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To explore whether the known decrease in fetal heart rate variability, which follows antenatal betamethasone administration is related to fetal acid-base changes.A retrospective study of 42 women with premature delivery following a single course of betamethasone. The study group consisted of 21 women who delivered within 48 h following first injection of betamethasone. The 21 women who delivered later than 48 h formed the control group. Fetal heart rate variability measurements and cord acid-base values were compared.The mean fetal heart rate variability (beats per minute) before the administration of betamethasone was significantly higher than at 24 h [8.05 (SD 3.15) vs. 5.32 (SD 2.27); p0.001]. This was evident in both the groups, with no significant difference between them. In the control group, the mean variability before betamethasone administration and the variability prior to delivery were not significantly different [8.48 (SD 3.46) vs. 7.26 (SD 3.03); p=0.36]. There were no significant differences between study and control groups regarding the arterial cord acid-base values at delivery [pH 7.29 (SD 0.15) vs. 7.31 (SD 0.1); p=0.38].Assuming that the fetal heart rate and the acid-base status prior to delivery would be a reflection of the effects of betamethasone as evident by reduced fetal heart rate variability, our data does not support acid-base changes as a pathophysiological mechanism.

Background. The levels of midtrimester triple test constituents are known to be altered in hypertensive disorders of pregnancy. Objective. Our aim was to determine whether midtrimester triple test constituent levels differ in women with severe preeclampsia and those who also develop HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Methods. A retrospective chart analysis of 106 women with severe preeclampsia for whom midtrimester triple test data were available was made. None of these patients had fetuses with abnormal karyotype, nor did they deliver infants with malformations. The levels of midtrimester maternal serum alpha-fetoprotein (MSAFP), human chorionic gonadotropin (MShCG) and unconjugated estriol (MSuE3) of 74 patients with severe preeclampsia were compared with those of 32 patients who also developed HELLP syndrome. Results. The mean MShCG was significantly higher and the mean MSuE3 was significantly lower in patients with HELLP syndrome than in those with only severe preeclampsia [1.78 multiple of the medians (MoM), standard error (SE) 0.18 vs. 1.27 MoM, SE 0.07, p = 0.015 and 0.86 MoM, SE 0.05 vs. 1.04 MoM, SE 0.07; p = 0.03, respectively]. The two groups did not differ significantly with regard to MSAFP levels. Conclusion. Unexplained high levels of midtrimester MShCG and low levels of MSuE3 may be associated with the development of HELLP syndrome in women with severe preeclampsia.

Up to 70% of women with ovarian cancer are diagnosed in the advanced stage. The standard treatment for advanced ovarian cancer is a combination of debulking surgery and chemotherapy. The goal of surgery is to reduce the intra-abdominal tumor burden as much as possible. The survival of patients with no residual disease post-surgery is superior to that of patients with visible residual lesions. In order to minimize the probability that a patient has residual disease, several aggressive surgical techniques have been proposed, including the removal of all visible disease on the diaphragm, the colon and elsewhere in the abdomen. These techniques include diaphragm resection, splenectomy and peritonectomy. Neoadjuvant chemotherapy is used to treat patients if it is expected that adequate debulking surgery is unlikely to be successful or if they are evaluated to be too ill to undergo an extensive and lengthy operation. Several multi-center prospective randomized studies have shown that patients who are treated with neoadjuvant chemotherapy followed by surgery are more likely to achieve the status of no residual disease than are patients treated with surgery alone. Consequently, it has been proposed that neoadjuvant chemotherapy is justified in order to achieve a status of no residual disease; however, treatment with neoadjuvant chemotherapy has not yet been shown to result in better survival than treatment with primary debulking surgery. On the other hand, large retrospective single institute studies have shown clear survival benefit to patients undergoing primary surgery with no residual disease at the end of surgery. Although it is hard to compare prospective randomized studies to retrospective studies, they could not be ignored. The goal of treatment should be no residual disease at the end of primary surgery. To achieve this goal, patients with advanced stage ovarian cancer should undergo a thorough evaluation prior to the decision on the right treatment. This evaluation should include imaging studies to assess the sites and size of metastasis, age and performance status. Furthermore, the surgical competence of each center should be evaluated periodically and a decision should be made individually for each patient and center. The aim of this review is to analyze the updated relevant data on the approach to advanced ovarian cancer, primary debulking (PDS) versus neoadjuvant chemotherapy (NACT).

Objective: To study whether sonographic findings suggestive of ovarian stromal edema are associated with tissue ischemia in patients with adnexal torsion. Methods: A study of 79 patients with adnexal torsion was performed. Patients were divided into an ischemic group, in which the twisted adnexa were seen as blue or black, and a non-ischemic group, in which the adnexa retained normal color and appeared viable. Clinical and ultrasonographic findings, specifically the presence of ultrasonographic signs suggestive of ovarian stromal edema, were compared between the two groups. Results: Of the 79 patients with torsion, in 44 (55.7%) the adnexa appeared ischemic at surgery. The presence of ischemia was not associated with age, pregnancy, duration of pain, vomiting or findings at physical examination. There was no significant difference between the ischemic and the non-ischemic group in the proportion of patients with signs of ovarian stromal edema (59 vs. 40%, p = 0.11), in the proportion of patients with absent/diminished stromal Doppler flow (36 vs. 28%, p = 0.12%) or in the proportion of patients with both signs of stroma edema and absent/diminished stromal Doppler flow (20 vs. 12%, p = 0.36). Conclusion: Ultrasonographic signs of ovarian stromal edema do not assist in differentiating between ischemic and non-ischemic adnexal torsion.

