Medical treatment for early pregnancy loss following in vitro fertilization compared to spontaneous pregnancies.

BACKGROUND: Misoprostol is a well-studied medical treatment for early pregnancy loss (EPL), with success rates ranging between 70 and 90%. However, treatment failure is associated with major patient discomfort, including the need for surgical intervention to evacuate the uterus. It was previously reported that medical treatment was especially successful among women who conceived after in vitro fertilization (IVF). We aimed to study if there is a difference in rates of medical treatment failures for EPL between pregnancies conceived by IVF and spontaneous pregnancies. METHODS: In this retrospective cohort study, we included all women who underwent medical treatment for EPL at our institute between 07/2015 and 12/2020. Treatment outcome was compared between IVF and spontaneous pregnancies. Treatment failure was defined as a need for surgical intervention, namely, dilation & curettage (D&C) and/or hysteroscopy, due to retained products of conception, which was defined as a gestational sac or endometrial thickness greater than 15 mm in a TVS scan. RESULTS: Overall, 775 patients were included, of which 195 (169/775 = 25.1%) ultimately required surgical intervention. There was no difference between the study groups in the rate of treatment failure. However, among IVF pregnancies, the rate of emergency D&C was lower (3.6% vs. 9.8%, p = 0.001), compared to spontaneous group. CONCLUSION: In cases of medical treatment for EPL, IVF pregnancies had no differences in rates of treatment failure compared to spontaneous pregnancies. That being said, IVF pregnancies have lower chances to undergo emergency D&C, compared to spontaneous pregnancies.

High prevalence of low prognosis by the POSEIDON criteria in women undergoing planned oocyte cryopreservation.

OBJECTIVE: Planned oocyte cryopreservation (OC) is being increasingly utilized worldwide. However, some women cannot accumulate sufficient oocytes because of poor response to stimulation. The POSEIDON classification is a novel system to classify patients with 'expected' or 'unexpected' inappropriate ovarian response to exogenous gonadotropins. Our study aimed to examine the prevalence of POSEIDON patients among women undergoing planned OC. STUDY DESIGN: We retrospectively reviewed the first cycles of 160 consecutive patients undergoing planned OC. Patients were classified into the four POSEIDON groups or as 'non-POSEIDON' based on age, AMH level and the number of oocytes retrieved. The primary outcome measure was the prevalence of POSEIDON patients. RESULTS: Overall, 63 patients (39.4 %) were classified as POSEIDON patients, 12 in group 1, 12 in group 2, 8 in group 3, and 31 in group 4. Compared to non-POSEIDON patients, POSEIDON patients had increased basal FSH levels and reduced serum AMH levels and antral follicle counts, required higher FSH starting doses and increased gonadotropin requirements and reached lower peak serum estradiol levels. Additionally, POSEIDON patients had a lower number of oocytes retrieved (7.6 ± 3.1 vs.20.2 ± 9.9, p < 0.001) and vitrified (5.8 ± 2.9 vs.14.7 ± 6.8, p < 0.001) than non-POSEIDON counterparts, respectively. CONCLUSION: We found a high prevalence of patients being classified as low prognosis according to the POSEIDON criteria among patients seeking planned OC. POSEIDON patients had increased gonadotropin requirements and a significantly lower number of oocytes retrieved and vitrified. This novel, unexpected finding adds clinically relevant information for counselling and management of patients undergoing planned OC.

Umbilical cord blood gases sampling in low-risk vaginal deliveries as a predictor of adverse neonatal outcome.

