Interpregnancy interval after vacuum delivery and subsequent perinatal outcomes.

OBJECTIVE: To evaluate whether a short interpregnancy interval (IPI) after vacuum extraction (VE), poses similar perinatal risks in a subsequent pregnancy. METHODS: This was a retrospective, single-center cohort study between 2011 and 2021. Nulliparous women with term, singleton VE deliveries and with known pregnancy outcomes in their subsequent pregnancy were eligible for inclusion in the study. Each woman was allocated into one of two groups based on the IPI, <18 months and between 18 and 60 months. The primary outcome was the risk of spontaneous preterm birth (PTB) <37 weeks in the consecutive birth. RESULTS: We included 1094 pregnancies: 212 (19.4%) with IPI <18 months and 882 (80.6%) with IPI between 18 and 60 months following the previous VE delivery. The VE characteristics were comparable between the groups. Young maternal age was a risk factor for a short IPI (28.0 ± 4.8 vs 30.3 ± 4 years, P < 0.01). Spontaneous PTB <37 weeks was significantly higher in the IPI <18 months group with 18-60 months (7.1% vs 2.6%, P = 0.002). Polynomial regression analysis also confirmed a significantly increased risk of preterm birth <37 weeks (P < 0.01). Short IPI <18 months was also associated with an increase in the risk of low birthweight <2500 g (6.1% vs 2.8%, P = 0.02) and admission to the neonatal intensive care unit (6.1% vs 2.6%, P = 0.013). The incidence of recurrent VE, albeit significant (2.3% vs 4.9%, P = 0.049), was low in both groups. No differences were noted in any of the other secondary outcomes. CONCLUSION: Short IPI (<18 months) following term VE delivery is associated with higher neonatal risks, particularly PTB, in the subsequent pregnancy. These findings are particularly important when counseling women planning an optimal IPI.

Healing after surgical retreatment at four time points: A retrospective study.

AIM: To evaluate the outcome of surgical retreatment at four time points, that is 6, 12, 24 and 48 months post-operatively, and to search for prognostic factors that may affect the outcome. METHODOLOGY: Clinical records and intraoral periapical radiographs were collected from patients who had undergone surgical retreatment between 2009 and 2015 and attended 6-, 12-, 24- and 48-month follow-up visits. Surgical retreatment was performed by one endodontist and involved minimal root-end resection and maximal length root-end preparation using prebent ultrasonic files. Outcomes were categorized as complete, incomplete, uncertain or unsatisfactory healing, based on clinical and radiographic findings. The complete and incomplete categories were pooled and considered successes, while uncertain and unsatisfactory outcomes were considered failures. Changes in healing outcome were analysed using the McNemar-Bowker test, and prognostic factors were analysed using univariate analysis. RESULTS: The study cohort included 297 patients with 384 teeth. The overall success rate after 48 months was 90.6% compared with 88.5%, 93% and 92.4% after 6, 12 and 24 months respectively. Age, gender, presence of isthmus and length of canal preparation had no significant influence on the outcome. Lesion size and tooth type had a significant influence only after 6 and 12 months, respectively, with no significant differences at other time points. Fifty per cent of the teeth classified as unsatisfactory or uncertain healing at the 6 months follow-up improved to incomplete or complete healing after 12 months. None of the cases classified as unsatisfactory healing after 12 months subsequently improved, and only 2 cases that were classified as uncertain healing after 12 months improved after 24 months. CONCLUSIONS: Surgical retreatment was found to be a predictable procedure with a high success rate of 90.6% after 4 years. Over the follow-up periods, only a minor regression in the success rate was found. The 12 months follow-up results closely indicated the long-term outcome of surgical retreatment.

Vaginal birth after cesarean in women with pre-labor rupture of membranes at term.

