Risk factors for relaparotomy after a cesarean delivery: a case-control study.

BACKGROUND: Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center. METHODS: A retrospective case-control single-center study (2013-2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders. RESULTS: During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24 h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08-10.24, p = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11-9.05,p = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43-11.79,p = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29-9.3,p = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15-5.88, p = 0.029); complications during CD (aOR 1.62, 95%CI 1.09-3.21,p = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29-4.12,p = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24 h. CONCLUSION: We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.

Routine Automated Assessment Using Surgical Intelligence Reveals Substantial Time Spent Outside the Patient's body in Minimally Invasive Gynecological Surgeries.

OBJECTIVE: To demonstrate the use of surgical intelligence to routinely and automatically assess the proportion of time spent outside of the patient's body (out-of-body-OOB) in laparoscopic gynecological procedures, as a potential basis for clinical and efficiency-related insights. DESIGN: A retrospective analysis of videos of laparoscopic gynecological procedures. SETTING: Two operating rooms at the Gynecology Department of a tertiary medical center. PARTICIPANTS: All patients who underwent laparoscopic gynecological procedures between January 1, 2021 and December 31, 2022 in those two rooms. INTERVENTIONS: A surgical intelligence platform installed in the two rooms routinely captured and analyzed surgical video, using AI to identify and document procedure duration and the amount and percentage of time that the laparoscope was withdrawn from the patient's body per procedure. RESULTS: A total of 634 surgical videos were included in the final dataset. The cumulative time for all procedures was 639 hours, of which 48 hours (7.5%) were OOB segments. Average OOB percentage was 8.7% (SD = 8.7%) for all the procedures and differed significantly between procedure types (p < .001), with unilateral and bilateral salpingo-oophorectomies showing the highest percentages at 15.6% (SD = 13.3%) and 13.3% (SD = 11.3%), respectively. Hysterectomy and myomectomy, which do not require the endoscope to be removed for specimen extraction, showed a lower percentage (mean = 4.2%, SD = 5.2%) than the other procedures (mean = 11.1%, SD = 9.3%; p < .001). Percentages were lower when the operating team included a senior surgeon (mean = 8.4%, standard deviation = 9.2%) than when it did not (mean = 10.1%, standard deviation = 6.9%; p < .001). CONCLUSION: Surgical intelligence revealed a substantial percentage of OOB segments in laparoscopic gynecological procedures, alongside associations with surgeon seniority and procedure type. Further research is needed to evaluate how laparoscope removal affects postoperative outcomes and operational efficiency in surgery.

Apoptosis versus necrosis in tubal ectopic pregnancies following Methotrexate.

Methotrexate administration for the treatment of tubal ectopic pregnancies has been shown to cause tubal mass enlargement. Our hypothesis was that, by administrating Methotrexate, a local necrotic reaction occurs, leading to hematoma formation and eventually fallopian tube rupture. Salpingectomy specimens were collected, analysed and divided into three equal groups: patients who received Methotrexate but who ultimately failed medical treatment, patients who had a viable ectopic pregnancy and patients with a self-resolving ectopic pregnancy that were operated due to other medical indications. The specimens were dyed using the Cleaved Caspase-3 (Asp175) Rabbit mA. Specimens were divided into three equal groups and analysed. The patients in self-resolving ectopic pregnancy group were older and had more pregnancies. Rates of apoptosis were found to be less than 1% per slide. Necrosis was not evident in any of the pathological specimens. It seems Methotrexate administration does not lead to a significant tubal necrotic reaction. Further studies are required.

Primary Resectoscopic Treatment of First-Trimester Miscarriage.