INTRODUCTION: There is no clear correlation between abnormal umbilical cord blood gas studies (UCGS) and adverse neonatal outcome in low-risk deliveries. We investigated the need for its routine use in low-risk deliveries. METHODS: We retrospectively compared maternal, neonatal, and obstetrical characteristics among low-risk deliveries (2014-2022) between "normal" and "abnormal" pH groups: A:normal pH ≥ 7.15; abnormal pH < 7.15; B: normal pH ≥ 7.15 and base excess (BE) > - 12 mmol/L; abnormal pH < 7.15 and BE ≤ We retrospectively compared 12 mmol/L; C: normal pH ≥ 7.1; abnormal pH < 7.1; D: normal pH > 7.1 and BE > - 12 mmol/L; abnormal pH < 7.1 and BE ≤ - 12 mmol/L. RESULTS: Of 14,338 deliveries, the rates of UCGS were: A-0.3% (n = 43); B-0.07% (n = 10); C-0.11% (n = 17); D-0.03% (n = 4). The primary outcome, composite adverse neonatal outcome (CANO) occurred in 178 neonates with normal UCGS (1.2%) and in only one case with UCGS (2.6%). The sensitivity and specificity of UCGS as a predictor of CANO were high (99.7-99.9%) and low (0.56-0.59%), respectively. CONCLUSION: UCGS were an uncommon finding in low-risk deliveries and its association with CANO was not clinically relevant. Consequently, its routine use should be considered.

Failure Rate of Medical Treatment for Miscarriage Correlated with the Difference between Gestational Age According to Last Menstrual Period and Gestational Size Calculated via Ultrasound.

Objective: To study whether the interval between gestational age calculated using the last menstrual period (GA-LMP) and gestational age calculated via ultrasound (GA-US) is correlated with the success rate of medical treatment in cases of miscarriages. Methods: This was a retrospective cohort study conducted in a gynecology unit in a tertiary medical center. Women who underwent medical treatment with Misoprostol for miscarriage at the Edith Wolfson Medical Center between 07/2015 and 12/2020 were included. Incomplete or septic miscarriages, multiple pregnancies, patients with irregular periods, and cases of missing data were excluded. Failure of medical treatment was defined as the need for surgical intervention due to a retained gestational sac, severe bleeding or retained products of conception. The cohort study was divided into two groups: patients with successful treatment and patients for whom surgical intervention was eventually needed. We performed both a univariate and multivariate analysis in order to identify whether a correlation between GA-LMP and GA-US interval is indeed a factor in the success rate of a medical abortion. Results: Overall, 778 patients were included in the study. From this cohort 582 (74.9%) had undergone a successful medical treatment, while 196 (25.1%) required surgical intervention due to the failure of medical treatment, as defined above. The GA-LMP to GA-US interval (in weeks) was 2.6 ± 1.4 in the success group, while the GA in the failure group was 3.1 ± 1.6 (p < 0.001). After performing a multivariant regression analysis, we were able to show that the GA-LMP to GA-US interval was found to be independently correlated with an increase in the treatment failure rate (aOR = 1.24, CI 95% (1.01-1.51), p = 0.03). Conclusions: In cases of miscarriage, longer GA-LMP to GA-US interval has been shown to be an independently correlated factor to lower success rate of the medical treatment option.

Pregnancy and placental outcomes according to maternal BMI in women with preeclampsia: a retrospective cohort study.

PURPOSE: Obesity and preeclampsia share similar patho-mechanisms and can both affect placental pathology. We aimed to investigate pregnancy outcomes in correlation with placental pathology among pregnancies complicated by preeclampsia in three different maternal body mass index (BMI, kg/m2) groups. METHODS: In this retrospective cohort study, medical and pathological records of patients with preeclampsia and a singleton pregnancy delivered between 2008 and 2021 at a single tertiary medical center were reviewed. Study population was divided into three BMI groups: BMI < 22.6 kg/m2 (low BMI group), 22.7 ≤ BMI ≤ 28.0 kg/m2 (middle-range BMI group), and BMI > 28.0 kg/m2 (high BMI group). Data regarding maternal characteristics, neonatal outcomes, and placental histopathological lesions were compared. RESULTS: The study groups included a total of 295 patients diagnosed with preeclampsia-98, 99, and 98 in the low, middle-range, and high BMI groups respectively. Neonatal birth weight was significantly decreased in the low maternal BMI group compared to both middle and high BMI groups (p = 0.04) with a similar trend seen in placental weight (p = 0.03). Villous changes related to maternal malperfusion were more prevalent in the low and high BMI groups compared to middle-range BMI group (p < 0.01) and composite maternal vascular malperfusion lesions were also more prevalent in the groups of BMI extremities compared to the middle-range BMI group (p < 0.01). CONCLUSION: Maternal BMI might influence neonatal outcomes and placental pathology in pregnancies complicated by preeclampsia. Both extremes of BMI were associated with higher rates of placental maternal vascular malperfusion. Balanced BMI in women at risk for preeclampsia may reduce the incidence of placental lesions.

