Incidence and causes of perinatal death in prenatally diagnosed vasa previa: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to estimate the perinatal mortality associated with prenatally diagnosed vasa previa and to determine what proportion of those perinatal deaths are directly attributable to vasa previa. DATA SOURCES: The following databases have been searched from January 1, 1987, to January 1, 2023: PubMed, Scopus, Web of Science, and Embase. STUDY ELIGIBILITY CRITERIA: Our study included all studies (cohort studies and case series or reports) that had patients in which a prenatal diagnosis of vasa previa was made. Case series or reports were excluded from the meta-analysis. All cases in which prenatal diagnosis was not made were excluded from the study. METHODS: The programming language software R (version 4.2.2) was used to conduct the meta-analysis. The data were logit transformed and pooled using the fixed effects model. The between-study heterogeneity was reported by I2. The publication bias was evaluated using a funnel plot and the Peters regression test. The Newcastle-Ottawa scale was used to assess the risk of bias. RESULTS: Overall, 113 studies with a cumulative sample size of 1297 pregnant individuals were included. This study included 25 cohort studies with 1167 pregnancies and 88 case series or reports with 130 pregnancies. Moreover, 13 perinatal deaths occurred among these pregnancies, consisting of 2 stillbirths and 11 neonatal deaths. Among the cohort studies, the overall perinatal mortality was 0.94% (95% confidence interval, 0.52-1.70; I2=0.0%). The pooled perinatal mortality attributed to vasa previa was 0.51% (95% confidence interval, 0.23-1.14; I2=0.0%). Stillbirth and neonatal death were reported in 0.20% (95% confidence interval, 0.05-0.80; I2=0.0%) and 0.77% (95% confidence interval, 0.40-1.48; I2=0.0%) of pregnancies, respectively. CONCLUSION: Perinatal death is uncommon after a prenatal diagnosis of vasa previa. Approximately half of the cases of perinatal mortality are not directly attributable to vasa previa. This information will help in guiding physicians in counseling and will provide reassurance to pregnant individuals with a prenatal diagnosis of vasa previa.

Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus.

BACKGROUND: There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE: This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN: A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS: A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION: Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.

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

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

[NUCHAL TRANSLUCENCY CONCURRENT WITH EARLY ANOMALY SCAN: TIME TO RECONSIDER].

INTRODUCTION: During the last decades, a major achievement was reported in detecting Down's syndrome in the first trimester of pregnancy. This is attributed to the use of high-resolution accurate ultrasound machine allowing the detection of a "nuchal translucency" in the back of the fetus during 11-14 weeks' gestation. This is considered to be a physiologic finding, but when increased, may alert for chromosomal abnormality (mainly Down's syndrome), cardiac and other organ anomalies and other genetic syndromes. Later additional sonographic findings were found, including nasal bone assessment, and Doppler flow studies of the ductus venosus and tricuspid regurgitation Technology advancement accompanied by sonographers' skills enhancement allows (at the time frame of the nuchal scan) a detailed anomaly scan. Additional screening for pregnancy complication was achieved using first trimester multi marker assessment, alerting for preeclamptic toxemia or placenta accreta. Currently, many national and international professional organizations recommend performing the nuchal scan concurrent with an early anomaly scan both at the same time of gestation. This approach is different than the one performed in Israel, whereas the nuchal scan is conducted separately and 2-3 weeks later an anomaly scan is offered. We call for reconsideration of the sequential approach and performing all the tests in a comprehensive first trimester clinic.

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

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

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

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

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

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

Timing of birth and adverse pregnancy outcomes in cases of prenatally diagnosed vasa previa: a systematic review and meta-analysis.

