Outcomes of IVF treatments in women with antiphospholipid antibodies or antiphospholipid syndrome.

BACKGROUND: Ovulation induction for in vitro fertilization (IVF) may increase intravascular thromboses among patients with antiphospholipid autoantibodies (aPLs) or antiphospholipid syndrome (APS) due to the high estrogen levels. While natural or modified natural IVF treatment cycles (MNC) are sometimes used instead of stimulated cycles with empiric anticoagulant treatment among these infertile patients, their efficacy is unclear. MATERIALS AND METHODS: A retrospective cohort study including all IVF cycles of patients diagnosed with aPLs or APS in a tertiary, university-affiliated hospital between 2012 and 2022. The outcomes of stimulated cycles with anticoagulants and MNC and natural IVF cycle attempts were compared. RESULTS: 121 oocyte retrievals from 38 women were analyzed: 93 stimulated and 28 MNC or natural IVF cycles. The rates of cycle cancellation (0 % vs. 17.9 %, p < 0.001) and cycles in which no oocytes were retrieved (0 % vs. 43.5 %, p < 0.001) were significantly lower following stimulated cycles vs. natural and MNC. In parallel, positive ß-hCG (31.9 % vs. 10.9 %, p = 0.03), clinical pregnancy rate (23.6 % and 3.6 %, p < 0.001) and live birth rates (18.1 % vs. 3.6 %, p = 0.01) were significantly higher following stimulated cycles. No thrombotic events or bleeding occurred in any cycle. CONCLUSION: Ovarian stimulation for IVF is more effective for successful pregnancy and delivery than natural cycles and MNC and can be safely undertaken in aPLs or APS women undergoing IVF. Rates of complication from hormonal treatment are not increased when treated with LMWH during ovarian stimulation.

Diagnosis and management of multiple myeloma during pregnancy: case report, review of the literature, and an update on current treatments.

The simultaneous occurrence of pregnancy and multiple myeloma (MM) is rare. The challenge of diagnosing MM during pregnancy is demonstrated in the case presented here. Despite the rarity of concurrent MM and pregnancy, this possibility should be considered in patients with signs and symptoms that may be attributed to MM so as not to delay the diagnosis and decision about pregnancy continuation and initiation of an appropriate and safe therapy to the mother and fetus. Treating physicians should be aware of the potential effects of MM therapies on the fetus and pregnancy outcomes.

Neurodevelopmental outcomes of preterm infants born to preeclamptic mothers - A case-control study.

OBJECTIVE: Preeclampsia during pregnancy is associated with an increased risk for various neonatal morbidities. We aimed to investigate the association between prematurity due to maternal preeclampsia and developmental outcomes. STUDY DESIGN: This retrospective matched case-control study included 39 preterm infants (<32 weeks gestation) born to preeclamptic mothers between 2012 and 2016, compared with 39 infants born to mothers without preeclampsia. The two groups were matched for gestational age (±1 week), gender and plurality. Neurodevelopmental outcome was assessed using the Griffith's Mental Developmental Scales at 6, 12 and 24 months corrected age. RESULTS: The groups were comparable in terms of gestational age (30.2 weeks vs 29.8, P = 0.6), exposure to antenatal glucocorticosteroids and magnesium sulfate. The two groups differed significantly in birthweight so that cases had significantly lower birthweight, 1100 (IQR 844.5-1316.5) vs. 1370 (IQR 1174-1604.5) grams. 19/39 (48.7%) cases were small for gestational age compared with only 4/39 (10.3%) controls (P < 0.01). 16/39 of cases were born less than 1000 g, compared with only 5/39 controls (41% vs 12.8%, P < 0.01). Early complications were similar. Compared with controls, an overall trend for better neurodevelopmental performance on Griffith's score was found for cases, especially for early (6 months) non-motor performance. All severely disabled infants (Griffith's score < 55) at 24 months assessment were among controls. CONCLUSION: Although significantly smaller and smaller for gestational age, neurodevelopmental assessment by Griffiths' Mental Development Scales was similar for cases and controls with a trend towards better performance of cases at 6 months. Further studies are needed to determine whether the trend for better performance implies a developmental advantage.

