Hydrosalpinx: Tubal surgery or in vitro fertilisation? An everlasting dilemma nowadays; a narrative review.

The decision on how to treat tubal diseases, specifically hydrosalpinx, is a difficult one. Ιt involves surgical, medical, social, emotional and economic factors. This narrative review aims to increase awareness of tubal disease diagnosis and treatment, to compare between tubal surgery and in vitro fertilisation (IVF) for tubal factor infertility, and to investigate the effect of the combination of both. This way, we can be more effective, safe and provide our patients with better treatment results. The review analysed randomised studies, trials and meta-analysis, which give new aspects on the treatment methods for tubal pathology before IVF. Recent papers published in English have been studied, alongside guidelines and committee opinions from previous years. Tubal surgery and IVF aim to exploit a woman's reproductive potential. IVF and endoscopic tubal surgery must be thought of as complementary, rather than competing techniques in tubal disease cases, in order to improve fertility outcome. The first-line treatment for young women less than 35 years old with minor tubal pathology, is tubal surgery. IVF should be offered if there are other factors in a couple's subfertility, if the patient is >38 years old, if moderate to severe tubal disease is present, and if it has been more than 12 months post-surgery.

Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer: a network meta-analysis.

OBJECTIVE: The presence of hydrosalpinx impairs the outcome of in-vitro fertilization embryo transfer (IVF-ET). Surgical methods to either aspirate the fluid or isolate the affected Fallopian tubes have been attempted as a means of improving outcome. The aim of this network meta-analysis was to compare the effectiveness of surgical treatments for hydrosalpinx before IVF-ET. METHODS: An electronic search of MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (Central) and the US Registry of clinical trials for articles published from inception to July 2015 was performed. Eligibility criteria included randomized controlled trials of women with hydrosalpinx before IVF-ET comparing ultrasound-guided aspiration of the fluid, tubal occlusion, salpingectomy or no intervention. Ongoing pregnancy was the primary outcome and clinical pregnancy, ectopic pregnancy and miscarriage were secondary outcomes. A random-effects network meta-analysis synthesizing direct and indirect evidence from the included trials was carried out. We estimated the relative effect sizes as risk ratios (RRs) and obtained the relative ranking of the interventions using cumulative ranking curves. The quality of evidence according to GRADE guidelines, adapted for network meta-analysis, was assessed. RESULTS: Proximal tubal occlusion (RR, 3.22 (95% CI, 1.27-8.14)) and salpingectomy (RR, 2.24 (95% CI, 1.27-3.95)) for treatment of hydrosalpinx were superior to no intervention for ongoing pregnancy. For an outcome of clinical pregnancy, all three interventions appeared to be superior to no intervention. No superiority could be ascertained between the three surgical methods for any of the outcomes. In terms of relative ranking, tubal occlusion was the best surgical treatment followed by salpingectomy for ongoing and clinical pregnancy rates. No significant statistical inconsistency was detected; however, the point estimates for some inconsistency factors and their CIs were relatively large. The small study number and sizes were the main limitations. The quality of evidence was commonly low/very low, especially when aspiration was involved, indicating that the results were not conclusive and should be interpreted with caution. CONCLUSIONS: Proximal tubal occlusion, salpingectomy and aspiration for treatment of hydrosalpinx scored consistently better than did no intervention for the outcome of IVF-ET. In terms of relative ranking, proximal tubal occlusion appeared to be the most effective intervention, followed by salpingectomy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Appendectomy for asymptomatic appendicitis during caesarean section - an interesting case report.

