Shmuel Goldberger

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.

Severe juvenile vaginal bleeding due to Glanzmann's thrombasthenia : Case report and review of the literature

Glanzmanns thrombasthenia is a rare inherited hematological disorder defined by deficiency or abnormality of the glycoprotein (GP) IIb‐IIIa complex. Presenting symptoms are hemorrhagic events, mainly epistaxis, purpura, or menorrhagia. We describe the clinical course and management of a 14‐year‐old girl with Glanzmanns thrombasthenia and severe menorrhagia. Following treatment with 20 U of packed red blood cells, 37 U of platelets, 7 U of fresh frozen plasma, cryoprecipitate, intravenous estrogens, and methylergotrine maleate with no improvement, the uterine cavity was packed for 48 hr. This unusual procedure halted the bleeding and avoided the necessity for a hysterectomy. When treating acute menorrhagia in patients with Glanzmanns thrombasthenia, the physician should be familiar with the characteristics and all treatment modalities for this disorder. Am. J. Hematol. 57:225–227, 1998.

Is it necessary to perform a prophylactic oophorectomy during hysterectomy

OBJECTIVE To evaluate the subsequent pelvic sonographic characteristics as well as the clinical outcome following hysterectomy with and without oophorectomy. STUDY DESIGN A prospective study of sonographic evaluation of 164 women, aged 29-72 years, with a history of hysterectomy was performed. Ninety-one patients underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and 73 women had either hysterectomy (abdominal or vaginal) only or hysterectomy with unilateral salpingo-oophorectomy. RESULTS The mean time interval between surgery and sonographic evaluation was 4.3 years (range, 1-25 years). Out of the 73 women with left ovaries, 37 (50.7%) were found to have pelvic lesions and four women underwent re-operations following these findings. The histologic finding were cystadenoma, hydrosalpinx with periovarian adhesions and two paraovarian cysts. In comparison, only five of the 91 women (5.5%) following bilateral salpingo-oophorectomy were found to have pelvic lesions (P < 0.0005). None of the women with prophylactic oophorectomy were operated upon following these findings. CONCLUSIONS In comparison to patients after total hysterectomy and bilateral salpingo-oophorectomy, women with prior hysterectomy and ovarian preservation are prone to subsequent pelvic lesions. They need to be closely followed with clinical, laboratory and sonographic means, and may undergo reoperations in order to rule out the possibility of neoplasia.

Estrogen Replacement in Postmenopausal Women: Are We Currently Overdosing Our Patients?

As there are no proven optimal serum estradiol levels, we sought to evaluate the pharmacokinetic profiles of serum estradiol levels following a single oral dose of 2 mg estradiol and 1 mg of estriol (Trisequens) among 26 surgically induced, postmenopausal patients. Their serum estradiol levels were periodically measured over 24 h following oral administration of the drug. They were divided into two groups according to the computed hourly mean estradiol values: group A, < 250 pg/ml/h ( < 918 pmol/l/h) and group B, > 250 pg/ml/h ( > 918 pmol/l/h). The mean peak estradiol concentrations were noted 2 h after drug administration and amounted to 595 +/- 190 pg/ml (2,184 +/- 697 pmol/l) in the entire cohort; 435 +/- 117 pg/ml (1,597 +/- 430 pmol/l) in group A and 712 +/- 142 pg/ml (2,614 +/- 521 pmol/l) in group B (p < 0.001). The mean total area under the curve in group A was 4,887 pg/ml (17,940 pmol/l), which was significantly lower than that of 7,995 +/- 652 pg/ml/24 h (29,350 +/- 2,393 pmol/l/24 h) found for group B (p < 0.001). The mean body mass index showed a significant difference (p < 0.003) between group A and group B (29.4 +/- 0.56 vs. 24.3 +/- 0.24). We found that 57% of our patients were exposed to excessively high levels of estradiol during the 24-hour period following drug ingestion. We advise monitoring estradiol levels and individualizing estrogen replacement therapy, to avoid the long-term exposure of postmenopausal patients to superphysiological estradiol levels.

