Z. Ben-Rafael

Endometrial polyps during menopause, characterization and significance

BACKGROUNDnTo characterize postmenopausal women with endometrial polyps and to evaluate their significance.nnnMETHODSnThe study population included all consecutive postmenopausal patients with a diagnosis of endometrial polyp, treated at our center over a two-year period. Demographic, medical and gynecological data were assessed with regard to the endometrial histologic findings.nnnRESULTSnOf the 146 eligible patients, 15 had endometrial hyperplasia (four with atypia); there were no cases of endometrial carcinoma. The 20 patients (13.7%) using hormone replacement therapy had a significantly higher rate of endometrial hyperplasia than non-hormone users (p<0.006). No differences were observed among the endometrial histological categories for any of the presenting symptoms and signs, ultrasonographic findings, or medical histories.nnnCONCLUSIONSnPostmenopausal endometrial polyp is a common, mostly benign entity. However, the relatively high rate of concomitant endometrial hyperplasia, especially in patients receiving hormone replacement therapy, dictates a thorough histological evaluation in all cases.

The effect of betamethasone and dexamethasone on fetal heart rate patterns and biophysical activities, A prospective randomized trial

UNLABELLEDnBACKGROUND; Contradictory findings on the effect of betamethasone versus dexamethasone on antenatal tests of fetal well-being have been reported. The purpose of this study was to compare the effects of these steroid compounds on fetal heart rate patterns and biophysical activities in a prospective. randomized trial.nnnSTUDY DESIGNnForty-six pregnant women (gestational age range 27-34 weeks) at risk for preterm delivery were randomized to receive betamethasone or dexamethasone for enhancement of fetal lung maturity. Fetal heart rate was recorded for 60 minutes and analyzed with the Sonicaid System 8000 before (0 hours), and 48 hours and 96 hours after steroid administration. Subsequently, fetal limb, body and breathing movements were sonographically observed and quantified for 30 minutes. To account for fetal circadian rhythms, all examinations were performed between 1 p.m. and 5 p.m., at least one hour after maternal meals.nnnRESULTSnFetal heart rate accelerations (p<0.001; p<0.01), short-term variation (p<0.0001; p<0.05), long-term variation (p<0.01; p=NS), duration of high episodes (p<0.001; p<0.05), total movement count (p<0.001; p<0.05), and duration of breathing time (p<0.0001; p<0.0001) were substantially reduced 48 h after betamethasone and dexamethasone administration, respectively, with percent reduction being larger for the betamethasone group, except for breathing movements (p<0.05; p<0.001; p<0.001; p<0.005; p<0.05; p=NS; respectively). In 68.2%( and 45.5% of fetuses, less than 30 seconds of continuous breathing movements were found in the betamethasone and dexamethasone groups, respectively. In 71.8% and 12.5%, of fetuses, respectively, less than 2 body/limb movements were observed. Therefore five and two fetuses in the betamethasone and dexamethasone study group, respectively, had both nonreactive fetal heart rate monitors for 60 minutes and biophysical profiles of < or =4/10. All parameters returned to baseline values at 96 h. Baseline fetal heart rate and numbers of decelerations remained unchanged (p=NS).nnnCONCLUSIONSnBoth betamethasone and dexamethasone induce a profound, albeit transient, suppression of fetal heart rate characteristics and biophysical activities in the preterm fetus. However, the effect of betamethasone is more pronounced. Awareness of these phenomena might prevent unwarranted iatrogenic delivery of preterm fetuses.

Clinical Assisted Reproduction: Are Singleton Assisted Reproductive Technology Pregnancies at Risk of Prematurity?

