Can we decrease breakthrough bleeding in patients with endometriosis on norethindrone acetate?

OBJECTIVE: To compare the breakthrough bleeding in endometriosis patients treated with Lupron-Depot alone, norethindrone acetate following Lupron-Depot, and norethindrone acetate alone. PATIENTS AND METHODS: 71 women with symptomatic surgically diagnosed endometriosis were retrospectively evaluated for this study. 28 women were treated with 6 doses of 3.75 mg Lupron-Depot every 4 weeks (Group I). 15 women were treated first with Lupron-Depot 3.75 mg every 4 weeks for 3 to 6 doses, followed by 5 mg norethindrone acetate (Group II). 28 patients were treated for 6 months with 5 mg per day norethindrone acetate alone (Group III). Breakthrough bleeding during treatment was scored mild (some spotting), moderate (lighter than patient's normal menstruation), or severe (as much as patient's normal menstruation or heavier). Multiple comparisons were done by ANOVA (SPSS) among three groups. The age of patients was not significantly different between groups 134.9-36.8 years). BMI of the three groups was significantly different 126.6 +/- 5.8, 27.4 +/- 6.4, 23.6 +/- 4.5, respectively). RESULTS: Breakthrough bleeding was reported by 14% of Group I, 20% of Group II, and 68% of Group III. CONCLUSION: Endometriosis patients who were treated with norethindrone acetate following Lupron-Depot had significantly less breakthrough bleeding than those given norethindrone acetate alone, and the incidence was comparable to Lupron-Depot alone.     

Should ICSI be recommended routinely in patients with four or fewer oocytes retrieved?

Purpose  

To determine if patients with a low response to controlled ovarian hyperstimulation during IVF benefit from intracytoplasmic sperm injection (ICSI)     

Induction of labour with previous caesarean delivery: where do we stand?

PURPOSE OF REVIEW: This paper reviews the literature to elucidate the international stance on induction of labour in women with previous caesarean section. RECENT FINDINGS: There is no evidence to suggest that current induction methods are less effective in women with previous caesarean section. It would, therefore, seem logical to use the same regimens as for women with intact uteri, including prostaglandins, particularly in women with unfavourable cervices. The clinical decision making and counselling, however, will always focus on safety, not effectiveness. There is no question that induction of labour is associated with higher risk of uterine rupture, but quantifying this risk remains elusive. SUMMARY: For the present, we will continue our practice, based on the sources of the best evidence available. Improvements in obstetric care have not only reduced the risks associated with uterine rupture but also risks associated with caesarean section. Therefore, both elective caesarean section and induction of labour, with or without prostaglandins, are reasonable choices for women who need induction with previous caesarean section. The efforts to better quantify the benefits/risks of various policies and regimens should continue, but should be complemented with qualitative studies to obtain crucial insight into the demands and challenges confronting women and clinicians to identify factors influencing their decision-making or their preferences.     

Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor?

OBJECTIVE: To estimate the rate of successful vaginal birth including operative vaginal delivery in patients with a previous cesarean for cephalopelvic disproportion in the second stage of labor. METHODS: Data from all patients who underwent trial of labor after a previous cesarean between 1990 and 2000 at our tertiary care institution were analyzed. Medical records were reviewed and data collected for the following variables: indication for the previous cesarean, birth weight and cervical dilatation at previous cesarean delivery, as well as the mode of delivery (spontaneous, vacuum, forceps, cesarean) and the birth weight for the subsequent pregnancy. Pearson's chi(2) test and one-way analysis of variance were used for statistical analyses. RESULTS: There were 2002 patients included in the study. Two hundred fourteen (11%) had their previous cesarean for dystocia in the second stage of labor, 654 (33%) for dystocia in the first stage of labor, and 1134 (57%) for other indications. The vaginal birth after cesarean success rate was 75.2% (P = .015 vs other indications), 65.6% (P < .001 vs other indications), and 82.5%, respectively. The rate of operative vaginal delivery was 15%, 12%, and 10% (P = .109). CONCLUSION: A trial of labor is reasonable in women whose previous cesarean was for dystocia in the second stage of labor. In this series, patients who underwent a trial of labor after a previous cesarean for dystocia in the second stage had 75.2% (95% confidence interval 69.5, 81.0) chance of achieving vaginal delivery.     

