Intraoperative rupture of benign mucinous cystadenoma does not increase its recurrence rate.

PURPOSE: Laparoscopy has become the standard of care in the management of ovarian benign mucinous cystadenomas. One concern of the operative approach is the risk of recurrence. A previous study has found intraoperative cyst rupture and cystectomy to be the risk factors for recurrence. Our objective was to assess the incidence and risk factors for recurrence of benign mucinous cystadenomas after surgical removal. METHODS: We conducted a retrospective analysis of all cases of patients who underwent removal of benign mucinous cystadenomas by either cystectomy or adnexectomy in our institution between December 2006 and June 2013. RESULTS: 722 women underwent surgical treatment for benign ovarian cysts in that time period, out of which 38 women (5.2%) had benign mucinous cystadenomas confirmed by pathologic examination. Most of the patients underwent laparoscopy (94.7%). Half of the patients underwent cystectomy, and the other half underwent adnexectomy. One patient underwent re-operation due to cyst recurrence. This patient initially underwent laparoscopic cystectomy, during which intraoperative cyst rupture did not occur. CONCLUSION: Recurrence of benign mucinous cystadenomas was uncommon and was not associated with intraoperative cyst rupture.

Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy.

PURPOSE: The aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy. METHODS: We retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013. RESULTS: We reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7 ± 1.9 weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1 ± 4.3 weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (p < 0.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (p = 0.014) and persistent ovarian mass (p = 0.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2 ± 24.0 vs. 6.8 ± 10.6 h, p = 0.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes. CONCLUSION: In our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome.

Endometrial nerve fibre density in patients undergoing IVF: a pilot study.

The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. Presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. This prospective pilot study assessed the presence of nerve fibres in endometrium of women undergoing IVF due to various causes and examined the correlation between the presence of nerve fibres and IVF success. A total of 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Correlations between the presence and density of nerve fibres and aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. Presence of nerve fibres was not correlated with cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without correlation to presence of nerve fibres in the endometrium. Nerve fibres were identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. The presence of nerve fibres does not appear to interfere with implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research. The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. The presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. Our aim was to assess the presence of nerve fibres in endometrium of women with various causes of infertility undergoing IVF and to examine the association between the presence of nerve fibres in the endometrium and IVF success. In a prospective study, 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Associations between the presence and density of nerve fibres and the aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. No association was found between the presence of nerve fibres and the cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without association with the presence of nerve fibres in the endometrium. Nerve fibres can be identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. Their presence does not interfere with embryo implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research.

The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome.

OBJECTIVE: To study the effect of a departmental program designed to shorten the decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR) on maternal and neonatal outcome. STUDY DESIGN: A protocol for managing ECS that included documenting precise time-intervals, identification of delaying obstacles and debriefing of each case, was implemented from March 2011. All women who delivered by ECS for NRFHR, as the only indication were included. Detailed information regarding DDI, maternal intraoperative and postoperative complications, and neonatal early outcomes were compared before (period-P1) (-27 months) and after (period 2) (+27 months) program implementation. RESULTS: During 54 months of study, 593 ECS DDI were included. Mean DDI decreased at period 2 (12.3 ± 3.8 min, n = 301) compared with period 1 (21.7 ± 9.1 min, n = 292), P < .001. Rate of cord pH ≤7.1 and 5 min Apgar score ≤7 decreased at period 2 compared with period 1, P = .016 and P = .031, respectively. Worse composite neonatal outcome decreased at period 2 compared with period 1, 15.6% vs 32.2%, respectively, P ≥ .001. Composite maternal outcome did not differ between the groups. Worse neonatal outcome was dependent on time period (period 1), odds ratio, 2.12; 95% confidence interval, 1.27-3.55; P = .004 and on gestational age at delivery, odds ratio, 0.68; 95% confidence interval, 0.62-0.76; P < .001. CONCLUSION: Introduction of a management protocol to shorten DDI in ECS for NRFHR was associated with improved early neonatal outcome without change in maternal complications.

Total and differential leukocyte count percentiles in healthy singleton term women during the first stage of labor.

