Umbilical cord blood gases sampling in low-risk vaginal deliveries as a predictor of adverse neonatal outcome.

INTRODUCTION: There is no clear correlation between abnormal umbilical cord blood gas studies (UCGS) and adverse neonatal outcome in low-risk deliveries. We investigated the need for its routine use in low-risk deliveries. METHODS: We retrospectively compared maternal, neonatal, and obstetrical characteristics among low-risk deliveries (2014-2022) between "normal" and "abnormal" pH groups: A:normal pH ≥ 7.15; abnormal pH < 7.15; B: normal pH ≥ 7.15 and base excess (BE) > - 12 mmol/L; abnormal pH < 7.15 and BE ≤ We retrospectively compared 12 mmol/L; C: normal pH ≥ 7.1; abnormal pH < 7.1; D: normal pH > 7.1 and BE > - 12 mmol/L; abnormal pH < 7.1 and BE ≤ - 12 mmol/L. RESULTS: Of 14,338 deliveries, the rates of UCGS were: A-0.3% (n = 43); B-0.07% (n = 10); C-0.11% (n = 17); D-0.03% (n = 4). The primary outcome, composite adverse neonatal outcome (CANO) occurred in 178 neonates with normal UCGS (1.2%) and in only one case with UCGS (2.6%). The sensitivity and specificity of UCGS as a predictor of CANO were high (99.7-99.9%) and low (0.56-0.59%), respectively. CONCLUSION: UCGS were an uncommon finding in low-risk deliveries and its association with CANO was not clinically relevant. Consequently, its routine use should be considered.

Pregnancy and placental outcomes according to maternal BMI in women with preeclampsia: a retrospective cohort study.

PURPOSE: Obesity and preeclampsia share similar patho-mechanisms and can both affect placental pathology. We aimed to investigate pregnancy outcomes in correlation with placental pathology among pregnancies complicated by preeclampsia in three different maternal body mass index (BMI, kg/m2) groups. METHODS: In this retrospective cohort study, medical and pathological records of patients with preeclampsia and a singleton pregnancy delivered between 2008 and 2021 at a single tertiary medical center were reviewed. Study population was divided into three BMI groups: BMI < 22.6 kg/m2 (low BMI group), 22.7 ≤ BMI ≤ 28.0 kg/m2 (middle-range BMI group), and BMI > 28.0 kg/m2 (high BMI group). Data regarding maternal characteristics, neonatal outcomes, and placental histopathological lesions were compared. RESULTS: The study groups included a total of 295 patients diagnosed with preeclampsia-98, 99, and 98 in the low, middle-range, and high BMI groups respectively. Neonatal birth weight was significantly decreased in the low maternal BMI group compared to both middle and high BMI groups (p = 0.04) with a similar trend seen in placental weight (p = 0.03). Villous changes related to maternal malperfusion were more prevalent in the low and high BMI groups compared to middle-range BMI group (p < 0.01) and composite maternal vascular malperfusion lesions were also more prevalent in the groups of BMI extremities compared to the middle-range BMI group (p < 0.01). CONCLUSION: Maternal BMI might influence neonatal outcomes and placental pathology in pregnancies complicated by preeclampsia. Both extremes of BMI were associated with higher rates of placental maternal vascular malperfusion. Balanced BMI in women at risk for preeclampsia may reduce the incidence of placental lesions.

Antenatal Corticosteroids for Small for Gestational Age in Late Preterm Newborns.

