Risk for fetal malformations and unfavorable neonatal outcomes in early-onset gestational diabetes mellitus.

BACKGROUND: Early-onset gestational diabetes mellitus (GDM) is diagnosed before the 24th gestational week. Since early GDM is associated with first trimester hyperglycemia, many clinicians treat these women as having pre-GDM. However, whether early GDM increases the risk for unfavorable pregnancy outcomes and particularly for fetal malformations to a greater extent than late-onset GDM were not studied sufficiently. We aimed to examine the effect of early-onset GDM on unfavorable pregnancy outcomes. METHODS: A retrospective cohort study of women with GDM delivering singletons during 2005-2018 was conducted. Women were divided into GDM diagnosed at the first (Trimester1; up to 13.6 weeks; N = 117), the second (Trimester2; up to 23.6 weeks; N = 126), and the third trimester (Trimester3; N = 2334). The primary outcomes were neonatal malformations and a composite of large-for-age newborns, hypoglycemia and hyperbilirubinemia treated with phototherapy. Comparisons were made between early- (Trimester1 + Trimester2-groups) and late-onset GDM (Trimester3-group), and between the three trimesters. RESULTS: Fetal malformations were low and comparable between the trimester1, trimester2, trimester3 groups (2 (1.7%), 3 (2.4%), and 110 (4.7%), respectively). The composite neonatal complications was similar between the groups (68 (58%), 58 (46%), and 1087 (47%), respectively). In early-onset, the rates of neonatal hypoglycemia and shoulder dystocia were higher than in the late-onset GDM group (OR 95% CI 3.5 [2.0-6.1] and 10.3 [2.4-44.6], respectively). Macrosomia was higher in trimester1 compared with trimester2 and trimester3 cohorts (OR 95% CI 5.3 [1.7-16.9] and 2.8 [1.5-5.2], respectively). CONCLUSIONS: The risk for fetal malformations was low and comparable between the first, second and third trimester GDM. Since the risks for macrosomia, shoulder dystocia, and neonatal hypoglycemia are higher in early-onset GDM, these women should undergo strict glycemic control, intensive monitoring, and careful neonatal evaluation.

The safety of quinolones and fluoroquinolones in pregnancy: a meta-analysis.

BACKGROUND: Quinolones were contraindicated during pregnancy because of concerns regarding fetal malformations and carcinogenesis in animals. The literature is conflicting regarding their safety in humans. OBJECTIVES: To conduct a meta-analysis evaluating the risk for fetal malformations and pregnancy complications following exposure to quinolones during pregnancy. SEARCH STRATEGY: We searched Embase, PubMed, Medline, the Cochrane database, clinicaltrials.gov, and Dart Databases. We added articles found through the references of included articles. SELECTION CRITERIA: Relevant English citations using the terms quinolone/s, fluoroquinolone/s, and pregnancy in humans. Exclusion criteria were case reports, reviews, and articles without data regarding the study outcomes. DATA COLLECTION AND ANALYSIS: Two authors performed the database search, assessment of eligibility, and abstraction of data from included studies. Disagreement was settled by consensus among all authors. The pooled odds ratios (with 95% CIs) were estimated. The Cochrane's Q-test of heterogeneity and I² were used for the measurement of heterogeneity. A total of 256 papers were retrieved, 13 of which met the inclusion criteria and were then analysed. MAIN RESULTS: No association was found between quinolones and fetal malformations (pooled odds ratio, OR 1.08; 95% CI 0.96-1.21), preterm delivery (pooled OR 0.97; 95% CI 0.75-1.24), stillbirth (pooled OR 1.11; 95% CI 0.34-3.6), or miscarriage (pooled OR 1.78; 95% CI 0.93-3.38). CONCLUSIONS: Quinolones are not associated with unfavourable pregnancy outcomes; however, larger studies are needed before safety is established. Until then, it is suggested that quinolones should not be used as a first-line therapy during the first trimester. TWEETABLE ABSTRACT: Quinolones were associated with favourable pregnancy outcomes; caution should be taken in the first trimester.

Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain: a randomised controlled trial.

