Abstract Objective: The current study aimed to evaluate the profile of women who are most likely to undergo caesarean delivery on maternal request (CDMR) and clarify their reasons for this decision. Methods: For this multicentre case–control study, data were collected from 429 women who underwent CDMR and 429 matched controls who delivered vaginally from June, 2008 through February, 2009. Participants were interviewed by telephone regarding sociodemographic variables, health and lifestyle. Results: CDMR predictors were as follows: increasing age (OR = 1.09/year; 95%CI: 1.05–1.14), family status (unmarried without a steady partner versus married – OR = 3.60; 95%CI: 1.08–11.97), decreasing level of religiosity (secular versus ultra-orthodox – OR = 11.82; 95%CI: 3.75–37.21), and never having engaged, or ceasing sports activity during pregnancy (OR = 1.79; 95%CI: 1.09–2.91 and 2.38; 95%CI: 1.28–4.43, respectively). Above average income reduced the probability of CDMR (OR = 0.56; 95%CI: 0.33–0.94). The most frequent reasons for choosing CDMR were concern for pain (21.9%), concern for their own or baby's health (20.4% and 16.5%, respectively) and emotional aspects (10.0%). Conclusions: Older, unmarried and/or secular women had increased probability of CDMR. Addressing specific concerns regarding vaginal delivery may provide the basis for a patient-oriented intervention for preventing unnecessary surgery.

Objective: To compare trends and rates of cesarean section delivery by indication in one academic center.Materials and Methods: A retrospective analysis of the indications of all cesarean sections performed in Edith Wolfson Medical Center, Holon, Israel, a tertiary healthcare university facility, during 1997-2012 was done. Each delivery was assigned to the primary indication noted for that pregnancy, regardless of other indications reported. Whenever more than one indication was present, the principle indication chosen by the attending obstetrician was chosen for the analysis.Results: The cesarean section rate gradually rose from 15.29% in 1997 to 21.10% in 2012, with an overall cesarean section rate of 20.66%. The cesarean section rate between 1997 and 2000 was 17.52%, between 2001 and 2004 was 18.5%, between 2005 and 2009 was 22.86%, and between 2009 and 2012 was 22.07% (p < 0.001). The five leading primary indications across the years were previous cesarean section (26.0%), non-reassuring fetal heart rate pattern (18.1%), malpresentation (16.9%), labor dystocia (8.8%), and suspected macrosomia (7.2%).Conclusion: Previous cesarean section persistently increased and was the leading indication throughout the years. Any attempt to reverse this trend must be based on reduction of the primary cesarean section rate. Copyright (C) 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC.

Purpose Laparoscopy has become the standard of care in the management of ovarian benign mucinous cystadenomas. One concern of the operative approach is the risk of recurrence. A previous study has found intraoperative cyst rupture and cystectomy to be the risk factors for recurrence. Our objective was to assess the incidence and risk factors for recurrence of benign mucinous cystadenomas after surgical removal. Methods We conducted a retrospective analysis of all cases of patients who underwent removal of benign mucinous cystadenomas by either cystectomy or adnexectomy in our institution between December 2006 and June 2013. Results 722 women underwent surgical treatment for benign ovarian cysts in that time period, out of which 38 women (5.2 %) had benign mucinous cystadenomas confirmed by pathologic examination. Most of the patients underwent laparoscopy (94.7 %). Half of the patients underwent cystectomy, and the other half underwent adnexectomy. One patient underwent re-operation due to cyst recurrence. This patient initially underwent laparoscopic cystectomy, during which intraoperative cyst rupture did not occur. Conclusion Recurrence of benign mucinous cystadenomas was uncommon and was not associated with intraoperative cyst rupture.

