Thrombophilia polymorphisms and intrauterine growth restriction.
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Birth Weight↗
Biomedical subjects
Joseph B Lessing
Publications and source records attributed to Joseph B Lessing.
Tension-free vaginal tape for stress urinary incontinence: Is there a learning curve?
AIM: To assess the learning curve characteristics of the first 30 tension-free vaginal tape (TVT) procedures carried out in our medical center and to evaluate its safety and short-term effectiveness. METHODS: A total of 30 incontinent women with urodynamically proven SUI were enrolled. None had undergone any previous anti-incontinence procedure. All were operated on by one surgeon, in accordance with the technique described by Ulmsten et al. in 1996. Mean follow-up was 11.4+/- 3.6 months (range, 5-17 months). RESULTS: Five (17%) bladder perforations occurred at the beginning of the study, due to inadvertent insertion of the applicator. All perforations were identified by intraoperative cystoscopy. Five other patients (17%) had increased intraoperative bleeding (>200 mL) necessitating vaginal tamponade. Blood transfusions were not required. Eight (27%) patients had immediate postoperative voiding difficulties, necessitating catheterization for 2-10 days, but none needed long-term catheterization. There was no local infection or rejection of the Prolene tape was found. All patients were subjectively cured of their stress incontinence; however, urodynamic evaluation revealed "asymptomatic genuine stress incontinence" in one patient. Sixteen of 21 patients (80%) with preoperative urge syndrome, had persistent postoperative symptoms. No patient developed de novo urge incontinence. CONCLUSION: The TVT operation is a new, minimally invasive surgical procedure with excellent short- and medium-term cure rates. However, there is a definite learning curve, and we believe that the operation should only be performed by experienced surgeons.
Aged↗
Clinical and economic implications of adding HPV tests to the routine cytology follow-up and management of patients with histologically defined cervical intraepithelial neoplasia grade 1.
OBJECTIVE: The objective of this study was to evaluate the clinical and economic implications of adding human papillomavirus (HPV) testing to the follow-up and management protocol of women with a histological diagnosis of low-grade cervical intraepithelial neoplasia (CIN1). METHODS: The study cohort consisted of 314 women with histological diagnosis of CIN1 and who met the inclusion criteria. They were followed-up by pap smears and samples for HPV tests that were obtained and analyzed on the first visit after referral. HPV assessment was carried out later. Colposcopy and biopsies were performed when there were two consecutive abnormal pap results or positive HPV tests. Women with any degree of CIN underwent cone biopsies. RESULTS: The positive predictive value (PPV) of low-grade squamous intraepithelial lesion and high-grade squamous epithelial lesion to identify high-grade lesions (CIN2-3) were 48.9 and 95%, respectively. The PPV of low-risk HPV type for CIN1 and that of high-risk HPV type for CIN2-3 were both 97%. Of the 314 study participants, 68 (21.6%) patients were positive for HPV analysis, and 67 of these (98.5%) had either CIN1 or CIN2-3 on the cone biopsy, with an overall PPV of 95%. The cost effectiveness ratio was $1457 per additional case detected by the "HPV approach." CONCLUSIONS: Testing for the presence of high-risk HPV types is both clinically and economically more beneficial than cytology in the follow-up and management of patients with a diagnosis of CIN 1 because of its better sensitivity, specificity, and PPV reports.
Adolescent↗
Efficacy of methotrexate treatment in extrauterine pregnancies defined by stable or increasing human chorionic gonadotropin concentrations.
OBJECTIVE: To evaluate the efficacy of methotrexate treatment in selected cases of extrauterine pregnancy (EUP) defined by stable or increasing hCG concentration. DESIGN: Prospective cohort study. SETTING: Gynecology department of the Lis Maternity Hospital. PATIENT(S): Fifty women with EUP diagnosed whenever an intrauterine gestational sac was not seen on transvaginal ultrasonography. INTERVENTION(S): Women received IM methotrexate at a dose of 50 mg/m(2) of body surface area. Failure of hCG levels to fall by >/=15% during any successive week resulted in repeated administration of methotrexate. Surgical intervention was performed for presumed tubal rupture. MAIN OUTCOME MEASURE(S): Serial hCG measurement was performed weekly until hCG concentration reached 15 mIU/mL. Success was defined as the achievement of hCG concentration of 25 mIU/mL without surgical intervention. RESULT(S): Forty-four women (88%) were successfully treated. The mean time from first methotrexate injection to success was 34 +/- 2.4 days. Women treated successfully and unsuccessfully differed significantly only with regard to serum hCG levels of 1,876 +/- 243 and 3,489 +/- 376 mIU/mL, respectively. When the initial hCG levels were lower or higher than 2,000 IU/L, the success rate was 97% and 74%, respectively (significant by Fisher's exact test). CONCLUSION(S): When methotrexate treatment is administrated in a selected group of EUP defined by stable or increasing hCG, it may fail more frequently (26%) when initial hCG levels are >2,000 mIU/mL.
