Climacteric symptoms in women undergoing risk-reducing bilateral salpingo-oophorectomy.

BACKGROUND: The most effective strategy for prevention of ovarian and breast cancer in high-risk women is bilateral salpingo-oophorectomy. The inevitable consequence of the procedure is early menopause with the associated climacteric symptoms. Little is known about the nature of the symptoms in women who undergo risk-reducing bilateral salpingo-oophorectomy. OBJECTIVES: To compare the nature, frequency, severity, duration, and overall effects of climacteric symptoms in a group of women who underwent preventive bilateral salpingo-oophorectomy as compared to women who experienced natural menopause. METHODS: Forty-eight women at high risk for ovarian cancer who had risk-reducing bilateral salpingo-oophorectomy were compared to 60 postmenopausal women who had natural menopause. The participants were interviewed about their climacteric complaints, thoughts and feelings regarding the surgical procedure and their general well-being. The climacteric symptoms were evaluated by a modified Greene Climacteric Scale. RESULTS: Surgical menopause, as compared to natural menopause, was associated with more severe psychological, vasomotor and somatic climacteric symptoms (total score 17.36 vs. 8.65, respectively, p < 0.001) and more significant sexual dysfunction (1.848 vs. 0.900, respectively, p < 0.01). On a 0-10 scale, the satisfaction rate from the surgical procedure was 8.23 +/- 2.21. The surgery did not affect the perceived quality of life (p = 0.347) and decreased the score of anxiety and cancer fear (from 7.75 +/- 3.31 preoperatively to 2.94 +/- 3.08 postoperatively, p < 0.001). CONCLUSIONS: Risk-reducing bilateral salpingo-oophorectomy as compared to natural menopause is associated with more severe climacteric symptoms. However, the procedure does not interfere with the overall perceived quality of life and improves the perception of cancer risk.

Ehlers-Danlos type IV in pregnancy. A case report and a literature review.

BACKGROUND: Ehlers-Danlos syndrome is a heterogeneous group of connective tissue disorders, characterized by a defect in the synthesis of collagen. The syndrome is subdivided into different clinical subtypes, the most hazardous of which is type IV, the vascular type. It can manifest itself in various complications such as rupture of arteries and hollow organs. The obstetrical manifestations are the risk of uterine rupture during labor, damage to the vagina and perineum, bleeding and rupture of blood vessels and colon during the puerperium. CASE REPORT: We describe a primigravida suffering from Ehlers-Danlos type IV who was followed and successfully delivered by a cesarean section at 36 weeks of gestation and made an uneventful recovery. CONCLUSION: Following a thorough literature review, it seems wise to perform early delivery by cesarean section for pregnant women suffering from Ehlers-Danlos type IV.

Increased imidazoline and alpha 2 adrenergic binding in platelets of women with dysphoric premenstrual syndromes.

An association between dysphoric premenstrual syndromes (PMS) and a lifetime history of major depressive disorders has previously been documented. Other studies have demonstrated an increase in the binding of radiolabeled imidazoline compounds to platelets of depressed patients. Clonidine and related imidazoline compounds interact with alpha 2 adrenoceptors to inhibit neuronal noradrenergic activity and in higher concentrations, they stimulate noradrenergic activity through their interaction with imidazoline receptors. Here we report increased 3H para-aminoclonidine binding to high affinity alpha 2 adrenoceptor sites as well as to nonadrenergic imidazoline binding sites in platelets of women with dysphoric PMS. This higher binding was most pronounced during the late-luteal-symptomatic phase of the menstrual cycle and, to a lesser degree, during the non-symptomatic mid-follicular phase. Binding to the imidazoline site distinguished women with dysphoric PMS from women with no such symptoms, was highly positively correlated with the severity of symptoms, and was negatively correlated with plasma levels of progesterone. These findings suggest that platelet imidazoline binding sites might be a biological marker for dysphoric states in PMS or for the vulnerability to develop them. These findings also point to a possible biological link between dysphoric PMS and major depressive disorders.

Estrogen augments serotonergic activity in postmenopausal women.