BACKGROUND: The authors present an interesting case report of an appendectomy during caesarean section in an asymptomatic pregnant woman, which highlights the need of peritoneal cavity check during every caesarean section. MATERIALS AND METHODS: A 32-year-old para 0 woman at 34 weeks of gestation attended to the present clinic because of a feeling of reduced fetal movements in the last 24 hours. She underwent a non-stress test (NST), that was non-reassuring and no contractions were recorded. The woman underwent a caesarean section, which revealed a large phlegmonic appendix. Appendectomy was decided after the closure of the uterine cavity. RESULTS: The woman was treated with appendectomy. Histology came back as an appendicitis three days later. CONCLUSIONS: Acute appendicitis during pregnancy may be associated with serious maternal and fetal complications. It is also associated with a high risk of premature delivery. In the absence of lower abdominal pain and inflammatory changes, the incidence of acute appendicitis is low, but exists. In every caesarean section at any week of gestation, we should check the peritoneal cavity and especially the appendix, as appendicitis is the most pregnant woman who mentions preterm contractions or/and reduced fetal movements.

Obstetric and neonatal outcome after assisted fertilization and spontaneous conception: a comparative study.

PURPOSE: The widespread use of assisted reproduction technology (ART) is accompanied by concerns for potential adverse outcomes. The aim of the present study was to evaluate the impact of ART in obstetric and neonatal outcome. METHODS: Data from labor ward records from 913 consecutive births were analyzed retrospectively, and the obstetric and neonatal outcomes of pregnancies after ART were compared with those after natural conception. RESULTS: No major complications were noted after ART. A higher probability of cesarean section, lower gestational age at birth, lower birth weight and hospitalization in the Neontal Intensive Care Unit (NICU) was noted after ART, as compared with spontaneous conception. However, after exclusion of multifetal pregnancies, there was no significant difference in outcomes, except for cesarean section rates. CONCLUSIONS: The higher proportion of multiple pregnancies after ART is associated with lower gestational age at birth, lower birth weights and higher NICU hospitalization rates.

Human placental lactogen and color Doppler in predicting expulsion of retained adherent placenta: a new clinical observation.

PURPOSE: To present a new clinical observation made in three cases of retained adherent placenta, a rare obstetrical complication, associated with potentially life-threatening hemorrhage. METHODS: Three consecutive cases of retained adherent placenta are presented. RESULTS: Diagnosis of placenta increta in two and placenta percreta in one case was established with ultrasound and MRI. Methotrexate 50 mg i.v. (300 mg total dose) and follinic acid 0.1 mg/kg were administered on alternating days, over 12 days. On follow-up, placental perfusion on color Doppler was present up to the point when circulating hPL levels were no longer detectable; this was followed in all cases by spontaneous placental expulsion within 10 days. CONCLUSIONS: The observation that both color Doppler and human placental lactogen can be used to monitor response to therapy and predict placental expulsion should be evaluated in future cases of retained adherent placenta.

Changes in levator hiatus dimensions during pregnancy and after delivery in nulliparas: a prospective cohort study using 3D transperineal ultrasound.

PURPOSE: The purpose of this study was to investigate the changes that occur in the levator ani muscle (1) during pregnancy and (2) after labor depending on the mode of delivery in a cohort of nulliparas. MATERIALS AND METHODS: A prospective cohort longitudinal study, consisting of 84 primiparas who were examined and recruited in an antenatal clinic was conducted. All participants were submitted to a real-time three-dimensional (3D) ultrasonographic evaluation of the levator ani at (1) 12, (2) 22, and (3) 32 weeks of pregnancy (4) and 4-6 months postdelivery. The 3D volumes were acquired and stored for an offline analysis. RESULTS: Data from 59 women with at least two measurements were available for analysis. 35 women were delivered vaginally and 24 via cesarean section. There was a statistical increase in the dimensions of the levator hiatus at each pregnancy trimester when compared to the measurements of the previous trimesters. After vaginal delivery, hiatal dimensions increased compared to the third-trimester measurements; after cesarean section, hiatal dimensions decreased. CONCLUSIONS: This study supports that in primiparas, the dimensions of the levator hiatus increase significantly during pregnancy and subsequently either increase further after vaginal delivery or decrease to the first-trimester levels after cesarean section.

