I Gull

West Georgia Obstetrics and Gynecology, Georgetown, Georgia, United States

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Publications (62)151.24 Total impact

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    Ultrasound in Obstetrics and Gynecology 10/2010; 36(S1):178. · 3.56 Impact Factor
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    ABSTRACT: Retained products of conception (POC)—a relatively common finding after vaginal and cesarean delivery as well as termination of pregnancy—is a major diagnostic challenge. Sonohysterography has been shown to diagnose retained POC with nearly a 100% success rate, but has a number of drawbacks including the need for special equipment and considerable operator experience, its invasiveness, and high cost. Ultrasonography is a common part of the gynecologic examination and widely available but has not been useful for diagnosis of retained POC. However, with improved ultrasonographic technology and experience with its use, transvaginal sonographic (TVS) evaluation has shown increasing promise for retained POC diagnosis. The investigators conducted a retrospective chart review to assess the accuracy of an evaluation protocol based on clinical treatment with uterotonics combined with TVS evaluation for the detection of retained POC. The participants were 339 women referred to an obstetrics ultrasound unit because of abnormal bleeding, fever, abdominal pain, or a combination of these symptoms after labor or pregnancy termination. Upon enrollment, all participants underwent a TVS evaluation and were divided into 2 groups: one with negative TVS results and the other with positive results. Patients with negative results were discharged and instructed to return to the hospital if bleeding, abdominal pain, or fever recurred. Those with positive results were treated conservatively with methyl ergometrine for 5 days and reexamined with TVS. Patients with positive results in the second TVS evaluation were referred for curettage and pathological examination of the uterine content. The sensitivity, specificity, and positive and negative predictive values were determined for the total cohort. A total of 269 patients (79.4%, 269/339) were negative for retained POC and were discharged. The remaining 20.6% (70/339) with positive results received conservative treatment with methyl ergometrine and were reevaluated with TVS. For 33 (47.1%) of the 70 positive patients, the results were negative at the second TVS, leaving 37 patients who remained positive. These 37 positive patients and an additional 2 (0.07%) who had been negative initially but were revaluated because of recurrent bleeding underwent uterine curettage. The sensitivity for identifying retained POC with TVS was 94% and the specificity was 98%; the positive and negative predictive values were 84% and 99%, respectively. These findings indicate that that the proposed protocol provides an accurate and highly sensitive diagnosis of retained POC that may help avoid unnecessary surgery in nearly 50% of women with suspected retained POC after labor or abortion.
    Obstetrical and Gynecological Survey 12/2009; 65(1):13-15. · 2.51 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 10/2009; 34(S1):236. · 3.56 Impact Factor
  • Acta Obstetricia Et Gynecologica Scandinavica 08/2009; 77(2):182-185. · 1.85 Impact Factor
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    ABSTRACT: Retained products of conception (RPOC) present a major clinical challenge. We assessed the accuracy of an evaluation protocol based on clinical management and transvaginal ultrasonographic evaluation for the detection of retained products of conception. This combined clinical and sonographic evaluation protocol offers a high sensitivity for the accurate diagnosis of RPOC.
    Fertility and sterility 03/2009; 92(3):1162-4. · 3.97 Impact Factor
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    ABSTRACT: Women who have retained products of conception are usually referred for curettage or hysteroscopy, both performed in most cases under general anesthesia in an operating theater and sometimes requiring hospitalization. We propose that for most of these patients the procedure can be just as safely and effectively carried out in an obstetric ultrasound unit.
    Fertility and sterility 01/2009; 91(4 Suppl):1586-8. · 3.97 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 08/2008; 32(3):440-440. · 3.56 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 09/2005; 26(4):330 - 330. · 3.56 Impact Factor
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    ABSTRACT: To evaluate the application of transvaginal sonography assessment of cervical length before fetal reduction for predicting spontaneous preterm birth in triplet gestations reduced to twins. This retrospective study was conducted at the ultrasound unit of a university-affiliated municipal hospital. The study cohort consisted of 25 women with triplet gestations following ovulation induction or assisted-reproduction techniques who underwent fetal reduction to twins. Cervical length was assessed via transvaginal sonography before fetal reduction, and data on pregnancy outcome were retrieved from maternal records and/or maternal interviews. Cervical length (mean +/- SD) at reduction was 4.0 +/- 0.85 (range: 1.2-5.5). Five women were excluded from statistical evaluation because pregnancy complications precluded spontaneous delivery. Two of 3 (67%) women with a cervical length of <3.5 cm delivered prior to 33 weeks' gestation compared with 1/17 (6%) women with a cervical length > or = 3.5 cm. This difference was statistically significant (P < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value of cervical lengths <3.5 cm to predict delivery prior to 33 gestational weeks was 67%, 94%, 67%, and 94%, respectively. Measurement of cervical length in triplet pregnancies before fetal reduction provides useful predictive information on the risk for preterm delivery.
