Influence of ovarian torsion on reproductive outcomes and mode of delivery.

Purpose: To investigate differences in reproductive outcomes among patients before and following ovarian torsion. Study design: In this retrospective cohort study, we investigated the reproductive outcomes of patients who underwent surgery for ovarian torsion between 1988 and 2015 in a tertiary medical center. Data on deliveries before and after ovarian torsion were compared. Results: During the study period, 199 women underwent surgery due to ovarian torsion. The majority (91.4%; n = 182) underwent detorsion, and 8.6% (n = 17) underwent unilateral adnexectomy. At the time of the torsion, 27.6% (n = 55) of patients were pregnant. Among women who suffered from ovarian torsion, about half (52%) of the deliveries occurred before the torsion and 48% following the torsion. No significant difference in the live birth rate was noted (p = 0.19). The fertility treatment rate in our cohort was 7.5% before and 5% after the torsion (p = 0.01). In addition, live birth, cesarean delivery, and fertility treatment rates were similar in women who underwent detorsion vs. those who had adnexectomy. Conclusion: Surgically treated ovarian torsion does not appear to negatively influence fertility and live birth potential.

The impact of cerclage placement on gestational length in women with premature cervical shortening.

OBJECTIVES: Cervical insufficiency (CI) is a condition consistent with painless cervical dilatation that can lead to preterm delivery. Cervical cerclage is a procedure in which cervical suture is performed for preventing preterm labor in several indications. Late emergency cerclage is technically more challenging compared to elective cerclage, performed earlier during pregnancy, prior to cervical changes. Pregnancy outcomes with emergency cerclage were found to be improved in previous reports, but there is still inconclusive data. To assess the effectiveness and safety of emergency cerclage vs. conservative management with progesterone and/or bed resting, in preventing preterm birth and improving neonatal outcomes in women with clinically evident cervical insufficiency. METHODS: This is a retrospective cohort study conducted on all women diagnosed with cervical insufficiency between the 16th and 24th gestational week who met the inclusion criteria, from January 2012 to December 2018. Obstetric and neonatal outcomes: time from diagnosis to delivery, duration of pregnancy, birth weight and Apgar score, were compared between women who underwent cerclage and those who treated conservatively. RESULTS: Twenty eight women underwent emergency cerclage (cerclage group) and 194 managed with a conservative therapy, progesterone and/or bed rest (control group). Time from diagnosis to delivery 13 weeks vs. 8 weeks and birth weight 2,418 g vs. 1914 g were significantly higher in the first cohort. Average pregnancy duration was three weeks longer in the cerclage group, but that was not significant. No complications occurred in the cerclage group and no difference in mode of delivery were found. CONCLUSIONS: Emergency cerclage is an effective and safe procedure in preventing preterm birth and prolongation of pregnancy, in women with cervical insufficiency in the late second trimester.

Obstetric Outcomes after Perforation of Uterine Cavity.

We aimed to evaluate the pregnancy characteristics and obstetric outcomes in patients after perforation of the uterus. Study design: A retrospective cohort study was conducted and included all patients who were diagnosed with uterine perforation and treated in a tertiary referral medical center between the years 1996 and 2018. Up to two deliveries after perforations were investigated. Results: During the study period, 51 women were diagnosed with uterine perforation during gynecological procedures, including intrauterine device (IUD) insertion. The mean age of patients at the time of diagnosis was 27.9 (±4.7) years. The majority, 76.5% (n = 39), experienced perforation during IUD insertion, and 23.5% (n = 12) of the patients experienced perforation during surgical procedures. Most of the patients were multiparous or grand multiparous, 45.8. % (n = 22) and 39.6% (n = 19) respectively. Anteflexed uterus was found in 86.4% of the patients (n = 38). Five patients (9.8%) had pelvic abscesses after the IUD insertion. A total of 50 patients had 71 deliveries subsequent to uterine perforation. One patient experienced intrauterine fetal death due to fetal malformations. One patient experienced uterine rupture. No other major obstetric complications were noted. Conclusions: Uterine perforation may be associated with adverse obstetric outcomes. The possibility of uterine rupture must be considered while managing the deliveries of patients after uterine perforation. Moreover, a larger cohort and further studies are needed to establish an association between uterine perforation and adverse outcomes of the subsequent deliveries.