Early-onset preeclampsia - The impact of antiphospholipid antibodies on disease severity.

OBJECTIVES: Antiphospholipid antibodies have been associated with various obstetric complications, including recurrent pregnancy loss, preeclampsia, intrauterine growth restriction, placental insufficiency, and late fetal loss. Despite the amassed body of evidence emphasizing the association between antiphospholipid antibodies and preeclampsia, the severity of preeclampsia with regard to antiphospholipid antibodies status has not been elucidated. This study aimed to evaluate whether early-onset preeclampsia with severe features before 34 weeks' gestation is clinically different when associated with antiphospholipid antibodies. STUDY DESIGN: In this retrospective case-control study, we collected data on pregnancy outcomes of 101 women with singleton pregnancies who delivered prior to 34 weeks of gestation due to preeclampsia with severe features. The antiphospholipid antibodies status of 55 of these women was available for analysis. The study group comprised 20 women with positive antiphospholipid antibodies (positive-aPL group), while the control group comprised 35 women without antiphospholipid antibodies (negative-aPL group). Obstetric and neonatal outcomes, laboratory results and pregnancy complications were extracted from medical records. RESULTS: In the clinical setting of early-onset preeclampsia with severe features necessitating delivery before 34 weeks gestation, positive-aPL women were hospitalized earlier (29, IQR 26.3-32, vs. 32, IQR 28-33 weeks gestation, P = 0.05), gave birth at a significantly earlier gestational age (30, IQR 28.3-32.8 vs. 33, IQR 30-34, P = 0.02) with a lower mean birth-weight (1266.7 ±â€¯579.6 vs. 1567.3 ±â€¯539.7 g, P = 0.058) compared with negative-aPL women. Furthermore, platelet nadir was significantly lower for positive-aPL compared with negative-aPL women (97 ±â€¯49×103/µL vs. 141 ±â€¯61×103/µL, P < 0.001) and maximal serum creatinine was higher (1.0 ±â€¯0.3 mg/dL vs. 0.9 ±â€¯0.1 mg/dL, P = 0.03). Rates of neonatal complications were low and comparable between groups, except for higher rates of retinopathy of prematurity requiring treatment in the study group (30.0% vs. 5.7%, p = 0.02), and there was a trend for higher perinatal mortality among study group infants. CONCLUSIONS: The presence of antiphospholipid antibodies in women with early-onset preeclampsia with severe features is associated with earlier, more severe disease course. Expedited screening for antiphospholipid antibodies in cases of early-onset severe preeclampsia may be considered, along with close monitoring for pregnant women with positive antibodies.

Amniotic fluid embolism - implementation of international diagnosis criteria and subsequent pregnancy recurrence risk.

OBJECTIVES: An international diagnostic criterion for amniotic fluid embolism (AFE) diagnosis has recently been published. Data regarding subsequent pregnancies is scarce. We sought to implement recent diagnostic criteria and detail subsequent pregnancies in survivors. METHODS: A case series of all suspected AFE cases at a tertiary medical center between 2003 and 2018 is presented. Cases meeting the diagnostic criteria for AFE were included. Clinical presentation, treatment, and outcomes described. Pregnancy outcomes in subsequent pregnancies in AFE survivors detailed. RESULTS: Between 2003 and 2018 14 women were clinically suspected with AFE and 12 of them (85.71%) met the diagnostic criteria for AFE. Three cases occurred during midtrimester dilation and evacuation procedures, and the remaining occurred in the antepartum period. Of the antepartum cases, mode of delivery was cesarean delivery or vacuum extraction for expedited delivery due to presentation of AFE in 8/9 cases (88.88%). Clinical presentation included cardiovascular collapse, respiratory distress and disseminated intravascular coagulopathy (DIC). Heart failure of varying severity was diagnosed in 75% (9/12) cases. Composite maternal morbidity was 5/12 (41.66%), without cases of maternal mortality. 11 subsequent pregnancies occurred in four AFE survivors. Pregnant women were followed by a high-risk pregnancy specialist and multidisciplinary team if pregnancy continued beyond the early second trimester. Six pregnancies resulted in a term delivery. No recurrences of AFE were documented. CONCLUSIONS: Use of a diagnostic criterion for diagnosis of AFE results in a more precise diagnosis of AFE. Nevertheless, the accuracy of clinical diagnosis is still high. Subsequent pregnancies were not associated with AFE recurrence.

