Routine ultrasonographic and hysteroscopic evaluations of women undergoing postpartum manual removal of placenta: a retrospective cohort study.

PURPOSE: This study aimed to assess the rates of retained products of conception (RPOC) after routine postpartum evaluation of patients who underwent post-delivery manual uterine revision due to retained placenta. METHODS: This is a retrospective cohort study of 599 consecutive women who underwent manual removal of placenta during 2010-2018. Group A comprised 465 women who underwent postpartum symptom-based evaluation (2010-2016). Group B comprised 134 women who were routinely evaluated by ultrasound and subsequently by hysteroscopic examination 6 weeks after delivery (2016-2018). RESULTS: The rates of abnormal postpartum bleeding were similar between groups A and B (12% and 13%, respectively, p = 0.72%). A significantly smaller proportion of women underwent hysteroscopy in group A than group B (12% vs. 37%, p < 0.05). The rate of persistent RPOC confirmed by hysteroscopy was significantly lower in group A than group B (9.7% vs. 23%, p < 0.05). CONCLUSION: Among patients who underwent post-delivery manual removal of placenta, a threefold higher rate of RPOC was discovered by routine elective evaluation than by evaluating only symptomatic patients. Future studies may show whether this approach translates to an effect on fertility.

Barbed Versus Conventional Suture for Uterine Repair During Caesarean Section: A Randomized Controlled Study.

OBJECTIVE: This study sought to compare the short-term outcome of uterine incision repair during a Caesarean section (CS) using a bidirectional knotless barbed suture versus polyglactin suture. METHODS: A randomized controlled trial was conducted at a university hospital. Participants undergoing a CS were randomly assigned to uterine incision closure by bidirectional knotless barbed suture (group A) or polyglactin (group B). The primary outcome was the time needed to repair the uterine incision. The analysis was by intent to treat. A sample size of 35 per group (n = 70) was planned to detect a 30% reduction in uterine repair time (Canadian Task Force Classification I). RESULTS: From July 2016 through October 2017, 150 women were screened, and 70 were statistically analyzed: group A (n = 35) and group B (n = 35). Time to complete uterine incision repair was 308 ± 57 seconds for group A and 411 ± 74 seconds for group B (P < 0.001). Total surgery time (33.4 ± 8.8 minutes vs. 33.2 ± 7.5 minutes; P = 0.64) was not significantly different between groups A and B, respectively. CONCLUSION: Repair of the CS uterine incision with barbed suture compared with polyglactin suture reduces suturing time.

Are Ultrasonographic Findings Suggestive of Ovarian Stromal Edema Associated with Ischemic Adnexal Torsion?

OBJECTIVE: To study whether sonographic findings suggestive of ovarian stromal edema are associated with tissue ischemia in patients with adnexal torsion. METHODS: A study of 79 patients with adnexal torsion was performed. Patients were divided into an ischemic group, in which the twisted adnexa were seen as blue or black, and a non-ischemic group, in which the adnexa retained normal color and appeared viable. Clinical and ultrasonographic findings, specifically the presence of ultrasonographic signs suggestive of ovarian stromal edema, were compared between the two groups. RESULTS: Of the 79 patients with torsion, in 44 (55.7%) the adnexa appeared ischemic at surgery. The presence of ischemia was not associated with age, pregnancy, duration of pain, vomiting or findings at physical examination. There was no significant difference between the ischemic and the non-ischemic group in the proportion of patients with signs of ovarian stromal edema (59 vs. 40%, p = 0.11), in the proportion of patients with absent/diminished stromal Doppler flow (36 vs. 28%, p = 0.12%) or in the proportion of patients with both signs of stroma edema and absent/diminished stromal Doppler flow (20 vs. 12%, p = 0.36). CONCLUSION: Ultrasonographic signs of ovarian stromal edema do not assist in differentiating between ischemic and non-ischemic adnexal torsion.

GnRH-agonist ovulation trigger in patients undergoing controlled ovarian hyperstimulation for IVF with ultrashort flare GnRH-agonist combined with multidose GnRH-antagonist protocol.