Chorionic Gonadotropin↗
Effect of paracentesis of ascitic fluids on urinary output and blood indices in patients with severe ovarian hyperstimulation syndrome.
OBJECTIVE: To determine the isolated effect of abdominal paracentesis of ascitic fluid in women with severe OHSS on urine production and blood indices. DESIGN: Retrospective interventional study. SETTING: Gynecology department at the Lis Maternity Hospital, affiliated to Tel Aviv University. PATIENT(S): Thirty women with severe OHSS. INTERVENTION(S): Abdominal paracentesis according to clinical indications. MAIN OUTCOME MEASURE(S): Urinary output, blood urea nitrogen, as well as a complete blood count were measured before and following the procedure. RESULT(S): Urinary output increased from 1890 +/- 128 mL per 24 hours on the day before paracentesis to 2,660 +/- 226 mL per 24 hours after the procedure. Blood urea nitrogen values were 8.9 +/- 0.56 mg/dL and 7.8 +/- 0.53 mg/dL on the days before and after paracentesis, respectively. White blood cell count decreased from 15.4 +/- 1.1 (x 10(3) cells/mm(3)) on the days before the paracentesis to 13.3 +/- 0.9 (x 10(3) cells/mm(3)) after the procedure. Hematocrit was reduced significantly from 35.2 +/- 1.0% before the paracentesis to 33.4 +/- 0.8% after paracentesis. CONCLUSION(S): Paracentesis of ascitic fluids in women with severe OHSS has an isolated effect in improving renal function, as is evident by the increased urinary output and reduced blood urea nitrogen.
Adult↗
Efficacy of hydroxyethyl starch and haemaccel for the treatment of severe ovarian hyperstimulation syndrome.
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Adult↗
Third-trimester unexplained intrauterine fetal death is associated with inherited thrombophilia.
OBJECTIVE: To determine the risk of thrombophilias in women with unexplained intrauterine fetal deaths (IUFD). METHODS: All women with IUFD at 27 weeks' gestation or greater were initially assessed during a period of 26 months. Subjects with multiple pregnancies, congenital anomalies, intrauterine infection, chorioamnionitis, immune hydrops, diabetes mellitus, previous thromboembolism, and severe hypertensive disease were excluded. The remaining 40 women with unexplained IUFD (study group) were matched for age and ethnicity with 80 healthy women who had at least one normal pregnancy (control group). All participants were tested at least 2 months after delivery for mutations of factor V Leiden, prothrombin gene, methylenetetrahydrofolate reductase, and for deficiencies of protein S, protein C, and antithrombin III. They were also tested and found to be negative for anticardiolipin antibodies. RESULTS: The gestational age at delivery and birth weight were significantly lower in the study group. The prevalence of inherited thrombophilias was 42.5% in the study group compared with 15% in the control group (odds ratio 2.8, 95% confidence interval 1.5, 5.3, P =.001). The prothrombin mutation and protein S deficiency rates were significantly higher in the study group (odds ratio 2.3, 95% confidence interval 1.3, 4.0, and odds ratio 3.2, 95% confidence interval 2.4, 4.1, respectively). CONCLUSION: Third-trimester IUFD is significantly associated with thrombophilias. These findings suggest that thrombophilia work-ups should be part of IUFD investigations and may have therapeutic and prognostic implications in future pregnancies.
Adult↗
A simple, inexpensive method of specimen removal at laparoscopy.