OBJECTIVE: The ideal time for birth in pregnancies diagnosed with vasa previa remains unclear. We conducted a systematic review aiming to identify the gestational age at delivery that best balances the risks for prematurity with that of pregnancy prolongation in cases with prenatally diagnosed vasa previa. DATA SOURCES: Ovid MEDLINE, PubMed, CINAHL, Embase, Scopus, and Web of Science were searched from inception to January 2022. STUDY ELIGIBILITY CRITERIA: The intervention analyzed was delivery at various gestational ages in pregnancies prenatally diagnosed with vasa previa. Cohort studies, case series, and case reports were included in the qualitative synthesis. When summary figures could not be obtained directly from the studies for the quantitative synthesis, authors were contacted and asked to provide a breakdown of perinatal outcomes by gestational age at birth. METHODS: Study appraisal was completed using the National Institutes of Health quality assessment tool for the respective study types. Statistical analysis was performed using a random-effects meta-analysis of proportions. RESULTS: The search identified 3435 studies of which 1264 were duplicates. After screening 2171 titles and abstracts, 140 studies proceeded to the full-text screen. A total of 37 studies were included for analysis, 14 of which were included in a quantitative synthesis. Among 490 neonates, there were 2 perinatal deaths (0.4%), both of which were neonatal deaths before 32 weeks' gestation. In general, the rate of neonatal complications decreased steadily from <32 weeks' gestation (4.6% rate of perinatal death, 91.2% respiratory distress, 11.4% 5-minute Apgar score <7, 23.3% neonatal blood transfusion, 100% neonatal intensive care unit admission, and 100% low birthweight) to 36 weeks' gestation (0% perinatal death, 5.3% respiratory distress, 0% 5-minute Apgar score <7, 2.9% neonatal blood transfusion, 29.2% neonatal intensive care unit admission, and 30.9% low birthweight). Complications then increased slightly at 37 weeks' gestation before decreasing again at 38 weeks' gestation. CONCLUSION: Prolonging pregnancies until 36 weeks' gestation seems to be safe and beneficial in otherwise uncomplicated pregnancies with antenatally diagnosed vasa previa.

Prenatally diagnosed isolated perimembranous ventricular septal defect: Genetic and clinical implications.

OBJECTIVE: To evaluate the incidence of chromosomal aberrations and the clinical outcomes following the prenatal diagnosis of isolated perimembranous ventricular septal defect (pVSD). METHODS: This retrospective study was composed of a cohort of pregnant women whose fetuses were diagnosed with isolated pVSD. Complete examinations of the fetal heart were performed, as well as a postnatal validation echocardiography follow-up at 1 year of age. The collected data included: spontaneous closure of the pVSD, need for intervention, chromosomal aberrations and postnatal outcome. RESULTS: Fifty-five pregnant women were included in the study. 34/55 (61.8%) of the fetuses underwent prenatal genetic workup which revealed no abnormal results. No dysmorphic features or abnormal neurological findings were detected postnatally in those who declined a prenatal genetic workup during the follow-up period of 2 years. In 25/55 of the cases (45.4%), the ventricular septal defects (VSD) closed spontaneously in utero, whereas in 17 cases of this group (30.9%) the VSD closed during the first year of life. None of the large 3 VSDs cases (>3 mm), closed spontaneously. CONCLUSION: Prenatally isolated perimembranous VSD has a favorable clinical outcome when classified as small-to-moderate size, children in our cohort born with such findings had no macroscopic chromosomal abnormalities.

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

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

Prospective Evaluation of the Ultrasound Signs Proposed for the Description of Uterine Niche in Nonpregnant Women.

OBJECTIVES: To evaluate the new ultrasound-based signs for the diagnosis of post-cesarean section uterine niche in nonpregnant women. METHODS: We investigated prospectively a cohort of 160 consecutive women with one previous term cesarean delivery (CD) between December 2019 and 2020. All women were separated into two subgroups according to different stages of labor at the time of their CD: subgroup A (n = 109; 68.1%) for elective CD and CD performed in latent labor at a cervical dilatation (≤4 cm) and subgroup B (n = 51; 31.9%); for CD performed during the active stage of labor (>4 cm). RESULTS: Overall, the incidence of a uterine niche was significantly (P < .001) higher in women who had an elective (20/45; 44.4%) compared with those who had an emergent (21/115; 18.3%) CD. Compared with subgroup B, subgroup A presented with a significantly (P = .012) higher incidence of uterine niche located above the vesicovaginal fold and with a significantly (P = .0002) lower proportion of cesarean scar positioned below the vesicovaginal fold. There was a significantly (P < .001) higher proportion of women with a residual myometrial thickness (RMT) > 3 mm in subgroup A than in subgroup B and a significant negative relationship was found between the RMT and the cervical dilatation at CD (r = -0.22; P = .008). CONCLUSIONS: Sonographic cesarean section scar assessment indicates that the type of CD and the stage of labor at which the hysterotomy is performed have an impact on the location of the scar and the scarification process including the niche formation and RMT.

