Uriel Elchalal

Cervical Pregnancy: Past and Future

Cervical pregnancy (CP) is a rare life-threatening form of ectopic pregnancy occurring in 1 of 8628 deliveries. We reviewed 117 cases of CP in the English language literature from 1978 and added three cases from our department. Etiology of CP is still unknown, but there is evidence for its association with cervicouterine instrumentation. The possible role of embryo chromosomal abnormality in the CP etiology is considered. Sonography improved pretreatment diagnosis up to 81.8 percent. Obligatory sonographic criteria of CP include endocervical localization of the gestational sac and trophoblastic invasion. About 60 percent of cervical pregnancies are with a viable fetus. The majority of patients with a cervical pregnancy are women with low parity, thus, the current treatment trend is to preserve their reproductive function. The main problem of conservative treatment is life-threatening hemorrhage after pregnancy evacuation. The use of cervical canal tamponade with a Foley catheter balloon led to reliable hemostasis in 92.3 percent of cases in which this method was used. Early diagnosis of CP allowed for treatment by chemotherapy in 32 cases, with an 81.3 percent success rate. Serial beta-human chorionic gonadotropin levels and transvaginal ultrasound with color Doppler are used to monitor therapy. Another conservative treatment modality is local intrasac KCI injections. Hysterectomy is recommended mostly for second and third trimester cervical pregnancy, or for uncontrolled bleeding.

Postpartum umbilical cord blood collection for transplantation: A comparison of three methods

OBJECTIVE This study was undertaken to compare 3 methods of collection of human umbilical cord blood. STUDY DESIGN Seventy-five women with uncomplicated vaginal deliveries were divided equally into 3 groups. One of 3 cord blood collection methods was applied to each woman. Method 1 was collection of cord blood into a standard donation blood bag. Methods 2 and 3 used a syringe to perform a sodium chloride solution flush and drain, which included withdrawal of cord blood by a syringe until the delivery of the placenta, followed by flushing through a catheter one of the umbilical arteries with sodium chloride solution and collection of the cord blood either into an open sterile container (method 2) or into a standard donation blood bag (method 3). Analyses included comparisons among the 3 groups of volume collected, total number of white blood cells, and bacterial contamination rates (positive culture results). In addition a correlation was made between the different variables and the collected cord blood nucleated cells. RESULTS Cord blood collection by the blood bag method (method 1), which is presently the standard clinical practice, resulted in a mean blood volume of 76.4 +/- 32.1 mL and a mean total white blood cell count of 835 +/- 507 x 10(6) cells. With collection methods 2 and 3, in which as much blood as possible was withdrawn by syringe while the placenta was still in utero followed by a second collection after infusion of the umbilical artery with sodium chloride solution, the mean volume collected was significantly higher (P <.05) at 174.4 +/- 42.8 mL and 173.7 +/- 41.3 mL, respectively, with significantly higher (P <.001) mean total white blood cell counts of 1624 +/- 887 x 10(6) cells and 1693 +/- 972 x 10(6) cells, respectively. A direct correlation was observed between the cord blood volume collected and placental weight, whereas no correlations were observed with maternal age, pregnancy duration, or the neonates weight. Bacterial contamination was significantly higher (P =.04) in cord blood collections obtained by method 2 (48%) than by methods 1 (16%) and 3 (19%). CONCLUSIONS The syringe-assisted sodium chloride solution flush collection method with a blood bag (method 3) was found to be the most effective method for human umbilical cord blood collection. This method doubles the total white blood cells collected with respect to current yields, which may make cord blood transplantation applicable for adults.