PurposeThe aim of this study was to evaluate whether preoperative positron emission tomography/computed tomography (PET/CT) in patients with early-stage cervical carcinoma reduced the proportion of patients with metastatic lymph nodes identified after surgery.Patients and MethodsThis is a multicenter case-control study of 599 patients with early cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy at 1 of 10 gynecological oncology units in Israel. The patients were divided into 2 groups according to whether or not they underwent a preoperative PET/CT. The primary outcome was the proportion of patients with nodal involvement. The 2 groups were compared with regard to the clinical and histological variables.ResultsOf the 599 patients who underwent surgery, 180 (36%) had preoperative PET/CT study. There were no significant differences between the PET/CT and control groups with regard to clinical and histological risk factors. The proportion of patients with involved nodes was similar in the control and PET/CT groups (20.8% vs 19%; P = 0.73) as well as the proportion of patients receiving adjuvant radiotherapy/chemoradiation (58.3% vs 55.1%; P = 0.55).ConclusionsPreoperative PET/CT in patients with early cervical cancer does not reduce proportion of patients with metastatic nodal involvement and the employment of multimodality treatment. Prospective clinical trials comparing management based on PET/CT findings are warranted.

Objective: To create diameter-by-age reference curves for the uterine cervix using computerized tomographic studies. Methods: Measurements of the anterior-posterior (AP) and lateral diameters of nonpathological cervices were made at the level of the vaginal fornices in 499 computerized tomographic studies. Patients were grouped by 10-year age intervals. For each age group, median AP and lateral cervical diameters were calculated, as were 10th and 90th percentile values. Values for the 3 curves were smoothed across age categories using second-order polynomial regression procedures. Results: The median AP diameter was 26 mm (range, 15―45 mm), and the median lateral diameter was 32 mm (range, 20―70 mm). For both measurements, the range of values between the 10th and 90th percentiles decreased with increasing age, creating funnel-shaped plots. Conclusions: Radiological measurements of cervical diameters and comparison to standard curves may contribute information in the evaluation of uterine cervical pathology or may heighten awareness of pathologies not previously identified.

In an attempt to examine whether body mass index (BMI) may influence IVF outcome in patients undergoing COH with either GnRH-agonist (agonist group) or GnRH-antagonist (antagonist group), we studied 799 IVF cycles: 481 in the agonist group and 318 in the antagonist group. In patients with BMI25 kg/m(2), COH with either GnRH-agonist or GnRH-antagonist achieved a comparable outcome; whereas in patients with BMI25 kg/m(2), the use of GnRH-agonist suppressive protocol revealed significantly higher pregnancy rates.

Aims To evaluate the role of pretreatment CA 15-3 levels as a predictor of disease-free survival in patients with advanced epithelial ovarian cancer. Methods A cohort of 65 patients with FIGO stage III or IV epithelial ovarian cancer was evaluated. Patients were treated either with primary cytoreductive surgery followed by adjuvant platinum-based chemotherapy or with neoadjuvant chemotherapy with interval debulking surgery. All patients had pretreatment CA 15-3 and CA 125 tumor marker determinations. The patients were divided into a group with elevated CA 15–3 and a group with normal levels. The two groups were compared with regard to clinical and survival measures. Results The patients' median age was 65 years (range, 37–90); 34 (52%) were at stage III and 31 (48%) at stage IV. CA 15–3 was elevated (>30 units/mL) in 44 (68%) patients, with a median level of 39 units (range, 4-2282). CA 125 was elevated (>35 units/mL) in 61 (94%) patients, with a median level of 947 units (range, 4-30,642). CA 125 and CA 15-3 levels were not correlated (r = 0.015, P = 0.332). The median follow-up was 22 months (range, 3–120 months). Fifty-three (81%) patients had disease recurrence and 43 (66%) died. Survival analysis showed that patients with elevated and normal CA 15-3 levels had similar recurrence-free survival ( P = 0.78) and overall survival ( P = 0.55). Conclusions Although elevated in the majority of patients with advanced epithelial ovarian cancer, CA 15-3 levels are not predictive of survival.

Objective. To study whether there is an epidemiological association between liver hemangiomas and oral contraception use, as may be suggested by clinical observations of liver hemangioma growth dur...

Background. The incidence of ovarian metastasis in women with clinical stage I endometrial carcinoma is generally reported to be 5%, leading to the practice of removing the ovaries at surgery even in young patients. Methods. A retrospective study of 84 patients with clinical stage I endometrial cancer was carried out. Patients were excluded if the pathologic study revealed any evidence of extrauterine, apart from adnexal, spread or if the peritoneal cytology was positive. Patients with serous papillary or clear cell tumor histology were also excluded. Results. Sixty-seven patients fulfilled the inclusion criteria. Only three (4%) patients were found to be in surgical stage IIIA, all three had grade 3 tumors. Of these patients, two had uterine serosal involvement and one had a microscopic tumor implant in a fallopian tube; none had ovarian metastasis. Conclusions. The risk of ovarian metastasis in women with well to moderately differentiated endometrial cancer, myometrial invasion limited to less than one ...