The Late Effects of Pregnancy on Aortic Dimensions in Patients with Marfan Syndrome.

While the immediate effects of pregnancy on aortic dimension in patients with Marfan syndrome (MFS) have been evaluated, the late effects of subsequent pregnancies in these patients are less known. For this purpose, we evaluated 2 groups of women with MFS who were under specialized care in our institution. Group A included 23 women with MFS who experienced 55 pregnancies; group B included 12 nulliparous MFS patients. Patients in group A were similar in age (36.13 ± 5.6 years vs. 34.25 ± 6.54 years, p = 0.41) and follow-up time (group A 6.05 ± 3.56 years and group B 4.92 ± 3.37 years, p = 0.37). Baseline aortic root diameters as well as the aortic root diameters at follow-up visits were similar between groups (35.60 ± 4.42 vs. 35.08 ± 3.82 mm, p = 0.73, and 37.57 ± 4.66 vs. 37.33 ± 4.83 mm, p = 0.89, respectively). The aortic root diameter increased by 0.5 (0, 2) mm in group A and 1 (0, 4.5) mm in group B (p = 0.54). The rate of aortic dilation per year of follow-up was similar between the groups (0.34 ± 0.52 mm/year in group A vs. 0.55 ± 0.75 mm/year in group B [p = 0.52]). Chronic medical treatment was similar in both groups. Patients in both groups were treated similarly with ß-blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. In summary, subsequent pregnancies in patients with MFS were not associated with an increase in the rate of aortic root dilation in these patients.

Impact of the mode of conception on gestational hypertensive disorders at very advanced maternal age.

RESEARCH QUESTION: To study gestational hypertensive disorders in oocyte donation pregnancies compared with other modes of conception at very advanced maternal age. DESIGN: A historical cohort study of all women aged 45-47 years who gave birth to singletons at a tertiary medical centre between March 2011 and May 2018, at 24 weeks' gestation or later. Pregnancy outcomes were compared between donor oocyte (IVF-OD), IVF using autologous oocytes (IVF-A) and naturally conceived pregnancies. A multivariate logistic regression was used to evaluate the association between the mode of conception and gestational hypertensive disorders. RESULTS: The final analysis included 159, 68 and 73 patients in the IVF-OD, IVF-A and natural conception groups, respectively. The rate of gestational hypertensive disorders was significantly higher among those who conceived by IVF compared with those who conceived naturally but did not differ between the two IVF groups (27.0% for IVF-OD, 19.1% for IVF-A, P = 0.204; 5.5% for natural conception, P < 0.001 and P = 0.013 compared with IVF-OD and IVF-A, respectively). The results remained similar in a multivariate logistic regression analysis. The rate of Caesarean deliveries was significantly higher in the IVF-OD and IVF-A groups compared with the natural conception group (83.6%, 70.6% and 37.0%, respectively, P < 0.001), but other pregnancy outcomes did not differ between the groups. CONCLUSIONS: IVF pregnancies in the late fifth decade of life were associated with significantly higher rates of gestational hypertensive disorders compared with naturally conceived pregnancies. No difference existed between the two IVF groups. These results may highlight the impact of IVF itself on gestational hypertensive disorders at very advanced maternal age.

Maternal and Neonatal Complications of Pregnant Women with Mitral Stenosis.