Placenta previa in in vitro fertilization and unassisted pregnancies-is there a difference in perinatal outcomes and placental histology?

INTRODUCTION: In-vitro-fertilization (IVF) is an independent risk factor for placenta previa (PP). Our aim was to study this link by comparing the clinical characteristics and placental histology of pregnancies complicated by PP in IVF versus unassisted pregnancies. METHODS: A retrospective-cohort study of deliveries with PP between 2008 and 2021. Placental histology, obstetric and neonatal outcomes were compared between IVF and unassisted pregnancies. Included, were singleton deliveries complicated by PP at gestational weeks (GA) >24. RESULTS: A total of 182 pregnancies were included - 23 IVF pregnancies (IVF group) and 159 unassisted pregnancies (Control group). The control group was characterized by higher gravidity (p = .007) and parity (p < .001) and a trend of more past cesarean deliveries, whereas the IVF group- by a higher rate of nulliparity (p < .001) and diabetes mellitus (p = .04). The control group was characterized by a higher rate of placental weight below the 10th percentile (47.8 versus 13.9%, p = .001) and by a trend of a lower overall placental weight. No differences were noted in maternal and fetal vascular lesions. DISCUSSION: While PP in non-assisted pregnancies is probably associated with previous CDs, in IVF it is more "sporadic," and may complicate any index pregnancy. A lower placental weight was more prevalent in the control group, supporting the concept that pregnancies complicated by PP following IVF can be attributed to initial abnormal location of placentation, rather than an underlying pathological uterine segment of implantation. Nevertheless, IVF and unassisted pregnancies entail similar perinatal outcomes in cases of PP.

Surgical Treatment for Rectocele by Posterior Colporrhaphy Compared to Stapled Transanal Rectal Resection.

Background: Rectocele is defined as a defect in the rectovaginal septum, causing symptoms like obstructed defecation syndrome (ODS), vaginal bulging, etc. Once the rectocele is larger than 3 cm and/or symptomatic, surgery should be considered. The surgical approach can be either transvaginal, transanal or transperineal. Two of the most common procedures in treating rectocele are posterior colporrhaphy (PC) and stapled trans anal rectal resection (STARR). The purpose of this study was to compare surgical outcomes of both procedures. Methods: This is a retrospective cohort study. Included were patients of the age of 18−85 years that underwent either STARR (n = 49 patients) or PC (n = 24 patients) procedures after a full clinical (defecography and physical exam before and after the surgery) and physiologic (a detailed questionnaire before and after the surgery) surveys. Symptoms of ODS before and after surgery were evaluated by questioners. Results: Preoperatively, the patients in the STARR group had significantly higher rates of ODS: straining (90.9% vs. 65.2%), incomplete evacuation (100% vs. 69.6%), hard stool (57.8% vs. 43.5%), sense of obstruction (76.1% vs. 56.5%), and use of digitation (64.4% vs. 47.8%), or laxatives (70% vs. 47.8%), p < 0.001. Anatomically, the mean rectocele size was smaller for the STARR group, compared to the PC group (3.8 ± 1.4 vs. 5.3 ± 2.2 cm, respectively, p < 0.001). Postoperatively, in the STARR group, higher rates of patients complained about straining (36.4% vs. 21.7%, p < 0.001) and use of digitation (64.4% vs. 26.1%, p < 0.001), whereas lower rates of patients complained about incomplete evacuation (41.2% vs. 56.5%, p = 0.05) and sense of obstruction (17.6%, vs. 34.8%, p = 0.03), compared to the PC group. Among patients who underwent the STARR procedure, a decrease in rates of all symptoms was noted (straining 54.5%, incomplete evacuation 58.8%, hard stool 29.2%, sense of obstruction 58.5%, use of digitation 0.1%, and use of laxatives 31.5%). Both procedures are effective in reducing rectocele size (STARR- 1.9 ± 1 cm, PC- 3.1 ± 1). Conclusions: Both STARR and PC are effective in treating rectocele. It seems that the STARR procedure is superior to the PC procedure in treating symptoms of ODS.