Study Objective To show the possibility of laparoscopic management of uterine rupture. Design Video with explanations. Setting In the medical management with misoprostol for termination of pregnancy at any time the risk of uterine rupture may be possible. The risk is likely higher in women with a previous uterus surgery. In a systematic review of available studies, the risk of rupture was .28% among women with a prior cesarean delivery who were undergoing second-trimester misoprostol-induced abortion, meaning if 414 women with a history of cesarean delivery were given misoprostol for second-trimester abortion, 1 would experience uterine rupture. Uterine rupture has only been reported 3 times in first-trimester abortion and only once managed via laparoscopy: a missed abortion reported in 2005, a case of a ruptured unscarred uterus in a women undergoing medical abortion, and a case of a delayed miscarriage at 8 weeks’ gestation after misoprostol managed by laparotomy and sharp curettage. Interventions Total laparoscopic management in a patient with uterine tear after misoprostol treatment. Conclusion Early second-trimester medical abortions with misoprostol can cause uterine rupture. In hemodynamically stable cases, total laparoscopic management is possible approach.

SummaryPapillary serous carcinoma of the peritoneum is indistinguishable from ovarian serous cancer in terms of histology, histochemistry, immunohistology and ultra-structure. The process involves the peritoneum diffusely, sparing or only superficially invading the ovaries. The clinical presentation is similar to advanced ovarian cancer, but the ovaries are of normal size. Histopathologically, the disease must be differentiated from malignant mesothelioma through appropriate studies. Treatment entails total abdominal hysterectomy, bilateral salpingectomy, oophorectomy, and cytoreductive surgery followed by platinum-based chemotherapy. Response and survival rates are similar to those in serous ovarian cancer.

Aims To assess the rate of parametrial involvement in a large cohort of patients who underwent radical hysterectomy for cervical cancer and to suggest an algorithm for the triage of patients to simple hysterectomy or simple trachelectomy. Methods Multicenter retrospective study of patients with cervical cancer stage I through IIA who underwent radical hysterectomy and pelvic lymphadenectomy. The patients were divided into 2 groups according to whether or not the parametrium was involved. The two groups were compared with regard to the clinical and histopathological variables. Logistic regression of the variables potentially assessable prior to definitive hysterectomy such as age, tumor size, lymph-vascular space invasion (LVSI) and nodal involvement was performed. Results Five hundred and thirty patients had specific histological data on parametrial involvement and in 58 (10.9%) patients, parametria was involved. Parametrial involvement was significantly associated with older age, tumors larger than 2 cm, deeper invasion, LVSI, involved surgical margins, and the presence of nodal metastasis. By triaging patients with a tumor ≤2 cm and no LVSI, the parametrial involvement rate was 1.8% (2/112 patients). With further triage of patients with negative nodes, the rate of parametrial involvement was 0% (0/107 patients). Conclusion Using a pre-operative triage algorithm, patients with early small lesions, no LVSI and no nodal involvement may be spared radical surgical procedures and parametrectomy. Further prospective data are urgently needed.

Objective We sought to determine the effect of nonclosure of the visceral and parietal peritoneum during cesarean section on the formation of adhesions. Study Design This was a prospective randomized trial of 533 women undergoing primary cesarean section; in 256 the peritoneum was left open and in 277 it was closed. Fifty women in the nonclosure group and 47 women in the closure group were subsequently evaluated intraoperatively at a repeat cesarean. The presence of adhesions and their severity were evaluated at several sites. Results The nonclosure and closure groups were comparable with regard to the proportion of patients with adhesions at any site (60% vs 51%, respectively; P = .31). Time from incision to delivery was comparable in the nonclosure and closure groups (8.98 ± 4.7 vs 9.32 ± 5.2 minutes, respectively; P = .84). Conclusion Closure or nonclosure of the peritoneum at cesarean section did not lead to large differences in the adhesion rate.

To study the temporal pattern of endometrial cancer recurrence in relation to histological risk factors in a large multicenter setting.843 patients with apparent stage I endometrial cancer were followed for a median time of 38 months, documenting all recurrences. Patients were stratified as high risk based on the presence of at least one of the established histological risk factors: high tumor grade, penetration to the outer half of the myometrium, lymphvascular space involvement, lower uterine segment involvement and non endometroid histology. Survival analysis, including Kaplan-Meier curves, log-rank tests and multi-variate Cox proportional hazard regression were used to evaluate the equality of recurrence-free distributions for different levels of risk.Recurrence was documented in 66 cases. The presence of one or more of the histological risk factors was associated with significantly shorter recurrence free survival, not attenuating over time (p0.001). Age-adjusted Cox regression model demonstrated a significantly decreased recurrence-free survival (HR = 2.8 95% CI 1.5, 5.1) in the presence of risk factors.In patients with stage I endometrial cancer, the presence of histological risk factors is associated with a significantly higher recurrence rate, which does not attenuate over follow up time. This may allow for a selective approach in the follow- up of endometrial cancer patients.

