Fetal surgery using fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: a single-center experience.

PURPOSE: To provide a comprehensive report of the experience gained in the prenatal treatment of congenital diaphragmatic hernia (CDH) using fetoscopic endoluminal tracheal occlusion (FETO) following its implementation at a newly established specialized fetal medicine center. METHODS: Mothers of fetuses with severe CDH were offered prenatal treatment by FETO. RESULTS: Between 2018 and 2021, 16 cases of severe CDH underwent FETO. The median gestational age (GA) at balloon insertion was 28.4 weeks (IQR 27.8-28.6). The median GA at delivery was 37 weeks (IQR 34.4-37.8). The survival rate was 8/16 cases (50%). None of the survivors required home oxygen therapy at 6 months of age. Comparison between the survivors and deceased showed that survivors had balloon insertion 1 week earlier (27.8 vs. 28.4 weeks, p = 0.007), a higher amniotic fluid level change between pre- to post-FETO (3.4 vs 1.3, p = 0.024), a higher O/E LHR change between pre- to post-FETO (50.8 vs. 37.5, p = 0.047), and a GA at delivery that was 2 weeks later (37.6 vs. 35.4 weeks, p = 0.032). CONCLUSIONS: The survival rate at 6 months of age in cases of severe CDH treated with FETO in our center was 50%. Our new fetal medicine center matches the performance of other leading international centers.

Attentional networks during the menstrual cycle.

The menstrual cycle is characterized partially by fluctuations of the ovarian hormones estradiol (E2) and progesterone (P4), which are implicated in the regulation of cognition. Research on attention in the different stages of the menstrual cycle is eclectic with discrepancies in attention definitions, and the three attentional networks (alerting, orienting and executive) and their interaction were not explored during the menstrual cycle. In the current study, we used the ANT-I (attentional network test - interactions) to examine naturally cycling women (NC) and women using oral contraceptives (OC). We tested their performance at two time points that fit, in natural cycles, the follicular phase and the luteal phase. We found no differences in performance between the two time points (day 4 / day 18) for the OC group: the response pattern replicated known ANT-I findings. However, the NC group showed differences between the two time points. In the follicular phase, responses replicated known ANT-I results, but in the luteal phase, alertness did not interact with executive and orienting networks, resulting in a larger congruency effect (executive network) when attention was not oriented to the target in alerting and no alerting conditions. Results-driven exploratory regression analysis of E2 and P4 suggested that change in P4 from the follicular phase/day 4 to the luteal phase/day 18 was a mediator for the alerting effect found between groups. In conclusion, the alerting state, found with or without alertness manipulation, suggests that there is a progesterone-mediated activation of the alerting system during the luteal phase.

Prediction of gestational diabetes based on nationwide electronic health records.

Gestational diabetes mellitus (GDM) poses increased risk of short- and long-term complications for mother and offspring1-4. GDM is typically diagnosed at 24-28 weeks of gestation, but earlier detection is desirable as this may prevent or considerably reduce the risk of adverse pregnancy outcomes5,6. Here we used a machine-learning approach to predict GDM on retrospective data of 588,622 pregnancies in Israel for which comprehensive electronic health records were available. Our models predict GDM with high accuracy even at pregnancy initiation (area under the receiver operating curve (auROC) = 0.85), substantially outperforming a baseline risk score (auROC = 0.68). We validated our results on both a future validation set and a geographical validation set from the most populated city in Israel, Jerusalem, thereby emulating real-world performance. Interrogating our model, we uncovered previously unreported risk factors, including results of previous pregnancy glucose challenge tests. Finally, we devised a simpler model based on just nine questions that a patient could answer, with only a modest reduction in accuracy (auROC = 0.80). Overall, our models may allow early-stage intervention in high-risk women, as well as a cost-effective screening approach that could avoid the need for glucose tolerance tests by identifying low-risk women. Future prospective studies and studies on additional populations are needed to assess the real-world clinical utility of the model.

Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain.

PURPOSE: To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion. MATERIALS AND METHODS: Retrospective cohort analysis of 322 women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion. RESULTS: The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026). CONCLUSION: Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.

Second Trimester Biochemical Markers as Possible Predictors of Pathological Placentation: A Retrospective Case-Control Study.

