The Effect of "Off Hours" on Maternal and Perinatal Outcomes in a Diverse U.S. Cohort.

OBJECTIVE: This study aimed to evaluate the "off-hour effect" on maternal and neonatal adverse events in a large cohort representing U.S. STUDY DESIGN: A secondary analysis of the Consortium on Safe Labor (CSL) dataset with 208,695 women and 229,385 deliveries was performed. The study included the deliveries of ≥23 gestational weeks from 19 hospitals in the United States from 2002 to 2008. Babies with congenital anomalies were excluded from neonatal outcomes. We compared maternal and neonatal outcomes of patients delivered during weekdays versus off hours (nights and weekends). The primary outcomes of the study were composite maternal and composite neonatal adverse events. The secondary outcomes were delivery type and individual maternal and neonatal adverse events including maternal death and perinatal mortality rate. Associations between off hours and all the outcomes were analyzed in bivariable and multivariable analyses. The same analyses were performed in strata by indication for admission (spontaneous labor or induction of labor). RESULTS: Composite maternal adverse events (6.19 vs. 6.06%, p = 0.41) and maternal death (0.01 vs. 0.01%, p = 0.19) were not significantly different between off hours and weekday groups. In contrast, composite neonatal adverse events (6.91 vs. 5.84%, p < 0.001) and perinatal mortality rate (1.03 vs. 0.77%, p < 0.001) were higher in the off-hour group. After adjusting for confounding variables, only the composite neonatal outcome continued to be associated with off hours (adjusted odds ratio [aOR] = 1.10, 95% confidence interval [CI]: 1.04-1.16). Stratified analyses showed that the off-hour effect for the neonatal composite outcome was not present in those presenting in spontaneous labor (6.1 vs. 5.9%, p = 0.40). CONCLUSION: Off-hour delivery was not associated with severe maternal morbidity and was only modestly associated with severe neonatal morbidity. This association was observed in women undergoing induction, not in those presenting in spontaneous labor. These data draw into question the existence of a clinically meaningful and correctable "off-hour effect" in obstetrics. KEY POINTS: · The presence of a significant off-hour effect in obstetrics is still questionable.. · If the off-hour effect exists, it seems that not to be related with staffing issues.. · There is not a big difference for adverse events at off hours in spontaneously laboring patients..

Perinatal outcomes and survival predictors of severe red-cell alloimmunization treated by intrauterine transfusion.

OBJECTIVE: To evaluate perinatal survival rates and predictors in severely anemic fetuses that underwent intrauterine transfusion (IUT). METHOD: This was a retrospective study of both Turkish and Syrian patients who underwent IUT for fetal anemia due to Rh alloimmunization between 2015 and 2019. The association between pretransfusion factors and perinatal survival was evaluated by multivariate logistic regression. Receiver operating characteristics (ROC) curves were used to identify the level of fetal hemoglobin deficits that predict perinatal survival. RESULTS: Eighty-seven IUTs were performed in 42 pregnancies. Approximately 75% of fetuses were severely anemic and the overall perinatal survival rate was 50%. The survival rate was better in Syrian refugees compared to Turkish patients (71.4% vs. 39.3%, p < 0.05). In univariate analysis, hydrops presence (odds ratio [OR] = 0.2; 95% confidence interval [CI] = 0.05-0.7; p < 0.05), first IUT week (OR = 1.4; 95% CI = 1.1-1.8; p < 0.05), pretransfusion hemoglobin level (OR = 1.99; 95% CI = 1.22-3.27; p < 0.05), hemoglobin deficit (OR = 0.5; 95% CI = 0.3-0.8; p < 0.05), and birth week (OR = 2.3; 95% CI = 1.3-3.9; p < 0.05) were associated with survival. However in a multivariate analysis, only hemoglobin deficit (OR = 0.47; 95% CI = 0.22-0.99; p < 0.05) and birth week (OR = 3.3; 95% CI = 1.1-10.3; p < 0.05) were found to be associated with survival. On ROC analysis, a hemoglobin deficit of ≤6.25 g/dl showed a sensitivity of 0.95 and specificity of 0.62 for predicting perinatal survival. CONCLUSION: Despite the improvement in the treatment of fetal anemia, perinatal survival rate remains extremely low in severely anemic cases. Among pretransfusion factors, hemoglobin deficit seemed to be most important in predicting survival during fetal anemia.

Is mediolateral episiotomy angle associated with postpartum perineal pain in primiparous women?