In a study on the influence of salpingectomy on the same patient ipsilateral ovarian response, 15 patients who were admitted to our department with the diagnosis of uni- or bilateral hydrosalpinges and who were successfully treated by laparoscopic salpingectomy were evaluated. The observed significant decrease in the ipsilateral ovarian response after salgingectomy, as reflected by the quantity of developing follicles during controlled ovarian hyperstimulation for IVF, should be presented to patients during the decision-making process, before offering salpingectomy for the treatment of hydrosalpinx.

Background: Adrenal oncocytomas are uncommon, nonfunctioning tumors occurring most often in endocrine organs. Case: A 32-year-old woman presented at 25 weeks’ gestation complaining of right flank pain. Abdominal ultrasonography and computed tomography revealed a 9 × 10-cm solid right-sided adrenal mass. Endocrine evaluation was normal. At 36 weeks’ gestation, she underwent cesarean followed by resection of the adrenal mass. Histopathologic and ultrastructural studies revealed a benign adrenocortical oncocytoma. Conclusion: Although rare, adrenocortical oncocytomas should be included in the differential diagnosis of solid, nonfunctioning, adrenal tumors in pregnancy.

Background. Suboptimal cytoreduction of advanced ovarian cancer is related to initial tumor bulk which correlates with CA125 level. Methods. Retrospective record study of 40 patients with stage III ovarian cancer. The ability of a CA125 threshold level of 500 U/mL to predict suboptimal cytoreduction was determined. Results. Twenty-four (60%) of the patients were optimally cytoreduced. At the CA125 cut off level of 500 U/mL the sensitivity for predicting suboptimal debulking was 62% and specificity was 83%. Above a CA 125 level of 1500 U/mL none of the patients were optimally cytoreduced. Conclusions. More data are needed to determine the CA125 cut off level at which the standard approach of initial laparotomy and cytoreduction may be modified.

Background. Suboptimal cytoreduction of advanced ovarian cancer is related to initial tumor bulk which correlates with CA125 level. Methods. Retrospective record study of 40 patients with stage III ovarian cancer. The ability of a CA125 threshold level of 500 U/mL to predict suboptimal cytoreduction was determined. Results. Twenty-four (60%) of the patients were optimally cytoreduced. At the CA125 cut off level of 500 U/mL the sensitivity for predicting suboptimal debulking was 62% and specificity was 83%. Above a CA 125 level of 1500 U/mL none of the patients were optimally cytoreduced. Conclusions. More data are needed to determine the CA125 cut off level at which the standard approach of initial laparotomy and cytoreduction may be modified.

To determine the incidence of BRCA1 and BRCA2 mutations in an enlarged series of uterine serous carcinoma (USC) patients and to determine whether patients with USC are associated with a personal or familial history of breast or ovarian carcinoma.A cohort of all consecutive patients with diagnosed USC was identified for 9 years. Family pedigrees were drawn as far back and laterally as possible. In all patients, genomic DNA was extracted from peripheral blood samples and analyzed for the 3 mutations common in Ashkenazi Jewish patients. All patients went through total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. Tubal, ovarian, and peritoneal carcinoma were ruled out clinically and pathologically in all patients.Of 51 consecutive patients with USC in Ashkenazi Jews studied, we identified 13 patients (25.5%) who were previously found to have breast carcinoma, 17 patients (33.3%) who had a first-degree relative with breast or ovarian carcinoma, and 8 patients (15.7%) who were found to be carriers of 1 of the 3 BRCA germline mutations.This series of USC patients, the largest consecutive series to date, suggests a higher incidence of BRCA carriers among Ashkenazi Jews as compared with the general population. This high rate of BRCA germline mutations in USC patients coupled with a high rate of personal and familial cancer histories may suggest that USC is associated with the hereditary breast-ovarian syndrome. This potential association of USC to the BRCA-associated cancer spectrum may have implications for the clinical management and intervention of unaffected BRCA1-2 germline mutation carriers. However, at the current time, there are insufficient data to provide evidence-based guidelines regarding the optimal timing or specific intervention to prevent cancers in these high-risk women.

Objectives The genes associated with familial Endometrial Cancer (EC) are largely unknown. While EC is an integral part of Hereditary Non-Polyposis Colon Cancer, there is an ongoing debate if EC is indeed overrepresented in hereditary breast/ovarian cancer families. Methods Unselected Jewish women with EC who were diagnosed from January1982 to January 2008 were genotyped for the predominant mutations in Jewish individuals in BRCA1 (185delAG, 5382InsC, Tyr978X) BRCA2 (6174delT), MSH2 (A636P, 324delCA) and MSH6 (c.3984_3987dup). Results Overall, 289 Jewish women with EC were included, the majority (217–75%) were Ashkenazim. Mean age at diagnosis was 62.6±12years, the most common histopathology was type I (endometrioid carcinoma) (80.4% of participants) with 29 having type II (Uterine papillary serous and clear cell cancer) Most patients (85.4%) had stage 1 disease by the FIGO staging. Five women (1.7%–2.3% of the Ashkenazim) carried either the BRCA1 *185delAG ( n =4) or BRCA2 *6174delT ( n =1) mutations, a rate similar with that of the general Ashkenazi population. Notably, none of 34 women with type II EC carried any BRCA1/BRCA2 mutations. Four (1.8%) and three (1.4%) of the 217 Ashkenazim patients harbored the c.3984_3987dup, A636P, MSH6 and MSH2 mutations, respectively, and 1/72 (1.4%) of the non-Ashkenazi patients harbored the 324delCA MSH2 mutation. Three of 42 (7.1%) women with EC diagnosed BRCA1 MSH6 or MSH2 mutations. Conclusions Our data do not support screening for BRCA1/2 mutations in consecutive EC patients.