OBJECTIVE: We aimed to evaluate the association between second trimester biochemical markers and pathological placentation. METHODS: This was a retrospective case-control study (2007-2014) of singleton gestations at a university-affiliated tertiary center. Women with pathologic placentation were subdivided into three groups: placenta accreta (group A), placenta previa (group B), or both (group C). We compared second trimester biochemical screening markers taken between 16 + 0 and 19 + 6 weeks of gestation between groups A, B, and C, and women with normal placentation (group D). Obstetrical and neonatal outcomes, risk factors for pathologic placentation, and second trimester biochemical marker values were compared between groups. RESULTS: Overall, 301 deliveries were evaluated: 64 (21%) in group A, 66 (22%) in group B, 17 (6%) in group C, and 153 (51%) in group D. Each of the pathological placentation groups individually had a higher median alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) multiples of median (MoM) than the controls, with the highest values of AFP and hCG observed among women with placenta accreta and the lowest values among the controls. When a multivariant analysis was applied, the hCG levels remained significantly correlated with pathological placentation. Receiver operation characteristic curves for AFP, hCG, or both were computed. For AFP the area under the ROC curve (AUC) was 0.573 (95% CI 0.515-0.630, p < 0.0274) and a cut-off value above 0.99 MoM demonstrated a sensitivity and specificity of 71 and 46%, respectively, for the prediction of pathological placentation. For hCG, the AUC was 0.662 (95% CI 0.605-0.715, p < 0.0001) and a cut-off value of 1.25 MoM demonstrated a sensitivity and specificity of 53 and 68%. When both markers were plotted, the AUC was 0.668 (95% CI 0.611-0.721, p < 0.0001) and sensitivity and specificity were 63 and 64%, respectively. A percentile MoM cut-off approach distinguished between two groups: a high-risk group (patients with AFP or hCG or both above the 75th percentile, odds ratio (OR) for pathological placentation 2.27, 95% CI 1.42-3.63), and a low-risk group (patients with AFP or hCG or both below the 25th percentile, OR for pathological placentation 0.38, 95% CI 0.24-0.60). CONCLUSION: Second trimester biomarkers such as hCG and AFP can be used to raise a suspicion towards characterizing women into high-risk and low-risk groups for pathological placentation.

The association of different progesterone preparations with preterm birth prevention.

Objective: We aimed to compare the efficacy of commonly available progesterone preparations for preterm birth prevention. Methods: A retrospective cohort study of all women treated with progesterone to prevent preterm birth and delivered in a single university-affiliated tertiary medical-center. Four progesterone preparations were compared: vaginal Endometrin 100 mg twice daily, vaginal Crinone 8% gel 90 mg daily, vaginal Utrogestan 200 mg daily, and intramuscular 17α-hydroxyprogesterone caproate (17-OHPC) 250 mg weekly. All women were considered at risk for preterm birth according to: prior preterm birth or cervical length below 25 mm measured during the second trimester. Significant maternal morbidity, pregnancy achieved by artificial reproductive technique and cerclage placement were excluded. Primary outcome was the rate of preterm birth prior to 37 weeks of gestation. Results: Overall, 422 women were allocated to four study groups according to progesterone preparation: Endometrin 175 (41.5%), Crinone 73 (17.3%), Utrogestan 154 (36.5%), and 17-OHPC 20 (4.7%). Rates of preterm birth prior to 37 gestational weeks were lowest on the Endometrin treatment group (12.6 versus 20.5, 17.5, and 35% in the rest, p = .05). Multivariate analysis revealed that the progesterone preparation was associated with preterm birth prior to 37 gestational weeks (LR = 8.3, p = .004). The need for maternal red blood cells transfusion was significantly higher in the Endometrin subgroup (4% versus 0 in all others, p = .018). This finding remained significant after adjustment to potential confounders (LR 16.44, p < .001). Neonatal outcomes did not differ between groups. Conclusions: Different progesterone preparations prescribed to women at risk, may possess different efficacy in preventing preterm delivery prior to 37 weeks of gestation.

Can hair steroids predict pregnancy longevity?