The impact of hymenectomy on future gynecological and obstetrical outcomes.

Background: Imperforated hymen is a rare condition usually diagnosed at puberty due to amenorrhea accompanied by cyclic pelvic pain and sometimes other significant complications such as hematometra, endometriosis, and infertility. The accepted surgical treatment for imperforate hymen and some other hymenal malformation is hymenectomy. However, given low incidence rates, long-term obstetrical and gynecological outcomes in post-hymenectomy women remain poorly understood.Objective: To investigate long-term obstetrical and gynecological outcomes in nulliparous women who underwent a hymenectomy.Study design: Retrospective study comparing gynecological and perinatal outcomes of nulliparous women with and without hymenectomy, who delivered between the years 1988 and 2015 at the Soroka University Medical Center. Univariate analysis was performed as accepted with multivariate logistic regression model used to assess long-term effects of hymenectomy.Results: During the study period, 56 of 74,598 nulliparous women who delivered at the Soroka University Medical Center had previously undergone a hymenectomy. In a univariate analysis, cesarean deliveries were significantly more prevalent among women who had undergone a hymenectomy (30.4 versus 17.6% p = .01) as were infertility treatments (10.7 versus 4.4% p = .04) and dyspareunia (42.9 versus 0.2% p <.001). In a multivariate logistic regression model hymenectomy was found to be an independent risk factor for significant obstetrical and gynecological outcomes defined as one or more of the following: caesarean deliveries, cervical laceration, vaginal laceration, perineal laceration, preterm delivery, cervical incompetence, endometriosis, infertility, and dyspareunia (OR 2.5, 95% CI 1.26-4.93; p = .001).Conclusions: Hymenectomy is associated with significant long-term obstetrical and gynecological complications. Informing medical teams of these risks might promote early detection and minimize associated complications such as laceration-associated blood loss and preterm delivery.

Intrapartum cervical lacerations and their impact on future pregnancy outcome.

Objective: To investigate the significance of intrapartum cervical lacerations on subsequent pregnancies.Study design: A retrospective cohort analysis was conducted, comparing outcomes of subsequent singleton pregnancies, in women with and without a history of cervical lacerations in a previous delivery. Deliveries occurred between the years 1991-2014 at the Soroka University Medical Center. Multiple logistic regression models were constructed to control for clinically significant confounders.Results: During the study period 187,162 deliveries met the inclusion criteria. Of them, 429 (0.2%) occurred in women with a history of cervical lacerations in the previous pregnancy (study group). The study group exhibited significantly higher rates of recurrent cervical lacerations (21/429, 4.9% versus 275/187 162,0.1%, p value = .001), cerclage (13/429, 3% versus 260/187 162, 0.1% p value = .001), cervical incompetence (8/429, 1.9% versus 609/187 162, 0.3% p value = .001) cesarean delivery (CD) (97/429, 22.6% versus 26 280/187 162,14%, p value = .001), severe perineal tears (third or fourth degree; 2/429, 0.5%, versus 164/187 162, 0.1%, p value = .056) and blood transfusion (11/429, 2.6% versus 2448/187 162, 1.3%, p value = .022) as compared with the comparison group. Using a multivariable logistic regression model, history of cervical laceration in a previous pregnancy was found to be an independent risk factor for subsequent CD (OR 1.4, 95% CI 1.1-1.9), recurrent cervical laceration (OR 29.3, 95% CI 17.7-48.5), severe perineal lacerations (OR 11.7, 95% CI 5.1-27.2), and preterm delivery (OR 1.8, 95% CI 1.1-2.8) in the subsequent pregnancy.Conclusions: A history of intrapartum cervical laceration is an independent risk factor for recurrent cervical lacerations, CD, preterm delivery, and severe perineal lacerations in the subsequent pregnancy.

Endometrial Polyp Size and the Risk of Malignancy in Asymptomatic Postmenopausal Women.