To compare perinatal outcome of deliveries complicated by cord prolapse between cases in which bladder filling was performed in addition to supporting presenting part and cases where only support was employed. A retrospective review of 44 deliveries complicated by prolapse occurring after admission was made. The first group included 29 patients who were rushed to a cesarean section with doctor’s hand inside the vagina pushing the presenting part. The second group of 15 patients, included women whose bladder was filled with 500 cc of normal saline in addition to manual support. Time to delivery was similar in the first and second group (19.7 ± 9.46 and 21.6 ± 11.9, P = 0.57; respectively) as well as the mean neonatal pH values (7.28 ± 0.09 and 7.26 ± 0.07, P = 0.55; respectively). There was no significant difference in proportion of neonates with an Apgar score of less than 7 between the two arms. The addition of bladder filling to further displace the presenting part did not improve the neonatal outcome which was not compromised regardless of the measures employed.

To compare contemporary and historical clinical presentation of complete moles (CMs) and the rates of gestational trophoblastic neoplasia (GTN).A study was conducted of a current cohort of 108 consecutive cases of CM from 3 medical centers in Israel accrued during a 5-year period and 87 CM cases reported by the New England Trophoblastic Disease Center (NETDC) from the years 1988 to 1993. Clinical presentation and the rate of GTN of our cohort of CM and cases from the NETDC were compared.Fewer current CMs presented with vaginal bleeding than historic NETDC cases (52% vs. 84%, p0.001, respectively), and a greater proportion of current patients with CM were referred to termination of the pregnancy due solely to ultrasonographic findings (38% vs. 9%, p0.001, respectively). GTN rates were significantly lower in the current patients with CM compared to NETDC controls (14% vs. 23%, p0.05, respectively).First-trimester ultrasound examination leads to early diagnosis of molar and of nonviable pregnancies subsequently histologically diagnosed as CM. The early evacuation of the molar pregnancy is associated with a reduction in the rate of GTN.

Objective: To determine the prevalence of hydronephrosis in patients with genital prolapse and evaluate contributing factors. Methods: Retrospective study of the records of 189 patients with pelvic organ prolapse who underwent preoperative renal imaging studies. Results: Of the 189 patients 31 (17.4%) had hydronephrosis; in 20 (10.6%) patients the hydronephrosis was mild, in 7 (3.7%) it was moderate and in 4 (2.7%) it was severe. The patients with hydronephrosis were older (mean age 68±9.5 SD vs. 60.5±10.8 SD, P

To compare the validity of four predictive models of preoperative computerized tomography (CT) scans in predicting suboptimal primary cytoreduction in patients treated for advanced ovarian cancer.Preoperative CT scans of patients with stage III/IV epithelial ovarian cancer who underwent primary cytoreductive surgery at one of four medical centers were reviewed by radiologists blinded to surgical outcome. The validity of each set of CT criteria previously published by Nelson, Bristow, Dowdy, and Qayyum as predictors of suboptimal cytoreduction was assessed.Data of 123 patients were evaluated. Optimal cytoreduction (largest diameter of residual tumoror =1cm) was obtained in 90 (73.2%) patients. All CT models were able to significantly predict surgical outcome (p0.02). The respective sensitivity, specificity, and accuracy of the CT models to predict sub-optimal cytoreduction was 64%, 64% and 64% for Nelson's criteria, 70%, 64% and 66% for Bristow's criteria, 79%, 60%, and 65% for Dowdy's criteria, and 67% 57% and 60% for Qayyum's criteria.Apart from Dowdy's criteria, the accuracy rates of CT predictors of suboptimal cytoreduction in the original cohorts could not be confirmed in this cross validation. This study underscores the difficulty in devising universally applicable selection criteria or models that reliably predict surgical outcome across institutions and surgeons.

Objective To quantify the relative risk associated with lower uterine segment involvement (LUSI) on outcome measures in patients with apparent stage I endometroid endometrial cancer. Methods A cohort of 769 consecutive patients with endometroid endometrial carcinoma apparent stage I, who underwent surgery in five gynecological oncology centers in Israel; 138 patients with and 631 without LUSI were followed for a median time of 51 months. Local recurrence, recurrence-free and overall survival were compared between the two groups. Results LUSI was associated with grade 3 tumor (p = 0.002), deep myometrial invasion (p

To evaluate the appropriate controlled ovarian hyperstimulation (COH) protocol in patients with repeated IVF failures and poor embryo quality we compared the stimulation characteristics of ten cycles which included ultrashort flare GnRH agonist combined with flexible multidose GnRH antagonist with the patients' earlier failed IVF attempts. The use of ultrashort GnRH agonist/GnRH antagonist COH protocol resulted in a significantly higher number and proportion of top-quality embryos, with a consequent improvement in clinical pregnancy rate (50%).

