery because of heterotopic pregnancy over 12 years.nnnINTERVENTIONnLaparoscopic surgery.nnnMEASUREMENTS AND MAIN RESULTSnInfant development and future pregnancy. Extrauterine pregnancies were located in the tube (n = 13), uterine cornua (n = 3), ovary (n = 1), and tubal stump (n = 2). During laparoscopy, a ruptured tube was found in 6 tubal pregnancies (46%), blood transfusion was needed in 7 heterotopic pregnancies (37%), and salpingectomy was performed in 12 women with tubal pregnancies (91.7%). The pregnancy outcome consisted of 13 babies (term and preterm) taken home and 5 miscarriages. Long-term follow up demonstrated that 10 of 13 infants (76.9%) exhibited normal development. Three infants, all from 1 triplet pregnancy, exhibited borderline to normal development. Ten of 15 women achieved additional pregnancies, with 10 deliveries and only 1 extrauterine pregnancy in the tubal stump.nnnCONCLUSIONSnWomen with a heterotopic pregnancy are at high risk for late diagnosis and at risk for hypovolemic shock at diagnosis, and may require blood transfusion. The outcome of intrauterine pregnancy in association with heterotopic pregnancy requiring surgical intervention is good, and most complications were associated with multifetal pregnancy and preterm delivery.

Omentin, an adipokine with insulin-sensitizing properties, is negatively associated with insulin resistance in normal gestation.

Abstract Objective: Omentin, a newly identified adipokine, enhances insulin mediated glucose uptake in human adipocytes, thus, inducing systemic insulin-sensitizing effect. The aims of this study were to determine whether circulating maternal omentin levels are associated with insulin resistance indices and to assess which compartment, maternal, fetal, or placental, is the source of omentin in maternal circulation. Methods: Fasting serum glucose, insulin, and omentin were determined in 25 healthy pregnant women at the third trimester, before and 3 days after elective cesarean section. Cord blood omentin was measured in the 25 term neonates. Homeostasis model assessment (HOMA) was used to evaluate insulin sensitivity before and after delivery. Results: Antepartum maternal omentin levels were negatively correlated with insulin levels (r=–0.41, P=0.04) and positively correlated with insulin sensitivity (HOMA%S; r=0.4, P=0.04). Postpartum omentin levels were negatively correlated with maternal body mass index (r=–0.44, P=0.02). Median maternal omentin levels was comparable before and after delivery (57.2, inter-quartile range: 38.2–76.2 ng/mL vs. 53.4, 39.8–69.4 ng/mL, respectively, P=0.25) and highly correlated (r=0.83, P<0.001). Antepartum maternal and neonatal omentin levels did not differ significantly (fetal: 62.2, 44.3–74.2 ng/mL, P=0.77) and did not correlate (P=0.6). Conclusions: Circulating maternal omentin levels are correlated with insulin resistance indices, suggesting that this adipokine may play a role in metabolic adaptations of normal gestation. The strong correlation between anteparum and postpartum maternal omentin levels, as well as the lack of association between maternal and neonatal omentin levels, suggest that placental or fetal compartments are unlikely as the main source of circulating maternal omentin.

Outcome of magnetic resonance–Guided focused ultrasound surgery (MRgFUS) for FIGO class 1 fibroids

OBJECTIVEnIntracavitary uterine fibroids and fibroids that distort the uterine cavity are associated with excessive vaginal bleeding and infertility. While intracavitary fibroids smaller than 4u202fcm are usually treated safely by operative hysteroscopy, larger fibroids may require multiple surgeries or more extensive surgery with possible damage to the integrity of the uterine wall. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a noninvasive approach for treating uterine fibroids, mainly the intramural type. We present the outcome of MRgFUS treatment for intracavitary fibroids (FIGO class 1) in cases that could not be treated by hysteroscopy due to either fibroid size or patient refusal. (Canadian Task Force II-1).nnnSTUDY DESIGNnA retrospective cohort study from a single tertiary referral center. A total of 68 patients were treated by MRgFUS for symptomatic uterine fibroids from January 2013 to December 2016. Six of them had FIGO class 1 fibroids. Adverse effects and short- and long-term outcomes (quality of life issues and need for additional surgical intervention) were assessed during ambulatory clinic visits and by phone interviews.nnnRESULTSnThe meanu202f±u202fSD fibroid volume on MRI screening was 86.3u202f±u202f60.9u202fcm3. Six of those patients underwent the procedure (mean age 40.5u202f±u202f5.6u202fyears, range 33-48). The follow-up duration was 24.1u202f±u202f12.0u202fmonths. Four patients were not interested in future fertility and did not undergo additional treatment, while the two who planned to conceive underwent another surgical intervention (one underwent operative hysteroscopy after reduction of fibroid size and the other underwent laparoscopic myomectomy).nnnCONCLUSIONnThis preliminary study shows that MRgFUS can be a feasible treatment option for FIGO class 1 uterine fibroids. Shrinkage of fibroids by MRgFUS can obviate or facilitate subsequent surgical intervention in selected cases.