The Effect of Preemptive Local Infiltration on Postoperative Pain After Vaginal Hysterectomy: A Retrospective Study.

STUDY OBJECTIVE: To investigate the effect of preemptive infiltration on postoperative pain and the use of analgesics after vaginal hysterectomy (VH). DESIGN: A retrospective study. SETTING: An urogynecology unit in a tertiary medical center. PATIENTS: A total of 120 patients who had undergone VH. INTERVENTIONS: The study group contained 60 patients who participated in a former randomized control study, in which preemptive local infiltration of bupivacaine (n = 30) or sodium chloride 0.9% (n = 30) was performed. The control group included 60 consecutive patients who underwent a VH, for whom no local infiltration was performed. MEASUREMENTS AND MAIN RESULTS: Postoperative pain at rest was assessed using the 10 cm visual analog scale at 3, 8, and 24 hours after surgery. The levels of pain, as well as the use of analgesics, postoperatively, were compared between the groups. The mean surgery length in the infiltration group was shorter (86.4±29 vs 118.6±30, p <.001) and the rate of posterior colporrhaphy was lower (73.1% vs 91.3%, p = .010) than the control group. There were no differences in levels of pain at all points of time. However, the infiltration group required a lower morphine dose in the recovery unit (3.7 ± 2.3 mg vs 5.3 ± 2.4 mg, p <.001) and less use of analgesia (all kinds) 24 hours after surgery (54.2% vs 79.6%, p <.001) compared with the control group. On multivariant analysis, preemptive infiltration was found to be independently inversely associated with the dose of morphine used in recovery, as well as analgesics used 24 hours after surgery. CONCLUSION: Preemptive local infiltration of either bupivacaine or sodium chloride 0.9% reduced the use of morphine in the recovery unit, as well as the use of analgesics 24 hours after VH, compared with no infiltration at all.

Surgical intervention after medical treatment for early pregnancy loss according to gestational size.

OBJECTIVE: To study the rate of surgical intervention for unsuccessful medical treatment in early pregnancy loss (EPL), according to gestational size by ultrasound (GS-US). METHODS: This was a retrospective cohort study. All women who were treated with misoprostol for EPL between July 2015 and December 2020 were included. The cohort was divided according to GS-US: group 1: gestational sac without an embryonic pole; group 2: an embryonic pole with crown-rump length (CRL) compatible with <7 weeks; group 3: CRL compatible with 7+0 -7+6 weeks; group 4: CRL compatible with 8+0 -8+6 weeks; group 5: CRL compatible with ≥9 weeks. We compared the rate of any surgical intervention due to treatment failure. RESULTS: Overall, 783 patients were included: group 1, 236 (30.1%); group 2, 319 (40.7%); group 3, 115 (14.7%); group 4, 78 (10.0%); and group 5, 35 (5.0%) patients. The rate of any surgical intervention was significantly lower in groups 1-4 (54, 22.9%; 85, 26.6%; 28, 24.3%; and 22, 28.2%, respectively) compared with group 5 (17, 48.6%; P = 0.030). On multivariant analysis, GS-US greater than 9 weeks was independently associated with the need for surgical intervention (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.51; P = 0.040). CONCLUSION: When treating EPL medically, GS-US greater than 9 weeks increases the risk of undergoing additional surgical intervention compared with younger weeks.

The effect of SARS-CoV-2 mRNA vaccination on AMH concentrations in infertile women.