INTRODUCTION: Women with a successful vaginal birth after cesarean delivery (VBAC) have less morbidity than women undergoing repeat cesarean delivery. Although several scores and models predict VBAC success, none focus on pregnant women with pre-labor rupture of membranes (PROM). We evaluated different clinical variables that might predict the likelihood of VBAC success in women with PROM. STUDY DESIGN: A retrospective, 5-year study in a large referral center from December 2013 to December 2018. Inclusion criteria were women with singleton pregnancy, at or beyond 37 weeks' gestation, admitted with spontaneous PROM, with one previous cesarean delivery that consented trial of labor. Exclusion criteria were history of two cesarean deliveries, multiple gestations or obstetrical contraindications for TOLAC, including maternal request for repeat cesarean delivery. Variables associated with successful VBA C were identified using multivariate logistic regression. RESULTS: Of 302 women in the cohort, 74.8% (226/302) delivered vaginally (successful VBAC) and 25.2% (76/302) by repeat CD (failed TOLAC). Multiple logistic regression showed that duration of PROM-to-delivery time was the only significant factor associated with successful TOLAC (78% delivered vaginally within 24 h and 93.3% within 36 h), while none of the other variables (maternal age, gravidity, BMI, gestational and birthweight at delivery, effacement or station at admission, previous indication for cesarean delivery, time interval between previous and current delivery, presence of meconium-stained liquor, and documented temperature >38 °C) were associated with the prediction of successful VBAC. CONCLUSION: Women with spontaneous pre-labor PROM and previous cesarean delivery have high success rates of VBAC. The only significant variable associated with successful TOLAC in women with spontaneous PROM at term was the duration of PROM-to-delivery time. Our findings suggest that the success rate of VBAC is likely multifactorial, not-necessarily related to a specific underlying factor, and in the absence of contraindications, a fair trial of labor after cesarean delivery is justified.

Optimizing cervical ripening in women presenting with decreased fetal movements.

OBJECTIVE: To determine the optimal method for cervical ripening in women presenting with decreased fetal movements at term. We hypothesized that women who undergo induction of labor for decreased fetal movements represent a higher risk group, and will benefit from mechanical intervention with cervical ripening balloon rather than with pharmacological prostaglandin E2 vaginal insert. STUDY DESIGN: Retrospective cohort study from January 2014 and January 2019. We recommended induction of labor to every woman ≥39 weeks' gestation with complaints of persistent decreased fetal movements. We excluded women with major fetal anomalies, Bishop score of ≥6 on admission, and cases with contraindications to prostaglandins. Women were allocated into one of two groups based on the cervical ripening agent used. In group 1 we introduced the prostaglandin E2 vaginal insert (10 mg dinoprostone in a timed-release formulation). In group 2 we placed the mechanical cervical ripening balloon. The primary outcome of the study, analyzed separately to nulliparous and multiparous women, was the rate of cesarean delivery in each of the groups. RESULTS: During the 5-years study, 294 women were included in the final analysis, of which 201 were in the prostaglandin E2 vaginal insert group and 93 were in the cervical ripening balloon group. The rate of cesarean delivery was comparable between the groups (nulliparous: 20.8%, 16/77 versus 21.3%, 10/47. multiparous: 16.9%, 21/124 versus 7%, 3/46, respectively). Other maternal and neonatal secondary outcomes, including the induction-to-delivery time (nulliparous: 32.5 ± 25.3 h versus 26.5 ± 12.2 h. multiparous: 24.6 ± 17.2 h versus 21.25 ± 12.3 h, respectively), were also not different between the two induction methods used. A longer induction-to-delivery time was observed in nulliparous women who had repeat prostaglandin E2 vaginal insert compared with the cervical ripening balloon group (74.6 ± 27.3 h versus 26.5 ± 12.2 h, p < .01). CONCLUSION: Both pharmacological and mechanical methods can safely and efficiently be used for cervical ripening in women presenting with decreased fetal movements at term. With repeat prostaglandin E2 use, nulliparous women may experience a prolong labor compared with the cervical ripening balloon group, but maternal or fetal safety are not compromised.

