Sharon Maslovitz

Improved accuracy of postpartum blood loss estimation as assessed by simulation

Objective. Caregivers underestimate the amount of blood loss, but this almost five decades‐old assumption has not been validated. We aimed at assessing the accuracy of estimated blood loss by obstetrical teams during a simulated Postpartum hemorrhage (PPH) scenario. Study design. a prospective study conducted as part of the simulation‐based training course, using sophisticated mannequin simulators adapted for obstetrical training by specially designed devices. Setting. Part of the simulation‐based training course. Population. Obstetrical teams consisted of physicians and obstetrical nurses. Methods. Each of the participating obstetrical teams assessed blood loss during PPH scenarios. Their estimates were compared to the actual predefined 3.5‐liter blood loss. An intervention group underwent a similar course in which they recorded their estimations after 1, 2 and 3.5 liters were lost. Outcome measures. Blood loss estimates after completion of the scenario in both groups. Results. Fifty obstetrical teams took part in the study. Eight comprised the interventional group. The average estimated blood loss was 1,780 ml (49% underestimation) for non‐interventional teams. The interventional groups estimated blood loss to be 2,400 ml (32% underestimation). The main method of estimating blood loss was ‘gut feeling’, followed by verbalized guesses of team members and assessments of the ‘patients’ hemodynamic status. Conclusions. Accuracy of blood loss estimations by a simulation‐based PPH scenario was 50–60%. Measurements at predetermined intervals significantly improved accuracy of these estimations. Our study suggests that implementation of periodic estimations of blood loss in the management of PPH might improve clinical judgment.

The Significance of Clinical Signs and Blood Indices for the Diagnosis of Appendicitis during Pregnancy

Objective: To evaluate the significance of clinical signs and blood indices for the diagnosis of appendicitis during pregnancy. Sample: Of the 40,112 women delivering at our institution (January 1995 to June 2002), 38 women (0.094%) were operated due to the suspicion of appendicitis during pregnancy. Methods: Body temperature, clinical examination, white blood cell counts and lag time from arrival to operation were obtained for each patient. All women were operated with the clinical diagnosis of appendicitis, and their appendices were removed and examined by a pathologist. Results: Inflammatory appendix was discovered in 19 (0.047%) of the pregnancies with subsequent deliveries while a normal appendix was found in 19 of the 38 (50%) appendices removed. The group with normal appendix did not significantly differ from women with inflamed appendix with regard to gestational age at presentation, signs of peritoneal irritation, body temperature, leukocyte count, time elapsed between arrival and surgery, gestational age at delivery and birth weight. Conclusions: The accurate diagnosis of appendicitis during pregnancy is a difficult task requiring a very high level of suspicion and clinical skills and not merely relying upon laboratory and classic signs.

Low molecular weight heparin versus no treatment in women with previous severe pregnancy complications and placental findings without thrombophilia.

Low molecular weight heparin (LMWH) treatment has been recommended for pregnant women with previous adverse pregnancy and who were diagnosed as having a thrombophilia. We now examined the effect of LMWH on pregnant women without thrombophilias who had severe pregnancy complications and placental vasculopathy in an earlier pregnancy. Seventy-two women with a history of severe preeclampsia, fetal growth restriction (FGR) less than fifth percentile, severe placental abruption and/or stillbirth after 20 weeks, whose thrombophilia workup was negative, were enrolled. Placental vasculopathy was defined as villous infarcts, fibrinoid necrosis of decidual vessels, fetal vessel thrombosis, evidence of placental abruption and perivillous fibrin deposition. The study group consisted of 32 pregnant women who were treated with LMWH and 40 pregnant women who were not treated with LMWH (control group) in their ensuing pregnancy in our institution between 2003 and 2007. The incidences of severe preeclampsia, FGR, placental abruption and stillbirth in the previous pregnancies were similar for both groups. The incidences of severe preeclampsia and placental abruption in the study group in the index pregnancy were significantly lower than the control group (3.13 versus 20%, P = 0.03; and 0 versus 15%, P = 0.03, respectively). The respective incidence of FGR was 6.25 versus 22.5%, and of overall adverse outcome was 9.4 versus 60% (P = 0.001). Treatment with LMWH may reduce the rate of the recurrence of severe pregnancy complications and significant placental vasculopathy in women without thrombophilias.

