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Background: There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies., Objective: This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique., Study Design: A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated., Results: A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa., Conclusion: Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry., Objective: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies., Study Design: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions., Results: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9)., Conclusion: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to estimate the perinatal mortality associated with prenatally diagnosed vasa previa and to determine what proportion of those perinatal deaths are directly attributable to vasa previa., Data Sources: The following databases have been searched from January 1, 1987, to January 1, 2023: PubMed, Scopus, Web of Science, and Embase., Study Eligibility Criteria: Our study included all studies (cohort studies and case series or reports) that had patients in which a prenatal diagnosis of vasa previa was made. Case series or reports were excluded from the meta-analysis. All cases in which prenatal diagnosis was not made were excluded from the study., Methods: The programming language software R (version 4.2.2) was used to conduct the meta-analysis. The data were logit transformed and pooled using the fixed effects model. The between-study heterogeneity was reported by I 2 . The publication bias was evaluated using a funnel plot and the Peters regression test. The Newcastle-Ottawa scale was used to assess the risk of bias., Results: Overall, 113 studies with a cumulative sample size of 1297 pregnant individuals were included. This study included 25 cohort studies with 1167 pregnancies and 88 case series or reports with 130 pregnancies. Moreover, 13 perinatal deaths occurred among these pregnancies, consisting of 2 stillbirths and 11 neonatal deaths. Among the cohort studies, the overall perinatal mortality was 0.94% (95% confidence interval, 0.52-1.70; I 2 =0.0%). The pooled perinatal mortality attributed to vasa previa was 0.51% (95% confidence interval, 0.23-1.14; I 2 =0.0%). Stillbirth and neonatal death were reported in 0.20% (95% confidence interval, 0.05-0.80; I 2 =0.0%) and 0.77% (95% confidence interval, 0.40-1.48; I 2 =0.0%) of pregnancies, respectively., Conclusion: Perinatal death is uncommon after a prenatal diagnosis of vasa previa. Approximately half of the cases of perinatal mortality are not directly attributable to vasa previa. This information will help in guiding physicians in counseling and will provide reassurance to pregnant individuals with a prenatal diagnosis of vasa previa., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The ideal time for birth in pregnancies diagnosed with vasa previa remains unclear. We conducted a systematic review aiming to identify the gestational age at delivery that best balances the risks for prematurity with that of pregnancy prolongation in cases with prenatally diagnosed vasa previa., Data Sources: Ovid MEDLINE, PubMed, CINAHL, Embase, Scopus, and Web of Science were searched from inception to January 2022., Study Eligibility Criteria: The intervention analyzed was delivery at various gestational ages in pregnancies prenatally diagnosed with vasa previa. Cohort studies, case series, and case reports were included in the qualitative synthesis. When summary figures could not be obtained directly from the studies for the quantitative synthesis, authors were contacted and asked to provide a breakdown of perinatal outcomes by gestational age at birth., Methods: Study appraisal was completed using the National Institutes of Health quality assessment tool for the respective study types. Statistical analysis was performed using a random-effects meta-analysis of proportions., Results: The search identified 3435 studies of which 1264 were duplicates. After screening 2171 titles and abstracts, 140 studies proceeded to the full-text screen. A total of 37 studies were included for analysis, 14 of which were included in a quantitative synthesis. Among 490 neonates, there were 2 perinatal deaths (0.4%), both of which were neonatal deaths before 32 weeks' gestation. In general, the rate of neonatal complications decreased steadily from <32 weeks' gestation (4.6% rate of perinatal death, 91.2% respiratory distress, 11.4% 5-minute Apgar score <7, 23.3% neonatal blood transfusion, 100% neonatal intensive care unit admission, and 100% low birthweight) to 36 weeks' gestation (0% perinatal