Objective: To compare the efficacy and tolerability of vaginal misoprostol and laminaria for cervical preparation before second-trimester surgical abortion.Study design: We performed a prospective, randomized trial comparing midnight administration of misoprostol 600 mcg vaginally to midnight placement of laminaria, before surgical abortions among women at 13-20 weeks of gestation. The primary outcome was preoperative cervical dilation. Secondary outcomes were the need for further dilation, procedure duration and difficulty, immediate complications and side effects.Results: Eighty-four women were randomized, with a median gestational age of 16.5 weeks. The mean time interval between misoprostol and laminaria placement and dilatation and evacuation initiation was 11.0 +/- 2.9 and 11.2 +/- 2.0 h, respectively (p=.17). Cervical dilation was not greater in the laminaria group as compared to the misoprostol group (12.8 vs. 12.4 mm, respectively; p=.32). No difference was demonstrated regarding the need for additional dilation or the difficulty of the procedure. Procedures performed after laminaria insertion were 1 min longer (median 11 vs. 10 min, p=.04). Participants found laminaria placement more uncomfortable than vaginal misoprostol placement. Other than pain, additional side effects occurred only in the misoprostol group, primarily nausea and vomiting. One participant in the misoprostol group experienced fetal expulsion during the night before the intended procedure.Conclusion: Either vaginal misoprostol or laminaria provides adequate dilation for second-trimester surgical abortion. Laminaria causes more pain at insertion and misoprostol causes more side effects. Implications statement: We found that cervical preparation in an inpatient setting for approximately 11 h with misoprostol 600 mcg vaginally is comparable to 11 h of laminaria. However, given the potential for spontaneous expulsion and more side effects with misoprostol, laminaria is likely a better general option in such a setting. (C) 2015 Elsevier Inc. All rights reserved.

Objective: To assess the association between normal CA125 levels at diagnosis of epithelial ovarian carcinoma (EOC) with prognostic factors and with outcome. Methods: The study group consisted of histologically confirmed EOC patients with normal pretreatment CA125 levels, and the controls consisted of EOC patients with elevated (≥35 U/mL) pretreatment CA125 levels, diagnosed and treated between 1995 and 2112. Study and control group patients fulfilled the following criteria: 1) their pretreatment CA125 levels were assessed; 2) they had full standard primary treatment, i.e. cytoreductive surgery and cisplatin-based chemotherapy; and 3) they were followed every 2–4 months during the first two years and every 4–6 months thereafter. Results: Of 114 EOC patients who fulfilled the inclusion criteria, 22 (19.3%) had normal pretreatment CA125 levels. The control group consisted of the remaining 92 patients with ≥35 U/mL serum CA125 levels pretreatment. The proportion of patients with early-stage and low-grade disease, with optimal cytoreduction, and with platin-sensitive tumors was significantly higher in the study group than in the control group. The progression-free survival (PFS) and overall survival (OS) were significantly higher in the study group than in the control group on univariate analysis but not on multivariate analysis. Conclusion: It seems that a normal CA125 level at diagnosis in EOC may also be of prognostic significance for the individual patient.

PURPOSE:The aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy.METHODS:We retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013.RESULTS:We reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7 ± 1.9 weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1 ± 4.3 weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (p < 0.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (p = 0.014) and persistent ovarian mass (p = 0.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2 ± 24.0 vs. 6.8 ± 10.6 h, p = 0.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes.CONCLUSION:In our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome.

Fetal growth restriction (FGR) is one of the major contributors to adverse perinatal outcome. However, the diagnostic tools used for the assessment of fetal well-being are limited due to the great variability among fetuses. The purpose of this study was to estimate the dynamics of fetal circulation during the advanced stages of the gestational period. A methodology for estimating fetal hemodynamic parameters is presented. The method combines a mathematical model of the fetal circulation, optimization algorithm, and measurements of power-Doppler ultrasound. The model estimates fetal indices of the fetal circulation that are not accessible for direct measurement, aimed at the identification of the degree of circulatory compromise in fetuses diagnosed as FGR. The method was tested on a cohort of 20 normal and 22 growth-restricted fetuses. Model predictions indicated significant changes in the circulation of FGR fetuses compared to normal fetuses. Cardiac output was significantly lower in the FGR group compared to the control group (330 ± 52 mL min−1 kg−1 compared to 396 ± 52 mL min−1 kg−1, p < 0.001). Furthermore, placental blood flow was lower for the FGR group (145 ± 49 mL min−1 kg−1 compared to 181 ± 31 mL min−1 kg−1, p < 0.01). In the FGR fetuses with adverse outcome, both indices were reduced even further (297 ± 56 mL min−1 kg−1, p < 0.001 and 97 ± 46 mL min−1 kg−1, p < 0.001, respectively). In the adverse outcome group the model indicated also significant increase in cardiac output distribution towards the brain (9.6 ± 0.7%, compared to 8.0 ± 1.6%, p < 0.01) and an increase in the ratio of blood shunted by the ductus venosus (60.6 ± 17.7%, compared to 39.7 ± 14.8%, p < 0.01), indicating a severe brain sparing effect in these fetuses. In conclusion, patient-specific modeling may provide a reliable estimate of the important hemodynamic indices of the fetal circulation which may be clinically relevant for the management of FGR pregnancies.

