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Purpose: to summarize and present a single tertiary center’s 25 years of experience managing patients with caesarean scar pregnancies and their long term reproductive and obstetric outcomes. Methods: A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians’ decisions, patient counseling, and parental requests. Results: Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%). Conclusion: CSP treatment focusing on reducing morbidity and preserving fertility has favorable long term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

Objective: To describe the feasibility of hysteroscopy assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA). Design: Prospective single-arm cohort study. Setting: University-affiliated department of Obstetrics and Gynecology. Patients: Women admitted for surgical evacuation in cases of early pregnancy loss were offered participation in the study. Intervention: Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy’s implantation wall, followed by ultrasound guided suction and curettage directed to the implantation wall, and diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy. Main Outcome Measure: Identification of the pregnancy’s implantation wall on hysteroscopy, and intra- and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic and restrictions on elective procedures. Results: 40 patients were included in the study group. Their mean age was 34.0 ± 6.6 years, and their mean gestational age was 8.9 ± 1.6 weeks. In 33 out of 40 cases (82.5%), the implantation wall was clearly visualized on hysteroscopy. The mean operative time was 17.2 ± 8.8 minutes, and no intraoperative complications occurred. In 4 cases, suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed. The histology examination confirmed the presence of RPOC in 3 out of these 4 suspected RPOC cases. Follow-up office hysteroscopy was performed in 9 women, diagnosing mild IUA in one case and a normal cavity in 8 cases. In 15 cases, a new pregnancy was reported at time of follow-up, while 12 women declined to attend the follow up-hysteroscopy and 4 were lost to follow-up. Conclusions: Hysteroscopy assisted suction curettage for early pregnancy loss is a safe, short, and inexpensive procedure, which allows the identification of the pregnancy’s wall in most cases and may reduce the rates of RPOC and IUA.

SUMMARY Ovarian adrenal rest tumors (OARTs) are very rare. We describe a case of a young woman with uncontrolled classical congenital adrenal hyperplasia (CCAH), presenting with bilateral OARTs, successfully treated with steroid replacement. A 20-year-old woman, known to have 21OH-CCAH, presented with severe abdominal pain, vomiting, diarrhea, and fever. As a result of poor compliance, 6 months before her admission hirsutism worsened and amenorrhea, hyperpigmentation, and weakness developed. ACTH levels were 278 < pmol/L and 17OHP 91.3 nmol/L. She was admitted for parenteral antibiotics and high-dose hydrocortisone treatment. CT revealed bilateral juxta-ovarian masses (6.2 x 3.6 x 7.4 cm left and 5 x 2.2 x 3.2 cm right) that on MRI were iso-intense in T1 and hypointense in T2, with early enhancement and rapid washout. One week of high-dose hydrocortisone resulted in significant clinical and laboratory improvement and the patient was discharged with 2 mg dexamethasone/day. One month later US revealed shrinkage of the masses and dexamethasone dose was decreased. At three months from discharge, she has resumed regular menses, and a repeated MRI revealed the para-ovarian masses have shrunk. One year after the diagnosis, the para-ovarian masses have shrunk more to 2.8 x 1.9 x 4.3 on the left and 2.1 x 0.9 x 1.2 on the right with less contrast enhancement in comparison to previous test possibly due to fibrotic changes of the tissue. OARTs are rare tumors with a poorly known natural history, and surgery has been the first option in the few reported cases. We demonstrate that medical treatment is a good alternative, leading to significant tumor shrinkage over a short period.

Background This retrospective study compared perioperative measures, costs, quality of life and survival after open vs. robotic surgery, among obese women diagnosed with low-grade endometrial cancer. Methods Obese women (body mass index (BMI) ≥ 30) who underwent open or robotic surgery for endometrial cancer, in one of two tertiary medical centers in the center of Israel, 2013–2016, postoperative grade 1–2, were included. Costs per patient, including 30-days post-surgery were calculated. Quality of life was evaluated by Physical and Mental Components of the SF-36 and a recovery from surgery questionnaire. Overall survival outcomes were obtained from patients’ files. Surgical outcomes, including operating and anesthesia times, length of hospital stay, and intraoperative and postoperative complications according to the Clavien-Dindo classification scale were reviewed. Results In all, 138 women with BMI ≥30 underwent open (n = 61) or robotic surgery (n = 77) during the study period. The groups had similar BMI, comorbidities, demographics and tumor characteristics. Robotic surgery was associated with shorter hospital stays (mean 1.7 vs. 4.8 days; P > 2, 5.2% vs. 19.7%; P = .0008), but longer operating theater time (3.8 vs. 2.8 h; P P P P P = 0.330). Conclusions Obese women with low-grade endometrial cancer had better quality of life after robotic vs. open surgery. They also had shorter hospital stays and fewer postoperative complications. Centers with high volumes of robotic surgery can achieve similar costs when comparing both methods. These results were achieved without jeopardizing survival. Our results further emphasize the need for the Israeli healthcare system to include specific reimbursement for robotic procedures in the population we studied.