BACKGROUND: The administration of antenatal corticosteroids (ACS) is standard practice for management of threatened preterm birth. Its benefit, especially in small for gestational age (SGA) late preterm, is unclear. OBJECTIVES: To evaluate the impact of ACS on perinatal outcome of late preterm SGA neonates. METHODS: We conducted a retrospective cohort study of all women carrying a singleton gestation who had late preterm delivery (34-36 gestational weeks) of SGA neonates at a single tertiary university-affiliated medical center (July 2012-December 2017). Exclusion criteria included termination of pregnancy, intrauterine fetal death, and birth weight ≥ 10th percentile. Outcomes were compared between ACS and non-ACS treatment prior to delivery. Neonatal composite outcome included neonatal intensive care unit (NICU) admission, respiratory distress syndrome, mechanical ventilation, and transient tachypnea. RESULTS: Overall, 228 women met inclusion criteria; 102 (44.7%) received ACS and 126 did not (55.3%). Median birth weight among the non-ACS group was significantly higher (1896.0 vs. 1755.5 grams P < 0.001). Rates of NICU and jaundice requiring phototherapy were higher among the ACS group (53.92% vs. 31.74%, P = 0.01; 12.74% vs. 5.55%, P = 0.05, respectively). Composite neonatal outcome was significantly higher among the ACS group (53.92% vs. 32.53%, odds ratio [OR] 2.42, 95% confidence interval [95%CI] 1.41-4.15, P = 0.01). After adjustment for potential confounders, this association remained significant (OR 2.15, 95%CI 1.23-3.78, P = 0.007). CONCLUSIONS: ACS given during pregnancy did not improve respiratory outcome for SGA late preterm neonates. ACS may be associated with a worse outcome.

The association between chronic liver diseases and preeclampsia.

BACKGROUND: Preeclampsia is a multisystem disorder characterized by an abnormal vascular response to placentation associated with increased systemic vascular resistance. As liver involvement is one of the main clinical features of preeclampsia, we sought to determine if there is an association between chronic liver diseases and preeclampsia. METHODS: A retrospective matched case-control analysis was conducted in a tertiary medical center. Three hundred eleven (311) pregnant women with preexisting chronic liver disease (study group), including viral and autoimmune hepatitis, non-alcoholic fatty liver, Wilson disease, and cirrhosis, were match for age, parity, and number of fetuses to 933 healthy pregnant women (control group). The primary outcome measure was the incidence of preeclampsia in each group. Secondary outcome measures were obstetrical and neonatal complications. Confounders found to be significant on univariate analysis were evaluated using logistic regression models, and odds ratios (OR) and confidence intervals (CI) were calculated. RESULTS: Preeclampsia was diagnosed in 28 women (9.0%) in the study group and 33 women (3.54%) in the control group (p < 0.001). On multivariate analysis adjusted for maternal age, parity, previous preeclampsia, chronic hypertension, gestational diabetes mellitus, pregestational diabetes mellitus, antiphospholipid syndrome, and mode of conception, chronic liver disease was found to be an independent risk factor for preeclampsia (aOR 2.631, 95% CI 1.518-4.561). Although there was no difference in the gestational week at delivery between the groups (38.6 ± 2.13 vs. 38.8 ± 2.17 for study and control group, respectively, p = 0.410), the study group had a lower mean neonatal birthweight (3088 ± 551 vs. 3182 ± 566 g, p = 0.011). There were no between-group differences in the other parameters evaluated. CONCLUSION: In our study, preexisting chronic liver disease was associated with a 2.6-fold increased risk of preeclampsia.

Obstetric and perinatal outcomes in parturients with active SARS-CoV-2 infection during labor and delivery: a retrospective cohort study.

BACKGROUND: The COVID-19 pandemic is an ongoing global healthcare crisis that negatively affects pregnant women. Although patients with an acute infection during pregnancy have been widely studied, information regarding labor and delivery while infected is sparse. The aim of the study was to ascertain maternal, obstetrical, and perinatal outcomes of women who gave birth while infected with SARS-CoV-2. METHODS: Patients diagnosed with COVID-19 during pregnancy at a tertiary medical center in 4/20-2/21 were identified by a retrospective database search. Those with an active intrapartum SARS-CoV-2 infection were compared with those who recovered at least 10 days before labor and delivery. RESULTS: Of the 176 women included in the study, 84 had a SARS-CoV-2 infection at the time of delivery and 92 had recovered from the infection. There was no statistically significant between-group difference in mean gestational age at delivery (39 weeks for both, p = 0.71) and overall rate of cesarean delivery (26.2% vs 17.4%, respectively, p = 0.35) or non-elective cesarean delivery (10.71% vs 4.34%, respectively, p = 0.48). In the active-infection group, the rate of severe disease was 2.4%, and of critical disease (with intensive care unit admission, mechanical ventilation, and ECMO), 3.6%, compared to zero for both in the recovered group. No differences were found between the groups in adverse perinatal outcomes. CONCLUSION: Delivery is safe and feasible in women with active SARS-CoV-2 infection. Nevertheless, we found a non-significant trend for more severe disease and for cesarean delivery and urgent cesarean delivery (for COVID-19-related indications) in women with an intrapartum SARS-CoV-2 infection.

