Ultrasound diagnosis of fourth branchial arch sinus at 22 weeks' gestation.

Fourth branchial arch sinus is the rarest of the branchial cleft anomalies and its prenatal detection has not previously been reported in the English literature. We describe a case of fourth branchial arch sinus identified in a fetus during a routine ultrasound evaluation at 22 weeks' gestation. Survey of the fetal anatomy revealed a small 'nipple-like' structure on the neck, arising anteriorly to the sternocleidomastoid muscle, midway between the chin and the left shoulder. The structure persisted unchanged throughout the pregnancy. The prenatal diagnosis of fourth branchial arch sinus was confirmed at delivery at term.

Results of in vitro fertilization cycles in women aged 43-45 years.

Our objective was to evaluate the results of in vitro fertilization (IVF) cycles in the elderly (43-45 years old) female population. All consecutive women aged 43-45 years admitted to our IVF unit from January 1996 to December 2001 were enrolled in the study. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred and pregnancy rate were assessed. Seven hundred and eight consecutive IVF cycles in 276 patients were evaluated. Two hundred and seven cycles were cancelled (cancellation rate 29.2%). Forty-seven patients achieved a clinical pregnancy (pregnancy rate 6.6% per cycle and 9.4% embryo transfer) with a 30% live birth rate. In patients who underwent embryo transfer, there were no differences between conception and non-conception cycles in patient's age, number of gonadotropin ampules used, length of ovarian stimulation, number of oocytes retrieved, fertilization rate or cleavage rate. However, the conception cycles were associated with a significantly lower peak estradiol level (p < 0.04) and higher number of total (p < 0.03) and good-quality (p < 0.005) embryos transferred, in addition to a lower ratio of estradiol level/number of follicles > 14 mm on day of human chorionic gonadotropin administration and of estradiol level/number of oocytes retrieved. We conclude that, although older female age is a major contributor to IVF failure, successful IVF cycles can be expected in patients aged 43-45 years in the presence of low ratios of peak estradiol to either number of follicles > 14 mm on day of human chorionic gonadotropin administration or number of oocytes retrieved that reach the stage of embryo transfer with at least two good-quality embryos.

Effect of the WHI study on the attitude of Israeli gynecologists to hormonal therapy during menopause.

OBJECTIVE: To evaluate the attitude of Israeli gynecologists to the use of hormonal therapy (HT) during menopause consequent to the recent publication of the Women's Health Initiative (WHI) study. DESIGN: Gynecologists present at the annual convention of the Israeli Society of Obstetrics and Gynecology in the community were asked to complete a 5-item questionnaire on their opinions regarding hormone therapy (HT) use in light of the WHI study. RESULTS: Ninety-five percent of the physicians believed that HT is still a legitimate treatment modality during menopause, although almost 40% would now limit it to the management of climacteric symptoms. As a result of the WHI study, 65% of the physicians recommended cessation of HT use in up to 30% of their treated postmenopausal patients. The responders estimated that about 40% of their patients using HT ceased treatment on their own initiative following publication of the WHI study. CONCLUSIONS: Both physicians and patients were clearly influenced by the WHI study. Today, HT is being reserved by most gynecologists in Israel for the treatment of menopausal symptoms and is not being used as a preventive measure against future complications of heart disease and osteoporosis.

Routine hemoglobin testing following an elective Cesarean section: is it necessary?

OBJECTIVE: To determine the clinical relevance of routine hemoglobin testing following an elective Cesarean section. METHODS: The charts of all women who underwent elective Cesarean section at a public teaching hospital during 2001 were reviewed for pre- and postoperative hemoglobin values, demographic data, indication for surgery and need for blood transfusion. RESULTS: The study group included 383 patients. Mean (+/- SD) hemoglobin level was 12.24 +/- 1.09 g/dl prior to surgery and 10.87 +/- 1.2 g/dl after, a mean loss of 1.37 +/- 0.87 g/dl (p < 0.001). There was no significant difference in blood loss by indication for surgery. None of the patients needed an intraoperative or postoperative blood transfusion. CONCLUSION: Routine postoperative hemoglobin measurement after an uncomplicated elective Cesarean section in asymptomatic low-risk women is not necessary and should be eliminated.

Self-health attitudes and practices of obstetrics and gynecology nurses in Israel.

OBJECTIVE: To assess the attitude of obstetrics and gynecology nurses towards their own health and their health-related behaviors. METHODS: Two hundred and ninety community obstetrics and gynecology nurses in Israel were asked to complete a questionnaire on attitude to self-health, way of life, smoking habits, and regular breast, blood and PAP smear examinations. RESULTS: The average body mass index of the responders was 25.2 kg/m2. However, more than half the nurses (163/287, 56.8%) considered themselves as being above-average in weight, and only 41.1% as being appropriate in weight; 55% were on weight-loss diets. Smoking was reported by 44.8%. Blood tests, PAP smears and breast evaluations were regularly done by 72.5%, 83.0% and 55.7%, respectively. CONCLUSION: Obstetrics and Gynecology nurses in Israel are aware of the importance of their own health and have good health habits, except for cigarette smoking, which remains a problem among this group.