AIMS: To establish leukocyte count and differential percentiles in healthy singleton term laboring women during spontaneous normal vaginal labor following an uncomplicated pregnancy. METHODS: An analysis of the records of all women (n = 762) who delivered at our delivery ward during a 2-month period was performed. After exclusion for cesarean delivery, induction of labor, pregnancy complications, preterm labor, multiple pregnancy, fever on admission, and lack of full blood count on admission, 365 parturient women during the 1st stage of labor were included in the final analysis. The total and differential leukocyte counts were determined by standard procedure by an automated cell counter. RESULTS: The leukocyte count range on admission to the delivery ward during the 1st stage of labor in healthy parturient women was between 4.4 × and 21.7 × 10(3)/µl and the 99th percentile limit was 20.06 × 10(3)/µl. The total leukocyte count was not influenced by cervical dilatation, ruptured membranes, or the presence and regularity of uterine contractions. CONCLUSION: An observed leukocyte count within the 99th percentile limit (20.06 × 10(3)/µl) in an otherwise normal parturient woman is reassuring in the absence of other clinical evidence.

CA125 expression in the tissue of uterine leiomyosarcoma.

UNLABELLED: Background: Elevated serum levels of the epithelial marker CA125 are occasionally observed in leiomyosarcoma (LMS) patients. OBJECTIVES: To assess the immunohistochemical expression of this marker in the tissue of LMS. METHODS: The consecutive unselected records of all patients with LMS diagnosed during the period 1995-2012 were located and abstracted. After verification of the diagnosis, 4 µm unstained slides were prepared from each case for immunohistochemical staining for CA125. Sections of ovarian carcinoma known to express CA125 were used as positive controls. RESULTS: We located 17 LMS patients from the period under study. Bleeding was the presenting symptom in 9 patients; the diagnosis was established prior to treatment in 11 patients. The tumor was in an advanced stage in 6 patients, and in 7 unstaged patients it was grossly confined to the uterus. Ten patients died within 14 months after the diagnosis. Serum CA125 levels prior to treatment were assessed in only 8 patients and were above normal limits (> 35 U/ml) in 3 of them. Two of the three with elevated serum levels were in stage III, and the third was an unstaged apparent stage I patient. None of the LMS tissue specimens demonstrated immunohistochemical expression of CA125. CONCLUSIONS: CA125 was not immunohistochemically expressed in the tissue of any LMS tumors examined by us. The origin of elevated serum CA125 in some of these tumors is therefore not in its tissue and remains unknown.

The significance of the pattern of serum CA125 level ascent to above the normal range in epithelial ovarian, primary peritoneal and tubal carcinoma patients.

OBJECTIVE: A rise of the CA125 marker above the normal range during follow-up of ovarian, primary peritoneal and tubal carcinoma patients with a complete clinical response after initial treatment signifies recurrence. We assessed whether the pattern of CA125 ascent to above the normal range at recurrence is associated with outcome. METHODS: The records of all recurrent ovarian primary peritoneal and tubal carcinoma patients diagnosed during 1998-2007 were abstracted. Included were patients who fulfilled the following criteria: CA125 levels were ≥35 U/mL at diagnosis and at recurrence, they had full primary treatment with a complete clinical and radiographic response, were followed-up according to schedule, and had at least two CA125 results within the normal range during follow-up. Two patterns of CA125 ascent to above the normal range were compared: a gradual rise and an abrupt rise. RESULTS: 52 patients with recurrent disease who met the inclusion criteria were identified. The median progression free and overall survival were significantly longer in patients with a gradual than in those with an abrupt rise (22.96 vs 14.07; P=0.0014; and 44.37 vs. median not yet reach, respectively). Multivariate analysis showed that the pattern of CA125 ascent is an independent predictor of progression free and overall survival. CONCLUSIONS: Our data seem to indicate that at recurrence the pattern of ascent of serum CA125 levels to above the normal range in patients in complete clinical remission is of prognostic value.

Interstitial pregnancy management and subsequent pregnancy outcome.

We report on management and subsequent fertility outcome of interstitial pregnancy in a retrospective cohort study (Canadian Task Force classification II-3) at a university affiliated teaching hospital. Of 706 women with extrauterine pregnancy, 14 consecutive women with interstitial pregnancy were treated by methotrexate, laparotomy or laparoscopy between 1997 and 2007. The first four women, with significant hemoperitoneum, were treated by laparotomy. Of the next 10 women, four were selected for medical treatment with methotrexate. Only one case was treated successfully. The other six women had laparoscopic treatment. Of nine laparoscopies, one was converted to laparotomy due to excessive blood loss during the procedure. Of nine women desiring a child, three were infertile, whereas six conceived with an intrauterine pregnancy. A change from diagnosis later in pregnancy and laparotomy to more conservative treatment, mainly by laparoscopy, suggests a possibly better subsequent pregnancy rate.