Fetal congenital heart disease - mode of delivery and obstetrical complications.

BACKGROUND: The optimal mode of delivery in cases of fetal congenital heart disease (CHD) is not established. The few relevant studies did not address operative vaginal delivery. The aim of this study was to assess the impact of fetal CHD on mode of delivery during a trial of labor, and to secondarily describe some obstetric complications. METHODS: The database of a tertiary medical center was searched for women who gave birth to a singleton, liveborn neonate in 2015-2018. Mode of delivery was compared between women carrying a fetus with known CHD and women with a healthy fetus matched 1:5 for maternal age, parity, body mass index, and gestational age. RESULTS: The cohort included 616 women, 105 in the CHD group and 511 in the control group. The rate of operative vaginal delivery was significantly higher in the CHD group (18.09% vs 9.78%, OR 2.03, 95% CI 1.13-3.63, p = 0.01); the difference remained significant after adjustment for nulliparity and gestational age at delivery (aOR 2.58, 95% CI 1.36-4.9, p < 0.01). There was no difference between the CHD and control group in rate of intrapartum cesarean delivery (9.52% vs 10.76%, respectively, OR 0.97, 95% CI 0.47-1.98, p = 0.93). The most common indication for operative vaginal delivery was non-reassuring fetal heart rate (78.94% vs 64%, respectively). Median birth weight percentile was significantly lower in the CHD group (45th vs 53rd percentile, p = 0.04). CONCLUSIONS: Our findings suggest that operative vaginal delivery, performed mostly because of non-reassuring fetal heart rate, is more common in pregnancies complicated by a prenatal diagnosis of CHD than non-anomalous pregnancies.

Illuminating spatial A-to-I RNA editing signatures within the Drosophila brain.

Adenosine-to-inosine (A-to-I) RNA editing, catalyzed by ADAR enzymes, is a ubiquitous mechanism that generates transcriptomic diversity. This process is particularly important for proper neuronal function; however, little is known about how RNA editing is dynamically regulated between the many functionally distinct neuronal populations of the brain. Here, we present a spatial RNA editing map in the Drosophila brain and show that different neuronal populations possess distinct RNA editing signatures. After purifying and sequencing RNA from genetically marked groups of neuronal nuclei, we identified a large number of editing sites and compared editing levels in hundreds of transcripts across nine functionally different neuronal populations. We found distinct editing repertoires for each population, including sites in repeat regions of the transcriptome and differential editing in highly conserved and likely functional regions of transcripts that encode essential neuronal genes. These changes are site-specific and not driven by changes in Adar expression, suggesting a complex, targeted regulation of editing levels in key transcripts. This fine-tuning of the transcriptome between different neurons by RNA editing may account for functional differences between distinct populations in the brain.

Mobile Self-Operated Home Ultrasound System for Remote Fetal Assessment During Pregnancy.