Purpose Recurrence of adnexal torsion involving otherwise normal adnexa is not rare. Various oophoropexy (ovarian fixation) procedures have been suggested to prevent recurrence, however, long-term information of their efficacy is lacking. The aim of this study was to investigate the recurrence rate of adnexal torsion following oophoropexy. Methods Retrospective cohort study, including all consecutive patients who underwent an oophoropexy procedure for the prevention of recurrent torsion of “normal adnexa” in our department from 2008 to 2021. Oophoropexy techniques included shortening of the utero-ovarian ligament (between 2008 to 2019) or combined utero-ovarian and round ligament fixation (from 2020). Results Twenty-one patients (age range 7-35 years) with a mean follow-up of 82.7 ± 60.6 months were identified. Fifteen of them (71.4%) were re-operated for recurrent torsion following an oophoropexy procedure, while six (28.6%) did not experience recurrence. Twelve (57.1%) torsion recurrences following an oophoropexy occurred within the first 2 postoperative years. There were no differences in mean age and menarchal status )pre- or post-menarchal) at the time of the first torsion event, age at the time of oophoropexy, oophoropexy side, number of adnexal torsion events before oophoropexy, and follow-up duration between those with and those without post-oophoropexy recurrences. Conclusion Oophoropexy procedures may not prevent recurrent torsion of otherwise normal adnexa. Further studies to determine whether combined fixation (utero-ovarian plication and round ligament) is more efficacious than isolated utero-ovarian plication for the prevention of recurrent torsion are warranted.

Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding.To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage.All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration.Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort.Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Objective During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). Study design This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018–2019. Results The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P

Objectives To compare survival measures of women with early-stage endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure. Methods An Israel Gynecologic Oncology Group multicenter study of 1324 patients with stage I endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. Results There were 355 patients in the hysteroscopy group and 969 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12–120 months). There were no differences between the groups in the 5-year recurrence-free survival (90.2% vs. 88.2%; p=0.53), disease-specific survival (93.4% vs. 91.7%; p=0.5), and overall survival (86.2% vs. 80.6%; p=0.22). Conclusions Our findings affirm that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.

Study Objective: To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions. Design: Retrospective study. Setting: Gynecology department in a University affiliated hospital. Patients: All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016. Intervention: Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6â8 weeks. Measurements and Main Results: 50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women. Conclusion: Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions. Keywords: abortion, hysteroscopy, intrauterine adhesions, retained products of conception

Growing evidence suggests that cesarean scar pregnancy (CSP) and morbidly adherent placenta (MAP) may represent a continuum of the same disease.To investigate and compare the prior risk factors in women with either CSP or MAP.The study included 33 women diagnosed with CSP in our department between 2006 and 2014. For each CSP case, two pregnant patients with MAP were matched for hospitalization date from delivery ward records, constituting the control group.In both groups, maternal age, parity, and previous early and late abortions were similar. The rate of conception by assisted reproductive technologies was 9% in both groups. Although the number of previous cesarean sections was statistically different between CSP versus MAP (2.0 ± 1.0 vs. 1.0 ± 1.0, respectively, P = 0.006), the leading indication of previous cesarean section was breech presentation in both groups (28.1% and 27.8%, respectively, P0.05).CSP and MAP share similar prior risk factors. Due to high morbidity in both diseases, further research is needed toward reducing the known etiological factors contributing to the growing number of both complications.

