Shabtai Romano

Spontaneous resolution of ectopic tubal pregnancy: natural history

OBJECTIVE To determine the characteristics and long-term outcome of women succeeding or failing expectant management of ectopic pregnancy (EP). DESIGN Prospective, defined protocol. SETTING University-affiliated gynecology department. PATIENTS We used a protocol that selected women with laparoscopic confirmed ectopic tubal pregnancy and declining plasma hCG values. Over a 5-year period, 60 women representing 20.1% of EPs fulfilled the inclusion criteria. Women were followed with serial hCG testing and transvaginal ultrasound. MAIN OUTCOME MEASURE Success or failure of expectant management. RESULTS Expectant management was successful in 28 (47.7%) of the patients. Thirty-two (53.3%) failed expectant management, and a treatment procedure was required. There was no difference in the resultant ipsilateral tubal patency or 1-year fertility rates of those women succeeding or failing expectant management. Analysis showed that in the face of declining values and with a starting hCG > 2,000 mIU/mL (conversion to SI unit, 1.00), 93.3% failed expectant management, whereas < 2,000 mIU/mL, 60.0% succeeded. CONCLUSION We conclude that expectant management should be offered as a treatment option only in those women fulfilling the criteria for a good prognosis.

Retrograde seeding of endometrial carcinoma during hysteroscopy

Fractional dilatation and curettage remain the most reliable methods in the diagnosis of endometrial carcinoma in the symptomatic patient. In the past few years hysteroscopy has become a helpful method, improving the specificity of the diagnosis of this pathology. We report a case of clinical stage IA grade 2 endometrial adenocarcinoma diagnosed by hysteroscopy and endometrial biopsy. Surgical staging revealed positive cytology. We suggest that irrigation of the endometrial cavity during the hysteroscopic procedure with saline may disseminate the disease to the abdominal cavity and may change the prognosis and the course of treatment.

Limited role for intratubal methotrexate treatment of ectopic pregnancy

OBJECTIVE To test the effectiveness of laparoscopic intratubal methotrexate (MTX) injection or salpingostomy in the treatment of ectopic pregnancy (EP). DESIGN Prospective predefined protocol. SETTING Department of Obstetrics and Gynecology of a university-affiliated hospital. PATIENTS AND INTERVENTIONS Between January 1988 and December 1993, we treated 342 women with EP, of which 99 were treated by either laparoscopic salpingostomy (n = 55) or intratubal MTX injection (n = 44). MAIN OUTCOME MEASURES The success and failure rates were calculated for each treatment protocol. Also analyzed were subsequent tubal patency and fertility rates. RESULTS Salpingostomy was successful in 51 of 55 patients (92.7%), whereas intratubal MTX injection was successful in only 27 of 44 women (61.4%). Methotrexate injection particularly was unsuccessful if the initial hCG was > 2,000 mIU/mL (conversion factor to SI unit, 1.00) or the size of the tubal mass was > 2.0 cm as measured during laparoscopy. There was no difference in the subsequent tubal patency rates of fertility rates between women undergoing MTX injection or salpingostomy. CONCLUSIONS These results suggest that salpingostomy is effective in the treatment of EP. Methotrexate injection failed in more patients despite preferential selection criteria, suggesting that its use should be limited to the subgroup of women with initial hCG < 2,000 mIU/mL and size at laparoscopy < 2.0 cm.

Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial.

OBJECTIVE: To examine the effect of prophylactic balloon catheters on bleeding morbidity among women with a prenatal diagnosis of placenta accreta. METHODS: In a randomized trial, women with a prenatal diagnosis of placenta accreta were randomized to either preoperative prophylactic balloon catheters (intervention group) or to a control group. Other than placement of the prophylactic balloon catheters in the anterior division of the internal iliac arteries, the same multidisciplinary approach was used in both groups. The primary study outcome was the number of packed red blood cell (RBC) units transfused. To detect a mean reduction of three packed RBC units with the prophylactic balloon catheters, 12 women in each group were needed. RESULTS: Between January 2009 and March 2015, 27 women were randomized: 13 in the intervention group and 14 in the control group. Demographic and obstetric characteristics were similar between the groups. Six (46.2%) women in the intervention and seven (50.0%) in the control group underwent cesarean hysterectomy (P=.84). There were no significant differences between the intervention and control groups in the mean number of packed RBC units transfused, 5.2 (±6.2) and 4.1 (±3.8), respectively (P=.90), or in the calculated blood loss, 4,950 (±5,051) and 4,709 (±3,434) mL (P=.72). The number of women with blood loss greater than 2,500 mL, number of plasma products transfused, duration of surgery, peripartum complications, and hospitalization length did not differ significantly between the groups. Reversible adverse effects related probably to prophylactic balloon catheter insertion were noted in 2 of 13 (15.4%) women. CONCLUSION: In women with preoperative suspicion of placenta accreta, preoperative placement of prophylactic balloon catheters did not affect the number of packed RBC units transfused. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01373255. LEVEL OF EVIDENCE: I

Laparoscopic Detorsion of Adnexa in Childhood: A Case Report

A case of adnexal torsion in premenarchal child is presented. Prompt diagnosis was made with the use of pelvic ultrasound and laparoscopy. The later was used for establishing the diagnosis and furthermore for untwisting the adnexa. We suggest that laparoscopy should precede laparotomy and that conservative detorsion should be done more liberally in the young patient.