Obstetric outcome of in vitro fertilized pregnancies complicated by severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE To assess the outcome of pregnancies conceived with the use of IVF that are complicated by severe ovarian hyperstimulation syndrome (OHSS). DESIGN A retrospective nationwide multicenter study. SETTING Sixteen of 19 tertiary care medical centers in Israel. PATIENT(S) All patients undergoing IVF who were hospitalized for severe OHSS between January 1987 and December 1996. MAIN OUTCOME MEASURE(S) Pregnancy rate (PR) and rates of multiple gestation, miscarriage, ectopic pregnancy, obstetric complications, and intervention. RESULT(S) A total of 163 patients who had severe OHSS after IVF treatment were identified, of whom 142 (87.1%) had undergone ET. The clinical PR was 73.2%; 42.3% were singletons, 33.6% were twins, 17.3% were triplets, and 6.7% were quadruplets. The miscarriage rate was 29.8%, whereas the incidence of ectopic pregnancy was 1.9%. Forty-four percent of all births were premature, and 62.1% of all newborns had low birth weight. The most common antenatal complications were pregnancy-induced hypertension (13.2%), gestational diabetes (5.9%), and placental abruption (4.4%). The rate of cesarean section was 44.1%. CONCLUSION(S) Among patients who have severe OHSS after IVF treatment, the pregnancy rate and the rates of multiple gestation, miscarriage, prematurity, low birth weight, pregnancy-induced hypertension, gestational diabetes, and placental abruption are significantly higher than those reported previously for pregnancies conceived with the use of assisted reproductive techniques.

Pulmonary manifestations of severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE To assess the pulmonary manifestations of severe ovarian hyperstimulation syndrome (OHSS). DESIGN A retrospective nationwide 10-year multicenter study. SETTING Sixteen of 19 tertiary medical centers in Israel. PATIENT(S) All patients hospitalized at these centers for severe OHSS between January 1987 and December 1996. MAIN OUTCOME MEASURE(S) Clinical presentation, arterial blood gases on room air, and chest roentgenogram results. RESULT(S) Of 209 patients, 4% had lobar pneumonia, 2% had adult respiratory distress syndrome (ARDS), and 2% had pulmonary thromboembolism. Most patients had dyspnea, tachypnea, moderate hypoxemia, increased alveolar-arterial oxygen difference, hypocarbia, respiratory alkalosis, and metabolic compensation. The most common findings on chest roentgenogram were bilateral elevation of the diaphragm, pleural effusion, and pulmonary atelectasis. Patients with pulmonary thromboembolism, ARDS, and pneumonia presented with severe hypoxemia and alveolar-arterial oxygen difference and distinct radiographic findings. CONCLUSION(S) Severe OHSS is characterized by an extraparenchymal restrictive type of pulmonary dysfunction, attributed to intraabdominal or pleural fluid accumulation, which limits descent of the diaphragm and expansion of the thoracic cage. This may induce uncoordinated lung ventilation and atelectasis with subsequent ventilation-perfusion mismatch and hypoxemia. The clinical picture may deteriorate further because of pulmonary infection, pulmonary thromboembolism, or ARDS, all of which have distinct clinical, radiographic, and blood gas characteristics.

Fetal intracranial hemorrhage (fetal stroke): does grade matter?

To determine if the severity of antenatally diagnosed hemorrhagic fetal brain insults and fetal stroke detected by ultrasound and magnetic resonance imaging (MRI) predicts postnatal neurodevelopmental prognosis.

Geophagy During Pregnancy in Africa: A Literature Review

Introduction. Geophagy is a form of pica characterized by craving and eating of soil. The main materials ingested include anthill soils and soft stone. In this review, our objectives were to study the prevalence of geophagy in pregnancy (GiP), establish the risk factors for GiP, assess the effects of GiP on pregnancy outcomes, and recommend possible interventions for reducing GiP. Prevalence. Geophagy among pregnant women is common in many cultures. In some African countries, GiP prevalence of up to 84% has been observed. In Nigeria, the most populous country in Africa, the prevalence of GiP is estimated at 50%. The practice has been associated with religious practice, culture, and famine. Risks. It is postulated that GiP is due to micronutrient deficiencies, cultural influences, and gastrointestinal upsets. Despite their potential to supply micronutrients, soils interfere with bioavailability of micronutrients leading to micronutrient deficiency and can also act as a pathway for ingestion of geohelminths and heavy metals, putting woman and fetus at risk. Gaps. Despite its association with anemia, pregnancy, and micronutrients, many antenatal care guidelines or National guidelines on micronutrient deficiency control are silent on GiP. The guidelines generally recommend iron supplementation and deworming of pregnant women as anemia control measures. However, not all women seek antenatal services; hence, there is need for more innovative ways of addressing micronutrient deficiencies in pregnancy. Recommendations. It is imperative to enquire whether pregnant women are geophagous and discourage geophagy, strengthen and expand the existing supplementation programs, and mandate flour fortification to enhance population-wide iron supply and safer pregnancies. Target Audience: Obstetricians & Gynecologists and Family Physicians. Learning Objectives. After completing this CME activity, physicians should be better able to analyze the prevalence of GiP, identify the risk factors for GiP, and assess the effects of GiP on pregnancy outcomes. In addition to propose remedial interventions for reducing GiP.

