[FETAL LACERATIONS DURING CESAREAN SECTION - AN INEVITABLE COMPLICATION].

INTRODUCTION: Cesarean section is the most prevalent in obstetrics and its rate is rising worldwide every year. Although this operation is considered safe, it is not free from complications. In the present review the topic of lacerations in the fetus during cesarean section is discussed. The rate of fetal lacerations during cesarean section is 0.79-1.9% of all cesareans. Several risk factors for this complication have been elaborated in the literature and are presented in this review. However, so far there is no proven method or technique that has been proven effective in the prevention of this complication. Fetal lacerations are not always identified in the operating room and are discovered later in the newborns department. Most lacerations occur on the fetal scalp and face, however, they can occur everywhere in the body of the fetus. Treatment is performed with adhesive medications or by surgical stitches. Normally, fetal lacerations are expressed later in life as a cosmetic problem but some may cause functional handicap of the affected organs. Every delivery that ends with this complication is followed by a lawsuit against the physicians involved in the case and almost always, the alleged physicians are found guilty. A possible solution to this problem is discussed in the present review.

[THE USE OF VAGINAL RINGS FOR THE TREATMENT OF GENITAL ORGAN PROLAPSE].

INTRODUCTION: The rise in women's age globally, as well as lifetime hard physical work and high parity rate in the third world countries, is a substantial cause for female genital organ prolapse of variable degrees of severity. This, in turn, has a negative effect on the function of the affected women. The definitive treatment for this condition is surgery of various types in accordance with the anatomic injury, although it is not easily available throughout the world. Hence the use of vaginal pessaries, which is quite prevalent among the affected women, mainly in third world countries. These contraptions enable fixation of the prolapsed female pelvic organs in the pelvis and prevent their descent to the vagina and beyond. The most prevalent vaginal ring is the pessary ring, although a large variety of vaginal rings are available. In this article the authors review some of the aspects regarding the use of vaginal rings for pelvic organ prolapse. Generally, the use of these rings was found safe and effective - both by physicians as well as users, however, reports of some negative complications related to the use of these devices have been published. Another clinical experimental aspect of the use of these rings is to try to prevent premature delivery in pregnant women. Currently, this treatment option is still regarded as being controversial in terms of its effectiveness for this purpose.

[PERI- AND POST-MORTEM CESAREAN SECTION].

INTRODUCTION: Cesarean section has been practiced since the 2nd millennium BC. It received its name due to the manner of the birth of Julius Caesar, who allegedly yet incorrectly, was born in this way. The main indications for Cesarean section were "king's law" for the implementation of inheritance rights and later because of the doctrine of the Catholic Church that mandated separate burial of the fetus for the purpose of his soul to reach heaven after being baptized. As of the late 19th Century, Cesarean section became safer, hence it gained popularity and nowadays it is quite prevalent as a mode of delivery worldwide. Furthermore, the massive rise in law suit claims against obstetricians also plays its role in the popularity of cesarean section as a mode of delivery. In this review article, the issue of special and rare types of Cesareans, i.e. peri- and post-mortem Cesarean sections is discussed.

[PEDIATRIC AND ADOLESCENT GYNECOLOGY - VULVAR DISEASES].

INTRODUCTION: Vulvovaginitis and labial adhesion are the most common gynecological morbidity among girls and adolescents. Even though pediatricians or family physicians should be capable of dealing with these "ailments", in Israel, these patients are referred to gynecologists because physicians from these two medical specialties are deterred to treat these populations. Treatment is based on softening and antibiotic creams applied locally. In the current relevant literature the present notion regarding these two pathologies is shifted toward follow-up and habit changes in terms of proper hygiene and clothing. In the present review the relevant current literature is examined and updated recommendations are suggested.

[ALCOHOL DRINKING DURING PREGNANCY AND ITS EFFECTS ON THE FETUS AND THE NEWBORN].

INTRODUCTION: Alcohol consumption during pregnancy has become a prevalent phenomenon worldwide in general, as well as in Israel in particular. This habit is associated with an increase in various complications during pregnancy - mainly fetal alcohol syndrome and post-natal fetal alcohol spectrum disorder. There is no "safe limit" for alcohol consumption during pregnancy and alcohol drinking may be detrimental to the fetus or to the newborn when consumed at any stage of the pregnancy. The negative effects of alcohol consumption during pregnancy are also related to a shortage of key nutritional elements due to this habit. The main negative results of this habit are fetal alcohol syndrome and fetal alcohol spectrum disorders. Pregnant women after infertility treatment are also not deterred from drinking alcohol. Education of pregnant women is currently regarded as the best treatment.

