[TERMINATION OF PREGNANCY DUE TO FETAL ABNORMALITIES PERFORMED AFTER 24 WEEKS OF GESTATION: THE EXPERIENCE OF THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY AT SHAMIR (ASSAF HAROFE) MEDICAL CENTER BETWEEN THE YEARS 1998-2021].

BACKGROUND: Termination of pregnancy is a difficult moral dilemma that provokes a discussion in the public, from an ethical, moral and religious point of view. This process is complex, especially when it comes to a fetus at a viability age (late abortion, after week 24), which requires the approval of a regional supreme committee. OBJECTIVES: To examine the various causes of abortion both before and after the fetal viability age (24 weeks of gestation and beyond) in a singleton pregnancy, as well as to examine the sequence of events that led to a late abortion. METHODS: In this cohort study, 4,057 patients who had abortions due to fetal abnormalities in the Shamir Medical Center during the years 1998-2021, were divided according to the abortion indications. Of these, 3539 (91.28%) had early abortion (24 weeks and below) and 338 (8.72%) had late abortions (24 week and later). RESULTS: In general, the leading reasons for abortions are chromosomal and genetic (1862 [46%]) as well as anatomical indication (1868 [46%]). It was found that the leading indication for early abortion is the chromosomal or genetic abnormalities (1702 [48.1%]), while the leading indication for late abortion is anatomical defects (204 [60.4%]) (p=0.000). In late abortion, the leading anatomical cause is heart defects (62 [30.54%]) followed by central nervous system defects (56 [26.6%]), and the leading chromosomal cause is trisomy 21 (Down syndrome) (23 [22.33%]). When examining the sequence of events that led to late abortion, the leading reason is abnormal findings that required further studies (125 [37%]). CONCLUSIONS: There is great importance in trying to reduce late pregnancy abortion by understanding the sequence of events and the reasons that led to it. Changing the processes that need to be performed can be implemented by combining pathways: improving the technological means, using more accurate instrumentation and advanced molecular genetics. Furthermore, it is essential to raise the awareness of the pregnant women on screening tests, and conducting this as early as possible. Additionally, it is important to raise the skill of the operators. We believe that incorporating all those actions will lead to earlier diagnosis and to a decrease in late abortions, a promising message both from the point of view of the women and the medical staff, due to the difficulty in carrying out late pregnancy terminations.

Pregnancy with Facial Cleft: 20 Years of Experience at a Single Center.

BACKGROUND: Fetal facial clefts are among the most common congenital anomalies detected prenatally. This finding may lead to termination of pregnancy in some cases. OBJECTIVES: To compare a cohort of fetuses with facial clefts in which the pregnancy was terminated to the cohort of cases that were born with facial clefts. To investigate risk factors for facial clefts. METHODS: We conducted a retrospective chart review of all women with prenatal and postnatal diagnosis of facial cleft that were managed in our institute. A telephone questionnaire was conducted regarding a positive family history and/or genetic predisposition for facial clefts abnormalities. RESULTS: The final cohort consisted of two group. One group included 54 cases of termination of pregnancy (TOP) that were performed due to cleft lip (CL) or cleft palate (CLP); 27 women answered the telephone questionnaire. The second group comprised 99 women who delivered children with facial cleft during the same period; 60 answered the questionnaire. Only seven cases were diagnosed prenatal. Among the two groups, no correlation to family history was discovered. Of note, there was one case of three consecutive fetuses with CL in one woman, without any significant genetic findings. CONCLUSIONS: To the best of our knowledge, this is the first study to describe an anatomical malformation posing an ethical dilemma before TOP. Primary prevention with folic acid and early sonographic detection of CL/CLP with multidisciplinary consultation should be considered.

Intrahepatic portosystemic shunts, from prenatal diagnosis to postnatal outcome: a retrospective study.

