Stamatios Petousis

Open versus closed vitrification of blastocysts from an oocyte-donation programme: a prospective randomized study

The use of open carriers for embryo vitrification has raised safety concerns and therefore vitrification in closed systems has been proposed. However, the drop in the cooling rate emerges as a major drawback. The objective of the present study was to compare the efficiency of vitrification in open versus closed conditions. Blastocysts were randomly allocated either to open ultra-rapid vitrification (group I) or closed aseptic vitrification (group II). In group I, blastocysts were exposed to two solutions of ethylene glycol/dimethylsulphoxide (10%/10% and 20%/20%), while in group II, blastocysts were pretreated with a solution of lower concentration (5%/5%). A total of 208 and 224 vitrification-warming cycles were performed for groups I and II, respectively. Both groups were equal in terms of maternal age, sperm parameters and number and quality of blastocysts vitrified, warmed and transferred per cycle. Importantly, there was no significant difference between the groups in the analysed outcomes; embryo survival rate (84.1% versus 82.1%), clinical pregnancy rate (45.9% versus 42.4%), implantation rate (25.6% versus 24.5%), cycle cancellation rate (6.7% versus 8.5%) and live birth rate (41.2% versus 41.0%). These data suggest that ultra-rapid vitrification may be replaced by aseptic vitrification without affecting clinical efficiency.

GnRH antagonist versus long GnRH agonist protocol in poor IVF responders: a randomized clinical trial.

OBJECTIVE To compare the efficacy of the long GnRH agonist and the fixed GnRH antagonist protocols in IVF poor responders. STUDY DESIGN This was a randomized controlled trial performed in the Iakentro IVF centre, Thessaloniki, from January 2007 to December 2011, concerning women characterised as poor responders after having 0-4 oocytes retrieved at a previous IVF cycle. They were assigned at random, using sealed envelopes, to either a long GnRH agonist protocol (group I) or a GnRH antagonist protocol (group II). RESULTS Overall 364 women fulfilled the inclusion criteria and were allocated to the two groups: finally 330 participated in our trial. Of these, 162 were treated with the long GnRH agonist protocol (group I), and 168 with the fixed GnRH antagonist protocol (group II). Numbers of embryos transferred and implantation rates were similar between the two groups (P=NS). The overall cancellation rate was higher in the antagonist group compared to the agonist group, but the difference was not significant (22.15% vs. 15.2%, P=NS). Although clinical pregnancy rates per transfer cycle were not different between the two groups (42.3% vs. 33.1%, P=NS), the clinical pregnancy rate per cycle initiated was significantly higher in the agonist compared to the antagonist group (35.8% vs. 25.6%, P=0.03). CONCLUSIONS Although long GnRH agonist and fixed GnRH antagonist protocols seem to have comparable pregnancy rates per transfer in poor responders undergoing IVF, the higher cancellation rate observed in the antagonist group suggests the long GnRH agonist protocol as the first choice for ovarian stimulation in these patients.

Parameters affecting latency period in PPROM cases: a 10-year experience of a single institution

Abstract Objective: To investigate the association of epidemiological and pregnancy-related parameters with the latency period achieved in cases of preterm premature rupture of membranes (PPROM). Method: A retrospective study was performed enrolling cases admitted in high-risk pregnancy unit (HRPU) with PPROM between 24 + 0 and 36 + 6 gestational week during 2002–2011. Cases with vaginal bleeding at admission, co-existing maternal or fetal pathology, placenta praevia, previous interventions in cervix or uterus, triplets or higher order pregnancies were excluded. Epidemiological parameters and latency period between admission due to PPROM and delivery were recorded. Obstetrical complications, mode of delivery, and neonatal morbidity parameters were also studied. A multivariate regression model was used to correlate latency period with epidemiological and pregnancy-related risk factors. Results: Overall, there were 319 cases of PPROM admitted, of which 303 (94.9%) met inclusion criteria. Median latency period was 5.2 d. The latency interval exceeded 48 h in 65.0% of cases (197/303). Emergency cesarean was demanded in 20.2% of cases, chorioamnionitis was diagnosed in 7.5% while 76.1% of neonates were admitted in neonatal intensive care unit. Higher gestational week at admission was associated with shorter latency interval (p < 0.001), twin pregnancy with shorter latency interval (p = 0.02), while latency interval was significantly lower in cases complicated with chorioamnionitis (p = 0.048). Conclusion: Gestational week at PPROM, twin gestation and chorioamnionitis are factors significantly affecting latency interval.

Factors implicated in the initiation of human parturition in term and preterm labor: a review.