To investigate the influence of estrogen replacement on serotonergic activity in postmenopausal women, the serotonin agonist meta-chlorophenylpiperazine (m-CPP) (0.5 mg/kg) was given orally to 18 normal postmenopausal women, 11 of whom were also tested following 30 days' treatment with estrogen transdermal patches (estraderm 0.1 mg). Fifteen normal, healthy women of reproductive status served as a control group. Cortisol and prolactin responses to m-CPP were measured. Without estrogen, the prolactin and cortisol responses of postmenopausal women to m-CPP were blunted compared to those of reproductive women. Estrogen replacement increased the hormonal responses. It is suggested that decreased serotonergic activity in postmenopausal women might contribute to their vulnerability to affective disorders. Estrogen replacement therapy might decrease this vulnerability and might add to the efficacy of serotonergic antidepressants when warranted.

Placenta accreta--summary of 10 years: a survey of 310 cases.

The objective was to study the incidence, risk factors, and outcome of pregnancies complicated by placenta accreta in our population. Retrospective analysis of all deliveries between the years 1990-2000, and identification of all cases of placenta accreta, defined by clinical or histological criteria. For comparison purposes we defined two sub-groups: (i) all cases that ended with severe outcome and (ii) all patients who had a previous event of placenta accreta in one or more of their previous deliveries. We evaluated the potential risk factors leading to these conditions. The SPSS software package was used for statistical analysis. Univariate and multivariate analyses were performed by stepwise logistic regression. The study covered 34 450 deliveries from which 310 cases of placenta accreta were diagnosed (0.9 per cent). The risk factors associated with placenta accreta were previous cesarean delivery (12 per cent), advanced maternal age, high gravidity, multiparity, previous curettage and placenta previa (10 per cent). Hysterectomy was performed in 11 patients (3.5 per cent) with one case of maternal death, whereas 21 per cent of the patients required postpartum blood products transfusion. Antenatal diagnosis of placenta accreta or percreta by ultrasound or MRI, was achieved only in eight of the cases. In the sub-group of 15 patients (4.8 per cent) with severe outcome, the only significant risk factors were increased parity (O.R.=1.29, 95 per cent CI 1.056-1.585), anteriorly low placenta (O.R.=6.1, 95 per cent CI 1.4-25.3) and repeated cases of caesarean sections (O.R.=3.3, 95 per cent CI 0.9-12.5), whereas in the 49 (16 per cent) patients with repeated cases of placenta accreta the only significant risk factor was the number of deliveries (O.R.=1.5, 95 per cent CI 1.0-2.2). Repeated cesarean delivery, high parity, and anteriorly low placental location are associated with severe outcome in case of placenta accreta. Women with repeated events of placenta accreta may have better outcome and a genetic factor may serve as a cause for this condition.

Menstrual irregularities associated with bupropion treatment.

The authors report two cases of menstrual irregularities associated with bupropion treatment. This is the first report of such an association, and it is supported by data collected by the Burroughs Wellcome Co. Since the mode of action of this effective new antidepressant is basically unknown and does not operate through any of the putative mechanisms of the classical antidepressants, its side effect profile is of heuristic as well as practical importance.

Influence of age, sex and diurnal variability on imipramine receptor binding and serotonin uptake in platelets of normal subjects.

Imipramine (IMI) binding and serotonin (5-HT) uptake were determined in platelets of 98 healthy volunteers; and their association with age, sex and circadian rhythm were evaluated. A large interindividual variability was found for both IMI and 5-HT parameters. There was a negative correlation of IMI affinity constant (Kd) and binding (Bmax) with age, but no such correlation of 5-HT affinity constant (Km) or uptake (Vmax). Significant age-related diurnal variability was found for 5-HT Km in the whole group as well as for IMI Kd in males, but not in females. There was no significant correlation between 5-HT Vmax and IMI Bmax. Our results underscore a cautious approach to the interpretation of platelet serotonergic studies. In light of the multiple variables influencing the results, the usefulness of IMI or 5-HT as clinical markers should be re-evaluated.

Elimination of ovulation and menstrual cyclicity (with danazol) improves dysphoric premenstrual syndromes.

OBJECTIVE: To assess whether the therapeutic effect of danazol on premenstrual syndromes (PMS) is associated with suppression of ovulation. DESIGN: After 1 month on placebo, we administered 200 mg/d of danazol for 90 days to 24 women with dysphoric PMS. Symptoms during ovulatory cycles were compared with anovulatory periods. SETTING: Outpatient PMS program in a general hospital. PATIENTS: Twenty-four women who had dysphoric PMS and otherwise were physically and mentally healthy. INTERVENTIONS: None (except the oral medication). MAIN OUTCOME MEASURE: Prospective daily monitoring of symptoms with the Daily Rating Form, before, during, and after treatment. RESULTS: Twenty of 23 anovulatory periods were symptom-free versus 6 of 32 ovulatory periods (chi 2 = 15.63, P = 0.0002). CONCLUSION: The beneficial effect of danazol as treatment depends mostly on achieving an an-ovulatory state and elimination of hormonal cyclicity and not on the drug per se.

