Uzi Dan

Combined gonadotropin releasing hormone agonist/human menopausal gonadotropin therapy (GnRH-a/hMG) in normal, high, and poor responders to hMG

Patients who failed to conceive after gonadotropin stimulation in in vitro fertilization treatment were classified into normal, high, or poor responders. They were routinely offered another cycle with a combination of a gonadotropin releasing hormone agonist and gonadotropin therapy (in order to evaluate whether this combined therapy could improve their response). The gonadotropin-induced cycle was compared with the combined therapy cycle. With the combination treatment, in the normal responders the phase of ovarian stimulation was significantly (P<0.001) prolonged, and the number of follicles and oocytes collected (5.7±0.7 vs 3.1±0.4) was increased, without any change in serum estradiol level compared to the control cycle. In high responders the number of oocytes was not modified by the combined treatment compared with the control cycle. However, serum estradiol level was significantly (P<0.005) decreased. The combined therapy did not modify any parameter of response in poor responders. We conclude that the response to combined agonist/gonadotropin therapy is dependent on the patients own basal response. No improvement in response was expected in poor responders.

Intravenous pethidine and nalbuphine during labor : a prospective double-blind comparative study

The perfect analgesic regimen is constantly sought, no matter how labor is conducted. The quest for an effective drug that will afford maximum relaxation and pain relief with minimum interruption of any natural homeostatic mechanism is a foremost subject in present obstetric analgesics research. Synthetic alternatives are being offered, promising perfect compatibility with the clinicians demands. Nalbuphine, a semisynthetic narcotic agonist-antagonist analgesic of the penanthren series, is supposed not to be liable to cause respiratory depression and is expected to have fewer side effects. A double-blind, randomised prospective study of 137 patients who received 10 mg nalbuphine or 50 mg pethidine i.v. during the active phase of labor in term was carried out. Maternal cardiovascular variables, pain intensity, progress of labor and fetal heart rate during labor were related to side effect and neonatal outcome (1- and 5-min Apgar scores and umbilical venous pH). Neither regimen showed an advantage over the other. Data analysis points to a possible transient depressive effect induced by nalbuphine on the fetal or neonatal central nervous system.

Prenatal diagnosis using sonographic guided cordocentesis

Cordocentesis has been practiced as a diagnostical tool for prenatal diagnosis of intrauterine infections, hematological disorders, metabolic status of the fetus and rapid cytogenetic analysis. The performance of 198 cordocentesis is presented over 3 years of experience. A 21 gauge spinal needle is inserted via the optimal point on the maternal abdomen under real-time ultrasonic guidance into the insertion of the umbilical cord in the placenta. Successful cordocentesis were achieved in 98.5% of the cases. Termination of pregnancy was directly related to the procedure in only 1%. Hematoma surrounding the puncturing site was demonstrated in one case, but without damage to the fetus. In our series the main indication for performing cordocentesis was the need for rapid karyotyping. The use of fetal lymphocytes for chromosomal analysis offers a rapid and a reliable method for routine clinical demands. The availability of a rapid chromosomal analysis offers a considerable advantage in pregnancies of advanced gestational age. In those pregnancies it appears to be most important to have a rapid diagnosis where anatomical structural anomalies are associated with chromosomal malformations in up to 30%. The metabolic status of the fetus is considered in either acute distress or in cases of suspected sub-optimal metabolic hemostasis, where IUGR or oligohydramnios are demonstrated. Cordocentesis, even though is a new technique, turns to play a major role in modern perinatology. The possibility of a direct rout to fetal blood vessels early during the pregnancy bears the tremendous potential of early diagnosis and treatment.

Management of Labor in Patients with Idiopathic Thrombocytopenic Purpura

Transient thrombocytopenia may occur in infants born to mothers with idiopathic thrombocytopenic purpura, suggesting transplacental passage of the antiplatelet factor. Labor in women with idiopathic thrombocytopenic purpura calls for a special management. Irrespective of the maternal platelet count, we believe that labor should be conducted vaginally but reassessed after a thrombocyte count of fetal scalp blood. Maternal thrombocytopenia, which may indicate a possible risk of coagulopathy, should be treated aggressively and followed up with replacement therapy. Percutaneous umbilical sampling is to be avoided because it carries an immediate risk of fetal and maternal complications. A count of 50,000/mm3, obtained early during the course of labor, may be taken as a threshold indicator for abdominal delivery via cesarean section.