Trial of labor in patients with a previous cesarean section: does maternal age influence the outcome?

OBJECTIVE: This study was undertaken to evaluate the effect of maternal age on the rate of vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior cesarean delivery. STUDY DESIGN: A cohort study of all women with a live singleton fetus undergoing a TOL after a previous low-transverse cesarean delivery was performed between 1988 and 2002 in a tertiary care center. Patients were divided into 3 groups according to maternal age: less than 30 years old, 30 to 34 years old, and 35 years or older. Women with no prior vaginal delivery and with at least 1 prior vaginal delivery were analyzed separately. The rate of vaginal delivery and the rate of symptomatic uterine rupture were calculated. Multivariate logistic regression analyses were performed to adjust for potential confounding variables. RESULTS: Of the 2493 patients who met the study criteria, there were 1750 women without a prior vaginal delivery (659, 721, and 370, respectively) and 743 women with a prior vaginal delivery (199, 327, and 217, respectively). The rate of uterine rupture was comparable between the groups (2.0%, 1.1%, 1.4%, P=.404 and 0%, 0.3%, 0.9%, P=.312). Successful vaginal delivery was inversely related to maternal age (71.9%, 70.7%, 65.1%, P=.063, and 91.5%, 91.1%, 82.9%, P=.005). After adjusting for confounding variables, maternal age equal to or greater than 35 years old was associated with a lower rate of successful vaginal delivery in patients without prior vaginal delivery (odds ratio [OR] 0.73, 95% CI: 0.56-0.94), and in patients with a prior vaginal delivery (OR: 0.47, 95% CI: 0.29-0.74). CONCLUSION: Patients who are 35 years or older are more prone to have a failed TOL after a prior cesarean delivery.     

Is colonization with GBS in a previous pregnancy associated with adverse perinatal outcomes?

Objective  

To investigate whether colonization with GBS in a previous pregnancy is associated subsequently with adverse obstetric and perinatal outcomes.     

Should we offer expectant management in cases of severe preterm preeclampsia with fetal growth restriction?

OBJECTIVE: The purpose of this study was to assess maternal and fetal morbidity and death in cases of severe preterm preeclampsia that were managed expectantly. STUDY DESIGN: It is a retrospective study that included 155 singleton pregnancies with severe preeclampsia at <34 weeks of gestation that were managed expectantly over a 10-year period. Perinatal outcomes of both mother and fetus were stratified according to gestational age and the severity of fetal growth restriction < or =3th percentile, 4th to 5th percentile, >5th to10th percentile, and >10th percentile. RESULTS: The mean gestational age at admission was 30.2 +/- 2.4 weeks (range, 23.9-34.0 weeks). The mean latency period was 5.3 +/- 5.2 days, with a perinatal mortality rate of 3.9%. Gestational age of <30 weeks of gestation was the strongest variable that affected perinatal outcome, whereas fetal growth restriction played a marginal role. CONCLUSION: Expectant management is recommended strongly in fetuses at <30 weeks of gestation, irrespective of fetal growth restriction. Delivery should be considered at >30 weeks of gestation.     

Should we continue performing intrauterine inseminations in the year 2004?

This review summarizes the existing evidence regarding intrauterine insemination (IUI) as a treatment for cervical hostility, male and unexplained subfertility. IUI in natural cycles has been proven effective in patients with cervical hostility and moderate male subfertility. IUI in cycles with mild ovarian hyperstimulation (MOH) should be the treatment of choice in couples with mild male subfertilty (average total motile sperm count above 10 million) and unexplained subfertilty. When MOH is applied, gonadotropins have been proven more effective compared with clomiphene citrate. Further large trials comparing clomiphene citrate with gonadotropins are mandatory. Prevention of multiple pregnancies in MOH/IUI programs is of paramount importance. A strategy with a low-dose step-up protocol and strict cancellation criteria is proposed. When multiple pregnancies are kept to a minimum, MOH/IUI is more cost-effective compared with in vitro fertilization and embryo transfer. Future research should focus on prediction models to predict the outcome of MOH/IUI treatment for individual couples before starting treatment.     