Maintaining pregnancy to term is important as preterm delivery is a risk factor for impaired infant development, which may have negative long-term consequences. Therefore, developing biomarkers that can predict pregnancy longevity during early gestation is essential for the prevention of preterm birth. Here we explored whether maternal hair testosterone and cortisol, representing the pre-conception and first trimester periods respectively, may be used to predict pregnancy longevity. We recruited 125 pregnant women that contributed hair samples and answered a personal information questionnaire that included pre-conception smoking. We quantified steroids using commercial enzyme-linked immunosorbent assay kits. Gestational age at delivery was obtained from medical records. We used General Linear Models to predict gestation length. The model that included first trimester cortisol, pre-conception smoking, pre-conception testosterone and the interaction between first trimester cortisol and pre-conception smoking predicted 13% of the variance in gestation length (R2 = 0.130; n = 105; p = 0.007). First trimester cortisol was the best predictor of gestational length. Women with high levels of cortisol in their first trimester had an increased probability of a full-term delivery. The effect of cortisol was especially pronounced in smokers (ß = 1.69), compared to non-smokers (ß = 0.45). Pre-conception testosterone also contributed to the model. Our study suggests that hair steroids may be used to predict pregnancy longevity, together with other contributing factors.

Isolated Fallopian Tube Torsion: A Unique Ultrasound Identity or a Serial Copycat?

OBJECTIVES: To report the preoperative ultrasound (US) signs of isolated fallopian tube torsion in surgically verified cases and to estimate whether preoperative US detection of this condition can be improved. METHODS: The charts of 27 women with a surgical diagnosis of isolated fallopian tube torsion at a tertiary medical center from 2005 to 2016 were retrospectively reviewed. Data were collected from the electronic database of the US unit and compared with the surgical findings. RESULTS: Isolated fallopian tube torsion was correctly diagnosed by US before surgery in 8 of the 27 women (29.6%). In the remainder, the US signs were attributed to torsion of the ovary or the entire adnexa (n = 13), or no torsion was suspected (n = 6). Fallopian tube edema was listed as a US finding in 7 patients, of whom 5 had a correct diagnosis of isolated fallopian tube torsion. The presence of a paraovarian cyst concomitant with normal-appearing ovaries was assumed by US in 5 of the 8 cases that were accurately diagnosed as isolated fallopian tube torsion. The most misinterpreted US finding was an ovarian cyst (suspected in 10 patients and verified at surgery in 2). Absence of blood flow was described in 12 women, of whom 5 had an accurate diagnosis of isolated fallopian tube torsion. Six of the patients with a correct US diagnosis were adults (37.5% of total adults), and 2 were adolescents (18.2% of total adolescents). CONCLUSIONS: The US diagnosis of isolated fallopian tube torsion is challenging. A high index of suspicion is necessary to improve its detection, especially when there are possible US signs of torsion in the presence of a normal-appearing ovary.

The Impact of a Cultural Lifestyle Intervention on Metabolic Parameters After Gestational Diabetes Mellitus A Randomized Controlled Trial.

OBJECTIVES: The prevalence of type 2 diabetes in Israel is increasing in all ethnic groups but most markedly in the Bedouin population. We aimed to assess the effects of a lifestyle change intervention on risk markers for type 2 diabetes after gestational diabetes mellitus (GDM). METHODS: One hundred eighty Jewish and Bedouin post-GDM women were randomly assigned to a lifestyle intervention group (IG) or a control group (CG) starting 3-4 months after delivery. The IG participated in healthy lifestyle sessions led by a dietician and a sports instructor for 24 months after delivery. The IG participants had three individual 45-min counseling sessions and four 90-min group meetings (10 women each). The dietary and exercise recommendations were culturally adapted. The primary outcome of the study was HOMA-IR. We monitored clinical and chemical biomarkers 1 and 2 years after delivery. RESULTS: After 1 and 2 years of intervention, the metabolic measures improved substantially. The intervention reduced the insulin, glucose and HOMA-IR levels in the IG compared with those in the CG (p < 0.001). CONCLUSIONS: This novel culturally tailored lifestyle intervention program significantly improved the metabolic and morphometric indices measured 1 and 2 years after delivery. These results highlight and underscore the importance of effective lifestyle change education following GDM.

[LAPAROSCOPICALLY-ASSISTED ULTRASOUND-GUIDED PERCUTANEOUS TRANSABDOMINAL OOCYTE COLLECTION: FERTILITY PRESERVATION IN A 17-YEARS-OLD GIRL WITH VAGINAL EWING SARCOMA].