[SURROGACY - ITS MEDICAL, LEGAL AND ETHICAL ASPECTS].

INTRODUCTION: During July 2018, Israel went through a social turmoil due to the completion of the legislation of the surrogacy act which exclude gay men from the option of having their own children through surrogate pregnancy. Gay men were outraged also because this denial of the state means that such treatment will not be subsidize since these treatments are quite expensive. In light of the public and media mayhem following the above mentioned law, we revise the relevant literature regarding surrogate pregnancies, mainly for the social aspect of this issue. It seems that most women, who experience surrogate pregnancy, are not affected physically or mentally. However, these finding may not be relevant to surrogate women in underdeveloped countries who, sometimes, are doing it for the financial benefit. More specifically, this review deals with the new Israeli legislation, which incorporates in it religious elements, hence it prevents certain populations (such as gay men) from the only feasible possibility to become fathers. We emphasize that we describe the situation as it is presented in the current literature as spectators but not as judges.

[ACTIVE AND SECONDHAND (PASSIVE) SMOKING DURING PREGNANCY].

INTRODUCTION: Quite a few people of both genders are still smoking today, although their number is decreasing in the developed countries. In Israel, people who smoke constitute 22% of the adult population and the ratio between male and female smokers is 4:1. Jewish women smoke 1.8 times more in comparison with Arab women. Smoking is known to constrict small blood vessels and hence there exists a more prevalent outcome of prematurity and small-for-gestational-age fetus in pregnant women who are exposed to secondhand (passive) smoking during their pregnancy. In the relevant literature, it is claimed that secondhand smoking is responsible for delivery at early stages, as well as low birth weight of newborns for women who were exposed to it. However, these findings were not found as such in a number of studies in which the question of a relation between passive smoking and adverse pregnancy outcomes was not proven. Moreover, exposure to passive smoking by other smokers is considered only one of the many pollutants that exist in our industrial and overcrowded world, hence focusing on that one variable only ignores the effect of many other pollutants that may possibly do harm to the fetus as well as to the pregnant woman. The relation between passive smoking and adverse effects on the fetus leads to the restriction of smoking in public places with no evident proof of its benefit on pregnant women.

[BLUNT AND PENETRATING ABDOMINAL INJURIES DURING PREGNANCY].

INTRODUCTION: Abdominal trauma, especially blunt trauma, is a prevalent complaint during all the stages of pregnancy, which mostly ends without any severe complications to the pregnant mother or the fetus. However, this kind of injury may carry a significant risk to the pregnant mother, to the fetus or to both in case of misdiagnosis regarding the severity of the damage - hence delaying the treatment. Diagnostic modalities are peritoneal lavage, ultrasonography and CT scans. Nevertheless, the high index of suspicion in any case of abdominal trauma during pregnancy remains the responsibility of the attending physician because there is not always a correlation between the complaints of the pregnant woman and the severity of her condition. Today, the main causes for abdominal trauma during pregnancy are car accidents, falls and assaults of pregnant women. In the present article the physiologic mechanisms that cause damage in cases of abdominal trauma during pregnancy, as well as the methods of diagnosis and treatment, are reviewed. It should be remembered that abdominal trauma during pregnancy may be a penetrating one - hence the rate, as well as the severity of the risk to both mother and fetus are significantly raised.

[IS THERE AN INDICATION FOR CLEANING OR DISINFECTING ULTRASOUND TRANDUCERS BETWEEN CONSECUTIVE EXAMINATIONS FOR FEAR OF TRANFERENCE OF INFECTION TO OR BETWEEN PATIENTS?]

INTRODUCTION: The use of ultrasound is a keystone in current obstetrics and gynecology. In several studies, the presence of various biological infecting agents (bacteria, viruses and fungi) has been demonstrated on various parts of the transducers. These findings led to other studies in which different methods of cleaning, disinfection and sterilization have been evaluated for their efficacy in the elimination of these infections. These studies are inconclusive in terms of the preferred method for the total cleaning of these agents from the transducers. The coupling gel, which is used during sonographic examinations, has also been found to harbor all kinds of polluting biological agents. Despite these findings and due to the lack of scientific evidence for transference of infection to the patients, between patients or the staff, the question for the need of those cleaning procedures has been raised in the current relevant literature.

[IS FEAR FROM MALPRACTICE CLAIMS AGAINST OBSTETRICIANS POSSIBLY RESPONSIBLE FOR THE RISE IN THE RATE OF CESAREAN SECTIONS?]