BACKGROUND: Rheumatic mitral stenosis (MS) is a relatively rare diagnosis in the developed countries and its treatment during pregnancy is challenging due to hemodynamic changes. With the demographic changes due to recent waves of immigration an increase in the prevalence of rheumatic heart disease is expected. OBJECTIVES: To evaluate maternal and neonatal complications in patients with mitral stenosis. METHODS: During the years 2006-2017, 22 women who underwent 31 pregnancies were followed at the Sheba Medical Center in Israel. We collected on regarding hemodynamic changes and their clinical course. MS was classified as mild, moderate, or severe according to mitral valve area by echocardiography. Maternal and fetal adverse events were evaluated according to severity of MS and compared by Poisson regression modeling. RESULTS: MS was severe in 7 pregnancies (22.6%), moderate in 9 (29%), and mild in 15 (48.4%). Twenty patients were managed conservatively and 2 underwent a successful percutaneous mitral balloon valvuloplasty (PBMVP) during pregnancy. All pregnancies ended with a liveborn neonate and with no maternal mortality. Peak and mean mitral pressure gradients increased during pregnancy from 13.3 ± 5.3 to 18.6 ± 5.1 mmHg and from 5.9 ± 2.3 to 9.6 ± 3.4 mmHg respectively (P < 0.05). Eight pregnancies (25.8%) were complicated by pulmonary congestion, 2/15 (13.3%) with mild MS, 2/9 (22.2%) with moderate, and 4/7 (57.1%) with severe MS. The adverse event rate was higher among patients with severe MS compared with moderate and mild MS [hazard ratio (HR) 3.15, 95% confidence interval (95%CA) 1.04-9.52 and HR 4.06, 95%CI 1.4-11.19 respectively, P < 0.05]. Nine of 31 deliveries were vaginal; 6 of 22 cesarean sections (27.3%) were performed for cardiac indications. CONCLUSIONS: The number of total adverse events were higher among patients with severe MS. Patients with moderate and mild MS should be treated attentively, but good obstetric and maternal outcome can be expected.

Outcomes of singleton versus twin pregnancies in the fifth and sixth decades.

BACKGROUND: Pregnancies in the fifth and sixth decades of life have been increasing, but current data are limited regarding the outcomes of twin compared with singleton pregnancies in this age group and to twin pregnancies at younger age. OBJECTIVE: To compare obstetrical and neonatal outcomes of IVF conceived pregnancies, in twin gestations of women who were ≥45 years old at delivery to singletons at similar age and twin gestations at the age of <35 years, and to assess if the complications are mainly influenced by the very advanced maternal age or by the multifetal pregnancy. STUDY DESIGN: A retrospective cohort study from a single tertiary medical center of women aged ≥45 at delivery between March 2011 and January 2018 and women aged <35 at delivery with twin pregnancies that conceived by IVF. Exclusion criteria were spontaneous pregnancies or pregnancies after ovulation induction, monochorionic twin pregnancies, higher order multiple gestations, or women that underwent fetal reduction. Pregnancy, delivery, postpartum and neonatal outcomes were compared between singleton and twin pregnancies. Multivariate logistic regression was used to evaluate the association between twin pregnancies and adverse outcomes. RESULTS: Out of 67,355 deliveries, 612 were of women ≥45 years old, of whom 492 women conceived via IVF (395 singleton and 97 twin pregnancies). Of those, 60 women were ≥50 years old, 49 of them carried singleton and 11 carried twin pregnancies. Baseline characteristics were similar between groups. Women at the fifth and sixth decades with twins had significantly higher rates of preeclampsia (32.0% vs. 10.9%, p < 0.001), gestational diabetes mellitus (35.4% vs. 23.8%, p = 0.020), preterm deliveries <32 weeks of gestation (8.2% vs. 1.3%, p = 0.001), and fetal growth restriction (18.6% vs. 7.6%, p = 0.001) compared with singleton pregnancies at similar maternal age. After multivariate analysis adjusting for confounders, the odds ratio for the composite of preeclampsia, gestational hypertension, intrauterine fetal growth restriction, and placental abruption was 3.19 for twin compared with singleton pregnancies and 1.73 for gestational diabetes mellitus. Pregnancy complications among older women with twins were also significantly higher when compared with younger women with twins (<35 years old). Women in the fifth and sixth decades with twins had higher rates of cesarean deliveries (91.8% vs. 56.4%, p<0.001), gestational hypertension, preeclampsia, and gestational diabetes mellitus (10.3% vs. 4.2%., p=0.016; 32.0% vs. 6.2%, p<0.001; 35.1% vs. 8.1%, p<0.001, respectively) than the younger group carrying twins. CONCLUSIONS: Twin pregnancies in the fifth and sixth decades carry significantly higher complications rate compared with singleton pregnancies at the same age and twin pregnancies at younger age.