Induction of bone formation in rat osteoprogenitor cell culture by sera of climacteric women before and after hormone replacement therapy.

OBJECTIVE: To evaluate the effect of hormone replacement therapy (HRT) on growth and differentiation of cultured osteoprogenitor cells. DESIGN: Prospective clinical study. SETTING: Outpatients in a menopause clinic. PATIENT(S): Women with climacteric symptoms. INTERVENTION(S): Daily oral conjugated estrogen, 0.625 mg, and medroxyprogesterone acetate, 2.5 mg, for 7-12 months. Bone density measurement before HRT and blood sampling before and after HRT. MAIN OUTCOME MEASURE(S): Sera of climacteric women were added to the culture of rat osteoprogenitor cells, and indices of cell proliferation and differentiation (alkaline phosphatase activity and mineralization) were measured before and after HRT. RESULT(S): Sera after HRT significantly decreased cell counts but not alkaline phosphatase activity or mineralization as compared with sera before HRT. However, mineralization induced in the bioassay by both sera showed a positive correlation (r = 0.56) with E2 levels before treatment and a negative correlation (r = -0.6181) with time in menopause of serum donors. The change in mineralization showed a significant correlation with hip bone mineral density z scores (r = -0.67) but not with spine z scores (r = -0.1915), whereas the change in cell count correlated with spine bone mineral density z scores (r = 0.49) only. CONCLUSION(S): Changes in serum-induced cell proliferation and mineralization may be helpful in studying the response to HRT in climacteric women. Serum-induced mineralization is more efficient in diagnosing osteopenia than in monitoring HRT effects.

Seasonal variability in fertilization and embryo quality rates in women undergoing IVF.

OBJECTIVE: IVF-ET provides unique controlled conditions for the study of seasonal influences on the human reproductive process. This study was designed to evaluate the effects of seasonality on fertilization rate, embryo quality, and conception rates. DESIGN: A retrospective observational cohort study. A chart review of all individuals undergoing IVF-ET from 1988 to 1991 at our institution was performed. SETTING: An assisted reproduction unit at a university-based tertiary medical center. PATIENT(S): 657 women, for a total of 1074 IVF-ET treatment cycles, were evaluated. From this population, we chose 305 women undergoing their first IVF-ET cycle for reasons of pure mechanical infertility. INTERVENTION(S): IVF-ET cycles. MAIN OUTCOME MEASURE(S): Seasonal variability in fertilization rates and quality-A embryo rates, and the correlation with the absolute number of light hours, as well as the influence of temperature, humidity, and other environmental parameters. RESULT(S): A significant seasonal variability in the fertilization rate and the quality-A embryo rate was demonstrated. The highest fertilization and quality-A embryo rates were observed during the spring and the lowest in the autumn. These changes correlated with the absolute number of light hours and its increment over time, but not with the temperature, humidity, or other environmental parameters. CONCLUSION(S): Seasonality seems to have a significant influence on the fertilization process and on the quality of the human embryos that are obtained in vitro, possibly because of the light/dark variations over time. If this finding is confirmed, these seasonal changes should be taken into account when evaluating infertility data and in everyday clinical practice.

Effects of hormone replacement therapy on weight, body composition, fat distribution, and food intake in early postmenopausal women: a prospective study.