death, 5.3% respiratory distress, 0% 5-minute Apgar score <7, 2.9% neonatal blood transfusion, 29.2% neonatal intensive care unit admission, and 30.9% low birthweight). Complications then increased slightly at 37 weeks' gestation before decreasing again at 38 weeks' gestation., Conclusion: Prolonging pregnancies until 36 weeks' gestation seems to be safe and beneficial in otherwise uncomplicated pregnancies with antenatally diagnosed vasa previa., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Research Question: What is the efficacy of sequential two-dimensional transvaginal ultrasound (2D-US) and hysterosalpingo-foam sonography (HyFoSy) after methotrexate (MTX) treatment for tubal pregnancy among patients who desire a future pregnancy?, Design: A prospective trial conducted between May 2019 and November 2020. Patients who had a suspected tubal ectopic pregnancy diagnosed by ultrasound and treated by MTX were included. These patients underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. The primary outcome was tubal obstruction in the affected side., Results: A total of 360 women underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. Of these, 40 (11.1%) women fulfilling the inclusion criteria were enrolled. In six out of 40 (15%), hydrosalpinx of the affected tube was found during the initial transvaginal ultrasound examination and were excluded from further investigation. In the remaining 34 (85%) patients, HyFoSy was carried out. Tubal block was found in 10 out of 34 (29.4%) patients. Of these, eight out of 34 (23.5%) and two out of 34 (5.9%) had a proximal block of the affected tube and bilateral proximal obstruction, respectively. Hysterosalpingography confirmed the tubal obstruction in all the affected cases. No procedure-related complications were documented., Conclusions: Forty per cent of women who were treated by MTX for tubal pregnancy were diagnosed with tubal obstruction. We recommend that sequential transvaginal ultrasound and HyFoSy become part of routine follow-up for these women, thus offering them timely referral to the appropriate specialist., (Copyright © 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Study Objective: To evaluate the efficacy of flushing the uterine cavity with lidocaine before hysterosalpingo-foam sonography (HyFoSy) to reduce procedure-related pain., Design: A double-blind randomized controlled trial was conducted at the Department of Obstetrics and Gynecology, Shamir Medical Center, Israel between June 2020 and September 2020 involving 80 women undergoing a HyFoSy procedure., Setting: University-affiliated medical center., Patients: A total of 40 women were assigned randomly to the lidocaine group and 40 to the saline (placebo) group using a predetermined randomization code. Intrauterine instillation before the procedure consisting of either lidocaine 2% or normal saline alone was conducted, respectively., Interventions: The primary outcome measure was the visual analog scale (VAS) pain score during the phase of intrauterine foam instillation reported by the women after the procedure. The VAS consisted of a 10-cm line ranging from 0 to 10 (anchored by 0 = no pain and 10 = very severe pain). On the basis of the VAS scores, the pain level ratings were classified as mild (rated 1-3), moderate (4-6), or severe (7-10)., Measurements and Main Results: The patient characteristics and obstetric data were found to be similar in both groups. Comparison of the VAS pain scores experienced during the procedure showed that women in the lidocaine flushing group rated the procedure less painful than the women in the saline group (3.0 ± 1.3 vs 6.3 ± 1.5, respectively; p = .001). The incidence of severe pain was significantly lower in the lidocaine group than the saline group (2.5% and 45.0%, respectively, p = .001)., Conclusion: Lidocaine flushing of the uterine cavity before HyFoSy significantly decreased the pain known to be caused by this procedure and had the advantage of no side effects. It is easily applied, relatively inexpensive, and may affect compliance with this procedure., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To describe the incidence of ovarian dermoid cysts associated with paraneoplastic encephalitis syndrome due to N-methyl-D-aspartic acid (NMDA) receptor antibodies among women undergoing surgical resection of dermoid cysts., Design: Retrospective cohort study., Setting: University-affiliated department of obstetrics and gynecology., Patients: All patients with pathology-proven ovarian dermoid cysts who underwent surgical resection in our department between January 2008 and December 2019. Their demographic, clinical, and