Abstract After accommodating the pregnancy for an average of 40 weeks, the uterus expels the fetus, the placenta and the membranes through the birth canal in a process named parturition. The absolute sequence of events that trigger and sustain human parturition are not yet fully clarified. Evidence suggests that spontaneous preterm and term labor seem to share a common inflammatory pathway. However, there are several other factors being involved in the initiation of human parturition. Placental corticotropin releasing hormone production seems to serve as a placental clock that might be set to ring earlier or later determining the duration of pregnancy and timing of labor. Estrogens do not cause contractions but their properties seem to capacitate uterus to coordinate and enhance contractions. Cytokines, prostaglandins, nitric oxide and steroids seem also to induce ripening by mediating remodeling of the extracellular matrix and collagen. Infection and microbe invasion resulting in chorioamnionitis also represents a common cause of early preterm labour. This review provides an overview of all these factors considered to be implicated in the initiation of human parturition. Chinese abstract 在调节平均40周的妊娠后,子宫通过产道排出胎儿，胎盘和胎膜的过程称为分娩。触发和维持人类分娩的绝对事件序列仍未完全阐明。有证据表明，自发早产和足月产似乎都遵循一条同样的炎症通路。然而，仍有一些其他的因素与人类分娩的触发有关。胎盘促肾上腺激素释放激素的产生似乎充当胎盘时钟的作用，时钟响的时间可能会设定的早或晚，决定了孕期的时长和分娩的时间。雌激素并不造成宫缩，但是它的性质可使子宫协调而加强宫缩。细胞因子、前列腺素、一氧化氮和类固醇似乎通过重塑细胞外基质和胶原来同样促进成熟。感染和微生物入侵所导致的绒毛膜羊膜炎也是常见的早产原因之一。这篇综述提供了与人类分娩的相关因素的概述。

Operator experience reduces the risk of second trimester amniocentesis-related adverse outcomes

OBJECTIVE To investigate the impact of operator experience on amniocentesis-related adverse outcomes. STUDY DESIGN Retrospective study of mid-trimester amniocenteses performed by the same operator on singleton pregnancies in a single private institution during 1994-2007. Outcomes were hemorrhagic or dark amniotic fluid aspiration, insufficient volume aspiration, repeated puncture and fetal loss. Rates were estimated annually, as well as for every 10% of procedures up to the total number. The association of each outcome with epidemiological aspects was also examined. RESULTS In total, 5913 amniocenteses were performed. The overall rate of adverse outcomes was 5.4%. The total adverse outcome rate reduced from 10.2% in the first 10% of cases to 3.0% in the last 10% (P=.001). The rate of hemorrhagic fluid gradually decreased from 4.4% to 1.5% (P=.05) over the same intervals. The fetal loss rate was also reduced from 0.5% during the first half to 0.3% in the second half of the study period (P=NS). Logistic regression analysis indicated no significant correlations between adverse outcomes with any of epidemiological parameters of women undergoing amniocentesis. CONCLUSION Operator experience has a beneficial impact on preventing procedure-related adverse outcomes.

Mature Ovarian Teratoma with Carcinoid Tumor in a 28-Year-Old Patient

Introduction. Coexistence of carcinoid tumor inside a mature cystic teratoma is an extremely rare phenomenon, especially in young women. We present the case of a 28-year-old woman diagnosed with a right ovarian carcinoid and treated uneventfully with conservative surgical approach. Case Report. A 28-year-old woman, gravid 0, parity 0, presented to our department for her annual gynecological examination and Pap smear test. During her examination, a mobile cystic mass was detected in the right lower abdomen. Ultrasound indicated a right ovarian mass 10.5 × 6.3 cm, confirmed by CT scan. Further investigation revealed AFP levels (1539 ng/mL). The ovarian mass was excised by laparoscopy, leaving intact the remaining right ovary. Frozen sections showed a mature cystic teratoma. However, paraffin sections revealed the presence of a small carcinoid within the teratomas gastric-type mucosa. The patient was set to a close followup. Nine months postoperatively, ultrasound pelvis imaging and CT scan of the abdomen as well as serum tumor markers have shown no evidence of recurrence disease. Conclusion. Despite the weak evidence, fertility spare surgical approach for women wanting to preserve their genital tract might be a reasonable option.

Conservative management of cervical pregnancy with intramuscular administration of methotrexate and KCl injection: Case report and review of the literature

We report the case of a cervical pregnancy successfully treated with intramuscular injection of methotrexate (MTX) and intramniotic administration of potassium chloride. A 41-year-old woman was admitted to our Department with the suspicion of ectopic pregnancy. Transvaginal ultrasound revealed empty endometrial cavity, gestational sac within the cervical canal and embryonic echo measuring crown rump length 1.5 mm. Serum beta human chorionic gonadotropine (β-HCG) was measured 28590 IU/L. No cardiac activity was detected. The diagnosis of a cervical pregnancy was made. Patient was treated with intramuscular administration of methotrexate (50 mg/m(2)) in combination with ultrasound-guided intramniotic injection of KCl (2 meq/mL). Gradual decrease of β-HCG levels as well as ultrasound observation of collapsed gestational sac was observed. No curettage was necessitated. Patient was discharged on day 10(th) and was set in follow-up on a weekly basis. β-HCG values were measured < 10 IU/L on 56(th) day after MTX administration. Intramuscular administration of MTX may be effective in treatment of cervical pregnancy without additional interventional measures.