Purpose: Our purpose was to determine the risk of premature delivery among singleton pregnancies derived from assisted reproduction technology (ART).Methods: Ninety-five singleton ART pregnancies and 190 matched spontaneous pregnancies were assessed for preterm delivery rates, pregnancy complications, and cesarean section rates in a retrospective study at an academic medical center.Results: Among the ART singleton deliveries group (n = 95), 19 (20%) were preterm, which was statistically significantly higher than the 4% (8 of 190) found in the control group. Among the pregnancies achieved by intracytoplasmic sperm injection (ICSI) in the severe male-factor infertility subgroup (n = 22), only one preterm delivery occurred (4.5%).Conclusions: Singleton ART pregnancies are at an increased risk of preterm delivery compared to singleton pregnancies after spontaneous conception. The higher rate may be attributed to various infertility cofactors, such as uterine malformations, previous operative procedures that involved cervical dilatation, and a history of pelvic infection. This is supported by the finding that ICSI-derived pregnancies in couples with strict male-factor infertility are not at an increased risk of preterm delivery.

Preservation of Fertility in Women Undergoing Chemotherapy: Current Approach and Future Prospects

Purpose:Anticancer treatment causes ovarian failure.Methods:Some hormones may have a protective effect on the ovary. Cryopreservation (freezing) of oocytes has had very limited success, and therefore, currently its use before chemotherapy is not a feasible option. However, cryopreservation of embryos is possible. Another solution is oocyte donation followed by in vitro fertilization (IVF).Results:Ovarian cortical slices containing primordial follicles have been cryopreserved successfully. To restore fertility, cryopreserved–thawed tissue taken from cancer patients before therapy could be replanted after recovery. The possible risk of malignancy restoration could be eliminated by obtaining unilaminar follicles from cryopreserved–thawed tissue and growing them in vitro, followed by routine IVF.Conclusions:Although women who undergo chemotherapy face limited options for fertility preservation, intensive studies in cryopreservation and in vitro maturation of follicles harbor hope for brighter prospects in the future.

The effect of betamethasone on fetal biophysical activities and Doppler velocimetry of umbilical and middle cerebral arteries

OBJECTIVEnPreliminary reports suggest that antenatal steroid administration may confound the assessment of fetal well-being by suppressing biophysical activities, consequently drug-induced effects could prompt unwarranted delivery of premature fetuses. The purpose of this study was to examine the effect of antenatal betamethasone administration on fetal biophysical activities and Doppler flow indices of the umbilical and middle cerebral circulation.nnnMETHODSnForty women at risk of premature delivery between 27-32 weeks gestation (mean 30.2 weeks) received two consecutive doses of intramuscular betamethasone, 24 hours apart. Ultrasonographic observations of fetal behavior for 30 minute periods and Doppler examination of the umbilical and cerebral arteries were performed prior to (0 hours), 48 hours after, and 96 hours after administration of the first dose. To account for fetal circadian rhythms and maternal prandial status, all examinations were carefully timed and performed between 1-4 pm. Analysis of Variance, chi-square test and Fishers Exact test were used for statistical analysis, as appropriate.nnnRESULTSnNine patients were excluded from analysis due to delivery prior to completion of all examinations. Number of breathing episodes as well as total breathing time at 48 hours decreased by 83.0% (p<0.01) and 90.4% (p<0.01), respectively, at 48 hours in comparison to baseline. Fetal limb and trunk movements decreased by 53.2% (p<0.01) and 48.6% (p<0.01), respectively. Amniotic fluid volume and fetal tone were normal in all patients. At 48 hours, 14 of 31 fetuses and 4 of 31 fetuses had a biophysical profile score of 6/8 and 4/8, respectively, in comparison to 0 of 31 and 0 of 31 at 0 hours (p<0.05 and p<0.001, respectively). All parameters returned to baseline values at 96 h. Pulsatility indices of umbilical and middle cerebral arteries remained unchanged at 48 hours and 96 hours (p=NS).nnnCONCLUSIONSnBetamethasone induces a profound, albeit transient, suppression of fetal breathing, limb and trunk movements, resulting in decreased biophysical profile scores. Awareness of this drug-induced effect might prevent unnecessary iatrogenic delivery of preterm fetuses.