Background: Mobile medical devices for self-patient use are a rapidly evolving section of telehealth. We examined the INSTINCT® ultrasound system, a portable, self-operated ultrasound device attached to a commercial smartphone for remote fetal assessment. We aimed to evaluate whether it is feasible to use remote fetal assessment during pregnancy. Materials and Methods: This is an observational noninterventional trial. We included women with a singleton fetus at 14 + 0 to 39 + 6 gestational weeks. Each participant received the device for a self-use period of 7-14 days and was instructed to perform one to three scans a day. Participants completed a self-assessment questionnaire to evaluate safety and usability (i.e., user experience and satisfaction). Each scan was evaluated for fetal heart activity, amniotic fluid volume, fetal tone, fetal body, and breathing movements. Results: One hundred women, completing 1,360 self scans, used the device for 8.1 ± 1.5 days, performing an average of 13.6 ± 6.2 scans each. There were no device-related serious adverse events. Success in detection was 95.3% for fetal heart activity, 88.3% for body movements, 69.4% for tone, 92.2% for normal amniotic fluid volume, and 23.8% for breathing movements. Interobserver agreement was 94.4% for fetal heart rate activity, 85.9% for body movements, 69.5% for fetal tone, 86.9% for amniotic fluid volume, and 94.0% for breathing movements. Self-assessed user experience was rated at 4.4/5, whereas device satisfaction was rated at 3.9/5. Conclusion: The INSTINCT ultrasound system is a feasible solution for remote sonographic fetal assessment. Further studies are needed to assess its role and impact in telehealth antenatal care and fetal surveillance.

Postpartum voiding dysfunction following vaginal versus caesarean delivery.

In this prospective study, we evaluated postpartum voiding dysfunction stratified by mode of delivery - vaginal delivery versus elective caesarean delivery (CD). We recruited nulliparous women carrying singleton gestation at term admitted to delivery room or elective CD. Pre-labour voiding function was assessed by recording the post-voiding residual volume (PVRV) using a bladder scan. PVRV evaluation was repeated at least 12 hours following delivery and before discharge. PVRVs were considered abnormal if ≥150 mL. PVRVs were compared between vaginal and CD. Overall, 54 women were included. Of them, 34 (63%) delivered vaginally and 20 (37%) had an elective CD. Postpartum mean PVRVs were significantly higher compared to pre-labour PVRVs (215 vs. 133 mL, p<.001). Abnormal postpartum PVRV was significantly higher in vaginal delivery compared to CD (73.5% vs. 45%, p<.05). In conclusion, delivery adversely affects voiding function. Vaginal delivery is associated with more severe voiding dysfunction compared to elective CD.Impact StatementWhat is already known on this subject? Delivery is associated with voiding dysfunction. While most studies on postpartum voiding dysfunction were related to vaginal delivery, little is known on the effect of mode of delivery (vaginal versus caesarean delivery (CD)) on voiding dysfunction.What the results of this study add? In this study, we found that postpartum post-voiding residual volume is significantly higher than the pre-labour PVRV in women delivered vaginally. In addition, postpartum PVRV was significantly higher in women delivered vaginally compared to elective CD.What the implications are of these findings for clinical practice and/or further research? This study implicates that women with vaginal delivery are more prone to voiding dysfunction compared to elective CD. However, larger observational studies are warranted to confirm these results and evaluate whether this difference still exists beyond the post-partum period.

Association between progesterone treatment and neonatal outcome in preterm births: a retrospective analysis.

This retrospective study was conducted to determine if infants born prematurely despite prophylactic maternal progesterone treatment during pregnancy may still benefit from its adjunct properties and have decreased neonatal complications. 248 women treated with vaginal/intramuscular progesterone during pregnancy and 2519 controls who gave birth to a preterm newborn (24 + 0-36 + 6 gestational weeks) at a tertiary medical centre in 2012-2019. The primary outcome measure was neonatal infectious composite outcome. Secondary outcome measures were other maternal and neonatal complications. Compared to controls, the study group was characterised by lower gestational age at birth (35.0 ± 2.66 vs. 36.0 ± 2.23 weeks, p < .001), lower birth weight (2294 vs. 2485 g, p < .001), higher rates of neonatal infectious composite outcome (27.82 vs. 21.36%, p = 0.024), NICU admission, periventricular leukomalacia, and mechanical ventilation. The higher neonatal infectious composite outcome is likely associated with the lower gestational age at birth in this high-risk group and not the progesterone treatment per se.IMPACT STATEMENTWhat is already known on this subject? Several randomised controlled trials have shown that progesterone administration in pregnancy significantly reduced the rate and complications of preterm birth. A recent study reported that vaginal administration of progesterone during pregnancy was more effective than intramuscular administration in decreasing vaginal group B Streptococcus (GBS) colonisation. This finding raises the question of whether progesterone treatment may have additional benefits besides preventing preterm birth and may reduce neonatal complication rate in preterm infants.What do the results of this study add? This is the first study examining the impact of gestational progesterone exposure on outcomes of preterm infants. The primary objective was a composite measure of infectious neonatal outcomes. Newborns who had progesterone exposure on average had lower gestational age, lower birth weight and higher neonatal infectious composite outcome. The significant difference is explained by lower gestational age.What are the implications of these findings for clinical practice and/or further research? Progesterone is widely used to prevent preterm birth, and may have important additive effects even when prematurity is not avoided. Although the findings did not support our initial hypothesis, they warrant further examination with larger cohorts.