The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study.

Diabet. Med. 27, 779–785 (2010)

Ritualistic female genital mutilation: current status and future outlook.

Ritualistic sexual mutilation of females dates back to the fifth century B.C. This traditional practice is a social as well as a health issue that affects the physical and mental well being of the women who undergo it. Although practiced mostly in African countries north of the equator and the Middle-East, concern has recently been expressed that female genital mutilation is also being practiced in the U.S., Europe, and other western countries by immigrants from these countries. This review describes the various types of female genital mutilation and presents the historical and cultural background of the tradition, outlines the medical, psychological and sexual problems, and discusses the current status and future outlook for this tradition, emphasizing social, medical, and legislative aspects.

Surgical treatment of vulvar lichen sclerosus: a review.

Surgical therapy of lichen sclerosus of the vulva consists of three main operations: vulvectomy (with or without a skin graft), cryosurgery, and laser ablation. It is indicated in two conditions, either when malignant transformation is present or is likely to occur, or when medical treatment has failed. The overall risk for malignant transformation of vulvar lichen sclerosus is low, ranging between 0 and 9 percent. However, specific histological criteria, such as mixed dystrophy, have recently been associated with higher malignancy rates. Vulvectomy is indicated only when these criteria are met. Both skinning and simple vulvectomies are associated with recurrence rates as high as 50 percent. However, better sexual function and cosmetic results have been reported in the former, especially with concomitant split skin grafting. Cryosurgery also has high recurrence rates, although short-term results are favorable. Although only small series have been reported, laser therapy seems to carry better long-term results than other modes of treatment. Convalescence is complete within 6 weeks posttreatment, and remission rates are as high as 85 percent at 3 years of follow-up. The high recurrence rate of all surgical modalities makes surgical treatment suitable only for patients who failed to respond to multiple medical treatments such as topical high potent steroid ointments, testosterone, and retinoids.

External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial.

OBJECTIVE: To compare the success of external cephalic version using spinal analgesia with no analgesia among nulliparas. METHODS: A prospective randomized controlled trial was performed in a tertiary referral center delivery suite. Nulliparous women at term requesting external cephalic version for breech presentation were randomized to receive spinal analgesia (7.5 mg bupivacaine) or no analgesia before the external cephalic version. An experienced obstetrician performed the external cephalic version. Primary outcome was successful conversion to vertex presentation. RESULTS: Seventy-four women were enrolled, and 70 analyzed (36 spinal, 34 no analgesia). Successful external cephalic version occurred among 24 of 36 (66.7%) women randomized to receive spinal analgesia compared with 11 of 34 (32.4%) without, P=.004 (95% confidence interval [CI] of the difference: 0.0954–0.5513). External cephalic version with spinal analgesia resulted in a lower visual analog pain score, 1.76±2.74 compared with 6.84±3.08 without, P<.001. A secondary analysis logistic regression model demonstrated that the odds of external cephalic version success was 4.0-fold higher when performed with spinal analgesia P=.02 (95% CI, odds ratio [OR] 1.2–12.9). Complete breech presentation before attempting external cephalic version increased the odds of success 8.2-fold, P=.001 (95% CI, OR 2.2–30.3). Placental position, estimated fetal weight, and maternal weight did not contribute to the success rate when spinal analgesia was used. There were no cases of placental abruption or fetal distress. CONCLUSION: Administration of spinal analgesia significantly increases the success rate of external cephalic version among nulliparous women at term, which allows possible normal vaginal delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00119184 LEVEL OF EVIDENCE: I