Vaginal progesterone treatment for the prevention of preterm birth and intrahepatic cholestasis of pregnancy: A case-control study.

INTRODUCTION: Intrahepatic cholestasis of pregnancy (ICP) is associated with a distinctive maternal pruritus, abnormal liver function tests, raised serum total bile acids, and increased rates of adverse fetal outcomes, including intrauterine fetal death. Progesterone has been implicated in the pathogenesis of ICP. We aimed to evaluate whether the incidence of ICP is altered in women receiving long-term daily vaginal progesterone, indicated for a short cervical length. STUDY DESIGN: A matched 1:3 case-control study of pregnant women between January 2014 and January 2019. Study cases included pregnant women with the diagnosis of ICP. Control cases were women without ICP. The primary outcome was the rate of vaginal progesterone treatment among the groups. RESULTS: The use of vaginal progesterone throughout pregnancy was higher in the ICP group compared with the control group (8/174 [4.6 %] versus 6/522 [1.1 %], respectively, P = 0.03, odds ratio 4 [95 % confidence interval 1.4-11.7]). CONCLUSIONS: Pregnant women treated with long-term vaginal progesterone preparations for the prevention of preterm birth are at increased risk of developing ICP. In the presence of pruritus during pregnancy, we recommend an early consultation and diagnostic test to confirm or rule-out ICP.

Vaginal progesterone for the prevention of preterm birth and the risk of gestational diabetes.

INTRODUCTION: We aimed to determine whether daily vaginal progesterone use for the prevention of preterm birth has an effect on the incidence of abnormal glucose challenge test or gestational diabetes. STUDY DESIGN: A retrospective study in a large referral center. Women with cervical length ≤ 25 mm were given 200 mg vaginal micronized progesterone capsules daily at bed time until 36 weeks` gestation or delivery. Each progesterone-treated woman was matched randomly with three untreated controls. The main outcome measures were; mean plasma glucose level following the glucose challenge test and the rate of abnormal 1-hour glucose challenge test. Secondary outcome was the rate of gestational diabetes. RESULTS: We identified 108 progesterone-treated women that were matched by age and BMI to 324 controls during the same time period. The mean plasma glucose level following the glucose challenge test was similar in both groups (115.3 ± 33.8 mg/dL versus 109.2 ± 26.6 mg/dL). Despite a higher rate of an abnormal glucose challenge test in the progesterone-treated group compared to the control group (21.1% vs. 13.9%), it did not reach statistical significance. Similarly, we could not detect any difference in the rate of gestational diabetes in either the study or the control group (2.8% versus 2.5%). CONCLUSION: Daily vaginal progesterone was not associated with higher rates of abnormal glucose challenge test or gestational diabetes. We are in a view that no earlier screening or diagnostic testing for gestational diabetes is required except the standard recommended schedule unless additional risk factors are present.

Acupuncture for the treatment of post-partum urinary retention.

STUDY OBJECTIVES: The aims of the present study were to evaluate acupuncture as an alternative treatment to an indwelling catheter for women with postpartum urinary retention, and to evaluate the accuracy of sonographic estimation of bladder volume by portable bedside equipment in women postpartum. STUDY BACKGROUND: Post-partum urinary retention is a common obstetric complication. The accepted method for diagnosing post void residual bladder volume is by ultrasound or catheterization. However, the accuracy of bedside sonographic evaluation of bladder volume in women postpartum is controversial due to anatomical and technical issues. The traditional treatment of urinary retention is catheterization for variable lengths of time. Acupuncture, while an accepted treatment method for urinary retention in traditional societies in the Far East, has not been proven scientifically to resolve the problem. Therefore, the aims of our study were to evaluate acupuncture as an alternative treatment to catheterization for urinary retention, and to evaluate the accuracy of sonographic estimation of bladder volume by portable bedside ultrasound in women postpartum. MATERIALS AND METHODS: The study was a prospective randomized case-controlled trial conducted in 55 women post-partum with urinary retention. All patients underwent a pre and post treatment sonographic evaluation of bladder volume. Women with urinary retention were given the choice of treatment by acupuncture or catheterization. Acupuncture was performed by an experienced acupuncturist licensed in Traditional Chinese Medicine and point selection was based on Meridian theory and clinical experience. RESULTS: In the acupuncture group, 23 women (92%) achieved spontaneous micturition within one hour following treatment. Bedside sonographic evaluation of bladder volume showed excellent correlation to actual volume as measured by catheterization (r2 = 0.988). CONCLUSION: Acupuncture proved to be an excellent alternative to catheterization in treatment of women with postpartum urinary retention.