OBJECTIVE: To evaluate, whether Gonadotropin-releasing hormone-agonist (GnRH-agonist or GnRH-ag) trigger in patients undergoing the ultrashort GnRH-ag/GnRH-antagonist (GnRH-ant) protocol is as effective as in patients at high risk to develop severe ovarian hyperstimulation syndrome (OHSS), who undergo the multidose GnRH-ant protocol. DESIGN: Cohort study. SETTING: University hospital. PATIENTS: All consecutive women aged ≤35 years admitted to our IVF unit from January 2011 to October 2011 who reached the ovum pick-up stage. INTERVENTIONS: Triggering final oocytes maturation by GnRH-ag instead of hCG, in high-responder patients undergoing either the ultrashort GnRH-ag/GnRH-ant or the multidose GnRH-antagonist controlled ovarian hyperstimulation (COH) protocols. MAIN OUTCOME MEASURES: Ovarian stimulation characteristics, percentage of mature oocytes, fertilization and pregnancy rates. RESULTS: No inbetween groups differences were observed in ovarian-stimulation related variable, percentage of mature oocytes, fertilization or pregnancy rates. No case of moderate-severe OHSS was reported in the study, or the control groups. CONCLUSIONS: Three consecutive doses of daily GnRH-ag administration at the beginning of ultrashort flare GnRH-ag/GnRH-ant COH protocol, did not interfere with the ability of the GnRH-ag to trigger final oocytes maturation at the end of the COH cycle.

GnRH agonist versus GnRH antagonist in ovarian stimulation: the role of elevated peak serum progesterone levels.

AIM: We sought to evaluate the influence of subtle serum progesterone elevation on in vitro fertilization (IVF) cycle outcome and to assess the impact of the type of gonadotropin-releasing hormone (GnRH)-analogue used during controlled ovarian hyperstimulation (COH) on the probability of clinical pregnancy. PATIENTS AND METHODS: We reviewed the files of all consecutive patients undergoing COH with either GnRH-agonist or antagonist in our IVF unit during a 10-year period and who had their peak serum progesterone levels determined on the day of human chorionic gonadotropin (hCG) administration. RESULTS: Of the 2244 IVF cycles evaluated, 2103 had peak progesterone level of <1.5 ng/mL (normal-P group) and 141 of >1.5 ng/mL (high-P group) (6.28% of all the study population). Clinical pregnancy rate was significantly higher in the normal-P group (25.4% versus 16.6%; p < 0.006). Moreover, among the high-P group patients, the use of the long GnRH-agonist suppressive protocol (GnRH-ag) was more prevalent in patients who conceived as compared to those who did not (60.9% versus 39%, respectively; p < 0.05), with a tendency toward an increase pregnancy rate in those using GnRH-ag compared with GnRH-antagonist protocol (GnRH-antag; p < 0.059) COH protocols. CONCLUSION: While subtle progesterone elevation in patients undergoing COH using GnRH-antag COH protocols, should dictate embryo cryopreservation and cancelation of the fresh transfer, in those undergoing the GnRH-ag COH protocol, a fresh embryo transfer should be recommended.

Amniotic fluid rubidium concentration association with newborn birthweight: a maternal-neonatal pilot study.

BACKGROUND: Although most biological systems, including human tissues, contain rubidium, its biogeochemical functions and possible role in neonatal birthweight are largely unknown. An animal study indicated a correlation between rubidium deficiency in the maternal diet and lower newborn birthweight. OBJECTIVE: This pilot study measured rubidium concentrations in amniotic fluid during the second trimester of (low-risk) pregnancy and investigated potential correlations between rubidium levels and third-trimester newborn birthweight-small for gestational age, appropriate for gestational age, and large for gestational age-and between preterm birth and term birth in uncomplicated pregnancies. STUDY DESIGN: This prospective, single-center study investigated a possible relationship between rubidium concentration in second-trimester amniotic fluid and third-trimester birthweight percentile. Amniotic fluid (at a median gestational age of 19 weeks) was sampled to determine rubidium concentration. Maternal and newborn characteristics were obtained from participant and delivery records. RESULTS: After screening 173 pregnant women, 99 amniotic fluid samples were evaluated. Midpregnancy median rubidium concentrations were significantly lower among newborns that were classified as small for gestational age than among newborns that were classified as appropriate for gestational age (106 vs 136 µg/L; P<.01). Based on a logistic regression random forest model, amniotic fluid rubidium was identified as a significant contributing factor to appropriate-for-gestational-age birthweight with 54% of the total contribution. CONCLUSION: Amniotic fluid rubidium concentration seems to be a strong predictor of appropriate-for-gestational-age birthweight and a potential marker for newborn birthweight classifications. In particular, low rubidium concentrations in amniotic fluid during midpregnancy are linked to third-trimester lower birthweight percentile. These findings could potentially serve as a valuable tool for early identification of pregnancy outcomes. Further investigation is necessary to fully explore the effect of rubidium on fetal development.

Procedure-to-delivery interval after late amniocentesis and the need for routine antenatal corticosteroids.