Effect of Additional Treatments Combined with Conventional Therapies in Pregnant Patients with High-Risk Antiphospholipid Syndrome: A Multicentre Study.

The effect of additional treatments combined with conventional therapy on pregnancy outcomes was examined in high-risk primary antiphospholipid syndrome (PAPS) patients to identify the most effective treatment strategy. The study's inclusion criteria were (1) positivity to lupus anticoagulant alone or associated with anticardiolipin and/or anti-ß2 glycoprotein I antibodies; (2) a history of severe maternal-foetal complications (Group I) or a history of one or more pregnancies refractory to conventional therapy leading to unexplained foetal deaths not associated with severe maternal-foetal complications (Group II). Two different additional treatments were considered: oral-low-dose steroids (10-20 mg prednisone daily) and/or 200 to 400 mg daily doses of hydroxychloroquine and parenteral-intravenous immunoglobulins at 2 g/kg per month and/or plasma exchange. The study's primary outcomes were live birth rates and pregnancy complications. A total of 194 pregnant PAPS patients attending 20 tertiary centres were retrospectively enrolled. Hydroxychloroquine was found to be linked to a significantly higher live birth rate with respect to the other oral treatments in the Group II patients. The high (400 mg) versus low (200 mg) doses of hydroxychloroquine (p = 0.036) and its administration before versus during pregnancy (p = 0.021) were associated with a significantly higher live birth rate. Hydroxychloroquine therapy appeared particularly efficacious in the PAPS patients without previous thrombosis. Parenteral treatments were associated with a significantly higher live birth rate with respect to the oral ones (p = 0.037), particularly in the Group I patients. In conclusion, some additional treatments were found to be safe and efficacious in high-risk PAPS pregnant women.

Pregnancy outcome in patients with Takayasu's arteritis: cohort study and review of the literature.

OBJECTIVE: The objective of this study is to investigate the clinical features of pregnancy in women with Takayasu's arteritis managed in a tertiary medical center and review the literature in order to establish the course and recommended follow up and treatment for these pregnancies. MATERIALS AND METHODS: Retrospective analysis of 20 pregnancies in 6 women with Takayasu's arteritis. Patients were recruited from the high risk pregnancy clinics at Sheba Medical Center, where follow up included strict control of blood pressure and treatment of obstetric and disease-related complications. RESULTS: Mean maternal age was 29.3 ± 3 years. Thirty-six patients had both supra and infradiaphragmatic arterial disease, of them two had an abdominal aorta involvement and three out of six patients had an isolated supradiaphragmatic disease. Of 20 pregnancies, six pregnancies (30%) resulted in early spontaneous miscarriages, and one pregnancy was terminated at 17 weeks due to fetal anomalies. The remaining 13 pregnancies (65%) resulted in live births. Three out of 13 (23%) neonates were small-for-gestational-age. The most common complication was maternal hypertension affecting 8/13 (61.5%) pregnancies. Preeclampsia occurred in one pregnancy. Four out of 13 (30.7%) pregnancies necessitated preterm induction of labor due to obstetric indications or uncontrolled disease. CONCLUSIONS: Although Takayasu's arteritis is associated with pregnancy complications, tight preconception disease control, strict follow up, and targeted treatment of high blood pressure can result in positive pregnancy outcome.

Cumulative pain-related stress and developmental outcomes among low-risk preterm infants at one year corrected age.