INTRODUCTION: In recent years there is a growing local, as well as global, tendency among obstetricians to end labor by cesarean section in various circumstances. Current literature suggests that the leading factor for this preference is closely related to the amount of malpractice allegations submitted against obstetricians. The extensive use of cesarean sections has its toll in reducing the skills of future obstetricians in handling breech, instrumental and vaginal delivery after cesarean section and vaginal delivery of twins, and other types of deliveries. The acceptance of the absolute autonomy of the parturient on her body, combined with rising prevalence of a cesarean section upon maternal request, has further added to the use of cesarean sections. In the present review, various aspects that led to the rise in the numbers of cesarean sections performed are discussed.

[PERINEAL TEARS THAT INVOLVE THE ANAL SPHINCTER - IS IT AN UNPREVENTABLE OBSTETRIC PROBLEM AND WHAT ARE ITS REPRECUSSIONS?]

INTRODUCTION: Perineal tears that involve the anal sphincter, especially those which are occult, are common in cases of vaginal delivery or instrumental deliveries. Parturients who experience such types of perineal tears may suffer from flatus or fecal incontinence and also fistula to various surrounding organs. There is no consensus in the relevant medical literature regarding the risk factors for the development of these tears, as contradictive results are presented in various relevant studies. Traditional methods for perineal protection, executed by midwives, such as perineal massage with oil, have also failed to be proven as an effective measure for that purpose. The only theme on which there appears to be a consensus is the fact that protective episiotomy is not helpful in protecting the perineum during vaginal delivery. The inability to predict which parturient will have a perineal tear that involves the anal sphincter, as well as the lack of predictive measures to avoid their occurrence, drive more and more women to demand and receive cesarean section by maternal request, which is accepted by most obstetricians nowadays.

[DENTAL CARE DURING PREGNANCY].

INTRODUCTION: Pregnancy is a period, in which, and due to hormonal changes, the prevalence of periodontal diseases rises. The causing organisms for these diseases may migrate to the uterus and cause premature delivery. The diet during pregnancy may also have a deleterious effect on the oral and dental health of the parturient woman, as well as to the teeth of her child. Some unique dietary, as well as pathological conditions, which may appear in pregnant women are known. These are referred to as pica and epulis. Physicians involved in taking care of pregnant women, such as dentists, obstetricians and family physicians, are normally reluctant to refer, or to perform dental care on a pregnant patient. The present review of the current literature suggests that there is no basis for this avoidance. This is because dental care has been found safe for both mother and fetus during the whole period of pregnancy. Furthermore, dental care is even recommended, if not mandatory, because it has been shown that such treatment may prevent early delivery and possible future damage to the newborn's teeth. Considering the lack of knowledge among those who are responsible for the welfare of both the mother and the fetus during pregnancy, we suggest a publication of an official recommendations paper for dental care during pregnancy, which will be issued by the relevant professional medical societies in Israel.

[STRIAE GRAVIDARUM - ETIOLOGY, PREVALENCE AND TREATMENT].

INTRODUCTION: Striae gravidarum is the second most prevalent skin manifestation after skin pigmentation during pregnancy. Its etiology is uncertain, but it is assumed that changes in the structure of collagen, mediated by hormonal changes during pregnancy, are the causative factor. These marks normally appear during the third trimester of pregnancy and disappear several months after delivery. Striae gravidarum have no adverse health implications though they have negative psychological effects on the affected gravid women. Several treatments for this coetaneous affliction have been tested but only skin rubbing of almond oil as well as extracts from the Centella tree have proved to be of limited therapeutic value. Nevertheless, it has been proven that the mere application of various creams for this coetaneous problem during pregnancy is effective in improving the feeling of the users.

[THE MEDICAL CARE OF TRANSGENDER PEOPLE].

INTRODUCTION: The phenomenon of the discrepancy between a person's sexual self-perception and his/her genetic sex has been known to medicine since the mid-19th century. Initially, this discrepancy was considered to be a mental disorder. Over time, advances in medical abilities in surgery, hormonal treatment and infertility, have enabled physicians to help those who are affected to fulfill their wish. The present notion is that transsexualism is a solvable problem (whether the desired wish is for a man to become a woman or vice versa). Treatment is both complicated (surgery) as well as chronic (hormones). In this review the various medical aspects of the different possible treatments are discussed, excluding the psychological part of this intriguing condition.

[THE RIDDLE OF FEMALE ORGASM].