    Journal of Clinical Ultrasound 09/2005; 33(7):329-32. · 0.70 Impact Factor
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    ABSTRACT: A unique cast model of the placenta in a rare case of feto-feto-fetal triplet transfusion syndrome (FFFTTS) allowed the demonstration of why the transfusion syndrome developed in one fetus and not in the other two in that single placenta. The vasculature anatomy of a monochorionic triamniotic triplet placenta with FFFTTS of three healthy infants (one donor, two recipients) born in the 35th week of gestation was cast by means of dental casting materials. After the cast hardened, the tissue was corroded, revealing the cast blood vessels. The diameters and lengths of the chorionic blood and intraplacental vessels of the cast placenta were measured with a digital caliper. The cast revealed two artery-artery (A-A) anastomoses on the chorionic plate between the two recipients and the donor. Seven artery-vein (A-V) deep anastomoses connected only the arteries of the donor and the veins of the two recipients. The blood vessel connections among the fetuses allowed the evaluation of a pathologic case with its own control in a single placenta. From the vascular appearance, we speculate that the A-A anastomoses between the two fetuses protected them from developing blood transfusions, but that the A-V anastomoses contributed to their development.
    Placenta 06/2005; 26(5):432-6. · 3.12 Impact Factor
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    ABSTRACT: To generate nomograms for the sonographic measurement of the fetal philtrum and chin during pregnancy. A prospective, cross-sectional study in normal singleton pregnancies. One hundred and fifty-three fetuses between 13 and 42 weeks of gestation were studied. 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. 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.
    Fetal Diagnosis and Therapy 01/2005; 20(2):127-31. · 1.90 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 08/2004; 24(3):365 - 365. · 3.56 Impact Factor
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    ABSTRACT: Our technical ability to diagnose fetal anomalies of the central nervous system by ultrasonography and by fetal magnetic resonance imaging far exceeds our current knowledge of their possible neurodevelopmental implications later in life. This limitation often makes obstetric and clinical decisions very difficult. We retrospectively reviewed the ultrasonographic records of 6220 women who had been followed up at two large medical centers between 1994 and 1999. One hundred and sixty (2.6%) women had abnormal fetal central nervous system findings. The neurodevelopmental outcome of these children was assessed by a telephone interview with the parents. Small cerebellar size was the most frequent anomaly, followed by isolated mild ventriculomegaly and isolated choroid plexus pathology. Suboptimal neurodevelopmental outcome was found in 24% of children with isolated ventriculomegaly and in 9% with choroid plexus pathology. In the group of children with a "small cerebellum," suboptimal neurodevelopment was found in 19%. The measurement of transcerebellar diameter in respect to its developmental implication is, to our knowledge, described here for the first time. We believe that cerebellar measurements and their possible neurocognitive implications should be an integral part of future studies.
    Journal of Child Neurology 07/2004; 19(6):435-8. · 1.39 Impact Factor
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    ABSTRACT: To assess the feasibility of nuchal translucency in triplets compared with singletons. Nuchal translucency thickness as part of routine first-trimester screening in the general population was compared between 3128 singleton pregnancies and 51 triplets (153 fetuses). Crown-rump length was also noted. The 5th, 50th, and 95th percentiles were determined and compared between the 2 groups, and regression curves of nuchal translucency measurements plotted against crown-rump length were drawn. The mean nuchal translucency thickness was 1.23 mm for singletons and triplets. The 5th and 95th percentiles were also the same between the 2 studied groups. The regression curves of 5th, 50th, and 95th percentiles of nuchal translucency plotted against crown-rump length of triplets and singletons overlapped. Nuchal translucency values and distribution are the same in triplets and singletons, validating the utility of the cutoff values.
    Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 05/2004; 23(4):501-4. · 1.40 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 08/2003; 22(S1):172 - 172. · 3.56 Impact Factor
