Yaakov Melcer

A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception

To compare the reproductive outcome of women who underwent blind dilatation and curettage (D&C) with those who underwent hysteroscopic resection of pathologically confirmed retained products of conception (RPOC).

Prediction of morbidly adherent placenta using a scoring system

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

Long-term outcomes of children with umbilical vein varix diagnosed prenatally

The current study aims were to assess the long‐term outcomes of children who were diagnosed with umbilical vein varix (UVV) prenatally.

Predicting of morbidly adherent placenta using a scoring system: A prospective study

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

Prenatal diagnosis and management of vasa previa in twin pregnancies: a case series and systematic review

BACKGROUND: Twin pregnancies are at higher risks of velamentous cord insertion and vasa previa. In vitro fertilization is an additional risk factor of abnormal cord insertion and thus the incidence of vasa previa is likely to increase over the next decades. OBJECTIVE: We sought to evaluate the role of ultrasound imaging in optimizing the management of twins diagnosed with vasa previa antenatally. STUDY DESIGN: We searched our database for twin pregnancies diagnosed with vasa previa and managed antenatally using measurements of cervical length and performed a systematic review of articles that correlated prenatal diagnosis of vasa previa in twins and pregnancy outcome. PubMed and MEDLINE were searched for studies published from 1987 through October 20, 2016, using specific medical subject heading terms, key words, and their combination. The primary eligibility criteria were articles that correlated prenatal ultrasound imaging of vasa previa and pregnancy outcome in twins. The secondary eligibility criteria was the use of cervical length in the management of twin pregnancies diagnosed antenatally with vasa previa. Two authors independently assessed inclusion criteria, data extraction, and analysis. The final selection included 3 case report series, 9 retrospective cohort studies, and 1 retrospective case‐control study of vasa previa diagnosed prenatally and confirmed at birth in twin pregnancies. RESULTS: The search of our databases identified 6 cases of dichorionic‐diamniotic twins and 1 case of monochorionic‐diamniotic twins diagnosed prenatally with vasa previa between 22‐29 weeks and managed using cervical length. Two cases were delivered by emergency because of rapid changes in cervical length in one and bleeding on placenta previa in the other at 33 and 30 weeks, respectively. The systematic review identified data on 56 cases. The incidence of twin pregnancies diagnosed antenatally with vasa previa in the cohort and case‐control studies was 11.0%. Data on chorionicity were available in only 34 cases and cervical length measurements were used by only the authors of 2 case reports and 4 cohort studies. Velamentous cord insertion was the most common additional ultrasound findings in twins presenting with vasa previa in both our series and the systematic review. CONCLUSION: Vasa previa is associated with specific prenatal and obstetric complications with different outcomes in singletons compared to twins. Data on the diagnosis and management of vasa previa in twin pregnancies are limited but there is enough evidence to warrant guidelines for targeted screening. To enable the development of efficient management protocols tailored to the need of individual cases, future studies of the screening, diagnosis, and management of vasa previa should be prospective and multicentric with detailed data on twins including chorionicity and use of cervical length.

Monochorionic diamniotic in vitro fertilization twins have a decreased incidence of twin-to-twin transfusion syndrome

OBJECTIVE To compare the incidence of twin-to-twin transfusion syndrome (TTTS) in spontaneous versus IVF-conceived twin pregnancies. DESIGN Retrospective multicenter study. SETTING University-affiliated tertiary medical centers. PATIENT(S) Women admitted for 11-14 weeks scan between January 1997 and July 2013 who were diagnosed with monochorionic (MC) diamniotic twin pregnancies. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Mode of conception, TTTS. RESULT(S) The study cohort included 327 pregnant women with live MC diamniotic twins. Of them, 284 (86.9%) and 43 (13.1%) were spontaneous and IVF conceived, respectively. The mean maternal age was significantly higher in IVF compared with in spontaneously conceived pregnancies (33.8 ± 5.5 vs. 31.6 ± 5.4, respectively). Thirty-seven twins (11.3%) had TTTS, of whom 36/284 (12.7%) versus 1/43 (2.3%) were spontaneously and IVF conceived, respectively. The mean week of delivery was significantly lower in MC twins diagnosed with TTTS compared with those without TTTS (32.7 ± 3.3 vs. 35.5 ± 2.5, respectively). Furthermore, there was a significantly higher birthweight discordancy in twins diagnosed with TTTS compared with those without (20.6% vs. 11%, respectively). CONCLUSION(S) The significantly lower proportion of TTTS found in IVF-conceived twins may suggest a different embryological process that lies at the core of IVF conception of monozygotic twinning.