RESEARCH QUESTION: Does SARS-CoV-2 mRNA vaccination affect the ovarian reserve of infertile women undergoing IVF? DESIGN: This was a prospective observational study at a single university-affiliated IVF unit that included infertile women aged 18-44 years who were undergoing IVF/intracytoplasmic sperm injection between November 2020 and September 2021, had received two doses of SARS-CoV-2 mRNA vaccination and had undergone measurement of baseline anti-Müllerian hormone (AMH) concentration within the 12 months preceding their recruitment. AMH concentrations before and after vaccination were evaluated and compared. RESULTS: Overall, 31 women were included in the study. The median AMH concentrations before and after COVID-19 vaccine were comparable (1.7 versus 1.6 g/ml, respectively, P = 0.96). No correlation was found between the participant's anti-COVID-19 antibody titre and the change in AMH concentration. CONCLUSIONS: SARS-CoV-2 mRNA vaccination does not adversely affect ovarian reserve, as shown by comparing serum AMH concentrations before and after vaccination. These findings may serve as a counselling tool for clinicians to reassure women undergoing fertility treatment that SARS-CoV-2 mRNA vaccination is safe.

Is there an impact of fetal sex in dichorionic discordant twins on placental histopathological abnormalities?

INTRODUCTION: Growth discordancy in dichorionic diamniotic (DCDA) twin gestations is a known complication associated with adverse neonatal outcomes. We aimed to study the differences in placental pathology, in relation to fetal sex, in DCDA twin gestations complicated with growth discordancy. METHODS: The medical files of all DCDA twin deliveries complicated by growth discordancy between 2010 and 2020 were reviewed. Growth discordance was defined as a gap between twin birthweights > 20%. A comparison was made between female vs. male growth discordant twins. Placental lesions were classified as lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions. RESULTS: Included 174 DCDA twins. Eighty-eight were in the discordant female group and eighty-six in the discordant male group. The groups did not differ in maternal demographics, pregnancy characteristics, and neonatal outcome. The discordant male group had a higher rate of placental MVM lesions as compared to the discordant female group (p = 0.003). The increased rate of placental MVM lesions in the discordant male group compared to the discordant female group did not change whether its co-twin was of similar or opposite sex. DISCUSSION: Higher rate of MVM lesions characterizes growth discordant male neonates in DCDA twin gestations. This finding could represent a different adaptation of male fetuses to a hostile intrauterine environment.

The effect of preemptive local anesthesia on postoperative pain following vaginal hysterectomy: A randomized controlled trial.

OBJECTIVE: We aimed to study the effect of preemptive local anesthetic without adrenaline on postoperative pain following vaginal hysterectomy and concomitant trans obturator tape (TOT). STUDY DESIGN: This was a double-blinded, randomized, controlled trial. Women who undergone elective vaginal hysterectomy were included. Solutions of either Bupivacaine-Hydrochloride 0.5%, or Sodium-Chloride 0.9% as a placebo, were prepared prior to surgery, according to randomization. The chosen solution was injected before incision, in a circumferential manner, to the cervix. The amount of fluid administered was 10 ml. When colporrhaphy was also performed, an additional 5 ml of solution were injected in the midline of the vaginal wall prior to each incision line. We conformed to the CONSORT recommendations. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. We estimated that the intervention would cause a 25% reduction in the primary outcome. The required total sample size was calculated to be 30 patients women for each group. We used ANOVA for continuous variables and the Chi-square or Fisher exact tests for categorical variables. RESULTS: A total of 30 women were included in each group. The level of postoperative pain, as assessed by VAS, was not significantly different between the groups, in all points of time. In addition, there was no difference between the groups in opioid based analgesics during recovery, nor in postoperative analgesic use. CONCLUSION: Preemptive local anesthesia was not shown to be efficient in reducing postoperative pain after vaginal hysterectomy and TOT.

Evaluation of SARS-CoV-2 in the Vaginal Secretions of Women with COVID-19: A Prospective Study.

