Biomedical subjects
Publications and source records attributed to E Maymon.
We report a case of a chorioangioma of the placenta which was associated with elevated maternal serum HCG in the second trimester, severe early polyhydramnios and premature delivery. Chorioangioma should be considered in the differential diagnosis of an elevated HCG observed as part of the triple test.
OBJECTIVE: To determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in a low risk population at term gestation and to investigate whether MSAF is a predictor for intrapartum and neonatal morbidity. METHODS: A very low risk population including 37 085 consecutive deliveries at term composed the study population. A cross-sectional study was conducted and two groups of patients were identified according to the presence (n=6164) or absence (n=30921) of meconium in the amniotic fluid at delivery and the outcomes of the two groups compared. RESULTS: The prevalence of MSAF was 16.6%. The incidence of cesarean section (5.6% vs 2.3% P<0.01), instrumental deliveries (3.2% vs 1.8% P<0.01), fetal distress (6.5% vs. 2.1% P<0.01), clinical chorioamnionitis (0.2% vs. 0.1% P<0.01), post-partum infection (0.5% vs. 0.2% P<0.01), 1-minute Apgar score <3 (1.9% vs. 1.1% P<0.01), small for gestational age (7.4% vs. 6.4% P<0.01). was significantly higher in the MSAF compared with the clear amniotic fluid group. Intrapartum and neonatal mortality in this low risk population was significantly higher in the MSAF group (1.7/1000) compared with women with clear AF (0.3/1000). CONCLUSIONS: MSAF in a low risk population at term gestation is a predictor for adverse perinatal outcome and peripartum complications.
OBJECTIVE: To determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in women with preterm delivery. STUDY DESIGN: The study population consisted of consecutive patients who arrived with intact membranes and delivered preterm, singleton neonates at the Soroka Medical Center between 1 January 1985 and 31 December 1995. Only vertex presentation was included. Antepartum death was excluded from the study. Patients were classified according to the color of amniotic fluid into two groups: MSAF and clear amniotic fluid. Maternal puerperal complications were defined in our study as the presence of at least one of the next variables: clinical chorioamnionitis; major puerperal infection including endometritis, cesarean section or postpartum hemorrhage. Perinatal complications were defined in our study as: (1) intrapartum death (IPD) or postpartum death (PPD); (2) one or more of the following: 1-min Apgar score <3, 5-min Apgar score <7 or small for gestational age. Rates of perinatal complications were assessed at: (1) 24-27 weeks; (2) 28-31 weeks; (3) 32-36 weeks. Logistic regression was used to investigate the relationship of MSAF to perinatal complications and maternal morbidity in a multivariate model. RESULTS: During the study period, a total of 96 566 deliveries occurred in our institution and 4872 (5.0%) deliveries were preterm. Among the women delivering preterm meeting eligibility criteria, 276 (5.7%) women had intrapartum MSAF. A higher rate of IPD and PPD was observed only between 32 and 36 weeks' gestation in patients with MSAF in comparison with patients with clear amniotic fluid [6.1% (14/230) vs. 2.1% (85/4045), respectively, P=0.0001]. A statistically significant higher rate of perinatal complications was found between 28 and 31 weeks' gestation, and even a higher rate was noted between 32 and 36 weeks' gestation in the MSAF group in comparison with patients with clear amniotic fluid [51% (18/35) vs. 27.2% (93/341), respectively, P=0.003; 20% (46/230) vs. 9.8% (396/4045), respectively, P=0.0004]. CONCLUSIONS: (1) MSAF is an independent risk factor for perinatal complications in preterm deliveries (OR=1.73, CI: 1.057-2.43, P=0.001; OR=2.35, CI:1.34-4.12, P=0.002, respectively). (2) MSAF was not found to be an independent risk factor for maternal morbidity.