Mode of delivery in a subsequent pregnancy following previous instrumental delivery.

OBJECTIVE: To assess mode of subsequent delivery in women with previous instrumental vaginal delivery. STUDY DESIGN: In this retrospective longitudinal study we followed women who underwent instrumental delivery. The study group included all consecutive parturient women who underwent an instrumental vaginal delivery during a 24-month period (1996-1999). We then identified women who had a subsequent delivery in our center until the end of the year 2010. The control group included women who had a spontaneous vaginal delivery from the same time. RESULTS: During the index period we had 349 consecutive successful instrumental vaginal deliveries. Of those, 125 women had a subsequent delivery in our center (35.8%). In subsequent pregnancies, the spontaneous vaginal delivery rate was 76.8% and 90.4%; the instrumental delivery rate was 8.8% and 1.6%; and the cesarean rate was 14.4% and 8.0%, in the instrumental delivery, and spontaneous vaginal delivery groups, respectively (P<0.05). The odds ratio for a woman to undergo either an instrumental delivery or a cesarean after having an instrumental delivery in a previous pregnancy was 2.8 (95% confidence interval 1.4-5.9, P<0.05). CONCLUSION: Women with a previous instrumental delivery are at an increased risk of requiring either an instrumental delivery or a cesarean section in a subsequent pregnancy compared with women with a previous spontaneous vaginal delivery.

Controlled ovarian stimulation using a long gonadotropin-releasing hormone antagonist protocol: a proof of concept and feasibility study.

BACKGROUND/AIMS: To evaluate the feasibility of a long protocol of controlled ovarian stimulation prior to in vitro fertilization (IVF) and embryo transfer with a gonadotropin-releasing hormone (GnRH) antagonist used for pituitary and ovarian suppression. METHODS: Thirty patients undergoing IVF/intracytoplasmic sperm injection were randomized into two groups. The control group (n = 16) received a standard flexible GnRH antagonist protocol. Ovarian stimulation consisted of 225 IU/day of recombinant follicle-stimulating hormone for 5 days, followed by 225 IU/day of human menopausal gonadotropin until human chorionic gonadotropin (hCG) administration. The study group (n = 14) received 0.25 mg of GnRH antagonist daily for 7 days, thereafter, upon confirmation of pituitary and ovarian suppression, ovarian stimulation was commenced with the same protocol as used in the control group. Hormone and follicle dynamics, as well as laboratory characteristics and cycle outcome, were compared for both groups. RESULTS: Both groups were comparable in baseline characteristics. Pituitary and ovarian suppression were effectively achieved in 12/14 patients in the study group. The duration of ovarian stimulation and gonadotropin consumption were similar in both groups, as was also the number and size of follicles on hCG day. CONCLUSION: The results of our study confirm the feasibility of a long GnRH antagonist protocol. This regimen could become another option to optimize GnRH antagonist protocols, and should thus be further explored.

Need for episiotomy in a subsequent delivery following previous delivery with episiotomy.

PURPOSE: To assess the need of episiotomy in a subsequent delivery in women with previous primiparous vaginal delivery with episiotomy. METHODS: In this historical prospective study, we followed primiparous women who had an episiotomy at a normal vaginal delivery. The study group included parturient women (n = 201) who underwent an episiotomy at a vaginal delivery during a 2-year period (2001-2002). Inclusion criteria were: primiparity, term singleton vaginal delivery, episiotomy, and a subsequent vaginal delivery in Edith Wolfson Medical Center. Exclusion criteria were instrumental delivery at the index delivery, preterm delivery or twins at the subsequent delivery. Episiotomy in the enrolled parturient women was done when it is thought that failure to perform episiotomy would result in perineal tears. The control group (n = 201) was formed from the same time period and included women who had a spontaneous vaginal delivery without episiotomy. RESULTS: Of the 201 women with episiotomy at the index delivery, 48 (23.9 %) had episiotomy at the subsequent delivery compared to only 20 women (10.0 %) out of the 201 women without an episiotomy at index delivery (p < 0.05). Having an episiotomy at the index delivery significantly increased odds of a subsequent episiotomy (OR 2.84, 95 % CI 1.62-4.99, p < 0.05) and the risk of spontaneous perineal tears (59.2 vs. 23.4 %, p < 0.05) at the subsequent delivery. CONCLUSION: Episiotomy at first vaginal delivery significantly and independently increased the risk of repeated episiotomy and spontaneous perineal tears in a subsequent delivery.