OBJECTIVE: We aimed to investigate the likelihood of vaginal colonization with Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in pregnant and non-pregnant women with Coronavrus Disease 2019 (COVID-19). MATERIALS AND METHODS: Vaginal swabs were taken from women diagnosed with mild to moderately acute SARS-CoV-2 infection, at Wolfson Medical Center, Israel, from March 2020 through October 2020. COVID-19 was diagnosed by real-time polymerase chain reaction (RT-PCR) performed on nasopharyngeal swabs. Vaginal swabs were tested for the presence of SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR). RESULTS: In total, 51 women diagnosed with COVID-19 were included in the study. Of the 51 women with COVID-19 enrolled in this study, 16 (31.4%) were pregnant at enrollment and 35 (68.6%) were non-pregnant. Mean age was 43.5 ± 15.3 years (range 21-74 years). Compared to the non-pregnant group, the pregnant group was characterized by a higher white blood cell and absolute neutrophil count (p = 0.02 and p = 0.027, respectively). The non-pregnant patients were more likely to have chronic diseases (p = 0.035) and to be hospitalized (p < 0.001). Only one patient (1.9%) aged 60 years tested positive for SARS-CoV-2 in vaginal secretions. Mean gestational age at the diagnosis of COVID-19 of the pregnant group was 32.3 ± 7.8 weeks. Thirteen patients delivered during the study period; all delivered at term without obstetric complications and all neonates were healthy. CONCLUSIONS: Detection of SARS-CoV-2 in the vaginal secretions of patients diagnosed with COVID-19 is rare. Vaginal colonization may occur during the viremia phase of the disease, although infectivity from vaginal colonization needs to be proven.

The effectiveness of McCall culdoplasty following vaginal hysterectomy in advanced stages of uterine prolapse.

INTRODUCTION AND HYPOTHESIS: Following vaginal hysterectomy (VH), fixation of the vaginal vault is needed to prevent post-operative recurrence/exacerbation of vault prolapse. The effectiveness of McCall culdoplasty in cases of advanced prolapse is unclear. We aimed to compare the effectiveness of McCall culdoplasty following VH in patients with mild versus advanced stages of uterine prolapse. METHODS: In this retrospective study, the Pelvic Floor Distress Inventory (PFDI-20) was utilized to compare the subjective results of vaginal hysterectomy plus McCall culdoplasty between women with mild uterine prolapse stage 2 (mild prolapse group) and advanced uterine prolapse stages 3-4 (advanced prolapse group). The primary outcome, the subjective awareness of prolapse, was analyzed as well as all other aspects of PFDI-20. A sample size of 130 was calculated. RESULTS: The mild prolapse group consisted of 26 (19.3%) patients and the advanced prolapse group consisted of 109 (80.7%) patients. There were no differences between the groups in demographic and clinical characteristics. The rates of concomitant prolapse and incontinence surgeries, performed at the time of VH and post-operative complications. were the same between groups. The mean follow-up was more than 5 years in both groups. Awareness of prolapse was similar between the groups (11.5% in the mild prolapse group and 5.5% in the advanced prolapse group, p = 0.374). There was no significant correlation between the stage of apical prolapse before surgery and awareness of prolapse after the surgery (r = 0.0132, p = 0.879). All aspects of the PFDI-20 questionnaire were similar in the two groups. CONCLUSION: McCall culdoplasty was found to have an equal subjective effectiveness following VH in both mild and advanced stages of uterine prolapse.

The effect of subcutaneous and intraperitoneal anesthesia on post laparoscopic pain: a randomized controlled trial.