OBJECTIVES: To determine the feasibility and safety of resectoscopic treatment for uterine evacuation of first-trimester miscarriage. METHODS: A single-centre prospective study performed between April 2021 and October 2021 at a university-affiliated tertiary medical centre. Patients diagnosed with early miscarriage of up to 12 weeks from the last menstrual period were eligible for participation. Recruited patients underwent hysteroscopic uterine evacuation under general anaesthesia by a Versapoint 2 bipolar resectoscope 24Fr (Johnson and Johnson, Germany). RESULTS: A total of 15 patients were recruited for the study. The procedural characteristics as well as intra- and postoperative adverse events were recorded. The mean duration of the procedure was 14.3 ± 3.7 minutes. The achievement of complete evacuation was recorded in all cases, and no adverse events occurred during any procedure. Post-procedure follow-up 6 weeks after treatment was conducted by office hysteroscopy in 10 women and by ultrasonography in 4 women. One woman had conceived prior to her scheduled follow-up visit. In total, 2 (13.3%) cases of retained products of conception were diagnosed during office hysteroscopy and they were removed by the "see-and-treat" technique without anaesthesia. The diagnosis was confirmed pathologically. No intrauterine adhesions were detected and none of the women required a second hysteroscopy under anaesthesia due to retained products of conception. CONCLUSIONS: Hysteroscopic evacuation of first-trimester miscarriage by a standard resectoscope is a safe and feasible technique.

Expectant vs medical management for retained products of conception after medical termination of pregnancy: a randomized controlled study.

BACKGROUND: Despite the rise of medical treatments for the termination of pregnancy, to date, no prospective trial has evaluated the efficacy of misoprostol in treating retained products of conception after induced termination of pregnancy. OBJECTIVE: This study aimed to compare medical management with misoprostol with expectant management for retained products of conception after first-trimester medical termination of pregnancy. STUDY DESIGN: This was an open-label randomized controlled trial conducted at a university-affiliated tertiary medical center. Consenting consecutive women who underwent a routine 3-week follow-up evaluation after medical termination of pregnancy and had a sonographic suspicion of retained products of conception, defined as sonographic evidence of intrauterine remnant (>12 mm) with a positive Doppler flow, were recruited. The participants were randomized into a medical treatment group (800 µg of sublingually administered misoprostol) or expectant management. They all underwent repeat ultrasound scans every 2 weeks until a maximum of 6 weeks, and those suspected of persistent retained products of conception were referred to operative hysteroscopy. The primary endpoint was successful treatment defined as no need for surgical intervention because of persistent retained products of conception within 8 weeks from pregnancy termination. RESULTS: There was no marked difference in demographic characteristics between the study groups. The median sonographically demonstrated retained product length was 20 mm (interquartile range, 17-25) in the medically managed group compared with 20 mm (interquartile range, 17-26) in the expectantly managed group (P=.733). Treatment succeeded in 42 of 68 women (61.8%) in the medically managed group compared with 36 of 63 women (57.1%) in the expectantly managed group (relative risk, 1.12; 95% confidence interval, 0.74-1.70; P=.590). There was no difference in adverse outcomes between the 2 groups. CONCLUSION: There was no clinically meaningful advantage for medical treatment with misoprostol compared with expectant management after first-trimester medical termination of pregnancy in women with suspected retained products of conception. Surgical intervention can be avoided in up to 60% of women who are managed expectantly for 8 weeks of follow-up.

Incidence of endometrial carcinoma in patients with endometrial intraepithelial neoplasia versus atypical endometrial polyp.

ObjectiveOur study's primary aim was to compare the incidence of endometrial carcinoma in patients with a presurgical diagnosis of endometrial intraepithelial neoplasia confined to the endometrium (EIN-E) versus endometrial intraepithelial neoplasia confined to a polyp (EIN-P). Our secondary aim was to examine the difference in pathological features, prognostic risk groups and sentinel lymph node involvement between the two groups. METHODS: We conducted a retrospective cohort study between January 2014 and December 2020 in a tertiary university-affiliated medical center. The study considered the characteristics of women who underwent hysterectomy with sentinel lymph node dissection for endometrial intraepithelial neoplasia (EIN). We compared EIN-E diagnosed by endometrial sampling via dilatation curettage or hysteroscopic curettage vs EIN-P. A multivariate logistic regression analysis was used to assess risk factors for endometrial cancer. RESULTS: Eighty-eight women were included in the study, of those, 50 were women with EIN-P (EIN-P group) and 38 were women with EIN following an endometrial biopsy (EIN-E group).The median age was 57.5 years (range; 52-68) in the EIN-P group as compared with 63 years (range; 53-71) in the EIN-E group (p=0.47). Eighty-nine percent of the women in the EIN-E group presented with abnormal uterine bleeding whereas 46% of the women in the EIN-P group were asymptomatic (p=0.001). Pathology results following hysterectomy revealed concurrent endometrial carcinoma in 26% of women in the EIN-P group compared with 47% of women in the EIN-E group (p=0.038). Multivariate analysis showed that endometrial cancer was significantly less common in the EIN-P group (overall response (OR)=0.3 95% confidence interval (CI)=0.1-0.9, p=0.03). Eighty-four percent of cancers were grade one in the EIN-P group compared with 50% in the EIN-E group (p=0.048). CONCLUSIONS: Concurrent endometrial cancer is less frequent with EIN-P than with EIN-E. The high incidence of endometrial carcinoma in both groups supports the current advice to perform hysterectomy for post-menopausal women. Our data does not support performing sentinel lymph node dissection for EIN-P that was completely resected. The benefit of sentinel lymph node dissection for women with pre-operative EIN-E is yet to be determined.