Prenatal management and postnatal separation of omphalopagus and craniopagus conjoined twins.

Two cases of prenatally diagnosed conjoined twins are presented: a set of omphalopagus twins sharing a common liver, and a set of craniopagus with involvement limited to the skull. In both cases, prenatal diagnosis allowed accurate planning of pre- and postnatal management. Prenatal management involved serial imaging and counseling with participation of different specialists according to imaging findings. In the rare case of conjoined twins, an interdisciplinary approach is required, with feto-maternal specialists playing a pivotal role in co-ordinating teamwork and planning successive stages of management.

Fetal abdominal subcutaneous tissue thickness measured by ultrasound at term is associated with birth weight and mode of delivery.

PURPOSE: To determine if measurement of fetal abdominal subcutaneous tissue thickness (FASTT) at term can predict birth weight, mode of delivery and perinatal outcome. METHODS: A prospective study with 352 normal, singleton pregnancies in the vertex presentation examined with real-time ultrasound at 37-39 weeks' gestation. RESULTS: FASTT was positively correlated with birth weight (Pearson's, r = 0.784, p < 0.001). Fetuses with low FASTT were more likely to be delivered through normal vaginal delivery (7.8 +/- 0.1 mm), while higher FASTT was correlated with operative vaginal delivery (7.9 +/- 0.2 mm) and cesarean section (8.6 +/- 0.3 mm) (ANOVA, p = 0.034). In contrast, FASTT was not correlated with intrapartum CTG, labor duration and Apgar scores. CONCLUSIONS: In normal pregnancies, FASTT at term is positively associated with birth weight. With increasing FASTT the likelihood of operative vaginal and cesarean delivery increases. FASTT is not associated with perinatal outcome.

Nuchal cord detected by ultrasound at term is associated with mode of delivery and perinatal outcome.

OBJECTIVES: To evaluate the clinical relevance of nuchal cord in normal, vertex, singleton pregnancies at term, and its effect on mode of delivery and perinatal outcome. STUDY DESIGN: Prospective study with 352 normal, singleton pregnancies, with fetuses in the vertex presentation, examined with real-time ultrasound at 37-39 weeks. Health care workers at labour and delivery blinded to previous detection of nuchal cord. RESULTS: Fetuses of nulliparous women with a nuchal cord were more likely to be delivered with operative vaginal or caesarean delivery (n = 153, p < 0.0001). This was not the case with higher parity (n = 199, p = 0.07). There was no difference between nuchal cord (n = 144) and control groups (n = 208) in amniotic fluid quantity at 37-39 weeks (p = 0.554) or intrapartum CTG (p = 0.9). On the other hand, nuchal cord group had lower Apgar scores at 1 and 5 min (p = 0.001 and 0.027 respectively); this difference remained significant when adjusted for birth weight (p = 0.001 and 0.016), but disappeared when adjusted for mode of delivery (p = 0.048 and 0.319). CONCLUSIONS: Nuchal cord in normal pregnancies at term is associated with increased rate of operative vaginal and caesarean delivery in nulliparae. The presence of a nuchal cord results in slightly lower Apgar scores at 1 and 5 min, mainly as a consequence of higher operative delivery rates.

Three-dimensional versus two-dimensional ultrasound for fetal nasal bone evaluation in the second trimester.