A few modes of perioperative local analgesia have been studied in order to reduce postoperative pain after laparoscopy, including preemptive local anesthetics in the trocar sites and intraperitoneal anesthetics administration at the end of the surgery. However, the evidence regarding their efficacy are conflicting. In addition, the combination of both aforementioned methods has been rarely studied. Our aim was to evaluate whether subcutaneous trocar site and/or intraperitoneal analgesia reduce pain after gynecologic operative laparoscopy. This was a single-centered, randomized, controlled, double-blinded trial. The patients were randomly assigned to one of four equally sized groups: group 1-subcutaneous and intraperitoneal analgesia; group 2-subcutaneous analgesia and intraperitoneal placebo; group 3-subcutaneous placebo and intraperitoneal analgesia; Group 4-subcutaneous and intraperitoneal placebo. The patients, the surgeons, and the pain evaluators were all blinded to the patient's allocation. Included were patients who underwent elective operative laparoscopy. Exclusion criteria were: active infection, pregnancy, known sensitivity to Bupivacaine-Hydrochloride, chronic pelvic pain, surgeries with additional vaginal procedures, conversion to laparotomy, and malignancy. A total of 9 ml of Bupivacaine-Hydrochloride (Marcaine) 0.5%, or Sodium-Chloride 0.9%, as a placebo, were injected subcutaneously to the trocar sites (3 ml to each trocar site), prior to skin incision. In addition, 10 ml of Bupivacaine-Hydrochloride 0.5%, diluted with 40 ml of Sodium-Chloride 0.9% (a total of 50 ml solution), or 50 ml of Sodium-Chloride 0.9%, as a placebo, were injected intraperitoneally at the end of the surgery. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. The study was approved by the local Institutional Review Board and has been registered at clinicaltrials.gov. We conformed to the CONSORT recommendations. Between December 2016 and July 2019, a total of 119 patients were included in the study. Demographic and interventional characteristics were similar among the groups. The level of postoperative pain, either at rest or with change of position, was not significantly different between the groups, at all-time points. Application of subcutaneous and/or intraperitoneal analgesia is not effective in reducing pain after gynecologic operative laparoscopy.Clinical trial identification number: NCT02976571. Date of trial registration 11/29/2016. URL of the registration site: https://clinicaltrials.gov .

Posterior reversible encephalopathy syndrome case report in an untreated, normotensive, ovarian cancer patient in the presence of paraneoplastic antibodies.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a rare neurological condition with many associated risk factors. The presentation varies and consists of seizures, impaired visual acuity or visual field deficits, disorders of consciousness, headaches, confusion and focal neurological deficits. The diagnosis relies on clinical presentation and MRI findings. Treatment and prognosis are related to the underlying etiology. CASE PRESENTATION: We present a 58-year-old woman with ovarian cancer who developed symptoms and radiologic signs of PRES with no apparent trigger other than a sudden increase in blood pressure for the first time in her life and before any treatment has begun. Antibodies to collapsin response-mediator protein-5 (CRMP-5), a malignancy related paraneoplastic protein, were identified in her CSF. CONCLUSIONS: We present a novel and intriguing association between PRES and antibodies against CRMP-5 which may highlight a new etiology for this condition.

Pregnancy outcomes in association with placental histopathology in pregnancies complicated by macrosomia in diabetic vs. non-diabetic women.

OBJECTIVE: We aimed to compare pregnancy outcomes in association with placental pathology in pregnancies complicated by macrosomia in diabetic vs. non-diabetic women. STUDY DESIGN: Pregnancies complicated by macrosomia (≥4000gr) were included. Pregnancy and delivery characteristics, neonatal outcomes and placental histopathology reports were compared between macrosomia in diabetic [pre-gestational or Gestational Diabetes Mellitus (GDM)] women (diabetic-macrosomia group) vs. non-diabetic women (non-diabetic macrosomia group). Adverse neonatal outcome was defined as ≥1 neonatal complications. Multivariate analysis was used to identify independent associations with adverse neonatal outcome. RESULTS: The diabetic macrosomia group (n = 160) was characterized by higher maternal age (p = 0.002), Body Mass Index (BMI) (p < 0.001), and smoking (p = 0.03), and lower gestational age at delivery (p = 0.001). The diabetic-macrosomia group had higher rates of scheduled Cesarean deliveries (CDs) (58.9 % vs23.7 %,p < 0.001) while the non-diabetic macrosomia group (n = 214) had higher rates of emergent CDs (76.3 % vs.40.7 %,p < 0.001), perineal tears (p = 0.027) and Post Partum Hemorrhage (PPH) (p = 0.006). Placentas from the non-diabetic macrosomia group were characterized by higher rates of maternal and fetal inflammatory response lesions (p < 0.001). Except for higher jaundice rate in the diabetic macrosomia group (p < 0.001), none of the other neonatal outcomes including shoulder dystocia differed between the groups. In multivariate analysis GA < 37 weeks (aOR = 1.4,95 %,CI-1.2-3.9), and emergent CDs (aOR = 1.7,95 %,CI-1.4-4.1) but not diabetes (aOR = 1.1,95 %,CI-0.7-3.9) were associated with adverse neonatal outcome. CONCLUSIONS: Despite major differences in maternal demographics, mode of delivery, maternal morbidity, and placental characteristics- adverse neonatal outcome did not differ between macrosomia in diabetic vs. non-diabetic women and was high in both groups. Clinicians should be aware of the high rate of adverse neonatal outcome in macrosomic fetuses, even in the absence of diabetes mellitus.