OBJECTIVE: To assess the importance of birth order and advanced maternal age on maternal and peripartum complications. STUDY DESIGN: The study population consisted of 12 296 multiparous women (six deliveries or more) with singleton gestation. Patients were classified into two groups according to the birth order: grand multiparous (between six and nine deliveries) and huge multiparous (ten or more deliveries). Peripartum complication was defined when at least one of the following conditions occurred: massive hemorrhage, uterine rupture, abruptio placentae, dysfunctional labor or malpresentations. Logistic regression analysis was used to evaluate the relationship between birth order and maternal age and peripartum complications. RESULTS: Among the study population, 9587 (78%) were grand multiparous and the remaining 2709 were huge multiparous women. The rate of peripartum complications was higher in huge multiparous than in grand multiparous women: malpresentation (6.2% versus 5%, P<.005), massive hemorrhage (0.7% versus 0.4%, P<.001) and dysfunctional labor (6.4% versus 3.5%, P<.001). Huge multiparous women also had a higher rate of the following complications than grand multiparous women: cesarean section (14.4% versus 10.4%, P<.01), chronic hypertension (7.9% versus 3%, P<.001), severe pregnancy induced hypertension (2.6% versus 1.1%, P<.01), diabetes class A (10.7% versus 7.5%, P<.005), diabetes class B-R (4.3% versus 2%, P<.01) congenital anomalies (3.3% versus 2.6%, P<.05) and large for gestational age infant, (17% versus 12.4%, P<.01). When adjusted for maternal age, high birth order remained strongly associated with the occurrence of peripartum complications. CONCLUSIONS: Huge multiparity was associated with a higher rate of maternal and peripartum complications than grand multiparity. Higher birth order remained an independent risk factor for peripartum complications after adjustment for maternal age.
The Joel-Cohen incision followed by nonclosure of pelvic and parietal peritoneum has been advocated as an alternative method to the Pfannenstiel incision with peritonealization at cesarean section. A randomized trial was designed to compare intra- and postoperative morbidity between the two techniques. Women to undergo a cesarean section were randomly allocated to have either the Joel-Cohen incision with the parietal and pelvic peritoneum left open (group 1) or to have the Pfannenstiel incision with both peritoneal layers sutured (group 2). The myometrium was closed with 1-0 polyglactin 910 suture using a continuous single-layer nonlocking technique. Patients in group 2 had the peritoneum approximated with 2-0 polyglactin 910 suture. The fascia was sutured with continuous 1-0 polyglactin 910 suture in all cases. Opening time was defined as the interval from skin incision to the opening of the uterine cavity. Febrile morbidity was defined as a temperature > or =38 degrees C on two occasions 4 hours (hr) apart excluding the first postoperative day. Endometritis was defined as postpartum temperature > or =38 degrees C on two occasions 4 hr apart, with uterine tenderness and/or foul-smelling lochia. One hundred forty-nine and 150 patients were allocated to group 1 and to group 2, respectively. A shorter median (range) opening time [4 min (2-21) vs. 6 min (2-19), respectively, p < 0.01] and a shorter median (range) operative time [30 min (10-65) vs. 40 min (20-110), respectively, p < 0.01] were observed in group 1. No difference was found in terms of intraoperative complications, proportion of patients who required transfusion, endometritis, sepsis, febrile morbidity, and urinary tract infections. A higher rate of wound infections was found in group 2 than in group 1 [14 of 150 (9.3%) vs. 2 of 149 (1.3%), respectively, p < 0.01]. The Joel-Cohen incision without peritonealization resulted in a shorter opening and total operative time than the Pfannenstiel laparotomy with peritonealization. This was accomplished with a reduction of wound infections.
The expression levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) were evaluated in normal and cancerous ovarian tissue and primary cell lines (PCL). Seven normal and 10 cancerous, formalin-fixed ovarian samples were examined for TNF-alpha and IL-6 expression by immunohistochemical staining using polyclonal rabbit anti-human TNF-alpha and IL-6 antibodies. Fresh normal and cancerous specimens were also examined for TNF-alpha and IL-6 secretion by bioassay and immunoassay prior to and following in vitro stimulation with lipopolysaccharide (LPS). The levels of IL-6 and TNF-alpha were higher in cancerous tissues than in normal specimens. In vitro stimulation of normal and cancerous ovarian tissues and PCL revealed their capacity to secrete IL-6. Cancerous tissue and PCL secreted higher levels than normal tissue and PCL. Stimulation of both groups with LPS increased their capacity to secrete IL-6. Optimal secretion of IL-6 by the cancerous tissue was observed after 72 hours with or without LPS (10 microg/ml). Normal tissue secreted maximal levels of IL-6 after 96 hours with or without LPS. PCL from normal ovarian tissue secreted IL-6 constitutively and optimal expression was detected after 96 hours. Carcinoma PCL from cancerous ovarian tissue demonstrated optimal secretion of IL-6 after 24 hours. Stimulation of both types of cells with LPS, IL-1 or TNF-alpha increased their capacity to secrete IL-6. TNF-alpha activity was detected in vitro only in supernatants of ovarian cancerous tissue and only after LPS stimulation; optimal levels were detected after 48 hours and 1 microg/ml LPS. Our results indicate that IL-6 and TNF-alpha are expressed in cancerous ovarian tissue at a higher level than in normal ovarian tissues. Carcinoma cells of ovarian tissues are the main cellular source of these cytokines. The conditions controlling the secretion of these cytokines, under in vitro conditions, are different in cancerous and normal ovarian tissues.