OBJECTIVES: The aim of this study is to assess the procedure-to-delivery interval (PDI), the obstetric complications, and the early neonatal outcome in patients that did or did not receive glucocorticosteroids (GCSs) before third-trimester amniocentesis (TTA). METHODS: A retrospectively analysis of 445 TTA procedures divided into two groups based on the administration (study group = 220 patients) or not (control group = 225 patients) of GCSs before TTA. The PDI was calculated for all patients. Obstetric and neonatal outcomes were compared between the groups. RESULTS: The rate of procedure-associated complications was similar between the groups. The mean PDI was 47.2 ± 16.8 days. The overall incidence of preterm birth was 11.7%; 9% delivered between 34 and 37 weeks and 2.7% between 28 and 34 weeks. Only nine patients (2%) delivered within seven days following TTA. The incidence of respiratory distress syndrome in the study and control groups was 1.8% and 1.3%, p = .71, respectively. There were no significant differences in other neonatal outcomes in term and preterm deliveries between the study and control groups. CONCLUSIONS: In the present study, the administration of glucocorticoids prior to TTA did not reduce the rates of neonatal complications, which was similar in both groups and not higher than the general population.

Local cerebroplacental ratio reference ranges are better predictors for adverse delivery outcomes in normal weight fetuses during pregnancy.

OBJECTIVE: To evaluate the predictive value of local versus external cerebroplacental ratio (CPR) reference ranges for delivery outcomes in low-risk pregnancies. METHODS: A retrospective analysis of all feto-maternal demographic and biometric data in fetuses with normal estimated fetal weight (EFW) and a CPR examination between the years 2014-2019, in a university medical center. The study group included healthy singleton pregnancies from 32-week gestation, with an examination-to-delivery interval of <31 days. The three models compared two thresholds: <5th percentile (CPR 1, CPR 3) and <10th percentile (CPR2). The CPR1 and CPR2 models both use local CPR reference ranges, while the CPR3 model uses an external CPR reference range. The main outcome was predictive accuracy for urgent cesarean delivery (CD), operative delivery (OD), and composite outcome (CO), defined as an Apgar score of <7, fetal blood pH < 7.1 or admission to the neonatal intensive care unit (NICU). RESULTS: Overall, 410 low-risk pregnancies with normal weight fetuses were enrolled in the study. All three CPR models turned out to be significant predictors of CD, with an odds ratio (OR) of 9, 95% CI (2.7-27), p < .001 for CPR1, and an OR of 2.9, 95% CI (1.1-7.4), p < .04 for CPR2, and an OR of 3.4, 95% CI (1.7-6.8), p < .001 for CPR3. All the three models were also found to be predictors of OD, and an OR of 6.9, 95% CI (2.1-22) p < .04 for CPR1, and an OR of 2.8, 95% CI (1.2-6.7), p < .04 for CPR2, and an OR of 2.8, 95% CI (1.4-5.3) p < .01 for CPR3. The positive predictive values (PPV) for CD and OD were both 50% for CPR1, versus 28% and 26% in CPR2, and 24% and 25% in CPR3. The negative predictive value (NPV) was similar, around 88% in all three models. None of the models were found to be significant predictors for CO. CONCLUSIONS: A CPR model based on local reference ranges and <5th percentile cutoffs showed the highest PPV for CD and OD. The calculation of local references for CPR should be encouraged.

U-turn of uterine arteries: a novel sign pathognomonic of uterine inversion.

A uterine inversion occurs when the uterine fundus collapses into the endometrial cavity. It is a rare complication in obstetrics following delivery, and it is even more infrequently encountered in gynecology with the non-puerperal uterus. A submucous fibroid is the most common reported cause of the non-puerperal uterine inversion. If not promptly recognized and treated, uterine inversion may lead to a severe hemorrhagic shock and death. We describe a novel three-dimensional power Doppler feature for the diagnosis of uterine inversion.

Is umbilical vein varix associated with changes in cerebroplacental ratio?

Objective: We aimed to review a single-center experience in follow-up and management of fetuses with umbilical vein varix (UVV) and to assess the effect of UVV on fetal Doppler parameters.Methods: We reviewed retrospectively maternal antenatal records, delivery records, and newborn records to identify cases of UVV. Further, we retrospectively compared 25 fetuses with isolated UVV and available cerebroplacental ratio (CPR) analysis with 75 matched controls.Results: We identified 67 cases of UVV. The median gestational age (GA) at diagnosis was 34 weeks (range: 26-41 weeks). The average diameter of UVV at diagnosis was 10.1 mm (range: 9-14 mm). The median GA at delivery was 36 + 6 (range: 33-41 weeks), with an average birth weight of 2918 g (range: 1278-4140 g). There was a single case of intrauterine death at 35 weeks. CPR was 2.13 ± 0.62 in isolated UVV group compared with 1.84 ± 0.61 in the control group (p < .05). Other Doppler parameters did not differ between fetuses with UVV compared with controls.Conclusions: CPR was significantly increased in the UVV group compared with control fetuses. This finding suggests that UVV is not associated with chronic fetal oxygen deprivation; it, therefore, may contribute to our understanding of the pathophysiology explaining abnormal pregnancy outcome in cases with UVV.