Subsidised oocyte donation in Israel (1998-2000): results, costs and lessons.

BACKGROUND: Israeli law stipulates that all women aged 45-51 who need oocyte donation are entitled to as many donations as necessary, up to the birth of one child. Only oocytes donated by women who themselves are undergoing assisted reproduction are allowed. The government subsidizes all oocyte donation cycles through the medical insurer of the recipient, whether or not the procedure is performed in a public or private institution. The aim of the present study was to investigate the success of oocyte donation cycles in Israel for the period 1998-2000 and to estimate costs and pregnancy rates. METHODS: Data were derived from the Dan District Registry of the General Health Services (Sheirutei Bri'ut Clalit), the largest medical insurer in Israel. RESULTS: 171 women underwent 254 oocyte donation cycles within these 3 years, and 45 babies were born, for a positive outcome of 17.7%. Average annual cycle cost was US$1742 and average annual cost per patient, US$2521. The total annual cost for the district accounted for only 0.05% of the budget. CONCLUSIONS: These findings suggest that IVF with donated oocytes is relatively efficient and that government funding of oocyte donation cycles ensures a reasonable cost.

A survey of physicians' attitude and approach to hormone replacement therapy during menopuase.

OBJECTIVE: A major problem with postmenopausal hormone replacement therapy (HRT) is its relatively low long-term continuation rate. The aim of the present study was to assess the contribution of physicians to the low long-term continuation rate by surveying their attitude and approach to the use of HRT in postmenopausal women. PATIENTS AND METHODS: A questionnaire was sent to registered members of the North American Menopause Society. Data were collected on demographics, medical education and affiliation, attitude to the use of HRT and its contraindications, and follow-up, strategies. RESULTS: The response rate was 21% (n = 218). Sixty-six percent of the physicians recommended HRT for every postmenopausal woman with no contraindications. and 11% also took age and/or time since menopause into consideration. Eighty-six percent claimed they would try to persuade symptom-free women not interested in HRT into changing their minds. There was no correlation between the time since completion of residency or affiliation with a medical school and physicians' attitude to prescribing HRT or contraindication to HRT, or management strategy. However, type of specialty was significantly correlated with physicians' tendency to recommend HRT. Specialists in menopause showed a lower tendency to unconditionally recommend HRT (in the absence of contraindications) (67%) than specialists in reproductive endocrinology (90%), infertility (90%). gynecology (83%), and perinatology (84%) (p < 0.006, C-measure = 0.25). CONCLUSIONS: The attitude toward HRT and the management strategies of members of the North American Menopause Society correlate with contemporary recommendations in the literature, indicating good training of young physicians and adequate updating of older ones. Thus, to increase the continuation rate of HRT, educational efforts should be directed primarily to the public rather than to medical professionals.

Munchausen syndrome in obstetrics and gynecology.

Munchausen syndrome (MS) is a well-defined clinical psychiatric entity. Furthermore, it is a complicated and intriguing problem in medicine in general and in obstetrics and gynecology in particular. The proportion of MS cases in obstetrics and gynecology is rising. This review covers relevant reports from the last four decades. Emphasis is put on the clinical expression of MS cases in obstetrics and gynecology. A discussion about their validity as such is included. Awareness of attending physicians to this type of illness in the era of patient rights, on the one hand, and the existence of defensive medicine on the other, is crucial.

Real-time intraoperative ultrasound guidance: the transrectal approach.

OBJECTIVE: To assess the role of real-time transrectal ultrasound guidance in complicated gynecologic procedures. DESIGN: In 1998-99, real-time guidance with transrectal ultrasound was utilized in our department to assist the gynecologic surgeon in two procedures: completing the evacuation of the uterine cavity after identification of uterine wall perforation during first trimester termination of pregnancy, and drainage of infected vaginal vault hematoma following hysterectomy. RESULTS: The technique was applied for 11 patients, six abortions and five infected hematomas. All the procedures were completed without any further complications and the patients were discharged on the following day. Follow-up was uneventful. CONCLUSIONS: On-line intraoperative transrectal ultrasound can effectively provide real-time assistance to the gynecologic surgeon during complicated pelvic procedures.

10% hydroxyethyl starch for plasma expansion in the treatment of severe ovarian hyperstimulation syndrome. A case report.