Sexual function after childbirth by the mode of delivery: a prospective study.

PURPOSE: The objective of the present study was to evaluate sexual behavior longitudinally in the postpartum period by mode of delivery. METHODS: In this prospective study, five groups were defined: women who delivered vaginally without an episiotomy (n = 16), women who delivered vaginally with an episiotomy (n = 14), women who delivered by instrumental delivery (n = 16), women who delivered by an emergent cesarean section (n = 19), and women who delivered by an elective cesarean section (n = 17). Sexual behavior was assessed by the female sexual function index (FSFI) questionnaire at 6, 12, and 24 weeks postpartum and by the timing of resumption of sexual intercourse. RESULTS: The mean ± SD self-reported timing of resumption of sexual activity was 4.5 ± 1.8, 7.9 ± 3.0, 7.3 ± 3.4, 6.1 ± 2.6, and 6.1 ± 2.4 weeks in the vaginal delivery without an episiotomy group, in the vaginal delivery with an episiotomy group, in the instrumental delivery group, in the elective cesarean delivery group, and in the emergent cesarean delivery group, respectively (p = 0.013). The FSFI total score in the entire study group (n = 82) was 14.1 ± 10.8, 24.6 ± 7.6, and 27.7 ± 5.1 at 6, 12, and 24 weeks postpartum, respectively (p < 0.05). The FSFI total score did not differ significantly across types of mode of delivery at 6, 12, or 24 weeks postpartum. CONCLUSION: The significance by delivery mode difference in the postpartum resumption of sexual activity was not accompanied by difference in sexual function scores. Specifically, elective cesarean delivery was not associated with a protective effect on sexual function after childbirth.

Prognostic significance of rising serum CA-125 levels within the normal range in patients with epithelial ovarian, primary peritoneal, and tubal cancers, who, after initial treatment, had a complete clinical response.

OBJECTIVE: This study aimed to assess the ability of 3 criteria of rising CA-125 levels within the reference range to predict recurrence in patients with ovarian, primary peritoneal, and tubal carcinomas after complete clinical response to initial treatment. MATERIAL AND METHODS: Included were patients diagnosed during 1998 to 2008 who fulfilled the following criteria: CA-125 levels of 35 U/mL or greater at diagnosis and recurrence, full primary treatment with a complete clinical and radiographic response, follow-up according to schedule, and at least 2 CA-125 results within the reference range during follow-up. Three criteria of rising CA-125 values within the reference range were used for the prediction of recurrence: (1) an absolute increase of 5 U/mL or higher from the nadir value at completion of chemotherapy, (2) early signal of progressive disease criterion, and (3) a rise to an absolute level of 20 U/mL or greater. RESULTS: Of 82 patients who satisfied study inclusion criteria, 58 (70.7%) had disease recurrence. Early signal of progressive disease and a rise to an absolute level of 20 U/mL or greater were highly statistically significant predictors of disease recurrence (odds ratio, 12.62 [95% confidence interval, 2.71-58.7], P = 0.0012; and odds ratio, 6.7 [95% confidence interval, 2.18-20.54], P = 0.001, respectively) and preceded recurrence by a median of 3 and 3.3 months, respectively. CONCLUSIONS: Our data indicate that the early signal of progressive disease criterion and a single rise to an absolute level of 20 U/mL or greater within reference limits are highly predictive of clinical recurrence, although the latter is simpler to use. However, whether this is of practical clinical value remains to be proven.

Reactivity of blood vessels in response to prostaglandin E2 in placentas from pregnancies complicated by fetal growth restriction.