INTRODUCTION: Options for preserving fertility in children and adolescents with cancer depend on patient age, the available time frame, and the treatment regimen. Ovarian stimulation with mature oocyte preservation is often the optimal method in post-menarcheal adolescents. We describe a case of a 17-year-old girl with vaginal soft-tissue Ewing sarcoma in whom transvaginal oocyte collection for fertility preservation was ruled out by the large tumor. To overcome the limitations of the transabdominal approach, we applied a novel method of laparoscopically-assisted ultrasound-guided percutaneous transabdominal oocyte collection. In this manner, we were able to both perform oophorectomy and obtain superficial and deep ovarian follicles for cryopreservation.

[FERTILITY PRESERVATION IN YOUNG CANCER PATIENTS - CAN WE OPTIMIZE THE PATH?]

INTRODUCTION: Advances in cancer therapy have improved the long-term survival of cancer patients. Concerns about fertility represent a major issue for young cancer patients. The emergent discipline of oncofertility, an intersection between oncology and fertility, is a new concept that describes an integrated network of clinical resources that focus on fertility preservation from both clinical and research perspectives. Patients and methods: In this article we describe our designated multidisciplinary program for fertility preservation in pediatric and young adult populations. The program is also designed to serve as a prospective platform for the evaluation of reproductive outcomes in this patient cohort. RESULTS: We have observed considerably higher referral rates following launching the program and earlier referral of chemonaïve patients that concedes maximal fertility preservation. Two hundred and thirty five patients were referred to the program over a period of 3 years. CONCLUSIONS: Our program demonstrates that multidisciplinary programs that encompass relevant specialists, skilled laboratory resources and a facilitated path that drives the process in the shortest time, maximizes the yield.

Urinary bladder injury during cesarean delivery: Maternal outcome from a contemporary large case series.

BACKGROUND: Urinary bladder injury is a rare complication during cesarean delivery. Little is known on maternal outcome following this injury. OBJECTIVE: To evaluate short and long-term maternal outcome following bladder injury during cesarean delivery. STUDY DESIGN: A retrospective case series of all pregnancies complicated by full-thickness bladder injury during cesarean delivery in a single university affiliated tertiary medical center (August 2007-June 2016). Data on demographics, labor and surgery parameters, postpartum sequelae, and cystography were collected and reviewed by study personnel. Short-term maternal outcome included catheterization period, cystography results (if performed), any febrile illness and/or need for second operation prior to maternal discharge. Long term maternal outcome was obtained by searching our urology departmental and ambulatory database for follow up for all women. Univariate analysis was used to compare maternal outcome following first or repeat cesarean delivery. RESULTS: Of 17,326 cesarean deliveries performed during study period, 81 (0.47%) were complicated by bladder injury. Of them, 8 cases (9.9%) occurred during primary cesarean delivery (overall risk in primary cesarean 0.07%). Of the other 73 cases that followed repeated cesarean, adhesions were documented in 55 (75.3%) of them. Six cases (8.2%) had placenta accreta. Bladder injury occurred at peritoneal entry in 55 (67.9%) cases, and involved the bladder dome in 49 (60.5%) of them. Injury was diagnosed during cesarean delivery in all but 3 women, in whom abdominal pain and bloating prompted evaluation on first to third postoperative day. All 3 underwent re-laparotomy with bladder closure without further adverse sequelae. Cystography was performed in 35 patients on median postoperative day 8 (6-11 days). Eleven patients had abnormal findings as follows: 5 urinary leakage, 4 bladder wall irregularity and two urinary reflux. Two of the 11 patients (18%) required additional interventions: One patient required bilateral nephrostomy and re-laparotomy for bladder closure followed by additional surgery to repair consequent vesico-vaginal fistula. The second patient required left nephrostomy and ureteral re-implantation. Both women had combined ureteral and bladder injury. For the rest of the cohort, no febrile illness or other short- or long-term adverse events were reported. There were no clinically significant differences in adverse maternal outcomes between women with repeat cesarean delivery compared to primary cesarean delivery. CONCLUSION: Bladder injury is a rare complication of cesarean delivery. In our case series, unless there is combined ureteral and bladder injury, prognosis was favorable without any long-term sequelae.