OBJECTIVES: To compare the efficacy, safety and satisfaction from two modes of oral analgesia administration for the treatment of post-caesarean pain in the first 48 h following surgery: on-demand versus fixed time interval administration. DESIGN: Open label parallel-group, randomised-controlled trial from February to December 2013. SETTING: University-affiliated hospital in Israel. POPULATION: Two-hundred women who underwent caesarean delivery with regional anaesthesia. METHODS: Patients were randomly assigned to receive predetermined combinations of tramadol, paracetamol and diclofenac either following patient demand or at predetermined 6-h intervals for the first 48 h. If the patient requested additional analgesia, Percocet (oxycodone and paracetamol) was given as a rescue treatment. MAIN OUTCOME MEASURES: Pain intensity and satisfaction were self-evaluated with visual analogue scale of 0 (no pain/least satisfaction) to 10 (worst pain/highest satisfaction). Breastfeeding, need for supplemental formula, and maternal and neonatal adverse effects were also evaluated. RESULTS: The 'fixed time interval' group, compared with the 'on-demand' group, had lower mean pain score (2.8 ± 0.84 versus 4.1 ± 0.48, respectively; P < 0.0001), higher satisfaction rate (9.1 ± 1.2 versus 8.3 ± 1.5, respectively; P < 0.0001), more breastfeeds (23.7 ± 6.5 versus 19.2 ± 6.2, respectively; P < 0.0001) and less use of supplemental formulas (8.2 ± 5.2 versus 11.9 ± 6.5, respectively; P < 0.0001). The number of times that drugs were given was slightly higher in the 'fixed time interval' group without an increase in maternal adverse effects, which were mild. No adverse effects were reported for the neonates. CONCLUSION: Administration of oral analgesia in fixed time intervals is superior to drug administration following patient demand without increasing maternal or neonatal adverse outcomes. TWEETABLE ABSTRACT: Oral analgesia in fixed time intervals is superior to analgesia following demand.

Cervical ripening with the balloon catheter and the risk of subsequent preterm birth.

OBJECTIVE: To examine the risk of subsequent preterm birth after cervical ripening using a balloon catheter. STUDY DESIGN: A retrospective study was held at a university teaching hospital between January 2007 and June 2013. The study group included women who underwent cervical ripening using a balloon (single or double) catheter in the previous pregnancy followed by a subsequent singleton delivery (balloon catheter group). Two control groups were included. The first was similar to the study group except that ripening was achieved in the previous pregnancy with vaginal prostaglandin E2 (PGE2 group). The second control group had a previous pregnancy that resulted in spontaneous onset of labor at term (unexposed group). The primary outcome was the incidence of spontaneous preterm birth (before 37 weeks) in the index pregnancy. RESULT: Overall, 558 women were included; each group consisted of 186 women. The incidence of spontaneous preterm birth in the index pregnancy did not differ between the groups (0.5, 1.6 and 2.7% in the balloon catheter, PGE2 and in the unexposed groups, respectively, P=0.31). Among the balloon catheter group, 58 (31.2%) women had the ripening performed with a single-balloon catheter and 128 (68.8%) women with a double-balloon catheter. The rate of the spontaneous preterm birth in the index pregnancy did not differ between the two groups (P=1.0). CONCLUSION: Cervical ripening with a balloon catheter does not increase the rate of subsequent spontaneous preterm birth.

Are there modifiable risk factors that may predict the occurrence of brachial plexus injury?

OBJECTIVE: To identify risk factors, particularly modifiable, associated with brachial plexus injury. STUDY DESIGN: A retrospective case-control study conducted at a single hospital between the years 1993 and 2012. All neonates who were diagnosed of brachial plexus injury were included. A control group matched at a ratio of 1:2 was randomly selected. Demographic and obstetric data were obtained from the hospital discharge register with ICD-9 codes and crosschecked with the labor medical records. All medical files were manually checked and validated. A stepwise logistic regression model was performed to identify independent predictors for brachial plexus injury before delivery among those found significant in the univariate analysis. RESULTS: Of all 83 806 deliveries that took place during this period, 144 cases of brachial plexus injury were identified (1.7/1000 deliveries). Overall, 142 cases and 286 controls had available data. Among the study group, 41 (28.9%) had documented shoulder dystocia compared with 1 (0.4%) among the controls (P<0.0001). Logistic regression analysis revealed that maternal age above 35 years (P=0.01; odds ratio (OR) 2.7; 95% confidence interval (CI) 1.3 to 5.7), estimated fetal weight before delivery (P<0.0001; OR 2.5; 95% CI 1.7 to 3.8, for each 500 g increase), vaginal birth after cesarean (P=0.02; OR 3.3; 95% CI 1.2 to 8.8) and vacuum extraction (P=0.02; OR 3.6; 95% CI 1.2 to 10.3) were all found to be independent predictors for developing brachial plexus injury. When stratifying the analysis according to parity, vacuum delivery was found to be an independent risk factor only among primiparous women (OR 6.0; 95% CI 1.7 to 21.6). CONCLUSIONS: The findings suggest that very few factors contributing to brachial plexus injury are modifiable. For that reason, it remains an unpredictable and probably an unavoidable event.