Prematurity is the leading cause of perinatal morbidity and mortality in the industrial world, occurring in 4% to 9% of all deliveries, a rate that has remained unchanged during the past decades. Despite the relative minority of obstetric patients affected by this problem, prematurity is responsible for approximately 70% to 80% of perinatal morbidity and mortality corrected for congenital anomalies. To date, treatment modalities (tocolysis) that have been applied to patients who have preterm labor (PTL) and preterm premature rupture of membranes have been found to be of limited value in reducing both the rate of prematurity and of perinatal mortality and morbidity. A possible explanation for this failure in prevention of prematurity can be attributed to the poor understanding of the mechanisms of parturition in general and the pathophysiology of PTL in particular.
Food-withdrawal has been proposed as a possible mechanism for initiating the onset of labor in animals and humans. The hypothesis was based upon the reported increase in deliveries of infants during the Yom Kippur fast. We studied the effect of the fast on full term deliveries of Jewish women, with non-fasting Bedouin women as controls (1988-1995, 1,313 Jewish and 1,091 Bedouin deliveries). To determine the effect of Yom Kippur itself, delivery rates on Sukkot and Yom Kippur were compared in both groups. The mean delivery rate in the Jewish population was significantly higher during Yom Kippur and the day after, than during the 7 days before Yom Kippur (15.1 +/- 5.1 and 14.6 +/- 4.7 vs 10.7 +/- 3.5, p < 0.04 and p < 0.01, respectively). There was an increase in delivery rate during the 6 hours before the end of the fast. In the Bedouin women there were no changes in delivery rate during any of these periods. There were no significant differences in the rates of deliveries during the Sukkot festival between Jewish and Bedouin women. We conclude that fasting is associated with a significant increase in the rate of deliveries at term.
Immunohistochemical staining of normal and cancerous ovarian tissues has demonstrated that both IL-1 alpha and IL-1 beta are more strongly expressed in cancerous than in normal tissues and are secreted mainly by epithelial cells. We have shown by bioassay and immunoassay that cancerous, but not normal ovarian tissues constitutively secrete IL-1 in vitro. Activation of cancerous ovarian tissues by lipopolysaccharide (LPS) increased its capacity to secrete IL-1. Normal ovarian tissues secreted low amounts of IL-1 only after prolonged stimulation (72-96 h) by high doses of LPS (10-100 micrograms/ml). On the other hand, constitutive IL-1 was detected in homogenates of normal ovarian tissues and stimulation by LPS increased its capacity to produce IL-1. IL-1 beta was the main type of IL-1 secreted by cancerous ovarian tissues. IL-1 alpha was detected at lower levels. In contrast, in normal tissues similar amounts of both IL-1 alpha and IL-1 beta were detected in the supernatants. The levels of both types of IL-1, and also the bioactivity of IL-1 were significantly higher in cancerous than in normal ovarian tissues. Established primary cell lines from normal ovarian tissues did not secrete IL-1 into supernatants but did express it at very low levels. Stimulation with LPS did not affect the capacity of these cell lines to secrete IL-1 but it increased their capacity to express it. In contrast, primary established epithelial cell lines from cancerous ovarian tissues did secrete and express high levels of IL-1 and these levels were increased under stimulation with LPS. Cancerous ovarian tissues did not only secrete higher levels of both IL-1 alpha and beta than normal ovarian tissues, but also the mechanism controlling the secretion of these factors in cancerous ovarian tissues seemed to be different from that found in normal ovarian tissues. Our results suggest that paracrine/autocrine factors may be involved in the regulation of both types of IL-1 secreted by ovarian tissues. These cytokines may play a role in regulating the physiological, pathophysiological and oncogenic processes of the ovary.