Nuchal translucency in twins according to mode of assisted conception and chorionicity

The impact of nuchal translucency (NT) screening in twins conceived after use of assisted reproduction technology (ART) has not been addressed properly in the literature. The aim of the current study was to assess, in a large cohort from a single center, NT in twins following various modes of ART as compared with NT in spontaneously‐conceived twins and to differentiate results with regard to chorionicity.

The association of crown–rump length discrepancy with birthweight discordance in spontaneous versus assisted conception dichorionic twins

This study aimed to compare the associations of crown–rump length (CRL) discrepancy with birthweight discordance in spontaneous versus vitro fertilization (IVF) conceived dichorionic twin pregnancies.

Impact of targeted scanning protocols on perinatal outcomes in pregnancies at risk of placenta accreta spectrum or vasa previa

BACKGROUND: Placenta accreta spectrum and vasa previa (VP) are congenital disorders of placentation associated with high morbidity and mortality for both mothers and newborns when undiagnosed before delivery. Prenatal diagnosis of these conditions is essential to allow multidisciplinary management and thus improve perinatal outcomes. OBJECTIVE: The objective of the study was to compare perinatal outcome in women with placenta accreta spectrum or vasa previa before and after implementation of targeted scanning protocols. STUDY DESIGN: This retrospective study included 2 nonconcurrent cohorts for each condition before and after implementation of the corresponding protocols (2004–1012 vs 2013–2016 for placenta accreta spectrum and 1988–2007 vs 2008–2016 for vasa previa). Clinical reports of women diagnosed with placenta accreta spectrum and vasa previa during the study periods were reviewed and outcomes were compared. RESULTS: In total, there were 97 cases of placenta accreta spectrum and 51 cases with vasa previa, all confirmed at delivery. In both cohorts, the prenatal detection rate increased after implementation of the scanning protocols (28 of 65 cases [43.1%] vs 31 of 32 cases [96.9%], P < .001, for placenta accreta spectrum and 9 of 18 cases [50%] vs 29 of 33 cases [87.9%], 87.9%, P < .01 for vasa previa). The perinatal outcome improved also significantly in both cohorts after implementation of the protocols. In the placenta accreta spectrum cohort, the estimated blood loss and the postoperative hospitalization stay decreased between periods (1520 ± 845 vs 1168 ± 707 mL, P < .01, and 10.9 ± 14.1 vs 5.7 ± 2.2 days, P < .05, respectively). In the vasa previa cohort, the number of 5 minute Apgar score ≤5 and umbilical cord pH <7 decreased between periods (5 of 18 cases [27.8%] vs 1 of 33 cases [3%]; P < .05, and 4 of 18 cases [22.2%] vs 1 of 33 cases [3%], P < .05, respectively). CONCLUSION: The implementation of standardized prenatal targeted scanning protocols for pregnant women with risk factors for placenta accreta spectrum and vasa previa was associated with improved maternal and neonatal outcomes. The continuous increases in the rates of caesarean deliveries and use of assisted reproductive technology highlights the need to develop training programs and introduce targeted scanning protocols at the national and international levels.

Fetal diagnosis of testicular torsion: what shall we tell the parents?

The objectives of this study are to present our collective experience with the prenatal diagnosis of testicular torsion and to propose a possible prenatal management scheme.