In-office Hysteroscopic Extraction of Intrauterine Devices in Pregnant Patients Who Underwent Prior Ultrasound-guided Extraction Failure

STUDY OBJECTIVEnTo determine an effective method of intrauterine device (IUD) retrieval from pregnant women who had previous unsuccessful ultrasound-guided IUD extraction failure.nnnDESIGNnA retrospective cohort study (Canadian task force classification II-1).nnnSETTINGnA gynecology department of an outpatient clinic.nnnPATIENTSnPregnant patients in their first trimester with IUD in situ who underwent prior unsuccessful ultrasound-guided IUD extraction.nnnINTERVENTIONSnHysteroscopic IUD extraction guided by transabdominal ultrasound.nnnMEASUREMENTS AND MAIN RESULTSnBetween 2011 and 2014, 7 of 8 pregnant patients who had undergone previous failed attempts at IUD retrieval via ultrasound guidance underwent successful removal via ultrasound-guided hysteroscopy performed without anesthesia. The sole patient with extraction failure was in her 12th week of pregnancy, and the procedure was concluded to avoid risk to the fetus. Minimal vaginal bleeding was experienced by 2 patients after the procedure. Seven of 8 patients delivered at term without any obstetric complications. One patient had a miscarriage in her 8th week of pregnancy, 2xa0weeks after successful IUD removal.nnnCONCLUSIONnA novel, easy outpatient hysteroscopic technique without anesthesia is presented in case of failure of previous ultrasound-guided IUD removal in early pregnancy. Results are encouraging in this difficult context.

Significant increase in serum hCG levels following methotrexate therapy is associated with lower treatment success rates in ectopic pregnancy patients

OBJECTIVEnTo determine the association between early increase in the serum hCG levels (days 0-4) and treatment success rates following methotrexate therapy in ectopic pregnancy patients.nnnSTUDY DESIGNnA level II-2 case-control study of involving 140 patients treated with methotrexate for ectopic pregnancy at the gynecology department in a tertiary care hospital.nnnRESULTSnA logistic regression model for the failure of treatment was fitted with serum hCG levels change between day 0 and day 4, patient age, pregnancy age at day-0, and day-0 β-hCG level as predictors. The logistic regression analysis indicated that having more than 50% increase in the β-hCG levels between days 0 and 4 significantly (Pu2009=u20090.011) increases the risk of MTX treatment failure.nnnCONCLUSIONnThe results of this study indicate that >50% increase in β-hCG levels between days 0 and 4 significantly increases the risk of methotrexate treatment failure. This novel information could assist patients and physicians in making decisions regarding ectopic pregnancy treatment.

How Artificial Intelligence Can Improve Our Understanding of the Genes Associated with Endometriosis: Natural Language Processing of the PubMed Database

Endometriosis is a disease characterized by the development of endometrial tissue outside the uterus, but its cause remains largely unknown. Numerous genes have been studied and proposed to help explain its pathogenesis. However, the large number of these candidate genes has made functional validation through experimental methodologies nearly impossible. Computational methods could provide a useful alternative for prioritizing those most likely to be susceptibility genes. Using artificial intelligence applied to text mining, this study analyzed the genes involved in the pathogenesis, development, and progression of endometriosis. The data extraction by text mining of the endometriosis-related genes in the PubMed database was based on natural language processing, and the data were filtered to remove false positives. Using data from the text mining and gene network information as input for the web-based tool, 15,207 endometriosis-related genes were ranked according to their score in the database. Characterization of the filtered gene set through gene ontology, pathway, and network analysis provided information about the numerous mechanisms hypothesized to be responsible for the establishment of ectopic endometrial tissue, as well as the migration, implantation, survival, and proliferation of ectopic endometrial cells. Finally, the human genome was scanned through various databases using filtered genes as a seed to determine novel genes that might also be involved in the pathogenesis of endometriosis but which have not yet been characterized. These genes could be promising candidates to serve as useful diagnostic biomarkers and therapeutic targets in the management of endometriosis.