OBJECTIVE: Our aim is to elucidate the relationship between mediolateral episiotomy (MLE) angle and postpartum perineal pain. METHODS: This study was designed prospectively. Primiparous women with MLE in the postpartum period were included in the study and divided into three groups according to episiotomy angle ranges (Group 1: <40°, Group 2: 40°-60°, and Group 3: >60°). Postpartum perineal pain was quantified with the short-form McGill Pain questionnaire (SF-MPQ) consisting of the following three parts: Sensory-affective-verbal descriptions, visual pain scale (VPS), and present pain intensity scale (PPI). Postpartum perineal pain scores on days 1 and 7 were compared among the angle group. RESULTS: Overall, 86 eligible women were enrolled in this study. Seventy-three women (85%) scored the perineal pain between 0 and 3 on the VPS and 13 women (15%) rated the pain from 4 to 6 on the 1st postpartum day. No significant differences were noted among the three groups regarding the total pain scores on SF-MPQ and on the each part of form at the 1st postpartum day. At 7 days postpartum, total pain score was found significantly high in Group 1 [Med; IQR (min-max)=0; 4 (0-5)] compared with Group 2 [Med; IQR (min-max)=0; 0(0-5)]. The pain scores obtained from the sensory, affective, VPS, and PPI parts of the questionnaire were [Med; IQR (min-max)=0; 1 (0-2)], [Med; IQR (min-max)=0; 1 (0-1)], [Med; IQR (min-max)=0; 2 (0-2)], and [Med; IQR (min-max)=0; 0.25 (0-1)], respectively, in Group 1. For Group 2, pain scores obtained from the sensory, affective, and PPI were [Med; IQR (min-max)=0; 0(0-1)]; and VPS was [Med; IQR (min-max)=0; 0(0-2)]. No significant differences were observed between Groups 1 and 2 for each part of the questionnaire on day 7. Percentage of need for analgesics on day 7 was found significantly higher in Group 1 (42.9%) than Group 2 (31.2%). CONCLUSION: MLE at an angle <40° to the midline is associated with a higher score of perineal pain and an increase need for analgesics during the early postpartum days.

Perinatal outcomes of the antenatally diagnosed omphalocele cases: a single tertiary center experience.

OBJECTIVES: To evaluate the perinatal outcomes of antenatally diagnosed omphalocele cases. MATERIAL AND METHODS: This was a retrospective study conducted between July 2014 and February 2020 at the prenatal diagnosis center of a university clinic. Gestational week of diagnosis, associated anomalies, karyotype analysis results, complications during pregnancy, termination/delivery characteristics, and postnatal results were evaluated. RESULTS: The analysis was performed on 58 patients. The median diagnosis time was 14.5 weeks of gestation. Thirty-three cases (57%) were defined in the first trimester. 33 (57%) of 58 patients had one or more concomitant anomalies, while 25 patients (43%) had isolated omphalocele. The most common associated anomaly was a cardiac anomaly which was observed in 17 fetuses (30% of all omphalocele cases). Karyotype analysis was performed in forty-five patients (41 in the prenatal period, 4 in the postnatal period). A normal karyotype was detected in 27 cases (60%). Trisomy 18 was the most common chromosomal anomaly (n = 15, 33.3%). Thirty of 58 patients (52%) requested termination of pregnancy (TOP) in the early pregnancy period. Thirteen of the cases died in-utero (22%). Fifteen pregnancies resulted in live births (26%), of those eight were lost in the first year of life (six of them had additional anomalies, while two of them had isolated omphalocele but the omphalocele pouch was containing the liver in those two babies). CONCLUSIONS: Most of the cases with an omphalocele can be diagnosed in the first trimester. Cardiac anomalies were the most common associated anomalies, while trisomy 18 is the most common chromosomal anomaly. Thus, earlier and effective counseling can be made about the prognosis of pregnancy.

Characteristics of Stillbirths Associated With Diabetes in a Diverse U.S. Cohort.