surgical characteristics are described, with emphasis on cases diagnosed with anti-NMDA receptor encephalitis., Interventions: Ovarian dermoid cyst resection by cystectomy or salpingo-oophorectomy., Measurements and Main Results: A total of 233 patients were operated on for ovarian dermoid cysts, comprising 2 cases diagnosed with anti-NMDA receptor encephalitis (0.85%). Among the women without NMDA receptor encephalitis, the mean age was 33.3 ± 14.9 years, 84.0% were of reproductive age, 5.2% were premenarchal, and 10.8% were menopausal. The mean diameter of the dermoid cyst in this group was 77.3 ± 33.3-mm. The 2 patients diagnosed with anti-NMDA receptor encephalitis were 21 years old and 42 years old. The diameters of their dermoid cysts were 15-mm and 80-mm, respectively. The patients with anti-NMDA receptor encephalitis were managed with laparoscopic resection, plasmapheresis, intravenous immunoglobulins, and corticosteroids; 1 patient also received immunosuppressive treatment. Both recovered without significant neurologic sequela., Conclusion: Paraneoplastic syndrome due to NMDA receptor antibodies is a rare complication of dermoid cysts. This complication may occur in younger or older women, as well as in small- or large-diameter cysts. Thus, a high index of suspicion is required to correctly diagnose and treat women presenting with neurologic symptoms in the presence of dermoid cysts., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To investigate the rates of intrauterine adhesion following hysteroscopy for removal of RPOC associated with surgical termination of pregnancy., Methods: We conducted a retrospective cohort study of all cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy carried out at the Yitzhak Shamir (Assaf Harofe) Medical Center from January 2013 to December 2018. The rates of postoperative intrauterine adhesion were assessed by follow-up hysteroscopy., Results: Our study involved 85 cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy. The mean size of the RPOC was 1.9 ± 0.9 cm, and the mean time from termination of pregnancy to hysteroscopy was 1.5 ± 0.9 months. Two patients (2.4%) were readmitted for postoperative complications (fever). Postoperative follow-up information was available for 49 cases (57.6%). A total of 47 of these women had a normal uterine cavity (95.9%) while 2 women (4.1%) were diagnosed with mild intrauterine adhesions., Conclusions: Hysteroscopy for removal of RPOC following surgical termination of pregnancy is associated with low rates of postoperative intrauterine adhesions. Additional studies may determine whether this is the procedure of choice in these cases., (Copyright © 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Study Objective: To investigate whether hysteroscopic features can contribute to the diagnosis of malignancy in endometrial polyps., Design: Retrospective review., Setting: Obstetrics and gynecology department., Patients: All women who underwent operative hysteroscopy for the removal of endometrial polyps between January 2012 and September 2017. Their medical records were reviewed, and information on medical, surgical, and obstetric history and hysteroscopic findings (including the number, size, and vascular appearance of the polyps) were abstracted., Interventions: Operative hysteroscopy with resection or biopsy of endometrial polyps., Measurements and Main Results: Five hundred fifty-six women were included in the study. Their mean age was 55.4 ± 12.4 years, and 322 (57.9%) were menopausal. Endometrial carcinoma was found in 26 (4.7%) cases, whereas endometrial hyperplasia was found in 5 (0.9%) cases. Endometrial carcinoma or hyperplasia was significantly associated with patients' age, menopausal status, increased polyp vascularity on hysteroscopy, and the presence of 3 or more polyps on hysteroscopy (p <.01 for all comparisons). However, the size of the largest polyp was not associated with endometrial carcinoma or hyperplasia. On logistic regression analysis, only increased polyp vascularity was associated with endometrial carcinoma or hyperplasia (odds ratio =13.5; 95% confidence interval, 5.6-32.3; p <.001). The sensitivity, specificity, positive predictive value, and negative predictive value of polyp vascularity for the diagnosis of polyps of nonbenign pathology were 51.6%, 94.3%, 34.8%, and 97.1%, respectively., Conclusion: Hysteroscopic findings of increased vascularity of endometrial polyps and numerous endometrial polyps may suggest the diagnosis of malignant polyps, in addition to demographic parameters such as age and menopausal status., (Copyright © 2019. Published by Elsevier Inc.)