OBJECTIVES: To compare two-dimensional with three-dimensional ultrasound evaluation of the fetal nasal bone in the second trimester. METHODS: A prospective, non-interventional study was conducted, in 55 singleton fetuses, between 18 and 24 weeks' gestation. Fetal nasal bone length was measured in the midsagittal plane by two-dimensional imaging and in the midsagittal and coronal plane with three-dimensional ultrasound. All three measurements were compared with one another using one-way repeated samples-measures ANOVA and paired samples t-test. RESULTS: The average fetal nasal bone length (mean ± SD) as determined by the three methods was 7.01 ± 0.94 mm for the two-dimensional midsagittal, 6.96 ± 1.34 mm for the three-dimensional midsagittal, and 6.98 ± 1.32 mm for the three-dimensional coronal plane; comparisons between one another were not statistically significant. Unilateral hypoplasia and bifid shape of the fetal nasal bone were detected in 8.2% and 20.4% of cases, respectively, by three-dimensional ultrasound, whereas all cases evaded detection with two-dimensional ultrasound (p < 0.001 and p = 0.001, respectively). CONCLUSIONS: Fetal nasal bone length measured with two-dimensional ultrasound does not differ significantly from three-dimensional measurements. However, three-dimensional ultrasound is superior in detecting unilateral nasal bone hypoplasia or absence and in assessing fetal nasal bone shape. Hence, fetal nasal bone examination in the second trimester should include three-dimensional ultrasound evaluation.

The safety of obstetric ultrasonography: concern for the fetus.

It has been estimated that more than half of all pregnant women in the United States undergo diagnostic ultrasound during their pregnancies. In light of this, the question of safety is of fundamental importance. Nondiagnostic ultrasound has been shown to produce biologic effects by thermal and cavitational activities. However, diagnostic ultrasound uses much lower intensities, and no evidence exists to suggest that it is associated with adverse effects. Numerous studies have examined the biologic effects of diagnostic ultrasound in insects, plants, cell suspensions, and even small mammals. The data from these experiments are confusing when attempting to relate these findings to the human. Epidemiologic data in humans, used to evaluate the potential adverse effects of exposure to diagnostic ultrasound, have revealed no ill effects from such exposure. Current data indicate that there are no confirmed biologic effects on patients and their fetuses from the use of diagnostic ultrasound and that the benefits to patients exposed to prudent use of diagnostic ultrasound outweigh the risks, if any. This review discusses the available information on the safety of obstetric ultrasonography.

Assessment of carbohydrate tolerance in pregnancy.

A review is given of the various methods of assessing carbohydrate tolerance in pregnancy. Oral glucose tolerance screening and diagnostic tests have been in use for more than 25 years. They are easily administered, relatively inexpensive, and present reasonable sensitivity; therefore, they continue to be used quite extensively. However, lack of reproducibility of the results and side effects such as nausea, vomiting, and headache have led to the use of alternate methods including glucose polymer (Polycose) and standard breakfast meals. These methods have been reported to present satisfactory results in clinical practice. Glycosylated hemoglobin (HbA1c) and fructosamine assays are also alternate forms of testing carbohydrate metabolism HbA1c measurement have been proven insensitive as a screening test for gestational diabetes, while their use as an index of overall glucose control remains valuable. The role of fructosamine in the assessment of carbohydrate intolerance remains controversial with conflicting claims made by various investigators regarding its sensitivity in detecting gestational diabetes and its response to alterations in glycemic control. In this review, the relative advantages and disadvantages of each glucose tolerance test are discussed and recommendations are given regarding their utility in pregnancy.

Pregnancy outcome. Influence of antiphospholipid antibody titer, prior pregnancy losses and treatment.

OBJECTIVE: To evaluate the effectiveness of combination therapy in preventing fetal loss in women with circulating antiphospholipid antibodies and a previous history of adverse pregnancy outcomes. STUDY DESIGN: We identified 18 pregnant women with antiphospholipid antibodies who had a total of 59 prior pregnancies. Of these pregnancies, spontaneous first-trimester abortions occurred in 36 (61.0%); fetal demise after the first trimester occurred in 9 (15.2%); voluntary terminations were elected in seven (11.9%) pregnancies; and there were seven (11.9%) surviving infants. During their next pregnancies, these patients were treated with prednisone and/or low-dose aspirin. RESULTS: Fourteen patients delivered successfully between 33 and 39 weeks' gestation, resulting in a live birth rate of 77.8% and a pregnancy loss rate of 22.2%. We also observed an association between the number of prior fetal losses, the anticardiolipin antibody titer and the fetal survival rate following therapy. Two or more prior fetal losses and high autoantibody titer resulted in a fetal survival rate of 50-75% with varying therapeutic regimens and dosages. However, an improved fetal survival rate of 75-100% was observed with less than two prior fetal losses and low-mid anticardiolipin antibody titer with the same therapy. CONCLUSION: Therefore, the results of this study suggest that although pharmacologic prophylaxis improves the outcome of pregnancies complicated by circulating antiphospholipid antibodies, such an outcome is influenced by the number of prior fetal losses and the anticardiolipin antibody titer.