Pseudotumor cerebri (PTC) is a syndrome characterized by intracranial hypertension and associated with headaches, visual disturbances and papilledema, but without any identifiable intracranial pathology. PTC during pregnancy is uncommon; we report 2 such cases. Neither patient had specific complications associated with PTC. In 1 case, US of the optic nerve was used in the management. Both delivered vaginally and each had a normal puerperium. We conclude that PTC during pregnancy has no adverse effect on outcome.
OBJECTIVE: The purpose of this study was to investigate whether maternal serum CA 125 determination in women with uterine bleeding has a prognostic value in the detection of women at risk for delivering a small-for-gestational-age neonate. STUDY DESIGN: The patients population consisted of women with uterine bleeding at a gestational age greater than 20 weeks. Patients with abruptio placentae, placenta previa, fetal distress and history of coagulopathy were excluded. Maternal serum CA 125 was measured at admission. Receiver operating characteristics curve analysis and logistic regression were used for statistical purposes. RESULTS: Fifty-nine women were enrolled into the study. Six of these had a small-for-gestational-age neonate, 8 had premature rupture of membranes and 33 delivered preterm. No relationship was found between maternal serum CA 125 concentrations and preterm delivery or PROM. Women who delivered a small-for-gestational-age infant (10.1%) had lower maternal serum CA 125 levels than those who delivered an appropriate-for-gestational-age infant (P < 0.02). Patients with uterine bleeding and serum CA 125 < or = 10 U/ml had a twofold risk to deliver a small-for-gestational-age neonate. Sensitivity, specificity, positive and negative predictive values were 66.6%, 79.2%, 26.6% and 95.4%, respectively. CONCLUSION: Our results show that a decreased maternal serum CA 125 concentration in women with uterine bleeding during the second half of pregnancy is of prognostic value in identifying those who will deliver a small-for-gestational-age infant.
OBJECTIVE: To investigate the clinical significance of polyhydramnios as a predictor of perinatal death and intrapartum morbidity in patients with preterm delivery. STUDY DESIGN: The study population consisted of 4211 patients with singleton gestation, intact membranes and preterm delivery (< 37 weeks). Two groups were identified and compared according to the sonographic assessment of the amniotic fluid volume: increased and normal amniotic fluid. Analyses were conducted for the entire cohort as well as for the cohort excluding from each group all cases with congenital malformations. Logistic regression was used to assess the unique contribution of polyhydramnios to mortality and morbidity in the presence of other known risk factors. RESULTS: The prevalence of polyhydramnios among women who delivered preterm was 5% (210/4211) including and 3.7% (142/3818) excluding the cases of congenital malformations, respectively. Polyhydramnios was associated with a higher rate of diabetes, large for gestational age neonates, fetal malpresentation at delivery, previous perinatal death and with a lower Apgar score at 1 and 5 min. Polyhydramnios was an independent predictor of perinatal mortality and intrapartum morbidity. When adjusted for well recognized risk factors for perinatal mortality and intrapartum morbidity (e.g. diabetes, severe pregnancy induced hypertension, multiparity, congenital malformation, previous perinatal death, low gestational age at delivery), the presence of polyhydramnios significantly increased the rate of perinatal mortality (odds ratio (OR) 5.8; 95% confidence interval (CI) 3.68-9.11) and of intrapartum morbidity (OR 2.8; 95% CI 1.94-4.03). CONCLUSION: In the setting of preterm delivery, polyhydramnios is an independent risk factor for perinatal mortality and intrapartum complications even in the absence of congenital malformation and other conditions traditionally associated with increased perinatal mortality and morbidity.