Background: Placenta accreta spectrum and vasa previa (VP) are congenital disorders of placentation associated with high morbidity and mortality for both mothers and newborns when undiagnosed before delivery. Prenatal diagnosis of these conditions is essential to allow multidisciplinary management and thus improve perinatal outcomes., Objective: The objective of the study was to compare perinatal outcome in women with placenta accreta spectrum or vasa previa before and after implementation of targeted scanning protocols., Study Design: This retrospective study included 2 nonconcurrent cohorts for each condition before and after implementation of the corresponding protocols (2004-1012 vs 2013-2016 for placenta accreta spectrum and 1988-2007 vs 2008-2016 for vasa previa). Clinical reports of women diagnosed with placenta accreta spectrum and vasa previa during the study periods were reviewed and outcomes were compared., Results: In total, there were 97 cases of placenta accreta spectrum and 51 cases with vasa previa, all confirmed at delivery. In both cohorts, the prenatal detection rate increased after implementation of the scanning protocols (28 of 65 cases [43.1%] vs 31 of 32 cases [96.9%], P < .001, for placenta accreta spectrum and 9 of 18 cases [50%] vs 29 of 33 cases [87.9%], 87.9%, P < .01 for vasa previa). The perinatal outcome improved also significantly in both cohorts after implementation of the protocols. In the placenta accreta spectrum cohort, the estimated blood loss and the postoperative hospitalization stay decreased between periods (1520 ± 845 vs 1168 ± 707 mL, P < .01, and 10.9 ± 14.1 vs 5.7 ± 2.2 days, P < .05, respectively). In the vasa previa cohort, the number of 5 minute Apgar score ≤5 and umbilical cord pH <7 decreased between periods (5 of 18 cases [27.8%] vs 1 of 33 cases [3%]; P < .05, and 4 of 18 cases [22.2%] vs 1 of 33 cases [3%], P < .05, respectively)., Conclusion: The implementation of standardized prenatal targeted scanning protocols for pregnant women with risk factors for placenta accreta spectrum and vasa previa was associated with improved maternal and neonatal outcomes. The continuous increases in the rates of caesarean deliveries and use of assisted reproductive technology highlights the need to develop training programs and introduce targeted scanning protocols at the national and international levels., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Twin pregnancies are at higher risks of velamentous cord insertion and vasa previa. In vitro fertilization is an additional risk factor of abnormal cord insertion and thus the incidence of vasa previa is likely to increase over the next decades., Objective: We sought to evaluate the role of ultrasound imaging in optimizing the management of twins diagnosed with vasa previa antenatally., Study Design: We searched our database for twin pregnancies diagnosed with vasa previa and managed antenatally using measurements of cervical length and performed a systematic review of articles that correlated prenatal diagnosis of vasa previa in twins and pregnancy outcome. PubMed and MEDLINE were searched for studies published from 1987 through October 20, 2016, using specific medical subject heading terms, key words, and their combination. The primary eligibility criteria were articles that correlated prenatal ultrasound imaging of vasa previa and pregnancy outcome in twins. The secondary eligibility criteria was the use of cervical length in the management of twin pregnancies diagnosed antenatally with vasa previa. Two authors independently assessed inclusion criteria, data extraction, and analysis. The final selection included 3 case report series, 9 retrospective cohort studies, and 1 retrospective case-control study of vasa previa diagnosed prenatally and confirmed at birth in twin pregnancies., Results: The search of our databases identified 6 cases of dichorionic-diamniotic twins and 1 case of monochorionic-diamniotic twins diagnosed prenatally with vasa previa between 22-29 weeks and managed using cervical length. Two cases were delivered by emergency because of rapid changes in cervical length in one and bleeding on placenta previa in the other at 33 and 30 weeks, respectively. The systematic review identified data on 56 cases. The incidence of twin pregnancies diagnosed antenatally with vasa previa in the cohort and case-control studies was 11.0%. Data on chorionicity were available in only 34 cases and cervical length measurements were used by only the authors of 2 case reports and 4 cohort studies. Velamentous cord insertion was the most common additional ultrasound findings in twins presenting with vasa previa in both our series and the systematic review., Conclusion: Vasa previa is associated with specific prenatal and obstetric complications with different outcomes in singletons compared to twins. Data on the diagnosis and management of vasa previa in twin pregnancies are limited but there is enough evidence to warrant guidelines for targeted screening. To enable the development of efficient management protocols tailored to the need of