Apical extrusion of debris during the preparation of oval root canals: a comparative study between a full-sequence SAF system and a rotary file system supplemented by XP-endo finisher file.

OBJECTIVES: The purpose of this study was to assess the amount of apically extruded debris during the preparation of oval canals with either a rotary file system supplemented by the XP-endo Finisher file or a full-sequence self-adjusting file (SAF) system. MATERIALS AND METHODS: Sixty mandibular incisors were randomly assigned to two groups: group A: stage 1-glide path preparation with Pre-SAF instruments. Stage 2-cleaning and shaping with SAF. Group B: stage 1-glide path preparation with ProGlider file. Stage 2-cleaning and shaping with ProTaper Next system. Stage 3-Final cleaning with XP-endo Finisher file. The debris extruded during each of the stages was collected, and the debris weights were compared between the groups and between the stages within the groups using t tests with a significance level set at P < 0.05. RESULTS: The complete procedure for group B resulted in significantly more extruded debris compared to group A. There was no significant difference between the stages in group A, while there was a significant difference between stage 2 and stages 1 and 3 in group B, but no significant difference between stages 1 and 3. CONCLUSIONS: Both instrumentation protocols resulted in extruded debris. Rotary file followed by XP-endo Finisher file extruded significantly more debris than a full-sequence SAF system. Each stage, in either procedure, had its own contribution to the extrusion of debris. CLINICAL RELEVANCE: Final preparation with XP-endo Finisher file contributes to the total amount of extruded debris, but the clinical relevance of the relative difference in the amount of apically extruded debris remains unclear.

Effects of Pneumoperitoneum and the Steep Trendelenburg Position on Heart Rate Variability and Cerebral Oxygenation during Robotic Sacrocolpopexy.

STUDY OBJECTIVE: The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy. DESIGN: Prospective study (Canadian Task Force classification III). SETTING: Rambam Health Care Campus. PATIENTS: Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse. INTERVENTIONS: Robotic sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: A 5-minute computerized electrocardiogram, cerebral O2 saturation (cSO2), systemic O2 saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO2 tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO2 at baseline was 73% ± 9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66 ± 10 vs 55 ± 9 bpm, p < .05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8 ± .8 vs 3.3 ± .9 ms2/Hz and 2.5 ± 1.2 vs 3.2 ± .9 ms2/Hz, respectively, p < .05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation. CONCLUSION: This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability.

The effects of oxytocin and atosiban on the modulation of heart rate in pregnant women.

OBJECTIVE: To evaluate autonomic modulation of heart rate in pregnant women treated with oxytocin to induce labor and with atosiban (an oxytocin antagonist) to arrest preterm labor. METHODS: A prospective study with two cohorts: 14 pregnant women treated with atosiban for premature uterine contractions, and 28 women undergoing induction of labor with oxytocin. Computerized analyses of the electrocardiogram were performed with spectral and nonlinear dynamic analyses. RESULTS: Atosiban did not alter any of the variables associated with heart rate variability, whereas oxytocin showed a dose-dependent decrease in heart rate (p < 0.05) and a significant increase in all spectral variables studied (p < 0.01). CONCLUSIONS: Atosiban has no adverse effects on the cardiovascular system or the modulation of heart rate. Oxytocin, on the other hand, can cause a dose-dependent bradycardic effect and an increase in the spectral power, thus should be used with caution in certain pregnant women.