Pregnancy outcomes in women with moderate-to-severe psoriasis.

BACKGROUND: The association between psoriasis and pregnancy outcomes has not been adequately examined, although psoriasis onset is common in the reproductive period. OBJECTIVE: To evaluate the association between moderate-to-severe psoriasis and pregnancy complications. METHODS: A retrospective, matched cohort study of 68 deliveries in 35 women with moderate-to-severe psoriasis compared to 237 deliveries in 236 women without psoriasis randomly selected after matching for age, parity and gestational age. RESULTS: The psoriasis patients had higher mean of past spontaneous (0.42±0.58 vs. 0.26±0.63, P=0.002) and induced (0.32±0.60 vs. 0.06±0.25, P=0.001) abortions than controls. They had a higher percentage of pregnancy-induced hypertensive diseases (7.4% vs. 2.1%, P<0.05) and premature rupture of membranes (16% vs. 5.5%, P<0.008). Newborns to women with psoriasis had higher birth weight (3375±543 g vs. 3247±460 g, P=0.03), increased percentage of large-for-gestational age (24% vs. 12%, P=0.02), and macrosomia (13% vs. 4.2%P=0.02). In multivariate analysis, moderate-to-severe psoriasis was an independent risk factor for previous spontaneous abortions, induced abortions, premature rupture of membranes (PROM), and newborn macrosomia. CONCLUSION: Moderate-to-severe psoriasis is associated with spontaneous and induced abortions, pregnancy-induced hypertensive diseases, premature rupture of membranes, large-for-gestational age newborns, and macrosomia.

Lack of association between unexplained elevated maternal serum alpha fetoprotein and/or human chorionic gonadotropin and the occurrence of placental thrombotic lesions.

OBJECTIVE: To investigate the significance of unexplained elevated maternal serum alpha fetoprotein (MSAFP) and/or human chorionic gonadotropin (HCG) on the occurrence of placental thrombotic changes. STUDY DESIGN: Between January 2007 to April 2009, placentas of all women who delivered and had unexplained elevated MSAFP and/or HCG (above 2 MOM) were sent to histological examination. Women were divided into 2 groups. Group A included women who had uneventful pregnancies and delivered at term. Group B included women with antepartum complications attributed to thrombosis. Women in both groups (A and B) had elevated MSAFP and/or HCG. Group C was a frequency matched group of women who had normal MSAFP and HCG levels with uneventful pregnancies and delivered at term. MAIN OUTCOME MEASURE: Incidence of placental thrombotic lesions in each group. RESULTS: Of 9695 women who delivered during the study period there were 76 women with elevated MSAFP and or HCG, 48 in group A and 28 in Group B. Group C, included 30 women. The number of placentas in which any thrombotic lesion was identified was 22 (45.8%), 19 (67.9%) and 10 (33%) respectively. Changes differed significantly only between group B and C (p = 0.03). Although the rate of changes in group A was higher than in group C it did not reach statistical significance even when considering only women with two abnormal results (MSAFP and HCG) or when a cutoff of 2.5 MOM or more was set. CONCLUSION: Placental histopathological changes are associated with pregnancy complications and can only marginally be attributed to unexplained elevated MSAFP and/or HCG.

The effects of dimenhydrinate, cinnarizine and transdermal scopolamine on performance.

