Zvi Weinraub

Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar

Case report A 28 year old woman was referred at seven weeks of gestation because of vaginal bleeding. Three years before she had undergone caesarean section because of breech presentation of a baby who weighed 3.8 kg at birth. The puerperium was complicated by febrile morbidity. Other than slight vaginal bleeding, there were no clinical findings. Ultrasound examination showed a pregnancy located in the i s t h c a l region (Fig. 1). Since the gestational sac was displaced anteriorly, the possibility of ectopic implantation in the previous caesarean section scar was considered. After discussion with the couple, a mutual decision. was reached to avoid any intervention at that point. It was judged that the sac, located in the isthmical region, would eventually coalesce with the uterine cavity and continue as a normal pregnancy. Repeated ultrasound examinations at 13 and 14 weeks’ gestation (Fig. 2A, B) showed a tip of the sac bulging towards the uterine cavity. However, several weeks later, the sac remained outside the uterine cavity (Fig. 2C, D). The findings and the potential dangers were discussed again, but because of the increased risk of hysterectomy associated with termination at that stage, management was unchanged. Besides diet-controlled gestational diabetes, the course of the pregnancy was uneventful. Vaginal examinations disclosed a normal cervix displaced up and laterally by the sac that was bulging into the right fornix. Caesarean delivery was planned for the 36th week of gestation, and she was admitted to the hospital two weeks before this. At 35 weeks an urgent caesarean section was performed because of acute abdominal pain. A longitudinal incision was made into the coverings of the amniotic sac and a healthy male infant weighmg 3.6 kg was born. The membranes were covered with thin fibromuscular tissue and peritoneum. The uterus was displaced to the left by the pregnancy sac and both cavities communicated at the isthmical level. There was no chorion free in the peritoneal cavity, and the placenta and its vessels were visible through transparent thin uterine wall and peritoneum. The placenta was of normal size, attached firmly to the low anterior aspect of the sac, and was

Mifepristone (RU486) alone or in combination with a prostaglandin analogue for termination of early pregnancy: a review

The availability of a medical mode of termination of early pregnancy by the administration of RU486, an antiprogesterone alone, or in combination with one of the PG analogues significantly reduces the maternal morbidity and mortality associated with the classical surgical abortion. RU486 given alone in early pregnancy induces complete abortion in 60% to 85% of cases, and when combined with prostaglandin analogues, gemeprost or sulprostone, reaches a success rate of 95% to 99%. RU486 may also be of potential value in the medical treatment of ectopic pregnancy. Its use as a postcoital contraception is suggested, but further research is required to determine whether RU486 can be used on a once-a-month basis for contraception.

Prevention of the respiratory distress syndrome in premature infants by antepartum glucocorticoid therapy.

A trial of antepartum dexamethasone therapy was carried out in 55 mothers in whom premature delivery threatened between 28 to 36 weeks gestation in the hope of reducing the incidence of respiratory distress syndromes (RDS). The control group was made up of 62 mothers who delivered prematurely in the same gestational age without any treatment. In the treated group isoxsuprine was used to delay delivery when necessary. The respiratory distress syndrome occurred less often in the treated group of infants (8.3 per cent) than in the controls (35.2 per cent; p<0.001). The difference was more marked in babies of under 32 weeks gestation. Considering only cases with intact membranes the incidence of RDS was significantly (p<0.01) lower in the treated group. Early neonatal mortality was 6.6 per cent in the treated group and 38 per cent (p<0.0001) in the controls. In 12 cases the L/S ratio was measured during dexamethasone administration and in the majority of these the L/S ratio rose sharply to mature values following treatment. This rise was observed as soon as 48 hours after beginning of dexamethasone. Antepartum isoxsuprine in the treated group had no apparent effect on the incidence of RDS. No adverse effects of steroid therapy were observed. This trial confirms the studies of others that antepartum glucocorticoid can significantly reduce the incidence of RDS in premature infants.

Ovarian hyperstimulation syndrome following D-Trp-6 luteinizing hormone-releasing hormone microcapsules and menotropin for in vitro fertilization.

In 143 cycles of in vitro fertilization the ovarian hyperstimulation syndrome (OHSS) occurred in 12 (8.4%) cycles. Six were in the moderate form and 6 severe. Ovarian stimulation by menotropins was preceded by induction of hypopituitary hypogonadism using D-Trp6-LH-RH microcapsules. The OHSS cycles are characterized by improved ovarian response expressed by the increased serum levels of estradiol, number of follicles, oocytes, embryos and pregnancy rate as compared to cycles with no OHSS. All patients recovered uneventfully. The follicular puncture did not have the suggested protective effect against OHSS. It is suggested that the substantial incidence of OHSS is probably related to the excessive ovarian stimulation not interrupted by early luteinization which is practically abolished by this protocol. The role of the given luteal hCG doses in the genesis of OHSS is questioned.