Multi-fetal pregnancy reduction (MFPR) to twins or singleton - medical justification and ethical slippery slope.

Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery - 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions.

Glucose tolerance in singleton, twin and triplet pregnancies.

BACKGROUND: Data regarding the effects of multifetal pregnancy on the incidence of gestational diabetes mellitus (GDM) are inconsistent and even conflicting. Twin pregnancies have been associated with no increase, a marginal increase or a higher incidence of gestational diabetes. In triplet pregnancies, these effects have not been investigated yet. OBJECTIVES: To analyze the results of the glucose challenge and tolerance tests in singleton, twin and triplet pregnancies. STUDY DESIGN: A retrospective database analysis of pregnant women with singletons, twins or triplets who had complete results of the 50 g glucose challenge test (GCT) and the 100 g oral glucose tolerance test (OGTT). The cohort included 12,382 singletons, 515 twins and 39 triplets. RESULTS: There were significantly higher rates of abnormal GCTs in twins and triplets compared to singletons (45.4% and 33.3%, respectively vs. 13.7%, P<0.001 and P<0.05). Significantly higher rates of gestational diabetes in twins (10.1% vs. 2.9 %, P<0.001) and triplets (12.8% vs. 2.9%, P<0.05) compared to singletons were observed. Mean glucose levels after the GCT were higher in twins compared to singletons, and even more in triplets (108 mg/dL in singletons vs. 120 mg/dL in twins vs. 129 mg/dL in triplets, P<0.001). CONCLUSIONS: Glucose intolerance is aggravated in multifetal pregnancies. The likelihood of an abnormal GCT and gestational diabetes is higher in twins and triplets compared to singletons.

Developmental changes in electrophysiological characteristics of human-induced pluripotent stem cell-derived cardiomyocytes.

BACKGROUND: Previous studies proposed that throughout differentiation of human induced Pluripotent Stem Cell-derived cardiomyocytes (iPSC-CMs), only 3 types of action potentials (APs) exist: nodal-, atrial-, and ventricular-like. OBJECTIVES: To investigate whether there are precisely 3 phenotypes or a continuum exists among them, we tested 2 hypotheses: (1) During culture development a cardiac precursor cell is present that-depending on age-can evolve into the 3 phenotypes. (2) The predominant pattern is early prevalence of a nodal phenotype, transient appearance of an atrial phenotype, evolution to a ventricular phenotype, and persistence of transitional phenotypes. METHODS: To test these hypotheses, we (1) performed fluorescence-activated cell sorting analysis of nodal, atrial, and ventricular markers; (2) recorded APs from 280 7- to 95-day-old iPSC-CMs; and (3) analyzed AP characteristics. RESULTS: The major findings were as follows: (1) fluorescence-activated cell sorting analysis of 30- and 60-day-old cultures showed that an iPSC-CMs population shifts from the nodal to the atrial/ventricular phenotype while including significant transitional populations; (2) the AP population did not consist of 3 phenotypes; (3) culture aging was associated with a shift from nodal to ventricular dominance, with a transient (57-70 days) appearance of the atrial phenotype; and (4) beat rate variability was more prominent in nodal than in ventricular cardiomyocytes, while pacemaker current density increased in older cultures. CONCLUSION: From the onset of development in culture, the iPSC-CMs population includes nodal, atrial, and ventricular APs and a broad spectrum of transitional phenotypes. The most readily distinguishable phenotype is atrial, which appears only transiently yet dominates at 57-70 days of evolution.

Accuracy of ultrasound in estimating fetal weight and growth discordancy in triplet pregnancies.