Despite awareness regarding tubal pregnancy, ovarian pregnancy still remains a diagnostic challenge. The correct diagnosis is most frequently made intraoperatively and requires histopathologic confirmation. Therefore, additional diagnostic measurements are needed for earlier and more accurate detection of ovarian pregnancies which will allow more rapid and efficient treatment.To assess the time trends, clinical manifestations, surgical management and post-procedure outcome of 46 primary ovarian pregnancies in a single institution during three time periods.In this retrospective study we compared 20 patients with primary ovarian pregnancy during the years 1971- 1989 (first period), 19 patients in 1990-2001 (second period) and 7 patients in 2002-2013 (third period). In all cases the pathology examination confirmed primary ovarian pregnancy.The number of tubal ectopic pregnancies almost doubled, from 637 in the first period to 1279 in the third period (P0.001). However, there was a significant fall in the number of ovarian ectopic pregnancies, from 20 cases in the first period to 7 cases in the third (P = 0.009). A significant difference was noted when we compared the postoperative hospitalization time (4.06 ± 1.4 vs. 2.0 ± 0.6 days respectively, P = 0.001) in the second versus the third time period.Ovarian pregnancy continues to be a diagnostic challenge, associated with a high rate of circulatory collapse, hemoperitoneum and requirements for blood transfusions, all leading to longer hospitalization.

Background:Endometriosis-associated malignant transformation in abdominal surgical scar (EAMTAS) is a very rare and aggressive phenomenon. Our current article aims to provide a clinical overview, focusing on risk factors affecting survival.Methods:We performed a Preferred Reporting Items for

Objective To compare adnexal torsion characteristics and torsion recurrence rates in a pre- and postmenarchal pediatric and adolescent population. Design Retrospective cohort study. Setting University-affiliated medical center. Patient(s) Females Intervention(s) Adnexal detorsion, cystectomy, salpingectomy, or salpingo-oophorectomy by laparoscopy or laparotomy. Oophoropexy using the utero-ovarian ligament plication technique was performed in cases of recurrent torsion of normal adnexa. Main Outcome Measure(s) The clinical presentation, laboratory and ultrasound characteristics, surgical findings, surgical procedures, pathologic diagnosis, and torsion recurrence rates were analyzed and compared between pre- and postmenarchal patients. Result(s) Twenty premenarchal and 24 postmenarchal patients were identified. The clinical presentation, laboratory findings, and ultrasound characteristics were similar between the two groups, except for a higher prevalence of paraovarian cysts on preoperative ultrasound in the postmenarchal compared with in the premenarchal group (20.8% vs. 0%). For the whole cohort, torsion of normal adnexa constituted 25.0% (11/44) of cases, while torsion of "pathologic" adnexa constituted 75.0% (33/44) of torsion cases. Torsion recurrence was significantly more common among girls whose first torsion episode occurred in the premenarchal period compared with in postmenarche (35% vs. 4.2%). On multivariate logistic regression analysis, torsion recurrence was significantly associated with premenarchal status (odds ratio [OR] = 12.7; 95% confidence interval [CI], 1.1–152.0) and with torsion involving normal adnexa (OR = 19.1; 95% CI, 2.3–154.5). Conclusion(s) Recurrent torsion is common in patients whose first torsion episode occurred in the premenarchal period and involved otherwise normal adnexa. Ovarian fixation procedures may be considered in patients at risk for torsion recurrence.

Objective To describe the option of ultrasonographic-guided percutaneous transabdominal puncture for ovum pickup in a rare case of Rokitansky syndrome with subcostal located ovaries and a right single kidney. Design Technique and instrumentation. Setting A university-based hospital IVF and Reproductive Medicine Unit. Patient(s) A woman with congenital agenesis of the uterus in a surrogate gestation program. Intervention(s) Ultrasonographic-guided percutaneous transabdominal puncture for oocyte retrieval. Main Outcome Measure(s) Number of oocytes retrieved and fertilized. Result(s) Oocyte retrieval was feasible in four treatment cycles with subsequent embryo transfer to the surrogate mother. Conclusion(s) Ultrasonographic-guided percutaneous transabdominal oocyte collection is a feasible and efficacious procedure for IVF in a case of Rokitansky syndrome with elevated subcostal ovaries and a single kidney.

Repair of injured lungs represents a longstanding therapeutic challenge. We show that human and mouse embryonic lung tissue from the canalicular stage of development (20-22 weeks of gestation for humans, and embryonic day 15-16 (E15-E16) for mouse) are enriched with progenitors residing in distinct niches. On the basis of the marked analogy to progenitor niches in bone marrow (BM), we attempted strategies similar to BM transplantation, employing sublethal radiation to vacate lung progenitor niches and to reduce stem cell competition. Intravenous infusion of a single cell suspension of canalicular lung tissue from GFP-marked mice or human fetal donors into naphthalene-injured and irradiated syngeneic or SCID mice, respectively, induced marked long-term lung chimerism. Donor type structures or 'patches' contained epithelial, mesenchymal and endothelial cells. Transplantation of differentially labeled E16 mouse lung cells indicated that these patches were probably of clonal origin from the donor. Recipients of the single cell suspension transplant exhibited marked improvement in lung compliance and tissue damping reflecting the energy dissipation in the lung tissues. Our study provides proof of concept for lung reconstitution by canalicular-stage human lung cells after preconditioning of the pulmonary niche.