OBJECTIVE: The appropriate management of endometrial polyps in asymptomatic postmenopausal patients remains controversial. The aim of the study was to evaluate the relationship between endometrial polyp size and malignancy risk among asymptomatic postmenopausal women. METHODS: This observational retrospective study investigated 472 postmenopausal asymptomatic women who underwent hysteroscopic polypectomy between 2010 and 2014 (Canadian Task Force Classification II-3). RESULTS: Of the 472 women, premalignant and malignant lesions were found in 11 (2.33%) cases; four (0.84%) had endometrial carcinoma, and seven (1.49%) had atypical endometrial hyperplasia. The incidence of premalignant or malignant lesions among various cut-offs of polyp size (10, 15, 20 mm) was not significantly different. CONCLUSION: In the current series no significant risk factor for malignancy was found among different cut-offs of polyp size.

Correction to: Once episiotomy, always episiotomy?

The original article can be found online.

Colostrum of Preeclamptic Women Has a High Level of Polyphenols and Better Resistance to Oxidative Stress in Comparison to That of Healthy Women.

Preeclampsia is a common pregnancy complication. Abnormal development of the placenta is the prevailing cause theory of this complication. Women with preeclampsia suffer from acute oxidative stress and high lipid oxidation in plasma. The aim of this study was to compare levels of polyphenols and lipid peroxidation in colostrum of nursing mothers with and without preeclampsia. The study was conducted at the Department of Obstetrics and Gynecology at Soroka University Medical Center. The study group consisting of 18 women, who were diagnosed with preeclampsia, was compared to the control group: 22 healthy women. The total phenolic content in the colostrum was determined by using the Folin-Ciocalteu method. Lipid peroxidation was determined by measuring MDA, using the TBARS assay. Polyphenol concentrations were significantly higher (about 33%) in the colostrum of the study group compared with the control group (p = 0.00042). Lipid peroxidation levels (MDA) were significantly lower (about 20%) in the colostrum of the study group compared with the control group (p = 0.03). Negative correlation was found between MDA concentration and the polyphenol level (R = -0.41, p = 0.02). In conclusion, we showed in this study a potential compensation mechanism that protects the newborn of a mother with preeclampsia from the stress process experienced by its mother.

Once episiotomy, always episiotomy?

OBJECTIVE: To investigate the association between episiotomy and perineal damage in the subsequent delivery. STUDY DESIGN: A retrospective cohort study was conducted, comparing outcome of subsequent singleton deliveries of women with and without episiotomy in their first (index) delivery. Deliveries occurred between the years 1991-2015 in a tertiary medical center. Traumatic vaginal tears, multiple pregnancies, and cesarean deliveries (CD) in the index pregnancy were excluded from the analysis. Multiple logistic regression models were used to control for confounders. RESULTS: During the study period, 43,066 women met the inclusion criteria; of them, 50.4% (n = 21,711) had subsequent delivery after episiotomy and 49.6% (n = 21,355) had subsequent delivery without episiotomy in the index pregnancy. Patients with episiotomy in the index birth higher rates of subsequent episiotomy (17.5 vs. 3.1%; P < 0.001; OR 1.9; 95% CI). In addition, the rates of the first and second degree perineal tears as well as the third and fourth degree perineal tears were significantly higher in patients following episiotomy (33.6 vs. 17.8%; P < 0.001, and 0.2 vs. 0.1%; P = 0.002, respectively). Nevertheless, there was no significant difference at the rates of CD and instrumental deliveries, between the groups. While adjusting for maternal age, ethnicity, birth weight, and vacuum delivery-the previous episiotomy was noted as an independent risk factor for recurrent episiotomy in the subsequent delivery (adjusted OR 6.7; 95% CI 6.2-7.3, P < 0.001). The results remained significant for term (adjusted OR 6.8; 95% CI 6.2-7.4, P < 0.001) as well as preterm deliveries (adjusted OR 4.5; 95% CI 3.3-6.3, P < 0.001) in two different models. CONCLUSION: Episiotomy is an independent risk factor for recurrent episiotomy in the subsequent delivery.

Fetal heart rate monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis.