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    ABSTRACT: To evaluate the effect of long-term (1-week) oral hydration on amniotic fluid volume in women with an amniotic fluid index (AFI) < 10th percentile. This prospective, nonrandomized, interventional study was conducted on 30 women with AFI < 10th percentile. Study inclusion criteria were singleton pregnancy, well-established gestational age, intact membranes, no maternal complications (e.g., hypertension, cardiovascular disease, hyperthyroidism), no evidence of preeclampsia, no fetal structural malformations and no evidence of fetal distress. The women were instructed to drink at least 2L of water daily; their AFI was evaluated before and 1 week after the initiation of oral hydration. The study group was compared to a control group of 30 women matched for age and gestational age, with AFI > 10th and < 90th percentile. AFI increased from 8.1 +/- 0.73 (mean +/- SD) to 11.8 +/- 2.4 1 week later (P < .01) in 25 (83%) of the study subjects. The AFI was similar before and 1 week after oral hydration in all the controls. Long-term maternal oral hydration seems to significantly increase the AFI in selected women with reduced fluid and possibly prevents oligohydramnios.
    The Journal of reproductive medicine 03/2003; 48(3):187-90. · 0.75 Impact Factor
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    Ultrasound in Obstetrics and Gynecology 01/2003; 22:128-128. · 3.56 Impact Factor
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    ABSTRACT: To conduct a prospective evaluation of the incidence and neonatal outcome of fetuses with persistent right umbilical vein. This condition had traditionally been considered to be extremely rare and to be associated with a very poor neonatal prognosis, but later evidence has raised some doubts about the veracity of these contentions. Between August 1995 and November 1998, 8950 low-risk patients were prospectively evaluated at two medical centers. The sonographic diagnosis of a persistent right umbilical vein was made in a transverse section of the fetal abdomen when the portal vein was curved toward the stomach, and the fetal gall bladder was located medially to the umbilical vein. Persistent right umbilical vein was detected in 17 fetuses during the study. Four of them had additional malformations, of which three had been detected antenatally. We established that the incidence of persistent right umbilical vein in a low-risk population is 1 : 526. We believe that the sonographic finding of this anomaly is an indication for conducting targeted fetal sonography and echocardiography. When the persistent right umbilical vein is connected to the portal system and other anomalies are ruled out, the prognosis can generally be expected to be favorable.
    Ultrasound in Obstetrics and Gynecology 07/2002; 19(6):562-4. · 3.56 Impact Factor
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    ABSTRACT: To assess the contribution of additional examiners to: the average discrepancy between estimated and actual fetal weights; the correlation between estimated and actual fetal weights; the reduction in major (> 10%) discrepancies between estimated and actual fetal weights. Three experienced sonographers independently measured fetal biparietal diameter, head circumference, abdominal circumference and femur length in 39 fetuses at term. The estimated fetal weights were calculated for each examiner. Fetal biometric measurements were analyzed to obtain the source of differences in estimations among the examiners. Discrepancy, correlation and number of major (> 10%) discrepancies between the estimated and actual fetal weights were calculated for each examiner, and the contribution of additional examiners was analyzed. The differences in measurements of the biparietal diameter and femur length were lower than those of the head and abdominal circumferences. For each of the three examiners, the average discrepancy between the estimated and actual fetal weights was 6.1%, 5.9% and 6.3%. When the estimation was based on two examiners, the discrepancy decreased to 4.8-5.6%. The contribution of a third examiner was nil. Major (> 10%) discrepancies between estimated fetal weight and actual birth weight were found in seven, eight and nine estimations of the examiners. Estimation by two examiners decreased the number of major discrepancies, and estimation by all three examiners further decreased by approximately 50% the number of major discrepancies between the estimated and actual fetal weights. Measurements by multiple examiners changes only slightly the average number of discrepancies between estimated and actual fetal weights. However, the reduction in major (> 10%) discrepancies is statistically and clinically significant.
    Ultrasound in Obstetrics and Gynecology 07/2002; 20(1):57-60. · 3.56 Impact Factor
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    ABSTRACT: 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. 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. MSHCG levels were significantly higher (18.5%) in week 3 post-fertilization in the presence of a female fetus (P < 0.0002). 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.
    Human Reproduction 02/2002; 17(2):485-9. · 4.67 Impact Factor

Publication Stats

301 Citations
151.24 Total Impact Points

Institutions

  • 1998–2009
    • West Georgia Obstetrics and Gynecology
      Georgetown, Georgia, United States
  • 1995–2005
    • Tel Aviv Sourasky Medical Center
      • • Obstetrics Gynecology
      • • Ultrasound
      Tel Aviv, Tel Aviv, Israel
  • 1998–2002
    • Tel Aviv University
      • Department of Obstetrics and Gynecology
      Tel Aviv, Tel Aviv, Israel