The association between maternal cytomegalovirus urinary excretion and congenital infection rate.

BACKGROUND: In utero Cytomegalovirus (CMV) vertical transmission occurs predominantly during primary maternal infection. There are no known non-invasive methods for diagnosis of fetal infection before delivery, however some risk factors have been suggested. We aimed to evaluate the association between maternal CMV urinary excretion and congenital CMV infection. METHODS: A retrospective cohort study of all women who were diagnosed with primary CMV infection during pregnancy in a single university affiliated tertiary medical center, between 2012 and 2016. We examined congenital CMV infection and disease rates among infants born to women with and without CMV urinary excretion. RESULTS: Overall, 126 women were included, 77 in the positive urinary excretion group, and 49 in the negative urinary excretion group. There was no difference in maternal symptoms between the groups. We found no difference in congenital CMV infection and disease rates between infants born to women with and without urinary excretion of CMV (congenital infection rate 37.1% vs. 24.4%, p = 0.209, congenital disease rate of 18.2% vs. 22.4%, p = 0.648). Women with positive urinary CMV excretion had lower IgG avidity values (36.7% vs 54.6%, p = 0.007), with no additional difference in serology pattern. Compared to asymptomatic women, those with CMV related symptoms did not have significantly higher rates of urinary excretion of CMV (70% vs. 60.5%, p = 0.38) or congenital infection rates (40.7% vs. 31.2%, p = 0.48). CONCLUSION: Among infants of women with primary CMV infection in pregnancy, we did not find an association between urinary excretion of CMV and congenital CMV infection.

Association of term isolated microcephaly with mode of delivery and perinatal outcome - a retrospective case-control analysis.

BACKGROUND: We aimed to evaluate the association of isolated fetal microcephaly measured by ultrasound prior to delivery at term with mode of delivery and perinatal outcome. METHODS: A single-center retrospective study was conducted in 2012-2016. Fetal microcephaly was defined as head circumference > 2 standard deviations of the mean for gestational age and sex. We compared the obstetric, delivery, and outcome parameters of women in whom ultrasound performed up to 10 days prior to term delivery showed isolated fetal microcephaly (study group) or normal head circumference (reference group). Exclusion criteria were intrauterine fetal death, birthweight below the 10th percentile, and antepartum cesarean delivery for any indication. RESULTS: Of 3677 women included in the study, 26 (0.7%) had a late ultrasound finding of isolated fetal microcephaly. Baseline characteristics were similar in the two groups except for estimated fetal weight based on abdominal circumference and biparietal diameter, which was lower in the microcephaly group (3209.8 ± 557.6 vs. 2685.8 ± 420.8 g, p < .001). There was no significant between-group difference in rate of vaginal operative deliveries (11.7% vs 14.8%, respectively, p = 0.372). The study group had no intrapartum cesarean deliveries compared to 6.3% of the reference group (NS). Compared to controls, neonates in the study group were smaller (3323.2 ± 432.2 vs. 2957.0 ± 330.4 g, p < .001), with lower birthweight percentile (60.5 ± 26.5 vs. 33.6 ± 21.5%, p < .001) and were more often males (48.2 vs. 90.0%, p < .001). No significant differences were noted in perinatal outcomes between the groups, including admission to neonatal intensive care unit, intraventricular hemorrhage, 5-min Apgar score < 7, asphyxia, seizures, and sepsis. CONCLUSIONS: Isolated microcephaly in term fetuses is not advantageous for a vaginal delivery, nor does it does not pose a greater than normal risk of adverse perinatal outcome.

