Sonographic appearance of the uterus in the early puerperium in vaginal versus cesarean deliveries: a prospective study

Purpose: The purpose of this study is to compare uterine sonographic characteristics in early puerperium, following vaginal versus cesarean deliveries; and in women with abnormal third stage of labor, compared to uncomplicated vaginal delivery.

Materials and methods: This is a prospective study of women after delivery of singleton, appropriate-for-gestational-age weight, term neonates; 66 women delivered vaginally and 33 delivered by cesarean section. Sonographic uterine dimensions (height, length, and width), intracavitary thickness and its echogenicity (at level of fundus, midcavity and cervix) were recorded at less than and after 24?h from delivery, and compared between women delivered vaginally and by cesarean section. Among women delivered vaginally, data were further analyzed according to whether women underwent manual revision of the uterine cavity.

Results: Sonographic evaluations were taken at 15.4 (4.3–24.0) and 39.5 (28.8–108.8) hours after delivery (median, range). We found no clinically significant differences in uterine characteristics according to mode of delivery or according to manual revision of the uterine cavity. The sonographic appearance of the uterus was similar when performed at less than or after 24?h from delivery.

Conclusions: Postpartum sonographic evaluation of the uterus appears similar after vaginal and cesarean deliveries.     

Foley catheter versus intravaginal prostaglandins E2 for cervical ripening in women at term with an unfavorable cervix: a randomized controlled trial

Objective: The objective of this study is to compare the efficacy of labor induction by Foley catheter balloon (FCB) insertion to intravaginal dinoprostone tablet placement in women with an unfavorable cervix.

Materials and methods: A prospective randomized controlled trial was conducted. Women were assigned to insertion of a FCB or placement of a vaginal dinoprostone tablets and their outcome were compared.

Results: The study comprised 300 women. The time to active labor was significantly shorter in the FCB compared with the dinoprostone group, but required more oxytocin administration. A lower rate of cesarean section was found only in nulliparous women in the FCB group. The neonatal outcome was favorable and similar in both groups.

Conclusion: Both methods had similar results regarding achieving vaginal delivery within 24?h and cesarean section rate. For nulliparous women, the FCB induction method had the advantage of a shorter time to active labor and a lower rate of cesarean section.     

The optimal cutoff serum level of human chorionic gonadotropin for efficacy of methotrexate treatment in women with extrauterine pregnancy

ObjectiveTo evaluate the efficacy of methotrexate treatment for extrauterine pregnancy and define criteria for prediction of success.MethodsOf 829 patients with an ectopic pregnancy admitted to E. Wolfson Medical Center, Holon, Israel, from January 1997 through December 2009, 238 had asymptomatic tubal pregnancies and increasing serum β-human chorionic gonadotropin (βhCG) levels. These patients were treated with a single intramuscular injection of 50 mg of methotrexate (MTX) per square meter of body surface. Success was defined as undetectable βhCG levels without the need for a surgical intervention.ResultsThe groups of patients successfully treated (n = 167 [70%]) and unsuccessfully treated (n = 71 [30%]) were compared. They were similar regarding age and gravidity. The initial serum βhCG level was significantly higher in the latter group than in the former (3798 mIU/mL vs. 1601 mIU/mL, P < 0.01). The success rate was 88% when initial βhCG levels were less than 1000 mIU/mL, 71% when they were between 1000 and 2000 mIU/mL, and only 59% when they were between 2000 and 3000 mIU/mL.ConclusionMethotrexate treatment is a safe and effective alternative to surgery. However, patients with initial βhCG levels higher than 2000 mIU/mL should only be offered the surgical approach.     