OBJECTIVE: Congenital intrahepatic portosystemic shunts (IHPSS) are rare vascular malformations resulting in blood bypassing the liver to the systemic circulation. Previous studies included symptomatic patients diagnosed postnatally, but the outcome of IHPSS diagnosed prenatally is rarely reported. We present a cohort of children prenatally diagnosed with IHPSS and report their natural course and outcome. METHODS AND DESIGN: This was a retrospective study of all fetal cases diagnosed by ultrasound with IHPSS between 2006 and 2019 at a single tertiary centre which were prospectively followed up at the paediatric gastroenterology unit. The postnatal outcome was compared between patients with a single versus multiple intrahepatic shunts. RESULTS: Twenty-six patients (70.3% boys) were included in the study, of them, eight (30.8%) patients had multiple intrahepatic shunts. The median gestational age at diagnosis was 29.5 weeks. Growth restriction affected 77% of the cohort. Postnatally, spontaneous shunt closure occurred in 96% of patients at a median age of 7.5 months (IQR 2.2-20 months). Failure to thrive (FTT) and mild developmental delay were observed in eight (30.8%) and seven (26.9%) patients, respectively. FTT was significantly more prevalent in patients with multiple shunts compared with patients with a single shunt (62.5% vs 16.7%, p=0.02); however, the rate of shunt closure and age at time of closure were similar between these groups. All patients survived with limited to no sequelae. CONCLUSIONS: IHPSS usually close spontaneously by 2 years of age. Children with prenatally detected IHPSS may develop FTT and mild developmental delay. Close surveillance at a paediatric gastroenterology unit may be beneficial.

Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria.

OBJECTIVES: Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation. METHODS: A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus. RESULTS: The ß-HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P = .01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P = .036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P = .01). CONCLUSIONS: The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision-making, patient care, and the follow-up of CSP.

Caesarean scar pregnancy: is there a light in the end of the tunnel?

PURPOSE: To summarize and present a single tertiary center's 25 years of experience managing patients with caesarean scar pregnancies and their long-term reproductive and obstetric outcomes. METHODS: A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians' decisions, patient counseling, and parental requests. RESULTS: Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%). CONCLUSION: CSP treatment focusing on reducing morbidity and preserving fertility has encouraging long-term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

Recurrence of Ovarian Dermoid Cysts: A Single Center Experience.

BACKGROUND: Laparoscopic removal of ovarian dermoid cysts has been associated with increased risk for recurrence. OBJECTIVES: To investigate the risk factors associated with recurrence of dermoid cysts. METHODS: We conducted a retrospective review of all women who underwent cystectomy for ovarian dermoid cysts by laparoscopy or laparotomy. At discharge, patients were instructed to undergo a yearly ultrasound exam. A follow-up telephone call was conducted to assess whether an additional surgery for dermoid cysts was required and whether ultrasound recurrence of dermoid cysts was suspected. RESULTS: The study cohort included 102 participants (92 [90.2%] operated by laparoscopy and 10 [9.8%] by laparotomy). The mean follow-up from the index surgery to the interview was 72.1 ± 38.2 months. The rates of recurrent surgery were similar among women who underwent laparoscopic cystectomy compared with laparotomy (5/92 [5.4%] vs. 1/10 [10.0%], respectively; P = 0.5), while the rates of reported ultrasound recurrence were significantly lower in the laparoscopy group compared with the laparotomy group (10/102 [10.9%] vs. 4/10 [40.0%], respectively; P = 0.03). Additional factors including age, cyst diameter, diagnosis of torsion, intraoperative cyst spillage, estimated blood loss, intraperitoneal adhesions, and postoperative fever were not associated with recurrence. CONCLUSIONS: Ultrasound recurrence of dermoid cysts is not uncommon and could be associated with the surgical approach.

Spontaneous pregnancy rates in infertile women after sequential hydrosonography and hysterosalpingo-foam sonography.

OBJECTIVE: To determine the clinical pregnancy rate following sequential hydrosonography and hysterosalpingo-foam sonography (HyFoSy) in tubal patency assessment among women undergoing infertility work-up. STUDY DESIGN: Prospective follow-up of women referred to our department between July 2019 and October 2020. Sequential hydrosonography and HyFoSy were carried out. RESULTS: Out of 250 having the procedure, 100 women were excluded from study due to limited infertility, semen abnormal or not examined, evaluation for social egg freezing or they were single. Of the remaining 150 women, 48 (32%) conceived during a 10-24 months follow-up period: 17 (11%) conceived naturally and 7 (4.7%) by IUI. The mean time to conception was 5.5 ± 5.4 months and the pregnancy rate was 52% within 6 months. Among the spontaneous pregnancies 47% occurred within a month and 76% within 3 months. CONCLUSION: Sequential hydrosonography and HyFoSy is a promising method for assessing the uterine cavity and tubal patency in women undergoing infertility workup. The findings suggest that the procedure may increase the chance of a spontaneous pregnancy following the procedure. Given the other known advantages of sequential hydrosonography and HyFoSy, this test is worth including in the initial workup for infertile patients.

Midgestational pre-labor spontaneous uterine rupture: a systematic review.