BACKGROUND: Extensive exposure of preterm infants to pain-related stress (PRS) at a time of physiological immaturity and rapid brain development may contribute to altered neurodevelopment. OBJECTIVE: To examine the relationship between early PRS and neurodevelopmental outcomes among low-risk very preterm infants at the age of one year corrected age (CA). METHODS: Participants included 107 infants born <32weeks gestational age (GA) and monitored prospectively at 12.5months CA. Excluded were infants with severe neonatal morbidities associated with impaired neurodevelopment. PRS documentation was performed via the number of skin-breaking procedures (SBP) and by the use of the neonatal infant stressor scale (NISS). Adjustment was made for early neonatal morbidities. RESULTS: Developmental outcomes among the study infants were within the norm (mean 100±11.03). Infants who underwent invasive mechanical ventilation (IMV) (n=31) were exposed to significantly more PRS than non-IMV infants (n=76) (p<0.000). Developmental outcomes were similar in both groups (99.7±11.1 vs. 100.8±11 p=0.63). Among IMV infants, increased exposure to PRS was associated with lower developmental scores independent of GA, gender or other sociodemographic factors. CONCLUSION: Increased exposure to PRS among low-risk preterm infants who underwent IMV is associated with lower developmental scores at 12.5month CA.

A man-made disease: Fetal neonatal alloimmune thrombocytopenia due to incompatibility between oocyte donor and gestational mother.

The incompatibility causing fetal and neonatal alloimmune thrombocytopenia (FNAIT) results from a fetus inheriting a paternal human platelet antigen (HPA), which is different from the maternal HPA. We present a unique case of FNAIT in a pregnancy involving an oocyte recipient mother with Turner syndrome. This is the first report of FNAIT in which the suggested mechanism involves antibodies produced by a gestational mother against the incompatible HPA of the oocyte donor.

Risk of Aortic Dissection in Pregnant Patients With the Marfan Syndrome.

Patients with Marfan syndrome (MS) face a high risk of aortic dissection during pregnancy. A dilated aortic root (>40 to 45 mm) is considered a relative contraindication for pregnancy. We investigated the risk for aortic dissection and pregnancy outcome in patients with MS. Women with MS who attended our cardiology high-risk pregnancy clinic from 2006 to 2015 were followed clinically and with serial echocardiograms by a multidisciplinary team. Beta blockers were offered and titrated by blood pressure and heart rate. Patients with aortic root dilation ≥40 mm were considered high-risk patients with MS. A consistent increase in aortic root diameter of >1 mm during pregnancy was classified as dilation during pregnancy; 31 pregnancies in 19 patients with MS were followed. Four pregnancies were terminated early because of prenatal diagnosis of fetal MS and 4 additional babies born with MS. Eight pregnancies were in patients with a dilated aortic root (40 to 46 mm); 21 patients (68%) were treated with ß blockers. There were 2 cases of postpartum aortic dissection (6.5%): 1 type A dissection in a woman with a dilated aortic root who declined ß blockers (1 of 8, 12.5%) and 1 type B dissection. Increasing aortic root diameter (>1 mm) in pregnancy was significantly associated with later aortic dissection (2 of 6 vs 0 of 21, p = 0.04). No maternal deaths occurred. All high-risk women with MS gave birth by cesarean section, whereas in the non-high-risk group mode of delivery was by obstetric indication. Preterm delivery rate was 41% (11 of 27). One antenatal fetal death and no major neonatal morbidity or mortality were observed. In conclusion, pregnant patients with MS, especially those with a dilating aortic root, are at high risk of aortic dissection, even with tight control of blood pressure and heart rate.

Factors Associated with Breast Milk Feeding of Very Preterm Infants from Birth to 6 Months Corrected Age.