After completing operative laparoscopy, it is often necessary to enlarge a 5-mm port to 10 or 12 mm for tissue removal. This may increase the risk of vessel injury and herniation, and has obvious cosmetic drawbacks. A simple, cost-effective technique for tissue removal does not require enlarging the 5-mm port. A long, firm thread is sutured to a sterile plastic bag. When tissue removal is required, the optic telescope is removed and the bag is blindly introduced through the available optical 11- or 12-mm cannula. The telescope is reintroduced, keeping the end of the thread outside the cannula sleeve. The specimen is placed in the bag and the bag is removed by pulling the suture through the optical cannula after removing the telescope. This technique was performed successfully in over 300 patients, with no difficulty or complication either during or after surgery. The device is inexpensive and takes 2 minutes to assemble.
Equipment Design↗
The mitochondrial DNA mutation (deltamtDNA5286) in human oocytes: correlation with age and IVF outcome.
PURPOSE: To evaluate the correlation between the presence of a newly described mitochondrial DNA (mtDNA) mutation (deltamtDNA5286), patients' age, and in vitro fertilization (IVF) outcomes. METHODS: The presence of deltamtDNA5286 was analyzed by nested-primer PCR in 224 unfertilized oocytes of 81 women undergoing IVF for various reasons. Age, number of oocytes retrieved, fertilization and embryo cleavage, number of embryos transferred, and pregnancy rates were compared between patients with and without a mtDNA mutation in their oocytes. RESULTS: The 23 patients in which deltamtDNA5286 was detected in at least one oocyte were significantly younger than the other 58 with no mutations (30.9 years vs. 33.8 years, respectively, P = 0.03), and had a significantly lower fertilization rate (28.9% vs. 42.1%, respectively, P = 0.01). No other outcome variable was significantly different between the two groups. CONCLUSION(S): The mtDNA mutation deltamtDNA5286 may serve as a marker of decreased oocyte quality in IVF.
Adult↗
The management of symptomatic hydronephrosis in pregnancy.
OBJECTIVE: To present and to evaluate the conservative and surgical management of hydronephrosis in pregnancy. DESIGN: Retrospective analysis of an interventional cohort. SETTING: A tertiary maternity ward. SAMPLE: Of the 30,552 women delivering in our institution between January 1998 and June 2001, 56 women (0.2%) were admitted to the prenatal care unit due to symptomatic hydronephrosis. METHODS: For each patient, renal sonography, urinalysis, serum creatinine levels, white blood cell counts and urine culture were obtained. All patients were treated conservatively by analgesics, intravenous fluids and antibiotics. Failure of these measures: non-resolving infection, deteriorating renal function, absence of Doppler sonographic evidence of ureteral flow or intractable pain led to instrumental drainage of the affected kidney. A double pigtail polyurethane ureteric stent was passed under cystoscopic vision and sonographic guidance. MAIN OUTCOME MEASURES: Resolution of clinical symptoms. RESULTS: Conservative treatment led to resolution in 52 women (92.9%), whereas four women (7.1%) failed to respond and were treated successfully and without complications by pigtail insertion. Early induction of labour was unnecessary and good perinatal outcome was the rule. CONCLUSIONS: Although the vast majority of cases of symptomatic hydronephrosis in pregnancy may be treated conservatively, pigtail insertion is an efficient and safe modality for the rare patient with refractory symptoms.
Adult↗
Mid-trimester severe intrauterine growth restriction is associated with a high prevalence of thrombophilia.
OBJECTIVE: To investigate the association between severe mid-trimester IUGR, whose causes are unknown in most cases, and maternal thrombophilias. DESIGN: Case-control study. SETTING: Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, The Sackler Faculty of Medicine, Tel Aviv University. POPULATION: Twenty-six women with severe mid-trimester (22-26 weeks of gestation) IUGR (birthweight <3rd centile) and 52 matched multiparous women with normal pregnancies (controls). METHODS: After excluding pregnancies with vascular maternal disease, chromosomal and structural aberrations and cytomegalovirus infection, 26 women out of 35 with severe mid-trimester IUGR remained and composed the study group. Each was matched for age, ethnicity and smoking status with two healthy women who had normal pregnancies. All the women were tested for genetic and acquired thrombophilias at least eight weeks after delivery. MAIN OUTCOME MEASURES: Prevalence of maternal thrombophilias. RESULTS: The frequency of thrombophilias was 69% in the study group compared with 14% in the control group [odds ratio (OR) 4.5; 95% confidence interval (CI) 2.3-9, P < 0.001]. The frequencies of factor V Leiden mutation, prothrombin gene mutation and protein S deficiency were significantly increased in the study group compared with the control group. The frequency of multiple thrombophilias was 33% in the study group versus none among the controls. Of the 26 pregnancies with severe mid-trimester IUGR, 13 ended in intrauterine fetal death before 25 weeks of gestation: 10 of these women had thrombophilia. CONCLUSION: Women with mid-trimester severe IUGR have an increased prevalence of inherited and acquired thrombophilias.