OBJECTIVE: Second and early third-trimester uterine rupture in a non-laboring woman is a very rare and life-threatening condition for both mothers and newborns. However, there are scant epidemiologic data on this event. STUDY DESIGN: Literature searches using Medical Subject Headings (MeSH) and non-MeSH terms were conducted in the PubMed/MEDLINE, Google Scholar and Embase databases from 1988 to 2020. Abstracts were reviewed and selected if they reported on uterine rupture in the second and third trimester. Uterine rupture was characterized as a full-thickness uterine wall defect. A total of 80 singleton intrauterine pregnancies between gestational ages of 14 and 34 weeks' gestation were included. RESULTS: The mean gestational age at diagnosis of uterine rupture was 22.4 ± 5.4 weeks. The associated events in obstetric history for uterine rupture were: ≥1 previous cesarean section (45%; 36/80 of the cases), previous uterine rupture (10%; 8/80), previous classical uterine incision (7.5%; 6/80), myomectomy (25%; 20/80) and congenital uterine malformations (16.3%; 13/80 of the cases). Uterine ruptures were associated with a short IP interval in 13.7% (11/80) and 43.7% (35/80) were associated with abnormal placentation: placenta accreta spectrum (PAS) disorders (n = 26), placenta previa (n = 2) and placenta previa and PAS (n = 7). The rate of related prenatal ultrasound findings was 67.5%. Cesarean hysterectomy was performed in 27% of the cases. Maternal death was reported in 2.5% (2/80). For the neonates delivered ≥24 weeks' gestation (n = 27) peripartum fetal death was reported in 33.3% (9/27). CONCLUSIONS: Midgestational pre-labor spontaneous uterine rupture is not an anecdotal event and may follow the worldwide increasing rate of cesarean sections. Health care providers should be familiar with the associated factors, presenting symptoms and complications of this obstetric emergency.

Oligohydramnios: how severe is severe?

OBJECTIVE: To investigate whether the severity of isolated oligohydramnios at term is associated with increased rates of adverse perinatal outcome. STUDY DESIGN: A retrospective study conducted in a single medical center from 2017 to 2019. All low-risk pregnancies with incidental isolated oligohydramnios at term were included. The degree of oligohydramnios was arbitrarily classified into mild (AFI = 41-50 mm), moderate (AFI = 21-40 mm) and severe (AFI = 0-20 mm). RESULT: A total of 610 women were included: 202 with a mild (33.1%), 287 moderate (47.0%), and 121 severe oligohydramnios (19.8%). Non-reassuring monitor requiring immediate delivery and worse composite neonatal outcome were more common among severe than mild or moderate oligohydramnios (14.0% and 6.4%, 7.3% respectively; p = .039 and 19.8%, 10.9% and 11.8%, respectively; p = .048). CONCLUSION: Low-risk pregnancies with isolated severe oligohydramnios at term have a higher tendency toward non-reassuring fetal monitoring requiring prompt delivery and adverse neonatal outcomes, this calls for close intrapartum surveillance.

Comparison between a prenatal sonographic scoring system and a clinical grading at delivery for Placenta Accreta Spectrum disorders.

OBJECTIVE: Placenta Accreta Spectrum (PAS) disorders have become a major iatrogenic obstetric complication worldwide. Data on the accuracy of ultrasound examination diagnosis are limited by incomplete confirmation and variability in the description of the different grades of PAS at delivery. The aim of this study was to compare our prenatal routine sonographic screening and diagnostic scoring system with a standardized clinical grading system at birth in patient at risk of PAS. STUDY DESIGN: This is a retrospective cohort study of 607 pregnant patients with at least one prior cesarean delivery between December 2013 and December 2018. All patients were assessed for PAS using our institutional prenatal sonographic scoring system and the corresponding ultrasound findings were compared with those of a standardized clinical intra-operative macroscopic grading system of the degree of accreta placentation at vaginal birth or laparotomy. RESULTS: PAS was diagnosed clinically at birth in 50 (8.2%) cases, 17 of which were confirmed by histopathology. A low (score ≤ 5), medium (score 6-7), high (score ≥ 8) probability for PAS was reported in 502, 61 and 44 cases, respectively. The probability score increased significantly (p < .001) in women ≥2 prior cesarean deliveries, with an anterior low-lying/placenta previa, with absent clear space, increased in retroplacental vascularity and with the size and numbers of lacunae. The number of cases classified clinically as grade 1 (non-PAS) and 3 (adherent PAS) was significantly (p < .001) lower in women with a high probability score whereas the rates of the other grades was significantly (p < .001) higher. The widest discrepancy between ultrasound probability score and clinical grade was found for grade 2 which, describes a partial placental adherence and grades 4 and 5 which, refer to placental percreta which describes tissue having invade trough the uterine serosa and beyond. CONCLUSIONS: Both ends of the spectrum of accreta placentation remain difficult to diagnose antenatal and clinically at birth, in particular when no histopathologic confirmation is available. There is a need to develop ultrasound accuracy score systems that can differentiate between the different grades of PAS and which are validated by standardized clinical and pathology protocols.