Objective To compare maternal outcomes when cesarean sections were performed in the second stage of labor to those performed in the first stage of labor by indication for the operation. Study design This is a retrospective cohort (n = 383) of term parturient women who underwent primary cesarean section during active labor. Cases were drawn from the Obstetrics Department, E. Wolfson Medical Center, a tertiary health care university facility, during a 24 month period. All cases were term singleton pregnancies in vertex presentation following unremarkable pregnancy. Maternal morbidity was assessed. Results A significantly higher rate of unintentional uterine incision extensions was observed in cesarean sections performed during second stage compared to first stage (17.1% vs. 4.6%, p = 0.001). It was higher whenever (at first or second stage) the fetal head was pushed (20.0% vs. 5.4%, p = 0.0024). Unintentional uterine incision extensions were significantly more frequent when the cesarean section was performed for non-progressive labor during the second stage compared to first stage (16.1% vs. 3.6%, p = 0.0052). Uterine atonia was more frequent among parturient women who underwent cesarean section for non-progressive labor during the first stage compared to second stage (16.7% vs. 4.8%, p = 0.0382). Conclusion Uterine atony during first stage cesarean section and unintentional uterine incision extensions during second stage cesarean section were significantly more frequent when the operation was performed for non-progressive labor.

Objective: Heparanase plays a central role in processes of placentation. Abnormal placentation may result in inadequate uteroplacental blood flow, leading to unsuccessful pregnancy outcome and preeclampsia. We aimed to evaluate heparanase expression in placentas of preeclamptic patients.Materials and methods: Placental tissue samples were collected immediately after delivery from 9 preeclamptic patients and 3 healthy controls at term, and were analyzed by immunohistochemistry, western blot analysis and real-time PCR, with regard to the presence of heparanaseResults: Immunohistochemistry staining for heparanase did not differ between normal and preeclamptic placental sections. On the other hand, western blot analysis revealed increased expression of heparanase in preeclpamptic placentas compared to controls, p = 0.001. Similarly, RT-PCR analysis showed also an increased expression of heparanase m-RNA compared to health controls, p = 0.005.Conclusion: Heparanase is over expressed in preeclamptic placentas compared to normal healthy controls, suggesting its role in the development of preeclampsia.

The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. Presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. This prospective pilot study assessed the presence of nerve fibres in endometrium of women undergoing IVF due to various causes and examined the correlation between the presence of nerve fibres and IVF success. A total of 32 IVF patients underwent endometrial biopsy during days 21–23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Correlations between the presence and density of nerve fibres and aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. Presence of nerve fibres was not correlated with cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without correlation to presence of nerve fibres in the endometrium. Nerve fibres were identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. The presence of nerve fibres does not appear to interfere with implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research.The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. The presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. Our aim was to assess the presence of nerve fibres in endometrium of women with various causes of infertility undergoing IVF and to examine the association between the presence of nerve fibres in the endometrium and IVF success. In a prospective study, 32 IVF patients underwent endometrial biopsy during days 21–23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Associations between the presence and density of nerve fibres and the aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. No association was found between the presence of nerve fibres and the cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without association with the presence of nerve fibres in the endometrium. Nerve fibres can be identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. Their presence does not interfere with embryo implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research.