Clinical Presentation of Paraovarian Cysts.

BACKGROUND: A paraovarian cyst (POC) is located between the ovary and the fallopian tube. In many cases POCs are diagnosed and managed as ovarian cysts. But since POC are a distinct entity in their clinical presentation and surgical intervention, they should be better defined. OBJECTIVES: To describe the clinical perioperative and operative characteristics of patients with POCs in order to improve pre-operative diagnosis and management. METHODS: A retrospective cohort study of patients with an operative diagnosis of POC between 2007 and 2019 in a single university-affiliated tertiary care medical center was included. Demographic characteristics as well as symptoms, sonographic appearance, surgery findings, and histology results were retrieved from electronic medical records. RESULTS: During the study period 114 patients were surgically diagnosed with POC, 57.9% were in their reproductive years and 24.6% were adolescents. Most presented with abdominal pain (77.2%). Preoperative sonographic exams accurately diagnosed POC in only 44.7% of cases, and 50.9% underwent surgery due to suspected torsion, which was surgically confirmed in 70.7% of cases. Among women with confirmed torsion, 28.9% involved the fallopian tube without involvement of the ipsilateral ovary. Histology results showed benign cysts in all cases, except two, with a pathological diagnosis of serous borderline tumor. CONCLUSIONS: POC should always be part of the differential diagnosis of women presenting with lower abdominal pain and sonographic evidence of adnexal cysts. If POC is suspected there should be a high level of suspicion for adnexal torsion and low threshold for surgical intervention, especially in adolescent, population who are prone to torsion.

Recurrence of Ovarian Dermoid Cysts: A Single Center Experience.

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

Second-trimester and early third-trimester spontaneous uterine rupture: A 32-year single-center survey.

BACKGROUND: Second-trimester and early third-trimester uterine rupture in a nonlaboring woman is a very rare and life-threatening condition for both mothers and newborns. We aimed to present clinical characteristics, prenatal findings, and maternal and neonatal outcomes following second-trimester and early third-trimester spontaneous antepartum uterine rupture in our institute. METHOD: The medical records of all women with full-thickness second-trimester and early third-trimester uterine rupture treated in our department from 1988 to 2019 were retrieved from the institutional database and reviewed. Small uterine defects, incomplete ruptures, and silent uterine incision dehiscence were excluded. RESULTS: From 1988 to 2019, 213 665 deliveries were recorded in our institute. Of these, 12 patients experienced second-trimester or early third-trimester spontaneous uterine rupture. Obstetric history revealed that 50% of the women in each period had undergone previous classical uterine incisions and 50% had a short interpregnancy (IP) interval. The mean age at diagnosis of uterine rupture was 26.3 ± 5.1 weeks. The ruptures were associated with abnormal placentation in 10 cases (83.3%): placenta previa (n = 7); and placenta previa and percreta (n = 3). No maternal mortality occurred. Seven of the 10 (70%) viable newborns survived. CONCLUSIONS: The increasing rates of cesarean births (CB) may lead to iatrogenic complications including midgestational prelabor spontaneous uterine rupture, an obstetric emergency, which is hard to diagnose. Maternal and neonatal outcomes can be optimized by a greater awareness of the risk factors, recognition of clinical signs and symptoms, and the availability of ultrasound to assist in establishing a diagnosis to enable prompt surgical intervention.