Third-trimester Reference Ranges for Cerebroplacental Ratio and Pulsatility Index for Middle Cerebral Artery and Umbilical Artery in Normal-growth Singleton Fetuses in the Israeli Population.

BACKGROUND: The ratio between the fetal umbilical artery pulsatility index (UA-PI) and the middle cerebral artery pulsatility index (MCA-PI) is termed the cerebroplacental ratio (CPR). The CPR represents fetal blood flow redistribution at the early stages of placental insufficiency; moreover, it has predictive value for adverse intrapartum and neonatal outcomes. However, internationally accepted reference ranges for CPR are lacking. OBJECTIVE: This study sought to establish UA-PI, MCA-PI, and CPR reference ranges in low-risk, normal-growth singleton fetuses during the third trimester of pregnancy. METHODS: A retrospective cohort cross-sectional study was performed in the obstetrics ultrasound unit of a university hospital in Israel. We reviewed all fetal and maternal electronic records of pregnant women referred for ultrasound assessment during the third trimester between January 2014 and January 2019. We included only singleton pregnancies with normal anatomy scans and a normal third-trimester estimated fetal weight. The UA-PI, MCA-PI, and CPR reference ranges were reconstructed for each of the vessels for each gestational age between 29 and 41 weeks. RESULTS: A total of 560 pregnancies met the inclusion criteria. Satisfactory waveforms and measurements were obtained in all cases. At least 18 women enrolled at each gestational week. The MCA-PI and CPR values showed a similar parabolic curve during the third trimester of pregnancy, with a peak value at 32 and 33 gestational weeks, respectively. The UA-PI showed a linear and gradual decrease over the gestational age. CONCLUSIONS: In this study we established UA-PI, MCA-PI, and CPR reference ranges in low-risk, normal-growth singleton fetuses during the third trimester based on the Israeli population.

Controlled ovarian hyperstimulation using multi-dose gonadotropin-releasing hormone (GnRH) antagonist results in less systemic inflammation than the GnRH-agonist long protocol.

OBJECTIVE: The aim of the study was to investigate whether controlled ovarian hyperstimulation (COH) using multi-dose gonadotropin-releasing hormone (GnRH) antagonist results in a lesser degree of systemic inflammation than the GnRH-agonist long protocol. DESIGN: Prospective, observational study. PATIENTS AND METHODS: Blood was drawn three times during the COH cycle from patients undergoing the long GnRH-agonist protocol (agonist group) (n = 12) or the multi-dose GnRH-antagonist protocol (antagonist group) (n = 15): the day on which adequate suppression was obtained (agonist group), or day 2 or 3 of the menstrual cycle and before gonadotropin treatment (antagonist group) (Day-0); the day of or prior to administration of human chorionic gonadotropin (Day-hCG); and the day of ovum pick-up (Day-OPU). Levels of sex steroids and serum C-reactive protein (CRP) were compared between the two study groups among the three time points. RESULTS: While no between-group differences were observed in patient age or ovarian stimulation characteristics, a significantly higher number of oocytes were retrieved in the antagonist compared with the agonist group. In both groups, serum CRP levels were significantly higher on Day-OPU than on Day-hCG and Day-0. While serum CRP levels were higher on Day-hCG than Day-0, the difference was statistically significant only for the agonist group (p < 0.05). Moreover, Day-OPU serum CRP levels were significantly higher in the agonist than in the antagonist subgroup. CONCLUSION: COH using the multi-dose GnRH-antagonist protocol yields a lesser degree of systemic inflammation, as reflected by CRP levels, than the GnRH-agonist long protocol.

Quality of nuchal translucency measurements in multifetal pregnancies.