Spontaneous Postpartum Rupture of an Intact Uterus: A Case Report

Rupture of uterus is an obstetrical complication characterized by a breach in the uterine wall and the overlying serosa. We report an unusual case of spontaneous rupture of an unscarred uterus in a 33-year-old woman, a day after her third successful vaginal delivery. A 33-year-old pregnant woman, gravid 3, para 3, was referred to our department at 39 gestational week because of rupture of membranes. Despite tocolysis administration, her pregnancy was delivered vaginally after 2 days, giving birth to a male neonate of 3,020 g with normal Apgar scores at first and fifth minute. Her uterus was intact and gynecological examination after delivery was normal without any potential signs or symptoms of pathology. However, the day following her labor, patient complained of left iliac fossa pain. Her blood tests revealed a CRP value at 27.6 mg/L, whereas the X-rays revealed an extensive impacted fecal mass in the colon. MRI revealed that the left lower myometrial part of the uterus was depicted abrupt, with simultaneous presence of hemorrhagic stuff. The decision of laparotomy was therefore made in order to further evaluate rupture of uterus and properly treat patient. And subtotal hysterectomy was performed. Postoperative follow-up period was not characterized by any complications and patient was finally discharged 4 days after hysterectomy.

Amniocentesis-related adverse outcomes in diamniotic twins: is there a difference compared to singleton pregnancies?

OBJECTIVE To investigate whether diamniotic twin gestations are at increased risk of amniocentesis-related adverse outcomes compared to singleton pregnancies. STUDY DESIGN This was a retrospective study of mid-trimester amniocenteses performed during the period 1993-2009. Cases were divided in two groups, one including singleton (Group 1) and the other diamniotic twin pregnancies (Group 2). All amniocentesis-related adverse outcomes were reviewed, including aspiration of insufficient amniotic fluid, aspiration of hemorrhagic amniotic fluid, repeated puncture and miscarriage. The incidence of these adverse outcomes was compared between the two groups. RESULTS In total, 6270 cases were included in the study (Group 1, n=6150 and Group 2, n=120). Advanced maternal age was the main indication for amniocentesis in both singleton and twin pregnancies. There was no difference in the incidence of insufficient sample aspiration (0.2% in singletons vs. 0.0% in twins, P=NS), in the incidence of blood-stained amniotic fluid (3.7% in singletons vs. 4.6% in twins, P=NS), in the rate of need for second attempt (2.1% in singletons vs. 1.7% in twins, P=NS) or in the miscarriage rate (0.24% in singletons vs. 0% in twins). CONCLUSION In our experience, the incidence of amniocentesis-related adverse outcomes is not increased in diamniotic twins compared to singleton pregnancies.

Effectiveness of Tocolytic Agents on Prevention of Preterm Delivery, Neonatal Morbidity, and Mortality: Is There a Consensus? A Review of the Literature.

Preterm delivery presents the main cause of neonatal morbidity and mortality worldwide. The rate of preterm delivery is 12% to 13% in the United States, of which 29% concerns preterm deliveries before 34 weeks of gestation. Basic parameter of prevention strategy is implementation of tocolytic therapy in cases of threatened preterm labor. Several therapeutic approaches have been proposed, among which betamimetic agonists, calcium channel blockers, magnesium sulfate, oxytocin receptor blockers, nitrates, and prostaglandin inhibitors, whereas new alternatives such as usage of thiocolchicoside have also been reported. This article is one among few that aims to review the comparative effectiveness of various tocolytic agents regarding prevention of preterm delivery, impact on perinatal morbidity and mortality, neonatal health status, and maternal complications. Main conclusions of recent randomized control trials and meta-analyses are summarized to assess about which agents consensus already exists on their effectiveness, which agents should be further studied to achieve conclusions, as well as those that are rather unlikely to have significant tocolytic impact or any other benefit on neonatal outcome. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to be informed that oral betamimetics may have a positive impact only to postpone preterm delivery for at least 48 hours. However, no significant advantage is indicated on any of the examined parameters of neonatal morbidity and mortality; understand that no significant benefit of calcium channel blockers on neonatal morbidity and mortality parameters may be supported, despite the potential benefit on prolongation interval; be informed that oxytocin receptor antagonists do not present significant tocolytic effect and are not associated with significant improvement of neonatal morbidity and mortality parameters; highlight that there are strong indications that progesterone administration is effective on preventing preterm delivery as well as improving neonatal morbidity and mortality; and be informed that antibiotics may not be suggested as a tocolytic therapy and their usage should rather be restricted in cases with preterm premature rupture of membranes to prevent chorioamnionitis.