Clinical, surgical, and histopathologic outcomes following failed medical abortion

ObjectiveTo address the consequences of surgical curettage following failed medical abortion.MethodsA retrospective case–control study was performed in a tertiary gynecologic department. The case group comprised 104 women who underwent surgical curettage following failed medical abortion; the control group included 104 women who underwent early surgically induced abortion. Clinical characteristics and surgical findings were examined. The extent of inflammation was quantified following immunohistochemical staining for cell-surface markers characteristic of T lymphocytes, B lymphocytes, and macrophages. The extent of necrosis was evaluated morphologically.ResultsAbnormal findings during surgical curettage were significantly more prevalent among women in the case group than in the control group (10.6% versus 1.9%; P = 0.019). The most frequent abnormality in the case group was the presence of intimately adherent products of conception, necessitating sharp curettage. The extent of inflammation (represented by increased numbers of T and B lymphocytes) was greater in the case group than in the control group (P = 0.046 and P = 0.001, respectively), as was the extent of necrosis (P < 0.05).ConclusionCurettage following failed medical abortion harbors particular difficulties, which may be attributed to an inflammatory response. The long-term consequences of curettage following failed medical abortion warrant further investigation.     

Differences Between Adnexal Torsion in Pregnant and Nonpregnant Women

Study ObjectiveTo compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women.DesignRetrospective case-control study (Canadian Task Force classification II-3).SettingTertiary care university hospital.PatientsSixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion.InterventionsSurgery to treat proved adnexal torsion.Measurements and Main ResultsThe mean (SD) gestational age in the pregnant group was 11.5 (7.7) weeks. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Sonographic demonstration of multicystic ovaries was more common in pregnant women with recurrent torsion than in women with a single episode of torsion (86% vs 31%; p = .009). Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001).ConclusionPregnancy after treatment for infertility is a risk factor for adnexal torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries.     

Universal hepatitis A vaccination in the United States: a call for action

Previous hepatitis A recommendations for the United States targeted vaccination of at-risk individuals and children living in states and communities with consistently elevated rates of hepatitis A. Recommendations now call for routine hepatitis A vaccination of all children in the United States beginning at age 1 year (12-23 months). Currently, vaccination coverage rates for hepatitis A remain below rates of other routine childhood vaccines. Achieving a national immunization rate greater than 90% for the recommended 2 doses of hepatitis A vaccine would lessen disease impact throughout society. Routine childhood immunization against hepatitis A can be a highly effective strategy to reduce infection in children and community transmission of the virus, and the elimination of indigenous transmission of hepatitis A is an attainable goal.     

Peri‐pharyngeal muscle response to inspiratory loading: comparison of patients with OSA and healthy subjects

Upper airway patency to airflow and the occurrence of obstructive sleep apnea involve a complex interplay between pharyngeal anatomy and synergic co‐activation of peri‐pharyngeal muscles. In previous studies we observed large differences in the response to sleep‐associated flow limitation between the genioglossus and other (non‐GG) peri‐pharyngeal muscles. We hypothesized that similar differences are present also during wakefulness. In the present study we compared the response to inspiratory loading of the genioglossus electromyogram and four other peri‐pharyngeal muscles. Studies were performed in eight obstructive sleep apnea patients, seven age‐matched healthy subjects and five additional younger subjects. Electromyogram activity was evaluated over a range of negative oesophageal pressures and expressed as % of maximal electromyograms. In healthy subjects, the slope response to inspiratory loading (electromyogram/pressures) was similar for the genioglossus and non‐GG muscles studied. However, the electromyogram responses were significantly higher in the young subjects compared with older subjects. In contrast, in the obstructive sleep apnea patients, the electromyogram/pressure response of the non‐GG muscles was similar to that of the age‐matched healthy subjects, whereas the slope response of the genioglossus electromyogram was significantly higher than non‐GG muscles. We conclude that both age and the presence of obstructive sleep apnea affect the response of peri‐pharyngeal muscles to inspiratory loading. In patients with obstructive sleep apnea the genioglossus seems to compensate for mechanical disadvantages, but non‐GG muscles apparently are not included in this neuromuscular compensatory mechanism. Our current and previous findings suggest that attempts to improve obstructive sleep apnea with myofunctional therapy should put added emphasis on the training of non‐GG muscles.