Second dose of PGE2 vaginal insert versus Foley transcervical balloon for induction of labor after failure of cervical ripening with PGE2 vaginal insert.

Abstract Purpose: To determine the success rate of induction of labor (IOL) using Foley transcervical balloon (FTB) versus prostaglandin E2 (PGE2) vaginal insert, following failure of cervical ripening with PGE2 vaginal insert. Materials and methods: A retrospective cohort study of all pregnant women admitted for IOL with either FTB or PGE2 vaginal insert. Either second dose of PGE2 vaginal insert or FTB was used as a second line treatment after failure (not giving birth in 24u2009h from insertion) of first PGE2 vaginal insert. Results: During the study period, 1162 women were admitted for IOL. Failure was reported in 322/852 (37.8%) in the FTB versus 162/310 (52.2%) in the PGE2 group (pu2009<u20090.001). Among 162 patients treated with PGE2 as first line who did not deliver after 24u2009h, 14 had spontaneous rupture of membranes, 15 underwent stripping and 42 were in still in active labor. The remainder were allocated to either second trial of PGE2 treatment (nu2009=u200958) or FTB (nu2009=u200933) with failure rate higher in the PGE2 group, not statistically significant (pu2009=u20090.23). Conclusion: IOL with FTB was not superior to PGE2 vaginal insert for IOL following failure of cervical ripening with PGE2 vaginal insert.

The Yield of Abdominal Ultrasound in the Evaluation of Elevated Liver Enzymes during the Second and the Third Trimester of Pregnancy

Aims: To determine the clinical yield of abdominal ultrasound in the evaluation of elevated liver enzymes (ELEs) in the second and the third trimester of pregnancy. Methods: A retrospective cohort study including all pregnant women admitted to a single tertiary care center was conducted between April 2011 and January 2015 with ELE. Inclusion criteria included gestational age above 24 weeks and ELEs, abdominal ultrasound report, and live fetus. Exclusion criteria included known maternal liver disease, structural or chromosomal fetal anomalies, and positive serology for viral hepatitis. All patients underwent abdominal ultrasound. A significant finding of this study led to a change in treatment. Results: One hundred and twenty patients (41.8%) met inclusion criteria: 93 (77.5%) had a normal scan and 27 (22.5%) had abnormal findings. Significant ultrasound findings were found only in 2 (1.6%) patients: gallstones in the common bile duct and suspected autoimmune hepatitis. There were no significant differences between patients with and without ultrasound findings in the rate of cholestasis of pregnancy, preeclampsia, chronic hypertension, and gestation diabetes. Conclusion: Abdominal ultrasound examination in this population has a low clinical yield. The decision to perform an abdominal ultrasound must be individualized based on the obstetric history, clinical findings, and the level of liver enzymes.

Feasibility and efficacy of repeated hysteroscopic cesarean niche resection

OBJECTIVEnCesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain and associated infertility. Hysteroscopic niche resection is usually a successful treatment, but can result in a failure to improve symptoms or symptoms can recur. In the present study we aim to evaluate the feasibility, effectiveness, and safety of a second hysteroscopic niche resection for patients in whom an initial hysteroscopic resection failed to improve symptoms.nnnSTUDY DESIGNnThis retrospective cohort study (Canadian Task Force classification II-2) hospital tell hashomer (tertiary center) included all patients who underwent a second hysteroscopic niche resection between 2011 and 2015.nnnMEASUREMENTSnFertility,obstetric outcomes, clinical outcome and complications were compared between the first surgery and the second RESULTS: Eight patients underwent a second hysteroscopy after failure of the first hysteroscopy to resolve symptoms or after recurrence of symptoms. Abnormal uterine bleeding (AUB) was the most common symptom, occurring in all patients. The average number of days of bleeding per cycle were significantly reduced following the second surgery [14.50 (range 8-21days) vs 11.75 (range 8-20days), respectivelyp=0.009]. The second surgery improved symptoms in 6 out of the 8 patients with AUB and 1 of 2 patients with pain. There were no significant differences in fertility and obstetric outcomes between the first and the second surgery and no complications were reported during any of the surgeries.nnnCONCLUSIONnReintervention with a second hysteroscopic niche resection is both feasible and effective treatment option following a failed first attempt or recurrence of symptoms. The second surgery improved symptoms, especially AUB, with no consequent detrimental effect on obstetric outcomes on our series.