OBJECTIVE: To characterize stillbirths associated with pregestational diabetes and gestational diabetes mellitus (GDM) in a large, prospective, U.S. case-control study. METHODS: A secondary analysis of stillbirths among patients enrolled in a prospective; multisite; geographically, racially, and ethnically diverse case-control study in the United States was performed. Singleton gestations with complete information regarding diabetes status and with a complete postmortem evaluation were included. A standard evaluation protocol for stillbirth cases included postmortem evaluation, placental pathology, clinical testing as performed at the discretion of the health care professional, and a recommended panel of tests. A potential cause of death was assigned to stillbirth cases using a standardized classification tool. Demographic and delivery characteristics among women with pregestational diabetes and GDM were compared with characteristics of women with no diabetes in pairwise comparisons using χ or two-sample t tests as appropriate. Sensitivity analysis was performed excluding pregnancies with genetic conditions or major fetal malformations. RESULTS: Of 455 stillbirth cases included in the primary analysis, women with stillbirth and diabetes were more likely to be older than 35 years and have a higher body mass index. They were also more likely to have a gestational hypertensive disorder than women without diabetes (28% vs 9.1%; P<.001). Women with pregestational diabetes had more large-for-gestational-age (LGA) neonates (26% vs 3.4%; P<.001). Stillbirths occurred more often at term in women with pregestational diabetes (36%) and those with GDM (52%). Maternal medical complications, including pregestational diabetes and others, were more often identified as a probable or possible cause of death among stillbirths with maternal diabetes (43% vs 4%, P<.001) as compared with stillbirths without diabetes. CONCLUSION: Compared with stillbirths in women with no diabetes, stillbirths among women with pregestational diabetes and GDM occur later in pregnancy and are associated with hypertensive disorders of pregnancy, maternal medical complications, and LGA.

Evaluation of prenatally diagnosed fetal sacrococcygeal teratomas: A case series of seventeen pregnancies from South-central Turkey.

OBJECTIVE: To evaluate sacrococcygeal teratoma (SCT) cases according to associated cardiac, extracardiac, and chromosomal anomalies in the prenatal period, and to review their outcomes. MATERIALS AND METHODS: Data of pregnancies with a prenatal diagnosis of SCT between 2009 and 2019 were retrospectively reviewed. RESULTS: One ongoing pregnancy was excluded. There were five medically terminated cases, three due to severe heart failure and the remaining two due to additional congenital defects. Two infants who had heart failure due to hyperdynamic flow died in the neonatal period. Nine infants are well and alive at the time of writing. CONCLUSION: When a lesion is detected in the sacrococcygeal region during fetal sonography, the differential diagnosis should be made with an appropriate evaluation with emphasis on a possible diagnosis of fetal SCT. Tumor growth and heart failure should be monitored with serial scans when SCT has been diagnosed prenatally.

The associtation between aberrant right subclavian artery and trisomy 21 in a tertiary center in Turkey.

OBJECTIVES: We hoped to reveal the frequency of Aberrant Right Subclavian Artery (ARSA) and to find the relationship of isolated/non-isolated ARSA with chromosomal defects and other fetal congenital heart diseases (FCHD) in a heterogeneous population. MATERIAL AND METHODS: This was a retrospective cohort study conducted between December 2015 to September 2018. Women admitted for routine ultrasound examination or referred to our hospital for a suspected fetal anomaly were underwent detailed fetal anomaly ultrasonography scan and tested for the presence of ARSA. RESULTS: ARSA was detected in 27 patients and an isolated finding in 13 (48%) cases. Among 13 cases with isolated ARSA, trisomy 21 was diagnosed in 1 case. In the non-isolated group (n: 14, 52%), five cases presented with trisomy 21. There was no significant difference of trisomy 21 frequency between isolated and non-isolated groups (7.6% vs 35.7%, p = 0.08). In 3 patients, FCHD was diagnosed and 2 of them had trisomy 21. CONCLUSIONS: Our study shows that ARSA can be the only marker in trisomy 21. The examination of the subclavian artery must be a part of the fetal anomaly ultrasonography. Detecting an ARSA should increase the attentiveness of the sonographer to investigate for the other markers of trisomy 21. In the existence of other findings, invasive diagnostic procedures should be offered to the patients, whereas in cases that arsa is the only finding, other risk factors should be investigated to offer karyotyping or cell-free DNA analysis.

Antiphospholipid syndrome: Diagnosis and management in the obstetric patient.

Antiphospholipid syndrome (APS) is a rare condition clinically characterized by thrombotic events or pregnancy complications and confirmed by one or more repeatedly positive antiphospholipid antibodies on two or more occasions at least 12 weeks apart. Several factors are thought to have roles in the pathogenesis of adverse obstetric events related to APS, including platelet and endothelial cell activation, complement activation, and ultimate activation of the thrombotic pathway. Despite standard treatment with a heparin agent and low-dose aspirin, 30% of women with definite APS cannot achieve a successful pregnancy outcome. Additional treatment options are still controversial, and prospective trials with appropriate controls are needed to investigate the efficiency of alternative treatments. In this chapter, we discuss diagnostic, clinical, and therapeutic approaches in the treatment of APS syndrome in pregnancy.

Abnormal Pap smear frequency and comparison of repeat cytological follow-up with colposcopy during patient management: the importance of pathologist's guidance in the management.