OBJECTIVE: To evaluate the effects of hormone replacement therapy (HRT) on body weight and composition, fat distribution, and food intake in women entering the climacteric. DESIGN: Prospective clinical study. SETTING: Outpatient menopause clinic at a tertiary medical center. PARTICIPANTS: Sixty-three early postmenopausal women (44 to 54 years old) were prospectively studied for 1 year. They consisted of two groups: group A, 34 subjects who initiated continuous estrogen and progestin treatment (daily oral conjugated estrogen 0.625 mg and medroxyprogesterone acetate 2.5 mg), and group B, 29 women who refused hormonal therapy and served as controls. The age, menopausal status, initial anthropometric measurements (weight, body mass index [BMI], fat mass, and waist-to-hip girth ratio), and daily food intake (total caloric intake and food composition) were similar in both groups. INTERVENTIONS: Anthropometric measurements were performed before commencement of HRT use and after 12 months. MAIN OUTCOME MEASURES: Anthropometric measurements included BMI, waist-to-hip girth ratio, and body composition (the percentage of body fat and water) estimated by means of infrared interactance. Daily food intake was also recorded. RESULTS: The body weight and fat mass increased significantly in both the treatment (73.22 +/- 2.01 [mean +/- SE] to 75.57 +/- 1.12 kg) and the control group (71.45 +/- 3.11 to 73.51 +/- 1.23 kg). However, a significant shift from gynoid to android fat distribution was observed only in the control group (waist-to-hip ratio shifted from 0.80 +/- 0.01 to 0.85 +/- 0.01), whereas no significant change was observed in the treatment group (0.81 +/- 0.01 to 0.82 +/- 0.01). Caloric and macronutrient intake did not change in either group. CONCLUSIONS: These results indicate that continuous daily estrogen and progestin replacement therapy neither prevents nor increases early postmenopausal weight gain and fat accumulation. However, it does minimize the shift from gynoid to android fat distribution.

Prophylactic antibiotics in abdominal hysterectomy.

BACKGROUND: The cephalosporins, which have been widely used in gynecologic surgery, are considered by many to be the drug of choice for chemoprophylaxis. However, their benefit in total abdominal hysterectomy has remained controversial. This study was done to evaluate the effectiveness of the commonly used cephalosporins in preventing inflammatory complications which may occur after elective abdominal hysterectomy. STUDY DESIGN: A MEDLINE and manual review of the literature from the past 15 years (1977 to 1991), using the terms "prophylactic antibiotics," "abdominal hysterectomy," and "cephalosporins," was performed. Seventeen prospective trials using cephalosporin prophylaxis alone for 24 hours perioperatively were evaluated. A meta-analysis of the 2,752 study and control patients abstracted was performed to compare postoperative infection and febrile morbidity rates. RESULTS: The cephalosporin group as well as the various generations and individual drugs were found to be useful in preventing postoperative infection (p < 0.001). Febrile morbidity, however, was effectively prevented (p < 0.001) by first but not by some second and third generation drugs. Multivariate analysis revealed no advantage for the newer, more expensive second and third generation cephalosporins studied. When adjusted for confounding factors, the number of doses, the amount of the dose, and the route of administration had significant impact on the outcome events. CONCLUSIONS: Chemoprophylaxis with cephalosporins was found to be effective in preventing posthysterectomy infectious complications. A single dose, preoperative injection of first (cefazolin) or second (cefoxitin) generation cephalosporin, when administrated intravenously, has been shown to yield the best, cost-effective clinical results.

Laparoscopic surgery during pregnancy.

In the last decade, operative laparoscopic procedures are performed increasingly in both gynecology and general surgery. The major advantages of this newer minimally invasive approach are: decreased postoperative morbidity, less pain and decreased need for analgesics, early normal bowel function, shorter hospital stay, and early return to normal activity. With the advancement of laparoscopic surgery, its use during pregnancy is becoming more widely accepted. The most commonly reported laparoscopic operation during pregnancy is laparoscopic cholecystectomy (LC). Other laparoscopic procedures commonly performed during pregnancy include: management of adnexal mass, ovarian torsion, ovarian cystectomy, appendectomy, and ectopic pregnancy. The possible drawbacks of laparoscopic surgery during pregnancy may include injury of the pregnant uterus and the technical difficulty of laparoscopic surgery due to the growing mass of the gravid uterus. Also, the potential risk of decreased uterine blood flow secondary to the increase in intraabdominal pressure and the possible risk of carbon dioxide absorption to both the mother and fetus should be taken into account. To date, data on laparoscopic surgery during pregnancy are insufficient to draw conclusions on its safety and exact complication rate. This is due to the few cases reported and the lack of prospective studies. Furthermore, there is a common tendency to underreport unsuccessful cases. Finally, most reports in the literature come from centers and surgeons with special interest, experience, and skills in laparoscopy, and their results may not reflect the real complication rates. We have reviewed the pertinent English literature from the last decade. The cumulative experience suggests that laparoscopic surgery may be performed safely during pregnancy, although more studies are needed to establish its exact rate of adverse events.