Analgesic Efficacy of Intrauterine Lidocaine Flushing in Hysterosalpingo-foam Sonography: A Double-blind Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate the efficacy of flushing the uterine cavity with lidocaine before hysterosalpingo-foam sonography (HyFoSy) to reduce procedure-related pain. DESIGN: A double-blind randomized controlled trial was conducted at the Department of Obstetrics and Gynecology, Shamir Medical Center, Israel between June 2020 and September 2020 involving 80 women undergoing a HyFoSy procedure. SETTING: University-affiliated medical center. PATIENTS: A total of 40 women were assigned randomly to the lidocaine group and 40 to the saline (placebo) group using a predetermined randomization code. Intrauterine instillation before the procedure consisting of either lidocaine 2% or normal saline alone was conducted, respectively. INTERVENTIONS: The primary outcome measure was the visual analog scale (VAS) pain score during the phase of intrauterine foam instillation reported by the women after the procedure. The VAS consisted of a 10-cm line ranging from 0 to 10 (anchored by 0 = no pain and 10 = very severe pain). On the basis of the VAS scores, the pain level ratings were classified as mild (rated 1-3), moderate (4-6), or severe (7-10). MEASUREMENTS AND MAIN RESULTS: The patient characteristics and obstetric data were found to be similar in both groups. Comparison of the VAS pain scores experienced during the procedure showed that women in the lidocaine flushing group rated the procedure less painful than the women in the saline group (3.0 ± 1.3 vs 6.3 ± 1.5, respectively; p = .001). The incidence of severe pain was significantly lower in the lidocaine group than the saline group (2.5% and 45.0%, respectively, p = .001). CONCLUSION: Lidocaine flushing of the uterine cavity before HyFoSy significantly decreased the pain known to be caused by this procedure and had the advantage of no side effects. It is easily applied, relatively inexpensive, and may affect compliance with this procedure.

Hysterosalpingo-Foam Sonography for the Diagnosis of Tubal Occlusion: A Systematic Review and Meta-analysis.

This systematic review and meta-analysis evaluated the diagnostic accuracy of hysterosalpingo-foam sonography in suspected cases of tubal occlusion. The combined sensitivity and specificity estimates were 0.99 (95% confidence interval [CI], 0.89-0.99) and 0.91 (95% CI, 0.53-0.98), respectively, with positive and negative likelihood ratios of 11.5 (95% CI, 1.5-87.5) and 0.006 (95% CI, 0.0003-0.12), respectively. The diagnostic odds ratio was 1931.008 (95% CI, 69.7-53,460.8). These findings confirm hysterosalpingo-foam sonography as a highly accurate test for the diagnosis of tubal occlusion and show that it is on a par with standard tests.

Tubal stump pregnancy after salpingectomy-Does the time interval from surgical intervention to conception matter?

AIM: Ectopic pregnancy implantation on the tubal stump after salpingectomy is a rare location for extrauterine pregnancy, whose pathogenesis is still unknown. The purpose of this study was to examine whether the time interval elapsed from salpingectomy may predispose the embryo to implantation on the tubal stump in the next pregnancy subsequent to tube removal. METHODS: Nine women operated for stump pregnancy (study group) between 2008 and 2019 were retrospectively identified. For each case in the study group, 12 consecutive cases that underwent laparoscopic salpingectomy constituted the control group. A sample size of 100 control patients was calculated to achieve statistical power (97.8%) and an α of 0.05. The control groups were triple-matched with the study group for patients' age, indications for salpingectomy (tubal pregnancy or hydrosalpinx prior to in vitro fertilization treatment) and mode of conception of the subsequent pregnancy following salpingectomy. RESULTS: Nine women underwent surgery for stump pregnancy during the study period. All women had a surgical history of laparoscopic salpingectomy. The time interval from prior salpingectomy to subsequent pregnancy was significantly shorter in study group than in the control group (4.3 ± 2.1 months vs. 15.6 ± 13.7 months, respectively, p = 0.016). CONCLUSION: A possible association between the short time interval from prior salpingectomy to ectopic implantation on the tubal stump in the subsequent pregnancy was found. The clinical implications of these findings and in particular whether patients should be advised to wait at least 4 months from the salpingectomy to the subsequent pregnancy remain unclear.