OBJECTIVE: Cervical cancer contributes to a significant global health burden with room for improvement of primary prevention methods. This study aimed to determine the prevalence of Turkish women with abnormal cytology and their management by comparing results from repeat cytological analysis with close follow-up and colposcopy. METHODS: A retrospective evaluation of 8738 women who underwent Pap smears at a single institution during 2011 was performed. Either repeat cytological analysis or colposcopic biopsy was used for follow-up evaluation of women who had abnormal index cytology. RESULTS: From the 8670 women, 8259 of had normal cytology results (95.3%) and 411 women had abnormal cytology (4.7%) in the index Pap smear. The frequency of initial abnormal cytology was 65% (n=267), 27% (n=111), 3.4% (n=14), 2.4% (n=10), 1.9% (n=8), and 0.3% (n=1) for atypical squamous cell of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), ASC cannot exclude high-grade intraepithelial lesion (ASC-H), high-grade SIL (HSIL), atypical glandular cells (AGC), and invasive cancer, respectively. Of the 267 women with initial ASCUS, 108 (40.4%) underwent repeat cytology analysis, 84 (31.5%) underwent colposcopic biopsy, and 75 (28.1%) were lost to follow-up. On histopathology, 8.3% (n=7) of patients had cervical intraepithelial neoplasm 2 (CIN2) on colposcopy. Of 60 women with LSIL that underwent colposcopic biopsy, 13.3% (n=8) had CIN2/3. CONCLUSION: The results of the study suggest that routine cytological follow-up may be an appropriate method in the management of ASCUS instead of immediate colposcopy while immediate colposcopy cannot place repeat cytology for LSIL in developing countries.

Prenatal diagnosis of persistent left superior vena cava: a retrospective study of associated congenital anomalies.

OBJECTIVE: To evaluate persistent left superior vena cava (PLSVC) cases according to associated cardiac, extracardiac, and chromosomal anomalies in the prenatal period and to review their outcomes. MATERIALS AND METHODS: The data of patients with a prenatal diagnosis of PLSVC between January 2013 and December 2017 were reviewed retrospectively. RESULTS: Data of 32 cases were reviewed. Nineteen (60%) cases were associated with cardiac defects, 5 (15%) were associated with both cardiac and extracardiac defects, and 8 (25%) had no associated anomalies. Two fetuses had karyotype anomalies. All patients with isolated PLSVC survived. Among the cases associated with extracardiac anomalies, cardiac anomalies, and with both extracardiac and cardiac anomalies, the survival rate was 40%, 40%, and 25%, respectively. Outcome was more favorable in cases with isolated PLSVC (100% vs. 40%). CONCLUSION: Prenatally diagnosed PLSVC is associated with cardiac and extracardiac anomalies in the majority of cases. The prognosis is good in isolated cases, but worsens when accompanied by cardiac or extracardiac anomalies.

Detection of major anomalies during the first and early second trimester: Single-center results of six years

Objective: Fetal structural malformations affect approximately 2-3% of all pregnancies. Only focusing on trisomy screening in first trimester and deferring the anatomic screening to second trimester may result with late detection of major anomalies that can be diagnosed earlier with careful examination. Material and Methods: This was a descriptive study of retrospective data that were obtained from all terminated single pregnancies due to ultrasonographic findings of major anomalies from 2011 to 2016 in our department. The study was based on a chart review and only abnormalities that were diagnosed before the 16th week were included. Results: Two hundred forty-four first trimester pregnancy terminations were performed. In total, 273 anomalies were detected in the 244 patients. Cranial NTD comprised 32% of all anomalies (n=89). Fifteen percent of anomalies (n=41) needed detailed anatomic scanning for early diagnosis. Conclusion: In this study, we presented the number and percentage of our early diagnosed anomalies by years, as well showed our diagnostic performance for specific anomalies such as atrioventricular septal defect during a 5-year period. The study provides valuable information for future studies in Turkey and shows the need for an anatomic scan protocol while performing aneuploidy screening during early gestation.

Investigation of the arterial stiffness and associated factors in patients with familial Mediterranean fever.

