Israel Medical Association Journal

Seroconversion to cytomegalovirus occurs in 1%-4% of pregnant women, most of whom are seropositive prior to pregnancy. In 0.2%-2.5% of their newborn infants there is evidence of intrauterine infection; most are born without any clinical findings The typical clinical symptoms of symptomatic congenital CMV[1] are observed in 10-20% of infected neonates. They include intrauterine growth restriction, microcephaly, hepatosplenomegaly, petechiae, jaundice, thrombocytopenia, anemia, chorioretinitis, hearing loss and/or other findings. Long-term neurodevelopmental sequelae include mental retardation, motor impairment, sensorineural hearing loss and/or visual impairment. These may occur even in infants who are free of symptoms at birth. Most infants born with severe neonatal symptoms of congenital CMV are born to mothers with primary infection during pregnancy. However, since about half of the infants infected with CMV in utero, including those with severe neonatal symptoms, are born to mothers with preconceptional immunity, we have to conclude that congenital CMV may be a significant problem even in children born to mothers with pre-pregnancy immunization. This may justify the use of invasive methods for the detection of possible fetal infection even in cases of non-primary CMV infection. This should also be a consideration when deciding upon population screening or immunization for CMV.

This paper does not attempt to deal with the legitimate ethical or moral debate on abortion. Utilizing abortion as a subject I will show how science and medicine in general, and abortion in particular, were used as weapons of mass destruction by Nazi physicians in their zeal to comply with the political climate of the time. Nazi policy on abortion and childbirth was just one of the methods devised and designed to ensure the extermination of those whom the Nazis deemed had "lives not worth living." Physicians implemented these policies, not with the fate of their patients in mind, but rather in the name of the "state." When discussing pregnancy, abortion and childbirth during the Holocaust it is imperative to include an essay of how these issues affected the Jewish prisoner doctors in the ghettos and camps. Nazi policy dictated their actions too. From an extensive search of their testimonies, I conclude that for these doctors ethical discourse comprised a fundamental component of their functioning. I do not propose to judge them in any way and one should not, in my opinion, argue whether their behavior was or was not morally acceptable under such duress; nevertheless, unlike their Nazi counterparts, a key theme in their testimonies was to "keep their medical values."

Objectives: To compare perinatal outcome between partially insured non-resident migrants in Israel and comprehensively insured Israeli women.

Methods: Parameters of perinatal outcome were compared between 16,012 Israeli and 721 foreign women living in Israel. Outcome measures included birth weight, distribution of gestational age at delivery, neonatal complications, cesarean section, neonatal intensive care unit admission, intrauterine fetal death rates, and duration of post-partum hospitalization.

Results: Deliveries prior to 28 weeks gestation occurred more frequently among non-residents (1.3% vs. 0.6%, P < 0.001). Gestational diabetes and preeclamptic toxemia were significantly more prevalent among non-residents (3.2% vs. 1.9%, P < 0.05 and 4.9% vs. 3.1%, P < 0.05, respectively). The cesarean rates were 18% and 35% for residents and non-residents, respectively (P < 0.001), and the post-cesarean recovery period was longer among non-residents (4.8 vs. 3.6 days, P < 0.05). The mean birth weight was similar in the two groups (3,214 vs. 3,231 g), although macrosomia (>4,000 g) was more prevalent among non-residents, who also had higher rates of NICU[1] admission ((9.6% vs. 8%, P < 0.05) and intrauterine fetal death (6.6/1,000 vs. 3.7/1,000, P < 0.05).

Conclusions: Non-resident parturients in Israel are more susceptible to an adverse perinatal outcome than their Israeli counterparts. We suggest that governmental subsidization of non-residents' health expenditures would reduce the differences in perinatal outcome between these two groups.

Objective: To describe the experience of our CF[1] center in the management of CF pregnant woman from 1977 to 2004.

Methods: We analyzed 27 years of records (1977–2004) of the national CF registry of all CF women who wished to conceive and became pregnant.

Results: Eight CF women (mean age 24 ± 4.5 years) who wished to conceive had 11 pregnancies and delivered 12 neonates. The pregestational results of forced expiratory volume per 1 second varied significantly among patients (59 ± 23%), yet most (10/11) stayed stable throughout the pregnancy course. Maternal deterioration in CF condition occurred in only one mother, necessitating cesarean section. In 9 of the 11 pregnancies the women were pancreatic-insufficient. Of the 11 pregnancies, 2 CF women had diabetes mellitus and 3 developed gestational diabetes. One pregnancy occurred in a mother with a transplanted lung. Of the 12 neonates, 3 were preterm and one was born with esophageal atresia. No miscarriages, terminations or neonatal mortalities occurred. Although most of the CF mothers had FEV_1[2] below 55% before pregnancy, the maternal and neonatal outcome was favorable and lung function tests generally remained stable.

Conclusions: We conclude that pregnancy in CF is feasible with a positive maternal and neonatal outcome. Early participation of the CF physician in the wish of the CF woman to reproduce is required. The integration of an intensive multidisciplinary approach during pregnancy, which includes close follow-up of maternal and fetal condition by the various specialists, should ensure an optimal outcome.