OBJECTIVE: A prospective comparative study was conducted to investigate the effect of multifetal pregnancies on the quality of nuchal translucency measurements using an image scoring method. METHODS: The study sample included 72 consecutive multiple gestations (164 fetuses) and 195 singleton gestations (control) matched for maternal age and fetal crown-rump length. Nuchal translucency ultrasound was performed similarly in singleton and multiple pregnancies. A single sonographer scored an elected ultrasound image of each fetus according to a nuchal translucency image scoring method and the mean image score was compared between the whole singleton and multiple gestation groups and between subgroups defined by fetal distance from the abdominal wall. RESULTS: There was no significant difference in mean image score between the multiple and singleton gestation groups (6.60 +/- 1.3 and 6.69 +/- 1.5, respectively; p = 0.595). Within the multiple gestation group, there was a significant difference in mean score between fetuses positioned proximal to the abdominal wall (n = 72) (3.7 +/- 1.1) and both the middle fetuses (6.2 +/- 1.4; p < 0.01) and distal fetuses (5.7 +/- 1.06; p < 0.008). There was no difference between the proximal fetuses and controls. CONCLUSIONS: The fetuses in multiple pregnancies that are located further from the abdominal wall have a poorer image score.

Do stimulation characteristics of the first in vitro fertilization cycle predict pregnancy in women of 40 years old and over?

The failure of tests of ovarian reserve to predict clinical pregnancy in women 40 years old and older prompted this study of the predictive value of information obtained during the first cycle of in vitro fertilization (IVF). Stimulation characteristics during the first IVF cycle attempt were unhelpful in predicting the possibility of clinical pregnancy within the first three consecutive IVF cycles.

GnRH agonist versus GnRH antagonist in ovarian stimulation: the role of endometrial receptivity.

To examine whether the choice of the GnRH analogues used during controlled ovarian hyperstimulation (COH), may influence endometrial receptivity, we studied 712 IVF cycles, in patients undergoing COH with GnRH agonist or antagonist and with the transfer of at least one top-quality embryo. The GnRH agonist group showed significantly higher endometrial thickness and higher pregnancy rate, suggestive of a higher endometrial receptivity, compared with the GnRH antagonist group.

GnRH agonist versus GnRH antagonist in ovarian stimulation: the influence of body mass index on in vitro fertilization outcome.

In an attempt to examine whether body mass index (BMI) may influence IVF outcome in patients undergoing COH with either GnRH-agonist (agonist group) or GnRH-antagonist (antagonist group), we studied 799 IVF cycles: 481 in the agonist group and 318 in the antagonist group. In patients with BMI >25 kg/m(2), COH with either GnRH-agonist or GnRH-antagonist achieved a comparable outcome; whereas in patients with BMI <25 kg/m(2), the use of GnRH-agonist suppressive protocol revealed significantly higher pregnancy rates.

Ultrashort gonadotropin-releasing hormone agonist combined with flexible multidose gonadotropin-releasing hormone antagonist for poor responders in in vitro fertilization/embryo transfer programs.

To evaluate the appropriate controlled ovarian hyperstimulation (COH) protocol in poor responders, we compared the stimulation characteristics of 21 cycles, which included the ultrashort gonadotropin-releasing hormone (GnRH) agonist combined with the flexible multidose GnRH antagonist, to the patients' previous failed in vitro fertilization attempts. The use of an ultrashort GnRH-agonist/GnRH-antagonist COH protocol resulted in a statistically significantly greater number of follicles larger than 14 mm on the day of hCG administration, a higher number of oocytes retrieved and embryos transferred, and a reasonable clinical pregnancy rate (14.3%).

Does physicians' experience influence in vitro fertilization success in patients undergoing controlled ovarian hyperstimulation with GnRH antagonists?

In an attempt to examine whether physicians' experience may influence IVF outcome in patients undergoing GnRH antagonist (GnRH-a) controlled ovarian hyperstimulation (COH) protocols, we studied 273 consecutive patients, with a favorable prognosis a priori, admitted to our IVF unit, of whom 88 conceived. The highest pregnancy rate (PR) (46.5%) was observed in patients achieving, on day of hCG administration, an E(2)-to-follicle ratio <100 pg/mL. The timing of hCG administration is crucial in patients undergoing the GnRH-a COH for IVF to optimize success rate.

Use of three-dimensional ultrasound in evaluating the intrauterine position of a levonorgestrel-releasing intrauterine system.

This paper reports the first case of three-dimensional (3-D) transvaginal ultrasonography (TVS) imaging of malpositioned levonorgestrel-releasing intrauterine system (LNG-IUS). In patients carrying LNG-IUS, the application of 3-D TVS with the adjunctive volume contrast imaging in the coronal plane (VCI-C) and inversion rendering modes clearly display the correct spatial position of the LNG-IUS in relation to the uterine cavity much better than two-dimensional ultrasound.