Results of in vitro fertilization and embryo transfer by combined long-acting gonadotropin-releasing hormone analog D-Trp-6-luteinizing hormone-releasing hormone and gonadotropins

To avoid cancellation of in vitro fertilization (IVF) because of early luteinization, pituitary suppression by gonadotropin-releasing hormone (GnRH) was carried out in 111 cycles. D-Trp-6-luteinizing hormone-releasing hormone (LH-RH) microcapsules were administered intramuscularly at menstruation and menotropin (hMG) stimulation was started 19 days (mean) later. In 3 cycles (2.7%), only early luteinization occurred. The mean number of oocytes per cycle was 6.7, with a fertilization and cleavage rate of 50 and 95%, respectively. A mean of 3.4 embryos were transferred per cycle. The 111 cycles resulted in 34 clinical pregnancies, 41% per cycle with embryo transfer. The early abortion, multiple pregnancy, and ovarian hyperstimulation rates were 24, 18, and 11%, respectively. It is concluded that D-Trp-6-LH-RH/hMG cycles are associated with a very low occurrence of early luteinization, high number of oocytes and embryos, and a substantial incidence of ovarian hyperstimulation syndrome.

The effect of chronic gonadotropin-releasing hormone analog (D-Trp-6) treatment on elevated and normal serum prolactin levels

A long-acting GnRHa (D-Trp-6 microcapsules) proved capable of lowering serum PRL levels in a young hyperprolactinemic patient treated for a large myomatous uterus. No similar inhibitory effect was found in normoprolactinemia. Chronic GnRHa therapy may constitute an alternative to the existing forms of treatment for hyperprolactinemia and pituitary adenomas.

Infections with mycoplasma and bacteria in induced midtrimester abortion and fetal loss.

Placentas and fetuses from cases of induced midtrimester abortion and fetal loss (13 weeks of pregnancy or more) were examined microbiologically. In the series of midtrimester fetal loss, bacteria were isolated in 14 per cent and genital Mycoplasma in 37 per cent of the placentas. In induced abortion, 18 per cent of the placentas grew bacteria and in only one case out of 27 was a Mycoplasma strain isolated. Fetal organs yielded cultures positive for bacteria in 16 per cent and for genital Mycoplasma in 23 per cent of the spontaneous fetal loss material, whereas pyogenic cocci were isolated from fetal organs in 18 per cent and Mycoplasma in no case of induced abortion. In the positive cases, the fetal lungs were most often infected (in 34 out of 37 positive cases of spontaneous and 4 out of 5 positive cases of induced abortion). On the other hand, microorganisms could be isolated from the brain in only 5 out of 28 cases of spontaneous and none of induced abortion. In the series of fetal loss, positive microbiologic findings from the fetal organs seemed correlated to prolonged bleeding before abortion or labor and to premature rupture of membranes.

Reproductive outcome after laparoscopic local methotrexate injection for tubal pregnancy

OBJECTIVE To evaluate reproductive outcome after laparoscopic local methotrexate (MTX) injection for tubal pregnancy. DESIGN Follow-up was performed after 77 women were treated with local MTX injection between January 1, 1987 and December 31, 1990. SETTING Department of Obstetrics and Gynecology in a university medical center. MAIN OUTCOME MEASURES Concise patient details about tubal patency in hysterosalpingography, pelvic findings at laparoscopy or laparotomy performed after the treatment, and the intrauterine and extrauterine pregnancy rates (PRs) are given. RESULTS Intrauterine PR of 67% and extrauterine PR of 13% were achieved. CONCLUSION Local MTX injection does not modify tubal or pelvic anatomy and does not impair subsequent reproductive performance.

TUBAL PATENCY AFTER LOCAL METHOTREXATE INJECTION FOR TUBAL PREGNANCY

Tubal patency was investigated by hysterosalpingography in 21 of 37 patients with unruptured tubal pregnancy treated by local methotrexate injection at laparoscopy. 18 of the 21 patients had bilateral tubal patency, and the only tube of a patient with a single fallopian tube was also patent. 6 subsequent intrauterine pregnancies have so far been recorded. Local methotrexate injection into the tubal pregnancy may provide an efficient and safe alternative to surgery in early unruptured ectopic pregnancy.

The role of tubal pathology and other parameters in ectopic pregnancies occurring in in vitro fertilization and embryo transfer

Contradictory findings were reported concerning the role of tubal disease in the genesis of ectopic pregnancy in in vitro fertilization and embryo transfer (IVF-ET). We report on six ectopics that occurred in 141 IVF-ET pregnancies (4.3%). All of the six cases were among 84 patients with tubal disease, and none occurred in the remaining 57 patients with other etiological factors. No correlation was found in other parameters including: ovulation induction, number of embryos transferred, and luteal support. A comparison between the ectopics and six matched controls demonstrated similar estradiol levels, but beta-hCG levels on day 15 to 17 after ET were lower. Homolateral salpingectomy was performed in all six cases, but a contralateral resection was carried out in three of them. More comprehensive studies are needed to clarify whether tubal pathology really increases the risk for ectopic gestation in IVF-ET.