Synchronous primary neoplasms of the uterine corpus and the ovary: a case report.

OBJECTIVE: To determine the frequency of synchronous primary neoplasia of the ovaries in patients with primary malignant neoplasia of the uterus, and to analyze the clinical and histological characteristics of these cases. MATERIALS AND METHODS: Clinicopathological data from a series of patients treated for primary malignant neoplasia of the uterus between 1985 and November 2003 have been studied retrospectively. RESULTS: Synchronous primary neoplasia of the ovaries was found in 13 out of 173 patients (7.5%) treated for primary malignant neoplasia of the uterus. In four patients (2.3%) the histological findings suggested ovarian metastases from primary endometrial adenocarcinoma. In four other cases (2.3%) there was extension of the primary uterine sarcoma to the ovaries. In the remaining five cases (2.9%) primary endometrial adenocarcinoma coexisted with: a) ovarian cystadenocarcinoma in two cases, b) ovarian fibromathecoma in two cases, and c) ovarian tumor of borderline malignancy in one case. CONCLUSIONS: Coexistence of distinct primary neoplasias in the uterus and ovaries is rare. Diagnosis of two primary malignancies in the uterus and ovaries should be based on histological examination. Treatment should be appropriate for both tumors, taking into consideration that treatment of one tumor will not lead to subtreatment of the other.

Caudal regression syndrome and sirenomelia in only one twin in two diabetic pregnancies.

Many authors consider sirenomelia to be an extreme form of caudal regression syndrome (CRS), while others argue that they are two distinct entities. Maternal diabetes mellitus is considered to be an important predisposing factor for both CRS and sirenomelia. Two rare cases of diabetic, dizygotic twin pregnancies, each with one normal and one affected fetus are presented. In case 1 the affected fetus had CRS. In case 2 the affected fetus had sirenomelia. The present cases suggest that the pathogenesis of CRS and sirenomelia is more complex than previously thought, that maternal diabetes is not the only underlying pathogenetic mechanism and that genetic or epigenetic factors probably contribute to the formation of these conditions.

Cesarean section rates and indications in Greece: data from a 24-year period in a teaching hospital.

OBJECTIVE: To assess the overall cesarean section rates and indications in a Greek teaching hospital over a period of 24 years. METHOD: Data from 34,575 deliveries between 1977 and 2000 were reviewed. Analysis of cesarean section rates and indications followed. RESULTS: The overall cesarean section rate increased progressively from 13.8% (1977-83) to 29.9% (1994-2000). Cesarean section rates due to previous cesarean delivery increased from 7.7% of all deliveries (1977-83) to 10.9% (1994-2000). Primary cesarean section rates increased more than three-fold from 6.1% (1977-83) to 19% (1994-2000). The main indications for primary cesarean section were: dystocia (including dysfunctional labor, cephalopelvic disproportion and malpresentations), fetal distress, breech presentation, and hypertensive disorders of pregnancy. CONCLUSIONS: The overall cesarean section rate increased more than two-fold over the study period. Previous cesarean section was the most common indication. However, the overall increase is mainly to increase of primary cesarean section rates.

Galanin in the amniotic fluid and neonatal birth weight: a prospective observational study.