Odorant binding protein 69a connects social interaction to modulation of social responsiveness in Drosophila.

Living in a social environment requires the ability to respond to specific social stimuli and to incorporate information obtained from prior interactions into future ones. One of the mechanisms that facilitates social interaction is pheromone-based communication. In Drosophila melanogaster, the male-specific pheromone cis-vaccenyl acetate (cVA) elicits different responses in male and female flies, and functions to modulate behavior in a context and experience-dependent manner. Although it is the most studied pheromone in flies, the mechanisms that determine the complexity of the response, its intensity and final output with respect to social context, sex and prior interaction, are still not well understood. Here we explored the functional link between social interaction and pheromone-based communication and discovered an odorant binding protein that links social interaction to sex specific changes in cVA related responses. Odorant binding protein 69a (Obp69a) is expressed in auxiliary cells and secreted into the olfactory sensilla. Its expression is inversely regulated in male and female flies by social interactions: cVA exposure reduces its levels in male flies and increases its levels in female flies. Increasing or decreasing Obp69a levels by genetic means establishes a functional link between Obp69a levels and the extent of male aggression and female receptivity. We show that activation of cVA-sensing neurons is sufficeint to regulate Obp69a levels in the absence of cVA, and requires active neurotransmission between the sensory neuron to the second order olfactory neuron. The cross-talk between sensory neurons and non-neuronal auxiliary cells at the olfactory sensilla, represents an additional component in the machinery that promotes behavioral plasticity to the same sensory stimuli in male and female flies.

Epidural/spinal anesthesia during delivery in women with factor XI deficiency, a single center experience.

INTRODUCTION: The safety of neuro-axial anaesthesia (epidural/spinal) at labour of women with partial factor XI (FXI) deficiency is uncertain. Although FXI deficiency is frequent in Ashkenazi Jews, it is not routinely measured before labour. Our institute serves a large Ashkenazi population. We assumed that 10% of them have undiagnosed FXI deficiency. AIM: Assess the incidence, bleeding tendency and coagulation status among Jewish Ashkenazi women with FXI deficiency that underwent neuro-axial anaesthesia at delivery. METHODS: Jewish Ashkenazi women who underwent neuro-axial anaesthesia at labour completed the SSC ISTH bleeding assessment tool (BAT) and had blood drawn for coagulation tests, FXI and thrombin generation after labour. Estimation for 10 years was calculated from the 1-year sample. RESULTS: We recruited 261 women during 12 months. Among them, 39 (15%) had FXI deficiency (<70%) with median FXI levels of 63% (range: 33%-70%). Around 50% of them underwent amniocentesis in the current pregnancy and prior neuro-axial anaesthesia with no bleeding complications. BAT score and thrombin generation did not differ between women regardless of FXI status. aPTT was longer in women with partial FXI deficiency (median - 28.6 sec vs 26.3 sec, P < .001, Table 2), although within the normal range in all women. No bleeding complications after neuro-axial anaesthesia at delivery were reported in our centre in the last decade though, and according to our estimation, at least 2150 women had partial FXI deficiency. CONCLUSIONS: A significant number of Jewish Ashkenazi women with undiagnosed partial FXI deficiency undergo neuro-axial anaesthesia at labour without bleeding complications.

Pregnancy outcome following fetal reduction from dichorionic twins to singleton gestation.