Adult↗
The ultrasonographic appearance of tubal pregnancy in patients treated with methotrexate.
BACKGROUND: The aim of the present study was to evaluate the effect of methotrexate (MTX) treatment on the ultrasonographic appearance of extrauterine pregnancy (EUP) and, particularly, to test the hypothesis that the ultrasonographic appearance is not predictive of treatment success. METHODS: A prospective cohort study. The study group included 56 women with tubal EUP who received a single-dose protocol of MTX. EUP was diagnosed whenever an intrauterine gestational sac was not identified by transvaginal ultrasonography (TVUS), accompanied by an abnormal rise or plateau in hCG concentration. Serial TVUS was performed weekly until hCG normalization or the size of the ectopic mass declined to 1 cm(2). RESULTS: Ectopic tubal mass was identified on TVUS in 45 (80%) women with a mean size of 4 +/- 0.5 cm(2). Following the first week of MTX injection, the mean size of the ectopic mass significantly increased to 6 +/- 0.8 cm(2) (P = 0.02). The initial size of the ectopic mass was not related to the success of the treatment nor to serum hCG levels. Ultrasonographic resolution of the ectopic mass was documented in 27 women following a mean of 42 +/- 2.4 days (range 7-63 days). CONCLUSIONS: The initial size of a tubal pregnancy is not related to the success of MTX treatment. MTX treatment in tubal pregnancy is followed by an initial increase in the size of the ectopic mass. Accordingly, such enlargement of the ectopic mass should not be considered as a higher risk for failure of treatment.
Adult↗
Maternal serum HCG is higher in the presence of a female fetus as early as week 3 post-fertilization.
BACKGROUND: Maternal serum HCG (MSHCG) is higher when the fetus is a female than when it is male. This has been demonstrated in the second and third trimesters of pregnancy, and recently at 10-14 weeks gestation. In this study we assessed whether this gender-related difference can be detected as early as week 3 post-fertilization. METHODS: The IVF setting was chosen because it provides precise dating of gestational age and early sonography for the number of gestational sacs. The study included 347 IVF cycles from 335 patients. Only pregnancies with a single implanted embryo that resulted in a single live birth of known gender were included. MSHCG was measured on days 14-20 post-fertilization, and levels were expressed as gestational age-corrected multiples of the median (MoMs). The log10 MSHCG MoMs were compared according to fetal gender. RESULTS: MSHCG levels were significantly higher (18.5%) in week 3 post-fertilization in the presence of a female fetus (P < 0.0002). CONCLUSION: Because a fetal gender-related difference in MSHCG can be demonstrated as early as week 3 post-fertilization, the difference may be attributed to placental factors and not to the effects of the fetal hypothalamic-hypophyseal-gonadal axis.
Chorionic Gonadotropin↗
Impact of pregnancy on respiratory capacity in women with muscular dystrophy and kyphoscoliosis. A case report.
BACKGROUND: Restriction of the chest wall in pregnancy prevents adaptive physiologic hyperventilation. This in turn might gradually promote respiratory insufficiency. CASE: Two consecutive pregnancies occurred in a woman with severe kyphoscoliosis due to juvenile muscular dystrophy. The patient died postpartum. CONCLUSION: Pregnancies with restrictive lung diseases, including severe scoliosis and kyphoscoliosis, should be considered high risk and thus should be monitored and managed carefully.
Adult↗
Correct listing of authors.
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Authorship↗
Pregnancy-induced hypertension is associated with elevation of aggregability of red blood cells.
