Yael Goldberg

Resistance to activated protein C and the Leiden mutation: High prevalence in patients with abruptio placentae

OBJECTIVE The Leiden mutation, a point mutation in the gene encoding coagulation factor V, is associated with a high frequency of thromboembolic phenomena. It has recently been connected with adverse outcomes of pregnancy. We carried out this study to define its connection with abruptio placentae. STUDY DESIGN Twenty-seven women who had abruptio placentae and 29 control subjects matched for age, parity, and ethnic origin were studied. We studied all women for possible hypercoagulation defects. All women demonstrating resistance to activated protein C were studied for the presence of the factor V Leiden mutation. RESULTS Seventeen of 27 case patients had an activated protein C ratio </=2.5, compared with 5 of 29 control subjects (odds ratio 8.16, 95% confidence interval 3.6-12.75, P =.00125). Participants with activated protein C ratios </=2.5 underwent deoxyribonucleic acid analysis. Eight case patients were found to have the factor V Leiden mutation (5 heterozygous and 3 homozygous, 29.6%), compared with 1 heterozygote among the control subjects who were tested (3.4%). CONCLUSION Factor V Leiden mutation was found quite frequently in patients with abruptio placentae.

Clinical and ultrasonographic weight estimation in large for gestational age fetus

OBJECTIVE To examine prospectively the effect on pregnancy outcome of a management protocol, that adds ultrasonographic weight estimation in fetuses suspected clinically as large. STUDY DESIGN Prospective follow up study of all singleton deliveries during a 1 year period. All patients underwent routine clinical estimation of fetal weight. When clinical estimation of fetal weight was > or = 3700 g, patients were referred for ultrasonographic estimation of fetal weight. When the latter was > or = 4000 g the patient was informed about the risks of birth trauma. Cesarean section was recommended only when > or = 4500 g. Ultrasonography was repeated every 4 days when possible. Predictive values of clinical and ultrasonographic estimations of fetal weight for diagnosing macrosomia, defined for the purpose of this study as 4000 g or more, and their effect on the rate of cesarean sections. RESULTS Five hundred fifty-five (14.4%) out of 3844 singletons were estimated as 3700 g or more. Only 315 fetuses had ultrasonographic estimation of weight within 3 days of delivery. The sensitivity of clinical and ultrasonographic prediction of macrosomia was 68 and 58%, respectively. Cesarean section rate in newborns weighing 4000 g or more was 22% when macrosomia was clinically suspected compared to 11% when it was not (P<0.05). In fetuses estimated ultrasonographically as 4000 g or larger the cesarean section rate was doubled (50.7% versus 24.9%, P<0.05) compared to those estimated as smaller than 4000 g, although actual weight of 4500 g or more was recorded in 10.6 and 8.5% of these groups, respectively. There were no cases of shoulder dystocia in macrosomic babies when macrosomia was not detected by ultrasound compared to two cases of shoulder dystocia (2.7%) when macrosomia was detected by ultrasound. CONCLUSION Antenatal suspicion of macrosomia increased the cesarean section rate while the associated improvement in pregnancy outcome remains questionable. The contribution of ultrasound, added to routine clinical estimation of fetal weight, was clinically insignificant apart from a further increase in cesarean section rate.

Cesarean Scar Pregnancy: A Case Series of Diagnosis, Treatment, and Results

The aim was to collect cases of cesarean scar pregnancy (CSP) and describe the evolution of diagnosis, treatment modalities, and outcome. A retrospective cohort study was conducted of patients who had been diagnosed with CSP. Treatment decision was made according to the type of CSP, levels of beta human chorionic gonadotropin (hCG), and estimated vascularity. Forty cases with CSP were recorded. Overall success of the primary treatment was recorded among 30 of 40 cases (75%) and significantly correlated with degree of vascularity, type of CSP, and beta hCG levels. The treatment methods included serial methotrexate in 20 cases; 15 of them (75%) were successful. In this specific group, we found type 2 scar and high vascularity to be significantly associated with treatment failure. In conclusion, cases with type 2 CSP, high vascularity, and high beta hCG levels should be considered high risk, and extra caution should be taken in choosing treatment modality and follow-up.

Diagnosis of Lower Gastrointestinal Tumors by Transvaginal Sonography

Sonography plays a primary role in the diagnosis of gynecological diseases. A retrospective review of incidental findings report by transvaginal sonography (TVS) was performed to evaluate the ability of TVS to visualize rectosigmoid carcinoma. The authors performed a retrospective review of 450 women who were referred for TVS because of suspected gynecological indications to evaluate those with incidental findings. Of these, 15 with incidental findings were subsequently diagnosed with rectosigmoid carcinoma. The sonographic properties and clinical findings were systematically evaluated. TVS findings included solid nonhomogeneous lesions (mean diameter of 4 cm; range, 1.6–8 cm), distended rectal walls, and gas inside the gastrointestinal lumen in 53% (n = 8) of the cases. Total wall invasion was suspected, and signs of edema were noticed in 60% (n = 9) of the cases. All lesions seen by TVS were pathologically confirmed as carcinoma of gastrointestinal origin. Inspection of the rectosigmoid during a TVS examination has the ability to detect unsuspected rectosigmoid lesions.