BACKGROUND: Microbial invasion of the amniotic cavity plays a major role in the pathogenesis of preterm labor and delivery in singleton pregnancy. Nevertheless, this association is not well established among patients with multiple gestations. The purpose of our study was to explore the role of intraamniotic infection in the setting of twin pregnancies. METHODS: Consecutive women with twin gestations, intact membranes and preterm labor who underwent transabdominal amniocentesis under sonographic guidance. Amniotic fluid (AF) was retrieved from both sacs and cultured for aerobic and anaerobic microorganisms as well as for Mycoplasma species. Intraamniotic infection was defined as a positive AF culture for microorganisms. Mann Whitney U test or Student t-test or Fisher's exact test were utilized for analysis. RESULTS: Amniotic fluid was obtained from 74 patients. Sixty-eight women delivered prematurely (91.9%). Amniotic fluid culture results were positive for microorganisms in nine cases and all women with intraamniotic infection delivered prematurely as well as 59 (90.7%) patients with negative culture. Among the nine patients with intraamniotic infection, microorganisms were isolated from the presenting sac in five cases (55.6%), from both sacs in three patients (33.3%) and from the upper sac in the remaining case (11.1%). Patients with a positive AF culture had a more advanced cervical dilatation, a shorter interval amniocentesis-to-delivery and a higher incidence of clinical chorioamnionitis than those with a negative AF culture. CONCLUSIONS: The prevalence of intraamniotic infection and clinical and histological chorioamnionitis in twin pregnancies and preterm labor is similar to singleton pregnancies and preterm labor. Therefore, women with multiple gestations and preterm labor should be managed as singleton pregnancies.
During the period of 4 years between 1985 and 1988, 190 patients suffering from hyperemesis gravidarum (HG) were hospitalized at the Soroka Medical Center. From the 190 patients, 164 were followed up throughout their pregnancies and delivered at our Medical Center. The epidemiology of HG as well as the incidence of maternal complications and pregnancy outcome were analyzed and compared with 209 controls. The incidence of HG in our patient population was 6.3/1000 live births. The patients in the study group had fewer pregnancies and deliveries and more spontaneous abortions in the past than in the control population. Premature contractions and vaginal bleeding during the first trimester were more common among women with HG. Other complications of pregnancy were no more common than among controls. Women with HG in their current pregnancy had a lower incidence of spontaneous abortions (3.1%) as compared with previously reported rates in the general population (15%). Perinatal outcome was no different in women with HG than in the controls. Women with severe HG did not have statistically significant differences in the incidence of pregnancy complications and their pregnancy outcome was the same as in those without severe HG.
There is a strong association between systemic and intrauterine infection and preterm delivery. C-reactive protein (CRP) is considered a nonspecific marker for intrauterine inflammation. We determined its blood level in 100 women who presented with preterm labor and intact membranes and delivered prematurely. CRP levels were used as a noninvasive marker for infection to compare clinical characteristics between women who delivered prematurely at 31-36 and 24-30 weeks of gestation. Women who delivered earlier than the 24th week of gestation had a higher rate of positive CRP levels than those who delivered later, 54% vs 24%, respectively (p < 0.0001). Moreover, women from the lower gestational age group with positive CRP levels had significantly different clinical characteristics than those in the same group but with negative CRP levels. There was a significant difference between Jewish and Bedouin women in cervical dilatation and time interval from hospitalization to delivery between those with positive CRP and those with negative CRP levels. We conclude that patients who delivered prematurely at 24-30 weeks had higher rates of an inflammatory etiology than women who also delivered prematurely, but at a more advanced gestational age.
Two women with preterm labor and intraamniotic infection with Listeria Monocytogenes are presented. In both patients, the prenatal diagnosis of Listeriosis was made by transabdominal amniocentesis. The immediate prominent observation was meconium staining of the amniotic fluid. We propose that an amniocentesis should be performed in women with premature labor and fever. If the amniotic fluid is meconium stained and the Gram stain examination reveals Gram positive rods, Listeria Monocytogenes should be suspected and the patient should be treated accordingly until the culture results are obtained.
We report a rare case of intraamniotic infection with Haemophilus influenzae in a woman presenting with preterm premature rupture of membranes. Review of the literature identified 7 cases of intraamniotic infection with Haemophilus influenzae in patients with preterm premature rupture of membranes or with preterm labor and intact membranes.
There is a paucity of data regarding the concentration of prostaglandins (PGs) in the amniotic fluid of women with preterm labor. The purpose of this study was to determine if preterm labor is associated with changes in amniotic fluid concentration of prostaglandins E2 and F2 alpha. Amniotic fluid was retrieved by transabdominal amniocentesis from women with preterm labor and intact membranes. Patients were classified into three groups according to the response to tocolysis and the presence or absence of intra-amniotic infection. PGE2 and PGF2 alpha were measured using specific and sensitive RIA kits. Amniotic fluid concentrations of PGE2 and PGF2 alpha were significantly higher in women with preterm labor and intra-amniotic infection than in women without infection, regardless of the response to tocolysis. These data suggest that both PGs are involved in the mechanism of preterm labor and may have prognostic value.