OBJECTIVES: To investigate factors that may affect breast milk feeding (BMF) practices among very preterm infants. MATERIALS AND METHODS: This retrospective study included infants born before 32 weeks gestational age (GA) and monitored up to 6 months corrected age (CA). Feeding method was assessed at day 14 of life, 36 weeks GA, 6 weeks after home discharge, and 6 months CA. Multivariable logistic regression analysis was used to examine which factors were associated with BMF initiation at cessation. RESULTS: Of 181 infants who qualified for the study, 146 (81%) initiated BMF. Of these, 80% were mainly BMF (≥75% of daily nutrition volume). At 36 weeks GA, 6 weeks postdischarge, and 6 months CA, 130 (71.8%), 87 (48%), and 36 (19.9%) infants, respectively, continued to receive some BMF. Multivariate analysis revealed that initiation of BMF was more common with younger GA and higher level of maternal education. Infants whose mothers failed to supply ≥75% of daily nutrition as BMF at day 14 were more likely to be exclusively formula fed 6 weeks after discharge. Cessation of BMF at 6 months CA was associated with birth at >28 weeks. CONCLUSIONS: Successful BMF can be commenced and maintained throughout hospitalization in the majority of very preterm infants. Despite a significant dropout rate occurring within several weeks after discharge, in this select cohort, infants with lower GA were more likely to be breastfed after discharge.

A simple model for prediction postpartum PTSD in high-risk pregnancies.

This study aimed to examine the prevalence and possible antepartum risk factors of complete and partial post-traumatic stress disorder (PTSD) among women with complicated pregnancies and to define a predictive model for postpartum PTSD in this population. Women attending the high-risk pregnancy outpatient clinics at Sheba Medical Center completed the Edinburgh Postnatal Depression Scale (EPDS) and a questionnaire regarding demographic variables, history of psychological and psychiatric treatment, previous trauma, previous childbirth, current pregnancy medical and emotional complications, fears from childbirth, and expected pain. One month after delivery, women were requested to repeat the EPDS and complete the Post-traumatic Stress Diagnostic Scale (PDS) via telephone interview. The prevalence rates of postpartum PTSD (9.9 %) and partial PTSD (11.9 %) were relatively high. PTSD and partial PTSD were associated with sadness or anxiety during past pregnancy or childbirth, previous very difficult birth experiences, preference for cesarean section in future childbirth, emotional crises during pregnancy, increased fear of childbirth, higher expected intensity of pain, and depression during pregnancy. We created a prediction model for postpartum PTSD which shows a linear growth in the probability for developing postpartum PTSD when summing these seven antenatal risk factors. Postpartum PTSD is extremely prevalent after complicated pregnancies. A simple questionnaire may aid in identifying at-risk women before childbirth. This presents a potential for preventing or minimizing postpartum PTSD in this population.

Neonatal morbidities and need for intervention in twins and singletons born at 34-35 weeks of gestation.

OBJECTIVE: To compare indications for delivery and neonatal morbidities between twins and singletons born between 34 and 35 weeks of gestation. STUDY DESIGN: A prospective observational study was performed in which all infants born between January and August 2008, at Sheba Medical Center at 34 0/7-35 6/7 weeks of gestational age were included. Indications for delivery, infants' morbidities and medical interventions were documented. Twins and singletons were compared for antenatal maternal characteristics, risks of short-term neonatal complications and interventions. RESULTS: One hundred and seventy-three mothers and 229 neonates (114 twins and 115 singletons) were included. Background maternal characteristics as well as the use of antenatal steroids and MgSO4 were similar between the groups. Only 44% of all deliveries were spontaneous, while the rest were indicated deliveries. Twins were born lighter and 31.9% of them were SGA. Nevertheless, singletons were significantly more likely to receive medical interventions such as prolonged oxygen use (>1 day) and phototherapy. All late preterm infants (n=5) needing surfactant administration were singletons. Overall, the risk of needing any medical intervention was significantly higher for singletons compared with twins (OR 1.8, 95% CI 1.02-3.2). CONCLUSIONS: A significant proportion of late preterm births is iatrogenic. Twins and singletons are dissimilar with regards to risks of short-term complications. Despite being born smaller and more SGA, twins are at lower risk of requiring medical intervention in the immediate neonatal period compared with singletons.

Combined effect of fetal sex and advanced maternal age on pregnancy outcomes.