The Role of Color Doppler Flow in the Management of Nonmetastatic Gestational Trophoblastic Disease

Three patients with findings suggestive of invasive gestational trophoblastic neoplasm and lung metastasis were assessed by color Doppler transvaginal ultrasound, before and during chemotherapy. The sonographic findings were correlated with beta-hCG levels measured at various stages of treatment. Results were compared with blood flow indices found during normal first trimester pregnancies, and those following elective termination of pregnancy. The mean resistance indices were significantly lower in the patients treated with chemotherapy (0.410 +/- 0.04) than in the early pregnancy control group (5-8 weeks gestation; n = 20, resistance index = 0.494 +/- 0.06). The difference between the groups was statistically significant (chi 2; p < 0.05). No pathological flow patterns could be discerned in 10 patients, who after termination of pregnancy had beta-hCG levels below 5 IU/ml. The response of gestational trophoblastic neoplasms to chemotherapy could be reliably assessed by observing the changes in flow resistance, which paralleled the gradual decrements in serial measurements of beta-hCG levels. Thus, the statistically significant results of our study are very encouraging and may indicate that color Doppler flow is a noninvasive, reproducible, useful and highly reliable new diagnostic approach for the diagnosis and management of patients suffering from uterine malignant gestational trophoblastic disease.

Placental insufficiency as a possible cause of low maternal serum human chorionic gonadotropin and low maternal serum unconjugated estriol levels in triploidy

We report three cases in which triploidy (69,XXX) was detected by amniocentesis performed for very low maternal serum human chorionic gonadotropin levels. All three cases also had low maternal serum unconjugated estriol levels. We suggest placental insufficiency as the cause of the very low human chorionic gonadotropin because of histologic observations and because a known marker for placental insufficiency, estriol, was also very low.

Induced second trimester abortion by extra-amniotic prostaglandin infusion in patients with a cesarean scar: is it safe?

BACKGROUND One result of the advancement in prenatal diagnosis is an increase in the need for second trimester pregnancy terminations. Extra-amniotic infusion of prostaglandins is a common technique used for such pregnancy termination. Since prostaglandins cause strong uterine contractions, many practitioners are hesitant to use this technique on women with a uterine scar. In this study we tried to evaluate the effectiveness and safety of the technique for women with a previous uterine scar. METHODS This retrospective study included all women with a complete medical record who underwent a second trimester pregnancy termination at our institution by extra amniotic prostaglandin E2, during a 6 year period. The study group included all women with a previous uterine scar. The group of women without such a scar served as the control group. RESULTS Three hundred and forty women had their pregnancy terminated, but only in 282 cases was the medical information complete (research population). The study group (35 women) characteristics were similar to those of the control group (247 women). We found no difference in the abortion interval, the need to use an additional method, the need for curettage and in bleeding complication between the two groups. There was no case of uterine rupture. The group of women with multiple uterine scars was too small for analysis. CONCLUSIONS Our results suggest that extra amniotic prostaglandin infusion is an effective and safe technique in women with a uterine scar.

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.

Direct in‐vivo detection of atypical hormonal expression of a Sertoli‐Leydig cell tumour following stimulation with human chorionic gonadotrophin

A 60‐year‐old woman presented with progressive hirsutism and elevated serum testosterone levels. Selective bilateral ovarian and adrenal vein catheterization demonstrated mild elevated testosterone and androstenedione levels in the right ovarian vein, which increased considerably 15 minutes following intravenous injection of 5000 IU human chorionic gonadotrophin. Androgen levels decreased remarkably after administration of gonadotrophin hormone releasing hormone‐agonist (GnRH‐a). On histological examination, diffuse stromal hyperplasia of both ovaries was noted, with a small Sertoli‐Leydig cell tumour in the right ovary. This is the first report of preoperative, direct selective diagnosis of a small Sertoli‐Leydig cell tumour with such a hormonal expression.

The inability of preovulatory ovarian scan to predict multifetal pregnancy occurrence in a follow-up of induction of ovulation with menotropins.

OBJECTIVE To establish the predictive role of preovulatory ovarian ultrasonography in the occurrence of multiple pregnancy after hMG and hCG treatment for anovulatory infertility. DESIGN Prospective. SETTING Outpatient Infertility Clinic. PATIENTS Ninety-five anovulatory women who conceived after gonadotropin therapy. INTERVENTION Induction of ovulation by hMG and hCG monitored by plasma E2 measurements and ovarian ultrasonography. MAIN OUTCOME MEASURES All follicles visualized on the day of hCG administration were recorded and divided into the following four groups: group I, 10 to 12 mm; group II, 13 to 15 mm; group III, 16 to 18 mm; and group IV, 19 mm and larger. The sonographic findings were statistically evaluated to 80 singletons and 45 multiple pregnancies. RESULTS No statistical correlation was found to exist between the number of follicles from the different groups and the number of fetuses. CONCLUSIONS The number and sizes of follicles visualized on the day of hCG administration have no predictive value regarding the occurrence of a multiple pregnancy.