None, One, or Both Placentas Involved with Malperfusion Lesions in Twin Pregnancies Complicated by Preeclampsia-Does It Matter?

We aimed to study the association between the number of placentas with vascular malperfusion lesions in dichorionic twin pregnancies complicated by preeclampsia and the severity of the disease and pregnancy outcomes. Dichorionic twin pregnancies with preeclampsia (n = 125), from January 2007-June 2018, were reviewed. Affected placenta was defined as the presence of maternal/fetal vascular malperfusion lesions. Maternal demographics, pregnancy characteristics, and neonatal outcomes were compared between three groups: no pathological placentas, one pathological placenta, and two pathological placentas. Composite adverse neonatal outcome was defined as ≥ 1 early neonatal complication. Regression analysis models were used to recognize independent associations with the number of involved placentas. The two pathological placenta group (n = 57 pregnancies), the one pathological placenta group (n = 40 pregnancies), and the no pathological placenta group (n = 28 pregnancies) differed in terms of gestational age (GA) at delivery (p < 0.001, p = 0.008) and the rates of severe features (p = 0.028, p = 0.047). Neonates born to the two pathological placenta group (n = 114), the one pathological placenta group (n = 80), and the no pathological placenta group (n = 56) were characterized by lower birth weights (p < 0.001, p = 0.031), higher rates of small for gestational age (SGA) (p = 0.017, p = 0.748), neonatal intensive care unit admission (p = 0.004, p = 0.013), and composite adverse neonatal outcome (p < 0.001, p = 0.025). By regression analyses, the presence of two pathological placentas was found to be independently associated with severe features (aOR = 5.1), GA at delivery < 32 weeks (aOR = 2.0), SGA (aOR = 2.5), and composite adverse neonatal outcome (aOR = 2.7). In dichorionic twin pregnancies, there is an association between the presences of placental vascular malperfusion lesions in none, one, or both placentas and the development of early and severe preeclampsia, as well as with SGA and adverse neonatal outcome.

The association between isolated oligohydramnios at term and placental pathology in correlation with pregnancy outcomes.

INTRODUCTION: Isolated term oligohydramnios (ITO) is an obstetrical complication of which the etiology, management, and clinical importance are controversial. In attempt to deepen our understanding, we aimed to study placental pathology and pregnancy outcomes in pregnancies complicated by ITO. MATERIALS AND METHODS: - Maternal demographics, neonatal outcomes, and placental histopathology reports of all pregnancies complicated by ITO at 370/7 to 410/7 weeks were reviewed. Excluded were cases complicated by hypertensive disorders, intrauterine fetal growth restriction, placental abruption, and deliveries of undiagnosed small for gestational age neonates. Results were compared between the ITO group and a control group matched for gestational age and mode of delivery. Placental lesions were classified according to the current "Amsterdam" criteria. Composite adverse neonatal outcome was defined as one or more of the following early complications: neonatal intensive care unit admission, sepsis, blood transfusion, phototherapy, respiratory morbidity, cerebral morbidity, necrotizing enterocolitis, or death. RESULTS: The study group included 108 patients with ITO that were compared to matched controls. Placentas from the ITO group were characterized by higher rates of placental weights <10th centile (p < 0.001), abnormal cord insertion (p < 0.001), and maternal vascular malperfusion (MVM) lesions (p < 0.001). Neonates from the ITO group had lower birth weights (p < 0.002), and worse composite adverse neonatal outcome (p = 0.028) compared to controls. CONCLUSION: - The current study demonstrates higher rates of placental MVM lesions, and worse neonatal outcome in pregnancies complicated by ITO. These novel findings suggest that ITO should be seen as part of the "placental insufficiency" spectrum.