BACKGROUND: There are still some controversies regarding the risks and benefits of fetal reduction from twins to singletons. We aimed to evaluate if fetal reduction from twins to singleton improves pregnancy outcome. METHODS: Retrospective analysis of all dichorionic-diamniotic twin pregnancies, who underwent fetal reduction. Pregnancy outcome was compared to ongoing, non-reduced, dichorionic-diamniotic gestations. Primary outcome was preterm birth prior to 37 gestational weeks. Secondary outcomes included: preterm birth prior to 34 gestational weeks, gestational age at delivery, birthweight, small for gestational age, hypertensive disorders, gestational diabetes and stillbirth. RESULTS: Ninety-eight reduced pregnancies were compared with 222 ongoing twins. Preterm birth < 37 gestational weeks (39.6% vs. 57.6%, p < 0.001) was significantly lower in the reduced group compared to the ongoing twins' group. A multivariate analysis, controlling for parity and mode of conception, demonstrated that fetal reduction independently and significantly reduced the risk for prematurity (aOR 0.495, 95% CI -0.299-0.819). Subgroup analysis, similarly adjusted demonstrated lower rates of preterm delivery in those undergoing elective reduction (aOR = 0.206, 95% CI 0.065-0.651), reduction due to fetal anomalies (aOR = 0.522, 95% CI 0.295-0.926) and 1st trimester reduction (aOR = 0.297, 95% Cl 0.131-0.674) all compared to ongoing twins. A Kaplan-Meier survival curve showed a significant proportion of non-delivered women at each gestational week in the reduced group compared to non-reduced twins, after 29 gestational weeks. CONCLUSIONS: Fetal reduction from twins to singleton reduces the risk of preterm birth < 37 gestational weeks, but not for more severe maternal and perinatal complications.

Intrahepatic cholestasis of pregnancy as a risk factor for preeclampsia.

PURPOSE: Intrahepatic cholestasis of pregnancy and preeclampsia are two major pregnancy complications. We aimed to investigate the association between intrahepatic cholestasis of pregnancy (ICP) and preeclampsia. METHODS: Single-center retrospective study. Study group included 180 women (162 singletons and 18 twin gestations) who were diagnosed with ICP based on clinical presentation, elevated liver enzymes and bile acids. The reference group included 1618 women (1507 singletons and 111 twin gestations) who delivered during the study period, and were matched according to age, gravidity, parity and singleton or twin gestation. RESULTS: The incidence of ICP was 0.36%. The incidence of preeclampsia was higher in women with ICP compared to reference group (7.78% vs 2.41%, aOR, 3.74 95% CI 12.0-7.02, p < 0.0001), for either without-(3.89% vs 1.61%, aOR 2.83, 95% CI 1.23-6.5, p = 0.145) or with severe features (3.89% vs 0.80%, aOR 5.17 95% CI 2.14-12.50, p = 0.0003). For both singleton and twin pregnancies, overall preeclampsia rates were higher in the ICP group (5.56% vs 2.19%, aOR 2.91 95% CI 1.39-6.07 p = 0.0045; and 27.78% vs 5.41%, aOR 10.9 95% CI 2.16-47.19, p = 0.0033, respectively). Earlier diagnosis of ICP was associated with higher incidence of preeclampsia (31.1 ± 3.8 vs 34.86 ± 6.2 gestational weeks, p = 0.0259). The average time between ICP diagnosis and to the onset of preeclampsia was 29.7 ± 24 days. CONCLUSION: ICP is associated with an increased risk for preeclampsia. We suggest intensified follow-up for preeclampsia in women with ICP, especially among those with early ICP presentation and twins' gestations.

Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain.

PURPOSE: To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion. MATERIALS AND METHODS: Retrospective cohort analysis of 322 women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion. RESULTS: The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026). CONCLUSION: Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.

[PROSPECTIVE INVESTIGATION OF POSTOPERATIVE NAUSEA AND VOMITING FOLLOWING DUAL PROPHYLAXIS AND LOW DOSE NEURAXIAL MORPHINE FOR CESAREAN DELIVERY].