Recurrent Ovarian Torsion: Risk Factors and Predictors for Outcome of Oophoropexy.

STUDY OBJECTIVE: To identify risk factors for recurrent ovarian torsion and evaluation of the efficacy of oophoropexy techniques. DESIGN: Case control study. SETTING: Tertiary university-affiliated medical center. PATIENTS: A total of 79 women with recurrent ovarian torsion (study group) were matched with 158 women with a single episode of ovarian torsion (control group). INTERVENTIONS: Laparoscopic detorsion and oophoropexy. MEASUREMENTS AND MAIN RESULTS: Demographic data, clinical characteristics, ultrasound characteristics, surgical findings, surgical procedures, and torsion recurrence rates were analyzed and compared between the 2 groups between 2001 to 2020. RESULTS: There was an inverse association between women's age and the risk of recurrent torsion (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.83-0.96, p = .003). Moreover, in women younger than 20 years, the risk of recurrent event was substantially higher (aOR, 5.0; 95% CI, 1.56-6.15, p = .007). In addition, the absence of ovarian pathology was associated with increased risk for recurrent torsion (aOR, 14.3; 95% CI, 6.15-33.42; p <.001). Oophoropexy was performed in 46 women in the study group. The risk of recurrent torsion after oophoropexy was 30%. A long duration of pain before admission was associated with oophoropexy failure (37.5 ± 6.3 hours vs 11.7 ± 6.0 hours, p = .003). No single fixation procedure was superior to the others in terms of therapeutic success. CONCLUSION: Recurrent ovarian torsion is more common in young women with a normal-appearing ovary. Oophoropexy is a safe procedure with a risk of retorsion in 30% of the patients. We found no advantage for one fixation technique over the others.

Reproductive Outcomes and Overall Prognosis of Women with Asherman's Syndrome Undergoing IVF.

STUDY OBJECTIVE: To evaluate the impact of Asherman syndrome (AS) following hysteroscopic adhesiolysis on reproductive outcomes and the time to achieve pregnancy in women with infertility undergoing in vitro fertilization (IVF) treatment. DESIGN: Case-control study. SETTING: Tertiary university-affiliated medical center. PATIENTS: Fifty-one infertile women who were treated for AS and underwent IVF (study group) matched for age and etiology of infertility with non-AS controls at a 1:1 ratio. INTERVENTIONS: Medical records search, chart review, and phone survey were used to assess reproductive outcomes. MEASUREMENTS AND MAIN RESULTS: A multivariate logistic regression analyses was used to assess live birth, accounting for patient age at stimulation cycle start, parity, number of embryos transferred, and endometrial thickness. A survival analysis was performed to assess the times that had lapsed from interventions to conception. The study group of 51 women included 38 (74.5%) with moderate to severe disease. The mean number of embryo transfers per woman was similar for the study and control groups (4.9 ± 4.6 vs 6.22 ± 4.3, respectively, p = .78). The controls had a significantly higher mean endometrial thickness before embryo transfer (8.7 ± 1.8 mm vs 6.95 ± 1.7 mm, p = .001). The overall time to achieve live birth was significantly longer in women with AS (p = .022). In a logistic regression analysis, the presence of moderate to severe AS was shown to be an independent factor for achieving a live birth (adjusted odds ratio 0.174, 95% confidence interval [CI], 0.032-0.955, p = .004). Women with AS who had live births had a significantly thicker mean endometrial thickness (8.2 ± 1.4 mm vs 6.9 ± 1.2, p = .001). CONCLUSION: Moderate and severe AS has a detrimental effect on reproductive performance in infertile women. Endometrial thickness is an important predictor for live births among women with AS who undergo IVF.

Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions.

INTRODUCTION: Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions. METHODS: A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results. RESULTS: Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ±â€¯5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%. CONCLUSIONS: A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.

Obstetrical outcomes following laparoscopy during pregnancy: a retrospective case-control study.

PURPOSE: To evaluate pregnancy outcome of patients who undergo laparoscopy during pregnancy. METHODS: A retrospective case-control study, conducted in a single university-affiliated tertiary care medical center, comparing pregnancy outcomes of women who underwent laparoscopy during pregnancy to women without operations during pregnancy. The study group (n = 232) included all pregnant women who underwent a single laparoscopic surgery during pregnancy (4-28 weeks of gestation) which culminated in delivery between 2006 and 2017; this study group was matched to a control group (n = 463) without surgical intervention during pregnancy, in a 2:1 ratio by maternal age, parity, and multiple gestation. RESULTS: The main pregnancy outcomes included preterm birth, cesarean section, small for gestational age (≤ 10 percentile), and Apgar score of less than 7 in 5 min. Laparoscopy during pregnancy was associated with an increased risk for cesarean section (32.3% vs. 24.6%, adjusted OR = 1.9, CI 1.2-3.1, p = 0.011). We found no difference between the groups with regard to other outcomes, including rates of preterm birth (12.1% vs. 10.4%, adjusted OR = 1.3, CI 0.64-2.72, p = 0.451). In a subgroup analysis of the study group, various perioperative parameters such as operation duration, hospitalization length, and others, did not correlate with adverse pregnancy outcome. CONCLUSIONS: Laparoscopy during pregnancy may be associated with an increased rate of cesarean section. We did not find an increase in any other pregnancy or neonatal complication. Different perioperative parameters did not appear to predict adverse pregnancy outcome.

Complicated Clinical Course and Poor Reproductive Outcomes of Women with Tubo-Ovarian Abscess after Fertility Treatments.

STUDY OBJECTIVE: To assess the clinical course and surgical and fertility outcomes of patients diagnosed with tubo-ovarian abscess (TOA) after fertility treatment. DESIGN: Parallel case series over 10 consecutive years (Canadian Task Force classification II-2). SETTING: Tel Aviv Sourasky Medical Center, a tertiary university-affiliated hospital. PATIENTS: Thirty-seven women who were diagnosed with TOA after fertility treatments (in vitro fertilization and intrauterine insemination) were compared with 313 women who were diagnosed with TOA not associated with fertility treatments during the same time period. INTERVENTION: Medical records search, chart review, and phone survey were used to assess clinical course and surgical and reproductive outcomes. MEASUREMENTS AND MAIN RESULTS: Women with TOA after fertility treatments had significantly higher inflammatory markers upon admission compared with the nonfertility treatment group (mean white blood cell count, 16.1 × 1000/mm3 [standard deviation [SD], ±4.3] vs 13.8 × 1000/mm3 [SD, ±6.3], p = .001, respectively; and mean C-reactive protein, 149 mg/L [SD, ±78.3] vs 78.2 mg/L [SD, ±68.5], p = .001, respectively). In addition, TOA after fertility treatments was associated with a significantly higher surgical intervention rate and a more complicated clinical course, as evidenced by a shorter time interval from admission to surgery (2.1 days vs 3.2 days, p = .01), higher rates of antibiotic failure, higher conversion rate from laparoscopy to laparotomy (14.2% vs 3.2%, p = .005), increased perioperative complications rate (25.0% vs 3.8%, p = .0001), and a longer hospitalization stay (7.2 days vs 4.8 days, p = .01). Clinical pregnancy rate per cycle in women with TOA after fertility treatments was 9%, and 1 case of live birth was recorded. CONCLUSIONS: Our data indicate that TOA after fertility treatment has a substantial effect on the clinical course and surgical outcome. Prophylactic antibiotic treatment before ovum retrieval and deferral of embryo transfer should be considered in patients at risk of infection.