We assessed the influence of dimenhydrinate, cinnarizine and transdermal scopolamine on the ability to perform simulated naval crew tasks. The effect of single doses of dimenhydrinate, 100 mg, cinnarizine, 50 mg, and one transdermal scopolamine patch on psychomotor performance was evaluated using a double-blind, placebo-controlled, randomized, crossover design in three separate studies. A total of 60 young naval crew (20 for dimenhydrinate, 15 for cinnarizine and 25 for transdermal scopolamine) underwent a battery of computerized and paper and pencil performance tests, and filled out a questionnaire on side-effects and well-being self-assessment. Dimenhydrinate significantly impaired decision reaction time and auditory digit span. Most of the subjects who took dimenhydrinate also reported a subjective decrease in well-being and general performance abilities. Cinnarizine and transdermal scopolamine did not affect performance abilities. Cinnarizine was free of significant side-effects. Dry mouth was the only significant side-effect of transdermal scopolamine. These findings could be explained by the well-known sedative properties of dimenhydrinate and not by a specific effect on any particular cognitive or motor function. Our results suggest that dimenhydrinate, 100 mg, adversely affects psychomotor function, whereas single doses of cinnarizine, 50 mg, and transdermal scopolamine appear to be free of side-effects on performance and seem to be a preferable anti-seasickness drug for use by a naval crew.

Inner ear decompression sickness in sport compressed-air diving.

OBJECTIVE: We report our experience over the past 12 years with recreational diving-related inner ear decompression sickness (IEDCS). STUDY DESIGN: Retrospective, consecutive case series. METHODS: Twenty-four divers, representing 29 cases of IEDCS, are presented with regard to evaluation, treatment, and follow-up. RESULTS: These 29 cases represent 26% of the severe decompression sickness (DCS) cases treated in that period. The patient group includes 22 divers who had a single event of IEDCS, one diver who had two events, and one with five repeated episodes. The cause of injury in 23 cases (79%) was violation of the decompression schedule. The mean time from surfacing to appearance of symptoms was 47 +/- 65 minutes. In 83%, symptoms appeared within 1 hour of ascent, in 97% within 2 hours, and in only one diver after 5.5 hours. Ten divers (34%) had pure vestibular involvement, 4 (14%) had cochlear insult alone, and 15 (52%) had combined vestibulo-cochlear injury. Except for one patient who had central as well as peripheral vestibulo-cochlear DCS, all the remaining patients had end organ involvement only, as demonstrated by physical examination and laboratory test results. Fifteen (52%) had isolated IEDCS, whereas 14 had additional symptoms of DCS. Twenty-six cases were treated by hyperbaric oxygenation with supplementary daily hyperbaric sessions. Of the 25 cases with vestibular injury and the 19 with cochlear damage, only 7 (28%) and 6 (32%), respectively, made a full recovery, whereas the others remained with residual damage. Of the 17 treated within 6 hours of symptom appearance, 9 (53%) were cured, compared with one of the 9 treated later (P <.05). CONCLUSIONS: IEDCS related to compressed-air recreational diving is more common than previously thought, and might occur even when no decompression schedule violation took place. Prompt diagnosis leading to the early commencement of hyperbaric oxygen recompression therapy is the key to complete recovery of cochlear and vestibular function.

Vestibular findings in professional divers.

The purpose of the present study was to investigate possible inner ear changes related to professional diving, by the documentation of auditory and vestibular function in 13 asymptomatic professional divers and 12 nondiver controls. A higher average pure tone hearing threshold, although of no clinical significance, was found in the study group (8.53 +/- 4.85 versus 6.67 +/- 3.54 dB hearing level, p = .04). In the vestibular evaluation, the smooth harmonic acceleration test phase leads for 0.01, 0.02, and 0.04 Hz were significantly lower in the divers (0.01 Hz, 38.46 degrees +/- 7.15 degrees versus 45.83 degrees +/- 9.02 degrees, p = .02; 0.02 Hz, 21.08 degrees +/- 5.19 +/- versus 25.17 degrees +/- 5.78 degrees, p = .05: 0.04 Hz, 12.38 degrees +/- 3.69 degrees versus 14.25 degrees +/- 3.14 degrees, p = .05). We suggest that the lower smooth harmonic acceleration phase values found in the professional divers, reflecting longer vestibulo-ocular reflex primary time constants and enhancement of the velocity storage mechanism, are the result of a habituation process that augments the low-frequency response of the canal-ocular system.

Diabetes in pregnancy: efficacy and cost of hospitalization as compared with ambulatory management--a prospective controlled study.