A possible effect of ultrasound on RNA synthesis in cultured amniocytes

The effect of both diagnostic and therapeutic ultrasound on cellular RNA synthesis was investigated in amniocytes cultured in F‐10 medium enriched with fetal calf serum. The rate of RNA synthesis was tested using incorporation of H3 uridine, which was added following the exposure to acid insoluble RNA. Cultured amniocytes which were not exposed to ultrasound served as the control. Different results were obtained following the two ranges of exposure. A significant decrease in RNA synthesis was demonstrated immediately following diagnostic ultrasound and a certain increase in RNA synthesis was demonstrated soon after exposure to therapeutic doses. These effects were transient and could not be shown 24 hours later. It is concluded that the routine use of ultrasound can not have any clinical implications on RNA synthesis.

Sonography-guided fetal blood sampling for pH and blood gases in premature fetuses with abnormal fetal heart rate traces

In nine pregnancies, remote from term, with an abnormal Non‐Stress Test (NST) and Bio‐Physical Profile (BPP) of 3 or above, cordocentesis for fetal blood gas analysis was performed. In seven cases an immediate post‐partum blood sample was taken from the fetal cord for a similar analysis. The two tests gave very similar results. The results showed fetal acidemia (pH 7.09–7.19 and B. E. −10–15) in 4 cases, followed by immediate delivery. In the remaining 5 cases, normal blood gases were evident (pH 7.28–7.35); despite the abnormal NST, pregnancy was allowed to continue for 2 to 7 weeks, under close supervision. At birth, 2 out of 9 newborns were deemed by the neonatologist suffering from asphyxia. Both belonged to the acidemic group of women who were managed by immediate cesarean section. The other 5 fetuses, which were managed expectantly, had normal postpartum blood gases or Apgar score; none had asphyxia. Fetal blood gas analysis, on samples obtained by cordocentesis, provides useful information that can assist in the management of premature fetuses suspected of being distressed, according to their heart traces. Normal fetal blood gases can identify those fetuses falsely identified by the NST as in distress and thereby spare them unnecessary premature birth with its known complications.

Iatrogenic Mechanical Ileus due to Over-Distended Uterus

The combination of an over-distended uterus caused by a multiple-fetus pregnancy with therapeutic bed-rest may cause mechanical ileus. Iatrogenic triggering of a pathological consequence of events is presented in purpose to highlight the simplicity of its prevention.

The effect of thyroxine and corticosteroids upon amniotic fluid fluorescence polarization: a randomized controlled study

The efficacy of glucocorticoid and intra amniotic thyroxine therapy on fetal lung maturity were compared in a randomized prospective clinical trial. Eighty two patients received either intra amniotic thyroxine (n = 36), or intra muscular Dexamethasone (n = 46). The Fluorescence Polarization (FP) of amniotic fluid measured prior to and one week following treatment were similar in the two groups. The rate of decrease in FP value per unit of time (dFP/dt) was identical in the T4 and corticosteroid treated patients and the proportion of immature FP values obtained was similar in the two groups. The effect of thyroxine therapy was more pronounced in pregnancies above 33 weeks gestation. Intra amniotic thyroxine therapy appeared to be as effective as glucocorticoids for the enhancement of fetal lung maturity. This therapeutic modality may be of particular use on pregnant subjects in whom a relative contra indication for the administration of steroids exists.

Increased incidence of high-order and singleton conceptions after ovulation induction in winter

The possible relationship between the season of conception after ovulation induction and high-order multifetal pregnancies, was investigated. From 1975 to 1989, 111 high-order multiple births after ovulation induction were recorded at the Chaim Sheba Medical Center. This group was compared with 142 singleton pregnancies that resulted from induction of ovulation during 1989. Composite monthly cohorts of high-order multifetal pregnancies were constructed for each month of the year, and the probability of such pregnancies was estimated. The period of ovulation induction and the day of presumed conception were noted. A statistically-significant increase in the probability of high-order and singleton conceptions occurred during the winter. Our observation indicates a seasonal pattern in high order and singleton conceptions after ovulation induction.