Shlomo Markov

Induction of labor versus expectant management in macrosomia: A randomized study

Objective Macrosomia at term is associated with increased maternal and neonatal morbidity, including a higher rate of cesarean delivery and shoulder dystocia. Induction of labor has been suggested as a means to prevent further weight gain and improve outcome. The aim of this study was to determine whether or not induction of labor in these cases improves maternal and neonatal outcome. Methods Patients at term with an ultrasonic fetal weight estimation of 4000-4500 g were prospectively randomized into two groups: induction of labor (group I) and expectant management (group II). Patients with diabetes, a previous cesarean delivery, or nonvertex presentation were excluded. Outcome variables included mode of delivery, arterial cord pH, presence of shoulder dystocia, brachial plexus injury, clavicular fracture, cephalophematoma, and intraventricular hemorrhage. Results Of 273 patients who were eligible for the study, 134 were randomized to group I and 139 to group II. Parity, gestational age, and fetal weight estimation were similar in the two groups. The neonates of group II patients were significantly heavier (4132.8 ± 347.4 versus 4062.8 ± 306.9 g; P = .024). The rate of cesarean delivery was 19.4% in group I and 21.6% in group II patients (not significant [NS]). Cord pH was similar in both groups. shoulder dystocia was diagnosed in five grup I and six group Ii patients (NS). None developed brachial plexus injury in group Ii patients without documented shoulder dystocia. Mild intraventricular bemorrhage was diagnosed in three of 44 group I and two of 31 group II neonates evaluated (NS). Conclusion In this prospective, randomized study, induction of labor for suspected macrosomia at term did not decrease the rate of cesarean delivery or reduce neonatal morbidity. Ultrasonic estimation of fetal weight between 4000 and 4500 g should not be considered an indication for induciton of labor.

Diagnostic value of transvaginal color Doppler flow in ovarian torsion

OBJECTIVE To evaluate the role of Doppler flow in the diagnostic process of ovarian torsion. METHODS Twenty-two patients who displayed the clinical symptoms of abdominal pain concomitant with an ovarian mass and were scheduled for explorative laparoscopy were enrolled in the study. The cohort was divided into 3 groups: (A) 8 patients with clinical and sonographic evidence of torsion; (B) 8 patients with abdominal pain and sonographic diagnosis of hemorrhagic cyst; and (C) 6 patients with a simple cystic mass who had undergone explorative surgery due to abdominal pain. RESULTS After Doppler flow imaging, Group A displayed no blood flow within the mass, and surgery confirmed the diagnosis of ovarian torsion. Seven of the 8 group B patients showed ovarian vascular flow (RI = 0.472 +/- 0.067). Only 2 of the 6 Group C patients displayed vascular flow (RI = 0.680 +/- 0.129) within an untwisted cyst, confirmed by laparoscopy. CONCLUSIONS The combination of Doppler flow imaging with the morphologic assessment improves the diagnostic accuracy of ovarian torsion.

Ovarian volume in postmenopausal women-suggestions to an ovarian sue. nomogram for menopausal age

Background. Transvaginal ultrasonography is an accurate and reliable technique for measuring ovarian size. However, there is no consensus as to the normal ovarian size in postmenopausal women. The purpose of this study was to establish normal values for ovarian volume in postmenopausal age.

Microhysteroscopy and endometrial biopsy results following failed diagnostic dilatation and curettage in women with postmenopausal bleeding

OBJECTIVE: The aim of this study was twofold: firstly to evaluate and compare the diagnostic precision of the microhysteroscopy (MH) and endometrial biopsy in a group of menopausal women in whom D&C had failed to obtain an adequate endometrial sample, and secondly to quantitate the value of a hysteroscopy in determining endometrial sampling in these patients.