individual cases, future studies of the screening, diagnosis, and management of vasa previa should be prospective and multicentric with detailed data on twins including chorionicity and use of cervical length., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Iatrogenic twinning has become the main side-effect assisted reproduction treatment. We have evaluated the evidence for additional care that assisted-reproduction twins may require compared with spontaneous twins. Misacarriages are increased in women with tubal problems and after specific treatments. Assisted-reproduction twin pregnancies complicated by a vanishing twin after 8 weeks have an increased risk of preterm delivery and of low and very low birthweight compared with singleton assisted-reproduction pregnancies. Monozygotic twin pregnancies occur at a higher rate after assisted reproduction treatment and are associated with a higher risk of perinatal complications. The incidence of placenta praevia and vasa praevia is increased in assisted-reproduction twin pregnancies. Large cohort studies do not indicate a higher rate of fetal congenital malformations in assisted-reproduction twins. Overall, assisted-reproduction twins in healthy women <45 years of age are not associated with a notable increase in antenatal complication rates and thus do not require additional antenatal care compared with spontaneous twins. The risks of maternal and fetal morbidity and mortality associated with assisted-reproduction twins is only increased in women with a pre-existing medical condition such as hypertensive disorders and diabetes and most of these risks can be avoided with single-embryo transfer. Following the birth of the first IVF baby, rumours started to spread in both the medical literature and the media about the long-term health effects for children born following assisted reproduction treatment. However, after more than 30 years, the most common complications associated with IVF treatment remain indirect and technical such as the failure of treatment and ovarian hyperstimulation. Iatrogenic twinning has become the main side-effect of assisted reproduction treatment and the increasing number of twin pregnancies, in particular in older women, has generated numerous debates on the need for additional healthcare provision. In this review, we have evaluated the evidence for additional care that assisted-conception twin pregnancies may require compared with spontaneous twin pregnancies. Twin pregnancies are obviously at higher risk of perinatal complications than singletons due to a natural increase in the incidence of fetal anomalies, antenatal disorders and obstetric and neonatal complications associated with the development of two fetuses instead of one. Overall, our review indicates that some antenatal complications are more frequent in assisted-conception twin pregnancies than in spontaneous twin pregnancies but their prevalence is low and thus their impact on the morbidity and mortality of an individual assisted-conception twin pregnancy is limited. Assisted reproduction treatment has become available to older women with pre-existing maternal medical conditions such as chronic hypertension and diabetes. The increased obstetrical risks in this population must be considered prior to attempts at assisted conception, and the transfer of more than one embryo should be avoided in women with a pre-existing maternal medical condition., (Copyright © 2012 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Study Objective: To assess the efficacy of oophoropexy in obviating recurrent torsion and its possible long-term effects., Design: Case series and review of the literature (Canadian Task Force classification III)., Setting: University hospital., Patients: Women who underwent oophoropexy for recurrent torsion of normal adnexa between 2003 and 2008., Measurements and Main Results: Retrieved information included the indication for oophoropexy, surgical methods, recurrence, and follow-up. Seven women underwent oophoropexy during the study period because of recurrent torsion of normal adnexa. One additional patient had experienced 3 torsion events of cystic adnexa. Surgical methods included suturing of the ovary to the pelvic sidewall or to the round ligament and plication of the utero-ovarian ligaments. Recurrence occurred in 1 of 6 patients for whom follow-up was available. All 6 patients reported spontaneous menstruation, and 2 conceived spontaneously and gave birth. Ultrasound at long-term follow-up (9-58 months) demonstrated normal ovaries., Conclusion: Oophoropexy seems to be efficacious in preventing recurrent torsion. It is our impression that plication of the utero-ovarian ligaments has advantages over other approaches insofar as surgical feasibility and anatomical conservation., (Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objectives: To investigate the phenomenon of recurrent adnexal torsion during the same pregnancy, describe its risk factors, and suggest possible management of this entity., Design: Retrospective case-control study (Canadian Task Force classification