Similar but different: A comparison of rare site ectopic pregnancies.

OBJECTIVES: A comparative examination of the clinical, laboratory, ultrasound findings, and operative characteristics of rare site located ectopic pregnancies. METHODS: Retrospective analysis of all department cases of rare site located ectopic pregnancies diagnosed and treated from December 2006 to December 2019. RESULTS: Thirty rare ectopic pregnancies were identified. Of these, 11 were ovarian, 10 were interstitial and 9 were tubal stump. The patients treated for ovarian pregnancy had significantly lower human chorionic gonadotropin (hCG) levels than patients treated for interstitial or stump pregnancies (2025 ± 1105 mIU/ml, 18,424 ± 2579 mIU/ml and 11,204 ± 9221 mIU/ml, respectively, p = 0.003). The main presenting symptom in patients with an ovarian pregnancy was abdominal pain (90.9%, 60.0% and 44.4%, respectively, p = 0.031). Signs of abdominal peritoneal irritation (i.e., rebound tenderness and guarding) were more frequent upon physical examination in patients with an ovarian pregnancy (72.2%, 30.0% and 22.2%, respectively, p = 0.044) who also exhibited the highest rates of syncope and hypovolemic shock upon admission compared to patients with an interstitial or stump pregnancy (54.5%, 10.0% and 11.1%, respectively, p = 0.031). Ovarian pregnancies were associated with the lowest sonographic detection rates (9.1%, 80.0% and 100%, respectively, p = 0.0001) and with free fluid in the pouch of Douglas (72.7%, 20.0% and 22.2%, respectively, p = 0.02). Ovarian pregnancies experienced the highest rupture rate during surgery compared to interstitial or stump pregnancies (66.9%, 16.7% and 44.4%, respectively, p = 0.028), had a significantly higher estimated blood loss (1081 ± 647 ml, 760 ± 597 ml and 343 ± 318 ml, respectively, p = 0.003) and required blood transfusions in the perioperative period (63.6%, 20.0% and 11.1%, respectively, p = 0.025) significantly more often. CONCLUSIONS: Ovarian pregnancy remains the most challenging diagnosis compared to interstitial and tubal stump ectopic's. Health care providers should recognize these rare site ectopic pregnancies and to handle these gynecological emergencies promptly.

Tubal patency assessment using sequential transvaginal ultrasound and hysterosalpingo-foam sonography after methotrexate treatment for tubal pregnancy.

RESEARCH QUESTION: What is the efficacy of sequential two-dimensional transvaginal ultrasound (2D-US) and hysterosalpingo-foam sonography (HyFoSy) after methotrexate (MTX) treatment for tubal pregnancy among patients who desire a future pregnancy? DESIGN: A prospective trial conducted between May 2019 and November 2020. Patients who had a suspected tubal ectopic pregnancy diagnosed by ultrasound and treated by MTX were included. These patients underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. The primary outcome was tubal obstruction in the affected side. RESULTS: A total of 360 women underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. Of these, 40 (11.1%) women fulfilling the inclusion criteria were enrolled. In six out of 40 (15%), hydrosalpinx of the affected tube was found during the initial transvaginal ultrasound examination and were excluded from further investigation. In the remaining 34 (85%) patients, HyFoSy was carried out. Tubal block was found in 10 out of 34 (29.4%) patients. Of these, eight out of 34 (23.5%) and two out of 34 (5.9%) had a proximal block of the affected tube and bilateral proximal obstruction, respectively. Hysterosalpingography confirmed the tubal obstruction in all the affected cases. No procedure-related complications were documented. CONCLUSIONS: Forty per cent of women who were treated by MTX for tubal pregnancy were diagnosed with tubal obstruction. We recommend that sequential transvaginal ultrasound and HyFoSy become part of routine follow-up for these women, thus offering them timely referral to the appropriate specialist.