Antibiotic for cesarean section: the case for ‘true’ prophylaxis

OBJECTIVES: To assess prospectively the efficiency and safety of two extended spectrum cephlosporins used as pre‐operative prophylaxis in nonelective cesarean sections, and compare the results to those of a third group of patients that received cefamezine post cord clamping. METHODS: Two hundred and forty one patients undergoing a nonscheduled cesarean section were assigned to receive either cefonicid or ceftriaxone prior to skin incision. These patients were followed prospectively for infectious and fetal complications. The outcome of these patients was also compared with another group of 194 patients that received cefamezine prophylaxis post cord clamping, and whose data were collected retrospectively. Chi‐square analysis of variance were performed with P < 0.05 considered significant. RESULTS: There were no significant differences in the febrile complications among the two groups of patients that received pre‐operative prophylaxis. However, these patients had significantly less wound infections (P = 0.008) and a significantly shorter hospital stay (P < 0.001) than the patients who received their prophylactic antibiotics post cord clamping. CONCLUSIONS: Extended‐spectrum cephalosporins, when given pre‐operatively, are both effective and safe, and may have an advantage over intra‐operative first generation cephalosporins in the reduction of post cesarean section infectious morbidity.

Maternal and fetal serum and tissue levels of ceftriaxone following preoperative prophylaxis in emergency cesarean section

The use of antibiotic prophylaxis in emergency cesarean section has become the standard of care. Concern over fetal exposure has been the reason that antibiotics are traditionally given post cord clamping, but this does not allow adequate antibiotic levels in maternal blood and tissue to be achieved at the stage of incision and during surgery. We evaluated by bioassay maternal and fetal serum and placental ceftriaxone concentrations following the intravenous administration of 1.0 g of ceftriaxone upon the decision to perform cesarean section. The preoperative prophylaxis with ceftriaxone resulted in adequate protective levels in the mother and very low fetal blood levels.

The use of PGE2 for induction of labor in parturients with a previous cesarean section scar

Controversy still dominates the discussion of the correct method for delivering patients with a previous cesarean section (C/S) scar. Although many have abandoned the slogan of “once a cesarean, always a cesarean”, repeat cesareans are still the rule in many institutions. We have abandoned this dogma, and are now advancing to new ideas and are promoting a new protocol. Nineteen post‐one cesarean section patients were induced on various indications by means of PGE2 pessaries. Close surveillance revealed no complications and 16 were delivered vaginally. All neonates had good Apgar scores, and all scars were found to be intact upon examination. We recommend cautious use of prostaglandins for selected post‐cesarean patients.

Are Amniotic Fluid Alpha-Fetoprotein Levels Influenced by the Gender in Twin Pairs?

Objectives: To examine the assumption that amniotic fluid alpha-fetoprotein (AFAFP) levels are different in female and male twin fetuses. Design: Amniotic fluid levels of AFP in pregnancies with female and male fetuses in gender-concordant and gender-discordant twins were compared. A t test of p < 0.05 was considered significant. Material and Methods: Between 1995 and 1999, 332 genetic amniocenteses on twin pregnancies were performed at Meir Hospital, Kfar Saba, and Rambam Hospital, Haifa, Israel. One hundred and sixty-six were concordant for gender (84 females and 82 males) while 166 pairs differed in their gender. The amniotic fluid AFP levels of each sac were measured using fluorescent immunoassay methods by an AutoDELFIA machine. Results: The mean levels of AFAFP were lower in female twins compared to their male counterparts in same-gender twins (p = 0.07), although the difference was quite small. Nevertheless, there was no such difference between AFAFP of male versus female fetuses in gender-discordant twins. Conclusions: The levels of AFAFP were higher in the male twins of gender-concordant twins in comparison to female twins. No such difference was found between female versus male fetuses in gender-disconcordant twins.

Intrapartum external cephalic version of footling-breech presentation.

Background. External cephalic version is attempted prior to the onset of labor. Women who present in labor with footling breech presentation are usually delivered by cesarean section. We present our experience of external version in women in labor.

Intrapartum External Cephalic Version of Footling-Breech Presentation

BACKGROUND External cephalic version is attempted prior to the onset of labor. Women who present in labor with footling breech presentation are usually delivered by cesarean section. We present our experience of external version in women in labor. MATERIAL AND METHODS External cephalic version was attempted in thirteen patients in labor with footling breech presentation with the breech out of the pelvis. RESULTS The procedure was successful in twelve of the thirteen patients. Ten of them delivered vaginally. There were no maternal or neonatal complications. CONCLUSIONS It may be reasonable to attempt external cephalic version in patients in labor prior to performing a cesarean section.