Simon Shenhav

Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study.

OBJECTIVE We sought to determine the effect of nonclosure of the visceral and parietal peritoneum during cesarean section on the formation of adhesions. STUDY DESIGN This was a prospective randomized trial of 533 women undergoing primary cesarean section; in 256 the peritoneum was left open and in 277 it was closed. Fifty women in the nonclosure group and 47 women in the closure group were subsequently evaluated intraoperatively at a repeat cesarean. The presence of adhesions and their severity were evaluated at several sites. RESULTS The nonclosure and closure groups were comparable with regard to the proportion of patients with adhesions at any site (60% vs 51%, respectively; P = .31). Time from incision to delivery was comparable in the nonclosure and closure groups (8.98 ± 4.7 vs 9.32 ± 5.2 minutes, respectively; P = .84). CONCLUSION Closure or nonclosure of the peritoneum at cesarean section did not lead to large differences in the adhesion rate.

Budd-Chiari syndrome complicating severe preeclampsia in a parturient with primary antiphospholipid syndrome

A 27-year-old primipara with severe preeclampsia and primary antiphospholipid syndrome developed right upper quadrant pain, massive ascites, HELLP syndrome, and disseminated intravascular coagulation shortly following vaginal delivery. Computed tomography and color Doppler studies were compatible with complete thrombosis of the right hepatic veins, the Budd-Chiari syndrome. Anticoagulation was initiated, along with supportive measures, and the patient recovered completely. Imaging studies 6 months later were normal. This case demonstrates that nearly fatal forms of venous thrombosis may complicate preeclampsia in women with antiphospholipid syndrome; Doppler studies of the hepatic vein are of value in establishing the diagnosis.

Midtrimester triple test levels in women with severe preeclampsia and HELLP syndrome

Background.  The levels of midtrimester triple test constituents are known to be altered in hypertensive disorders of pregnancy.

Sonographically diagnosed pelvic hematomas and postcesarean febrile morbidity

Objective: To evaluate the incidence of ultrasonographically‐diagnosed postcesarean hematomas and correlate their presence with febrile morbidity. Methods: Prospective study of 111 consecutive patients who had a pelvic ultrasound 4–6 days post‐operatively. Ultrasonographic findings were correlated with clinical data. Results: Post‐operative fever was diagnosed in 28 (25%) patients. Fifteen (13.5%) women had hematomas; 10 (9%) had bladder‐flap and five (4.5%) had subfascial hematomas. Only subfascial hematomas were significantly associated with post‐operative fever (P=0.01). Conclusions: Postcesarean bladder‐flap hematomas are not predictive of post‐operative fever. The presence of subfascial hematomas should be specifically sought in the evaluation of a febrile postcesarean patient.

Short-term effects of closure versus non-closure of the visceral and parietal peritoneum at cesarean section: A prospective randomized study

Aim:  To determine the effect of non‐closure of the visceral and parietal peritoneum during cesarean section on short‐term postoperative morbidity.

Severe hyperlipidemia-associated pregnancy: prevention in subsequent pregnancy by diet

Severe asymptomatic hyperlipidemia is a rare complicationof pregnancy, usually occurring in the second and third trimester. Treatment modalities include a very low-fat diet, intravenous fluids, low-dose heparin, and plasma exchange. A 20-year-old asymptomatic primigravida was found to have a ‘milky blood sample’ at 33weeks’ gestation. At admissionher triglyceride and total cholesterol levels were 156 and 40mmol/ l, respectively. To decrease her serum lipid levels, intravenous fluids and an isocaloric low-fat and low-carbohydrate diet were implemented. This action was associated with a significant decrease in her plasma lipid levels. A healthy infant was delivered vaginally at 36weeks’ gestation. Inher second pregnancy this complicationwas avoided by strict restrictionof dietary fat and close monitoring of plasma lipids. Fasting followed by a hypocaloric low-fat, low-carbohydrate diet canrapidly and safely resolve extreme hyperlipidemia in pregnancy, thereby diminishing the risk of pancreatitis. The institutionof relatively simple management strategies can prevent this complication in future pregnancies. Plasma lipid levels normally rise inpregnancy as a result of estrogen-induced hepatic productionof triglyceride (TG)-rich lipoproteins and a decrease in hepatic lipase (predominantly) and postheparin lipoprotein lipase (PHLPL) activity (1). Inan analysis of lipoproteins during the course of pregnancy, a positive correlationbetweenthe lipids and gestational age was found, with a peak of low density lipoproteincholesterol (LDLC) at approximately 36weeks’ gestation (2). Innormal pregnancies plasma triglyceride levels increase betweentwoand four-fold, while plasma cholesterol levels rise by approximately 50% (3). However, severe hyperlipidemia, defined as plasma triglyceride levels above 22.6mmol/l, is a rare complicationof pregnancy (4). Inpatients with pre-existing abnormalities in lipid metabolism in which hyperlipidemia has not been unrecognized, pregnancy canbe complicated by pancreatitis (5– 9), respiratory distress syndrome, and evenby maternal death (10). We describe two pregnancies ina patient whose first pregnancy was complicated by severe hyperlipidemia but whose

