Samuel Lurie

Role of Sonography in the Diagnosis of Retained Products of Conception

Objective. To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings. Methods. This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty‐one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor. Results. Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false‐positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false‐positive rates were 28.9% and 51.5%, respectively. Conclusions. Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false‐positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Age-related prevalence of sonographicaly confirmed uterine myomas.

Uterine myomas are the most common tumour in women and are estimated to be clinically apparent in about 25% of women. The true prevalence may be even higher because examination of hysterectomy specimens suggested a 67 – 77% prevalence of myomas (Cramer and Patel, 1990). Information regarding the prevalence of uterine myomas in different age groups is limited. The aim of our study was to estimate the age specific prevalence of uterine myomas.

Comparison of the Differential Distribution of Leukocytes in Preeclampsia versus Uncomplicated Pregnancy

Objective: To describe leukocyte count and differential distribution in preeclampsia and uncomplicated pregnancy. Study design: Blood samples were obtained from 46 consecutive preeclamptic patients and 46 controls with uncomplicated pregnancy. Thirty met the criteria for mild preeclampsia and 16 for severe. The blood was tested within 1 h of venepuncture. An aliquot of the blood was tested in the Cell-Dyn 2000 for complete blood cell count. Main Results: The absolute neutrophil count was significantly elevated in preeclamptic patients as compared with that of controls with uncomplicated pregnancy (9,410.1 ± 3,066.9 vs. 7,498.6 ± 2,354.0 × 106/l, p < 0.05). In neutrophils, the elevation was more prominent in severe preeclamptic patients as compared with mild preeclamptic patients (10,658.8 ± 3520.4 vs. 8,694.4 ± 2,561.9 × 106/l, p < 0.05). The absolute lymphocyte and eosinophil counts declined in patients with preeclampsia as compared with uncomplicated pregnancy, whereas monocyte and basophil counts did not differ. Conclusion: Our results suggest that preeclampsia is associated with an increase in the absolute neutrophil count.

The history of the diagnosis and treatment of ectopic pregnancy: a medical adventure

From its indirect reference by Abulcasis (936-1013) and until the 19th century the ectopic pregnancy was known as a universally fatal accident. By reporting successful treatment of tubal pregnancy with salpingectomy in 1884 Robert Lawson Tait (1845-1899) started an era of almost 70 years of exclusively extirpative treatment of ectopic pregnancy. The technologic revolution of the 20th century improved diagnostic capabilities so that diagnosis of unruptured ectopic pregnancy becomes feasible and even mandatory. Side by side our understanding of the natural history of ectopic pregnancy improved. Many patients with early-resolving ectopic pregnancies escape surgical treatment. Preservation of future fertility became possible with the introduction of conservative surgical procedures and with the use of methotrexate. The main achievement in the treatment of ectopic pregnancy over the past 110 years is the dramatic decrease in mortality rate: from 72-90% in 1880 to 0.14% in 1990.

Transcutaneous electrical nerve stimulation (TENS) for adjuvant pain-relief during labor and delivery

Objective: We examined the efficacy of transcutaneous electrical nerve stimulation (TENS) in general and the new Freemom TENS device (LifeCare, Israel) in particular, for pain relief during labor and delivery. Methods: The study group consisted of 104 women. Forty‐six nulliparas (44.2%) and 58 multiparas (55.8%), all of whom used the TENS device for pain relief during labor. All participants completed a questionnaire on the degree of pain relief afforded them by TENS during the delivery and related questions. The objective evaluation was based on the documented labor and delivery parameters including medical interventions during delivery. Results: The majority of subjects (72% of the nulliparas and 69% of the multiparas) considered TENS effective for the relief of pain during labor. Most of them (67% of the nulliparas and 60% of the multiparas) responded positively to the use of TENS in future deliveries. Sixty‐five percent of the multiparas considered TENS at least as effective as the other pain relief methods they had used before. TENS significantly reduced the duration of the first stage of labor P<0.001 for nulliparas, P<0.005 for multiparas and it significantly decreased the amount of analgesics administered to individual patients. No significant difference was found in fetal heart rate tracings, Apgar scores and cord blood pH between the study group and an equal number of matched controls who used other forms of pain management. Conclusions: TENS is an effective non‐pharmacological, non‐invasive adjuvant pain relief modality for use in labor and delivery. TENS application reduced the duration of the first stage of labor and the amount of analgesic drug administered. There were no adverse effects on mothers or newborns.