Gynecological neoplasias in the patient with HIV infection.

HIV infection has been associated with progressive deterioration of the immune system and the development of opportunistic infections and various malignancies. As more experience has been accumulated on the nature and complications of AIDS, the gynecological implications of neoplasia developing in the HIV-positive patient became apparent. A type of cervical malignancy that takes a very aggressive course is being increasingly reported. Other lower genital tract tumors such as vaginal and vulvar neoplasia are also more prevalent in HIV-positive women and a closer follow-up is probably indicated in these patient population. Gestational trophoblastic disease in AIDS patients has also been reported to be more resistant to chemotherapy and may have a grave prognosis. Finally, nongynecological malignancies such as non-Hodgkin's lymphoma (NHL) and Kaposi's sarcoma (KS) may have their first site of appearance in the genital organs, thus simulating gynecological tumors. In this survey, we review the current knowledge accumulated in the English literature, and suggest guidelines for surveillance, diagnosis, and treatment by the practicing gynecologist.

Periurethral injection for the treatment of urinary incontinence.

Periurethral injection of substrates that compress, support, or narrow the bladder neck for the treatment of stress incontinence is not new. Several injectable compounds have been used in a small number of patients during the 1940s and through the 1960s; however, the results were not very successful and often led to significant complications. More recently, two major materials have been developed that seem to be useful in treating stress incontinence by periurethral injection: Polytef paste and GAX collagen. Other injectables include autologous fat tissue and silicone microimplants. The most suitable patients for periurethral injection are elderly women, patients who constitute high operative risk, and those with stress incontinence due to intrinsic sphincter failure. Patients with stress incontinence due to a combination of urethral hypermobility and intrinsic sphincter deficiency with failure of suspension procedure may also benefit from the procedure. The reported long-term (more than 24 months) success rates according to the various substances are as follows: Teflon (Polytef) (E.I.du Pont de Nemours and Co, Wilmington, DE): 30 to 38 percent cured or improved; repeated injections usually do not improve the outcome; mostly minor complications with case reports of more serious side effects such as periurethral granuloma formation and bladder outlet obstruction. GAX collagen: 69 to 77 percent subjectively cured or improved after 24 months; 54 to 57 percent objectively cured or improved, the reported morbidity in these procedures is minimal; repeated injections can improve the outcome. The experience with autologous fat and silicone microimplants is insufficient, with an overall success rate of 70 percent (1-40 months follow-up; mean 12 months) and 58 to 70 percent (17-36 months), respectively. Most of the procedures are performed as outpatient cases, and some under local anesthesia. These procedures are minimally invasive, usually safe and well tolerated, require shorter hospitalization, and are cost effective. In conclusion, in carefully selected patients, periurethral injection seems to be a reasonable option in the modern treatment of female stress incontinence.

High risk pregnancy outcome following induction of labour.

OBJECTIVE: To evaluate whether induction of labour, performed in a high risk obstetric population, when medically indicated, carries an increased risk for operative delivery and maternal and fetal complications. The secondary goal was to study the effect of the various induction methods used on these outcomes and labour time. STUDY DESIGN: This study was carried out at a level [1] university hospital. A group of 210 women who were induced for various indications, were compared to our general parturient population. Main outcome measures were cesarean section (CS) and instrumental delivery rates, intra-partum and post-partum complications, APGARs 1' and 5' and labour time by induction method. RESULTS: No significant increase in the rates of primary CS (8.6 vs. 7.1%) and instrumental delivery (15.7 vs. 12.7%), were found in the induction high risk group as compared to our general obstetric population. Intra-partum complications and fetal outcome were comparable in both groups. A comparison of methods of induction used (oxytocin, PgE2, Amniotomy) revealed a less favorable outcome with the oxytocin induction method which showed an elevated intra-partum complication rate (P < 0.01) and a tendency toward lower Apgar scores and higher CS rate. CONCLUSIONS: Induction of labour performed in a high-risk obstetric population is safe, carrying no significant increase in CS and neonatal complication rates. Of the three methods of induction used, oxytocin induction showed the least favorable outcome for both mother and her offspring.

Parasitic ovarian dermoid tumor of the omentum-A review of the literature and report of two new cases.

