Late midtrimester pregnancy termination in the presence of placenta previa.

OBJECTIVE: To examine the operative outcome in women undergoing late midtrimester pregnancy termination by dilatation and evacuation in the presence of complete placenta previa. STUDY DESIGN: The records of 306 consecutive women undergoing pregnancy termination at 19-24 weeks' gestation from January 1997 to December 2000 were reviewed and divided into those with and without complete placenta previa based on an ultrasound examination before the procedure. These two groups were then compared for differences in patient characteristics, previous gynecologic history and operative outcome, reflected by operative time, need for blood transfusion, discharge time, postoperative bleeding and postoperative fever. RESULTS: Complete placenta previa occurred in 2.6% of patients (8 of 306). Significantly more women with placenta previa were married (P = .04). There was also a significant difference between the two groups considering the indication for pregnancy termination, as all patients with placenta previa underwent late midtrimester termination due to structural and chromosomal fetal malformations, whereas 33.8% of patients without placenta previa demonstrated fetal malformations (P = .005). Furthermore, significantly more women with placenta previa had had previous pelvic surgery (P = .01). However, there was no significant difference between the two groups with regard to age, percentage of smokers, number of previous abortions, parity or number of previous cesarean sections. There was no significant difference in the number of inserted Laminaria, operative time, need for blood transfusion, postoperative morbidity and duration of hospital stay. CONCLUSION: Late midtrimester pregnancy termination by dilatation and evacuation in the presence of placenta previa appears to be safe and apparently does not increase maternal morbidity as compared with the outcome in patients without placenta previa undergoing the same procedure.

Termination of multiple pregnancy at 18-24 weeks' gestation by Laminaria dilatation and evacuation.

OBJECTIVE: To compare outcome in women undergoing termination of multiple pregnancy as compared with singleton pregnancy at 18-24 weeks' gestation by Laminaria dilatation and evacuation. STUDY DESIGN: The medical records of 372 consecutive women undergoing does not increase pregnancy termination by Laminaria dilatation and evacuation at 18-24 weeks' gestation between January 1997 and December 2001 were reviewed and divided into a group with multiple pregnancies (38 cases) and a group with singleton pregnancies (334 cases). The 2 groups were then compared for differences in patient characteristics, indications for pregnancy termination and operative outcome. Statistical methods included Student's t and chi2 test. RESULTS: Patients with multiple pregnancies were significantly older (P < .01), and a greater percentage of them were married (P < .001). The percentage of pregnancies following infertility treatment was also significantly higher in the group with multiple pregnancies (P < .0001). Furthermore, significantly more patients with multiple than singleton pregnancy underwent pregnancy termination due to preterm premature rupture of membranes (42.1% vs. 0.3%) (P < .00001), while significantly more singleton pregnancies were terminated due to structural and chromosomal fetal malformations (34.5% vs 10.6%) (P = .03). Operative outcome between the study groups differed mainly regarding blood transfusion; it was significantly greater in the group of patients undergoing multiple, as compared with singleton, termination (7.9% vs. 0.3%) (P < .00001). The group with multiple pregnancy had a longer hospital stay (1.7 +/- 0.9 vs. 1.2 +/- 0.5 days) (P < .001). CONCLUSION: Termination of multiple pregnancies at 18-24 weeks' by dilatation and evacuation appears safe when performed by skilled surgeons. There is an increased need for blood transfusion.

Sonographic versus clinical evaluation as predictors of residual trophoblastic tissue.

BACKGROUND: The study aims to compare the diagnostic accuracy of sonographic evaluation versus clinical estimation in women suspected to have retained trophoblastic fragments. METHODS: The study group consisted of 68 consecutive patients admitted to our department due to suspected residual trophoblastic tissue. Each woman underwent ultrasound and physical examination by expert clinicians. The clinicians performing the physical examination were not informed of the sonographic findings, and vice versa. RESULTS: Patients were divided into three subgroups: clinical suspicion only of residual trophoblastic tissue (n = 8), sonographic suspicion only (n = 44) and combined sonographic and clinical suspicion of residual trophoblastic tissue (n = 16). In the latter group, in 14 out of 16 women (87.5%) retained trophoblastic tissue was confirmed by histological examination, a significantly higher rate compared to ultrasonographic (45.5%, P < 0.002) or clinical suspicion only (62.5%, P = 0.07). The specificity and positive predictive value of the clinical examination were significantly higher compared to ultrasonographic evaluation (P < 0.05), while the sensitivity of the ultrasonographic evaluation was higher than the clinical estimation (P < 0.05). There was no statistically significant difference in the negative predictive value or in diagnostic accuracy between the two methods. CONCLUSIONS: Based on our current experience, it seems that the combination of both clinical and ultrasonographic evaluation is recommended before uterine curettage is performed, thus lowering the rate of unnecessary invasive procedures.

The major histopathologic characteristics in the vulvar vestibulitis syndrome.