Surgical Intervention in Patients with Tubo-Ovarian Abscess: Clinical Predictors and a Simple Risk Score.

STUDY OBJECTIVE: To identify the clinical characteristics associated with surgical intervention in patients with tubo-ovarian abscess (TOA). DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary university-affiliated hospital. PATIENTS: Three hundred thirty-five patients were diagnosed with TOA based on sonographic and clinical criteria. Patients who underwent surgical intervention were compared with patients managed conservatively. INTERVENTION: Electronic medical records were used to identify patients who were diagnosed with TOA between 2007 and 2015. All patients received the same antibiotic regimen upon admission. The data extracted included microbial and pathologic reports. Clinical characteristics such as disease severity and outcomes were compared. The clinical predictors available on patient admission for surgical intervention were identified retrospectively. A logistic regression was used to determine the independent predictors of treatment failure. A risk score was created by giving a nominal weight to each predictor. The score was validated by a random bootstrap analysis. An additional validation cohort that consisted of patients diagnosed with TOA during the 2 years after the original study period was applied to the final score. MEASUREMENTS AND MAIN RESULTS: The following variables of patients who underwent surgical intervention in comparison with those successfully treated and were enrolled into the score analysis differed significantly: age at admission (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3-3.5), mean leukocytosis at admission (OR, 2.2; 95% CI, 1.3-3.6), ultrasonographic measurement of abscess diameter (OR, 3.6 95% CI, 2.0-6.3), and the presence of bilateral abscess (OR, 2.2; 95% CI, 1.3-3.9). Risk groups A, B, C, and D were positively correlated with the need for surgical intervention. Those in the highest risk group D had an antibiotic failure rate of 92%, as compared with those with the lowest risk group, in which there was a 20% risk of antibiotic failure. CONCLUSIONS: Antibiotic treatment failure for TOA can be predicted on patient admission using a novel risk assessment score.

Fertility outcomes in patients with tubo-ovarian abscesses after an oocyte retrieval: a longitudinal cohort analysis.

PURPOSE: To determine the impact of pelvic inflammation caused by tubo-ovarian abscess (TOA) on ovarian response to stimulation. METHODS: This retrospective longitudinal cohort analysis that was carried out in a tertiary university-affiliated medical center included 15 women with TOA during in vitro fertilization (IVF) cycles. The ovarian response to stimulation and the pregnancy rate were compared in two subsequent cycles, the initial IVF cycle that was complicated by TOA after oocyte retrieval (first treatment cycle) and the following IVF treatment (second treatment cycle) that occurred within a period of a year from the first cycle. RESULTS: The mean number of retrieved oocytes was significantly higher in the first IVF cycle compared to the second cycle (8.1 ± 3.2 vs. 5.4 ± 2.5, P = .003], corresponding to a 30% reduction in ovarian response to gonadotropin stimulation. Fertilization rates were significantly lower in the second cycle (4.1 ± 2.9 vs. 2.9 ± 1.7, P = .015). Twelve women (80%) reached embryo transfer in the first cycle compared to 14 women (93.3%) in the second cycle. The mean number of transferred embryos was similar between the two cycles. There were no clinical pregnancies following the first cycle, and only one patient (6.6%) had a clinical pregnancy in the second treatment cycle. CONCLUSIONS: TOA following fertility treatment has a detrimental effect on ovarian function. The pregnancy rate in the immediate period following TOA is poor. Current data for recommending the deferral of fertility treatment following a TOA episode are insufficient, calling for more studies to address these issues.

Adnexal Torsion in Postmenopausal Women: Clinical Presentation and Risk of Ovarian Malignancy.