What can we expect if we measure hormones in eumenorrhoeic infertile patients?

This paper deals with the question of whether measuring hormones is necessary in eumenorrhoeic infertility patients. The answer presented here is yes, but there are some remaining and debatable problems. In our opinion, eumenorrhoea results from regular folliculogenesis, ovulation and luteal function. To be time- and cost-effective, only a limited number of hormones should be measured and assessment of the luteal phase in an eumenorrhoeic patient by measuring oestradiol and progesterone is questionable. The paper discusses the questions on the basis of the currently available literature.     

Cesarean techniques in cases with one previous cesarean delivery: comparison of modified Misgav-Ladach and Pfannenstiel–Kerr

Aim  

To compare the effectiveness of the Pfannenstiel–Kerr method (PKM) or modified Misgav-Ladach method (MMLM) in previous cesarean sections (C/Ss).     

Is it worth inducing labour in women with a previous caesarean delivery?

The aim of this study was to determine the outcome of labour induction following a previous caesarean section. A total of 43 cases were identified; 23 out of those (53.5%) achieved vaginal delivery. The remaining 20 cases (46.5%) had a repeat caesarean. A total of 25 women had ≥ 1 previous vaginal deliveries and in the remaining 18, the previous caesarean was the only pregnancy carried before the current pregnancy. Out of the 23 women who successfully delivered vaginally, 16 cases (69.6%) had a history of ≥ 1 previous vaginal delivery, while no such history was reported in the remaining seven cases (30.4%). The indications for a repeat caesarean were failed induction of labour in five cases (25%); fetal distress in seven cases (35%); failure-to-progress in eight cases (40%). Only one case (2.3%) of uterine rupture was reported. In conclusion, labour induction following a previous caesarean section is an effective and safe intervention. Vaginal delivery can be anticipated in the majority of these women. This study emphasises the need for thorough counselling of these women regarding benefits and risks of induction of labour, and also highlights the necessity of shared patient-doctor decision-making.     

Aspirin use in pregnancy: where are we and what next?

Aspirin is currently recommended from 12 weeks gestation until the birth of the baby for women with one high, or two moderate risk factors for pre-eclampsia, to reduce the risk of developing the condition. There is evidence to suggest aspirin use in pregnancy potentially reduces the risk of preterm birth and small for gestational age or fetal growth restricted babies. For women with recurrent pregnancy loss associated with anti-phospholipid syndrome, aspirin is recommended in combination with heparin. In this review, we discuss the history of aspirin use and its application to improving pregnancy outcomes. We also highlight the current evidence surrounding aspirin use in pregnancy and explore avenues for further research.     

Should we still advise infertile couples to use (barrier) contraception before IVF down-regulation?

OBJECTIVE: To determine the outcome of spontaneous conceptions in women who received GnRH agonists during mid-luteal phase down-regulation before IVF treatment. DESIGN: Retrospective analysis of case records and study of the literature. SETTING: Two university-affiliated reproductive medicine units. PATIENT(S): Seventy-three women who conceived spontaneously after starting down-regulation with a GnRH agonist before controlled ovarian hyperstimulation. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Course and clinical outcome of pregnancies. RESULT(S): Seventy-four pregnancies occurred in 73 women who received a GnRH agonist. Of these patients, 6 (8%) had a biochemical pregnancy, 6 (8%) had an ectopic pregnancy, 21 (28%) miscarried, and 41 pregnancies resulted in successfully delivered babies; there were 2 cases of congenital abnormalities. CONCLUSION(S): These cases, together with other published data, suggest that pregnancy outcome is not adversely affected by exposure to GnRH agonist during luteal-phase down-regulation. A central register of pregnant women who received a GnRH agonist is needed.