II-3)., Setting: Gynecologic endoscopy unit in a university hospital., Patients and Interventions: Pregnant women with surgically proved adnexal torsion were retrospectively identified from 1993 to 2007. Details of clinical presentation, method of conception, preoperative ultrasound findings, and operative findings were analyzed., Intervention: Comparison of characteristics of patients with recurrent episodes of adnexal torsion during the same pregnancy vs a single episode of torsion., Measurements and Main Results: Thirty-three pregnant women with 38 episodes of adnexal torsion were included in the study. Seventeen pregnancies (51.5%) were spontaneously conceived. Twenty-eight women had a single episode of torsion, and 5 women (15.1%) had recurrent episodes of torsion during the same pregnancy. No significant differences were found between the 2 groups in age, method of conception, and gestational age at time of torsion. However, ultrasound studies demonstrated that multicystic ovaries were significantly more common in women with recurrent torsion compared with women with a single episode of torsion (80% vs 25%; p =.02). The interval between the first and second episodes of torsion ranged from 1 to 4 weeks., Conclusion: Pregnant women are at risk for recurrent torsion, especially when the ovaries are enlarged and ultrasound studies demonstrate multiple cysts. Cyst aspiration may prevent recurrent torsion during the same pregnancy.

Pelvic splenosis is a post-traumatic spleen autotransplantation, which can mimic various gynaecological diseases. A case of a 39-year-old woman, who underwent partial splenectomy because of a road accident in her childhood, currently presenting with abdominal pain and suspected corpus luteus torsion. Diagnostic laparoscopy was conducted which ruled out twisted ovary. This confirmed disseminated pelvic splenosis as a coincidental finding. Following this procedure, the abdominal pain ceased. The current report aims to raise the awareness of splenosis so that it may be appropriately recognized and differentiated from other pelvic findings.

Assisted reproductive techniques have increased the number of pregnant women beyond the age of 35 years and the incidence of multiple pregnancies. Various non-invasive screening methods for Down's syndrome were introduced in clinical practice during the past two decades. Specific problems were encountered when these methods were applied for pregnancies achieved by assisted reproduction treatment and the aim of this review is to explore these issues and propose an adjusted methodological approach for this highly selected population. Overall, more women with assisted reproduction singleton pregnancies are found to be false-positive for Down's syndrome. This is because standard screening algorithms include maternal age. In addition, mid-trimester maternal serum screening is associated with a higher false-positive rate. This is due to changes in the feto-placental endocrinological metabolism in pregnancies achieved by assisted reproduction treatment. Ultrasound screening of Down's syndrome by means of nuchal translucency (NT) measurements at 10-14 weeks is associated with a lower false-positive rate than mid-trimester serum screening. The lowest false-positive rates reported in singleton pregnancies are observed when serum and nuchal translucency screening are combined at 10-14 weeks. In multiple pregnancies, mid-trimester maternal serum screening is of limited clinical value. Nuchal translucency measurement is among the best available and is the most efficient screening method for multiple pregnancies. This sonographical method for screening enables specific identification of those fetuses at high risk of Down's syndrome and other anomalies, and thus contributes to a better outcome. Therefore, it should be systematically performed before any fetal reduction in high-order multiple pregnancies is planned.

Human placental isoferritin (PLF) is a sub-type of human ferritin mainly composed of a 43 kD protein, which has an immunosuppressive activity and may be involved in the downregulation of the maternal immune system during pregnancy. The aim of this study was to evaluate the distribution of p43 in the placental tissue of abnormal first trimester pregnancies. Samples of villous and decidual tissues were collected between 7 and 12 weeks' gestation from 28 missed abortions and eight complete moles. Samples of placental tissue from 20 normal pregnancies of similar gestational age were used as controls. The localization of p43 was determined by immunohistochemical techniques using CM-H9 monoclonal antibody. Compared to controls, specific p43 immunoreactivity was low in the villous syncytiotrophoblast of missed abortions and absent from all villous cellular types in complete moles. These findings correlate well with the low level of maternal serum PLF found previously in early pregnancy failures and molar gestation. This suggests that PLF may be involved in the pathogenesis of early pregnancy disorders related to an abnormal placentation., (Copyright 2000 Harcourt Publishers Ltd.)