Ovarian adrenal rest tumor in congenital adrenal hyperplasia: Is medical treatment the first line option?

SUMMARY Ovarian adrenal rest tumors (OARTs) are very rare. We describe a case of a young woman with uncontrolled classical congenital adrenal hyperplasia (CCAH), presenting with bilateral OARTs, successfully treated with steroid replacement. A 20-year-old woman, known to have 21OH-CCAH, presented with severe abdominal pain, vomiting, diarrhea, and fever. As a result of poor compliance, 6 months before her admission hirsutism worsened and amenorrhea, hyperpigmentation, and weakness developed. ACTH levels were 278 < pmol/L and 17OHP 91.3 nmol/L. She was admitted for parenteral antibiotics and high-dose hydrocortisone treatment. CT revealed bilateral juxta-ovarian masses (6.2 x 3.6 x 7.4 cm left and 5 x 2.2 x 3.2 cm right) that on MRI were iso-intense in T1 and hypointense in T2, with early enhancement and rapid washout. One week of high-dose hydrocortisone resulted in significant clinical and laboratory improvement and the patient was discharged with 2 mg dexamethasone/day. One month later US revealed shrinkage of the masses and dexamethasone dose was decreased. At three months from discharge, she has resumed regular menses, and a repeated MRI revealed the para-ovarian masses have shrunk. One year after the diagnosis, the para-ovarian masses have shrunk more to 2.8 x 1.9 x 4.3 on the left and 2.1 x 0.9 x 1.2 on the right with less contrast enhancement in comparison to previous test possibly due to fibrotic changes of the tissue. OARTs are rare tumors with a poorly known natural history, and surgery has been the first option in the few reported cases. We demonstrate that medical treatment is a good alternative, leading to significant tumor shrinkage over a short period.

Ovarian adrenal rest tumor in congenital adrenal hyperplasia: Is medical treatment the first line option?

Ovarian adrenal rest tumors (OARTs) are very rare. We describe a case of a young woman with uncontrolled classical congenital adrenal hyperplasia (CCAH), presenting with bilateral OARTs, successfully treated with steroid replacement. A 20-year-old woman, known to have 21OH-CCAH, presented with severe abdominal pain, vomiting, diarrhea, and fever. As a result of poor compliance, 6 months before her admission hirsutism worsened and amenorrhea, hyperpigmentation, and weakness developed. ACTH levels were 278 < pmol/L and 17OHP 91.3 nmol/L. She was admitted for parenteral antibiotics and high-dose hydrocortisone treatment. CT revealed bilateral juxta-ovarian masses (6.2 × 3.6 × 7.4 cm left and 5 × 2.2 × 3.2 cm right) that on MRI were iso-intense in T1 and hypointense in T2, with early enhancement and rapid washout. One week of high-dose hydrocortisone resulted in significant clinical and laboratory improvement and the patient was discharged with 2 mg dexamethasone/day. One month later US revealed shrinkage of the masses and dexamethasone dose was decreased. At three months from discharge, she has resumed regular menses, and a repeated MRI revealed the para-ovarian masses have shrunk. One year after the diagnosis, the para-ovarian masses have shrunk more to 2.8 × 1.9 × 4.3 on the left and 2.1 × 0.9 × 1.2 on the right with less contrast enhancement in comparison to previous test possibly due to fibrotic changes of the tissue. OARTs are rare tumors with a poorly known natural history, and surgery has been the first option in the few reported cases. We demonstrate that medical treatment is a good alternative, leading to significant tumor shrinkage over a short period.

Analgesic efficacy of virtual reality for acute pain in amniocentesis: A randomized controlled trial.

BACKGROUND: To evaluate the efficacy of virtual reality (VR) as a distraction technique in the management of acute pain and anxiety during amniocentesis. STUDY DESIGN: A randomized controlled trial was conducted between September 2020 and October 2020 involving 60 women undergoing mid-trimester amniocentesis. Thirty women were assigned randomly to the VR intervention (immersive video content as a distraction method) group and 30 to the standard care group using a predetermined randomization code. The primary outcome measure was the visual analog scale (VAS) pain score, along with the women's ratings of their extent of anxiety experienced during the procedure. The VAS consisted of a 10 cm line ranging from 0 to 10 (anchored by 0 = no pain and 10=very severe pain). Anxiety was assessed on Spielberger's state-trait anxiety inventory (STAI) questionnaire. RESULTS: The patients' characteristics and obstetric data were similar in both groups. The ratings on the VAS indicated that the VR intervention was associated with significantly less pain than the ratings in the standard of care group; namely, 2.5 ± 1.5 vs. 3.8 ± 1.7, respectively (95 % CI 0.44-2.13; p = 0.003). There were no significant differences in maternal anxiety levels before and after amniocentesis. CONCLUSION: The VR intervention as a distractive technique emerged as effective in reducing pain during amniocentesis. It is easy to use, relatively inexpensive, has the advantage of no serious side effects, and may decrease the fear of pain that can affect patients' experiences and compliance with this procedure.