In order to differentiate between the contributions of cellular and plasmatic factors to the elevated aggregation in pregnancy-induced hypertension (PIH), we determined RBC aggregation in autologous plasma and in plasma-free medium. The aggregation was determined as a function of shear stress, to evaluate the strength of the intercellular interaction. These procedures were applied to RBC from PIH women (n=20), normotensive pregnant (NTP) women (n=15), and non-pregnant (control) women (n=15). The average aggregate size (AAS) in plasma for PIH, NTP and control RBC was 38.7+/-3.2, 28.4+/-3.0, and 11.5+/-2.2 (P<0.05, between the three groups), respectively. For the same groups, the aggregation in plasma-free standard medium was 17.3+/-2.0, 12.0+/-1.2 and 10.0+/-1.6 (P<0.05 between PIH and the other two groups), respectively. The contribution of plasma to the elevated aggregation was 75% and 88% for PIH and NTP respectively. Tau(S50), the shear stress required to singly disperse 50% of the RBC population, in plasma and in standard medium, was about the same for PIH and NTP, and both were markedly higher than that for control RBC. These findings suggest that the increased aggregation of RBC from women with PIH, over those at of NTP women, may be due largely to changes in cellular factors and the increased aggregability has the potential to affect blood flow mainly in low-flow states such as in the placental intervillous space.
Adolescent↗
Multiplex nested PCR for preimplantation genetic diagnosis of spinal muscular atrophy.
OBJECTIVE: Spinal muscular atrophy (SMA) is a common autosomal recessive neuromuscular disorder caused in most patients by homozygous deletion of the SMN1 gene. For a carrier couple at a 25% risk of affected offspring, preimplantation genetic diagnosis (PGD) offers an alternative to prenatal diagnosis and termination of affected pregnancies. Our objective was to develop an accurate and reliable single-cell multiplex nested PCR analysis for PGD of SMA. METHODS: The method was developed on single blood leukocytes, obtained from healthy controls and an adult SMA type III patient with a known homozygous deletion of SMN1 exon 7 and 8. Multiplex nested PCR on single cells was used to co-amplify exons 7 and 8 of SMN. Additional multiplexing was performed with the ZFX/ZFY gene for sexing. Following successful establishment of the multiplex nested PCR protocol in single leukocytes, the technique was employed for PGD in 4 patients for a total of 7 cycles. In 2 patients, sexing was simultaneously performed using ZFX/ZFY. RESULTS: 220 single leukocytes from a normal individual and 220 from an SMA patient were analyzed. Exon 7 of SMN1 was amplified in 99% of normal single leukocytes and in none of the SMA-affected leukocytes. Exon 7 of SMN2 was amplified in 100% of both normal and SMA-affected leukocytes. Exon 8 of SMN1 was amplified in 98% of normal cells and in none of the SMA-affected leukocytes. Exon 8 of SMN2 was amplified in 96% of both normal and SMA-affected leukocytes. Amplification efficiency was 99% for ZFX/ZFY. There were no false-negative results and no contamination was detected in all wash-drop blanks tested. Seven PGD cycles were performed in 4 SMA-carrier couples with successful molecular analysis of 34 embryos and a total of 15 normal embryos transferred in 7 cycles. One clinical pregnancy has resulted in the delivery of a healthy male. Amniocentesis performed at 17 weeks confirmed the correct diagnosis for both SMA and sexing. CONCLUSIONS: These results suggest that our multiplex nested PCR protocol offers an efficient and accurate method for PGD of SMA while enabling the simultaneous analysis of an additional loci.
Adult↗
Nomograms for the sonographic measurement of the fetal philtrum and chin.
OBJECTIVE: To generate nomograms for the sonographic measurement of the fetal philtrum and chin during pregnancy. DESIGN: A prospective, cross-sectional study in normal singleton pregnancies. SUBJECTS: One hundred and fifty-three fetuses between 13 and 42 weeks of gestation were studied. METHODS: The philtrum was measured from the base of the columella to the upper lip. The chin was measured from the tip of the lower lip to the skin under the lower tip of the mandible. Predictive models were evaluated to generate graphic description of the 5th, 50th and 95th centiles for the fetal philtrum and chin. RESULTS: Fetal philtrum length increased with gestational age. The regression equation for the philtrum length (y) according to gestational age in weeks (x) is best predicted by the S-curve (Gompertz) model, as described by the following equation: y = exp(a + b/x), where a = 2.778577, and b = -23.476723 (R(2) = 85.3%, p < 0.0001). The fetal chin length increased with gestational age. The regression equation for the mean chin length (y) according to gestational age in weeks (x) is best predicted by the S-curve model as described in the following equation. y = exp(a + b/x), where a = 3.7922, b = -28.043, (R(2) = 89.0%, p < 0.0001). CONCLUSIONS: The nomograms generated in this study for the fetal philtrum and chin during pregnancy can be used in confirming subjective impression of facial dysmorphism.
Chin↗