The objective of the study was to compare the outcome measures of patients with endometrial adenocarcinoma diagnosed by endometrial biopsy, uterine curettage, or hysteroscopy. Medical records of 392 women diagnosed with apparent early-stage endometrial adenocarcinoma were reviewed. Data concerning the mode of diagnosis, histologic type and grade, surgical stage, peritoneal washings and lymph nodes status, and patient's outcome were retrieved. During the study period, 99 (25.3%) cases were diagnosed by endometrial biopsy, 193 (49.2%) by uterine curettage, and 100 (25.5%) by hysteroscopy. There were 347 (88.5%) cases of endometrioid adenocarcinoma and 45 (11.5%) of poor histologic types, including serous papillary, clear cell, and small cell cancer. Three hundred and sixteen (80.6%) patients had stage I disease, 8 (2.0%) stage II, and 68 (17.4%) stage III. Peritoneal cytology was positive in only one case. Recurrent disease occurred in 6.9% patients, of which 50% had local recurrence and 50% had distant. Recurrent disease was found in 15.2% patients diagnosed by endometrial biopsy, in 4.7% where uterine curettage was used, and in 5% when hysteroscopy was applied. No statistically significant difference in the survival rate between the different diagnostic methods applied was found, although a higher recurrence rate was noted following endometrial biopsy. After a median follow-up time of 25 months for patients undergoing hysteroscopy, there was no difference in recurrence rates and/or overall survival compared to other diagnostic procedures implying that hysteroscopy can be safely used in the diagnosis of endometrial cancer.

To quantify the relative risk associated with lymphvascular space involvement (LVSI) on outcome measures in patients with apparent stage I endometrial cancer.Six hundred and ninety nine consecutive patients with endometrial carcinoma apparent stage I, who underwent surgery in one of four gynecological oncology centers in Israel, comprised the study population. Forty cases with and 659 without LVSI were followed for a median time of 39 months. Recurrence free, disease specific and overall survival was compared between the two groups. The effect of LVSI, adjusted for other clinical and histo-pathological prognostic factors, was assessed by multivariate analysis.The univariate Kaplan-Meier procedure for survival analysis showed that patients with LVSI had lower recurrence free survival (p=0.0003), worse disease specific (p=0.0007) and overall survival (p0.0001). Cox proportional hazards model demonstrated a trend toward shorter recurrence free survival (HR=2.0, 95% CI 0.9, 4.5; p=0.08), a worse disease specific survival (HR=2.8, 95% CI 1.1, 7.4; p=0.04) and decreased overall survival (HR=2.0, 95% CI 1.1, 3.8; p=0.03) in cases with LVSI.In patients with apparent stage I endometrial cancer the presence of LVSI, an independent poor prognostic factor, is associated with a two fold increased risk of death. The presence of LVSI warrants consideration when deciding upon post operative management.

Objective: To determine which perioperative factors influence the success of hysteroscopic endometrial ablation in patients with menorrhagia. Study Design: A longitudinal study of 128 women who underwent hysteroscopic endometrial ablation or resection. Clinical data included age, uterine size, the presence of intramural or submucosal myomas and polyps, and length of follow-up from initial hysteroscopic ablation to re-ablation or hysterectomy (‘failure’). Kaplan-Meier survival analysis, log-rank tests and Cox proportional hazard regression were used to evaluate the equality of survival distributions and to model the overall effects of the various predictor variables on surgical outcomes. Results: Patients were followed for a median time of 44 months. Thirteen women (10.2%) underwent a second operative procedure. Multivariate analysis identified submucosal myoma as a statistically significant positive predictor of the risk of failure [hazard ratio (HR) 5.22, 95% confidence interval (CI) = 1.63, 16.73)]. Older age was associated with a marginally lower risk of subsequent surgery (HR 0.90 per additional year of age, 95% CI = 0.81, 1.00). Conclusions: The presence of submucosal myoma increases the risk of subsequent surgery in patients undergoing endometrial ablation.

A 27-year-old primipara with severe preeclampsia and primary antiphospholipid syndrome developed right upper quadrant pain, massive ascites, HELLP syndrome, and disseminated intravascular coagulation shortly following vaginal delivery. Computed tomography and color Doppler studies were compatible with complete thromobsis of the right hepatic veins, the Budd-Chiari syndrome. Anticoagulation was initiated, along with supportive measures, and the patient recovered completely. Imaging studies 6 months later were normal. This case demonstrates that nearly fatal forms of venous thrombosis may complicate preeclampsia in women with antiphospholipid syndrome; Doppler studies of the hepatic vein are of value in establishing the diagnosis.

To provide a large database of pre-operative CA 125 levels which may predict inappropriate cytoreductive surgery in patients with advanced epithelial ovarian cancer.A multicenter review of the records of 424 patients with FIGO stage III and IV epithelial ovarian cancer of patients who underwent primary cytoreductive surgery was performed. The validity of pre-operative CA 125 level measurement as a single predictor of the possibility to achieve only suboptimal cytoreduction was evaluated by calculating the sensitivity and the specificity of various cut-off values. The relative importance of different cut-off values in achieving the best predictive validity was assessed by a receiver operating characteristics (ROC) curve.Optimal cytoreduction (largest diameter of residual tumouror =1 cm) was achieved in 242 patients. The median CA 125 level in optimally cytoreduced patients was lower than in those patients suboptimally debulked (304 vs 863 U/mL; p0.001). The area under the ROC curve was 0.65 (95% confidence interval, 0.60-0.71) and the CA 125 threshold derived from the ROC was 400 U/mL. The accuracy of the test at this level was 62%.The clinical applicability of the ROC derived CA 125 threshold is limited. The data accrued in the study provides a basis for decision-making regarding the place of primary surgery various CA 125 levels.