Rudimentary Horn Pregnancy Diagnosed by Ultrasound and Treated by Laparoscopy-A Case Report and Review of the Literature

Pregnancy in a rudimentary horn occurs once in 76,000 pregnancies. The most significant threat of pregnancy in a rudimentary horn is the risk of rupture. With the use of ultrasound the diagnosis can be made before symptoms occur. Management usually consists of excision of the rudimentary horn with the pregnancy and the ipsilateral tube, traditionally by laparotomy. We present a case of an 11-week pregnancy in a rudimentary horn with a nonviable fetus diagnosed by ultrasound and treated with laparoscopic resection. Review of the literature revealed 11 cases treated successfully with laparoscopic surgery. Laparoscopic treatment should be considered for pregnancy in rudimentary horn during the first trimester.

Laparoscopic gonadectomy in 46XY female patient.

The risk of gonadal neoplasia in XY gonadal streaks is high, dictating early prophylactic removal of the streaks. Laparoscopic removal of the streaks is recommended.

Plexin-B1, glycodelin and MMP7 expression in the human fallopian tube and in the endometrium

BackgroundTo study the expression of Plexin-B1, Glycodelin, and MMP7 during the menstrual cycle in the endometrium and in the fallopian tube.MethodsThe research included women undergoing hysterectomy, tubal sterilization or salpingo-oophoerectomy. Total RNA from endometrial and fallopian tube tissues was extracted using a total RNA isolation kit. Semi-quantitative RT-PCR was performed to examine mRNA relative expression.ResultsPlexin-B1 expression in the endometrium was significantly higher on days 19 - 23 compared to days 12 - 14 (1.166 +/- 0.42 versus 0.523 +/- 0.299), P < 0.005. In the fallopian tube the level of plexin-B1 did not change significantly throughout the menstrual cycle. Glycodelin expression was significantly higher on days 19 - 23 compared with days 12-14, both in the endometrium (0.819 +/- 0.564 versus 0.072 +/- 0.343, P < 0.05) and the fallopian tube (0.796 +/- 0.196 versus 0.329 +/- 0.398, P < 0.05). Although the level of MMP7 secretion was the highest in the secretory phase the difference from the proliferative phase did not reach statistical significance, neither in the endometrium nor in the fallopian tube. This could result from a lack of power.ConclusionsIn the endometrium, both Glycodelin and Plexin-B1 are exhibiting a cyclic pattern suggesting a possible steroid regulation and a role in endometrial receptivity.

Prenatal diagnosis using sonographic guided cordocentesis

Cordocentesis has been practiced as a diagnostical tool for prenatal diagnosis of intrauterine infections, hematological disorders, metabolic status of the fetus and rapid cytogenetic analysis. The performance of 198 cordocentesis is presented over 3 years of experience. A 21 gauge spinal needle is inserted via the optimal point on the maternal abdomen under real-time ultrasonic guidance into the insertion of the umbilical cord in the placenta. Successful cordocentesis were achieved in 98.5% of the cases. Termination of pregnancy was directly related to the procedure in only 1%. Hematoma surrounding the puncturing site was demonstrated in one case, but without damage to the fetus. In our series the main indication for performing cordocentesis was the need for rapid karyotyping. The use of fetal lymphocytes for chromosomal analysis offers a rapid and a reliable method for routine clinical demands. The availability of a rapid chromosomal analysis offers a considerable advantage in pregnancies of advanced gestational age. In those pregnancies it appears to be most important to have a rapid diagnosis where anatomical structural anomalies are associated with chromosomal malformations in up to 30%. The metabolic status of the fetus is considered in either acute distress or in cases of suspected sub-optimal metabolic hemostasis, where IUGR or oligohydramnios are demonstrated. Cordocentesis, even though is a new technique, turns to play a major role in modern perinatology. The possibility of a direct rout to fetal blood vessels early during the pregnancy bears the tremendous potential of early diagnosis and treatment.

The safety of quinolones in pregnancy.

Quinolones and fluoroquinolones are highly efficient antibiotics. However, concerns regarding possible harmful effects have limited their use during pregnancy. Nevertheless, accumulating clinical data suggest that they may be safe during pregnancy. This review aimed to explore the mechanisms of action of the quinolones and fluoroquinolones, which set the stage for concerns regarding possible teratogenic and mutagenic effects; to clarify the clinical dilemmas that brought forth the necessity in reevaluating the use of those medications during pregnancy; and to review the accumulated data regarding their safety during pregnancy in animal models and humans. Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to assess the mechanisms of action that had led to concerns regarding the use of fluoroquinolones during pregnancy, appraise the basic knowledge gained from animal studies about the effects of fluoroquinolones during pregnancy, and analyze the human data on the actual effect of variable fluoroquinolones in pregnancy.