BACKGROUND: Severe ovarian hyperstimulation syndrome is a complication of hormonal therapy for in vitro fertilization and carries the risk of renal failure. The injection of 6% hydroxyethyl starch has been used as a preventive measure. CASE: A 33-year-old woman was admitted with severe ovarian hyperstimulation syndrome after receiving gonadotropins as part of our in vitro fertilization protocol. Despite treatment with saline, albumin and abdominal taps, oliguria developed on the third day. The patient was transferred to the general intensive care unit and treated with 10% hydroxyethyl starch, furosemide and a further abdominal tap. Recovery was rapid. CONCLUSION: Ten percent hydroxyethyl starch is an efficient plasma expander. It is safe, biohazard free and cost-effective. It seems to effectively control severe ovarian hyperstimulation syndrome and to overcome acute prerenal failure. Larger prospective studies are necessary to further evaluate its role in the treatment of severe ovarian hyperstimulation syndrome.

[Spontaneous bilateral ectopic pregnancy--an rare and dangerous occurrence].

Bilateral, spontaneous ectopic pregnancy is rare (1 in 125-1580 ectopic pregnancies). We describe a 30-year-old, unmarried woman with no predisposing factors for ectopic pregnancy who presented in hypovolemic shock, in the 7th week of gestation, complaining of abdominal pain. On immediate laparoscopy there were found blood and clots in the abdominal cavity, a left ampullar pregnancy (5 cm in diameter), and there was active bleeding from the fimbria of the right tube. Bilateral salpingectomy was performed and she received 3 units of packed red cells. She was discharged in good condition 3 days later. The pathologic diagnosis was pregnancy in each tube. This case emphasizes the need for thorough sonographic and laparoscopic observation in order not to miss the presence of bilateral ectopic pregnancy.

Conservative management of ovarian cystic teratoma during pregnancy and labor.

OBJECTIVE: Our goal was to evaluate the adequacy of conservative management during pregnancy and labor in women with an ultrasonographically diagnosed ovarian cystic teratoma. STUDY DESIGN: Forty-nine women with ultrasonographically diagnosed ovarian cystic teratoma <6 cm were followed for detection of possible complications through pregnancy and labor. Serial ultrasonographic examinations before pregnancy, during pregnancy, and after delivery were performed to detect changes in the size of the cystic teratoma. RESULTS: In a group of 49 women with dermoid cysts (mean age, 30 years), 68 pregnancies resulted. Of the 68 pregnancies, 4 ended in miscarriages, 1 was electively terminated, and in the remaining 63 pregnancies, a total of 64 healthy infants were delivered. Five patients needed treatment with assisted reproductive techniques. Fifty-five pregnancies ended in normal vaginal deliveries and 8 were delivered by cesarean (cesarean delivery rate of 16%). None of the classical complications attributed to dermoid cysts such as torsion, dystocia, or rupture occurred in the study group. In a follow-up of 56 dermoid cysts throughout pregnancy, cyst size remained unchanged. CONCLUSIONS: Ovarian dermoid cysts <6 cm are not expected to grow during pregnancy or to cause complications in pregnancy and labor.

Severe unilateral hydrothorax as the only manifestation of the ovarian hyperstimulation syndrome.

BACKGROUND: Unilateral hydrothorax is rarely the sole manifestation of the ovarian hyperstimulation syndrome (OHSS) and is suggestive of the severity of the disease. CASE: A 35-year-old woman presented with mild dyspnea 2 weeks after ovarian stimulation with hMG and hCG and IVF-ET. Chest X-ray revealed a large pleural effusion on the right side. Three consecutive thoracocenteses were needed to drain a total of 6,800 cm(3) of fluid. Following drainage, the respiratory symptoms disappeared. An uneventful pregnancy is in progress. CONCLUSIONS: Thoracocentesis is safe and efficient for the treatment of hydrothorax and may be repeated as often as necessary. Clinicians should be aware of the possibility of unilateral hydrothorax as the sole symptom of OHSS.

Concurrent genital and rectal prolapse: two pathologies--one joint operation.

This study is a prospective assessment of a joint operation to repair concomitant genital and rectal prolapse, including 10 women treated for concomitant genital and rectal prolapse from 1991 to 1995. Joel-Cohen vaginal hysterectomy was used to correct the genital prolapse, followed by the Altemeier procedure (transperineal rectosigmoidectomy) to correct the rectal prolapse. The post-operative course was uneventful in all cases and there were no recurrences of prolapse in the three year follow up period. Improvement of sphincteric tone was shown in all cases by transrectal manometry, and bladder and rectal continence was maintained. The combined surgical procedure for concurrent genital and rectal prolapse is easy to perform and safe and efficient in terms of recurrence and continence. It is hoped this report will increase multidisciplinary awareness of an effective solution for a potentially debilitating problem.

Hyperemesis gravidarum during Ramadan.

During Ramadan, adult Muslims fast from dawn to dusk. We frequently encounter young pregnant Muslim women with hyperemesis gravidarum who fast during this holy month. We have investigated whether there is an association between the prolonged fasting during Ramadan and excessive vomiting during pregnancy. Possible psychologic and physiologic explanations are presented and discussed.