Prenatal sonographic findings in 187 fetuses with Down syndrome

We determined the type and frequency of abnormal sonographic findings in 187 Down syndrome fetuses. Examinations were performed transvaginally or transabdominally between 9 and 28 weeks gestation. Consecutive scans performed prior to knowledge of the fetal karyotype (n=144) were analysed separately for one of the participating centres. In 93 fetuses (49·7 per cent), a total of 138 abnormalities were observed. The most commonly detected anomalies were cystic hygroma and increased nuchal fold thickness (30·5 per cent), hydrops (9·6 per cent), cardiac defects (7·5 per cent), pyelectasis or hydronephrosis (5·9 per cent), echogenic bowel (4·8 per cent), and a large variety of internal organ abnormalities (16·0 per cent) which are not typically associated with Down syndrome. Two anomalies or three anomalies in the same fetus were observed in 21 and 5 fetuses, respectively. No patterns of concurrent malformations were apparent among these fetuses. Sensitivity for Down syndrome detection by ultrasound scans performed without knowledge of the fetal karyotype was 24·1 and 42·6 per cent before 13 weeks and between 14 and 23 weeks, respectively. We conclude that structural abnormalities are frequently observed in Down syndrome fetuses, but many sonographic findings are not typically associated with this syndrome.

Effect of Thrombophylaxis on Uterine and Fetal Circulation in Pregnant Women with a History of Pregnancy Complications

PURPOSEnThe aim of this study was to investigate the effect of thromboprophylactic therapy on fetal and maternal Doppler flow parameters in pregnant women with severe complications in previous pregnancies and evidence of acquired or congenital thrombophilia in the current pregnancy.nnnMETHODSnSixty-five patients with a history of recurrent abortions, intrauterine fetal death, intrauterine growth restriction (IUGR), and severe early-onset preeclampsia were tested for the presence of acquired or congenital thrombophilia. Those with positive findings were prescribed low-dose aspirin plus low-molecular-weight heparin (LMWH) (enoxaparin); the remainder received low-dose aspirin only. A Doppler flow study was performed before and after treatment and in the third trimester of pregnancy.nnnRESULTSnOf the 65 pregnancies, four ended in spontaneous abortion and were excluded from the analysis. Of the 61 women with completed pregnancies, 37 (61%) had evidence of acquired or congenital thrombophilia: 22 (36%) protein S deficiency; 1 (2%) protein C deficiency; 2 (3%) activated protein C resistance (APC-R); 2 (3%) IgG for antiphospholipid antibodies; 1 (2%) circulating anticoagulant; and 9 (15%) a combined defect. This group showed a significant decrease in mean uterine artery pulsatility index (PI) before and after treatment (1.32+/-0.36 vs. 1.04+/-0.23, P=.006), whereas the remaining 24 patients treated with low-dose aspirin only had nonsignificant changes. Pearsons correlation test yielded no correlations of the pregnancy outcome parameters with Doppler flow values in the umbilical or uterine arteries.nnnCONCLUSIONSnThromboprophylactic therapy transiently improves maternal circulation parameters in patients with thrombophilia at risk of fetal loss and other severe complications of pregnancy, but not in correlation with their pregnancy outcome. Therefore, Doppler examination of maternofetal circulation in the second trimester is not predictive of pregnancy outcome.

CAUTION: PRENATAL CLUBFOOT CAN BE BOTH A TRANSIENT AND A LATE‐ONSET PHENOMENON

Clubfoot (talipes equinovarus) is a common orthopaedic malformation that can be accurately diagnosed prenatally. The study was conducted to investigate possible in utero visualization of transient and late‐onset clubfoot. Early (13–16 weeks gestation) prenatal transvaginal sonographic diagnosis of clubfoot deformity was made in 36 cases during the study period. Only those cases where follow‐up examination revealed different sonographic findings were considered. The results showed that seven cases of transient (as well as relapsing) clubfoot were identified. In 4 of 7 cases, the clubfoot resolved (all after more than 10u2009min of observation) during the same examination. In the fifth and sixth cases, it initially resolved, later reappearing in follow‐up examinations (20 and 22 weeks gestation). In the seventh case, the clubfoot persisted for two consecutive examinations (2 weeks apart each) and later disappeared. In addition, six late‐onset (22–24 weeks gestation) clubfoot cases were identified during the study period. Although infrequent, in utero clubfoot can be both a transient and a late‐onset phenomenon. Over‐ and under‐diagnosis are potential hazards in these situations.