Recombinant luteinizing hormone induces increased production of ovarian follicular adiponectin in vivo: implications for enhanced insulin sensitivity

OBJECTIVE To determine in vivo whether LH supplementation during the late follicular phase induces increased production of ovarian follicle adiponectin in humans. DESIGN Randomized, double-blind, placebo-controlled study. SETTING Academic tertiary care medical center. PATIENT(S) Twenty infertile, healthy women (aged 18-39 years) undergoing IVF. INTERVENTION(S) Administration of recombinant FSH after down-regulation and equal randomization of subjects to receive recombinant LH 75 IU/day or placebo when two or more follicles reached a mean diameter of 14 mm. MAIN OUTCOME MEASURE(S) Follicular fluid (FF) adiponectin levels were measured. RESULT(S) Adiponectin FF levels were significantly higher in the recombinant LH group compared with the placebo group, and these differences were unaltered after correction to estrogen (E) levels and number of follicles in each cycle. CONCLUSION(S) This is the first demonstration of in vivo induction of adiponectin by gonadotropins in the human ovary. The addition of recombinant LH during the late follicular phase may enhance follicular insulin sensitivity, resulting in decreased androgen levels through a cascade mediated by increased production of adiponectin.

Regulation of vascular endothelial growth factor-A and its soluble receptor sFlt-1 by luteinizing hormone in vivo: implication for ovarian follicle angiogenesis

OBJECTIVE To determine in vivo whether LH supplementation during the late follicular phase induces ovarian follicle angiogenesis in humans, as reflected by vascular endothelial growth factor (VEGF)-A, its soluble receptor sFlt-1, and placental growth factor (PlGF) expression. DESIGN Randomized, double-blind, placebo-controlled study. SETTING Academic tertiary care medical center. PATIENT(S) Twenty infertile, healthy women (aged 18-39 years) undergoing IVF. INTERVENTION(S) Administration of recombinant FSH after down-regulation and equal randomization of subjects to receive recombinant LH 75 IU/day or placebo when two or more follicles reached a mean diameter of 14 mm. MAIN OUTCOME MEASURE(S) Serum and follicular fluid (FF) VEGF-A, sFlt-1, and PlGF protein levels were measured. RESULT(S) Recombinant LH increased both the FF VEGF-A/sFlt-1 ratio statistically significantly and PlGF/sFlt-1 insignificantly. Recombinant LH did not affect the serum VEGF/sFlt-1 ratio. Plasma levels of PlGF were undetectable. CONCLUSIONS This in vivo study demonstrates for the first time in humans that LH induces ovarian follicular angiogenesis via modulation of VEGF-A and its soluble receptor sFlt-1 expression. A constant VEGF-A/sFlt-serum ratio may prevent adverse effects of VEGF-A. Because angiogenesis is essential during the periovulatory period, recombinant LH supplementation during the late follicular phase may improve ovulation induction outcome.

Outcome of singleton pregnancy in women ≥45 years old: a retrospective cohort study

Objective: To investigate prematurity rate in women aged ≥45 carrying a singleton pregnancy. Other maternal and neonatal outcomes are also described. Design: Retrospective cohort study. Setting: Women delivering a singleton pregnancy at a single tertiary medical center. Population: The study included all women aged 45 years and over who delivered at 20 weeks gestation or beyond over a 9-year period from May 2000 to May 2009. Methods: Women aged 45 years and over were identified. The study group was compared to a control group of women <40 years with singleton pregnancies conceived by in vitro fertilization (IVF) who delivered during the same time period. Main Outcome Measure(s): Maternal complications during pregnancy and neonatal outcome. Results: During the study period 278 women ≥45 years delivered a singleton pregnancy. The control group included 304 women. The rate of delivery before 37 weeks as well as before 32 weeks were very high in our study group (18.7 vs. 10.9%, p = 0.009 and 5.4 vs. 2.0%, p = 0.04, respectively). In multivariate analysis, older maternal age was not independently related to prematurity. Chronic hypertension (HTN) was found to be a major risk factor associated with prematurity in advanced maternal age. Conclusions: Women ≥45-years-old with a singleton pregnancy carry a higher risk of maternal and perinatal complications. Preterm birth is a significant complication in this age group and is associated with preexisting chronic HTN.