Direct and Indirect Effects of Personality Traits on Psychological Distress in Women With Pelvic Floor Disorders.

OBJECTIVES: The diagnosis and treatment of pelvic floor disorders may involve subjective self-report symptom measures that may be related to personality traits. We aimed to construct a model that integrates pelvic floor disorders, personality variables (optimism and neuroticism), psychological distress, and related demographic variables. METHODS: In a cross-sectional study, conducted between August 2014 and June 2015, 155 women following an intake to an urogynecology outpatient clinic of a tertiary health center completed personality questionnaires of optimism and neuroticism (Life Orientation Test-Revised, 10-item Big Five Inventory), pelvic floor symptoms (Pelvic Floor Distress Inventory Short Form), psychological distress (18-item Brief Symptom Inventory), and a demographic questionnaire. RESULTS: A path analysis mediation model showed that patients who had more pelvic floor symptoms felt more psychological distress and that psychological distress increased as the level of neuroticism increased. As for optimism, the correlation to pelvic floor symptoms was nearly significant. Optimism and neuroticism had indirect effects on psychological distress through pelvic floor symptoms in women with urinary incontinence and pelvic organ prolapse. Neuroticism had a direct effect on psychological distress in these women as well. CONCLUSIONS: Our suggested statistical path analysis model supports the important role of personality traits in pelvic floor disorder self-reports and the effect of these traits on psychological distress. Therefore, the optimal treatment for pelvic floor symptoms should include psychological interventions in addition to traditional medical or surgical therapy in hope of reducing psychology distress associated with urinary incontinence and pelvic organ prolapse.

Information seeking and perceptions of anxiety and pain among women undergoing hysterosalpingography.

OBJECTIVE: Hysterosalpingography (HSG) is an accepted diagnostic tool for infertility workup and is considered an invasive procedure that is generally regarded as uncomfortable and painful, though research on psychological consequences is scarce and outdated. The study objective was to investigate women's experience of HSG in terms of fear, anxiety and pain, as compared to colposcopy. STUDY DESIGN: This cross sectional questionnaire study was conducted at two public women's health clinics in Israel between January 2013 and March 2014. 137 women were included in the study. 42 consecutively sampled women referred for outpatient HSG and 95 consecutively sampled women referred for outpatient diagnostic colposcopy. The main outcome measures were: state-trait anxiety, information seeking behavior, fear of pain, fear of the results, retrospective pain. RESULTS: Compared to those undergoing colposcopy, women undergoing HSG expressed significantly higher anxiety prior to the procedure, feared the pain involved more, and rated the procedure as more painful retrospectively. HSG patients tended to report a higher degree of information seeking. Information seeking was correlated with higher anxiety among HSG but not colposcopy patients. CONCLUSION(S): HSG is a highly stressful procedure associated with fear, anxiety, pain and information seeking. Research is needed to find possible ways of ameliorating these emotions and behaviors as they may have negative impact on patient cooperation.

Anatomical diversity of the female external genitalia and its association to sexual function.

OBJECTIVE: To provide data on the anatomical dimensions of adult female genitalia and to investigate the possible association of vulvar morphology and sexual function. STUDY DESIGN: This cross-sectional prospective cohort study, using measurements of the external genitalia was performed in a day-care unit of a tertiary, university-affiliated medical center from 2013 to 2014. Thirty-two premenopausal women aged 20-51 years, undergoing gynecological procedures under general anesthesia (not involving the external genitalia) were asked to respond to both a local general data questionnaire and a validated sexual function questionnaire (PISQ-12). Based on reported orgasmic performance during sexual intercourse, patients were divided into two groups, and the measured genital features were compared. RESULTS: Age, body mass index, parity and sexual activity history were recorded. A wide range of values was noted for each measurement. There was no statistically significant association between external genitalia measurements and age, parity or sexual activity. There was no statistically significant difference in any of the external genitalia measurements between the groups. CONCLUSION: Wide variability exists in the appearance of female external genitalia. Sexual function does not appear to be associated with genital dimensions. This information is important for both women and surgeons when considering cosmetic vulvar surgery.

Colpocleisis surgery in women over 80 years old with severe triple compartment pelvic organ prolapse.