To study whether there is an epidemiological association between liver hemangiomas and oral contraception use, as may be suggested by clinical observations of liver hemangioma growth during pregnancy and under estrogen administration.A case-control study of 40 women with liver hemangiomas, as diagnosed by imaging studies [ultrasonography (US) or computed tomography (CT) and nuclear scan], and 109 age-matched control with normal studies. The women were interviewed with respect to their menstrual, reproductive and oral contraception use history.The liver hemangioma and control groups did not differ significantly with regard to their menstrual or reproductive history. Ever oral contraception use was reported by 30% of the cases and 27% of controls. The odds ratio (OR) was 1.1 [95% confidence interval (CI) 0.52-2.60] for ever use, 1.64 (95% CI 0.37-7.13) for initiation before the age of 20, and 0.62 (95% CI 0.16-2.42) for use duration of less than 1 year. On the multivariate analysis only the women's age emerged as a predictor for liver hemangiomas (OR 3.1; 95% CI 1.16-8.96).In this study liver hemangiomas were not associated with menstrual, reproductive and oral contraception use history.

To determine whether lower uterine segment involvement (LUSI) correlates with recurrence and survival in women with stage I endometrial adenocarcinoma who do not receive postoperative radiotherapy on the basis of this histologic criterion.Eighty patients with endometrial adenocarcinoma stage I who underwent surgery between 1989 and 2002 were divided into 2 groups according to the presence of LUSI. Group 1 consisted of 25 patients with LUSI; group 2 consisted of 55 patients without LUSI. The 2 groups were compared with regard to prognostic factors and outcome measures.There were no statistically significant differences between the 2 groups with regard to the following parameters: age and proportion of patients who underwent complete surgical staging and postoperative adjuvant radiotherapy. Pathologic parameters of the 2 groups, such as histologic type, grade and deep myometrial invasion, were comparable. A greater proportion of patients with LUSI had capillary space-like involvement. The patients were followed for a median of 48 months (range, 11-168) from the date of surgery. The overall 5-year recurrence-free survival, disease-specific survival and overall survival rates were 91% (SE .04), 94% (SE .03) and 77% (SE .06), respectively. There was no significant difference between the two groups with regards to these measures (P.05).In patients with state I endometrial cancer, the presence of lower uterine segment involvement does not correlate with their outcome.

The incidence of ovarian metastasis in women with clinical stage I endometrial carcinoma is generally reported to be 5%, leading to the practice of removing the ovaries at surgery even in young patients.A retrospective study of 84 patients with clinical stage I endometrial cancer was carried out. Patients were excluded if the pathologic study revealed any evidence of extrauterine, apart from adnexal, spread or if the peritoneal cytology was positive. Patients with serous papillary or clear cell tumor histology were also excluded.Sixty-seven patients fulfilled the inclusion criteria. Only three (4%) patients were found to be in surgical stage IIIA, all three had grade 3 tumors. Of these patients, two had uterine serosal involvement and one had a microscopic tumor implant in a fallopian tube; none had ovarian metastasis.The risk of ovarian metastasis in women with well to moderately differentiated endometrial cancer, myometrial invasion limited to less than one half of the myometrium, negative peritoneal cytology and no evidence of metastatic lymph node spread is negligible. Young patients with a preoperative histological diagnosis of well to moderately differentiated endometrial carcinoma may be surgically staged, leaving the final decision regarding removal of the ovaries pending a thorough pathological review of the surgical specimens.

To investigate factors affecting the success of hysteroscopic endometrial ablation in order to improve patient counseling.Preoperative patient characteristics (age, parity, uterine length, and presence and location of myomas) and intraoperative factors (intracavitary findings, ablation or resection, and operator) were analyzed. Forty-three women with a uterine size ofor = 10 weeks underwent hysteroscopic endometrial ablation or resection and had a median follow-up of 20 months. All were treated with depot triptorelin, 3.75 mg, 1 month prior to the procedure. Alleviation of menorrhagia and amenorrhea was classified as treatment success. Comparative analyses were made between patients with failed vs. successful procedures and with reduced bleeding vs. those with amenorrhea following surgery.Thirty-seven women (86%) reported a decrease in menstrual flow or amenorrhea. In 6 patients (14%), bleeding persisted or became more severe. There were no statistically significant differences between women who had successful vs. failed procedures with regard to all preoperative and intraoperative parameters analyzed. Patients with amenorrhea were significantly older as compared to women with reduced bleeding (47.5 +/- SD 5.0) vs. 44.0 +/- SD 4.1 years, P = .03.Most women with uterine size ofor = 10 weeks may expect alleviation of menorrhagia or amenorrhea after surgery. Apart from age, all other preoparative and intraoperative factors examined had no predictive value for a successful procedure. These data are valuable for proper patient counseling before hysteroscopic endometrial ablation.

Chondroid syringoma of the vulva is an extremely rare tumor. Of the previously reported cases, only one was clinically malignant. The authors describe a case of chondroid syringoma of the right labium majus from which arose a papillary adenocarcinoma. A right inguinal lymph node was replaced with metastatic adenocarcinoma.