Two cases of a parasitic omental teratoma which originated from an ovarian dermoid that underwent torsion, autoamputation and omental reimplantation are presented. A review of the literature revealed 23 additional cases of omental teratoma which occurred mostly in females. In some cases, the mature teratoma of the omentum showed histological evidence of ovarian stroma, and was associated with a dermoid tumor of the remaining contralateral ovary. It is generally believed that autoamputation and reimplantation of an ovarian dermoid cyst is the most common etiology of omental teratomas. Abdominal pain is the main presenting symptom of these tumors, and on physical examination a mobile abdominal or pelvic mass is often found. Both ultrasonography with colour flow Doppler and CT-scan are helpful in the diagnosis of dermoid tumors, but the correct diagnosis of omental localisation is extremely difficult. Mature omental teratomas may be treated by simple resection. The immature teratomas of the greater omentum, however, are potentially malignant tumors requiring postoperative chemotherapy and radiotherapy.

Monoamniotic twins: an update on antenatal diagnosis and treatment.

OBJECTIVE: Monoamniotic twins are very uncommon and are characterized by a high perinatal mortality rate. Cord entanglement, prematurity, congenital anomalies and twin to twin transfusion are reportedly the main causes of death, which usually occurs before 24 weeks' gestation. The aim of this study was to review the newly developed methods for diagnosis and treatment and suggest a reasonable approach to the management of these rare cases. METHOD: We reviewed the English-language literature in the past 15 years through Medline search and subsequent examination of individual publications. RESULTS: In the past two decades, newer technologies such as advanced ultrasonography and color flow Doppler studies have enabled early diagnosis of this condition and its complications. Furthermore, new treatment modalities such as fetoscopy with laser coagulation of vascular anastomoses and treatment with non-steroidal anti-inflammatory drugs such as sulindac, to reduce amniotic fluid volume, may have contributed to a better outcome. Also, occlusion of one umbilical cord (fetal reduction) at an early stage has been suggested to prevent late complications. CONCLUSION: Cumulative experience suggests that the majority of cases can be diagnosed reliably at an early gestational age. Treatment with medical amnioreduction, surgical amnioreduction or fetal reduction in selected cases may be offered before 24 weeks' gestation. Later, intensive antepartum fetal surveillance should probably be offered until 32 weeks, at which point elective preterm delivery may be considered to prevent possible fetal death.

The use of fetal tissue for therapeutic applications.

In recent years, dramatic progress has been made through research using dead human fetal tissue. Cellular transplantation is an attractive alternative to organ grafting when only a discrete function of the organ is impaired. Early fetal donor cells have an advantage because they engraft readily and do not cause graft-versus-host disease. Similarly, the fetus is an ideal recipient of allogenic fetal cells as it is incapable of rejecting them early in gestation. Recent research advances have led to its use in endocrine, neurologic and immune system disorders as well as in hematologic and hepatic deficiencies. Concurrently, this research has led to controversy over the ethics of using human fetal tissue, particularly tissue from induced abortions. Although legalized abortion remains a hotly debated controversial issue in the USA and some other countries, a consensus has been forming, in the scientific community, on the ethical use of fetal tissue in research and clinical transplantation. This review presents the theoretical background and recent research and clinical advances in fetal tissue transplantation, in the light of the current debate on its ethical and moral implications.

Induction of labor in breech presentation.

OBJECTIVE: Induction of labor in breech presentation, although not contraindicated, has rarely been reported. We have undertaken to evaluate the safety and outcome of this practice in two Israeli institutions along with a literature review of this controversial subject. METHOD: The research design was a retrospective case control study covering the years: 1980-1999. We have studied 53 term (>37 weeks) breech deliveries induced for various medical and obstetrical reasons, in two major regional hospitals in Israel. Induction was performed with prostaglandin E(2) for the unripe cervix and with oxytocin for induction or augmentation when the cervix was ripe. Six women were induced by nipple stimulation. Controls were 53 women with spontaneous labor in breech presentation that had a trial of vaginal delivery, and 54 women with breech presentation who delivered by elective cesarean section. RESULT: No significant difference in the various maternal and fetal outcomes was observed. CS rate was comparable in both study and control groups (34% vs. 32%) and two-thirds gave birth vaginally. CONCLUSIONS: In properly selected and carefully managed cases of breech presentation, induction of labor seems a safe and reasonable option.