Objective To assess the prevalence and risk factors for intrauterine adhesions (IUAs) after hysteroscopic treatment of retained products of conception (RPOC). Design Retrospective cohort study. Setting Gynecologic endoscopy unit. Patient(s) A total of 167 women referred to our institution from 2009 to 2013. Intervention(s) Operative hysteroscopy for treatment of RPOC and office hysteroscopic follow-up to assess for IUA. Main Outcome Measure(s) We investigated demographic characteristics, obstetrics parameters, and surgical variables to evaluate which factors could be associated with IUA formation. Result(s) Of 167 women treated for RPOC, 84 (50.3%) had undergone a follow-up hysteroscopic evaluation after the operative hysteroscopy and were included in the study. Intrauterine adhesions were found in 16 cases (19.0%), of which only 3 (3.6%) were severe adhesions. Multivariate analysis showed that the presence of IUA was associated with RPOC after cesarean section (5 of 10 [50.5%] developed IUA, vs. 7 of 49 [14.3%] after vaginal delivery). Intrauterine adhesions were also found in 4 of 23 women (17.4%) undergoing hysteroscopy for RPOC after abortion. Patient age, gravidity, parity, and the interval between the index pregnancy and treatment for RPOC were not associated with postoperative IUA. Conclusion(s) Hysteroscopic treatment for RPOC had a 3.6% incidence of severe intrauterine adhesions formation in this descriptive series. Women with RPOC occurring after delivery by cesarean section are particularly at risk for development of IUA.

Cancer is a heterogeneous and tissue-specific disease. Thus, the tissue of origin reflects on the natural history of the disease and dictates the therapeutic approach. It is suggested that tissue differentiation, mediated mostly by epigenetic modifications, could guide tissue-specific susceptibility and protective mechanisms against cancer. Here we studied breast specific methylation in purified normal epithelium and its reflection in breast cancers. We established genome wide methylation profiles of various normal epithelial tissues and identified 110 genes that were differentially methylated in normal breast epithelium. A number of these genes also showed methylation alterations in breast cancers. We elaborated on one of them, TRIM29 (ATDC), and showed that its promoter was hypo-methylated in normal breast epithelium and heavily methylated in other normal epithelial tissues. Moreover, in breast carcinomas methylation increased and expression decreased whereas the reverse was noted for multiple other carcinomas. Interestingly, TRIM29 regulation in breast tumors clustered according to the PAM50 classification. Thus, it was repressed in the estrogen receptor positive tumors, particularly in the more proliferative luminal B subtype. This goes in line with previous reports indicating tumor suppressive activity of TRIM29 in estrogen receptor positive luminal breast cells in contrast to oncogenic function in pancreatic and lung cancers. Overall, these findings emphasize the linkage between breast specific epigenetic regulation and tissue specificity of cancer.

Identification of tissue-specific renal stem/progenitor cells with nephrogenic potential is a critical step in developing cell-based therapies for renal disease. In the human kidney, stem/progenitor cells are induced into the nephrogenic pathway to form nephrons until the 34 week of gestation, and no equivalent cell types can be traced in the adult kidney. Human nephron progenitor cells (hNPCs) have yet to be isolated. Here we show that growth of human foetal kidneys in serum-free defined conditions and prospective isolation of NCAM1(+) cells selects for nephron lineage that includes the SIX2-positive cap mesenchyme cells identifying a mitotically active population with in vitro clonogenic and stem/progenitor properties. After transplantation in the chick embryo, these cells-but not differentiated counterparts-efficiently formed various nephron tubule types. hNPCs engrafted and integrated in diseased murine kidneys and treatment of renal failure in the 5/6 nephrectomy kidney injury model had beneficial effects on renal function halting disease progression. These findings constitute the first definition of an intrinsic nephron precursor population, with major potential for cell-based therapeutic strategies and modelling of kidney disease.