Effect of Betamethasone Administration on Fetal Heart Rate Tracing: A Blinded Longitudinal Study

Objective: Computerized fetal heart rate (FHR) analysis revealed that antenatal corticosteroids transiently suppress multiple parameters of fetal well-being, potentially leading to the erroneous diagnosis of fetal distress and to unnecessary iatrogenic delivery of premature infants. Our aim was to determine whether clinicians who visually analyze FHR tracings detect these suppressive effects, thereby potentially affecting their clinical management decisions. Methods: Singleton pregnancies admitted for preterm labor between 26 and 34 weeks’ gestation received two doses of betamethasone, 24 h apart, and were monitored daily between 16:00 and 19:00 h for 5 days. FHR tracings were randomly coded and presented in a non-consecutive order to four clinicians, who were unaware of the time of steroid administration. FHR baseline, FHR variability, number of accelerations and amplitude of maximal FHR acceleration were determined. Variability was scored semiquantitatively based on a modified Hon score. Analysis of variance (ANOVA) with repeated measures was used for primary analysis and followed up with the Wald test of significance. Corrections for multiple comparisons were made and only p < 0.005 considered significant. ANOVA was also used to assess the uniformity of trend in the interpretation by the four examiners for each given day. Results: Baseline FHR was elevated, FHR variability was decreased, and the number of accelerations decreased on day 1 (p < 0.0001; p < 0.0001; p < 0.0001) and day 2 (p > 0.0001; p < 0.0001; p < 0.0001) in comparison to day 0. On day 3, the FHR baseline, variability and number of accelerations returned to pre-exposure values (p = NS). The maximal amplitude of FHR accelerations showed a trend towards reduction (p = 0.08). Subgroup analysis by gestational age (group I = 26–30 weeks and group II = 30–34 weeks) showed the same response patterns and significance levels for both groups. Conclusions: Betamethasone causes profound, but transient, suppression of FHR parameters, which can mimic fetal distress. This effect is clinically recognized by visual FHR analysis. Clinicians need to be aware of this phenomenon, in order to avoid unwarranted iatrogenic delivery.

Outcome of Pregnancies Derived from Assisted Reproductive Technologies: IVF versus ICSI

Purpose: To compare the course and outcome of in vitrofertilization (IVF) and intracytoplasmic sperm injection(ICSI) pregnancies. Methods: A retrospective study was conducted in a university-affiliatedIVF unit with 200 patients who conceived in1996–1997, 100 with ICSI and 100 with IVF. Data wereretrieved from our prospectively created computerized database.In addition, all patients were interviewed by telephone,and the interviewing physician completed a detailed questionnaire.Findings for the IVF and ICSI pregnancies werecompared. The main outcome measures were maternal age,implantation rate, early pregnancy complications, clinicalabortion rate, multiple pregnancy delivery rate, gestationalage at delivery, mode of delivery, and birth weight. Results: In all, 238 children were born, including 104 singletoninfants (45 IVF, 59 ICSI), 49 twin pairs (28 IVF, 21 ICSI),and 12 triplet sets (3 IVF, 9 ICSI). Statistically significantdifferences between the ICSI and IVF groups were noted formaternal age (31.3 ± 4.4 vs. 33.4 ± 4.8, respectively, P < 0.005)and clinical abortion rate (11% vs. 24%, respectively,P < 0.05). Conclusions: ICSI pregnancies in our series were characterizedby a lower clinical abortion rate than IVF pregnancies,probably because of the mean younger age of the ICSI group.