BACKGROUND: Pregnant diabetic women are often subjected to frequent and prolonged hospitalizations to assure tight glycemic control, but in recent years attempts have been made at ambulatory control. The financial and social advantages of ambulatory management are obvious, but no report to date has prospectively compared its efficacy with that of hospitalization. OBJECTIVES: To evaluate the efficacy and cost of ambulatory care as compared to repeated hospitalizations for management of diabetes in pregnancy. METHODS: We conducted an 8 year prospective controlled study that included 681 diabetic women, experiencing 801 singleton pregnancies, with commencement of therapy prior to 34 gestational weeks. During 1986-1989, 394 pregnancies (60 pregestational diabetes mellitus and 334 gestational diabetes mellitus) were managed by hospitalization, and for the period 1990-1993, 407 pregnancies (61 PGDM and 346 GDM) were managed ambulatorily. Glycemic control, maternal complications, perinatal mortality, neonatal morbidity and hospital cost were analyzed. RESULTS: There was no difference in metabolic control and pregnancy outcome in women with PGDM between the hospitalized and the ambulatory groups. Patients with GDM who were managed ambulatorily had significantly lower mean capillary glucose levels, later delivery and higher gestational age at induction of labor as compared to their hospitalized counterparts. In this group there were also lower rates of neonatal hyperbilirubinemia, phototherapy and intensive care unit admissions and stay. The saved hospital cost (in Israeli prices) in the ambulatory group was $6,000 and $15,000 per GDM and PGDM pregnancy, respectively. CONCLUSIONS: Ambulatory care is as effective as hospitalization among PGDM patients and more effective among GDM patients with regard to glycemic control and neonatal morbidity. This is not only more convenient for the pregnant diabetic patient, but significantly reduces treatment costs.

Scopolamine bioavailability in combined oral and transdermal delivery.

Transdermal therapeutic system scopolamine (TTS-S) is effective in preventing motion sickness for 72 h. However, by this route a prophylactic effect is obtained 6 to 8 h postapplication. By the oral route, scopolamine is effective within 0.5 h for a period of 6 h. To achieve safe as well as effective protection against seasickness during the first hours of a voyage until the TTS-S patch takes effect, the pharmacokinetics of scopolamine was investigated after patch application in combination with oral tablets, 0.6 mg, 0. 3 mg, or placebo. Subjects were 25 naval-crew volunteers, randomly divided into three groups: group 1 (n = 9), TTS-S patch + 0.6 mg of scopolamine per os (p.o.); group 2 (n = 8), TTS-S patch + 0.3 mg of scopolamine p.o.; and group 3 (n = 8), TTS-S patch + placebo tablet. Blood samples were collected before treatment and 0.5, 1, 1.5, 2.5, 3.5, 6, 8, and 22 h post-treatment, and were analyzed for scopolamine levels using radioreceptor assay. Significantly higher plasma scopolamine levels were found in group 1 at 0.5, 1, 1.5, and 2.5 h, and in group 2 at 1 and 1.5 h post-treatment, compared with group 3. Thereafter, plasma levels did not differ significantly between the groups. In all subjects of group 1 and seven subjects (88%) of group 2, therapeutic levels (>50 pg/ml) were measured during the first 2.5 h, compared with only two subjects (25%) of group 3 (P < 0.05). Heart rate, blood pressure, visual accommodation, performance test results, and subjective complaints of adverse effects did not differ significantly. The combination of transdermal and oral scopolamine (0.3 or 0.6 mg) provides the required plasma levels to prevent seasickness, starting as early as 0.5 h post-treatment, with no significant adverse effects.

Computerized dynamic posturography and seasickness susceptibility.

OBJECTIVE/HYPOTHESIS: The neural mismatch theory emphasizes the role of conflicting multimodal sensory interactions in producing both motion sickness and the rearrangement process that finally leads to habituation to the adverse motion conditions. If this theory is, indeed, correct, the patterns of the response to the integrated signal from simultaneous multisensory stimulation, characterized by unusual relationships between the senses responsible for spatial orientation, should differ according to motion sickness susceptibility. Computerized dynamic posturography (CDP) provides the opportunity to simultaneously change the interactions between visual, somatosensory, and vestibular inputs, thus giving an indication of the relative importance of these senses in maintaining balance. The objective was to investigate balance strategies in naval crew members with differing susceptibility to sea conditions using CDP. STUDY DESIGN: Cross-sectional, parallel-group design. METHODS: Twenty subjects susceptible to seasickness (SS) and 20 nonsusceptible subjects (NSS), healthy male volunteers aged 18 to 25, were tested using the EquiTest system (NeuroCom, Inc., Clackamas, OR). RESULTS: The SS group exhibited significantly less stability than the NSS group in condition 5 of the sensory organization test (SOT). The ratio of the SOT scores of conditions 5 to 1 (the vestibular organization pattern) was also found to be significantly lower in the SS group. CONCLUSIONS: The results suggest that SS might be more dependent on somatosensory and visual inputs and less on vestibular inputs for maintenance of balance compared with NSS. Higher susceptibility to seasickness might reflect abnormal weighting of sensory modalities during the integration process. This would result in disruption of the integration process required to maintain balance and a sense of orientation in space in conditions producing conflicting sensory inputs.