OBJECTIVE: To compare outcomes of Le Fort colpocleisis surgery, between women over 80 years old and younger women. STUDY DESIGN: We searched the medical files for all consecutive women who underwent Le Fort colpocleisis as a primary or recurrent surgery for severe pelvic organ prolapse at our university-affiliated tertiary center between February 2007 and July 2013. Exclusion criteria for performance of the procedure were post-menopausal bleeding, pelvic malignancy, pelvic irradiation, and the desire to preserve coital function. The objective and subjective recurrence of prolapse, intraoperative and postoperative complications, and patient satisfaction were measured. RESULTS: Forty-seven women underwent Le Fort colpocleisis. Of them, 23 were above 80 years, mean age 84.0±3.3, oldest: 91; and 24 were 80 years old and younger, mean age 70.8±6.1, youngest: 61. There were no intraoperative complications. Postoperative complications were recorded for 2 women with lower urinary tract infection and one woman had longer hospitalization time for warfarin treatment adjustment (9 days). Objective cure rates were 82.7% (19/23) and 83.3% (20/24), p=0.32, for women over 80, and women aged 80 and younger, respectively. The subjective cure rate was 86.7% (20/23) and 91.6% (22/24), respectively, p=0.28. CONCLUSIONS: Objective and subjective cure rates of Le Fort colpocleisis in women over age 80 years were similar to those for younger women. The complications were mild and few, and unrelated to age. This procedure may be offered for women over 80 years old with severe symptomatic pelvic organ prolapse and medical comorbidities.

Characteristics and Management of Ovarian Torsion in Premenarchal Compared With Postmenarchal Patients.

OBJECTIVE: To compare the clinical, ultrasonographic, and operative characteristics of premenarchal and postmenarchal patients with surgically verified ovarian torsion. METHODS: A retrospective cohort study of all patients with surgically verified ovarian torsion operated on at a single university-affiliated tertiary medical center during 1997-2013. Age at presentation, presenting symptoms, diagnostic studies, surgical procedure, and pathologic findings were analyzed. RESULTS: A total of 41 premenarchal and 208 postmenarchal patients were diagnosed with ovarian torsion during the study period. Median ages were 9 and 27 years, respectively. Median duration of symptoms before first presentation was longer among the premenarchal patients (24.0 compared with 8.0 hours, P<.001) as was the median interval from hospital admission to surgery (9.5 compared with 4.6 hours, P<.001). Premenarchal girls had a higher rate of restlessness, fever, and evidence of pelvic mass at presentation and a similar rate of ultrasonographic signs for torsion (78.5% compared with 73.1% P=.53). During surgery, a finding of a black-bluish ovary was more common in premenarchal girls (61.0% compared with 41.3%, P=.02). CONCLUSION: Ovarian torsion in premenarchal girls is associated with a longer interval from onset of symptoms and an increased rate of fever and pelvic mass at presentation compared with postmenarchal patients. These data may aid the physician in the evaluation of abdominal pain in premenarchal girls. LEVEL OF EVIDENCE: II.

Effectiveness of medical treatment with methotrexate for interstitial pregnancy.

BACKGROUND: In the last three decades, systemic methotrexate (MTX) has become widely accepted as the primary treatment for unruptured tubal pregnancy. This has prompted investigations into the use of MTX in the management of interstitial pregnancy. AIM: To determine the effectiveness of methotrexate for treatment of interstitial pregnancy. METHODS: We retrospectively reviewed 17 haemodynamically stable women admitted to our tertiary, university-affiliated medical centre with an intact interstitial pregnancy from January 2003 through February 2013. First-line treatment consisted of intramuscular MTX 1 mg/kg/day x4 alternating with folinic acid 0.1 mg/kg or, in cases of low beta-human chorionic gonadotropin (ß-hCG) and no embryonic pole, one dose of 50 mg/m(2) body surface area. Uterine artery MTX injection was administered on the ipsilateral side of the pregnancy followed by uterine artery embolisation as second-line treatment. Failure criteria were <15% decrease in ß-hCG or sonographic evidence of pregnancy development. Second-line failures were referred for surgery. RESULTS: Twelve women (70.5%) underwent successful first-line treatment and 5 (29.5%) required second-line treatment. Baseline characteristics were similar except for a higher rate of two previous ectopic pregnancies in the first-line failures (80% versus 8.3%, P = 0.01). Two women eventually required surgery, both with two previous ectopic pregnancies. Of the three women with fetal cardiac activity on admission, two had successful first-line treatment and one required surgery. CONCLUSION: Systemic MTX is effective for treatment of intact interstitial pregnancy in haemodynamically stable women. The success rate is increased with uterine artery MTX injection as second-line treatment.