OBJECTIVE: To determine whether fetal heart rate (FHR) monitoring categories during the 1st and 2nd stage of labor can predict arterial cord pH <7.2. MATERIALS AND METHODS: A case control study was conducted including 653 consecutive term deliveries (37 weeks gestation and above) that were divided according to fetal pH ≤ 7.2 (n = 315) and fetal pH > 7.2 (n = 338). Deliveries occurred during the year 2013 in tertiary medical center, where arterial cord pH is routinely taken after birth. Intrapartum FHR monitoring categorization was defined according to the ACOG committee guidelines by two obstetricians. Multivariable models were constructed to control for confounders. RESULTS: Variable decelerations, late decelerations and bradycardia during the 1st and 2nd stages of labor were significantly higher in group of deliveries ended in cord pH < 7.2 compared with group of deliveries ended in cord pH > 7.2. A significant association was observed between category 2 and 3 during the 1st stage of labor and pH ≤ 7.2. However, while controlling for FHR category 3 at the 2nd stage of labor, 1st stage categorization lost its association with pH <7.2, and only category 3 during the 2nd stage were noted as an independent risk factor for acidosis. CONCLUSION: FHR monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis as expressed by arterial cord pH < 7.2.

Antioxidants and Polyphenols: Concentrations and Relation to Male Infertility and Treatment Success.

Oxidative stress is induced by reactive oxygen substances (ROS) that are known to affect male fertility. The aims of this study were to prospectively investigate and characterize total antioxidant and specifically polyphenols concentrations and their relations to sperm quality and fertility treatment success. During their infertility treatment, sixty-seven males were prospectively recruited to this study. After separation of the sperm from the semen sample, the semen fluid samples antioxidants and polyphenols concentrations were determined. Antioxidant concentration was significantly associated with sperm concentration and total motile count. Antioxidants concentration in the group of male with sperm concentration ≥ 15 × 10(6) was significantly higher than in the group of male with antioxidants concentration < 15 × 10(6) (830.3 ± 350 µM and 268.3 ± 220 µM, resp., p < 0.001). Polyphenols concentration did not differ between the groups of sperm concentration above and below 15 × 10(6) (178.7 ± 121 µM and 161.7 ± 61 µM, resp., p-NS). No difference was found between fertilization rates and antioxidants or polyphenols concentrations. This is the first study that reports on polyphenols concentration within semen fluid. More studies are needed in order to investigate polyphenols role in male fertility.

Defensive Medicine Among Plastic and Aesthetic Surgeons in Israel.

BACKGROUND: Defensive medicine (DM) includes medical practices that are aimed at avoiding liability rather than benefitting the patient. DM has not been well characterized among plastic surgeons. OBJECTIVES: The authors examined the extents of intended and unintended DM among members of the Israeli Society of Plastic and Aesthetic Surgery (ISPAS) and identified risk factors for DM. METHODS: A total of 108 ISPAS members were asked to complete a questionnaire that addressed physician attitudes toward DM and intended or unintended DM practices. RESULTS: Seventy-eight surgeons (72.2% response rate) returned the questionnaire, although some questionnaires were returned incomplete. Forty respondents acknowledged practicing DM (ie, DM group), and 33 respondents did not (ie, non-DM group). There were no between-group differences in gender, years of practice, or number of previous litigations. Thirty-one percent of respondents in the DM group indicated that they avoid certain surgical procedures, compared with 6% of respondents in the non-DM group (P = .008). In private practice, 66.2% of respondents stated that they obtain written informed consent twice before surgery, and 100% request preoperative blood-coagulation testing. In contrast, 40% and 74% of respondents in public practice, respectively, acknowledged these behaviors (for consent, P = .027; for testing, P = .0059). Sixty-three percent of respondents prescribe antibiotics for more than 24 hours postoperatively, and this practice was slightly more common in the DM group (34 prescribe antibiotics vs 21 in the non-DM group; P = .079). CONCLUSIONS: DM is highly integrated into the daily medical practices of plastic surgeons in Israel.

Role of lycopene in preventing lipid peroxidation products, in commercial infant milk formula.