STUDY OBJECTIVE: To investigate the clinical presentation, operative outcome, and incidence of malignancy in postmenopausal women who were diagnosed with adnexal torsion. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary university-affiliated hospital. PATIENTS: Postmenopausal women diagnosed with adnexal torsion between 1995 and 2014 (study group) were reviewed and compared with 220 premenopausal patients diagnosed with adnexal torsion during the same time period. INTERVENTION: Demographic data, clinical signs and symptoms, and intra- and postoperative characteristics were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: During the study period 44 postmenopausal women were diagnosed with adnexal torsion. Continuous dull pain was the most common presenting symptom in the postmenopausal group (57%), whereas acute-onset sharp pain was the predominant symptom in the premenopausal group (86%). The time interval from admission to surgery was significantly longer in the postmenopausal group (24 vs 6 hours, p < .001). Laparoscopic surgery was performed in 84.5% of the cases in the premenopausal group, whereas it was carried out in only 50% of cases in the postmenopausal group (p < .001). Four women in the postmenopausal group were diagnosed with malignancy, whereas only 1 case of malignancy was found in the premenopausal group (9% vs .4%, respectively; p = .003). CONCLUSIONS: Adnexal torsion in postmenopausal women is an uncommon event with a unique presentation. Because ovarian malignancy is not an uncommon finding in this group of patients, preparation for more extensive surgery should be contemplated.

Severe intrahepatic cholestasis of pregnancy is a risk factor for preeclampsia in singleton and twin pregnancies.

OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP) is known to be associated with fetal complications. It recently was suggested to be associated possibly with preeclampsia (PET) as well. The objective of this study was to investigate that possibility. STUDY DESIGN: The study group included 78 women (54 singleton and 24 twin pregnancies) who had been diagnosed with ICP based on clinical presentation, elevated liver enzymes, and elevated total bile acids (>10 µmol/L). Disease severity was based on total bile acids levels as being severe (>40 µmol/L), moderate (20-40 µmol/L), or mild (10-20 µmol/L). The course of disease was reviewed carefully in each case. The control groups were comprised of apparently healthy women with singleton (n = 200) and twin (n = 100) pregnancies that were drawn randomly from a computerized registry of all the deliveries in our institution during the study period. RESULTS: The total incidence of PET was significantly higher for the patients with ICP who had singleton and twin pregnancies compared with the control groups (singletons: 7.4% vs 1.5%; P < .05; twins: 33.3% vs 6.2%; P < .05, respectively). The incidence of severe PET was also significantly higher in both singleton (11-fold) and twin (8-fold) pregnancies compared with control subjects. Severe ICP, but not mild ICP, was a major risk factor for PET among women with either singleton or twin pregnancies. The timing of the initial presentation of ICP had no effect on PET incidence rates. Preeclampsia occurred usually 2-4 weeks after the diagnosis of ICP, and proteinuria preceded elevated blood pressure in all cases. Moreover, the total bile acid levels among 33 women who were diagnosed as having PET, but not ICP, were within normal range. CONCLUSION: ICP increases the incidence of PET; severe disease was a major risk factor for preeclampsia. Therefore, we strongly suggest including routine evaluation for preeclampsia in the treatment of women with moderate and severe ICP.

Personnel-itis: a myth or a pathology? A retrospective analysis of obstetrical and perinatal outcomes for physicians and nurses.

OBJECTIVE: To evaluate whether medical personnel differ from the general population in obstetrical and perinatal outcomes. MATERIALS AND METHODS: The participants comprised 46 physicians and 116 nurses employed at one medical center who gave birth in its maternity hospital. General medical and obstetrical data on their latest ("index") pregnancy and delivery were extracted from real-time computerized patient files. The control group included 162 women who gave birth during the same period in the same hospital. RESULTS: The study group had significantly more deliveries, cesarean sections, and terminations of pregnancy prior to the index pregnancy. The medical personnel conceived significantly more often with assisted reproductive technologies (ART) (18.8% vs. 8% for controls, P<0.05), and had significantly more obstetrical complications, i.e., premature contractions, gestational diabetes mellitus, preeclamptic toxemia, and 2nd/3rd trimester bleeding or chorioamnionitis (42.5% vs. 29% for controls, P<0.05). The rate of vaginal birth after cesarean delivery (VBAC) was lower in the study group (22.2% vs. 33.3% for controls, P=0.03). There was no difference in gestational age at delivery, birth weight, or adverse neonatal outcome. CONCLUSIONS: Medical personnel utilized ART more frequently and had more pregnancy complications as well as a lower incidence of VBAC than non-personnel. Neonatal outcomes were similar for both groups.