INTRODUCTION: Female orgasm is not necessary for coitus and reproduction from an evolutionary point of view. Furthermore, many women have difficulties in achieving an orgasm. In the present review, the authors discuss the possible benefits of female orgasm, the ability to have an orgasm in different times of the woman's life cycle and in various states of health. We further explore the effect of hormones on orgasm and evaluate different types of treatments for the improvement of female orgasm. Based on the current literature, so far there is no well-established information regarding the precise physiologic causes of female orgasm, hence the bulk of research on this theme comes from psychology or sociology sources. This, of course, does not promote the physiologic, as well as the hormonal knowledge of female orgasm. Therefore, to date, female orgasm still remains a riddle to medicine.

[DYSMENORRHEA - ITS PREVALENCE, CAUSES, INFLUENCE ON THE AFFECTED WOMEN AND POSSIBLE TREATMENTS].

INTRODUCTION: Dysmenorrhea is a common condition among young menstruating women. It is defined as menstrual pains, which sometimes, may be so severe, as to completely cripple the affected woman in every aspect of her daily function. Dysmenorrhea may further cause female infertility problems. This disease is divided into two forms: primary - where no accompanying pelvic pathology is found, and secondary - where pelvic pathology is demonstrated. The most prevalent cause of the latter form is endometriosis. Treatment comprises of medication, such as NSAIDs or various hormonal preparations or several methods of complementary medicine, as well as surgery. Generally, medical and complementary forms of treatment have been found effective in alleviating the pain, while surgery was found effective in treating infertility. Dysmenorrhea, in general, and endometriosis, in particular, has a further immense financial burden on society - both in terms of medical cost, as well as absence from studies or work by young women. To date, no absolute effective treatment, in terms of pain prevention or long standing fertility preservation, has been found.

[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.

[ADVANCED ABDOMINAL PREGNANCY].

INTRODUCTION: Abdominal pregnancy is a very rare obstetric complication which is seriously hazardous to the mother as well as the fetus. It poses a diagnostic challenge to this day. Both maternal and fetal mortality rates in such cases are high, as well as the malformation rate among the affected fetus. The best diagnostic tools are ultrasound and MRI. The availability of these instruments, and especially the latter, is scarce in developing countries, hence the higher rate of this type of pregnancy in these regions. The higher incidence of abdominal pregnancy in developing countries is also associated with the greater prevalence of low socioeconomic status, pelvic infections and infertility - all are more prevalent in these countries. Abdominal pregnancy may be primary - that is fertilization of an ovum in the abdominal cavity, or secondary - re-implantation following tubal abortion, perforation of the uterine wall during curettage or expulsion of pregnancy material through uterine rupture or dehiscence. Heterotopic pregnancies, in which one or both fetuses are found as abdominal pregnancy have been reported. Treatment is surgery. The issue of removing the placenta during the operation is controversial to this day. Treatment of the remaining placenta with methotrexate has recently been abandoned. Lately, conservative treatment by potassium chloride (KCl) injection to the fetal heart by sonographic guidance has been suggested.

[SHIFT WORK AND ITS HEALTH HAZARDS].

INTRODUCTION: Work in repeated changing shifts, in general, and night-shifts, in particular, is considered a necessity, encompassing many professions, among them physicians and nurses. This type of work has been shown to adversely affect the normal function of the human body circadian rhythm. This negative influence in turn, is considered to increase characteristic types of morbidity such as metabolic syndrome, type 2 diabetes and increased rate of cardiovascular morbidity. Women working in night-shifts in particular, have been found to face increased rates of breast cancer, as well as menstrual disturbances and decreased fertility. Despite many physiologic explanations for the deleterious effects of changing or night-shifts on human's health, there is no clear notion for the prevention or treatment of these health hazards. In light of the necessity for such a mode of employment in our modern world, the issues of taking care of the affected workers should be considered on a national scale.

[PLASTIC SURGERY OF THE VULVA AND THEIR CIRCUMSTANCES].

Plastic surgery of the vulva for aesthetic reasons is recently gaining popularity in the Western world, as well as in Israel. There are different methods of executing these operations with no meaningful difference in the surgical results and the satisfaction of the patients. There are also more complicated plastic operations, in which the vulva is involved. These are performed in cases of pseudohermaphroditism, various states of intersex, sex change operations and developmental defects of the genitor-urinary systems. These are considered successful procedures. Furthermore, the issue of the illegal mutilation surgery of the external female genitalia, on religious or cultural background, is mentioned. All the above-mentioned types of operations involving the vulva are discussed.