OBJECTIVES The primary aim of this study was to compare the accuracy of sonographic fetal weight estimation models. The secondary aim was to define the most accurate time (4-7 or 3 days before delivery) for evaluating fetal weight. METHODS In this retrospective cohort study, a total of 12,798 sonographic fetal weight estimations were analyzed, of which 9459 were performed within 3 days of delivery and 3339 within 4 to 7 days. The cohort included all singleton pregnancies recorded at a single medical center from January 2000 to December 2010, with 24 weeks' gestation minimum. Predicted birth weights were calculated according to 23 sonographic fetal weight estimation models; in total, 294,354 sonographic weight estimations were evaluated and compared to the actual birth weights. RESULTS The accuracy of the models in predicting birth weight differed considerably. The most accurate models used 3 or more fetal measurements followed by models using abdominal circumference only. The models developed by Sabbagha et al (Am J Obstet Gynecol 1989; 160:854-862) proved most accurate, with a mean percent error of -0.2% and greater than 92% of estimates within 15% of birth weight (P < .05). Nineteen sonographic fetal weight estimation models (82.6%) better predicted fetal weight at 4 to 7 days before delivery (P < .001). Twenty-two (95%) of the models were less accurate at the extreme ends of fetal weight. CONCLUSIONS Different formulas for fetal weight estimation vary greatly; we recommend that each center should evaluate the most accurate formula according to its attending population. Estimation of fetal weight performed 4 to 7 days before delivery using most models was more accurate than estimations performed 3 days before delivery.

IV adrenaline increases coronary and cerebral perfusion pressures during cardiopulmonary resuscitation. We recently showed that endotracheal adrenaline can decrease blood pressure (BP), a detrimental effect presumably mediated by the beta 2-adrenergic receptor unopposed by alpha-adrenergic vasoconstriction. This prospective, randomized, laboratory comparison of endotracheal adrenaline (0.05 mg/kg diluted with normal saline to 10 mL total volume) with or without nonselective beta-blocker (propranolol) pretreatment was conducted in an attempt to clarify the mechanism of this BP decrease. Five mongrel dogs were given 0.05 mg/kg endotracheal adrenaline (diluted) or 0.05 mg/kg endotracheal adrenaline followed by an IV propranolol (0.1 mg/kg) pretreatment. Each dog served as its own control (10 mL of normal saline administered endotracheally) and received each regimen at least one week apart. Endotracheal adrenaline given after the propranolol pretreatment produced an increase in systolic, diastolic, and mean arterial BPs, from 165/110 mm Hg (mean 128 mm Hg) to 177.5/125 mm Hg (mean 142.5 mm Hg), respectively, as opposed to the hypotensive effect of isolated endotracheal adrenaline (P0.03). Thus, endotracheal adrenaline was associated with predominantly beta-adrenergic-mediated effects, causing hypotension via peripheral vasodilatation unopposed by alpha-adrenergic vasoconstriction. The search for the optimal dose of endotracheal adrenaline should be aimed at achieving the higher alpha-adrenergic vasoconstrictive threshold.

Objective To present four cases of twin tubal pregnancies and discuss possible etiologies. Twin tubal pregnancies are a rare event, with incidence rates estimated as 1 out of 725–1,580 of tubal pregnancies. Design Case series. Setting Department of obstetrics and gynecology at a tertiary health care facility. Patient(s) All women with twin tubal pregnancy diagnosed and treated in the department during the years 2007–2009, according to electronic files and histologic reports. Intervention(s) None. Main Outcome Measure(s) Artificial reproductive technique preceding twin tubal pregnancies Result(s) We diagnosed four twin pregnancies of 163 tubal pregnancies, an incidence of 2.4%. Of the four cases, two conceived after gonadotropin stimulation and intrauterine insemination. The third conceived following in vitro fertilization and intracytoplasmic sperm injection. The fourth was a spontaneous conception diagnosed as monochorial monoamniotic twin tubal pregnancy. Conclusion(s) Twin tubal pregnancies may not be as rare as previously thought. Three of the four cases indentified during a 2-year period followed artificial reproductive technique. We hope that this report will promote the study of the epidemiology of this event, improve diagnosis, and encourage the development of treatment modalities.

Background: During CPR, intravenous epinephrine increases coronary perfusion pressure and cerebral perfusion pressure. We have recently shown (Crit. Care Med 1992;20:1582-7) that endotracheal epinephrine, might cause a detrimental effect by decreasing blood pressure