AIMS: Sonographic estimation of fetal weight is a fundamental part of the routine obstetrical practice and may affect management decisions particularly in multiple gestations. The data available on the accuracy of sonographic estimation of fetal weight in triplets are very limited. In the present study we investigated the accuracy of sonographic fetal weight estimation and discordancy in triplet gestations. METHODS: We analyzed the sonographic data of 33 sets of triplets born at one medical center between January 2001 and March 2013. Estimated fetal weight was calculated from biometric measurements and compared with actual neonatal weights following delivery. The Pearson correlation coefficient, linear regression analyses, and Bland-Altman method were used for statistical comparisons. RESULTS: The differences between predicted and actual birth weights (ABW) were <10% in 69 newborns (70%), 10%-20% in 19 newborns (19%), and more than 20% in 11 newborns (11%). There was a good correlation between predicted and ABW (correlation coefficient=0.928, r2=0.86, P<0.0001). CONCLUSIONS: Weight assessment in triplets does not fall behind that of singletons or twins, and decisions based upon these examinations are reliable in the majority of cases.

The fractal nature of blood glucose fluctuations.

AIMS: Fluctuations of blood glucose are generated by multiple external and internal factors continuously modifying glucose concentrations through complex feedback loops. This equilibrium may be perturbed during physiological or pathological conditions. The traditional theory suggests that physiological systems achieve homeostasis when disturbed and restore equilibrium through linear feedback loops. Complex systems on the other hand, may function nonlinearly with feedback loops that operate at different time scales, exhibiting chaotic or fractal behavior. We hypothesized that blood glucose fluctuations recorded for prolonged time periods show chaotic, fractal-like behavior that may be altered in diabetes. METHODS: We applied nonlinear analytical methods such as detrended fluctuation analysis to glucose data derived from continuous glucose monitoring devices for prolonged time periods in healthy volunteers, diabetes type 1 and pregnant diabetes type 1 patients. RESULTS: Glucose fluctuations extracted for prolonged time periods show fractal-like behavior and power law behavior of the system. CONCLUSIONS: Hidden features underlying glucose fluctuations in health and in disease were revealed by using dynamic nonlinear analyses methods to discrete glucose readings extracted from continuous glucose monitoring devices. By using such methods we can enhance our understanding of the dynamics of blood glucose fluctuations in health and disease.

From beat rate variability in induced pluripotent stem cell-derived pacemaker cells to heart rate variability in human subjects.

BACKGROUND: We previously reported that induced pluripotent stem cell-derived cardiomyocytes manifest beat rate variability (BRV) resembling heart rate variability (HRV) in the human sinoatrial node. We now hypothesized the BRV-HRV continuum originates in pacemaker cells. OBJECTIVE: To investigate whether cellular BRV is a source of HRV dynamics, we hypothesized 3 levels of interaction among different cardiomyocyte entities: (1) single pacemaker cells, (2) networks of electrically coupled pacemaker cells, and (3) the in situ sinoatrial node. METHODS: We measured BRV/HRV properties in single pacemaker cells, induced pluripotent stem cell-derived contracting embryoid bodies (EBs), and electrocardiograms from the same individual. RESULTS: Pronounced BRV/HRV was present at all 3 levels. The coefficient of variance of interbeat intervals and Poincaré plot indices SD1 and SD2 for single cells were 20 times greater than those for EBs (P < .05) and the in situ heart (the latter two were similar; P > .05). We also compared BRV magnitude among single cells, small EBs (~5-10 cells), and larger EBs (>10 cells): BRV indices progressively increased with the decrease in the cell number (P < .05). Disrupting intracellular Ca(2+) handling markedly augmented BRV magnitude, revealing a unique bimodal firing pattern, suggesting that intracellular mechanisms contribute to BRV/HRV and the fractal behavior of heart rhythm. CONCLUSION: The decreased BRV magnitude in transitioning from the single cell to the EB suggests that the HRV of in situ hearts originates from the summation and integration of multiple cell-based oscillators. Hence, complex interactions among multiple pacemaker cells and intracellular Ca(2+) handling determine HRV in humans and cardiomyocyte networks.