OBJECTIVE: The authors aimed to study the contractility responses of normal and fetal growth restriction (FGR) placentas to prostaglandin E(2) (PGE(2) ) and to correlate the results to subsequent placental histological analysis. METHOD: A dual-perfused single cotyledon model was used. Placentas from pregnancies complicated by FGR and from normal pregnancies were obtained. Selected cotyledons were cannulated and dually perfused. Following stabilization, three concentrations of PGE(2) (0.05, 0.1, and 0.15 mg/mL) were administered to the fetal arterial side causing contraction/relaxation response. Fetal perfusion pressure was measured continuously during these contraction and relaxation phases. Following the perfusion experiments, the placentas were analyzed for fetal or maternal origin vascular lesions. RESULTS: A total of 21 complete experiments were performed (16 normal, 5 FGR). In response to PGE(2) , FGR placentas exhibited lower change in the perfusion pressure and lower relaxation time constant. Basal perfusion pressure did not differ significantly between the two groups. Placental histopathology lesions, fetal or maternal origin, were more common in the FGR compared with the controls placentas, 80% versus 25%, respectively, P= 0.047. CONCLUSIONS: The lower vascular reactivity in response to PGE(2) and the presence of fetal and maternal vascular placental lesions suggest a mechanism explaining the altered vascular supply in FGR.

Two-dimensional and three-dimensional Doppler assessment of fetal growth restriction with different severity and onset.

OBJECTIVES: To investigate the role of three-dimensional (3D) power Doppler ultrasonography in the assessment of fetal growth-restriction (FGR) with various degrees of severity and onset, and compare the results with the analysis of two-dimensional (2D) Doppler. STUDY DESIGN: Vascular indices extracted from 3D Doppler measurements of the placenta were compared with indices of flow-velocity waveforms extracted from 2D Doppler measurements of the major sites of the fetal circulation between FGR (study group) and uncomplicated pregnancies (control group) from 25 to 38 weeks' gestation. RESULTS: Three-dimensional indices were significantly lower in pregnancies complicated by FGR compared with uncomplicated pregnancies. When measured in placental periphery, vascularization index was 9.4 ± 9.6 in FGR pregnancies compared with 16 ± 14.7, P = 0.04. Flow index was 33.9 ± 6.9 compared with 38.7 ± 4.9, P = 0.03 and the vascularization-flow index was 3.8 ± 4.3 compared with 6.5 ± 6, respectively, P = 0.03. Among the conventional 2D indices, umbilical artery and middle cerebral artery pulsatility indices were not significantly different between the FGR and control groups. Higher rate of maternal or fetal compartment vascular lesions were detected in the FGR group. CONCLUSIONS: Three-dimensional Doppler was found to be more strongly associated with placental vascular compromise than conventional 2D Doppler, regardless of severity and onset of fetal growth restriction.

The placental component in early-onset and late-onset preeclampsia in relation to fetal growth restriction.

OBJECTIVE: To identify pathological placental differences between early-onset and late-onset preeclampsia, in relation to fetal growth restriction (FGR). METHODS: Placentas from patients with preeclampsia were analyzed for lesions of maternal vascular supply consistent with maternal underperfusion and lesions of fetal vascular supply consistent with fetal thrombo-occlusive disease. Findings were compared between patients who gave birth before 34 weeks (early-onset preeclampsia) and after 34 weeks (late-onset preeclampsia). RESULTS: Compared with the late-onset group (n = 93), the early-onset group (n = 37) had higher rates of FGR (62.2% vs 25.8%, P < 0.001) and lesions of maternal vascular supply (95% vs 60%, P < 0.001). Within the early-onset group, cases with FGR (n = 23) had more lesions of fetal vascular supply (47.8% vs 7%, P = 0.01), with similar high rates of lesions of maternal vascular supply (91% vs 100%) compared with those without FGR. Within the late-onset preeclampsia group, cases with FGR (n = 24) had higher rates of maternal vascular supply lesions (88% vs 51%, P = 0.003) than those without FGR, but similar rates of fetal vascular supply lesions (25% vs 16%, P = 0.32). CONCLUSION: The placental fetal vascular supply lesions in combination with maternal vascular lesions are more dominant in early-onset preeclampsia with FGR as compared with early-onset preeclampsia without FGR.

Personality, fear of childbirth and cesarean delivery on demand.