A fetal reduction from twin to singleton based on sonography and cell-free fetal DNA testing: A sequential approach to old pitfalls.

OBJECTIVE: We examined the potential value of combining ultrasound and non-invasive prenatal screening (NIPS) of maternal blood to screen for major aneuploidies as an early approach before selective fetal reduction from twin pregnancy to singleton. STUDY DESIGN: The sample was composed of pregnant women with di-chorionic di-amniotic twins who chose to undergo fetal reduction to singleton at 12-24 weeks of gestation. These women were asked to provide a blood sample for cell-free fetal DNA (cffDNA) testing prior to fetal reduction. RESULTS: A total of 24 pregnant women with a twin pregnancy prior to fetal reduction to singleton were enrolled. There were 8 cases with structural anomalies (33.3%) in one twin that dictated fetal reduction. The proportion of patients who underwent selective fetal reduction for fetal abnormalities was larger than in several other studies. The NIPS identified 1 case of Trisomy 13 (4.2%). The other 15 cases (62.5%) had no structural or chromosomal anomalies. The decision to undergo elective reduction of twin pregnancy to singleton was made for social reasons or upon the parents' request. Given the 33% of structural anomalies in the cohort, a cost analysis indicated that this procedure was 6.6-fold less expensive (vs. 4.6-fold with 4% structural anomalies in other publications) than conducting invasive procedures for the entire cohort. CONCLUSION: The findings suggest that an early anatomical scan and cffDNA can increase the overall safety margin and reduce interventional procedures before elective reduction of twin pregnancy to singleton. However, a larger cohort is needed to confirm these results.

Torsion of Functional Adnexal Cysts in Pregnancy: Aspiration and Drainage are Important in Preventing Recurrence.

BACKGROUND: Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding. OBJECTIVES: To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage. METHODS: All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration. RESULTS: Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort. CONCLUSIONS: Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Ovarian Dermoid Cysts Associated with Paraneoplastic Syndrome N-methyl-D-aspartic Acid Receptor Antibodies Encephalitis.

STUDY OBJECTIVE: To describe the incidence of ovarian dermoid cysts associated with paraneoplastic encephalitis syndrome due to N-methyl-D-aspartic acid (NMDA) receptor antibodies among women undergoing surgical resection of dermoid cysts. DESIGN: Retrospective cohort study. SETTING: University-affiliated department of obstetrics and gynecology. PATIENTS: All patients with pathology-proven ovarian dermoid cysts who underwent surgical resection in our department between January 2008 and December 2019. Their demographic, clinical, and surgical characteristics are described, with emphasis on cases diagnosed with anti-NMDA receptor encephalitis. INTERVENTIONS: Ovarian dermoid cyst resection by cystectomy or salpingo-oophorectomy. MEASUREMENTS AND MAIN RESULTS: A total of 233 patients were operated on for ovarian dermoid cysts, comprising 2 cases diagnosed with anti-NMDA receptor encephalitis (0.85%). Among the women without NMDA receptor encephalitis, the mean age was 33.3 ± 14.9 years, 84.0% were of reproductive age, 5.2% were premenarchal, and 10.8% were menopausal. The mean diameter of the dermoid cyst in this group was 77.3 ± 33.3-mm. The 2 patients diagnosed with anti-NMDA receptor encephalitis were 21 years old and 42 years old. The diameters of their dermoid cysts were 15-mm and 80-mm, respectively. The patients with anti-NMDA receptor encephalitis were managed with laparoscopic resection, plasmapheresis, intravenous immunoglobulins, and corticosteroids; 1 patient also received immunosuppressive treatment. Both recovered without significant neurologic sequela. CONCLUSION: Paraneoplastic syndrome due to NMDA receptor antibodies is a rare complication of dermoid cysts. This complication may occur in younger or older women, as well as in small- or large-diameter cysts. Thus, a high index of suspicion is required to correctly diagnose and treat women presenting with neurologic symptoms in the presence of dermoid cysts.