Impact of the Israeli Ministry of Health Cytomegalovirus Guidelines on the Local Pregnancy Outcome.

OBJECTIVE: In 2011, the Israeli Ministry of Health (MOH) published standard guidelines for the follow-up of pregnant women infected by CMV, recommending that amniocentesis be performed in cases of maternal serum viral seroconversion or abnormal sonographic findings suggestive of CMV, in order to prove fetal infection before electing for pregnancy termination. METHODS: A retrospective cohort study was performed, describing 448 pregnant women from 2006 to 2017. We collected data from all women that elected to continue their pregnancies after seroconversion and also of those who chose to undergo pregnancy termination. Subsequently, a telephone survey was then conducted to record outcomes of the newborns of women with CMV seroconversion during pregnancy. RESULTS: 325 (73%) women chose to continue their pregnancy, while 123 (27%) opted for termination of pregnancy. We found that pregnancy termination due to CMV infection was reduced by 7%, from 72 cases (32%) to 51 cases (25%) after the implementation of the MOH guidelines in 2011. In addition, 182/305 (60%) of women responded to our telephone questionnaire regarding newborn outcomes. Of these women, 45/305 (14%) reported complications, and no correlation was found between the prenatal findings and postnatal outcome among those who have responded to our survey. CONCLUSION: Implementation of the new MOH guidelines has reduced the rate of pregnancy termination, without increasing the rate of neonatal complications in Israel with a similar outcome of complication rate as reported in the literature.

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

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

[A COMPARISON OF ARABIN CERVICAL PESSARY AND VAGINAL PROGESTERONE VERSUS VAGINAL PROGESTERONE ONLY IN TWIN PREGNANCY FOR THE PREVENTION OF PRETERM BIRTH DUE TO SHORT CERVIX].

INTRODUCTION: Preterm labor is defined as delivery before 37 weeks of gestation. Up to 17% of twin pregnancy are preterm. Arabin cervical pessary has been proven as preventing preterm labor in singleton pregnancies. The benefit of it in twin pregnancy is controversial. OBJECTIVES: The purpose of this study was to compare the rate of preterm delivery in twin gestation with short cervical length in Israel- one center utilized the combined treatment of Arabin cervical pessary and vaginal progesterone (study group) and the others utilized vaginal progesterone approach (control group). METHODS: Multi-center retrospective cohort study, including "Shamir", "Wolfson", "Shaare Zedek" and "Galilee" medical centers, between the years 2012-2016. Inclusion criteria were twin gestations and short cervical length (<25mm) between 16-28 weeks' gestation. RESULTS: The study group included 68 women, the control group 78 women. The study group had shorter cervical length at intervention in comparison to the control group (13.6 ± 5.9 vs. 16.5 ± 5.7, respectively, p = .002). The treatment started later for the study group compared to the control group (23.2 +2.2 vs 22.6 +3.0). CONCLUSIONS: Despite having shorter cervical length at recruitment, the rate of spontaneous delivery < 34-weeks' gestation was similar in both groups (36.8 vs. 37.2%, respectively). DISCUSSION: Considering the conclusion in this research it seems that the combination of the mechanical effect of the pessary by embracing the cervix, keeping the cervical mucus, bending it in a way that the pressure is towards the anterior cervical wall together with the progestative effect which increases the estrogen/progesterone ratio, creating uterine quiescence and keeping the structural connective tissue of the cervix have an added benefit. It seems that the combined use of Arabin cervical pessary and vaginal progesterone in twin pregnancy with short cervical length have a synergic effect which may have a benefit in preventing preterm labor. The combination of cervical pessary and progesterone does not negatively affect twin pregnancy outcome and does not cause preterm birth.