Methotrexate success rates in progressing ectopic pregnancies: a reappraisal.

OBJECTIVE: The purpose of this study was to determine the success rates of methotrexate in progressing ectopic pregnancies and to correlate them with beta-human chorionic gonadotropin (ß-hCG) levels. STUDY DESIGN: This retrospective cohort study that was carried out in a tertiary university-affiliated medical center included women who had been diagnosed with ectopic pregnancies between January 2001 and June 2013. Daily ß-hCG follow-up examinations were performed to determine the progression of the ectopic pregnancy. Women with hemodynamically stable progressing ectopic pregnancies received methotrexate (50 mg/m(2) of body surface). We measured the success and failure rates for methotrexate treatment in correlation to ß-hCG level. RESULTS: One thousand eighty-three women were candidates for "watchful waiting" (ß-hCG follow up). Spontaneous resolution and decline of ß-hCG levels occurred in 674 patients (39.5%); 409 women (24.0%) had stable or increasing ß-hCG levels and were treated with methotrexate. In 356 women (87.0%), the treatment was successful; 53 women (13.0%) required laparoscopic salpingectomy. Compared with prompt administration of methotrexate, our protocol resulted in lower overall success rates for all levels of ß-hCG in women with progressing ectopic pregnancies: 75% in women with ß-hCG levels of 2500-3500 mIU/mL, and 65% in women with ß-hCG levels >4500 mIU/mL. A mathematic model was found describing the failure rates for methotrexate in correlation with ß-hCG levels. CONCLUSION: The success rates for methotrexate treatment in progressing ectopic pregnancies after daily follow-up evaluation of ß-hCG levels are lower than previously reported. This reflects redundant administration of methotrexate in cases in which the ectopic pregnancy eventually will resolve spontaneously.

Total fertilization failure in intra-cytoplasmic sperm injection cycles--classification and management.

In this retrospective cohort study we intended to propose a classification and preliminary management strategy for couples exhibiting total fertilization failure (TFF) in intra-cytoplasmic sperm injection (ICSI) cycles. Sixteen couples with a total of 27 cycles exhibiting TFF, age <40 and/or more than four M2 oocytes aspirated were enrolled. While TFF occurred in 4.3% of all 3723 ICSI cycles, in women younger than 40 with at least 5 M2 oocytes the TFF rate was 0.7%. Indications for ICSI were severe male factor and unexplained infertility. Of the 16 couples with TFF, 4 demonstrated a single episode of TFF, with either subsequent or former normal fertilizations, thus implying possible sporadic faulty laboratory conditions. Ten couples demonstrated repeated total or very low fertilization rates, hinting at a gamete defect not overcome by ICSI. Two couples experienced TFF in the first and only cycle performed at our unit. We conclude that initial and repeated TFF hints at severe gamete defects for which only donor gametes may prove successful while sporadic TFF events could simply imply a technical modifiable condition.

Embryo quality in controlled ovarian stimulation for in vitro fertilization in young poor responders.

This retrospective matched case control study was conducted to evaluate the effects of poor ovarian response in a group of young women (20-30 years) on embryos quality in controlled ovarian hyperstimulation (COH) for in vitro fertilization. Thirty-nine young patients with poor ovarian response (≤5 oocytes on retrieval) were enrolled and compared to age- and date-matched controls. Maximal Estradiol levels, number of oocytes aspirated, number of M2 oocytes and number of fertilized oocytes were significantly lower in the study group compared to controls. Implantation rate and rate of good quality embryos transferred of the study group and control were comparable (15.3 versus 16.3% and 62 versus 67.2%, respectively). Additionally, clinical pregnancy rate per transfer and delivery rate per transfer were also comparable (26.6 versus 35.8% and 23.3 versus 30.7%, respectively). The rate of cycles with no transfer, however, was 23.07% in the study group compared to zero cycles with no transfer in the control group. We conclude that young poor responders may still have reasonable proportion of good quality embryos when compared to controls. This results in comparable implantation rate and clinical pregnancy rate. Cycle transfer cancelation, however, represents a true barrier for achieving pregnancy.