OBJECTIVES: The aim of the study was to investigate whether lycopene from natural sources (tomato extract) is able to protect newborns milk formula, against oxidative damage caused by exposure to hydroxyl radicals, and is there a difference between milk substitutes from various sources. METHODS: Four commercial brands of infant milk formula: two of the formulas were dairy milk (A-d and B-d) and two were based on soy bean vegan milk (A-s and B-s), were exposed to ionizing radiation radical (·OH). Lipid peroxidation was determined by measuring malondialdehyde (MDA) using thiobarbituric acid reactive substance test (TBARS). RESULTS: When suspensions containing the four brands of formula were subjected to oxidizing media produced by ionizing radiation (hydroxyl radicals), lipid peroxidation increased linearly as a function of the irradiation dose (R = 0.99). It was found that lycopene in a concentration of 0.6 mM, reduced the radiation damage only in the soy-based formula; decrease of ∼40% of the damage achieved in B-s, and ∼20% reduction in the damage caused to A-s, significantly p < 0.01. CONCLUSIONS: Lycopene in dairy milk did not protect against hydroxyl radicals; however, lycopene found to protect against hydroxyl radicals in soy milk. This result suggests different mechanisms of radical production that arises from high iron levels present in the soy milk and involving the high-valent iron peroxo species.

Elements in maternal blood and amniotic fluid determined by ICP-MS.

OBJECTIVE: Knowledge about levels of toxic and non-toxic elements in amniotic fluid is limited. The aims of this study were: (1) to measure levels of trace elements Cu, Fe, Zn, B, Sr and Co in amniotic fluid and maternal serum during second trimester of pregnancy; and (2) to determine what correlations exists between elements levels in amniotic fluid and maternal serum. METHODS: The levels of, iron, copper, zinc, cobalt, strontium and boron were measured in blood and amniotic fluid during genetic amniocentesis using inductively coupled plasma mass spectrometry (ICP-MS). RESULTS: Concentrations of the elements: Fe, Cu, Zn, Co, Sr and B in amniotic fluid were significantly lower than in maternal blood. For iron, zinc, cobalt, strontium and boron there was a linear correlation between levels in amniotic fluid and maternal serum. CONCLUSIONS: The concentration of trace elements in amniotic fluid was found to be lower than maternal serum and linearly correlated to its level.

Aplasia cutis congenita: clinical management and a new classification system.

BACKGROUND: Aplasia cutis congenita is a rare, congenital disorder. In its severe phenotype, it is potentially life threatening. Its management and the timing of surgery remain controversial because of the risks involved with both conservative and surgical approaches. Most literature is based on case reports and very small case series because of the rarity of the disorder. The authors present their experience treating newborns with aplasia cutis congenita and its progressive development. METHODS: Using a hospital registry, the authors found all cases of newborns diagnosed with aplasia cutis congenita during the years 2000 to 2013. Clinical data were gathered from hospital and clinic records, and photographs were obtained by the plastic surgery team. RESULTS: Twenty-two cases of aplasia cutis congenita were included in this study: 21 on the scalp and one on the foot heel. Eleven patients were male and 11 were female. Defect size ranged from 1 to 150 cm (average, 29 cm). Three patients died as a result of uncontrollable hemorrhage. Six patients underwent emergency coverage, one with allografts later replaced by split-thickness skin grafts and five by immediate split-thickness skin grafting. All of the patients who underwent immediate skin grafting survived and thrived. CONCLUSIONS: The authors emphasize the role of emergency split-thickness skin grafting in the treatment of large aplasia cutis congenita or ones with large veins or sagittal sinus exposure. The authors also present a practical, treatment-oriented classification that could assist physicians in estimating the severity and therefore prognosis of the disease and offer a treatment guideline. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Perinatal outcome of pregnancies following in vitro fertilization and ovulation induction.

OBJECTIVE: To investigate pregnancy outcome in patient who conceived by assisted reproductive techniques. METHODS: A retrospective population-based study was conducted, comparing obstetrical complications and neonatal outcomes of singleton pregnancies conceived by in vitro fertilization (IVF; n = 1296) and ovulation induction (n = 1988) as compared to singleton pregnancies conceived spontaneously (n = 172 288). Multivariable models were constructed to control for confounders. RESULTS: A significant linear association (using the chi-square test for trends) was documented among the three groups in adverse outcomes such as gestational diabetes mellitus (17.3% in the IVF, 14.2% in the ovulation induction, 6.6% in the comparison group, p < 0.001), severe preeclampsia (2.7% in the IVF, 1.8% in the ovulation induction, 1.1% in the comparison group, p < 0.001) and perinatal mortality (3.3% in the IVF, 2.1% in the ovulation induction, 1.3% in the comparison group, p < 0.001). In vitro fertilization and ovulation induction treatments were found to be independent risk factors for gestational diabetes mellitus, using two different multiple logistic regression models controlling for confounders such as maternal age (adjusted OR = 1.77, 95% CI:1.52-2.07, p < 0.001 and adjusted OR = 1.93, 95% CI:1.69-2.21, p < 0.001; respectively). CONCLUSIONS: Pregnancies conceiving following assisted reproductive techniques are at an increased risk for adverse obstetrics outcomes. The risk is higher for pregnancies following IVF compared with these conceived following ovulation induction.