Objective: Human placental isoferritin, which is composed of a 43-kd protein subunit, is exclusively reactive with the CM-H9 monoclonal antibody. The p43 exerts immunosuppressive activity during pregnancy. The aim of this study was to localize the expression of p43 in the maternal-fetal tissue interface during normal gestation., Study Design: Villous tissues samples were collected between 5 and 20 weeks' gestation and at term from uncomplicated pregnancies. Immunohistochemical localization of p43 was performed with CM-H9 monoclonal antibody., Results: During the first trimester p43 was highly expressed in syncytiotrophoblast, Hofbauer cells, and decidual macrophages. From 15 weeks' gestation onward expression in the syncytiotrophoblast was below the level of detection; however, p43 was demonstrated in villous Hofbauer cells and decidual macrophages throughout gestation., Conclusions: Expression of p43 was demonstrated on both sides of the maternal-fetal tissue interface, with localization dependent on gestational age. This may suggest its immunologic function throughout pregnancy. First-trimester syncytiotrophoblast displayed high p43 levels, which disappeared later on, whereas maternal serum p43 level continued to increase, which suggests an extraplacental source for p43.

Serum placental isoferritin levels (PLF) levels were measured in 33 patients admitted for routine scanning of a first trimester normal singleton pregnancy and six patients who were hospitalized for uterine evacuation of a complete molar gestation. Venous blood was obtained upon admission and before curettage, when necessary. Serum was separated into glass tubes, immediately frozen and stored at -20 degrees C until analysed. The mean serum PLF levels were 18.1 (+/- 14) U/ml and 5.5 (+/- 2) U/ml for normal and molar gestations, respectively, with a significant difference between the two groups (P = 0.001). Sixty-seven per cent of normal pregnancies had serum PLF levels > or = 10 U/ml, whereas none of the molar gestation group reached this threshold level. Furthermore, the molar gestation group's low serum PLF levels remained unchanged throughout the entire follow-up period and until their beta-human chorionic gonadotrophin levels were undetectable. Unlike normal pregnancies, the molar trophoblast does not seem to secrete or synthesize PLF, suggesting that the complete molar placenta has different protein-producing capabilities when compared with those found in normal pregnancies. Further studies, including serum PLF among other categories of gestational trophoblastic neoplasms, are recommended before this data can be integrated into routine clinical work.

Prostaglandin E2 is a powerful oxytocic agent that reliably initiates labor, even in the presence of an unripe cervix. The low incidence of fetomaternal complication contributes to its universal use. We report a rare case of uterine rupture after intracervical application of prostaglandin E2 gel. Thus far no prostaglandin compound or method of administration seems to be exempt from such a complication.

Ketanserin, as a 5HT2 selective antagonist, was evaluated for its tocolytic effects in pregnant Charles River (CR) rats, at total doses of 1.5 and 3.5 mg/kg IU from day 22 to day 25 of pregnancy. After 18 hours of ethenyl estradiol induction, tocolytic evaluation was carried out by recording uterine activity. When compared to the control group, the administration of Ketanserin resulted in an apparent, nondose dependent suppression of uterine contractility.

The serum concentrations of placental isoferritin and normal ferritin were determined in 20 patients with preeclamptic toxemia of pregnancy and were compared with the level measured in normal pregnant women at the third trimester and in labor at term. The mean serum concentration of placental isoferritin for the women with preeclamptic toxemia was found to be low: 7.5 +/- 23 U/ml compared with 81.6 +/- 89.3 U/ml in normal pregnancy during the third trimester and 54.8 +/- 53 U/ml in term delivery. In comparison, there was no significant difference in the serum levels of normal ferritin in both pregnant women with toxemia and in those without toxemia. These results suggest that placental isoferritin may be a useful marker for preeclamptic toxemia of pregnancy.