The history of cesarean technique

Cesarean section has been practiced since ancient times. Unfortunately, no ancient medical documents describing the techniques for cesarean section are extant. In the early medieval period, cesarean section was usually performed by midwives. One of the first explicit instructions in medical literature on cesarean technique dates from about 1480 ce from southern Germany. We discuss the evolution of cesarean surgical technique and point up the contribution of many giants in the field of obstetrics and gynecology, such as Blundell, Frank, Harris, Joel-Cohen, Kehrer, Kerr, Lebas, Levret, Maylard, Pfannenstiel, Porro, Portes, and Sanger.

Personality, fear of childbirth and cesarean delivery on demand

Objectives. To investigate both the psychological traits and the demographic factors associated with cesarean section on maternal demand. Design. Cross‐sectional questionnaire study. Setting. Delivery ward, Edith Wolfson Medical Center, Holon, Israel. Sample. Fifty‐nine healthy primigravida with a singleton pregnancy were recruited during 2009, of whom 28 requested and were delivered by cesarean section without obstetrical indication, whereas 31 opted for spontaneous vaginal delivery. Methods. All questionnaires were administered to the two groups at term. Various psychological (fear of childbirth questionnaire, Millon Clinical Multiaxial Inventory III, Anxiety Sensitivity Index, State‐Trait Anxiety Index and social support scale) as well as demographic variables were measured before labor and compared. A priori power calculation yielded a power of 95%. Main Outcome Measures. Fear of childbirth, various personality disorders and psychiatric clinical syndromes (29 Millon Clinical Multiaxial Inventory III scales), Anxiety Sensitivity, State Anxiety Index, social support and demographic variables. Results. Differences in age and method of conceiving (p<0.001) were found between the groups. The study group reported a higher level of fear of childbirth (p<0.001), but no differences were found in all other personality characteristics measured (29 Millon Clinical Multiaxial Inventory III scales, State‐Trait Anxiety, Anxiety Sensitivity and social support scale). The origin of the difference regarding the fear of childbirth was located to two specific questions: ‘Have you always been afraid of giving birth?’ and ‘Have you sometimes thought of the delivery as something unnatural?’ Conclusions. The only psychological variable associated with the choice for cesarean section on maternal request was the fear of childbirth.

The changing motives of cesarean section: from the ancient world to the twenty-first century

BackgroundCesarean delivery has been practiced for ages, although originally as a universally postmortem procedure. It is referred to in the myths and folklore of many ancient societies, for some of the infants delivered in this way survived, even though their mothers did not. Since the Renaissance, the objective of the procedure has gradually shifted towards saving the lives of both the mother and the child, and this has become ever more possible, as maternal and perinatal mortality and morbidity decreased dramatically during the twentieth century.Current issues Today (at the beginning of twenty-first century), we are not only concerned with the safety and health of the mother and the child, but also with mother’s desires and preferences and the child’s rights.

Different degrees of fetal oxidative stress in elective and emergent cesarean section.