BACKGROUND: Spinal morphine provides the optimal treatment for post-cesarean analgesia, despite frequent nausea and vomiting. We investigated the incidence of nausea and vomiting 24 hours after cesarean delivery in women receiving intrathecal morphine 100 µcg and intravenous prophylactic dexamethasone and ondansetron. METHODS: In a prospective, observational, Institutional Review Board (IRB) approved study of women undergoing cesarean delivery according to a standardized anesthetic protocol, the subjects were approached preoperatively and underwent standardized interviews regarding prior anesthesia experience and history of postoperative nausea and vomiting. In the post anesthesia care unit and 24 hours postoperatively, the women were interviewed regarding the incidence of nausea and vomiting, Women with and without nausea at 24 hours were compared for potential associated risk factors. RESULTS: Among 201 women recruited, 29 (14.5%) had nausea and 7 (3.5%) vomited in the postoperative care unit. During the first 24 hours, 36 (17.9%) had experienced nausea and 19 (9.5%) had vomited when interviewed at the 24-hours postoperatively. Women who had nausea 24 hours postoperatively were more likely to have nausea in the post anesthesia care unit than women without nausea during 24 hours after cesarean delivery (41.7% versus 1.2%, p<0.001). We did not find preoperative risk factors for postoperative nausea and vomiting. CONCLUSIONS: We report that almost 20% of the women managed with prophylactic dual therapy of ondansetron and dexamethasone had nausea during the 24 hours after administration of low dose intrathecal morphine. Our findings suggested that women who experience nausea or vomiting in the immediate postoperative period are at increased risk of nausea and vomiting in the 24-hour postoperative period.

Induction of labor versus expectant management after successful external cephalic version.

BACKGROUND: External cephalic version (ECV) is a common procedure for women carrying a breech-presenting fetus, in an effort to avoid a cesarean birth. The benefit of immediate labor induction after ECV vs. expectant management is undetermined. We aimed to evaluate whether induction of labor immediately after a successful ECV improves the chances of a vaginal delivery compared with expectant management. METHODS: Retrospective analysis of 296 women who underwent successful ECV performed in term singleton gestations (2007-2018) in the Rabin Medical Center. Mode of delivery and other obstetrical and neonatal outcomes were compared between women undergoing immediate labor induction after ECV and those managed expectantly. RESULTS: Of 296 women after successful ECVs, 54 (18.2%) underwent immediate labor induction and 242 (81.8%) were managed expectantly. Immediate induction was associated with higher parity (2.4 vs 1.7, P = .03) and lower mean birthweight (3128 vs 3346 g, P < .01). Mode of delivery was similar between groups, and no other significant differences in obstetrical and neonatal adverse outcomes were noted. DISCUSSION: In our cohort, immediate labor induction after successful ECV apparently had no benefits in terms of obstetrical or neonatal complications, and did not reduce the risk of cesarean birth. Therefore, expectant management seems reasonable and safe.

Induction of labor versus expectant management for gestational diabetes mellitus at term.

PURPOSE: To evaluate whether induction of labor (IOL), as compared with expectant management, in gestational diabetes mellitus (GDM) mothers at term (between 370/7 and 406/7), decreases caesarean section (CS) rate and the rate of adverse composite neonatal outcomes. METHODS: A retrospective cohort study, of all women with GDM and a singleton gestation who delivered at term in a single, tertiary, university-affiliated medical center (2007-2014). We compared outcomes of women who underwent IOL at each week of gestation between 370/7 and 406/7 weeks with women who were managed expectantly. The primary outcome was CS rate. RESULTS: Overall, 2472 GDM patients included in the study, of which 880 women had IOL. CS rate was not found to be significantly different between the groups at any gestational age. IOL at 37 weeks was associated with adverse composite neonatal outcome (aOR 2.2, 95% CI 1.4-3.6) and NICU admission (aOR 2.5, 95% CI 1.4-4.4). At 38 weeks, with NICU admission (aOR 2.0, 95% CI 1.4-2.9), and at 39 weeks with fracture of the clavicle. In a sub-analysis of nulliparous women, IOL at 37 weeks had higher odds of NICU admission and adverse composite neonatal outcomes, at 38 weeks with CS and at 39 weeks with fracture of the clavicle. CONCLUSIONS: IOL in GDM mothers at term does not reduce CS rate and may be associated with increased CS rate among nulliparous women at 38 weeks. It is also associated with increased risk for adverse composite neonatal outcome or NICU admission when done prior to 390/7 weeks.