Background: Ovarian pregnancy is a rare type of ectopic pregnancy. Laparoscopic surgery is currently the cornerstone of ovarian pregnancy treatment. Few studies have analyzed the clinical outcomes of ovarian pregnancies after laparoscopic treatment, particularly subsequent pregnancies. Objective: The purpose of this study was to assess fertility outcomes subsequent to ovarian pregnancy treated by laparoscopy. Materials and Methods: A retrospective analysis was conducted of women with ovarian pregnancies that were diagnosed and successfully treated by laparoscopy at the E. Wolfson Medical Center during 1997–2009, and these women's subsequent fertility. Results: Eight of 829 women (1%) with ectopic pregnancy were diagnosed as having an ovarian pregnancy. All the patients were admitted either with abdominal pain, amenorrhea, or vaginal bleeding. Two patients (25%) carried an intrauterine device, 2 (25%) had been treated by in vitro fertilization because of male partner and tubal factors, and 1 patient (12.5%) had undergone two previous cesarean deliveries. In all patients, the sonographic results led to incorrect diagnosis of ectopic pregnancy or ruptured ovarian cyst. Additionally, in all patients, a laparoscopic wedge resection of the ovary was performed. Of the 8 patients, 2 did not desire further pregnancy. In another 6 patients, 5 reached term pregnancy and 1 had a miscarriage. Conclusions: Following an ovarian pregnancy treated by laparoscopy, there is a high rate of successful subsequent pregnancy with a good outcome. (J GYNECOL SURG 30:12)

Aims: To establish leukocyte count and differential percentiles in healthy singleton term laboring women during spontaneous normal vaginal labor following an uncomplicated pregnancy. Methods: An analysis of the records of all women (n = 762) who delivered at our delivery ward during a 2-month period was performed. After exclusion for cesarean delivery, induction of labor, pregnancy complications, preterm labor, multiple pregnancy, fever on admission, and lack of full blood count on admission, 365 parturient women during the 1st stage of labor were included in the final analysis. The total and differential leukocyte counts were determined by standard procedure by an automated cell counter. Results: The leukocyte count range on admission to the delivery ward during the 1st stage of labor in healthy parturient women was between 4.4 × and 21.7 × 103/µl and the 99th percentile limit was 20.06 × 103/µl. The total leukocyte count was not influenced by cervical dilatation, ruptured membranes, or the presence and regularity of uterine contractions. Conclusion: An observed leukocyte count within the 99th percentile limit (20.06 × 103/µl) in an otherwise normal parturient woman is reassuring in the absence of other clinical evidence.

OBJECTIVE:To study the effect of a departmental program designed to shorten the decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR) on maternal and neonatal outcome. STUDY DESIGN:A protocol for managing ECS that included documenting precise time-intervals, identification of delaying obstacles and debriefing of each case, was implemented from March 2011. All women who delivered by ECS for NRFHR, as the only indication were included. Detailed information regarding DDI, maternal intraoperative and postoperative complications, and neonatal early outcomes were compared before (period-P1) (-27 months) and after (period 2) (+27 months) program implementation. RESULTS:During 54 months of study, 593 ECS DDI were included. Mean DDI decreased at period 2 (12.3 ± 3.8 min, n = 301) compared with period 1 (21.7 ± 9.1 min, n = 292), P < .001. Rate of cord pH ≤7.1 and 5 min Apgar score ≤7 decreased at period 2 compared with period 1, P = .016 and P = .031, respectively. Worse composite neonatal outcome decreased at period 2 compared with period 1, 15.6% vs 32.2%, respectively, P ≥ .001. Composite maternal outcome did not differ between the groups. Worse neonatal outcome was dependent on time period (period 1), odds ratio, 2.12; 95% confidence interval, 1.27-3.55; P = .004 and on gestational age at delivery, odds ratio, 0.68; 95% confidence interval, 0.62-0.76; P < .001. CONCLUSION:Introduction of a management protocol to shorten DDI in ECS for NRFHR was associated with improved early neonatal outcome without change in maternal complications.