[Lycopene and tomatoes--their effect on prevention of prostatic cancer].

Prostate cancer is one of the most common types of cancer and it is the second most common cause of cancer-related death among men in the western world. Microscopic prostate cancer was found in up to 30% of men as early as 20-40 years old of age. Lycopene is a lipid soluble carotenoid molecule. It is found in high concentration in red fruit and vegetables. Lycopene has a significant anti-oxidative activity. There is laboratory evidence that explain it's function as an inhibitor of various tumors as well as epidemiological evidence that shows that lycopene-rich foods reduce the incidence of a few types of cancer and especially prostate cancer. This paper reviews the evidence that explain lycopene activity, its biological effect and availability and its effect on the prevention of prostate cancer.

Fatty acid composition of breastmilk of Israeli mothers.

We conducted this study to determine the fatty acid composition of breastmilk of Israeli women and compare it with baby milk substitutes. Samples of mature breast milk, from 29 lactating Israeli Jewish mothers were collected during feedings. Total milk lipids extracts were transmethylated and analyzed by using an improved gas-chromatographic method. About 72% of the total fatty acids in the investigated breast milk comprised oleic (18:1c; 31±4%), palmitic (16:0; 21±4%), and linoleic (18:2n-6; 20±4%) acids. Total saturated fatty acids represented 42±7% of total fatty acids. The monounsaturated fatty acids content was 33±5%, of which 94% was oleic acid, and the polyunsaturated fatty acids content was about 24±4%, of which 85% was linoleic acid. The a-linolenic acid level found in this study, 2.0±0.6%, was higher than the range of values reported for the world population (0.10-1.4%). The main fatty acids composition of the milk substitutes has very similar composition to the breast milk. Docosahexaenoic acid levels are particularly low among the population of Jewish nursing mothers in relation to the milk substitutes, containing docosahexaenoic acid in their formulations.

Saturated fatty acid composition of human milk in Israel: a comparison between Jewish and Bedouin women.

BACKGROUND: Breast milk is well established as the ideal source of nutrition for infants. Mature human breast milk generally contains 3.5-4.5% lipids comprising mostly triacylglycerols. In general, the fat composition of maternal human milk in developing countries shows higher levels of saturated fats, reflecting diets rich in carbohydrates. OBJECTIVES: To determine the profile of unsaturated fatty acids in the breast milk of two populations in southern Israel--urban Jewish and rural tent-dwelling Bedouin women. METHODS: This study involved 48 lactating Israeli mothers, 29 Jewish and 19 Bedouin (16-20 weeks postpartum), whose full-term infants were fed exclusively with breast milk. Total milk lipid extracts were transmethylated and analyzed by using an improved gas chromatographic method. RESULTS: The breast milk of the Bedouin women contained significantly higher levels of total major saturated fatty acids, lauric acid and palmitic acid (45.2 +/- 4.7% vs. 41.0 +/- 5.6%, P = 0.005; 5.2 +/- 2.1 vs. 6.8 +/- 2.0%, P = 0.03; and 22.7 +/- 2.4 vs. 20.6 +/- 3.8%, P = 0.02) respectively. No difference was found in the myristic acid level between the groups. The level of stearic acid was significantly higher in the Jewish group compared to the Bedouin group (5.7 +/- 1.1 vs. 5.1 +/- 1.1%, P = 0.04). There was a linear correlation between the levels of C14:0 and C12:0 in the Bedouin and lewish groups respectively (R = 0.87, R = 0.82, P < 0.001). CONCLUSIONS: Higher levels of saturated fatty acids were measured in the breast milk of Bedouin women, an economically weaker population. The results emphasize the importance of diet among lactating women and its influence on milk quality.