OBJECTIVE: Because of the ongoing and recurring inflammatory state in familial Mediterranean fever (FMF), patients may experience a high risk of cardiovascular events. Our aim was to investigate the arterial stiffness and associated factors in patients with FMF. METHODS: Sixty-nine consecutive FMF patients (including 11 females) and 35 controls (including 5 females) were enrolled in the study. The demographical, clinical, and laboratory data and genetic mutations of the patients were recorded. In the study, FMF patients according to the Tel-Hashomer criteria were included, whereas patients with other known inflammatory rheumatologic disease, atherosclerotic cardiovascular disease, hypertension, diabetes, those under the age of 18 years, or those refusing to participate in the study were excluded. Arterial stiffness measurements were performed using the TensioMed device (TensoMed Ltd, Budapest, Hungary). RESULTS: The patient and control groups were similar in terms of the mean ages, BMIs, gender, systolic blood pressures, and smoking. FMF patients had a higher pulse wave velocity (PWV) (7.73±1.3 and 7.18±1.1 m/s; p=0.03) and lower brachial and aortic augmentation indexes (-64.6±14.6% and -54.6±25.9%, p=0.041 and 4.9±7.4% and 14.0±11.5%, p=0.025, respectively) compared with the controls. Thirty-one (45%) patients were in the "during-attack" state and had higher PWV (8.17±1.6 and 7.38±0.9 m/s; p=0.027) compared with the asymptomatic patients. PWV was correlated to serum CRP, WBC, ESR, fibrinogen, and neutrophil/lymphocyte ratios (r=0.666, 0.429, 0.441, 0.388, and 0.460, respectively). The genetic mutation and predominant attack type had no effect on arterial stiffness. CONCLUSION: FMF patients have increased arterial stiffness during attacks compared with asymptomatic patients and controls. The impaired arterial stiffness is correlated to the severity of the inflammatory state rather than to the attack type or genetic mutations.

Relation between unconjugated bilirubin and RDW, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio in Gilbert's syndrome.

BACKGROUND: Unconjugated bilirubin (UCB) plays a protective role in coronary artery disease. Red cell distribution width (RDW), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are inflammatory biomarkers and higher levels are related to atherosclerosis and adverse cardiovascular events. AIM: We aimed to investigate the relation between UCB levels and RDW, NLR, PLR in people with Gilbert's syndrome (GS). MATERIALS AND METHODS: We selected 2166 subjects (1082 with GS and 1084 healthy controls) from a database having 33,695 people. RDW, NLR and PLR were investigated in the subjects with GS and compared with the healthy controls. Linear regression analysis was used to evaluate the relation between variables. RESULTS: NLR and PLR were higher in the subjects with GS compared to the controls (p < 0.001). RDW was similar in both groups (p = 0.318). UCB was negatively correlated with lymphocyte counts (p = 0.040), and positively correlated with RDW (p < 0.001) and PLR (p = 0.037) in the subjects with GS. There was no significant correlation between UCB and NLR (p = 0.078). RDW (p < 0.001) and lymphocyte counts (p = 0.030) were significantly associated with UCB levels in the regression analysis conducted in the subjects with GS. CONCLUSION: There is a negative association between UCB and NLR, PLR due to low amounts of lymphocyte counts, which causes increased risk of CVD. These results suggest that the cardio-protective effect of UCB is due to both anti-oxidative and anti-inflammatory ways indirectly.

Simultaneous thrombosis of multiple coronary arteries in a patient with rheumatoid arthritis.

We present a case of simultaneous coronary thrombosis of the left main, the left anterior descending artery and the right coronary artery in a patient, recently diagnosed with rheumatoid arthritis.

Comparison of ambulatory blood pressure measurement with home, office and pharmacy measurements: is arterial blood pressure measured at pharmacy reliable?

RATIONALE, AIMS AND OBJECTIVES: Standardizing arterial blood pressure (BP) measurement is difficult because of different performers like doctor or pharmacy employee. We investigated the reliability between different BP measurement methods. METHODS: The study was conducted in an internal medicine service with 160 patients in Ankara, Turkey. First, the subjects' BP was measured by doctor. Then, 24-hour BP monitoring devices were placed. Participants were then instructed to measure their BPs both at home and in pharmacy. The next day, arterial BP was measured by the doctor for the second time. RESULTS: The prevalence rates of masked and white coat hypertension were 8.8% (n = 14) and 8.1% (n = 13), respectively. There was no statistically significant differences between ambulatory measurement and home, office and pharmacy measurements (P > 0.05). The consistency rate between ambulatory and home measurements was 97.5% (kappa = 0.947, P < 0.001). The consistency rate between ambulatory and pharmacy measurements was 82.5% (kappa = 0.634, P < 0.001). When compared with ambulatory measurement, the most sensitive (98.0%) and most specific (96.8%) method was home measurement. There was a moderate positive correlation between ambulatory and other measurements in both systolic and diastolic values. There was a positive and very strong correlation between ambulatory and home measurements of systolic and diastolic ABP values (respectively; r = 0.926 and r = 0.968) and there was a statistically significant relation between these measurements (P < 0.001). CONCLUSION: The results of all measurement methods were close to each other. The most sensitive and specific method was home measurement when compared with ambulatory measurement. But both office and pharmacy measurements had also high sensitivity and specificity.