Outcome, complications and future fertility in women treated with uterine artery embolization and methotrexate for non-tubal ectopic pregnancy.

OBJECTIVE: To determine the effectiveness and safety of uterine artery methotrexate (MTX) infusion and embolization combined with systemic MTX for treatment of non-tubal ectopic pregnancy. STUDY DESIGN: We retrospectively reviewed the electronic files of all women admitted to a single tertiary, university-affiliated medical center with a diagnosis of non-tubal (cervical, interstitial or cesarean section scar) ectopic pregnancy, who were treated by a combination of uterine artery MTX infusion and embolization and systemic MTX between January 2001 and March 2014. The treatment protocol included a total of 4 MTX injections in doses of 1 mg/kg/day every other day (days 1, 3, 5, 7 of the protocol) alternating with folinic acid 0.1 mg/kg (days 2, 4, 6, 8). The first or second MTX dose was administered by transcatheter intra-arterial injection during the embolization procedure just before injecting Gelfoam for bilateral uterine artery occlusion, and the remaining doses were given intramuscularly. RESULTS: During the study period, 25 women underwent uterine artery infusion and embolization combined with systemic MTX treatment for non-tubal ectopic pregnancy. Ten of the pregnancies were cervical, 9 were interstitial, and 6 were cesarean scar pregnancies. Mean gestational age and beta-human chorionic gonadotropin (ß-HCG) level at admission were 68.6±12.9 days and 14,179 (range 436-61596) IU/L, respectively. Treatment was successful in 24 patients (96%) with mean ß-HCG resolution time of 52.6 (6-147) days. Mild immediate side effects were reported including 8 cases (32%) of abdominal discomfort, 3 cases (12%) of groin or leg pain and 3 cases (12%) of puncture-site local skin infection. No serious immediate side effects such as internal vascular bleeding, sepsis or early liver or renal failure were observed. Among 12 women who stated that they tried to conceive and were more than a year from the treatment, 10 (83.3%) had subsequent pregnancy. CONCLUSION: A combination of uterine artery MTX infusion and embolization with systemic MTX seems to be an effective and safe treatment for non-tubal ectopic pregnancies in women who try to conceive.

Characterizing the need for re-laparotomy during puerperium after cesarean section.

OBJECTIVE: As inconsistency exists concerning the rate and risk factors for re-laparotomy after cesarean section (CS), we aimed to determine the incidence, risk factors and indications for re-laparotomy after CS. METHODS: This is a retrospective study. Women underwent re-laparotomy following CS were compared to a control group in a 1:3 ratio. Demographic, obstetrical and surgical data were analyzed. CS complications were defined as intra-operative abnormal hemorrhage, summoning surgical personnel, inverted T incision, uterine and/or hypogastric arteries ligation or cesarean hysterectomy. RESULTS: Overall, 35,779 women delivered during the study, of them 7,926 by CS (22.1 %) and 62 patients (0.7 %) underwent re-laparotomy. Re-laparotomies occur during the first 24 h, first week and beyond it, following CS in 64.5, 22.6 and 12.9 %, respectively. Previous abdominal/pelvic surgery (14.5 vs. 8.1 %, p < 0.01), emergent surgery (24.2 vs. 13.4 %, p = 0.04), intra-operative complications (26.8 vs. 0.5 %, p < 0.001), post-operative complication (40.7 vs. 0.5 %, p < 0.001) and adhesions (65.5 vs. 33.3 %, p < 0.001) were significantly increased in the study group. Indications for re-laparotomy varied according to the interval elapsed to the re-laparotomy with post-partum hemorrhage (27.4 %) being the leading indication in the early period. CONCLUSION: Risk factors for re-laparotomy following CS can be recognized and are mainly associated with previous abdominal and/or pelvic surgeries and intra-operative adhesions.