Thyroid hormone levels in cord blood of infants with acidemia at birth.

OBJECTIVE To study the funic thyroid hormone levels in cases were fetal distress during labor resulted in acidemia at birth. MATERIAL AND METHODS Arterial and venous levels of TSH, total T4, free T4 and total T3 obtained from cord blood at birth of twelve acidemic fetuses were compared with normal controls. RESULTS Acidemic fetuses had a significanly higher TSH levels than controls (16.5+/-2. 1 microI/dl vs. 9.6+/-1.4 microI/dl, P=0.01). Total T3 levels were significantly lower in acidemic fetuses (49.2+/-2.9 ng/dl vs. 63+/-5. 5 ng/dl, P=0.04). Total and free T4 levels were similar and there was no difference between arterial and venous levels of the hormones. CONCLUSIONS Birth acidemia from fetal distress during labor is associated with higher TSH levels and lower T3 levels.

Safety of nifedipine in threatened preterm labor: Investigation by three-dimensional echocardiography

To evaluate atrial and ventricular parameters using real time three‐dimensional transthoracic echocardiography (RT3DTTE) in women treated with nifedipine in the early third trimester (III‐T) of pregnancy.

Is umbilical vein varix associated with changes in cerebroplacental ratio

Abstract Objective: We aimed to review a single-center experience in follow-up and management of fetuses with umbilical vein varix (UVV) and to assess the effect of UVV on fetal Doppler parameters. Methods: We reviewed retrospectively maternal antenatal records, delivery records, and newborn records to identify cases of UVV. Further, we retrospectively compared 25 fetuses with isolated UVV and available cerebroplacental ratio (CPR) analysis with 75 matched controls. Results: We identified 67 cases of UVV. The median gestational age (GA) at diagnosis was 34 weeks (range: 26–41 weeks). The average diameter of UVV at diagnosis was 10.1 mm (range: 9–14 mm). The median GA at delivery was 36 + 6 (range: 33–41 weeks), with an average birth weight of 2918 g (range: 1278–4140 g). There was a single case of intrauterine death at 35 weeks. CPR was 2.13 ± 0.62 in isolated UVV group compared with 1.84 ± 0.61 in the control group (p < .05). Other Doppler parameters did not differ between fetuses with UVV compared with controls. Conclusions: CPR was significantly increased in the UVV group compared with control fetuses. This finding suggests that UVV is not associated with chronic fetal oxygen deprivation; it, therefore, may contribute to our understanding of the pathophysiology explaining abnormal pregnancy outcome in cases with UVV.

Quantifying the effects of postcesarean adhesions on incision to delivery time

Abstract Objective: To quantify the effects of postcesarean section adhesions severity on the incision to delivery time. Methods: Secondary analysis of data of a prospective randomized controlled trial of women undergoing first repeat cesarean section. The presence and severity of adhesions were reported by surgeons postoperatively and accrued into an adhesion severity score. The primary outcome measure was the correlation between adhesion severity score and incision to delivery time. Results: Of the 97 women analyzed, 47 (48.5%) had an urgent cesarean delivery. Forty-four patients (45.4%) had adhesions. Adhesion score correlated with incision to delivery time (R = .38, p < .01). Patients with adhesions had a significantly longer incision to delivery time (10.3 + 5.9 versus 8.2 = 3.7 minutes, respectively; p = .04). In the Kaplan–Meier analysis, more patients with adhesions remained undelivered at any time point after incision (p = .036). The mean delivery time of patients with adhesion score three was significantly longer in comparison with women with no adhesions (13.0 versus 8.2 minutes, respectively; p = .002). Conclusions: Post cesarean adhesions delay delivery of the newborn. There is a linear correlation between adhesion severity and the incision to delivery interval.