Renal Blood Flow Alteration After Paracentesis in Women With Ovarian Hyperstimulation

OBJECTIVE: To evaluate renal arterial resistance to flow by Doppler indices concurrently with ascites drainage in women with severe ovarian hyperstimulation syndrome. METHODS: We conducted an interventional clinical study of 19 women with severe ovarian hyperstimulation syndrome, manifested by free peritoneal fluid. The subjects were evaluated before and after therapeutic paracentesis by measuring urine output, blood urea nitrogen, intra-abdominal pressure, and renal artery flow measures by Doppler ultrasonography (systolic/diastolic ratio [S/D] and resistance index). RESULTS: An average of 3,340 mL of ascitic fluid was drained, and the intra-abdominal pressure decreased from 17.5 ± 1.24 cm H2O to 10 ± 1.22 cm H2O. Urine output was increased (by 65%, from 925 ± 248 mL/d before paracentesis to 1,523 ± 526 mL/d on the day after paracentesis, P < .001). The mean renal arterial S/D decreased from 3 ± 0.15 to 2.29 ± 0.13 (P = .001). Most of the decrease in intra-abdominal pressure as well as in renal vasculature resistance was apparent after an initial drainage of 2,000 mL. Additional fluid drainage had only negligible effect on intra-abdominal pressure and renal flow. CONCLUSION: Paracentesis lowered intra-abdominal pressure and decreased renal arterial resistance (lowered S/D and resistance index), ultimately resulting in increased urine production. It is plausible that the beneficial effects of paracentesis on urine output in ovarian hyperstimulation syndrome are due to improved renal blood flow from a direct decompression effect. LEVEL OF EVIDENCE: II-3

Complications of trans-cervical Foley catheter for labor induction among 1,083 women

ObjectiveTo report complications associated with the use of trans-cervical Foley catheter with extra-amniotic saline infusion (EASI) for cervical ripening.MethodsThis is a retrospective descriptive study of 1,083 women who underwent EASI ripening. Data on perinatal outcome was retrieved from our computerized database and the medical charts. The primary study outcome was the occurrence of side effects related to the procedure.ResultsThe study population included 1,083 women. The balloon had to be removed due to complications in 95 (8.8%). The main complications were: acute transient febrile reaction in 32 (3%), non-reassuring fetal heart rate tracing in 22 (2%), vaginal bleeding in 20 (1.8%), unbearable pain that necessitated removal of the catheter in 19 women (1.7%) and altered presentation from vertex to breech in 14 (1.3%).ConclusionComplications associated with trans-cervical ripening and EASI occurred in 7.6% and included acute febrile reaction, pain, vaginal bleeding and altered fetal presentation.

Enhanced Erythrocyte Aggregation in Clinically Diagnosed Pelvic Inflammatory Disease

Objective: Enhanced erythrocyte aggregation, revealed using a simple bedside test, has been found recently in several inflammatory conditions. The diagnosis of pelvic inflammatory disease (PID) is at times difficult because of the vague symptoms and signs, but is crucial because even mild PID can have future reproductive consequences. Our objective was to determine the degree of erythrocyte aggregation in PID. The demonstration of an increase in aggregation could be of additive value in cases in which the diagnosis is difficult. Study design: A prospective case-control study was conducted. Fifteen consecutive women diagnosed clinically as having PID based on Centers for Disease Control and Prevention criteria, and 15 matched controls were enrolled. Blood samples were drawn for hematologic indices, C-reactive protein, fibrinogen levels, and red cell aggregation. We studied the degree of red cell aggregation using a simple slide test and image analysis. The variable measured was the erythrocyte percent (EP), equivalent to the slide area covered by erythrocytes. Results: Erythrocyte percent was 59.6 ± 4.2 and 80.0 ± 3.6 for the study group and controls, respectively (P <0.001). A significant difference was noted also for the other hematologic and biochemical markers of inflammation between patients and the controls. Conclusions: We conclude that the degree of erythrocyte aggregation is increased in PID. Its simplicity, rapidity, and low cost should be further evaluated as a diagnostic tool in the context of this frequent disease.

Outcomes of Mid-Trimester Emergency Cerclage in Twin Pregnancies

Introduction: Placement of emergency cerclage at mid-trimester is controversial. At present, clinical trials comparing outcomes of mid-trimester cerclage to bed rest in twin pregnancies are lacking. Our aim was to examine the efficacy, safety and outcomes of mid-trimester cerclage in patients carrying twin gestations. Material and Methods: We retrospectively studied the outcomes of 14 patients carrying twin gestations with significant cervical dynamics who underwent cerclage. Outcomes of patients with cervical effacement only and patients with bulging membranes through the external os were examined. The interval between cerclage and delivery and the complication rates were calculated. Results: The average time interval between cerclage placement and delivery was 71.1 days overall. Patients with cervical shortening or effacement only (n = 10) gave birth an average of 80.2 days after the procedure, while 4 patients with bulging membranes gave birth an average of 48.5 days after cerclage placement. The overall procedure failure rate, defined as delivery before 28 completed weeks, was 14.2%. Discussion: Patients carrying twin gestations with advanced cervical changes might benefit from therapeutic cerclage. Further studies are required to demonstrate whether there is a difference compared to bed rest alone.