OBJECTIVE: In order to better understand the etiology of the vulvar vestibulitis syndrome, we examined the histopathologic parameters in vestibular mucosa, and compared the findings in specimens obtained from women with vulvar vestibulitis with those obtained from the control group. STUDY DESIGN: Specimens of vestibulitis were obtained from 24 patients, undergoing circumferential vestibulectomy under general anesthesia due to the symptoms and signs consistent with vulvar vestibulitis. Control specimens were obtained from 16 women, without symptoms or signs of vulvar vestibulitis, undergoing reconstructive introital surgery due to roomy vagina, rectocele or painful episiotomy. All vestibular tissue specimens were examined for intensity of inflammation, extension of inflammatory cells into the epithelium, vascular proliferation, the presence of mast cells and proliferation of peripheral nerve bundles. RESULTS: No significant difference was found regarding the degree of inflammation, the extension of inflammatory cells into the epithelium, the vascular proliferation and the presence of mast cells while comparing the study and the control groups. The only histopathologic feature, differentiating the patients with vulvar vestibulitis from the control group, was the proliferation of peripheral nerve bundles found in 19 out of 24 (79.1%) specimens expressing vestibulitis and in none of 16 control specimens (p < 0.0001). CONCLUSION: Our results, therefore, support the existence of peripheral nerve hyperplasia in vestibular tissue obtained from patients with vulvar vestibulitis, and exclude the role of active inflammation or mast cells as probable etiologies for the vulvar vestibulitis syndrome.

Is there an increased rate of anencephaly in twins?

BACKGROUND: The Israeli Ministry of Health reported an increased rate of twin pregnancies among all cases locally diagnosed as having open neural tube defects. The current study aimed to evaluate whether the etiology of this phenomenon could be attributed either to the twinning or to the mode of conception. METHODS: Women admitted to our hospital between January 1997 and July 2004 for termination of pregnancy because of severe fetal abnormality enrolled into this retrospective case series study. They were further subdivided according to mode of conception (spontaneous, in vitro fertilization (IVF) or intracytoplasmic sperm injection (IVF-ICSI) pregnancies). RESULTS: Three-hundred and eighty consecutive pregnancies, of which 340 (89%) were singletons, participated in our study. Anencephaly was diagnosed in 26 cases: 19 singletons and 7 twins. In the entire twin population, they were all dichorionic twins and only one co-twin was affected. Five of the twins were conceived by IVF-ICSI. All the anencephalic IVF-ICSI twins had normal karyotypes. All IVF-ICSI study women had taken folic acid 400 mcg/day 3 months before conception and throughout the first trimester of pregnancy. In order to find out the cause of the high rate of anencephaly found in IVF-ICSI pregnancies (33.3%), either the twinning or the IVF-ICSI process, a logistic regression analysis was used. A significant correlation was found only between anencephaly and twinning (p = 0.001, CI = 1.86-12.63), with a risk ratio of 4.85. CONCLUSIONS: Our case series data suggest a comparatively higher rate of anencephaly in IVF-ICSI pregnancy secondary to twinning and not because of the assisted reproductive technology. It is suggested that larger epidemiologic studies are conducted to validate our preliminary results.

Conservative management of ectopic pregnancy with fetal cardiac activity by combined local (sonographically guided) and systemic injection of methotrexate.

OBJECTIVE: To evaluate the efficacy of conservative management of ectopic pregnancy with fetal cardiac activity by combined local sonographically guided and systemic injection of methotrexate. STUDY DESIGN: The study group included 12 patients with ectopic pregnancy and fetal cardiac activity, treated by combined local and systemic injection of methotrexate in the period from January 1, 2000 to July 1, 2002. The outcome of these patients was compared with the outcome of 53 patients who had ectopic pregnancy without fetal cardiac activity and were being treated only by systemic injection of methotrexate during the same period of time. RESULTS: The success rate was 91.6% (11 out of 12) in the group of patients with ectopic fetal cardiac activity and 90.5% (48 out of 53) in the group of patients with ectopic pregnancy, but without fetal cardiac activity. There was also no significant difference between the two groups comparing the percentage of cases treated by an additional dose of methotrexate (8.3 and 13.2%, respectively), nor comparing the number of days to resolution of beta-human chorionic gonadotrophin (BHCG; 40 +/- 2 and 34 +/- 10 days, respectively). Conversely, there was a significant difference in the initial BHCG level comparing the group of patients treated by combined local and systemic injection of methotrexate (12,616 +/- 9,585 mIU/ml) and the group of patients treated by systemic injection of methotrexate (1,499 +/- 2,065 mIU/ml) (p < 0.00001). Seventy-five percent of patients (6 out of 8) diagnosed with ectopic fetal cardiac activity, who desired to become pregnant, succeeded to conceive within 6 months following the combined local and systemic injection of methotrexate. CONCLUSION: The combined local sonographically guided and systemic injection of methotrexate is associated with a successful outcome in asymptomatic patients presenting with ectopic pregnancy and fetal cardiac activity.