Inner ear decompression sickness following altitude chamber operation.

Decompression sickness (DCS) is a known hazard of altitude chamber operation. The musculoskeletal, dermal, neurological and pulmonary manifestations of DCS are well recognized, but inner ear injury has not been reported. We present the unusual case of a medical corpsman suffering from vestibular DCS after an altitude chamber exposure to 25,000 ft. The patient had a good clinical response to hyperbaric treatment, but there was laboratory evidence of mild residual vestibular damage with full compensation. This case suggests that aviation medical personnel should be more aware of the possible occurrence of inner ear DCS among subjects exposed to altitude.

Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial.

OBJECTIVE: To compare perinatal outcome and glycaemic control in two groups of pregnant diabetic patients receiving two insulin regimens. DESIGN: Randomised controlled open label study. SETTING: University affiliated hospital, Israel. PARTICIPANTS: 138 patients with gestational diabetes mellitus and 58 patients with pregestational diabetes mellitus received insulin four times daily, and 136 patients with gestational diabetes and 60 patients with pregestational diabetes received insulin twice daily. INTERVENTION: Three doses of regular insulin before meals and an intermediate insulin dose before bedtime (four times daily regimen), and a combination of regular and intermediate insulin in the morning and evening (twice daily regimen). MAIN OUTCOME MEASURES: Maternal glycaemic control and perinatal outcome. RESULTS: Mean daily insulin concentration before birth was higher in the women receiving insulin four times daily compared with twice daily: by 22 units (95% confidence interval 12 to 32) in patients with gestational diabetes and by 28 units (15 to 41) in patients with pregestational diabetes. Glycaemic control was better with the four times daily regimen than with the twice daily regimen: in patients with gestational diabetes mean blood glucose concentrations decreased by 0.19 mmol/l (0.13 to 0.25), HbA(1c) by 0.3% (0.2% to 0.4%), and fructosamine by 41 micromol/l (37 to 45), and adequate glycaemic control (mean blood glucose concentration <5.8 mmol/l) was achieved in 17% (8% to 26%) more women; in patients with pregestational diabetes mean blood glucose concentration decreased by 0.44 mmol/l (0.28 to 0.60), HbA(1c) by 0.5% (0.2% to 0.8%), and fructosamine by 51 micromol/l (45 to 57), and adequate glycaemic control was achieved in 31% (15% to 47%) more women. Maternal severe hypoglycaemic events, caesarean section, preterm birth, macrosomia, and low Apgar scores were similar in both dose groups. In women with gestational diabetes the four times daily regimen resulted in a lower rate of overall neonatal morbidity than the twice daily regimen (relative risk 0.59, 0.38 to 0.92), and the relative risk for hyperbilirubinaemia and hypoglycaemia was lower (0.51, 0.29 to 0.91 and 0.12, 0.02 to 0.97 respectively). The relative risk of hypoglycaemia in newborn infants to mothers with pregestational diabetes was 0.17 (0.04 to 0.74). CONCLUSIONS: Giving insulin four times rather than twice daily in pregnancy improved glycaemic control and perinatal outcome without further risking the mother.

Gas embolism complicating obstetric or gynecologic procedures. Case reports and review of the literature.

Gas embolism is a rare life-threatening complication of obstetric or gynecologic procedures, arising as a result of gas bubbles being introduced into the circulation via severed blood vessels. Extensive brain damage and acute cardiovascular collapse will lead to a fatal outcome. A favourable outcome depends on early diagnosis and prompt treatment. Hyperbaric oxygenation, which reduces bubble size and increases the supply of oxygen to hypoxic tissues, is the definitive treatment for gas embolism. We report four cases of gas embolism complicating obstetric or gynecologic procedures which were treated at the Israel Naval Medical Institute followed by an updated review of the literature.