BACKGROUND: Fetal sex and maternal age are each known to affect outcomes of pregnancies. The objective of the present study was to investigate the influence of the combination of maternal age and fetal sex on pregnancy outcomes in term and post-term singleton pregnancies. MATERIAL AND METHODS: This was a retrospective study on term singleton pregnancies delivered between 2004 and 2008 at the Chaim Sheba Medical Center. Data collected included maternal age, fetal sex, and maternal and neonatal complications. The combined effect of fetal sex and maternal age on complications of pregnancy was assessed by multivariable logistic regression models. RESULTS: The study population comprised 37,327 pregnancies. The risk of operative deliveries increased with maternal age ≥ 40 and in pregnancies with male fetuses. The risk of maternal diabetes and of longer hospitalization increased as maternal age increased, and in women ≥ 40 carrying male fetuses. The risk of hypertensive disorders increased in pregnancies with males as maternal age advanced. The risk of shoulder dystocia and neonatal respiratory complications increased in male neonates born to women<40. The risk of neonatal hypoglycemia increased in males for all maternal ages. CONCLUSIONS: Risk assessment for fetal sex and advanced maternal age were given for different pregnancy complications. Knowledge of fetal sex adds value to the risk assessment of pregnancies as maternal age increases.

Peripartum cardiomyopathy ­ risk factors, characteristics and long-term follow-up.

AIMS: Peripartum cardiomyopathy (PPCM) is an infrequent form of cardiomyopathy causing significant maternal morbidity and mortality. We aimed to evaluate the risk factors, characteristics and prognosis of PPCM during the index and subsequent pregnancies. METHODS: A retrospective cohort of 36 women with PPCM in a tertiary medical center was analyzed and compared with 10,370 women who gave birth during a single calendar year at the same institution. RESULTS: Women diagnosed with PPCM were older (mean 33.5 years) than controls. A significantly higher proportion were primiparous (63.9%), carried multifetal pregnancies (33.3%) and had hypertensive pregnancy complications (38.9%). Thirty-six percent of PPCM patients conceived with in vitro fertilization, and six of them received ovum donation. Twenty-two women had severe left ventricular dysfunction at diagnosis, and these women tended to remain with residual disease, compared with women with milder ventricular dysfunction at diagnosis. Eight patients recovered completely within 2 weeks of diagnosis. Women who recovered early (n=8) had significantly higher ejection fractions on last follow-up compared with women (n=28) who had late or partial recovery. Nine women had 14 additional pregnancies; of them eight women had normal cardiac functions on subsequent pregnancy. CONCLUSIONS: Risk factors for peripartum cardiomyopathy include primiparity, hypertension and multifetal pregnancies. Assisted reproduction techniques are not independently associated with PPCM but rather through other risk factors for PPCM. The degree of cardiac dysfunction at diagnosis and time to recovery are important prognostic factors.

Advanced cervical dilatation and spontaneous preterm labor: a comparison between twin and singleton gestations.

OBJECTIVE: To determine the admission to delivery interval and the rate of immediate delivery in twin versus singleton gestation complicated by spontaneous preterm labor (SPTL). METHODS: A retrospective cohort study of pregnant women presenting with advanced cervical dilatation of 3-5 cm and frequent uterine contractions at 24-34 weeks of gestation was performed. The rate of progression to delivery within 12 h and 24 h, as well as rates of prolonged latency, were compared between twins and singletons gestations. RESULTS: Sixty-nine women were included, of which 25 carried twins and 44 singletons. The overall rate of spontaneous delivery within 12 h and 24 h was 47.8% and 59.4%, respectively, and similar between twins and singletons. Nevertheless, prolonged latency of 10 days or more after presentation was more frequent among twins compared with singletons [10/25 (40%) vs. 7/44 (15.9%), respectively; P=0.026]. Moreover, women carrying twins presenting with advanced cervical dilatation had a better chance of completing a full 2-dose antenatal betamethasone course compared with singletons [19/25 (76%) of twins compared with 21/44 (47.7%) of singletons, odds ratio 3.5, 95% confidence interval 1.16-10.34; P=0.022]. CONCLUSION: Up to 60% of women presenting with advanced cervical dilatation prior to 34 weeks' gestation give birth within 24 h. Nevertheless, women carrying twins have a better chance of completing a betamethasone course and having prolonged latency compared with singletons.