Steep Trendelenburg position during robotic sacrocolpopexy and heart rate variability.

OBJECTIVES: The objective of this study was to evaluate heart rate variability and hemodynamic parameters following steep Trendelenburg positioning during robotic sacrocolpopexy. STUDY DESIGN: For 19 women, median age 57 (range: 45-72), blood pressure and ECG were recorded during surgery. From the ECG signals interbeat intervals were used to assess heart rate variability, analyzed in time and frequency domains using the Fast Fourier transform. The low frequency and high frequency spectral bands were used to assess sympathetic and parasympathetic pathways respectively. RESULTS: All women underwent robotic supracervical hysterectomy and sacrocolpopexy. A statistically significant decrease in the mean values of the low-frequency and high-frequency spectral bands, representing sympathetic and parasympathetic activity, respectively were demonstrated 5min following Trendelenburg positioning of the patients (from 3.6±1.4 to 2.9±0.8ms(2)/Hz, and from 3.5±1.4 to 2.9±1ms(2)/Hz, P<0.05). These changes correlated with a mean 20% decrease in heart rate, which lasted for 30min, and with a second drop in sympathetic and parasympathetic activity and heart rate, commencing 2h from the start of surgery, and lasting until the end of the operation. CONCLUSIONS: Steep Tredelenburg positioning during robotic urogynecology surgery results in significant changes in the autonomic nervous system modulation of heart rate variability and in other hemodynamic parameters.

Cervical intraepithelial neoplasia 2, 3 in pregnancy: time to consider loop cone excision in the first trimester of pregnancy?

OBJECTIVES: To report the outcome of patients diagnosed with cervical intraepithelial neoplasia 2, 3 (CIN 2, 3) during pregnancy, who were treated by large loop excision of the transformation zone (LLETZ) in the first trimester or were followed up conservatively and treated after delivery. METHODS: Patients diagnosed with CIN 2, 3 during pregnancy who were treated with LLETZ or were conservatively followed up were included. Complications of the LLETZ, pathologic results, and pregnancy outcome of both groups were examined after delivery. RESULTS: Thirty-one patients were included in the study. Eighteen were conservatively followed up and 13 underwent LLETZ during the first 14 weeks of pregnancy. Four patients (12.9%) in the study group were diagnosed with invasive cervical cancer. From women who underwent LLETZ, 9 patients continued their pregnancy, 7 of which had term normal deliveries and 2 had late preterm deliveries. No complications of severe bleeding or miscarriage were reported in any of the treated patients. CONCLUSIONS: Large loop excision of the transformation zone procedure in the first trimester of pregnancy is a safe procedure, with the advantage of treating definitively CIN 2, 3 lesions and preventing the devastating consequences of undiagnosed cervical cancer. We suggest that LLETZ should be performed more liberally in the first trimester of pregnancy.

Triplet pregnancies--a three-decade perspective: do we fare better?

OBJECTIVES: To evaluate the impact of advances in perinatal and neonatal care in the past three decades on the outcome of triplet pregnancies. STUDY DESIGN: We compared the outcome of 29 sets of triplets born in our medical center during 1978-1987 with 34 sets of triplets born in the same medical center during 2001-2011. Data were extracted from maternal and neonatal medical records. RESULTS: There were no significant differences in mortality or morbidity in any of the studied outcome measures between the two epochs. Of the 34 women with triplet pregnancies in the present cohort only 28 (82%) took all three born babies home, not different from the 86% found in the early cohort. The overall take-home baby rate was 93% (95/102) in the present cohort, not different than the 86% (74/86) in the early cohort. CONCLUSIONS: Despite technological advances in perinatal and neonatal care, there was no significant improvement in the outcome of triplet pregnancies during the past three decades.