OBJECTIVES: To investigate both the psychological traits and the demographic factors associated with cesarean section on maternal demand. DESIGN: Cross-sectional questionnaire study. SETTING: Delivery ward, Edith Wolfson Medical Center, Holon, Israel. SAMPLE: Fifty-nine healthy primigravida with a singleton pregnancy were recruited during 2009, of whom 28 requested and were delivered by cesarean section without obstetrical indication, whereas 31 opted for spontaneous vaginal delivery. METHODS: All questionnaires were administered to the two groups at term. Various psychological (fear of childbirth questionnaire, Millon Clinical Multiaxial Inventory III, Anxiety Sensitivity Index, State-Trait Anxiety Index and social support scale) as well as demographic variables were measured before labor and compared. A priori power calculation yielded a power of 95%. MAIN OUTCOME MEASURES: Fear of childbirth, various personality disorders and psychiatric clinical syndromes (29 Millon Clinical Multiaxial Inventory III scales), Anxiety Sensitivity, State Anxiety Index, social support and demographic variables. RESULTS: Differences in age and method of conceiving (p<0.001) were found between the groups. The study group reported a higher level of fear of childbirth (p<0.001), but no differences were found in all other personality characteristics measured (29 Millon Clinical Multiaxial Inventory III scales, State-Trait Anxiety, Anxiety Sensitivity and social support scale). The origin of the difference regarding the fear of childbirth was located to two specific questions: 'Have you always been afraid of giving birth?' and 'Have you sometimes thought of the delivery as something unnatural?' CONCLUSIONS: The only psychological variable associated with the choice for cesarean section on maternal request was the fear of childbirth.

Differences between adnexal torsion in pregnant and nonpregnant women.

STUDY OBJECTIVE: To compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women. DESIGN: Retrospective case-control study (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: Sixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion. INTERVENTIONS: Surgery to treat proved adnexal torsion. MEASUREMENTS AND MAIN RESULTS: The mean (SD) gestational age in the pregnant group was 11.5 (7.7) weeks. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Sonographic demonstration of multicystic ovaries was more common in pregnant women with recurrent torsion than in women with a single episode of torsion (86% vs 31%; p = .009). Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001). CONCLUSION: Pregnancy after treatment for infertility is a risk factor for adnexal torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries.

Placental histopathological findings in obese and nonobese women with complicated and uncomplicated pregnancies.

PURPOSE: To investigate the role of placental abnormalities in complicated and uncomplicated pregnancies in obese women. METHODS: Placentas from patients with complicated or uncomplicated pregnancies and a pregravid body mass index (BMI) of ≥30 kg/m2 were analyzed histopathologically for lesions consistent with maternal and fetal circulation abnormalities and inflammatory lesions related to the maternal or fetal response. Findings were compared with a normal-weight control group matched by mode of delivery and presence/type of pregnancy complications. RESULTS: The obese group consisted of 28 women of whom 46% had a complicated pregnancy. The obese group had a higher rate of maternal inflammatory lesions than the normal-weight control group (43 vs. 3.6%, p<0.001). There was no difference between the obese women with complicated and uncomplicated pregnancies in mean placental weight or lesions associated with fetal or maternal vascular supply. CONCLUSION: Placental inflammatory lesions may underlie the worse pregnancy course of obese women relative to normal-weight women.

The care of sexual assault victims: the first regional center in Israel--10 years experience.

BACKGROUND: The management of sexual assault victims comprises complex medical, psychological, social and judicial care that was previously provided by various disciplines at several distant locations. This novel concept is the delivery of comprehensive care to victims of sexual assault at one location 24 hours a day. OBJECTIVES: To describe the characteristics of sexual assault victims, their assailants, the assault and the treatment, and provide descriptive data on the evidentiary examination. METHODS: We performed a retrospective analysis of the charts of all sexual assault victims presenting to the Regional Center for Care of Sexual Assault Victims between October 2000 and July 2010. The center, the first in Israel, provides comprehensive care to victims of sexual assault in one location 24 hours a day using a multidisciplinary approach. RESULTS: The study group comprised 1992 subjects; 91.5% of the victims were females and 8.5% were males, and the age ranged from 1 to 88 years (mean age 22.3 years). Of the 1992 victims, 1635 were single (82.2%), 195 were divorced (9.8%), 141 were married (7.1%), 18 were widowed (0.9%) and 3 were unspecified. The assailant was a stranger in 794 (39.8%) of the cases, someone familiar to the victim in 786 cases (39.0%), a partner in 127 cases (6.4%), a family member in 117 cases (5.9%), someone met via the internet in 53 cases (2.7%), an authority figure in 39 cases (2.0%), and unspecified in 76 (3.9%). In the majority of cases the attack occurred either in the evening or at night (71.7%). CONCLUSIONS: We identified several risk factors for sexual assault that can be used in prevention programs. The sexual assault victim in our study tended to be a young single woman who was attacked by a familiar assailant in the evening or at night. Our center provides comprehensive care to victims 24 hours a day at one location and includes a team of forensic, psychological, physical and legal specialists.