UNLABELLED:Background: Elevated serum levels of the epithelial marker CA125 are occasionally observed in leiomyosarcoma (LMS) patients.OBJECTIVES:To assess the immunohistochemical expression of this marker in the tissue of LMS.METHODS:The consecutive unselected records of all patients with LMS diagnosed during the period 1995-2012 were located and abstracted. After verification of the diagnosis, 4 μm unstained slides were prepared from each case for immunohistochemical staining for CA125. Sections of ovarian carcinoma known to express CA125 were used as positive controls.RESULTS:We located 17 LMS patients from the period under study. Bleeding was the presenting symptom in 9 patients; the diagnosis was established prior to treatment in 11 patients. The tumor was in an advanced stage in 6 patients, and in 7 unstaged patients it was grossly confined to the uterus. Ten patients died within 14 months after the diagnosis. Serum CA125 levels prior to treatment were assessed in only 8 patients and were above normal limits (> 35 U/ml) in 3 of them. Two of the three with elevated serum levels were in stage III, and the third was an unstaged apparent stage I patient. None of the LMS tissue specimens demonstrated immunohistochemical expression of CA125.CONCLUSIONS:CA125 was not immunohistochemically expressed in the tissue of any LMS tumors examined by us. The origin of elevated serum CA125 in some of these tumors is therefore not in its tissue and remains unknown.

Background/Aims: To evaluate the feasibility of a long protocol of controlled ovarian stimulation prior to in vitro fertilization (IVF) and embryo transfer with a gonadotropin-releasing hormone (GnRH) antagonist used for pituitary and ovarian suppression. Methods: Thirty patients undergoing IVF/intracytoplasmic sperm injection were randomized into two groups. The control group (n = 16) received a standard flexible GnRH antagonist protocol. Ovarian stimulation consisted of 225 IU/day of recombinant follicle-stimulating hormone for 5 days, followed by 225 IU/day of human menopausal gonadotropin until human chorionic gonadotropin (hCG) administration. The study group (n = 14) received 0.25 mg of GnRH antagonist daily for 7 days, thereafter, upon confirmation of pituitary and ovarian suppression, ovarian stimulation was commenced with the same protocol as used in the control group. Hormone and follicle dynamics, as well as laboratory characteristics and cycle outcome, were compared for both groups. Results: Both groups were comparable in baseline characteristics. Pituitary and ovarian suppression were effectively achieved in 12/14 patients in the study group. The duration of ovarian stimulation and gonadotropin consumption were similar in both groups, as was also the number and size of follicles on hCG day. Conclusion: The results of our study confirm the feasibility of a long GnRH antagonist protocol. This regimen could become another option to optimize GnRH antagonist protocols, and should thus be further explored.

Objective: To examine the influence of cigarette smoking during pregnancy on mode of delivery.Methods: A retrospective analysis of 6105 uncomplicated term singleton pregnancies for mode of delivery was performed with respect to smoking status.Results: Of all, 680 (84.0%) smokers and 4588 (86.7%) non-smokers had a spontaneous vaginal delivery, 65 (8.0%) smokers and 393 (7.4%) non-smokers had an instrumental delivery and 65 (8.0%) smokers and 314 (5.9%) non-smokers had a cesarean delivery (p = 0.051). Smoking during pregnancy increased the risk of any operative or instrumental intervention by OR 1.240, 95% CI 1.012-1.523. Non-reassuring fetal heart rate pattern that warranted either cesarean or instrumental intervention was present in 99 (12.2%) out of 810 smokers and in 392 out of 5295 (7.4%) non-smokers, p<0.001). Smoking during pregnancy increased the risk of non-reassuring fetal heart rate pattern that warranted either cesarean or instrumental intervention by OR 1.650 (95% CI 1.341-2.022).Conclusion: Women with uncomplicated term singleton pregnancies who smoke during pregnancy are at an increased risk of fetal compromise during labor (as judged by non-reassuring fetal heart rate pattern), leading to increased rates of operative delivery (cesarean either instrumental).

The objective of the present study was to evaluate sexual behavior longitudinally in the postpartum period by mode of delivery.