The levels of midtrimester triple test constituents are known to be altered in hypertensive disorders of pregnancy.Our aim was to determine whether midtrimester triple test constituent levels differ in women with severe preeclampsia and those who also develop HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome.A retrospective chart analysis of 106 women with severe preeclampsia for whom midtrimester triple test data were available was made. None of these patients had fetuses with abnormal karyotype, nor did they deliver infants with malformations. The levels of midtrimester maternal serum alpha-fetoprotein (MSAFP), human chorionic gonadotropin (MShCG) and unconjugated estriol (MSuE3) of 74 patients with severe preeclampsia were compared with those of 32 patients who also developed HELLP syndrome.The mean MShCG was significantly higher and the mean MSuE3 was significantly lower in patients with HELLP syndrome than in those with only severe preeclampsia [1.78 multiple of the medians (MoM), standard error (SE) 0.18 vs. 1.27 MoM, SE 0.07, p=0.015 and 0.86 MoM, SE 0.05 vs. 1.04 MoM, SE 0.07; p = 0.03, respectively]. The two groups did not differ significantly with regard to MSAFP levels.Unexplained high levels of midtrimester MShCG and low levels of MSuE3 may be associated with the development of HELLP syndrome in women with severe preeclampsia.

OBJECTIVES: Reassessment of predisposing factors to transverse lie presentation. METHODS: Retrospective analysis of delivery data on 92 women with transverse lie presentation, using ultrasonography, and 92 randomly chosen control vertex deliveries. RESULTS: The association between transverse lie and multiparity, prematurity, placenta previa, polyhydramnios and uterine anomalies is reaffirmed. Predisposing factors were found in 66% of primiparas but in only 33% of multiparas. CONCLUSIONS: Known predisposing factors to transverse lie presentation withstood a closer and more accurate assessment of their incidence.

Objective To study whether the degree of elevation of mid-trimester triple test markers differs in patients with early versus late onset severe pre-eclampsia. Methods A retrospective study of the medical records of 102 patients with severe pre-eclampsia for whom mid-trimester triple test result data were available was made. None of these patients had fetuses with abnormal karyotype nor delivered infants with malformations. Pre-eclampsia was defined as early onset when it presented before 32 weeks' gestation. The levels of mid-trimester maternal serum alpha-fetoprotein (MSAFP), human chorionic gonadotrophin (hCG) and unconjugated oestriol (MSuE3) in patients with early and late onset severe pre-eclampsia were compared. Results Twenty-five patients had early onset and 77 patients had late onset severe pre-eclampsia. The two groups did not differ significantly with regard to age, weight, parity and severity of pre-eclampsia. The mean MSAFP in patients with early onset was significantly higher than in patients with late onset severe pre-eclampsia (1.46 MoM, SE 0.12 versus 1.16 MoM, SE 0.05; p=0.01). The mean hCG in the early onset group was also significantly higher than in the late onset group (1.71 MoM, SE 0.18 versus 1.21 MoM, SE 0.07; p=0.03). Mean MSuE3 levels in patients with early onset were significantly lower than in patients with late onset severe pre-eclampsia (0.83 MoM, SE 0.05 versus 1.02 MoM, SE 0.03; p=0.04). Conclusions Higher MSAFP and hCG, and lower MSuE3, may be more significant markers of early rather than late onset severe pre-eclampsia. Copyright © 2002 John Wiley & Sons, Ltd.

Objective: To study the funic thyroid hormone levels in cases were fetal distress during labor resulted in acidemia at birth. Material and methods: Arterial and venous levels of TSH, total T4, free T4 and total T3 obtained from cord blood at birth of twelve acidemic fetuses were compared with normal controls. Results: Acidemic fetuses had a significanly higher TSH levels than controls (16.5±2.1 μI/dl vs. 9.6±1.4 μI/dl, P =0.01). Total T3 levels were significantly lower in acidemic fetuses (49.2±2.9 ng/dl vs. 63±5.5 ng/dl, P =0.04). Total and free T4 levels were similar and there was no difference between arterial and venous levels of the hormones. Conclusions: Birth acidemia from fetal distress during labor is associated with higher TSH levels and lower T3 levels.

Objective: To evaluate the incidence of ultrasonographically-diagnosed postcesarean hematomas and correlate their presence with febrile morbidity. Methods: Prospective study of 111 consecutive patients who had a pelvic ultrasound 4–6 days post-operatively. Ultrasonographic findings were correlated with clinical data. Results: Post-operative fever was diagnosed in 28 (25%) patients. Fifteen (13.5%) women had hematomas; 10 (9%) had bladder-flap and five (4.5%) had subfascial hematomas. Only subfascial hematomas were significantly associated with post-operative fever (P=0.01). Conclusions: Postcesarean bladder-flap hematomas are not predictive of post-operative fever. The presence of subfascial hematomas should be specifically sought in the evaluation of a febrile postcesarean patient.

In an attempt to examine whether physicians' experience may influence IVF outcome in patients undergoing GnRH antagonist (GnRH-a) controlled ovarian hyperstimulation (COH) protocols, we studied 273 consecutive patients, with a favorable prognosis a priori, admitted to our IVF unit, of whom 88 conceived. The highest pregnancy rate (PR) (46.5%) was observed in patients achieving, on day of hCG administration, an E(2)-to-follicle ratio