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[1] CF = cystic fibrosis

[2] FEV₁ = forced expiratory volume per 1 sec

Background: Iodine intake is necessary to maintain normal thyroid function and prevent iodine deficiency disorders. In 1990, a resolution calling for universal salt iodination to eliminate iodine deficiency worldwide was taken by the World Health Organization and endorsed by some 130 countries. As of today, very little is known about iodine intake and the prevalence of iodine deficiency disorders in Israel, and iodine enrichment of regular salt has not been authorized.

Objectives: To assess the current level of iodine intake in an unselected group of residents from the Israeli costal area.

Methods: Spot urine samples were collected from three groups: Group A comprising 51 pregnant women attending the Women s Health Clinic at our institution, with a mean age of 32 years and at gestational week 28; group B consisting of 35 healthy subjects, mean age 38; and group C consisting of 16 euthyroid subjects harboring nodular goiters. Tap drinking and mineral water were also analyzed for iodine content. Iodine concentration was measured using the catalytic reduction of ceric ammonium sulfate method.

Results: When considering all groups together the median urinary iodine concentration was 143 µg/L, with 27% of the study population having concentrations under 100 µg/L and 7.8% under 50 µg/L. Values were distributed similarly between sites of residency, and no significant differences were seen between groups. The mean iodine concentration for tap drinking water was 22.8 µg/L (range 0.5–53.5 µg/L) and for mineral water 7 µg/L (range 0–15 µg/L).

Conclusions: Overall, iodine intake appeared to be satisfactory in our study population, however mild deficiency may exist in up to 26% of this group. A nationwide survey is needed to better determine the status of iodine intake in Israel, allowing for recommendations on salt-iodine enrichment in the future.

Background: Bleeding in the first trimester of pregnancy is a common phenomenon, associated with early pregnancy loss. In many instances a subchorionic hematoma is found sonographically.

Objective: To evaluate the possible benefit of bed-rest in women with threatened abortion and sonographically proven subchorionic hematoma, and to examine the possible relationship of duration of vaginal bleeding, hematoma size, and gestational age at diagnosis to pregnancy outcome.

Methods: The study group consisted of 230 women of 2,556 (9%) referred for ultrasound examination because of vaginal bleeding in the first half of pregnancy, who were found to have a subchorionic hematoma in the presence of a singleton live embryo or fetus. All patients were advised bed-rest at home; 200 adhered to this recommendation for the duration of vaginal bleeding (group 1) and 30 continued their usual lifestyle (group 2). All were followed with repeated sonograms at 7 day intervals until bleeding ceased, the subchorionic hematoma disappeared, or abortion occurred. The groups were compared for size of hematoma, duration of bleeding, and gestational age at diagnosis in relation to pregnancy outcome (spontaneous abortion, term or preterm delivery).

Results: The first bleeding episode occurred at 12.6 ± 3.4 weeks of gestation (range 7–20 weeks) and lasted for 28.8 ± 19.1 days (range 4–72 days). The women who adhered to bed-rest had fewer spontaneous abortions (9.9% vs. 23.3%, P = 0.006) and a higher rate of term pregnancy (89 vs. 70%, P = 0.004) than those who did not. There was no association between duration of vaginal bleeding, hematoma size, or gestational age at diagnosis of subchorionic hematoma and pregnancy outcome.

Conclusions: Fewer spontaneous abortions and a higher rate of term pregnancy were noted in the bed-rest group. However, the lack of randomization and retrospective design of the outcome data collection preclude a definite conclusion. A large prospective randomized study is required to confirm whether bed-rest has a real therapeutic effect.

Background: Multifetal pregnancy reduction has been implemented for improving the outcome of multifetal pregnancies. Recent studies reported no difference in pregnancy outcome between reduced twins and non-reduced twins, but the neonatal course and subsequent outcome in reduced twin pregnancies were not well documented.

Objective: To compare the neonatal course and outcome, as well as the gestational and labor characteristics, in twins from reduced multifetal pregnancies and in non-reduced twins.

Methods: This is a retrospective case-control study of the neonatal course of twins from reduced multifetal pregnancies. We found 64 mothers with multifetal pregnancy reduction who delivered twins during 1989–1997; 64 gestational age-matched non-reduced twin pregnancies served as controls. The following neonatal variables were examined: major malformations; small birth weight for gestational age; and neonatal morbidities including respiratory distress syndrome, apnea, pneumothorax, bronchopulmonary dysplasia, hyperbilirubinemia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, seizures, intraventricular hemorrhage, periventricular leukomalacia, ventriculomegaly, and hydrocephalus. In addition, we evaluated several neonatal interventions (surfactant replacement, mechanical ventilation, phototherapy, total parenteral nutrition), and some laboratory abnormalities (thrombocytopenia, leukopenia, anemia, and hypoglycemia), duration of hospitalization, and neonatal mortality.

Results: Gestational and labor variables were not significantly different between multifetal pregnancies reduced to twins and non-reduced twin pregnancies. The neonatal morbidity and mortality were not significantly different between twin neonates from multifetal pregnancy reduction and non-reduced control twins.

Conclusions: Multifetal pregnancy reduction to twins appears to bear no adverse effect on the intrauterine course of the remaining fetuses or their neonatal course and outcome when born after 28 weeks of gestation.