OBJECTIVE: The aim of the present study was to examine whether an association is present between amniotic fluid (AF) galanin and neonatal birth weight (NBW). DESIGN: Prospective observational study. SETTING: Fetal maternal unit in a tertiary teaching hospital. POPULATION: Fifty women of singleton pregnancy who underwent amniocentesis during the second trimester and delivered after the 37th week of gestation. METHODS: Amniocentesis 18th-19th gestational week for genetic indication with the use of a 22G needle under real-time sonographic guidance and measurement of galanin concentration in the AF. MAIN OUTCOME MEASURES: Association between concentration of AF galanin and NBW at term. RESULTS: Galanin was isolated in all samples of AF (median concentration 19.95 pg/mL; range: 19.0-21.7). A strong linear correlation between AF galanin and NBW was detected (τ = 0.928; p < 0.001). Non-parametric linear regression analysis revealed that galanin concentration could explain 72.1% of the variance in the NBW, when controlling for gestational week at birth and mother's body mass index at delivery. CONCLUSIONS: AF galanin during the second trimester seems to have a strong linear correlation with NBW of term deliveries in singleton pregnancies, even when controlling for important confounders.

Large- and small-for-gestational-age neonates born by women with gestational diabetes mellitus diagnosed by the new IADPSG criteria: a case-control study of 289 patients and 1 108 controls.

BACKGROUND: The primary aim of this case-control study was to compare women whose pregnancy was complicated with gestational diabetes mellitus (GDM), diagnosed by the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria, with a control group of healthy, pregnant women in terms of incidence of large- (LGA) and small-for-gestational-age (SGA) neonates. Our secondary aim was to compare intrauterine growth of fetuses between the same 2 populations. PATIENTS AND METHODS: The study included 289 women diagnosed as having GDM in the current pregnancy and 1 108 pregnant controls. Women were followed-up every 2 (GDM group) or 4 weeks (control group). The main metabolic parameters recorded were body mass index, fasting plasma glucose, home blood glucose and glycated hemoglobin A1c. The main ultrasonographic parameters were estimated fetal weight (EFW), head (HC) and abdominal circumferences (AC). Decisions on treatment modification in the GDM group were based on both metabolic and ultrasonographic parameters. RESULTS: There was no evidence for a difference in the incidence of LGA (9.9 vs. 9.2%, Chi-square, p=0.745) or SGA (10.5 vs. 9.0%, p=0.524) in GDM and in control group, respectively. No significant differences were found in EFW or AC between GDM and control groups during the second and third trimester. CONCLUSIONS: Incidence of LGA and SGA neonates is similar among healthy pregnant women and women with GDM, diagnosed by the new IADPSG criteria and treated according to both metabolic and ultrasonographic parameters.

Mucocele of the vermiform appendix with sonographic appearance of an adnexal mass.

Mucocele of the vermiform appendix is caused by mucus retention in its lumen, due to obstruction or hyperproduction. Appendiceal malignancy can be the underlying cause, making accurate preoperative diagnosis imperative. In women, it can sometimes present as an adnexal mass. A rare case of an appendiceal mucocele is presented, mimicking a cystic tumor of the right adnexum, both clinically and ultrasonographically. In addition, serum levels of CA-125 were increased. This is the first case of a mucocele of the appendix simulating an adnexal mass on ultrasound with increased levels of CA-125 to be reported. This clinical entity should be considered in patients presenting on ultrasound with a right-sided adnexal mass as a rare potential diagnosis.

Erythropoietin umbilical serum levels during labor in women with preeclampsia, diabetes, and preterm labor.

In this study we determine the erythropoietin levels and hematocrit in 22 women with preterm labor, 21 with insulin-dependent diabetes, 22 with preeclampsia, and 20 with normal gestation. The erythropoietin level was higher in the preeclamptic group than in the diabetic group compared with the normal and premature groups. There were no hypoxic fetuses. From this study, we found that the mechanism of increased erythropoietin levels in neonates can be different from fetal hypoxia. Further studies are needed on this subject.