Background: Several studies have addressed the influence of labor and mode of delivery on oxidative stress. Still it is unclear whether oxidative stress is related to delivery itself or whether it reflects a pre-existing fetal oxidative status. Objective: To investigate whether the degree of fetal oxidative stress is different between distressed fetuses that were delivered by emergent cesarean section and non-distressed fetuses that were delivered by elective cesarean section. Methods: The protocol of this prospective study was approved by the Institutional Review Board Committee. Amniotic fluid and umbilical artery blood were prospectively collected from 21 parturients who were delivered by an emergent cesarean section for non-reassuring fetal heart rate pattern and from 21 parturients who were delivered by an elective cesarean section in a tertiary care center. Oxidative stress was evaluated in amniotic fluid, umbilical cord plasma and erythrocytes by determining malondialdehyde concentration and glutathione peroxidase (GPX) activity. Results: Malondialdehyde concentration was higher in amniotic fluid (mean ± SEM) (2.2 ± 0.7 nmol/l vs. 0.6 ± 0.02 nmol/l, p < 0.05), in umbilical cord plasma (1.2 ± 0.2 nmol/l vs. 0.7 ± 0.3 nmol/l, p < 0.05) and in umbilical cord erythrocytes (159.6 ± 48.6 nmol/g Hb vs. 85.8 ± 5.2 nmol/g Hb, p < 0.05) in women delivering by emergent cesarean compared to those delivering by elective cesarean. GPX activity was enhanced in amniotic fluid (12.4 ± 2.2 U/l vs. 5.1 ± 0.6 U/l, p < 0.05) and GPX activity/hemoglobin ratio was higher in cord blood (22.0 ± 0.8 U/g Hb vs. 18.7 ± 0.9 U/g Hb, p < 0.05) in women delivering by emergent cesarean compared to those delivering by elective cesarean. Conclusion: Distressed fetuses delivered by emergency cesarean exhibited increased malondialdehyde concentrations, an indicative parameter for oxidative damage, and enhanced GPX activity an antioxidant enzyme, in amniotic fluid and umbilical cord blood compared to non-distressed fetuses delivered by elective cesarean section. This is probably an indication of higher fetal oxidative stress.

Symptomatic hyponatraemia due to inappropriate antidiuretic hormone secretion following minor surgery

A rare case of the syndrome of inappropriate antidiuretic hormone secretion occuring after minor surgery is presented. A ten-year-old, previously healthy boy underwent general anaesthesia for detorsion and right orchiopexy. Throughout the operations, which lasted for one hour, he received 120 ml Ringer’s lactate solution. The immediate postoperative period was uneventful. Twenty-two hours postoperatively he was found unconscious with generalized tonic-clonic seizures. Simultaneously obtained serum sodium concentration (121 mEq · L−1) serum osmolarity (265 mEq · L−1), urine sodium concentration (87 mEq · L−1) and urine osmolarity (525 mEq · L−1) suggested inappropriate antidiuretic hormone secretion which was confirmed by an elevated serum arginine-vasopresin (AVP) level of 14.5 pcg · ml−1 (normal 1–5 pcg · ml−1) measured by radioimmune assay. He was treated with a single iv dose of 30 mg furosemide and fluid restriction, which produced a gradual increase of his serum sodium concentration to normal within two days. He was well during the remainder of his hospitalization.RésuméOn présente un rare cas d’ un syndrome de sécrétion inappropriee d’ hormone antidiurétique survenant après chirurgie mineure. Un enfant en bonne santé âgé de dix ans a subi l’ anesthésie générale pour détorsion et orchiopexie droite. Durant l’opération qui a durée une heure, il a reçu 120 ml de lactate Ringer. La période postopératoire fut sans complication. Vingt-deux heures après l’ opération, l’ enfant fut trouvé inconscient avec. des convulsions généralisées cloniques-toniques. La concentration simultanée de sodium sérique (121 mEq · L−1), l’osmolarité sérique (265 mEq · L−1), la concentration sodique d’ urine (87 mEq · L−1) et l’ osmolarité urinaire (525 mEq · L−1) out suggéré le syndrome de sécrétion inappropriée d’ hormone antidiurétique qui fut confirmé par l’ élévation de la concentration sérique de l’ arginine-vasopressine (AVP) de 14.5 peg · ml−1 (normle 1–5 peg · ml−1) mesurée par radioimmunoessai. Il fut traité par une dose intraveineuse unique de 30 mg de furosémide et la restriction hydrique qui amena graduellement une augmentation de la concentration du sodium sérique a la normale en dedans de deux jours. Il se sentait bien durant de son hospitalisation.